Nasal CPAP used in Neonates

 

By: Ryan Cutro, Erin Sventy, Afnan Al-Raimi, Kelvin K. Opoku

Case:

You are a respiratory therapist attending the delivery of an infant who is 28 weeks GA.  Upon delivery, the baby has a 1-minute Apgar score of 7 and a 5-minute Apgar score of 9. The infant was placed in a warmer and a pulse oximeter attached to the right hand shows SpO2 of 92%. Ten minutes after birth, the baby begins to show signs of respiratory distress with grunting and retractions. The respiratory therapist recommends that the baby be started on nasal CPAP.

Discussion:

Respiratory distress syndrome (RDS) is a primary cause of neonatal respiratory failure.  A neonate’s lungs may be underdeveloped, lack sufficient surfactant, as well as the necessary surface area for effective gas exchange.  Moreover, the neonate may not be able to maintain the strenuous work of breathing needed to support spontaneous breaths.^1,2  This process can then lead to atelectasis, increased V/Q mismatch, and lung injury.  Endotracheal intubation and mechanical ventilation has been the primary intervention for supporting neonates with RDS over the last 40 years.¹ However, even short-term invasive ventilation has been associated with lung inflammation and injury,  reduced efficacy of endogenous surfactant, and alveolar growth and development.  As a result, avoiding intubation and the related ventilator induced lung injury is a primary goal. ¹

Trauma associated with mechanical ventilation:

http://www.cmaj.ca/content/178/9/1174.figures-only

The child in this case had a five-minute Apgar score of 9, which indicates a healthy infant, but the grunting and retractions after 10 minutes are signs of respiratory distress. Ultimately, the infant is not overcoming the work of breathing.  As a result, I am in agreement with the respiratory therapist’s decision to start nasal CPAP to effectively oxygenate the child and avoid intubation.  This decision is supported by a number of high quality studies.

The first study is a multicenter randomized controlled trial involving 648 infants born at 26-29 weeks’ gestation.  The trial compared 3 approaches to the initial respiratory management of preterm neonates.  They compared prophylactic surfactant followed by a period of mechanical ventilation, prophylactic surfactant with rapid extubation to bubble nasal continuous positive airway pressure and initial management with bubble continuous positive airway pressure and selective surfactant treatment.  The trial concluded that management with early CPAP lead to a reduction in the number of infants who are intubated and given surfactant.²

Another study that was multicenter and randomized compared a strategy of treatment with CPAP and protocol-driven limited ventilation with that of administration of surfactant followed by conventional mechanical ventilation strategy.  The researchers concluded there was no significant difference between the two interventions assessed in the trial with respect to the primary outcome of death or bronchopulmonary dysplasia.³ The secondary outcome was that there was a significant reduction in the risk of death in the CPAP group, as compared with the early-intubation group, which resulted in a lower rate of intubation.³

Finally, a study out of the New Delhi hospital in India compared the outcomes of preterm neonates with RDS using a CPAP approach alone to that of mechanical ventilation.   The study concluded that using CPAP reduces the need for intubations and surfactant while not adversely affecting outcomes.⁴

In conclusion, starting CPAP on a neonate in respiratory distress may reduce the need to mechanically ventilate and is supported by high quality evidence.  This may help reduce inherent risks of intubation, lessen hospital stay, and decrease the costs associated with the care of preterm neonates.^2,3  It should be noted that each of the studies concluded with a strong statement about the importance of further research.

 

 

References:

1. DiBlasi RM. Neonatal Noninvasive Ventilation Techniques: Do We Really Need to Intubate?…includes discussion… 47th Respiratory Care Journal Conference, “Neonatal and Pediatric Respiratory Care: What Does the Future Hold?” November 2010, Arizona. Respir Care 2011;56(9):1273-1297 25p.
2. Dunn MS, Kaempf J, de Klerk A, de Klerk R, Reilly M, Howard D, et al. Randomized Trial Comparing 3 Approaches to the Initial Respiratory Management of Preterm Neonates. Pediatrics 2011;128(5):e1069-e1076.
3. Early CPAP versus Surfactant in Extremely Preterm Infants. N Engl J Med 2010;362(21):1970-1979.
4. Saxena A, Thapar RK, Sondhi V, Chandra P. Continuous Positive Airway Pressure for Spontaneously Breathing Premature Infants with Respiratory Distress Syndrome. The Indian Journal of Pediatrics 2012;79(9):1185-1191.