Bubble CPAP vs. Bubble CPAP vs. High Flow Nasal CannulaHigh Flow Nasal Cannula

Gil Urquidez, RRT-NPSGil Urquidez, RRT-NPSSupervisor, Respiratory Care Services Supervisor, Respiratory Care Services

Santa Clara Valley Medical CenterSanta Clara Valley Medical Center

Optimize Initial RespiratorySupport

Goal:Goal: To establish and maintain the VLBW infant’s respiratory efforts and functional residual capacity without injuring the lung (VVent IInduced LLung IInjury) from excessive use of positive pressure ventilation.

What is CPAP ?

Continuous Positive Airway Pressure

Technique of applying a continuous distending pressure to the lungs in a spontaneous breathing infant.

Usually< 10 cm of water pressure

5-10L humidified flow of blended air

How does it Work ?Distends the airway and alveoliMaintains lung volume in expiration/FRC

Makes breathing easierImproves gas exchange

Philosophy of use

Patience

Permissive Hypercapnea

Non invasive application

CPAP Beneficial effects immediately following Resuscitation

BenefitsDecreased requirements for Intubation Decreased requirement for high levels of inspired

OxygenDecreased Mechanical Ventilation Length of StayDecreased need of Postnatal steroids

Compared to Historical controls

P.Jegatheesan J of Perinatology 2006 26, 189 - 196

Tool-Kit Best Practice #7Optimize Initial Respiratory Support

Early use of CPAP (within 60 seconds of life)

Avoid Intubation (if possible)

Avoid prophylactic use of Surfactant in the DR

CPQCC Recommendation…

What Causes Chronic Lung Disease (CLD)?

CAUSECAUSE EFFECTEFFECT

Summary of Current Causes of CLD/BPD in VLBW

Barotrauma Volutrauma Atelectotrauma Developmentally

Impaired Alveolarization and Vascularization

Poor Nutrition Recurrent infections

Pressure Volume Repeated popping open Less alveoli

Not enough resources to grow Scarring and destruction

Why Did VMC Switch to Bubble CPAP Therapy?

Bubble Nasal CPAPCost EffectivenessLess Invasive Than A Other InterfacesTo Improve Overall OutcomesColumbia Medical Center’s Experience

CLD rates are the lowest in the country Bubble CPAP is SOLE form of Nasal CPAP.

Positive Outcomes Associated With The Change In Practice

Benefits Associated With Change In Practice

Improved Outcomes Associated With Change In Practice

VLBW survival WITHOUT significant IVH

SCVMC NICU

0102030405060708090

100

2006 2007 2008 2009 2010

VLBW

How do we create our own Bubble CPAP System?

• How do we do it?

• What equipment do we use?

• Where do we get it?

Creating our Setup• Where do we start?

• What hat to use?• Where do we get them?

Creating our Setup

• Preparing for the cannula

Creating our Setup

• Securing the cannula to the patient

Creating our Setup

• Chin straps

Creating our Setup

• Water Bottles

Creating our Setup

• Original Setup

Creating our Setup

How can we improve it!How can we improve it!

Creating our SetupCreating our Setup• Other options

Creating our SetupCreating our Setup• Other Options

Creating our SetupCreating our Setup• Other Options

Creating our Setup• Previous System

Current Set Up

New Circuit & Bubble Chamber

Multiple Sizes for Prongs/Mask

High Flow Nasal Cannula

Definition

High Flow Nasal Cannula is defined as heated humidified gas delivered at flows greater than 1lpm.

VMC defines High Flow Nasal Cannula as heated humidified gas delivered at 2lpm.

High Flow Nasal Cannula Set-Up

Cochrane Collaborative Review of High Flow Nasal Cannula 2011 Issue 5There is insufficient evidence to establish the safety or efficacy of HFNC as a form of respiratory support in the preterm infant

When used following extubation there may be a higher reintubation rate compared to NCPAP

More trials are needed

Early Weaning From NCPAP To HFNC Is Associated With Prolonged Oxygen Use

Randomized control trial

Clinically stable on < 30 % O2 for 24 hrs randomized to HFNC (2 L) or Stay on CPAP till go straight to room air.

NCAPAP N/C 2 L

Days on O2 5 14

Resp support

days10.5 18

Hany ES Early Human Development 2011

High Flow Nasal Cannula

PRO’s for HFNC UseEase of use Improved feeding and toleranceEasier nursing/patient handlingDecreased nasal septal trauma

CON’s for HFNC useLimited dataUnmeasured PEEPNo alarms

High Flow Nasal Cannula

VMC’s Position on HFNC

• High Flow Nasal Cannula usage when:• Patient fails multiple attempts off Bubble NCPAP• Is still needing more than 2lpm flow

Greg Is Not Happy with the Baby’s NCPAP Set Up

What’s wrong with this set up?

The Baby Is Agitated and Desating! What Can We Do To Fix This?

Aaahhh….I feel much better!

I Can See You!!!

Greg’s NOW a Happy Nurse!!!

A Happy Baby is a Happy Nurse And ULTIMATELY a HAPPY RTRT!!!

Conclusions

CPAP is Bubble CPAP is High Flow Nasal Cannula

Oxygen is a Drug

A. Needs Further Study

B. Good

C. Use with caution

D. Great

GoodGreat

Needs Further Study Use with Caution

MATCH the Definition on the RIGHT with the Therapy on the LEFT

Craig Ivie, Director, Respiratory Care ServicesDr. Balaji Govindaswami, Director, NICUAll Associate AttendingsAll NICU StaffMy Respiratory Care Staff

Thank Yous!!!