1. Maintenance and monitoring

â–º Flow
       ♦ Bubble minimal bubbling (2 to 7 liters/min)
       ♦ Ventilator 6 to 8 cms of water

â–º FiO₂ (21% to 60 %) : SpO₂ 90% - 95%

â–º CPAP (4 to 7 cms) : Recessions/ CXR and SpO₂

2. CPAP and FiO₂: Proportionality

3. CPAP

â–º CPAP of < 4 cm H₂O never given

â–º CPAP of 4-7 cm H₂O is a good range
      ♦ Advantages many, disadvantages few!

â–º CPAP of > 7 cm H₂O is a bad range
      ♦ Advantages some, disadvantages galore!

4. Warming and humidification

â–º Temperature of inspiratory gases at 37^o C

â–º Relative humidity of 100%

â–º No condensation in the inspiratory circuit

â–º Some condensation in the expiratory limb

5. Humidifier

6. Monitoring

â–º Patient
      ♦ HR, RR, SAS score, SpO₂, air entry and bubbling
      ♦ CFT, blood pressure, anterior fontannel, urine output,
        abdominal girth

â–º Machine
      ♦ CPAP pressure, FiO₂ and flow
      ♦ Water in humidifier, bubble chamber
      ♦ Condensation in circuit

â–º Interface
      ♦ Nasal injury, cap size, prong size, secretions

7. Chest X-ray

8. Adequacy of CPAP

â–º Satisfactory cardiorespiratory status

      ♦ Comfortable baby
      ♦ Minimal retraction, no grunt
      ♦ Normal capillary refill, BP
      ♦ Normal saturations: 90 - 94%
      ♦ Normal ABG
        (PaO₂: 60-80, PaCO₂: 40-60, pH 7.35-7.45, BE±2)

9. Weaning

â–º Decrease FiO₂ and then CPAP

â–º Every 1 cm decrease in CPAP, aim 10% in FiO₂

â–º CPAP 5cm & FiO₂ 50%, maintain CPAP till FiO₂ is 30%

â–º Decrease CPAP to 4 cm

â–º The disease process has improved

â–º Remove CPAP, if CPAP 4 cm & FiO₂ < 30% & clinically well
    (no RD, SpO₂ > 90% & normal ABG)

10. Procedure after the CPAP

â–º Oral and nasal suction/ saline nebulization, if secretions

â–º Watch for apneas, tachypnea, retractions and bradycardia

â–º Frequent change in positions

11. Failure of CPAP

â–º Continuing retractions, grunt

â–º Recurrent apneas

â–º SpO₂ <90 % & PaO₂ < 50 : PEEP > 7 & FiO₂ >60%

â–º PaCO₂ > 55, poor respiratory efforts

â–º Baby not tolerating CPAP

12. Reasons for failure

â–º Failure of the CPAP system

â–º Worsening of baby
       ♦ Respiratory
       ♦ Cardiovascular
       ♦ Neurological

13. Summary

â–º Titration
      ♦ Flow     Bubbling
      ♦ FiO₂      SpO₂
      ♦ CPAP    Recessions/CXR

â–º Proportionality of FiO₂ and CPAP

â–º Systematic evaluation: Failure of CPAP