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 Applications

ApneaCPAP

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ApneaCPAP

Apnea and breathing irregularities affect nearly every premature infant and newborn. The more premature the infant is, the more markedly apnea occurs. They represent a disruption in the respiratory mechanics as well as respiratory control. The most important feature of the apnea is the intermittent air flow in the patient’s airway.

Apnea is clinically significant for the patient due to the concomitant symptoms such as bradycardia <80 BPM (decreased heart rate) and hypoxia <80% (decreased oxygen saturation). The goal of prophylaxis and treatment of apnea is to avoid or minimize negative effects (Pantalitschka T, Sievers J, Urschitz MS, Herberts T, Reher C, Poets CF. Randomised crossover trial of four nasal respiratory support systems for apnoea of prematurity in very low birthweight infants. Arch Dis Child Fetal Neonatal Ed. 2009;94(4):F245-F248. doi:10.1136/adc.2008.1489811​, Therapie idiopatischer Apnoen, Bradykardien und Hypoxämien2​).

  • Additional breaths stimulate respiration

  • Airways are stabilized which facilitates breathing as a result

  • The patient’s own breathing is detected and the device switches into CPAP mode

  • Available in the devices medinCNO, medinCNOmini, medin-NC3

Importance of nCPAP for Apnea-therapy

The efficacy of nasal CPAP is proven in this context by studies and is a part of the applicable guidelines for the treatment of apnea and its concomitant symptoms (Pantalitschka T, Sievers J, Urschitz MS, Herberts T, Reher C, Poets CF. Randomised crossover trial of four nasal respiratory support systems for apnoea of prematurity in very low birthweight infants. Arch Dis Child Fetal Neonatal Ed. 2009;94(4):F245-F248. doi:10.1136/adc.2008.1489811​, Therapie idiopatischer Apnoen, Bradykardien und Hypoxämien2​, De Paoli AG, Davis PG, Faber B, Morley CJ. Devices and pressure sources for administration of nasal continuous positive airway pressure (NCPAP) in preterm neonates. Cochrane Database Syst Rev. 2008;2008(1):CD002977. Published 2008 Jan 23. doi:10.1002/14651858.CD002977.pub23​).

The mechanisms of action are:

  • Holding the airways open through positive pressure
  • Increasing the FRC
  • Increasing the respiratory drive through improved oxygenation
  • Reducing the breathing effort

ApneaCPAP treatment

The medin ApneaCPAP with apnea treatment can be used from the prophylaxis to the treatment of existing apnea.

Based on the nCPAP mode, central and obstructive apnea is detected with the unique MediTRIG technology and responded to with automatic additional breaths from the CPAP device. The level of the peak pressure of the breaths is adjusted with a second electronic flow meter and added to the basic flow. The parameters of the ApneaCPAP function as well as of the MediTRIG can be individually adapted to the patient.

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The following parameters are to be set

  • Sensitivity trigger: +/- mbar; upper and lower trigger threshold as the pressure difference with regard to the PEEP
  • Apnea time: From 2 s to 20 s; duration of breathing pause until device reacts
  • Inspiration time: From 0.2 s to 2 s; duration of breath
  • Push flow: Additional adjustable breathing gas flow with which peak pressure can be generated
  • Backup rate: Number of automatic breaths per minute which are administered to the patient after the end of apnea time

1 Apnea
2 Automated breath

References

  1. 1. Pantalitschka T, Sievers J, Urschitz MS, Herberts T, Reher C, Poets CF. Randomised crossover trial of four nasal respiratory support systems for apnoea of prematurity in very low birthweight infants. Arch Dis Child Fetal Neonatal Ed. 2009;94(4):F245-F248. doi:10.1136/adc.2008.148981
  2. 2. Christian F. Poets, Abt. für Neonatologie, Universitätsklinikum Tübingen; GNPI; Bettina Bohnhorst, Klinik für Pädiatr. Pneumologie, Allergologie u. Neonatologie, Medizinische Hochschule Hannover; GNPI; Gunter Kerst, Klinik für Kinderkardiologie, Universitätsklinikum RWTH Aachen; DGKJ; AWMF-Leitlinien-Register Nr. 024/013 Entwicklungsstufe S2k; 1997

 

  1. 3. De Paoli AG, Davis PG, Faber B, Morley CJ. Devices and pressure sources for administration of nasal continuous positive airway pressure (NCPAP) in preterm neonates. Cochrane Database Syst Rev. 2008;2008(1):CD002977. Published 2008 Jan 23. doi:10.1002/14651858.CD002977.pub2

Fußnoten

 

Randomised crossover trial of four nasal respiratory support systems for apnoea of prematurity in very low birthweight infants.

Pantalitschka T, Sievers J, Urschitz MS, Herberts T, Reher C, Poets CF. Randomised crossover trial of four nasal respiratory support systems for apnoea of prematurity in very low birthweight infants. Arch Dis Child Fetal Neonatal Ed. 2009;94(4):F245-F248. doi:10.1136/adc.2008.148981



BACKGROUND

Apnoea of prematurity (AOP) is a common problem in preterm infants which can be treated with various modes of nasal continuous positive airway pressure (NCPAP) or nasal intermittent positive pressure ventilation (NIPPV). It is not known which mode of NCPAP or NIPPV is most effective for AOP.

OBJECTIVE

To assess the effect of four NCPAP/NIPPV systems on the rate of bradycardias and desaturation events in very low birthweight infants.

