Bedside Management Strategies for infants on bubble CPAP

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Managing infants on bubble continuous positive airway pressure (Bubble CPAP) is like learning how to bike. The beginning is always difficult, it needs a lot of training and it requires careful attention to the details. However, it is healthy for the driver, less costly and better for the environment. Same for bCPAP. Starting a bCPAP program is not easy, but it is feasible and achievable. It needs extensive training for all staff members; physicians, nurse practitioners, bedside nurses, respiratory therapists, and feeding specialists, and it always demands careful attention to details. However, it yields better outcomes; is less costly in terms of comorbidities; and eventually reduces health costs.

In this chapter we will discuss management strategies, including:

When to manage infants with bCPAP:

  • When you should, you may, or you may not use bCPAP

How to manage infants on bCPAP?

If the infant is stable on bCPAP:

  • How to “cruise” the infant on a day-by-day trip on bCPAP
  • How to start and advance feeding while on bCPAP
  • How to manage abdominal distention on bCPAP
  • If the infant has a murmur and you suspect a patent ductus arteriosus (PDA), how to manage a PDA while on bCPAP
  • How to “wean” the infant off bCPAP What is Bubble Cpap

IF bCPAP is not providing the sick infant with enough respiratory support:

When and how to “escalate” the intervention:

  • How to “maximize” bCPAP
  • Using inhaled Nitric Oxide (iNO) with bCPAP
  • When to consider NIPPV? And how to do it
  • When to intubate the infant and use invasive mechanical ventilation

Case (0): A Common encounter

Late preterm infant with respiratory distress

You are called to assess this male infant with respiratory distress and desaturations at one hour of life. Infant is a baby boy 34 5/7 weeks gestational age (GA) with a negative perinatal history. He presented at birth with respiratory distress and was given two rounds of face mask CPAP in the delivery room. He improved and was transferred to the newborn nursery for observation.

Currently, the infant is in moderate distress with a respiratory rate (RR) in the mid-70s and oxygen saturation (SpO2) that is fluctuating between 87-92%.

This is a relatively common encounter. The number of full- and near- term infants who present with respiratory distress and require respiratory support is more than the number of very low birth weight (VLBW) infants managed with bCPAP. However, preterm infants require longer duration of bCPAP.

The most common diagnosis for full- or near- term infants presenting with respiratory distress is delayed transitioning (transient tachypnea of newborn or TTN) vs. presumed sepsis. Although straightforward, the challenge in managing these infants is in the potential for underestimating the condition.

In centers where bCPAP is not the primary mode of respiratory support, such infants may be managed with nasal cannula (NC), high flow NC, Oxy-hood or other similar interventions. In doing so, the supplemental oxygen given will feed into patent (non-collapsed) alveoli but may not reach collapsed or fluid filled ones. In such case, oxygen will mask hypoxemia and may give false sense of improvement to the managing clinician. These infants usually end up by treating themselves through continuous grunting (generating a peak end expiratory pressure) and distending their own collapsed alveoli.

However, oxygen flow without pressure to distend and recruit collapsed alveoli will not fix the ventilation/perfusion (V/Q) mismatch. If no improvement over the first few hours and no spontaneous lung recruitment takes place, continued hypoxia may lead to reactive pulmonary vascular constriction and consequently persistent pulmonary hypertension (PPHN) and potentially end on extracorporeal membrane oxygenation (ECMO).

Bubble CPAP for infants with respiratory distress

  • Early use of bCPAP in full- or near- term infants with mild – moderate respiratory distress
  • Proper recruitment of collapsed alveoli
  • Improved ventilation/perfusion (V/Q) mismatch
  • Improved oxygenation
  • Early wean of bCPAP to RA
  • Shorter length of stay/ avoid progression to PPHN

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