NNF Clinical Practice

Guidelines
Use
of
Con
tinu
ous
Pos
itiv
e
Air
way
Pre
ssu
re
in
the
Ne
wb
orn
Summary of
Recommendations
1 C
P
A
P

s
h
o
u
l
d

b
e used at
the
earliest
sign of
respirator
y distress
in preterm
infants at
risk for
RDS,
unless
there is a
contraindi
cation to
its use.
CPAP is
also
usef
ul
for
apne
a of
pre
mat
urit
y
and
post
-
extu
bati
on
resp
irato
ry
supp
ort.
1 Prophylacti
c CPAP in
asymptoma
tic babies is
not
recommend
ed.
2 Surfacta
nt
a
d
m
i
n
i
s
t
r
a
t
i
o
n

c
a
n

b
e

d
o
n
e

e
f
f
e
c
t
i

e
l
y

b
y

!
"
S
#R$
techni%u
e in
babies
re%uirin
g CPAP.
3 &ptimal
pressures
re%uired
to recruit
the lung
should be
used.
'hese ary
in the
range of (
to ) cm
*+&.
4 A
proportion
of babies,
especially
extremely
lo, birth
,eight,
those ,ith
more
seere
disease and
haing no
exposure to
antenatal
steroids
may fail on
CPAP.
Alternatie
arrangeme
nts of
mechanical
entilation
should be
made
aailable
for such
babies.
1 Short bi-
nasal
p
r
o
n
g
s

