Bubble CPAP vs.
High Flow Nasal Cannula
Gil Urquidez, RRT-NPS
Supervisor, Respiratory Care Services
Santa Clara Valley Medical Center
Optimize Initial Respiratory
Support
Goal:
To establish and maintain the VLBW infant’s
respiratory efforts and functional residual
capacity without injuring the lung (Vent Induced
Lung Injury) from excessive use of positive
pressure ventilation.
What is CPAP ?
Continuous Positive Airway Pressure
 Technique of applying a continuous distending pressure
to the lungs in a spontaneous breathing infant.
 Usually< 10 cm of water pressure
 5-10L humidified flow of blended air
How does it Work ?
Distends the airway and alveoli
Maintains lung volume in expiration/FRC
Makes breathing easier
Improves gas exchange
Philosophy of use
Patience
Permissive Hypercapnea
Non invasive application
CPAP Beneficial effects immediately
following Resuscitation
Benefits
 Decreased requirements for Intubation
 Decreased requirement for high levels of inspired
Oxygen
 Decreased Mechanical Ventilation Length of Stay
 Decreased need of Postnatal steroids
Compared to Historical controls
P.Jegatheesan J of Perinatology 2006 26, 189 - 196
CPQCC Recommendation…
Tool-Kit Best Practice #7
Optimize Initial Respiratory Support
Early use of CPAP (within 60 seconds of life)
Avoid Intubation (if possible)
Avoid prophylactic use of Surfactant in the DR
What Causes Chronic Lung
Disease (CLD)?
Summary of Current Causes of
CLD/BPD in VLBW
CAUSE
EFFECT
 Barotrauma
 Volutrauma
 Atelectotrauma
 Developmentally
Impaired Alveolarization
and Vascularization
 Poor Nutrition
 Recurrent infections
 Pressure
 Volume
 Repeated popping open
 Less alveoli
 Not enough resources to grow
 Scarring and destruction
Why Did VMC Switch to Bubble
CPAP Therapy?
Bubble Nasal CPAP
Cost Effectiveness
Less Invasive Than A Other Interfaces
To Improve Overall Outcomes
Columbia Medical Center’s Experience
CLD rates are the lowest in the country
Bubble CPAP is SOLE form of Nasal CPAP.
Positive Outcomes Associated
With The Change In Practice
Benefits Associated With
Change In Practice
Improved Outcomes
Associated With Change In
Practice
VLBW survival WITHOUT significant
IVH
SCVMC NICU
100
90
80
70
60
50
40
30
20
10
0
VLBW
2006
2007
2008
2009
2010
How do we create our own
Bubble CPAP System?
• How do we do it?
• What equipment do we use?
• Where do we get it?
Creating our Setup
• Where do we start?
Creating our Setup
• What hat to use?
• Where do we get them?
Creating our Setup
• Preparing for the cannula
Creating our Setup
• Securing the cannula to the patient
Creating our Setup
• Chin straps
Creating our Setup
• Water Bottles
Creating our Setup
• Original Setup
How can we improve it!
Creating our Setup
• Other options
Creating our Setup
• Other Options
Creating our Setup
• Other Options
Creating our Setup
• Previous System
Current Set Up
New Circuit & Bubble Chamber
Multiple Sizes for Prongs/Mask
High Flow Nasal Cannula
Definition
 High Flow Nasal Cannula is defined as heated
humidified gas delivered at flows greater than
1lpm.
 VMC defines High Flow Nasal Cannula as heated
humidified gas delivered at 2lpm.
High Flow Nasal Cannula
Set-Up
Cochrane Collaborative Review
of High Flow Nasal Cannula 2011
Issue 5
There is insufficient evidence to establish the
safety or efficacy of HFNC as a form of respiratory
support in the preterm infant
When used following extubation there may be a
higher reintubation rate compared to NCPAP
More trials are needed
Early Weaning From NCPAP To HFNC Is
Associated With Prolonged Oxygen Use
Randomized control
NCAPAP N/C 2 L
trial
Clinically stable on <
30 % O2 for 24 hrs
Days on
5
14
randomized to HFNC
O2
(2 L) or Stay on CPAP
Resp
till go straight to room
support
10.5
18
air.
days
Hany ES Early Human Development 2011
High Flow Nasal Cannula
PRO’s for HFNC Use
 Ease of use
 Improved feeding and tolerance
 Easier nursing/patient handling
 Decreased nasal septal trauma
High Flow Nasal Cannula
CON’s for HFNC use
Limited data
Unmeasured PEEP
No alarms
VMC’s Position on HFNC
• High Flow Nasal Cannula usage when:
• Patient fails multiple attempts off Bubble NCPAP
• Is still needing more than 2lpm flow
Greg Is Not Happy with the
Baby’s NCPAP Set Up
What’s wrong with this set up?
The Baby Is Agitated and Desating!
What Can We Do To Fix This?
Aaahhh….I feel much better!
I Can See You!!!
Greg’s NOW a Happy Nurse!!!
A Happy Baby is a Happy Nurse
And ULTIMATELY a HAPPY RT!!!
Conclusions
MATCH the Definition on the RIGHT with the Therapy on the LEFT
Good
A.
CPAP is
Great
Bubble CPAP is
B.
High Flow Nasal
Cannula Needs Further Study
Oxygen is a Drug Use with Caution C.
Needs Further
Study 
Good
Use with caution
D. Great
Thank Yous!!!
Craig Ivie, Director, Respiratory
Care Services
Dr. Balaji Govindaswami,
Director, NICU
All Associate Attendings
All NICU Staff
My Respiratory Care Staff