title: Effects of condensate in the exhalation limb of neonatal circuits on airway pressure during bubble CPAP.
abstract: BACKGROUND
  Bubble CPAP is frequently used in spontaneously breathing infants with lung disease. Often bubble CPAP systems lack pressure alarms and pressure-release valves. We observed a large volume of condensate in the exhalation limb of a patient circuit and conducted a series of experiments to test the hypothesis that accumulated condensate could affect delivered pressures.
  
  
  METHODS
  An anatomically accurate nasal airway model of a preterm infant was attached to a spontaneously breathing lung model. A bubble CPAP system was attached to the nasal airway with bi-nasal short prongs, and the rate of fluid condensation was measured. Next, tracheal pressures were monitored digitally to detect changes in airway pressure related to condensate accumulation. Measurements were obtained with volumes of 0, 5, 10, 15, and 20 mL of water in the exhalation limb, at flows of 4, 6, 8, and 10 L/min. Measurements with 20 mL in the exhalation limb were recorded with and without a pressure-relief valve in the circuit.
  
  
  RESULTS
  The rate of condensate accumulation was 3.8 mL/h. At volumes of ≥ 10 mL, noticeable alterations in the airway pressure waveforms and significant increases in mean tracheal pressure were observed. The pressure-relief valve effectively attenuated peak tracheal pressure, but only decreased mean pressure by 0.5-1.5 cm H2O.
  
  
  CONCLUSIONS
  Condensate in the exhalation limb of the patient circuit during bubble CPAP can significantly increase pressure delivered to the patient. The back and forth movement of this fluid causes oscillations in airway pressure that are much greater than the oscillations created by gas bubbling out the exhalation tube into the water bath. We recommend continuously monitoring pressure at the nasal airway interface, placing an adjustable pressure-relief valve in the circuit, set to 5 cm H2O above the desired mean pressure, and emptying fluid from the exhalation limb every 2-3 hours.
authors.affiliation: Center for Developmental Therapeutics, Seattle Children's Research Institute, Seattle, Washington.
authors.forename: Tiffany M
authors.initials: TM
authors.lastname: Youngquist
authors.forename: C Peter
authors.initials: CP
authors.lastname: Richardson
authors.forename: Robert M
authors.initials: RM
authors.lastname: Diblasi
mesh_terms: D000403:Airway Resistance / Q000502:physiology*; D045422:Continuous Positive Airway Pressure / Q000295:instrumentation*; D004867:Equipment Design; D006801:Humans; D052577:Infant, Extremely Low Birth Weight; D007231:Infant, Newborn; D007234:Infant, Premature; D008170:Lung Compliance; D008954:Models, Biological; D012127:Respiratory Distress Syndrome, Newborn / Q000503:physiopathology / Q000628:therapy*; D013990:Tidal Volume; D012122:Ventilators, Mechanical; D014939:Work of Breathing / Q000502:physiology*
keywords: airway pressure; bubble CPAP; condensate; lung protection; maintenance; neonatal intensive care; noninvasive ventilation; patient safety; resistance