a
r
e

t
h
e

b
e
s
t

a
m
o
n
g
s
t

t
h
e

c
u
r
r
e
n
t
l
y

a

ailable
patient
interfaces.
1 'here are
no clear
cut
demonstra
ble clinical
adantage
s among
arious
types of
CPAP
systems- a
particular
type may
perform
better in a
particular
setting.
.riting /roup :
Chairperson: Ashok
K Deorari ;
Members: M Jeeva
Sankar, Sai Sunil
Kishore; Reviewers:
P K Rajiv, Shiv Sajan
Saini
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.nnfp
ublic
ation
.org
NNF Clinical Practice Guidelines
!ntroduction
Continuous positive airway pressure (CPAP, a si!ple, low"#ost, an$ non"invasive !etho$ o% ventilatin&
a si#k new'orn, #oul$ well 'e a 'oon %or 'a'ies 'orn in resour#e restri#te$ #ountries( )% use$ early an$
ju$i#iously in in%ants with respiratory $istress, CPAP #an save !any lives an$ re$u#e upwar$ re%errals(
*
Su##ess o% CPAP therapy lies in #reation o% a syste! with a tea! o% #o!!itte$ health provi$ers well
verse$ in provi$in& holisti# #are to si#k new'orn(
+his &ui$eline reviews the evi$en#e an$ o%%ers re#o!!en$ations relate$ to CPAP therapy in neonates %or
the %ollowin& issues:
9. Clinical indications for CPAP
1. Respiratory distress syndrome (RDS)
1. ,vi$en#e %or use
2. +i!in& o% initiation - early vs( late, prophyla#ti# vs( $elivery roo! CPAP
3. .pti!al pressure to 'e use$
4. Role o% )/S0R,
5. 1eanin& o% CPAP
6. 2ailure o% CPAP
2. Apnea of prematurity
3. Post-extubation setting
35. $%uipment related
1. Pressure generators
2. Patient interfaes
A. Respiratory distress syndrome
i. $idence for use
$idence0 Ran$o!i3e$ trials evaluatin& use o% CPAP were #on$u#te$ !ostly in the *4567s on
!ore !ature neonates usin& a wi$e variety o% $evi#es( Moreover, they were #on$u#te$ 'e%ore
wi$esprea$ use o% antenatal #orti#osteroi$s an$ sur%a#tant( +he Co#hrane review (8669 that
in#lu$e$ si: trials #on#lu$e$ that use o% CPAP is asso#iate$ with a lower rate o% %aile$ treat!ent
($eath or use o% assiste$ ventilation ;relative risk (RR: 6(<=, 4=> C): 6(=8, 6(9*; nu!'er nee$e$
to treat (//+: =, 4=> C) ?, *6@, overall !ortality ;RR: 6(=8, 4=> C): 6(A8, 6(95; //+: 5, 4=>
C): ?, 8=@( +he use o% CDP is, however, asso#iate$ with an in#rease$ rate o% pneu!othora: ;RR:
8(<?, 4=> C): *(A4, =(6?; nu!'er nee$e$ to har! (//B: *5, 4=> C): *5, 8=@
*
( A re#ent trial in
in%ants 'orn at &estation o% CA6 weeks in level two neonatal units with respiratory $istress showe$
that CPAP resulte$ in a re$u#tion in the nee$ %or trans%er to a hi&her level o% #are 'ut there was
a&ain a tren$ towar$s an in#rease$ risk o% pneu!othora: in the CPAP &roup(
*
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Recommendation! )n preter! in%ants with RDS, appli#ation o% CPAP is asso#iate$ with re$u#e$
respiratory %ailure an$ re$u#e$ !ortality( CPAP shoul$ there%ore 'e use$ in all preter! in%ants
with RDS, unless there is a #ontrain$i#ation to its use(
2. Timing of initiation for respiratory distress in a preterm infant
$arly ersus late CPAP
$idence0 0se o% CPAP in the #ourse o% respiratory $istress syn$ro!e (RDS re$u#es the lun&
$a!a&e, parti#ularly i% applie$ early 'e%ore atele#tasis o##urs( ,arly CPAP #onserves the
neonate7s own sur%a#tant stores an$ !ini!i3es the sti!ulation o% in%la!!atory #as#a$e( +he
Co#hrane review that #o!pare$ early CPAP (initiate$ at ran$o!i3ation an$ $elaye$ initiation o%
CPAP (initiate$ at 2i.8 o% appro:i!ately 6(< #on#lu$e$ that early a$!inistration o% CPAP
re$u#es the su'seDuent use o% inter!ittent !an$atory ventilation ()ME ;typi#al RR 6(==, 4=>
C): 6(A8"6(4<; //+: <@
8
( 1ith early intro$u#tion o% CPAP, there is a si&ni%i#ant re$u#tion in the
$uration o% ventilator assistan#e (!ean $i%%eren#e AA(5 hours an$ nee$ %or !e#hani#al ventilation
(86(<>
A
( )n a re#ently pu'lishe$ trial, early CPAP with use o% sele#tive sur%a#tant was as
e%%e#tive as usin& prophyla#ti# sur%a#tant %ollowe$ 'y CPAP in re$u#in& the nee$ %or !e#hani#al
ventilation in in%ants 'orn at 8= to 89 weeks7 &estation
?
( Another re#ent trial that enrolle$ in%ants
'orn 'etween 8? an$ 85 weeks7 &estation $i$ not %in$ any $i%%eren#e in the rate o% FPD 'etween
the &roup initiate$ on CPAP in the $elivery roo! an$ the &roup that re#eive$ sur%a#tant an$
!e#hani#al ventilation within * hour o% 'irth
=
(
Recommendation: CPAP shoul$ 'e use$ early in the #ourse o% RDS, to re$u#e the nee$ %or
!e#hani#al ventilation unless there is a #ontrain$i#ation to use CPAP(
*o, early should CPAP be initiated- prophylactic 1or2 in deliery room 1or2 in
"!C#3
$idence0 A Co#hrane !eta"analysis evaluatin& the e%%i#a#y o% prophyla#ti# CPAP $i$ not show
any si&ni%i#ant 'ene%it in the rates o% $eath, FPD, su'seDuent en$otra#heal intu'ation or
intraventri#ular he!orrha&e ()EB
<
( Current availa'le evi$en#e $oes not support the use o%
prophyla#ti# CPAP(
Most o% the stu$ies in#lu$e$ in the !eta"analysis 'y Bo et al initiate$ CPAP i% the 2i.
8
reDuire!ent was G6(A in the Hearly CPAP &roup(
