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Journal of Neonatal-Perinatal Medicine 6 (2013) 53–59 DOI 10.3233/NPM-1363612 IOS Press

Original Research

A comparison of two nasal continuous positive airway pressure interfaces – a randomized crossover study T. Bushella , C. McHugha and M.P. Meyerb,∗ a Kidz

First Paediatrics Middlemore Hospital, Auckland, New Zealand of Auckland, Auckland, New Zealand

b University

Received 20 June 2012 Revised 20 September 2012 Accepted 6 November 2012

Abstract. BACKGROUND: In spite of widespread use of nasal CPAP there are comparatively few studies to guide the choice of nasal prongs. OBJECTIVES: To determine whether the Fisher & Paykel Healthcare (FPH) neonatal continuous positive airway pressure (CPAP) interface was effective in providing bubble CPAP when compared to the Hudson prong interface. METHODS: The study was a randomized cross-over study of twenty newborn infants 500 g or more requiring CPAP for respiratory support at birth. Infants were randomized to either the Fisher & Paykel Healthcare or Hudson CPAP interface for twenty four hours. Crossover between interfaces occurred after subsequent twenty four hour periods. The primary outcome was the provision of desired CPAP pressures, defined as provision of CPAP within ± one cm H2 O of set pressure. RESULTS: The percentage time CPAP was within ± one cm H2 O of set pressure was 66.5% for the Hudson and 71.8% for the FPH interface (p = 0.66). Oxygen saturations for the Hudson interface were in target range for a median of 97.8% of the time, and, with the FPH interface, for a median of 98.2% of the time (p = 0.76). Clinically significant differences in primary or secondary outcomes between the two groups were not detected. CONCLUSIONS: The nasal CPAP interfaces studied were equally effective in achieving desired bubble CPAP pressures and target saturations. Keywords: Nasal continuous positive airways pressure, newborn infant, respiratory distress syndrome

1. Introduction Nasal CPAP (nCPAP) is widely used for neonatal respiratory support. Two recent randomized studies have confirmed that nCPAP is an alternative therapy to intubation, surfactant and mechanical ventilation ∗ Corresponding

author: Dr. Michael Meyer, Neonatal Unit, Middlemore Hospital, Hospital Road, Auckland, New Zealand. Tel.: +64 9 276 0000/Extn.: 7273; Fax: +64 9 276 0091; E-mail: mmeyer@ middlemore.co.nz.

for preterm infants [1, 2]. Likewise, nCPAP has been successfully used in preterm infants following extubation and for apnea [3, 4]. In larger, more mature newborns, nCPAP has been used to treat a variety of causes of respiratory distress, including meconium aspiration syndrome, transient tachypnea of the newborn and pneumonia [5]. In spite of widespread use, there have been relatively few studies comparing different CPAP devices. A Cochrane review indicated the superiority of short

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T. Bushell et al. / Comparison of nasal CPAP interfaces

binasal prongs over single nasal prongs at preventing re-intubation in the week following extubation [6]. Several observational studies have recorded favorable respiratory outcomes from Columbia Presbyterian Hospital, New York where one type of binasal prongs (Hudson, RCI, USA) have been in use [7, 8]. In 2000 Fisher & Paykel Healthcare (FPH), released a midline patient interface for bubble CPAP and provided an opportunity to compare CPAP delivery with these two devices. The aim of the study was to determine whether the FPH midline CPAP interface was effective in achieving optimal bubble CPAP when compared to the Hudson prong interface in a cohort reflecting the population of newborn infants currently treated with nCPAP.

2. Methods 2.1. Study population Infants admitted to Middlemore Hospital Neonatal Intensive Care Unit weighing 500 grams or more, requiring respiratory support at birth were considered for the study, provided informed consent was obtained. Infants were eligible if they showed signs of respiratory distress (tachypnea, grunting, nasal flaring, intercostal or sternal recession), or had an oxygen requirement. Infants were excluded if they required intubation and ventilation from birth or if they failed CPAP within the first forty eight hours and required an escalation of respiratory support. Similarly infants who did not require at least forty eight hours of CPAP or infants with major congenital abnormalities were excluded. Infants were stratified into three cohorts: 1500 g. Stratified randomization was performed via opaque, numbered, sealed envelopes. Ethics approval for the study was obtained from the Northern Regional Ethics Committee, Auckland. 2.2. Study design Infants requiring bubble CPAP were randomized to either FPH or Hudson prongs. After a twenty four hour period on the first interface, the infant was changed over to the other. Crossover between the two interfaces occurred after each subsequent twenty four hour period until either the infant no longer required CPAP or twenty eight days had elapsed. A maximum of three infants could be accommodated in the study at any

one time due to equipment constraints. The primary study outcome was the generation of desired bubble CPAP pressure as this was thought to be important clinically for successful use of CPAP. It was recognized that other outcomes (such as time on respiratory support and chronic lung disease) are also important and would require a larger multicentre study. For the purposes of the current study, the desired CPAP pressure was defined as a CPAP pressure within ± one cm H2 0 of the set pressure. 2.3. Pressure and oxygen recordings Pressure recordings were obtained every thirty seconds at the patient interface by means of a pressure line in the afferent limb of the CPAP tubing, connected to a pressure transducer. The percentage of each twenty four hour time period for which desired CPAP pressure was provided was calculated. CPAP pressures were generally set at six cm of water - if an infant had an oxygen requirement or appeared to have increased work of breathing then this could be increased to seven cm or eight cm if necessary. Flow rates were set at six L/min. Flow rates greater than this were not used; if bubbling was not achieved, attention was given to positioning, chin straps, prong sizes and suctioning. A data logger was used to record interface pressure and FiO2 data (both at thirty second intervals). There was an oxygen sensor in the data logger (sampling from the inspiratory limb of the tubing) and the readings were recorded alongside the pressure data. The logger did not display the data as it was being recorded and therefore did not influence infant care. The set CPAP pressure was recorded by the bedside nurse and there was an additional oxygen analyzer (also in the inspiratory arm of the tubing) which provided data for bedside staff. 2.4. Nursing care Staff nurses working in NICU who had at least two years previous CPAP experience were trained to apply both interfaces. The application of the CPAP device to the face was critical, but different in the two methods. The Hudson attachment was to the sides of the hat and face, while the midline was fixed more centrally to the top of the hat, leaving the sides of the face free. (Figs. 1 and 2). Learning to use new equipment takes time and experience and this was achieved during the pilot study using midline CPAP (see below). In contrast, Hudson CPAP was the routine CPAP method in the nursery

T. Bushell et al. / Comparison of nasal CPAP interfaces

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Fig. 1. Photograph of infant with Hudson prongs.

Fig. 3. Box plot showing outcomes for pressure and oxygen saturation for infants on Hudson or Fisher & Paykel midline nasal CPAP. Boxplots shows median, quartile range and outliers for each variable.

of any significant nasal trauma. Infants

A comparison of two nasal continuous positive airway pressure interfaces--a randomized crossover study.

In spite of widespread use of nasal CPAP there are comparatively few studies to guide the choice of nasal prongs...
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