METHODS

Sixteen infants (mean gestational age at time of study 31 weeks, 10 males) with AOP were enrolled in a randomised controlled trial with a crossover design. The infants were allocated to receive nasal pressure support using four different modes for 6 h each: NIPPV via a conventional ventilator, NIPPV and NCPAP via a variable flow device, and NCPAP delivered via a constant flow underwater bubble system. The primary outcome was the cumulative event rate of bradycardias (< or =80 beats per minute) and desaturation events (< or =80% arterial oxygen saturation), which was obtained from cardio-respiratory recordings.

RESULTS

The median event rate was 6.7 per hour with the conventional ventilator in NIPPV mode, and 2.8 and 4.4 per hour with the variable flow device in NCPAP and NIPPV mode, respectively (p value<0.03 for both compared to NIPPV/conventional ventilator). There was no significant difference between the NIPPV/conventional ventilator and the underwater bubble system.

CONCLUSION

A variable flow NCPAP device may be more effective in treating AOP in preterm infants than a conventional ventilator in NIPPV mode. It remains unclear whether synchronised NIPPV would be even more effective.

Therapie idiopatischer Apnoen, Bradykardien und Hypoxämien

Christian F. Poets, Abt. für Neonatologie, Universitätsklinikum Tübingen; GNPI; Bettina Bohnhorst, Klinik für Pädiatr. Pneumologie, Allergologie u. Neonatologie, Medizinische Hochschule Hannover; GNPI; Gunter Kerst, Klinik für Kinderkardiologie, Universitätsklinikum RWTH Aachen; DGKJ; AWMF-Leitlinien-Register Nr. 024/013 Entwicklungsstufe S2k; 1997

Devices and pressure sources for administration of nasal continuous positive airway pressure (NCPAP) in preterm neonates.

De Paoli AG, Davis PG, Faber B, Morley CJ. Devices and pressure sources for administration of nasal continuous positive airway pressure (NCPAP) in preterm neonates. Cochrane Database Syst Rev. 2008;2008(1):CD002977. Published 2008 Jan 23. doi:10.1002/14651858.CD002977.pub2



BACKGROUND

Nasal continuous positive airway pressure (NCPAP) is used to support preterm infants recently extubated, those experiencing significant apnoea of prematurity and those with respiratory distress soon after birth as an alternative to intubation and ventilation. This review focuses exclusively on identifying the most effective pressure source and interface for NCPAP delivery in preterm infants.

OBJECTIVES

To determine which technique of pressure generation and which type of nasal interface for NCPAP delivery most effectively reduces the need for additional respiratory support in preterm infants extubated to NCPAP following intermittent positive pressure ventilation (IPPV) for respiratory distress syndrome (RDS) or in those treated with NCPAP soon after birth.

SEARCH STRATEGY

The strategy included searches of MEDLINE (1966 - 2006), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2006) CINAHL, abstracts from conference proceedings, cross-referencing of previous reviews and the use of expert informants.

SELECTION CRITERIA

Randomised or quasi-randomised trials comparing different techniques of NCPAP pressure generation and/or nasal interfaces in preterm infants extubated to NCPAP following IPPV for RDS or treated with NCPAP soon after birth.

DATA COLLECTION AND ANALYSIS

Data was extracted and analysed by the first three authors. Dichotomous results were analysed using the relative risk (RR), risk difference (RD) and number needed to treat (NNT).

MAIN RESULTS

1. Preterm infants being extubated to NCPAP following a period of IPPV for RDS:Meta-analysis of the results from Davis 2001 and Roukema 1999a demonstrated that short binasal prongs are more effective at preventing re-intubation than single nasal or nasopharyngeal prongs [typical RR 0.59 (CI: 0.41, 0.85), typical RD -0.21 (CI: -0.35, -0.07), NNT 5 (CI: 3, 14)]. In one study comparing short binasal prong devices (Sun 1999), the re-intubation rate was significantly lower with the Infant Flow Driver than with the Medicorp prong [RR 0.33 (CI: 0.17, 0.67), RD -0.32 (CI: -0.49, -0.15), NNT 3 (CI: 2, 7)]. The other study comparing short binasal prong devices (Infant Flow Driver versus INCA prongs, Stefanescu 2003) demonstrated no significant difference in the re-intubation rate but did show a significant reduction in the total days in hospital in the Infant Flow Driver group [MD -12.60 (95% CI: -22.81, -2.39) days].2. Preterm infants primarily treated with NCPAP soon after birth:In the one trial identified, Mazzella 2001 found a significantly lower oxygen requirement and respiratory rate in those randomised to short binasal prongs when compared with CPAP delivered via nasopharyngeal prong. The requirement for intubation beyond 48 hours from randomisation was not assessed.3. Studies randomising preterm infants to different NCPAP systems using broad inclusion criteriaThe studies of Rego 2002 and Buettiker 2004 did not examine the primary outcomes of this review. Of the secondary outcomes, Rego 2002 demonstrated a significantly higher incidence of nasal hyperaemia with the use of the Argyle prong compared with Hudson prongs [RR 2.39 (95% CI: 1.27, 4.50), RD 0.28 (95% CI: 0.10, 0.46)]. One study comparing different techniques of pressure generation is awaiting further assessment as it is currently available in abstract form only.

AUTHORS' CONCLUSIONS

Short binasal prong devices are more effective than single prongs in reducing the rate of re-intubation. Although the Infant Flow Driver appears more effective than Medicorp prongs the most effective short binasal prong device remains to be determined. The improvement in respiratory parameters with short binasal prongs suggests they are more effective than nasopharyngeal CPAP in the treatment of early RDS. Further studies incorporating longer-term outcomes are required. Studies are also needed to determine the optimal pressure source for the delivery of NCPAP.