Helping Newborns Heal Themselves

bCPAP reduces need for conventional ventilation in premature infants

 

BY STEVEN C. BARKLEY, MD, AND STELLA RIDDELL, RN

 

We want you to think about the premature infant for a moment.  These small newborns appear to be so fragile and vulnerable, and in many ways they are.  But they also contain all the keys to their own healing, and all the tools that they will need to thrive.  In the Cottage Children's Hospital Neonatal Intensive Care Unit (NICU), our job is to support them while they work it out.

 

Neonatology is, in a very real sense, a science of sustenance.  Few of the medications and technologies available to us are curative.

The real secret of caring for ill newborns is that, if one is able to support them and optimize their nutrition and growth, they will get better.  Our care for the premature infant centers on our ability to support their vital functions and literally let them "grow out of" whatever problem they have.

Steven Barkley, MD, and Stella Riddell, RN 

 

Advances in ventilatory and respiratory care of infants have allowed hundreds of thousands of children to survive and thrive who would have otherwise died.  For a small number of these children, the ventilatory support which saved them leaves them with chronic breathing problems that can take years to ameliorate.  Supporting the respiration of children without incurring the risk of long-term complications is part of the current focus of the NICU at CCH.

 

In the premature infant, the lungs are collapsed and non-compliant.  Traditionally, ventilators have been used as a means to maintain inflation of the lungs, but they have many undesirable side effects that can lead to long-term respiratory problems. The use of a specialized nasal cannula to provide a small but consistent pressure to the lungs can prevent the need for a breathing tube and ventilator in many infants. 

 

This system, known as "bubble Continuous Positive Airway Pressure" or bCPAP, was pioneered at Columbia University, and has been associated with the lowest rates of chronic lung disease in the country.  The NICU team at CCH traveled to Columbia in 2011 to learn the technique and bring it to the children of our area.  The results have been phenomenal, and are summarized in the table below.

Raeanne Ladwig holds her son Arthur who is being treated with bCPAP rather than conventional ventilation.

 


Bubble CPAP can be used to replace conventional ventilation for a large number of babies.  In our NICU after one year of implementation, the number of children requiring intubation and ventilatory support has been decreased by two-thirds.  The number of children diagnosed with chronic lung disease has decreased by half.  These results are promising and exciting.

 

Perhaps more importantly, the careful use of bCPAP allows a much more nurturing environment for mother and baby.  The need for sedative medications that are so commonly used for ventilated infants has almost been eliminated.  Mothers can hold and even breastfeed their babies while they are on bCPAP.

 

An examination of the available evidence actually suggests that bCPAP may refute our old axiom about not having any curative therapies in the NICU. There is good human and animal evidence that the use of bCPAP promotes lung growth. The improvement in lung volume, as well as the oscillatory nature of the bubbling, has been shown to shorten the total time that an infant requires oxygen, as well as to promote actual lung growth. In our NICU, the use of bCPAP until infants reach a gestational age of 31 to 33 weeks has been associated with a decrease in days on oxygen from 21 to 4.

 

Success with bCPAP is the result of a coordinated and sustained effort by physicians, nurses and therapists.  It requires fastidious bedside care and frequent assessment and adjustment.  But it brings enormous potential benefits to our patients.  We are proud to include bCPAP in the ongoing evolution of neonatal care here at CCH.

 

 

Year over year comparison of bCPAP results in CCH NICU

  Prior to Bubble CPAP
initiation (n=36)
After Bubble CPAP
initiation (n=59)
p-value
Gestational Age 31.9 (5.5) 32.9 (5.0)  0.409
 Admit Weight 1907 (1020) 2113 (931)  0.323
LOS 40.9 (40.5) 31.3 (28.5) 0.231
Respiratory Distress Syndrome*    23 (63.9) 35 (59.3) 0.657
O2 Days 20.7 (32.0) 3.9 (15.5) 0.005
Vent Days 11.0 (15.7) 3.5 (7.9) 0.01
Bubble CPAP Days --- 7.8 (16.0) ---
Days on Vent or Bubble CPAP 11.0 (15.7) 11.3 (17.3) 0.923

* number observed (percent of group)

 

Comparison of medication use for patients on respiratory assistance greater than 5 days

  Prior to Bubble CPAP
initiation (n=16)
After Bubble CPAP
initiation (n=30)
p-value
Days on Vent and / or Bubble CPAP 23 (17.2) 20.0 (21.3) 0.604
Ativan 59 (82) 2 (18) < 0.001
Fentanyl 2.5 (9.3) 1 (2) 0.437
Morphine 12 (21) 0 0.002
Phenobarb 1 (9) 0 0.029
Total Medication 98.5 (131.75) 10 (34) < 0.001

Medications are summarized as median (inter-quartile range)

 

NOTES

•   Patients were separated into two groups based on whether they were seen in the NICU before or after the initiation of the bubble CPAP
•   Patients were included in the summary if a ventilator ore bCPAP was indicated
•   Data are summarized as mean (standard deviation) and number of observed (percent of group)
•   Time frame 11/1/2010 to 10/31/2011 for pre-bCPAP rollout and 11/1/2011 to 10/31/2012 for post-bCPAP rollout

 

 << Return to Spring 2013 CCH Magazine

 

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