Weaning of CPAP

[hehady]

How do you practice CPAP weaning?. Gradual weaning of pressure? Cycling time off CPAP?

[Alexander Rakow]

We usually go from 4-5 cm, 1 cm at a time, to 2 cm. We have no strict protocol for CPAP weaning, it is more of a trial-and-error procedure which we start when the infant is clinically stable and oxygen needs go down.
Usually we go directly from 2 cm/low FiO2 -> low flow oxygen on mask -> nothing.

[Skysurfer]

Hello Hehady,

We usually ventilate our neo´s with BIPAP (Evita XL). Then, we cycle the Pinsp pressure down as much as we can to maintain normal Ventilation (4-6ml/Kilogram/weight). Once that goal is reached and the baby doesn´t need much FiO2 <35%, we would rapidly decrease the mandatory frequence in steps of 5 frequences applied by the ventilator until we have a Frequence of 10-15. We dont let the small preemies breath on CPAP, because of their periodic breathing. We usually apply ASB (Assisted Spontaneous Breathing) to help the baby to overcome the dead space of the Ventilator Circuit and the Resistance of the small Tube (a kind of Tube compensation). The ASB is set high enough to maintain a spontaneous Vte mentioned above. We usually extubate that way with a Peep of 5mbar. I say usually, because it happens that we have to choose another way sometimes, as we set the ventilator settings the way our patients need it :)

That´s one way to Rome.....
I dont say one can´t let preemies breath on CPAP(assumed that we´re talking about the Invasive CPAP Ventilation), sure you can, all you have to do is to assist the child´s efforts enough to overcome the dead space and the Resistance of the tube. We are applying ASB for that reason. In children with apnea or periodic breathing it might be helpfull to set the alarm settings right, then. In our case we dont use the apnea ventilation, so we use this kind of backup frequences (10-15). Most preemies end up on a Non-Invasive-CPAP device like our SIPAP´s just right after extubation. We usually extubate very rapidly and in combination with early Non-Invasive-CPAP Methods, this technique has worked very well for us.
Older children are usually weaned by reducing the BIPAP Frequences until zero, then the ventilator automatically changes into CPAP-ASB Mode.

i would be curious to know how others tend to wean their children off the Vent´s.
And, are ventilator checks and setting changes done by your Nursing Staff as in our case or is it something the Neo´s do?

thanks in advance
Norbert

[Alexander Rakow]

How do you practice CPAP weaning?. Gradual weaning of pressure? Cycling time off CPAP?

Do you mean weaning PEEP or nasal/noninvasive CPAP-pressure?
My reply was about the latter!

[hehady]

I meant Non-invasive CPAP

[neobirdog]

In another facility, we used high-flow cannula (aka:vapotherm) to wean from
CPAP, with good success.
Lately, there has been concern due to the removal from the market of Vapotherm, although Fisher-Paykel is trying to pick up this market, and Smith Medical is in the midst of getting approval of their Aquinox for neonates.

[p.mansvelt]

We use the cycling time off CPAP strategie.
With a peep of 4-5 starting 2-4 hours a day on low flow 0,4-0,6 l/min.
No protocol is used; it`s an trail and error management.

There are studies ( presentations in Barcelona, two weeks ago)that suggest pressure weaning is better in VLBW neonates and the neonates born before 28-30 weeks.

[kpsanghvi]

Till what birthweight/gestatinal age do you extubate to CPAP. Our policy is to extubate to CPAP only if the infant is < 2 kg.

When we extubate to CPAP esp the VLBW we use starting pressures of 5-6 and then decrease by 1 cm per day and wean off at CPAP pressures of 3 cm
In ELBW it is 1 cm every alternatel day. Of course we keep a check on ABGs and may speed up or delay the weaning accordingly

[shivugm33]

Are there any published studies comparing cycling CPAP vs reducing pressure ?

[hehady]

There is only one study from UK. Not yet published, but presented in PAS 2006 Meeting and ESPR 2006 Meeting