8
2iner et al $o#u!ente$ the %easi'ility o%
$elivery roo! CPAP even in ,IF1 in%ants(
5
)n the re#ently pu'lishe$ C.)/ trial, early CPAP
was use$ %ro! = !inutes o% li%e in neonates 'etween 8= an$ 89 weeks. )n the CPAP &roup the
in#i$en#e o% $eathJFPD is si&ni%i#antly less an$ sur%a#tant use was halve$ in #o!parison to the
ventilate$ &roup o% neonates( +he CPAP &roup re#eive$ si&ni%i#antly %ewer $ays o% intu'ation an$
ventilation thou&h the in#i$en#e o% pneu!othora: was !ore in the CPAP &roup as #o!pare$ to
the ventilate$ &roup (4> vs( A> respe#tively(
9
Recommendation: CPAP is not to 'e use$ prophyla#ti#ally (i(e( 'e%ore any si&n o% respiratory
$istress $evelops; it shoul$, however, 'e initiate$ at the earliest si&n o% respiratory $istress in
neonates at risk %or RDS( .ne o% the ar'itrary #riteria #oul$ 'e 2i.
8
reDuire!ent o% G 6(A( So!e
units also use respiratory $istress s#ores - either Downe7s or Silve!an s#ore - %or initiation o%
CPAP (usually a s#ore o% CA is use$ as the #ut"o%%( CPAP #an 'e initiate$ even in the $elivery
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roo! i% $elay in shi%tin& to /)C0 is anti#ipate$ rather than withhol$in& any %or! o% respiratory
support(
3. &ptimal pressure to be used
$idence0 +he pressure reDuire$ in an in%ant is 'est $eter!ine$ 'y the severity o% the $isease
(#hest retra#tions, 2i.8 reDuire!ent an$ lun& e:pansion (#lini#alJra$iolo&i#al: a 'a'y with
severe RDS - relatively sti%% lun&s, a hi&h 2i.8, an$ a #hest K"ray showin& opaDue lun&s -
woul$ nee$ a hi&her pressure than another 'a'y with relatively !il$ $isease(
1hile an initial pressure o% = #! B
8
. is use$ in !ost neonatal units, so!e units #ontinue to use
hi&her levels " o%ten startin& at 9 #! B
8
. an$ &oin& up to *6 #! B
8
.(
4
A stu$y o% in%ants with
!il$ RDS showe$ that the hi&hest en$ e:piratory lun& volu!e an$ ti$al volu!e, an$ the lowest
respiratory rate an$ thora#oa'$o!inal asyn#hrony were a#hieve$ with a pressure o% 9 #! B
8
. as
#o!pare$ to pressures o% 6,8,?, an$ < #! B
8
.(
*6
0n%ortunately, there is not !u#h evi$en#e in this
re&ar$ an$ the opti!al CPAP pressure to 'e use$ is yet to 'e as#ertaine$(
Recommendation: A pressure o% = #! B
8
. is a &oo$ startin& point( +he pressure #an 'e
in#rease$ in in#re!ents o% * #! B
8
. - upto a !a:i!u! o% 9 #! B
8
. - i% the in%ant shows
evi$en#e o% severe lun& $isease(
4. Role of surfactant ,ith CPAP
)/S0R, te#hniDue re%ers to )/ ()ntu'ation S0R(Sur%a#tant , (,:tu'ation( +his
#o!prises o% intu'ation only %or the a$!inistration o% e:o&enous sur%a#tant, %ollowe$ 'y
i!!e$iate e:tu'ation to CPAP(
$idence0 Co#hrane !eta"analysis #o!parin& early sur%a#tant a$!inistration with 'rie%
ventilation vs( sele#tive sur%a#tant an$ #ontinue$ !e#hani#al ventilation showe$ lower in#i$en#e
o% !e#hani#al ventilation (typi#al RR 6(<5, 4=> C): 6(=5"6(54, air leak syn$ro!es (typi#al RR
6(=8, 4=> C): 6(89"6(4< an$ FPD (typi#al RR 6(=*, 4=> C): 6(8<"6(44(
**
+he )2DAS trial was
ai!e$ to esta'lish whether the early use o% CPAP with prophyla#ti# sur%a#tant was an e%%e#tive
an$ sa%e in neonates o% 85-84 weeks(
*8
+he authors #on#lu$e$ that the use o% CPAP %ollowin&
prophyla#ti# sur%a#tant or CPAP alone was sa%e an$ re$u#e$ the nee$ %or !e#hani#al ventilation
when use$ as initial respiratory support, 'ut $i$ not $e!onstrate a re$u#tion in FPD(
Recommendation: Current availa'le evi$en#e su&&ests that )/S0R, te#hniDue is to 'e %ollowe$
i% a$!inistration o% sur%a#tant is reDuire$ an$ there is no other in$i#ation %or #ontinuin&
!e#hani#al ventilation(
5. .eaning of CPAP
1eanin& o% CPAP is #onsi$ere$ when the #lini#al #on$ition %or whi#h it was initiate$ is passive
an$ there are no other in$i#ations to #ontinue(
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$idence: +he opti!al !etho$ o% weanin& an in%ant o%% CPAP re!ains un#ertain( A survey o%
neonatal units in ,n&lan$ showe$ that !ost units weane$ 'y &ra$ually in#reasin& the ti!e o%%
CPAP(
*A
A ran$o!i3e$ trial #o!parin& the strate&y o% weanin& pressure with one o% in#reasin&
ti!e o%% CPAP showe$ a si&ni%i#ant shorter $uration o% weanin& with the Hpressure7 strate&y(
*?
Recommendation: )% the in%ant is sta'le, %irst wean o%% the 2i.8 to A6> (in steps o% => an$ then
wean the pressure to ? #! B8. (in steps o% * #! ( )% the 'a'y is #o!%orta'le - nor!al saturation
an$ !ini!al retra#tions - at this settin&, (she #an 'e weane$ o%% CPAP(
6. 4ailure of CPAP and its predictors
+he %a#tors $eter!inin& the su##ess o% CPAP are: #hoosin& the ri&ht in%ant (wei&ht an$
un$erlyin& $isease pro#ess, applyin& it early rather than late, knowin& the !a#hine well, $ili&ent
an$ patient nursin& #are an$ the #onvi#tion o% the tea!( )n a$$ition, the threshol$ or the #riteria
use$ to $e%ine %ailure will $eter!ine the CPAP %ailure rates( 1ith in#reasin& e:perien#e o% the
unit, the su##ess rates are likely to i!prove(
*=

