Download PDF
Am J Perinatol 2021; 38(11): 1167-1173
DOI: 10.1055/s-0040-1710557
Original Article

Use of the RAM Cannula with Early Bubble Continuous Positive Airway Pressure Requires Higher Pressures: Clinical and In vitro Evaluations

Colleen C. Claassen
1   Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, Missouri
,
Marya L. Strand 
1   Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, Missouri
,
Howard L. Williams
2   SSM Health Systems, SSM Health Cardinal Glennon Children's Hospital, St. Louis, Missouri
,
Noah H. Hillman
1   Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, Missouri
› Author Affiliations Funding Internal funding was received from the SSM Cardinal Glennon Foundation.
› Further Information
    Permissions and Reprints

Abstract

Objective Early bubble continuous positive airway pressure (bCPAP) in the delivery room (DR) reduces early intubation, mechanical ventilation, and bronchopulmonary dysplasia. The RAM cannula, adopted for ease of patient care, is a high resistance nasal interface that, when used with bCPAP, only transmits a portion of set pressures and attenuates the bubble effects. This study aimed to review early bCPAP pressures and bCPAP failure with the RAM cannula interface over a 6-year period.

Study Design Retrospective, single-center study of infants delivered <1,250 g from 2013 to 2018 (n = 735) begun on bCPAP in the DR with the RAM cannula. In vitro testing of bCPAP pressure transmission was also performed for multiple nasal interfaces and nasal occlusion percentages.

Results The percentage of infants intubated in the DR decreased over time (59 to 42%), while the average bCPAP pressure increased from 5.3 to 6.8 cmH2O. A total of 355 infants (48%) were admitted to the neonatal intensive care unit (NICU) from the DR on BCPAP. The failure rate for bCPAP in NICU within 72 hours decreased from 45 to 24% as the maximum CPAP increased from 5.8 to 7.6 cmH2O. Pneumothorax rates did not change. CPAP pressure transmission decreased with all sizes of the RAM cannula.

Conclusion When utilizing the RAM cannula for bCPAP, higher CPAP levels were associated with decreases in DR intubations and CPAP failure within the first 72 hours. If clinicians choose to use the RAM cannula for bCPAP, they will need higher set pressures to achieve lung inflation and the beneficial oscillatory effect will be diminished.

Key Points

  • The transmission of the pressure oscillations from bubble CPAP is diminished with the RAM cannula.

  • Increasing set CPAP pressures was associated with a decreased delivery room intubation rate and a decreased CPAP failure rate within 72 hours.

  • Clinicians using the RAM cannula for bCPAP will need to increase pressures to obtain adequate lung inflation or change to a nasal interface designed for bCPAP.

Keywords

delivery room intubation - CPAP failure - CPAP pressure - bubble CPAP

Note

The retrospective study was conducted on deidentified data from the medical record in accordance with the Saint Louis University Institutional Review Board (IRB # 30328).


Authors' Contributions

C.C.C., M.L.S., and N.H.H. generated the study design, collected the data from the medical record, analyzed the data, and drafted the manuscript. Mr. Williams and Dr. Hillman determined the Microsoft SQL Server code for data extraction. All authors have approved the manuscript for submission.




