[PDF] Performance Evaluation of Nasal Prong Interface for CPAP Delivery

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PerformanceEvaluat ionofNasalProngInterfa cefor CPAPDelive ryonaCriticalCare Ventilator: ABenchExperiment

Natalie Napolitano,Tracey Roberts,Amanda JNickel, JosephMcDonough, HaoruiSun, RuiFeng,

Erik AJensen, KevinDysart, andRichard Lin

BACKGROUND:Th eRAMcannula(Neotech ,Valencia, CA)has becomeacommonlyused interface forCPAP inneonatal intensive care.Performance characteristicsofthisin terfaceused with acritical careventilator arenot welldescri bed.METHO DS:This wasa benchstudyutiliz- ing alung simulator configuredasanactively breathinginfant (weightsof 800g, 1.5kg, and3 kg) withmoderate lungdisease anda criticalcare ventilatorin CPAPmode withleak compensa- tion on.Th reesizesofthe RAMcannul ae(preemie, newborn,and infant)were comparedto3

BabyFlow nasalprongs (Dra

ger Medical,Lu ¨beck, Germany)(medium,large, andext ra-large). Fabricated nasalmodels produced a70%occlusive fitfor theRAM cannulaandan occlusivefit with theDra ger prongs.Delivered flowand pressurelevels wererecorded at9 CPAPlevels between5 and20 cmH 2

O. RESULTS:TheDra ¨

ger prongsproduceda meanairway pressure P aw ) within0.20 cmH 2 O (range-0.10to 0.35)of theset CPAPacross allevaluated prong sizes and CPAPlevels.In contrast,the RAMcannula produced P aw valuesthat averaged8.5 cmH 2 O (range -15to -3.5)below theset CPAP levels.Th edeficit indeliveredversustarget CPAPlevel fort heRAMca nnul aincreasedwithg reatersetCPAP.SetCPAP of5cmH 2

O deliveredP

aw valuesthat rangedfr om0.6to1.5 cmH 2

O (differenceof3.5-4.4cmH

2

O).Se tCPAPof2 0

cm H 2

O deliveredP

aw valuesthat rangedfr om5.0to8.4 cmH 2

O (differenceof11.7-15cm

H 2 O).Ins piratoryflowrequired toachieve setCPAPlevelsdi dnot differbetweeni nterfac es, suggestinghighresi stancei ntheRAMcannuladevicemas ksthede livered CPAPlevel s. CONCLUSIONS:Use ofthe RAMcannula witha 30%leak ona criticalcare ventilator deliv- eredP aw valueslower thanse tCPAP. Thismaybeclinically meaningful andshou ldbe consid- ered whenchoo singanasalinterface. Key words:CPAP; high-flow nasalcannula;PEEP; infant; bench study..[Respir Care0;0 (0):1-?.© 0Daedalus Enterprises]

Introduction

AdministrationofnasalCPAP isa nevidence-b ased

approachtoreduc ee xposuretoinvas ivemechanicalve nti - lationinvery pre terminfa ntsanddecrea setheriskoflun g injuryand subseq uentdevelopmentofc hroniclungdis- ease.1,2

Thep hysiologicgoalofnasalCP APistoma intain

a consistentdistending pressurewithintheairways tomain- tainpa tencyofthere spirato rysystem ,reduceworkof breathing,andimpro veoxygen ationandventil ation,with- outt heuseofa nend ot rach ealtube. 3,4

NasalCPAP interfa -

cesty picallyusenasalpr ongso rmasksthatp roducean occlusivesealar oundtheex ternalairway. Unfor tunately, thesedevi cesmaycontrib utetopa tientdiscomfortand facialinjury insomeinf ants.Hi gh-flo wnasalcannula(HFNC),whichut ilizesbina salprongswitha60-80% occlusivefit,has beenstu diedasa nalternative ,potentially morecom fortableandlessinjur iousmeans toprovidenoni n- vasiveres piratorysupporttoprematur einfants. Howe ver, severalstudies raiseconcern thatHFNCmay notbeaseffec- tiveasn asalCP AP,part icularlywhen usedinextremelypre- termnewbor ns.5-8

TheRA Mcannu la(Neotech,Va lencia,California)was

introducedinNovemb er 2011asanewnasalca nnulai nter- face.The device iscomposedofso fte rmaterialsthant rad i- tionalnasal CPAPprongs (eg,Hu dsonprongs), usesa largerpron gdiametertha nothershortna salcannul a,and, unlikeHFNC, canbeatt achedtoa ven tilatorornasal

CPAPc ircuitwithouta dditionaladap tors.