CPAP %ailure: ,ven on a CPAP o% 5"9 #! B
8
. an$ 56> 2i.
8
i% the neonate has e:#essive work o%
'reathin& or PC.
8
C<6!!B& with pB L5(8 or re#urrent apnea or hypo:e!ia (Pa.
8
L=6 !!B&,
this shoul$ 'e #onsi$ere$ as %ailure o% CPAP(
$idence0 )n a stu$y 'y Koti J et al, <6 preter! neonates o% &estation LA= weeks with respiratory
$istress an$ #hest :" ray su&&estive o% RDS were enrolle$(
*<
CPAP %ailure was $e%ine$ as in%ants
reDuirin& invasive ventilation in the %irst one week( +he varia'les asso#iate$ with %ailure were: no
or only partial e:posure to antenatal steroi$s, white out on the #hest :"ray, Downe7s s#ore G 5 at
startin& o% CPAP an$ a%ter 8 hours o% CPAP , an$ 2i.
8
G =6> a%ter 8 hours o% CPAP( )n another
stu$y 'y A!!ari A et al, 8<* neonates o% M *8=6 &!s with RDS were enrolle$(
*5
+he pre$i#tors
o% CPAP %ailure, as $e%ine$ 'y reDuire!ent o% ventilation 'y 58 hrs were: nee$ %or positive
pressure ventilation (PPE at $elivery, alveolar"arterial o:y&en tension &ra$ient (A"a D.
8
C*96
!!B& on the %irst arterial 'loo$ &as (AFN, an$ severe RDS on the initial #hest :"ray( Another
stu$y %ro! )n$ia reporte$ hi&h %ailure rates in 'a'ies who are 'orn at lesser &estation an$ whose
!others $i$ not re#eive antenatal steroi$s(
*9

