Upload
marcia-thornton
View
217
Download
0
Tags:
Embed Size (px)
Citation preview
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
• 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
Lantos and Meadow, Neonatal Bioethics, 2006
First Reference to CPAP in Pub Med:
Revival of an Old Battle: Intermittent vs. Continuous Positive-Pressure Breathing• 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
VIENNA-09
VIENNA-09
8 Patients with “Severe Acute Respiratory Failure” Ventilated using a PEEP of 13 cmH2O
Kunar, et al., NEJM, 1970
VIENNA-09
Responses of Switching 8 Patients from PEEP=13 cmH2O to No PEEP
Kunar, et al., NEJM, 1970
Status of Hyaline Membrane Disease – Late 1960’s
• 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
VIENNA-09
Information about HMD in Late 1960’s
• 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)
VIENNA-09
VIENNA-09
Pediatr, 1968
5 Infants tested for change in Oxygenation with Intubation - on 90-95% Oxygen
PaO2 Values
Before Intubated Intubated Extubated91 ± 91 61 ± 58* 93 ± 92
*1.8±0.4 kg; Pco2=51±7 p<0.001
Harrison, et al., Pediatr, 1968
Fig. 1. Fleisch 00 Pnumotachograph, T-junction, and nasal piece.
Nasal Piece and Fleish Tube used for PFT Measurements
Harrison, et al., Pediatr, 1968
VIENNA-09
Abstract for SPR/APS Meeting 1970
VIENNA-09
VIENNA-09
25 - Increased O2 Only
51 Infants with IRDS
All Survived
20 - Required 100% or had Apnea
Bag & Mask Ventilation
CPAP
16 Survived
5 - Apnic at Birth
Ventilated
1 - Ventilated from Birth
1 Survived
All Died
20 Infants Treated with CPAP over 16 Months
UA lines, O2 for Pao2 of 50-70 mmHg
Data from Gregory NEJM, 1971
VIENNA-09
CPAP Device for use with Endotracheal Tube
Gregory, et al., NEJM, 1971
VIENNA-09
CPAP Device for use with Endotracheal Tube
Gregory, et al., NEJM, 1971
VIENNA-09
Head Box for CPAP without Endotracheal Tube
Gregory, et al., NEJM, 1971
Provided by G. Gregory
Results:
Provided by A. Wilkinson
CPAP (mmHg)
0 6
CPAP (mmHg)
FRC (ml)
Provided by A. Wilkinson
From Gregory, et al., NEJM - 1971
• “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)
VIENNA-09
CPAP Worked – and Rapid Innovation Occurred
• 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)VIENNA-09
VIENNA-09
A Bag and Y-Connector for CPAP
Barrie, The Lancet, 1973
VIENNA-09
Caliumi-Pellegrini, et al., Arch Dis Child, 1974
VIENNA-09
Schematic representation of the system used for applying continuous positive airway pressure (adapted from Gregory, et al.)
Cumarasamy, et al., Pediatrics, 1973
Artificial Ventilation in HMD: the use of PEEP and CPAP
Treatment Outcomes with PEEP + CPAP by Year
Years 1969 1970 1971Number of Patients% Ventilated% Survival Overall
3636%
53%
3858%
44%
4678%
74%
Ventilated 23% 23% 70%
Cumarasamy, Nussli, Vischer, Dangel & Duc, Pediatrics, 1973
VIENNA-09
VIENNA-09
Effect of CPAP (PEEP) on Intubated and Ventilated Infants with RDS
deLemos, McLaughlin, Robison, Schulz, Kirby, Anesthesia & Analgesia, 1973
Nasal Prongs for CPAP
Kattwinkel, Fleming, Cha, and Fanaroff, Pediatrics, 1973
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
Ventilated CPAPNumberBirth Weight (kg)Gestational Age (weeks)Duration of Supplemental O2 > 60% (hr)Duration of IPPV (hr)Duration of CPAP (hr)
111.6±0.2
31.7±0.638±1056±10
-
82.2±0.2
34.1±1.111±3
-48±9
Stocks and Godfrey, Pediatrics, 1976
CPAP
Airway Conductance Measured at Term and at 4-11 Months Post-Delivery
Stocks & Godfrey, Pediatrics, 1976
Meta-Analysis of CPAP vs. No CPAP for Infants with RDS
Outcome N-Studies
N-Patients
Risk Ratio
95% CI
Require Mech VentAir LeaksBPDDeath
4424
145165100165
0.662.620.870.66
0.50-0.861.28-5.360.33-2.310.45-0.97
Bancalari & Sinclair, in Effective Care of the Newborn Infant: Sinclair and Bracken, 1992
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 -
• Apnea of prematurity
• Post extubation after mechanical ventilation
• RDS in some locations (Columbia, Univ. Scandinavia)
CPAP-VENT
CPAP-VENT
Effect of a change in delivery room management for infants <1000g - allowing spontaneous breathing with FRC recruitment and CPAP
1994 1996(N)Intubation & Vent in DRNever intubatedPco2 on NICU admitBPDIVH G III & IVDeath
(56)84%7%
3811 mmHg32%24%27%
(67)40%*25%*
5415 mmHg*12%*12%22%
Lindner et al., Pediatr. 103:961, 1999
IMHRPI
CPAP-VENT
The Danish Approach to the Initiation of Ventilation and Surfactant
Description of Population of Infants <30Weeks GA
NumberGABWAntenatal SteroidsInitially given CPAPNo or Mild RDSGiven SurfactantVentilated by 7d
39727.2±1.61033±274
80%94%54%30%42%
Verder, et al., Pediatr. 103:e24, 1999
Nutri
The Coin Trial
Ventilation CPAP P
N
BW
% Intubated by 5d
% Surfactant by 5d
303
952
100%
77%
307
964
46%
38%
*
*
Morley, et al., NEJM, 2008
Ventilation CPAP P
Pneumothorax
Median Vent days
Death
BPD - 28d
BPD - 36wk
O2 Concentration at
36wk >30%
3%
4
5.9%
63%
31%
8.8%
9%
3
6.5%
51%
29%
9.4%
<0.01
<0.01
NS
0.01
NS
NS
Morley, et al., NEJM, 2008
• 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
Neonatal Bioethics: The Moral Challenges of medical Intervention
Lantos and Meadow, Neonatal Bioethics, 2006
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
My thanks to George Gregory for his help with this brief history of CPAP