9,10

Thema nufac-

turerof theRAM cannula recomme ndsa60-80%oc clusiveRESPIRATORYCARE???VOL?NO?1RESPIRATORY CARE Paper in Press. Published on July 6, 2021 as DOI: 10.4187/respcare.09018Copyright (C) 2021 Daedalus Enterprises ePub ahead of print papers have been peer-reviewed, accepted for publication, copy edited

and proofread. However, this version may differ from the final published version in the online and print editions of RESPIRATORY CARE

fitto all owforexha lation. Althoughthisdevicemay com- binethe poten tialbenefitsoftheHFNCin terfacewith the therapeuticgoalsofna salCPAP,th elimit edexisting data raiseconc ernthattheRA Mcannulama ynotad equately delivergoalpr essureleve lstotheairwaywith prongsize s thatfa cilitatetherecommen dedna salleak. 10,11

However,

anim portantunanswered questionishowtheinte rfaceper- formswhe nusedinco njunction with acriticalcareventila- torth ataugme ntsflowtocompe nsatefo rleak. Thepur poseofthis benc hstudyw astocom paresetPE EP andm easuremeanairw aypr essure( P aw ) levelsbetween a conventionalnasalCP APpronginter facewith anocc lusive fitand theNe otech RAMcannulausingac ritica lcareventi - lator.Wea lsoex aminedt heflowsgenerated bytheve ntilator in anat tempttodeliverg oa lPEEPlevelswith the2device s.

Methods

Study Designand Setup

We performedaseriesofbe nch experiment swi thalung simulatorandcus tom,pla sticinfantnasa lmodels.The nasalmodels weredesigned withnar esdiameterst hatpro - duced70% occlusi vefitfor3differen tNeote chRAMc an - nulae:pree mie(3.4mm),newbor n(4.0mm ),andin fant (4.6mm). Themode lswerepr oducedby HansRu dolph (Shawnee,Kansas)wi thastandard22 -15mmc onn ection to attachtothelung simu latora ndaside portwithamale lureco nnectorenablingc onnectionofapressu resensor(Fig.1). TheBab yFlowsy stem(Dra

¨gerM edical,Lu¨beck,

Germany)withna salprongss izedforan occlusivef itwas usedasth econ trolin terface.Anactiv elybreathinginfant lungmo delwasproduc edwith theASL5000lung simulator (version3.6,Ing MarMedica l,Pittsburgh,Pen nsylvania) usingthep re-sets criptsforpremat ure(800g),newborn (2,000g), andinfa nt(3,000 g)modelswith respir at orydis- tress.Thef ollowing alterationstothepre- setscriptswere madefor thisstudy :forthep reemieand newbor nmode ls, compliancewasseta t0.5mL /cmH 2

O,r esistancewassetat

100c mH

2

O/L/s,andb reathi ngfrequencywassetat40

breaths/min;fortheinfan tmodel, comp liancewasset at1.5 mL/cmH 2

O,r esistancewassetat50 cmH

2

O/L/s,and

breathingfrequenc ywassetat30brea ths/mi n. 12,13 ADra¨gerV 500venti lator(Dra¨gerMed ical)wassetin

CPAPmodew ithl eakcompensa tionturnedon. NinePEEP

levels(5,6,8, 10,12,14, 16,18, an d20cm H 2

O) weretes ted

for3mi neach toall ow forsy stemequilib ration. Data abstractedfrom thelast5b reathswer eutili zedf ortheanalyses. HighPE EPlevelsw eretestedt odetermine whetherleveling offor ar educ tioninflowoccur red,w hichmayind icateback pressurefromre sistanc einthecannulae.