Recommendation: +he availa'le evi$en#e su&&ests that si#ker an$ !ore i!!ature a neonate is
heJshe is !ore likely to %ail CPAP( Knowle$&e a'out the pre$i#tors o% CPAP %ailure woul$ help in
early i$enti%i#ation o% neonates who are likely to %ail CPAP an$ reDuire !e#hani#al ventilation(
+his woul$ help the atten$in& physi#ianJsta%% to 'e !ore vi&ilant $urin& CPAP a$!inistration an$
'e prepare$ with the ne#essary %a#ilities %or !e#hani#al ventilation an$Jor re%erral(
2. Apnea of prematurity
$idence0 CPAP has 'een shown to re$u#e the in#i$en#e an$ severity o% !i:e$ an$ o'stru#tive
apneas 'y preventin& the #ollapse o% pharyn: an$ upper airways an$ 'y splintin& the $iaphra&!(
+he Co#hrane review that in#lu$e$ a sin&le stu$y #on#lu$e$ that the %a#e"!ask CPAP is in%erior
to a!inophylline %or !ana&e!ent o% apnea(
*4
+he #urrent !etho$s o% CPAP $elivery in#lu$in&
nasal pron& CPAP have not 'een #o!pare$ with !ethyl:anthines( ,vi$en#e is now e!er&in& that
nasal inter!ittent positive pressure ventilation (/)PPE is pro'a'ly !ore e%%e#tive than nasal
CPAP in the !ana&e!ent o% apnea o% pre!aturity(
86

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Recommendation: CPAP is typi#ally use$ when #lini#ally si&ni%i#ant episo$es o% apnea persist
$espite opti!al !ethyl:anthine therapy(
3. Post-extubation
$idence0 +he Co#hrane review #on#lu$e$ that nasal CPAP re$u#es the in#i$en#e o% respiratory
%ailure (apnea, respiratory a#i$osis an$ in#rease$ o:y&en reDuire!ents in$i#atin& the nee$ %or
a$$itional ventilatory support ;typi#al RR: 6(<8, 4=>C): 6(=*, 6(5<; //+: <@ when applie$ to
preter! in%ants 'ein& e:tu'ate$ %ollowin& inter!ittent positive pressure ventilation(
8*