Publication History

Received: 15 November 2019

Accepted: 09 April 2020

Article published online:
23 May 2020

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Gupta S, Donn SM. Continuous positive airway pressure: physiology and comparison of devices. Semin Fetal Neonatal Med 2016; 21 (03) 204-211
    CrossrefPubMedGoogle Scholar
  • 2 Gregory GA, Kitterman JA, Phibbs RH, Tooley WH, Hamilton WK. Treatment of the idiopathic respiratory-distress syndrome with continuous positive airway pressure. N Engl J Med 1971; 284 (24) 1333-1340
    CrossrefPubMedGoogle Scholar
  • 3 Poli JA, Richardson CP, DiBlasi RM. Volume oscillations delivered to a lung model using 4 different bubble CPAP systems. Respir Care 2015; 60 (03) 371-381
    CrossrefPubMedGoogle Scholar
  • 4 Pillow JJ, Hillman N, Moss TJ. et al. Bubble continuous positive airway pressure enhances lung volume and gas exchange in preterm lambs. Am J Respir Crit Care Med 2007; 176 (01) 63-69
    CrossrefPubMedGoogle Scholar
  • 5 Diblasi RM, Zignego JC, Smith CV, Hansen TN, Richardson CP. Effective gas exchange in paralyzed juvenile rabbits using simple, inexpensive respiratory support devices. Pediatr Res 2010; 68 (06) 526-530
    CrossrefPubMedGoogle Scholar
  • 6 Morley CJ, Lau R, De Paoli A, Davis PG. Nasal continuous positive airway pressure: does bubbling improve gas exchange?. Arch Dis Child Fetal Neonatal Ed 2005; 90 (04) F343-F344
    CrossrefPubMedGoogle Scholar
  • 7 Claassen CC, Hillman NH, Brown K, Williams HL, Strand ML. Comparison of bubble CPAP devices using RAM cannula for extubation failure in very low birth weight infants: randomized and cohort studies. Neonatology 2019; 115 (01) 28-35
    CrossrefPubMedGoogle Scholar
  • 8 Wright CJ, Sherlock LG, Sahni R, Polin RA. Preventing continuous positive airway pressure failure: evidence-based and physiologically sound practices from delivery room to the neonatal intensive care unit. Clin Perinatol 2018; 45 (02) 257-271
    CrossrefPubMedGoogle Scholar
  • 9 Narendran V, Donovan EF, Hoath SB, Akinbi HT, Steichen JJ, Jobe AH. Early bubble CPAP and outcomes in ELBW preterm infants. J Perinatol 2003; 23 (03) 195-199
    CrossrefPubMedGoogle Scholar
  • 10 Schmölzer GM, Kumar M, Pichler G, Aziz K, O'Reilly M, Cheung PY. Non-invasive versus invasive respiratory support in preterm infants at birth: systematic review and meta-analysis. BMJ 2013; 347: f5980
    CrossrefPubMedGoogle Scholar
  • 11 Hillman NH, Moss TJ, Kallapur SG. et al. Brief, large tidal volume ventilation initiates lung injury and a systemic response in fetal sheep. Am J Respir Crit Care Med 2007; 176 (06) 575-581
    CrossrefPubMedGoogle Scholar
  • 12 Fischer HS, Bührer C. Avoiding endotracheal ventilation to prevent bronchopulmonary dysplasia: a meta-analysis. Pediatrics 2013; 132 (05) e1351-e1360
    CrossrefPubMedGoogle Scholar
  • 13 Katheria A, Poeltler D, Durham J. et al. Neonatal resuscitation with an intact cord: a randomized clinical trial. J Pediatr 2016; 178: 75-80.e3
    CrossrefPubMedGoogle Scholar
  • 14 Green EA, Dawson JA, Davis PG, De Paoli AG, Roberts CT. Assessment of resistance of nasal continuous positive airway pressure interfaces. Arch Dis Child Fetal Neonatal Ed 2019; 104 (05) F535-F539
    CrossrefPubMedGoogle Scholar
  • 15 De Paoli AG, Davis PG, Faber B, Morley CJ. Devices and pressure sources for administration of nasal continuous positive airway pressure (NCPAP) in preterm neonates. Cochrane Database Syst Rev 2008; (01) CD002977
    PubMedGoogle Scholar
  • 16 Gerdes JS, Sivieri EM, Abbasi S. Factors influencing delivered mean airway pressure during nasal CPAP with the RAM cannula. Pediatr Pulmonol 2016; 51 (01) 60-69
    CrossrefPubMedGoogle Scholar
  • 17 Singh N, McNally MJ, Darnall RA. Does the RAM cannula provide continuous positive airway pressure as effectively as the Hudson prongs in preterm neonates?. Am J Perinatol 2019; 36 (08) 849-854
    Article in Thieme ConnectPubMedGoogle Scholar
  • 18 Mukerji A, Belik J. Neonatal nasal intermittent positive pressure ventilation efficacy and lung pressure transmission. J Perinatol 2015; 35 (09) 716-719
    CrossrefPubMedGoogle Scholar
  • 19 Drescher GS, Hughes CW. Comparison of interfaces for the delivery of noninvasive respiratory support to low birthweight infants. Respir Care 2018; 63 (10) 1197-1206
    CrossrefPubMedGoogle Scholar
  • 20 Parry G, Tucker J, Tarnow-Mordi W. UK Neonatal Staffing Study Collaborative Group. CRIB II: an update of the clinical risk index for babies score. Lancet 2003; 361 (9371): 1789-1791
    CrossrefPubMedGoogle Scholar
  • 21 Hodgson KA, Manley BJ, Davis PG. Is nasal high flow inferior to continuous positive airway pressure for neonates?. Clin Perinatol 2019; 46 (03) 537-551
    CrossrefPubMedGoogle Scholar
  • 22 Gokce IK, Kaya H, Ozdemir R. A randomized trial comparing the short binasal prong to the RAM cannula for noninvasive ventilation support of preterm infants with respiratory distress syndrome. J Matern Fetal Neonatal Med 2019; 1-7 . doi: 10.1080/14767058.2019.1651268. (Epub ahead of print)
    PubMedGoogle Scholar
  • 23 Matlock DN, Bai S, Weisner MD. et al. Tidal volume transmission during non-synchronized nasal intermittent positive pressure ventilation via RAM® cannula. J Perinatol 2019; 39 (05) 723-729
    CrossrefPubMedGoogle Scholar
  • 24 Ammari A, Suri M, Milisavljevic V. et al. Variables associated with the early failure of nasal CPAP in very low birth weight infants. J Pediatr 2005; 147 (03) 341-347
    CrossrefPubMedGoogle Scholar
  • 25 Moya FR, Mazela J, Shore PM. et al; Preterm Neonate Early Respiratory Management Prospective Observational Study investigators. Prospective observational study of early respiratory management in preterm neonates less than 35 weeks of gestation. BMC Pediatr 2019; 19 (01) 147
    CrossrefPubMedGoogle Scholar
  • 26 Dargaville PA, Gerber A, Johansson S. et al; Australian and New Zealand Neonatal Network. Incidence and outcome of CPAP failure in preterm infants. Pediatrics 2016; 138 (01) e20153985
    CrossrefPubMedGoogle Scholar
  • 27 Fuchs H, Lindner W, Leiprecht A, Mendler MR, Hummler HD. Predictors of early nasal CPAP failure and effects of various intubation criteria on the rate of mechanical ventilation in preterm infants of <29 weeks gestational age. Arch Dis Child Fetal Neonatal Ed 2011; 96 (05) F343-F347
    CrossrefPubMedGoogle Scholar
  • 28 Jourdain G, De Tersant M, Dell'Orto V, Conti G, De Luca D. Continuous positive airway pressure delivery during less invasive surfactant administration: a physiologic study. J Perinatol 2018; 38 (03) 271-277
    CrossrefPubMedGoogle Scholar