April 2021 Newsletter

April 2021 Newsletter

We received several questions about the nasal interface. As a matter of disclosure, we do not endorse or promote any specific type or prongs to use in newborn infants.

That being said, our own experience, and our observation of centers that have been successful in reducing CLD using bubble CPAP, is that it was always tied to using nasal prongs that made of a transverse tube with curved nasal prongs that snuggly fit in the infant’s nares such as Hudson or BabiPlus. We are unaware of publications reporting significant reduction in CLD from baseline or achieving CLD rates that are less than 10% among infants <1500g using other types of prongs.

So, the answer to your question is ‘yes’ you can use ‘Flexitrunk’ with bubble CPAP circuit, but to achieve significant reduction in CLD in your unit you may need to replicate existing successful experiences using snuggly-fitting curved nasal prongs.

Thank you very much for creating this website which is being extremely helpful to set up the bCPAP program at our institution. I am in the process to develop some guidelines and although planning to start with newborns at 32 weeks and older first, I would like your opinion/suggestion for a couple of scenarios for babies under 26 weeks or so.

• The first scenario is a patient who is able to be managed initially with CPAP, but the oxygen requirements increase and need surfactant. In this scenario, I would give surfactant and quick extubate using ENSURE approach. Do you agree or would you use a different approach?

• The other scenario is if this particular patient is admitted from the LDR already intubated. What criteria would you use in this case for extubation? Quick extubation and if reintubated again use a more conservative approach for extubation or wait until the patient meets low oxygen requirements, low MAP, etc before extubation? ‘by Juan’

We commend your enthusiasm to start a bubble CPAP program at your NICU and we support your decision to start with infants equal to or more than 32 weeks gestational age. Your time will likely be successful to manage these infant with bubble CPAP and 4 months of doing so should be enough to familiarize them with such strategy, build their confidence, and build skills to troubleshoot issues with setup and nasal interface. The next step would be to go down to 28 weeks and again take your time with your staff to get to know how they can manage smaller infants with bubble CPAP. In this phase, the focus is on managing issues with creating and maintaining the prongs seal, functional circuit while preserving the nasal septum in preparation to the next phasae where you can start manging infants as low as 24 weeks. For more info on how to start a bubble CPAP program in your unit visit www.bcpap.org/quality

As for your questions, we would suggest not to start with 26 weeks in the earlier phases of introducing bubble CPAP in your unit. Take your time and let your team absorb it, phase by phase. The only exception would be, if you have a high volume and you feel that your team got enough exposure to proceed to next phases earlier than 4 months. When the time comes and you will be ready for the 26-week micro preemies, then yes, you can do INSURE (INtubation-SURfactant-Extubation) or the relatively less invasive LISA or MIST while the infants are continuing on bCPAP during the surfactant infusion.

We assume your infant who would be intubated in the delivery room would receive surfactant as well! Yes, we will suggest to extubate the infant when they hit the following parameters:

Blood gas measures: pH > 7.25 / pCO2 < 65 / Sat => 90%

On ventilator setting close to: PIP < 20 / Rate < 45 / FiO2 < 40%

Infants less than 750g may not generate enough tidal volumes in the first week of life, you may use CPAP with backup rate such as NIPPV or NAVA via the same nasal interface that you would use with bubble CPAP.

Hello, we have consistently been using size 8 Fr size OG tubes to vent our ELBW babies while on bubble cpap. I’m curious what your experience is with size 8 OG tubes and if there have ever been instances of esophageal perforation attributed to size 8 OG tube insertion in ELBW patients. Thanks

Thanks for reaching out to us and welcome to the Bubble CPAP Institute. Most centers who use Bubble CPAP as the primary mode of respiratory intervention prefer size 8fr orogastric tubes for better stomach ventilation similar to what you do. The exception would be preterm infants less than 500g where 6fr may be the only practical option.

There are no reports that describe increased esophageal perforation with using 8fr in infants <1500g. Some colleagues anecdotally noted esophageal perforations where 8fr OG tubes were used in infants <500g but we are unaware of published reports or case reports that describe this association.