Recommendation: Preter! EIF1 in%ants e:tu'ate$ a%ter a perio$ o% en$otra#heal intu'ation an$
ventilation are pre%era'ly !ana&e$ with CPAP so as to re$u#e the in#i$en#e o% reintu'ation an$
!e#hani#al ventilation(
CPAP deliery systems
1. Pressure generators
+he reDuire$ CPAP pressure is usually &enerate$ 'y usin& one o% these %our $evi#es:
1. Fu''le CPAP
2. EentilatorJstan$"alone CPAP
3. Earia'le %low $evi#es (e(&( in%ant %low $river
4. Bi&h %low nasal #annulae (B2/C
$idence: +he authors o% the Co#hrane review on HDevi#es an$ pressure sour#es %or
a$!inistration o% CPAP7 #on#lu$e that !ore stu$ies are nee$e$ to $eter!ine the opti!al pressure
sour#e %or the $elivery o% nasal CPAP "
88
+wo re#ent stu$ies %ro! )n$ia have reporte$ very &oo$
results with 'u''le CPAP in preter! low 'irth wei&ht in%ants with respiratory $istress
syn$ro!e(
*5, *4
+he su##ess rates (a'out 5= to 96> in these stu$ies were #o!para'le to that o%
another stu$y usin& ventilator $erive$ CPAP (Personal #o!!uni#ation( +here are not enou&h
stu$ies re&ar$in& the use o% other pressure &enerators( )n a re#ently pu'lishe$ stu$y %ro! 0nite$
Kin&$o!, 'u''le CPAP was %oun$ to 'e as e%%e#tive as )2D CPAP in the post "e:tu'ation
!ana&e!ent o% in%ants with RDS; in$ee$, in in%ants ventilate$ %or L*? $ays, 'u''le CPAP was
asso#iate$ with a si&ni%i#antly hi&her rate o% su##ess%ul e:tu'ation an$ re$u#e$ $uration o% CPAP
support(
8A
Recommendation0 +he evi$en#e availa'le at present $oes not per!it us to #hoose a sin&le 'est
$evi#e %or &eneratin& CPAP pressure( Bowever, &iven the e%%i#a#y, ease o% useJ%a!iliarity an$ the
low #ost, 'u''le CPAP $evi#e see!s to 'e a 'etter option than others(
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+a'le * &ives e:a!ples, appro:i!ate #ost, an$ the relative !erits an$ $e!erits o% ea#h o% these
!etho$s(
'able 50 A comparison of CPAP deices used for pressure generation
+6
Deice Adantages Disadantages $idence Remarks
5.7ubble CPAP Si!ple an$ 2low has to 'e 1hile earlier stu$ies in$i#ate$ that Stan$"alone option
ine:pensive altere$ to ensure the os#illations pro$u#e$ 'y !akes it an easy an$
Can i$enti%y
proper 'u''lin& an$ 'u''lin& %a#ilitate &as e:#han&e #ost e%%e#tive
a$eDuate pressure akin to B2E
8=
, later stu$ies were proposition in
lar&e leaks at the
not a'le to #on%ir! it
8<
$evelopin&
nares ('u''lin& Di%%i#ult to $ete#t #ountries
stops hi&h %low rates that +he results o% two re#ent )n$ian
#an lea$ to over stu$ies see! to 'e en#oura&in&
$istension o% lun&s (vide #nfra
**,*A
+a. Conentional /o nee$ o% a
entilator separate
deried CPAP eDuip!ent
Can 'e easily
swit#he$ over to
!e#hani#al
ventilation, i%
CPAP %ails
1 ,:pensive
2 Di%%i#ult to know i% the set %low is su%%i#ient or not (insu%%i#ient %low #an lea$ to in#rease$ 1.F
3 Stan$ar$ %low o% ="9IJ!in !ay 'e insu%%i#ient in the presen#e o% hi&h leak
A re#ent stu$y %ro! )n$ia %oun$ .% pra#ti#al utility
en#oura&in& results in preter! in units havin&
neonates with RDS (Personal neonatal ventilators
#o!!uni#ation
+b. Stand-alone ,#ono!i#al
CPAP machines
18!ndigenous
CPAP92
Most o% the! $o not /o stu$ies are availa'le yet +hou&h
have proper ine:pensive, they
'len$ers an$Jor have not 'een teste$
pressure !ano!eter a$eDuately; ni&&lin&
issues o'serve$
with $aily use
:. ;ariable flo, Maintains
!ore deices uni%or!
pressure
Mi&ht
$e#rease
the 1.F
Re#ruits
lun&
volu!e
!ore
e%%e#tivel
y
,:pensive +hou&h initial stu$ies ha$ shown Prohi'itive #ost an$
