Neonatal CPAP Therapy Overview

Neonatal CPAP Therapy

Continuous positive airway pressure (CPAP) therapy is a well-established mode of noninvasive respiratory support for spontaneously breathing patients.

Bubble CPAP System

Designed to provide consistent pressure through an auto-leveling feature. The system includes circuits, a pressure-relief manifold and a Bubble CPAP generator.

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FlexiTrunk™ nasal CPAP interface

An integrated solution that includes all the components for delivering CPAP: nasal masks, nasal prongs, bonnets, and headgear. Provides a complete system when combined with a Bubble CPAP generator.

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How does CPAP therapy work?

CPAP therapy delivers a mixture of heated, humidified air and oxygen and generates a continuous distending pressure throughout the respiratory cycle by means of a sealed interface.^1,2

Selecting an appropriately-sized interface is important for achieving an adequate seal. Short bi-nasal prongs or a nasal mask are the most commonly used types of interfaces for delivering CPAP.³ The efficacy of delivered therapy is not impacted by the choice of prongs or mask (when using a true CPAP system) and the two can be cycled in clinical practice to alleviate contact points.⁴

Bubble CPAP, a mode of CPAP therapy, may offer an additional benefit to patients in that it generates pressure oscillations which may improve gas exchange and carbon dioxide (CO₂) elimination.⁵ An underwater seal is created by submerging the expiratory tube in a variable depth of water. Gas exiting the expiratory tube produces bubbles that then generate pressure oscillations.¹ CPAP can be used in both the acute and recovery phases of respiratory distress syndrome (RDS).^6,7

There are several well-documented benefits and mechanisms of action associated with this therapy.

Maintains functional residual capacity (FRC)
Reduces the work of breathing
Promotes airway hydration
Decreases the need for invasive ventilation
Bubble CPAP generates pressure oscillations
CPAP can be used in neonates with RDS

Maintains functional residual capacity (FRC)

CPAP enhances lung volume recruitment and helps establish and maintain adequate FRC (the volume of air that remains in the lungs following a typical expiratory phase).^1,8,9 This volume is important for keeping the lungs open post exhalation.

CPAP has been shown to increase the volume of air remaining in the lungs after a typical expiratory phase, helping to keep the lungs open.^1,8

As early as the 1970s, CPAP was shown to restore FRC, improve hypoxemia, reduce pulmonary vascular resistance and conserve surfactant.^10,11

Fig 1. The impacts of CPAP on a neonatal lung under respiratory distress. Without positive airway pressure, FRC is decreased and resistance is high, resulting in alveolar collapse (pictured left). With the application of positive airway pressure (pictured right), FRC is maintained effectively and alveoli are held open.

Reduces the work of breathing

CPAP therapy can improve the work of breathing by reducing the energy required to expand the lungs for inspiration. ^8,12,13

Work of breathing is the force required to expand the lungs against their elastic properties. CPAP has been shown to elevate end-expiratory lung volume, which helps to unload the inspiratory muscles and reduce the work of breathing. ^8,12,13

Promotes airway hydration

During CPAP therapy, continuous distending pressure is generated throughout the respiratory cycle, and a heated and humidified mixture of air and oxygen is delivered.

Heated and humidified gas is an important aspect of delivering CPAP therapy, assisting with the natural defense mechanisms, maintaining airway mucosa and mucociliary function, and promoting conservation of energy for growth and development.^24,25

Decreases the need for invasive ventilation

The use of CPAP alone, or CPAP in combination with a surfactant when used for primary respiratory support, has been associated with a reduced need for intubation and invasive ventilation.^14,15

Invasive ventilation can be lifesaving, especially for preterm infants born less than 30 weeks’ gestation with respiratory distress syndrome (RDS). However, it may contribute to increased rates of chronic lung disease. The associated disadvantages of invasive ventilation have led to the development of more noninvasive ventilation strategies, including CPAP therapy.³ Research has shown that CPAP can be used as an alternative to routine intubation and invasive ventilation in neonates with RDS.^16,17

Bubble CPAP generates pressure oscillations

Pressure oscillations generated during bubble CPAP therapy produce vibrations that are similar to those produced by high-frequency ventilation, and may improve gas exchange and CO₂ elimination.⁵

Studies have demonstrated that these pressure oscillations may be transmitted down the airways and into the lungs.^5,18

Fig 4. Graphical representation of bubble CPAP generated pressure oscillations. The pressure vs. time plot shows how pressure oscillations vary over time (green line) alongside the resulting mean airway/nasopharyngeal (NP) pressure (blue line).

