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A History of CPAP for Infants

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

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  1. A History of CPAP for Infants Alan H. Jobe, MD, PhDCincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio

  2. 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

  3. 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

  4. 8 Patients with “Severe Acute Respiratory Failure” Ventilated using a PEEP of 13 cmH2O Kunar, et al., NEJM, 1970 VIENNA-09

  5. Responses of Switching 8 Patients from PEEP=13 cmH2O to No PEEP Kunar, et al., NEJM, 1970 VIENNA-09

  6. 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

  7. 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)

  8. Pediatr, 1968 VIENNA-09

  9. 5 Infants tested for change in Oxygenation with Intubation - on 90-95% Oxygen Harrison, et al., Pediatr, 1968

  10. Nasal Piece and Fleish Tube used for PFT Measurements Fig. 1. Fleisch 00 Pnumotachograph, T-junction, and nasal piece. Harrison, et al., Pediatr, 1968

  11. Abstract for SPR/APS Meeting 1970 VIENNA-09

  12. VIENNA-09

  13. 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

  14. CPAP Device for use with Endotracheal Tube Gregory, et al., NEJM, 1971 VIENNA-09

  15. CPAP Device for use with Endotracheal Tube Gregory, et al., NEJM, 1971 VIENNA-09

  16. Head Box for CPAP without Endotracheal Tube VIENNA-09 Gregory, et al., NEJM, 1971

  17. CPAP Provided by G. Gregory

  18. • 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

  19. Effects of CPAP on Lung Volume CPAP (mmHg) 0 6 FRC (ml) Provided by A. Wilkinson CPAP (mmHg)

  20. 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)

  21. 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)

  22. A Bag and Y-Connector for CPAP VIENNA-09 Barrie, The Lancet, 1973

  23. Caliumi-Pellegrini, et al., Arch Dis Child, 1974 VIENNA-09

  24. Schematic representation of the system used for applying continuous positive airway pressure (adapted from Gregory, et al.) VIENNA-09 Cumarasamy, et al., Pediatrics, 1973

  25. Artificial Ventilation in HMD: the use of PEEP and CPAP Cumarasamy, Nussli, Vischer, Dangel & Duc, Pediatrics, 1973 VIENNA-09

  26. Effect of CPAP (PEEP) on Intubated and Ventilated Infants with RDS deLemos, McLaughlin, Robison, Schulz, Kirby, Anesthesia & Analgesia, 1973 VIENNA-09

  27. Nasal Prongs for CPAP Kattwinkel, Fleming, Cha, and Fanaroff, Pediatrics, 1973

  28. Nasal CPAP (2-5 cmH2O) for Infants with Apnea. BW average = 1kg, age of study – 14 days Kattwinkel, et al., J. Pediatr, 1975

  29. Follow-up Measurements to Evaluate Mechanical Ventilation, Oxygen, and CPAP for Lung Damage Stocks and Godfrey, Pediatrics, 1976

  30. Airway Conductance Measured at Term and at 4-11 Months Post-Delivery CPAP Stocks & Godfrey, Pediatrics, 1976

  31. Meta-Analysis of CPAP vs. No CPAP for Infants with RDS Bancalari & Sinclair, in Effective Care of the Newborn Infant: Sinclair and Bracken, 1992

  32. 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

  33. CPAP was used frequently for - Apnea of prematurity Post extubation after mechanical ventilation RDS in some locations (Columbia, Univ. Scandinavia)

  34. Effect of a change in delivery room management for infants <1000g - allowing spontaneous breathing with FRC recruitment and CPAP

  35. The Danish Approach to the Initiation of Ventilation and Surfactant

  36. The Coin Trial

  37. The Coin Trial - 36 Week Outcome

  38. 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

  39. 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

  40. My thanks to George Gregory for his help with this brief history of CPAP

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