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A History of CPAP for Infants. Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio . Neonatal Bioethics: The Moral Challenges of medical Intervention. Lantos and Meadow, Neonatal Bioethics, 2006. The era of innovation and individualism 1965-1982

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a history of cpap for infants

A History of CPAP for Infants

Alan H. Jobe, MD, PhDCincinnati Children’s Hospital

University of Cincinnati

Cincinnati, Ohio

neonatal bioethics the moral challenges of medical intervention
Neonatal Bioethics: The Moral Challenges of medical Intervention

Lantos and Meadow, Neonatal Bioethics, 2006

  • The era of innovation and individualism 1965-1982
    • Mechanical Ventilation
    • CPAP
    • Total Parental Nutrition
    • Regionalization
  • Era of exposed ignorance – 1982-1992
  • The End of Medical Progress – after 1992
slide3
First Reference to CPAP in Pub Med:Revival of an Old Battle: Intermittent vs. Continuous Positive-Pressure Breathing

VIENNA-09

  • Continuous Pressure Breathing – effective in WWII for high altitude pilots, but increases work of breathing and decreases cardiac output.
  • Advantages of CPB over IPB
    • Improved oxygenation at lower FiO2
  • Disadvantages of CPP over IPB
    • Need to measure CO
    • “Indicated only in cases where alveolar pressure is not transmitted to the intra plural spaces”
    • Alveolar rupture and Pneumothorax

Editorial in NEJM – December, 1970, Claude Lenfant

slide4

8 Patients with “Severe Acute Respiratory Failure” Ventilated using a PEEP of 13 cmH2O

Kunar, et al., NEJM, 1970

VIENNA-09

slide5

Responses of Switching 8 Patients from PEEP=13 cmH2O to No PEEP

Kunar, et al., NEJM, 1970

VIENNA-09

status of hyaline membrane disease late 1960 s
Status of Hyaline Membrane Disease – Late 1960’s

VIENNA-09

HMD was leading cause of death for preterms (27%-43% survival with assisted ventilation worldwide) 1968-1971

Ventilation resulted in Bronchopulmonary Dysplasia (oxygen toxicity) – Northway (1967)

* No antenatal testing for lung maturation – (Gluck, 1971)

* No antenatal corticosteroids (Liggins – 1972)

* No surfactant treatments (Fujuwara – 1980)

* No effective therapy other than supplemental oxygen

information about hmd in late 1960 s
Information about HMD in Late 1960’s

VIENNA-09

Atelectasis in HMD interfered with oxygenation

Normal lungs contained surfactant (Clements – 1957)

HMD lungs were surfactant deficient (Avery and Mead – 1959)

Intubation of HMD infants abolished grunting and decreased oxygenation (Harrison, et al., 1968)

Ventilation with a long Ti increased oxygenation (Smith, et al., 1969)

slide8

Pediatr, 1968

VIENNA-09

5 infants tested for change in oxygenation with intubation on 90 95 oxygen
5 Infants tested for change in Oxygenation with Intubation - on 90-95% Oxygen

Harrison, et al., Pediatr, 1968

slide10

Nasal Piece and Fleish Tube used for PFT Measurements

Fig. 1. Fleisch 00 Pnumotachograph, T-junction, and nasal piece.

Harrison, et al., Pediatr, 1968

slide13

20 Infants Treated with CPAP over 16 Months

51 Infants with IRDS

UA lines, O2 for Pao2 of 50-70 mmHg

20 - Required 100% or had Apnea

5 - Apnic at Birth

1 - Ventilated from Birth

25 - Increased O2 Only

All Survived

Bag & Mask Ventilation

Ventilated

1 Survived

CPAP

All Died

16 Survived

Data from Gregory NEJM, 1971

VIENNA-09

slide14

CPAP Device for use with Endotracheal Tube

Gregory, et al., NEJM, 1971

VIENNA-09

slide15

CPAP Device for use with Endotracheal Tube

Gregory, et al., NEJM, 1971

VIENNA-09

slide16

Head Box for CPAP without Endotracheal Tube

VIENNA-09

Gregory, et al., NEJM, 1971

slide17
CPAP

Provided by G. Gregory

slide18

• 20 infants, BW 930 to 3,830g• Severe HMD (PaO2 <50 mmHg in 70-100% O2 or apneic)• Range of highest CPAP: 6-12 mmHg• PES by only 20% of applied CPAP• Duration of CPAP: 2-29 d• 16 of 20 survived• No CLD (chronic lung disease)