CPAP can be used in neonates with RDS

Randomized controlled trials and systematic reviews have evaluated the use of CPAP as primary and postextubation respiratory support for premature and low-birth-weight neonates with RDS, both in the acute and recovery phases of this condition.^3,6,7

In premature infants, RDS is the most common respiratory condition that CPAP has been used for since the 1970s.^19,20 Several studies, which include randomized controlled trials and systematic reviews, have evaluated the use of CPAP as a mode of respiratory support in preterm neonates and infants with RDS and have concluded that CPAP is an effective mode of respiratory support for these patients. ^3,14,21-23

CPAP: Neonates and Infants – Clinical Paper Summaries

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Gupta S and Donn SM. Seminars in Fetal and Neonatal Medicine - Continuous positive airway pressure: Physiology and comparison of devices. Semin. Fetal Neonatal Med. 21, 204–11 (2016). View abstract
Courtney SE and Barrington KJ. Continuous positive airway pressure and noninvasive ventilation. Clin. Perinatol. 34, 73–92, vi (2007). View abstract
Sweet DG et al. European consensus guidelines on the management of respiratory distress syndrome – 2019 update. Neonatology 115, 432–50 (2019). View abstract
Imbulana DI, Manley BJ, Dawson JA, Davis PG and Owen LS. Nasal injury in preterm infants receiving non-invasive respiratory support: a systematic review. Archives of Disease in Childhood. Fetal and neonatal edition 103, F29–F35 (2018). View abstract
Lee KS, Dunn MS, Fenwick M and Shennan AT. A comparison of underwater bubble continuous positive airway pressure with ventilator-derived continuous positive airway pressure in premature neonates ready for extubation. Biol. Neonate 73, 69–75 (1998). View abstract
Chan V and Greenough A. Randomized trial of methods of extubation in acute and chronic respiratory distress. Archives of Disease in Childhood. 68, 570–2 (1993). View abstract
Morley, S. L. Non-invasive ventilation in paediatric critical care. Paediatr. Respir. Rev. 20, 24–31 (2016). View abstract
Magnenant E et al. Dynamic behavior of respiratory system during nasal continuous positive airway pressure in spontaneously breathing premature newborn infants. Pediatr. Pulmonol. 37, 485–91 (2004). View abstract
Bhutani VK. Development of the Respiratory System. In: Manual of Neonatal Respiratory Care 3–15 (Springer US, 2012). doi:10.1007/978-1-4614-2155-9_1. View abstract
Saunders RA, Milner AD and Hopkin IE. The effects of continuous positive airway pressure on lung mechanics and lung volumes in the neonate. Biol. Neonate 29, 178–86 (1976). View abstract
Milner AD, Saunders RA and Hopkin IE. Effects of continuous distending pressure on lung volumes and lung mechanics in the immediate neonatal period. Biol. Neonate 31, 111–15 (1977). View abstract
Diblasi RM. Nasal continuous positive airway pressure (CPAP) for the respiratory care of the newborn infant. Respir. Care 54, 1209–35 (2009). View abstract
Higgins RD, Richter SE and Davis JM. Nasal continuous positive airway pressure facilitates extubation of very low-birth-weight neonates. Pediatrics 88, 999–1003 (1991). View abstract
Finer NN et al. Early CPAP versus surfactant in extremely preterm infants. N. Engl. J. Med. 362, 1970–79 (2010). View abstract
Tooley J and Dyke M. Randomized study of nasal continuous positive airway pressure in the preterm infant with respiratory distress syndrome. Acta Paediatr. 92, 1170–74 (2003). View abstract
De Paoli AG. Nasal CPAP for neonates: what do we know in 2003? Archives of Disease in Childhood. – Fetal Neonatal Ed. 88, 168F–172F (2003). View abstract
Morley C and Davis P. Continuous positive airway pressure: current controversies. Curr. Opin. Pediatr. 16, 141–45 (2004). View abstract
Hough JL et al. Effect of body position on ventilation distribution in preterm infants on continuous positive airway pressure. Pediatr. Crit. Care Med. 13, 446–51 (2012). View abstract
Avery ME et al. Is chronic lung disease in low-birth-weight infants preventable? A survey of eight centers. Pediatrics 79, 26–30 (1987). View abstract
Gregory GA, Kitterman JA, Phibbs RH, Tooley WH and Hamilton WK. Treatment of the idiopathic respiratory-distress syndrome with continuous positive airway pressure. N. Engl. J. Med. 284, 1333–40 (1971). View abstract
Morley CJ et al. Nasal CPAP or intubation at birth for very preterm infants. N. Engl. J. Med. 358, 700–8 (2008). View abstract
Thukral A, Sankar MJ, Chandrasekaran A, Agarwal R and Paul VK. Efficacy and safety of CPAP in low- and middle-income countries. J. Perinatol. 36 Suppl. 1, S21–8 (2016). View abstract
De Paoli AG, Davis PG, Faber B and Morley CJ. Devices and pressure sources for administration of nasal continuous positive airway pressure (NCPAP) in preterm neonates. Cochrane Database Syst. Rev. CD002977 (2008). View abstract
Pollett HF and Reid WD. Prevention of obstruction of nasopharyngeal CPAP tubes by adequate humidification of inspired gases. Can. Anaesth. Soc. J. 1977 Sep;24(5):615–17 (1977). View abstract
de Klerk A. In: Physiology of Humidification in Critically Ill Neonates. Springer Berlin Heidelberg (2012). View abstract

View references

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