ReDuires !ore
superiority o% )2D over #onstant la#k o% evi$en#e
%low $evi#es in ter!s o% $e#rease$ re&ar$in& its
te#hni#al e:pertise
o:y&en reDuire!ent, respiratory superiority pre#lu$e
rates an$ lesser nee$ %or !e#hani#al its wi$esprea$ use
ventilation
85
, re#ent stu$ies have
%aile$ to repro$u#e these results
8
9
6. *igh flo, ,asy
to use 0nrelia'le pressure
Mainly trie$ in apnea
o% pre!aturity Still
e:peri!ental
nasal cannulae $elivery
- pau#ity o% $ata in
other #on$itions
2i.8 $elivere$ !ay
'e hi&h
Iar&e leaks aroun$
the #annulae
($%&' wor( of breathing) *+,' high fre-ueny venti.ation) #+D' infant f.ow driver)
2. Patient interfaces
+he $evi#es use$ %or CPAP $elivery in#lu$e:
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NNF Clinical Practice Guidelines
1. /asal pron&s " sin&le or $ou'le
2. Ion& (or nasopharyn&eal pron&s
3. /asal !asks
2a#e !ask, en$otra#heal, an$ hea$ 'o: are no lon&er use$ %or CPAP $elivery in neonates; en$otra#heal
CPAP is not re#o!!en$e$ 'e#ause it has 'een %oun$ to in#rease the work o% 'reathin& (in%ant has to
'reathe Hthrou&h a straw7( +he a$vanta&es an$ $isa$vanta&es o% ea#h o% these $evi#es have 'een
su!!ari3e$ in /ab.e 0"
'able +0 A comparison of common CPAP deliery systems
Deliery system
"asal prongs
(sin&leJ'inasal
,:a!ple:
1 Ar&yle, Bu$son, Me$i#orp
2 )2D pron&s
3 2 O P pron&s
"asopharyngeal prongs
(e(&( usin& a #ut en$otra#heal tu'e
"asal masks
Adantag
es
1 Si
!ple
$evi#e
2 Io
wer
resistan#e
lea$s to
&reater
trans!issi
on o%
pressure
3 Mo
uth leak
!ay a#t
like a
Hpop"o%%7
!e#hanis
!
4 ,#
ono!i#al
an$ easily
availa'le
(i% #ut ,+
tu'e is
'ein&
use$
5 Se#
ure
%i:ation
Mini!al
nasal
trau!a Disadant
ages
1 Rel
atively
$i%%i#ult to
%i:
2 Ris
k o%
trau!a to
nasal
septu!
an$
tur'inates
3 Iea
k throu&h
!outh
!eans en$
e:piration
pressure is
varia'le
4 ,as
ily
'lo#ke$
'y
se#retions
5 Iik
ely to &et
kinke$
6 Mo
nitorin& o%
lo#al si$e
e%%e#ts is
$i%%i#ult
1 D
i%%i#ulty
in
o'tainin
& an
a$eDuat
e seal
2 Ri
sk o%
injury to
the
jun#tion
o% nasal
septu!
O
philtru!
$idence
Stu$ies have shown that short 'inasal pron&s are !ore
e%%e#tive than nasopharyn&eal pron&s espe#ially in post"
e:tu'ation settin&s
84
+hou&h
!ore
e#ono!i#a
l an$
easily
availa'le,
they are
%oun$ to
'e in%erior to
short 'inasal
pron&s
/ew
&eneration
!asks are
yet to 'e
stu$ie$ in
$etail
(IFD, infant flow driver)
$idence0 +he authors o% the
Co#hrane review on $evi#es an$
pressure sour#es %or a$!inistration
o% CPAP #on#lu$e that Pshort
'inasal pron& $evi#es are !ore
e%%e#ti
ve
than
sin&le
pron&s
in
re$u#i
n& the
rate o%
re"
intu'at
ion(
Althou
&h
the
)n%an
t
2low
Drive
r
appe
ars
!ore
e%%e#t
ive
than
Me$i#
orp
pron&s
, the
!ost
e%%e#ti
ve
short
'inasal
pron&
$evi#e
re!ain
s to 'e
$eter
!ine$(
+he
i!pro
ve!en
t in
respira
tory
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NNF Clinical Practice Guidelines
para!eters with short 'inasal pron&s su&&ests they are !ore e%%e#tive than nasopharyn&eal CPAP in the
treat!ent o% early RDSQ(
89
2ew re#ent stu$ies that have #o!pare$ $i%%erent CPAP $elivery $evi#es are
availa'le %ro! either )n$ia or other #ountries(
Recommendation! A!on& the CPAP $elivery syste!s, short 'inasal pron&s are pre%erre$; however, there
is not !u#h evi$en#e to #hoose a parti#ular type o% short 'inasal pron&(
References
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NNF Clinical Practice Guidelines
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