Pressure andFlow Measurements

The P aw wasm easuredat3locations :atth ev entilator,at thec ircuitY-piece,a ndatthenasalmodel(F ig.2). Pres sure transducers(HansRudolp h)wereconnec tedattheventi lator

Y-pieceandatt henas almode ltom easurethe

P aw in these locations.Flowvalue swerer ecordedwit haflowsens or (HansRudolph) placedbe tweenthenas almodelandthe

ASL5000t om easur etheflowduringthee ntire breath

cycle(Fi g.2).Thecont inuouss inusoid alpressureandfl ow waveformswerecap tured withPowerLabso ftware (ADInstruments,ColoradoSprings,C olorado)(Fig. 3). Criticalcare ventilators increaseinspiratoryfl owtocom- pensateforde tected airwayleakandac hievetarget pressure levels.Inthis stu dy,the peakinspirato ryflowwa s

QUICKLOO K

Currentknowled ge

Thereare manyinte rfaces usedtodelivernonin vasive respiratorysupportto infants.Thefit and qualityofthe interfacecanaffe ctthe pressuredeliv eredto thepatient.

Whatthi spapercont ributesto ourknowledge

Aftercom paringsetversusdel ivered pressureswith

RAMca nnulatothesame paramet erswith classic

occlusivenasal prongs,our resultsindicatethat the

RAMcan nuladidnotac hieve setpre ssureswithall

sizesand allset pressure ranges . MsN apolitano,MsNickel,a ndMr McDonoughare affiliated withthe DepartmentofRespira to ryTherapy,Children'sHos pitalofPhilade lphia, Philadelphia,Pennsylvania .MsRobertsisaffiliatedwiththeDepartment of RespiratoryTherapy,Lucile PackardChildren's Hospital, Stanford, California. MsSun isaffiliated withthe Pennsylvania StateCollege of Medicine,Hershey, Pennsylvania. MsFengisaffiliated withthe Departmentof Biostatistics, EpidemiologyandInformati cs,University of Pennsylvania,Philadelphia, Pennsylvania.DrsJensen andDysartare affiliated withthe Divisionof Neonatology, Children'sHospital of Philadelphia,Philadelp hia,Pennsylvania.Dr Linisaffiliatedwith the Division ofAnesthe siaandCriticalCare, Children's Hospitalof

Philadelphia,Philadelp hia,Pennsylvania.

Ms Napolitanopresented aversion ofthis paperat AARCCongress

2015, heldNovember 6-9,2015 inTampa, Florida,and atthe Pediatric

Academic Society/SocietyPediatricResearch, heldApril 30-May3,

2016 inBaltimore, Maryland.

Ms Napolitanohasdisclosed relationships withAerogen, Dra

¨ger

Medical, Vero-Biotech,SmithsMedical, andPhilips/R espironics.Ms Nickel hasdisclosed arelationship withNihon Kohden.The remaining authors havedisclosed noconflicts ofinterest. Correspondence:Natalie NapolitanoMPH RRTRRT-NPS, Children's Hospital ofPhiladelphia, Respiratory TherapyDepartment,Room

7NW149, 3401Civic CenterBlvd, Philadelphia, PA19104. E-mail:

napolitanon@email.chop.edu.

DOI:10.4187/respcare.09018

NASALPRONGINTERFACE FORCPAP DELIVERY

2RESPIRATORYCARE???VOL?NO?RESPIRATORY CARE Paper in Press. Published on July 6, 2021 as DOI: 10.4187/respcare.09018Copyright (C) 2021 Daedalus Enterprises ePub ahead of print papers have been peer-reviewed, accepted for publication, copy edited

and proofread. However, this version may differ from the final published version in the online and print editions of RESPIRATORY CARE

measuredatea chPEEP leveltoasse ssthelevel ofleak compensationamongtheva riousnasalpro ngdevic es.The peakinsp iratoryflowatthenas almodelwa sme asured fromth esinuso idalwaveformscapt uredwithPowerLab software.Peakin spiratoryfl owwasmeasuredateac h PEEPle veltodeterm ine theactualflowdel ivered tocom- pensateforth eleaka ndatte mpttoma intain setPEEP.