Results:

Provided by A. Wilkinson

slide19

Effects of CPAP on Lung Volume

CPAP (mmHg)

0 6

FRC

(ml)

Provided by A. Wilkinson

CPAP (mmHg)

from gregory et al nejm 1971
From Gregory, et al., NEJM - 1971

VIENNA-09

  • “We did not consider an elevation in Paco2 to be an indicator for mechanical ventilation as long as pH was greater than 7.20.”
  • Footnote for physiologic data –
    • Order NAPS document 01448 from National Auxiliary Publications Service – (the physiologic data has been lost)
cpap worked and rapid innovation occurred
CPAP Worked – and Rapid Innovation Occurred

VIENNA-09

  • Continuous negative Pressure (Chernick and Vidyasargar – 1972)
    • Fanaroff, et al. (1973)
  • Pressurized bag over head (Barrie, 1973)
  • Mask that covers the mouth and nose (Harris, 1972)
  • Nasal CPAP (Kattwinkel, et al., 1973)
  • Ventilation + CPAP = PEEP (Cumarassamy, et al., 1973)
slide22

A Bag and Y-Connector for CPAP

VIENNA-09

Barrie, The Lancet, 1973

slide24

Schematic representation of the system used for applying continuous positive airway pressure (adapted from Gregory, et al.)

VIENNA-09

Cumarasamy, et al., Pediatrics, 1973

artificial ventilation in hmd the use of peep and cpap
Artificial Ventilation in HMD: the use of PEEP and CPAP

Cumarasamy, Nussli, Vischer, Dangel & Duc, Pediatrics, 1973

VIENNA-09

slide26

Effect of CPAP (PEEP) on Intubated and Ventilated Infants with RDS

deLemos, McLaughlin, Robison, Schulz, Kirby, Anesthesia & Analgesia, 1973

VIENNA-09

slide27

Nasal Prongs for CPAP

Kattwinkel, Fleming, Cha, and Fanaroff, Pediatrics, 1973

slide28

Nasal CPAP (2-5 cmH2O) for Infants with Apnea.

BW average = 1kg, age of study – 14 days

Kattwinkel, et al., J. Pediatr, 1975

follow up measurements to evaluate mechanical ventilation oxygen and cpap for lung damage
Follow-up Measurements to Evaluate Mechanical Ventilation, Oxygen, and CPAP for Lung Damage

Stocks and Godfrey, Pediatrics, 1976

slide30

Airway Conductance Measured at Term and at 4-11 Months Post-Delivery

CPAP

Stocks & Godfrey, Pediatrics, 1976

meta analysis of cpap vs no cpap for infants with rds
Meta-Analysis of CPAP vs. No CPAP for Infants with RDS

Bancalari & Sinclair, in Effective Care of the Newborn Infant: Sinclair and Bracken, 1992

1980 s through early 2000
1980’s through early 2000

Ventilation replaced CPAP as primary therapy for RDS

Antenatal steroids and surfactant decreased severity of RDS

BPD was frequent in VLBW infants

cpap was used frequently for
CPAP was used frequently for -

Apnea of prematurity

Post extubation after mechanical ventilation

RDS in some locations (Columbia, Univ. Scandinavia)

slide35
Effect of a change in delivery room management for infants <1000g - allowing spontaneous breathing with FRC recruitment and CPAP
neonatal bioethics the moral challenges of medical intervention1
Neonatal Bioethics: The Moral Challenges of medical Intervention

Lantos and Meadow, Neonatal Bioethics, 2006

  • The era of innovation and individualism 1965-1982
    • Mechanical Ventilation
    • CPAP
    • Total Parental Nutrition
    • Regionalization
  • Era of exposed ignorance – 1982-1992
  • The End of Medical Progress
cpap in 2009 a new enthusiasm
CPAP in 2009 – A New Enthusiasm
  • Again frequently used as an initial therapy for RDS ± surfactant
  • Early (delivery room) use popular and under study
  • New types of CPAP
    • Nasal CPAP + Ventilatory assist (synchronized, NAVA)
    • Multiple CPAP devices (NeopuF)
    • High flow nasal cannula
    • Variable pressure CPAP