Nasal CPAP - Avoiding loss of pressure

[JACK]

I know that all of us use some sort of Nasal CPAP support in NICU. And as we get to learn about it, the more we prefer it to conventional tracheal intubation and ventilation.

I have often noticed that sometimes preterm babies keep their mouth open (intermittently) while on Nasal CPAP support. I am sure that will cause loss of pressure transmitted to the airways distal to the nasopharynx. "...The pressure in the upper airway is an important measure of how much pressure is transmitted from the CPAP system....It has been suggested that ensuring that a baby’s mouth is kept closed during nasal CPAP increases its effectiveness.....Clinicians should be aware that pressures transmitted to the airway may be very low when the mouth is not actively closed, particularly at low set pressures...." (From Ref 1 and 3)

I wanted to know how our colleagues around the world deal with this issue. Do you have any protocol to ensure that babies dont keep their mouths open? I am very eager to find out.

And if possible you could post some photos in this forum of how you enforce your protocols. ( You can use the attachment function while posting your replies, found in the "Additional Options" block below the text box. Please make sure that you use appropriate methods to hide the identity of your patients in the photos)

Relevant Articles:

1) De Paoli AG, Lau R, Davis PG, Morley CJ.
Pharyngeal pressure in preterm infants receiving nasal continuous positive airway pressure.
Arch Dis Child Fetal Neonatal Ed. 2005 Jan;90(1):F79-81.
LINK (http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1721805&blobtype=pdf)

2) Pedersen JE, Nielsen K.
Oropharyngeal and esophageal pressure during mono- and binasal CPAP in neonates.
Acta Paediatr. 1994 Feb;83(2):143-9.
LINK (http://www3.interscience.wiley.com/journal/119971421/abstract)

3) Krouskop RW, Brown EG, Sweet AY.
The early use of continuous positive airway pressure in the treatment of idiopathic respiratory distress syndrome.
J Pediatr 1975;87:263–7.
LINK (http://www.jpeds.com/article/S0022-3476(75)80599-3/abstract)

[hehady]

We use pacifier or chin strap to keep mouth closed. Non-pharmacologic sedation via nestting, incubator covers, demming of NICU lights also helps.

[ammar]

Hi

sometimes when usal values of PEEP and flow are not sufficient to ovoid apnea and bradycardia, baby’s mouth is kept closed during nasal CPAP by using soft chin strap or blocking mouth at prone position by header.

[Stefan Johansson]

Pacifier is our first technique-of-choice, but sometime we make a soft cushion of elastic band which we position under the chin. AND, parents (which sit by the incubators/beds a lot) are asked to help us to support their babies, i.e. keeping the pacifier and cushion in position.
Those of you using a chin strap, does it work well? Is it well tolerated (in terms of comfort)?

Although loss of cpap-pressure through the mouth is commonly seen, it is seldom a clinical problem according to my experience. As long as no clear symtom appear (apneas, "disturbingly" high TcCO2, or steady saturation less then 87%), we do not change anything, but look upon it a "weaning". However, some infants are very dependent on pressure. For example, those with severe BPD can be very problematic, especially since those infants can be much older and much more active.

[JACK]

Dear Stefan, do you use any special type of pacifiers for your preterms? Does keeping the pacifier in situ for a prolonged period cause any problems...any pressure effects on the palate?

[Stefan Johansson]

Dear Stefan, do you use any special type of pacifiers for your preterms? Does keeping the pacifier in situ for a prolonged period cause any problems...any pressure effects on the palate?
I do not really know from where we buy those, but they are not the usual ones from baby shops. They are quite small, and there a "vagination" on the upper rim, so it does not align too much against the cpap device (prong holder). I can take some photos and post later.

I am not aware of any pressure side-effects, but you got a point there.
On the other hand, the pacifiers are not there all the time, they go in and out so to speak :), and when infants are asleep they are usually not needed.

[JACK]

Dear Stefan, will be happy to see some photos....

[hehady]

TRy these sites,
Gumdrop pacifiers: http://www.preemiesrus.com/catalog/product_info.php/products_id/575
Cookie Cap: http://www.hawaiimedical.com/Products/index.html
Chin Strap: http://www.fphcare.com/neonatal/pdfs/185043351.pdf

Also INCA CPAP accessories

[Stefan Johansson]

Pacifiers, of various brands and sizes. The tiniest one is used only for infants <1500 grams.
The regular pacifiers are of the brand NUK and the special CPAP-pacifier has the product name Wee Thumbie.

[JACK]

Thanks.......