A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of...
-
Upload
marcia-thornton -
Category
Documents
-
view
214 -
download
0
Transcript of A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of...
![Page 1: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/1.jpg)
A History of CPAP for Infants
Alan H. Jobe, MD, PhDCincinnati Children’s Hospital
University of Cincinnati
Cincinnati, Ohio
![Page 2: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/2.jpg)
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
![Page 3: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/3.jpg)
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
![Page 4: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/4.jpg)
VIENNA-09
8 Patients with “Severe Acute Respiratory Failure” Ventilated using a PEEP of 13 cmH2O
Kunar, et al., NEJM, 1970
![Page 5: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/5.jpg)
VIENNA-09
Responses of Switching 8 Patients from PEEP=13 cmH2O to No PEEP
Kunar, et al., NEJM, 1970
![Page 6: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/6.jpg)
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
![Page 7: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/7.jpg)
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
![Page 8: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/8.jpg)
VIENNA-09
Pediatr, 1968
![Page 9: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/9.jpg)
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
![Page 10: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/10.jpg)
Fig. 1. Fleisch 00 Pnumotachograph, T-junction, and nasal piece.
Nasal Piece and Fleish Tube used for PFT Measurements
Harrison, et al., Pediatr, 1968
![Page 11: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/11.jpg)
VIENNA-09
Abstract for SPR/APS Meeting 1970
![Page 12: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/12.jpg)
VIENNA-09
![Page 13: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/13.jpg)
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
![Page 14: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/14.jpg)
VIENNA-09
CPAP Device for use with Endotracheal Tube
Gregory, et al., NEJM, 1971
![Page 15: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/15.jpg)
VIENNA-09
CPAP Device for use with Endotracheal Tube
Gregory, et al., NEJM, 1971
![Page 16: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/16.jpg)
VIENNA-09
Head Box for CPAP without Endotracheal Tube
Gregory, et al., NEJM, 1971
![Page 17: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/17.jpg)
Provided by G. Gregory
![Page 18: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/18.jpg)
Results:
Provided by A. Wilkinson
![Page 19: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/19.jpg)
CPAP (mmHg)
0 6
CPAP (mmHg)
FRC (ml)
Provided by A. Wilkinson
![Page 20: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/20.jpg)
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
![Page 21: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/21.jpg)
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
![Page 22: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/22.jpg)
VIENNA-09
A Bag and Y-Connector for CPAP
Barrie, The Lancet, 1973
![Page 23: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/23.jpg)
VIENNA-09
Caliumi-Pellegrini, et al., Arch Dis Child, 1974
![Page 24: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/24.jpg)
VIENNA-09
Schematic representation of the system used for applying continuous positive airway pressure (adapted from Gregory, et al.)
Cumarasamy, et al., Pediatrics, 1973
![Page 25: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/25.jpg)
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
![Page 26: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/26.jpg)
VIENNA-09
Effect of CPAP (PEEP) on Intubated and Ventilated Infants with RDS
deLemos, McLaughlin, Robison, Schulz, Kirby, Anesthesia & Analgesia, 1973
![Page 27: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/27.jpg)
Nasal Prongs for CPAP
Kattwinkel, Fleming, Cha, and Fanaroff, Pediatrics, 1973
![Page 28: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/28.jpg)
Nasal CPAP (2-5 cmH2O) for Infants with Apnea. BW average = 1kg, age of study – 14 days
Kattwinkel, et al., J. Pediatr, 1975
![Page 29: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/29.jpg)
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
![Page 30: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/30.jpg)
CPAP
Airway Conductance Measured at Term and at 4-11 Months Post-Delivery
Stocks & Godfrey, Pediatrics, 1976
![Page 31: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/31.jpg)
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
![Page 32: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/32.jpg)
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
![Page 33: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/33.jpg)
CPAP was used frequently for -
• Apnea of prematurity
• Post extubation after mechanical ventilation
• RDS in some locations (Columbia, Univ. Scandinavia)
![Page 34: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/34.jpg)
CPAP-VENT
![Page 35: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/35.jpg)
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
![Page 36: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/36.jpg)
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
![Page 37: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/37.jpg)
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
![Page 38: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/38.jpg)
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
![Page 39: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/39.jpg)
• 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
![Page 40: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/40.jpg)
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
![Page 41: A History of CPAP for Infants Alan H. Jobe, MD, PhD Cincinnati Children’s Hospital University of Cincinnati Cincinnati, Ohio.](https://reader033.fdocuments.us/reader033/viewer/2022051619/56649dba5503460f94aaa563/html5/thumbnails/41.jpg)
My thanks to George Gregory for his help with this brief history of CPAP