Statistical Analysis

Datafr omthela st5bre athsof eac hexperimentwere

abstractedfromthev entilator andsinu soidalwaveforms recordedbytheP owe rLabso ftwareandsumma rizedwi th standarddescrip tivestatistics.Differenc esinthesetversus deliveredmeasures werecalculatedby subtrac tingtheaver- aged elivered P aw fromt hesetCP APlevel .Linea rregres- sione xaminedtheassocia tionb etweenthesetandachie ved P aw valuesacro sstherange ofstudi edCPAPleve ls.

Results

A totalof3 ,780bre athswereca ptured,andvalue sfrom

210br eathswereanalyz ed.Whe nthesedataweresumma r-

izedac rossallna salint erfaces,theave rage P aw measuredatth eY-piec epriortoCPAPc annulaequ ipme ntappro xi- matedthe setCPAP levels (meand ifference-0.12 cmH 2 O, range-0.6 6to0.40).Si mila rresultswe reobtainedwhe n stratifyingbynasalin terf aceanda crosstherangeofstud ied CPAPle vels(Table1 ).Thesedatac onfirma dequatedeli v- eryo ftheta rgetCP APleveldirect lyproxi maltothena sal interfaceequipme nt.

Table2sh ows theaverag e

P aw valuesmeas uredatthe testn areschamber versusthesetCPAP levelforeach nasal pronginterf ace.Acrossthestudied prongsize sandCP AP levels,theDr a

¨gerpron gsproduced average

P aw valuesthat werewi thin0.20c mH 2

O (range-0.10to 0.35)ofthe set

CPAPle vels.Incontrast ,th e

P aw valuesprodu cedwiththe

RAMc annulaewere,onavera ge,8.5cm H

2

O (range-15

Fig.1. Nasa lmodels.

Pressure

Pressure

Flow

Signal Input

Conversion and

storage with

PowerLab

Software

Model nares

Flow transducer

Lung simulatorVentilator Fig.2. Expe rimentmodelsetup. *Indicateallth elocationsofpr essuremeasurement s. Fig.3. Sin usoidalflowwaveform.In spiratio nisindicatedbynega - tiveflow asthea rrow indicat esplacement forpeakinspiratory flow measurements.

NASALPRONGINTERFACE FORCPAP DELIVERY

RESPIRATORYCAREVOLNO3RESPIRATORY CARE Paper in Press. Published on July 6, 2021 as DOI: 10.4187/respcare.09018Copyright (C) 2021 Daedalus Enterprises ePub ahead of print papers have been peer-reviewed, accepted for publication, copy edited

and proofread. However, this version may differ from the final published version in the online and print editions of RESPIRATORY CARE

to -3.5)below thesetCPAP level. Thise quated toanaver- ageCP APdeliv eryofonly27%(ra nge 13%to42%) ofthe setta rget.Witheac hoftheRA Mcannula e,the absolute differencebetween thedesiredanddel ivered P aw increased withg reatersetCPAPleve l(Fig. 4).For instance, withthe

CPAPsetto5cm H

2

O, the3RA Mca nnulae achievedaver-

aged elivered P aw valuesatthete stna resch amberof 0.6-

1.5c mH

2

O (3.5-4.4cmH

2

O belowtarget level).Withth e

ventilatorsettoaCP APof20 cmH 2

O, theRAM cannul ae

achievedaverag edelivered P aw valuesof5-8.4 cm H 2 O (11.7-15cmH 2

O belowtarget level).Togene rateanaver-

aged elivered P aw of$5cmH 2

O requiredasetCP AP

levelof14 cm H 2

O withthe preemi eRAMinterfaceand

18-20cm H

2

O withthe newbor nandinfantRAMdevi ces

(Fig.4).

Table3sh ows themaximu minspir atoryflowmeasure d

betweenthenasa lmodel andthelung simulator foreac hset CPAPle vel.Therewere minimaldiff erence sinthemeas-quotesdbs_dbs25.pdfusesText_31

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