title: Evaluating the Effect of Flow and Interface Type on Pressures Delivered With Bubble CPAP in a Simulated Model.
abstract: BACKGROUND
  Bubble CPAP, used for spontaneously breathing infants to avoid intubation or postextubation support, can be delivered with different interface types. This study compared the effect that interfaces had on CPAP delivery. We hypothesized that there would be no difference between set and measured levels between interface types.
  
  
  METHODS
  A validated preterm infant nasal airway model was attached to the ASL 5000 breathing simulator. The simulator was programmed to deliver active breathing of a surfactant-deficient premature infant with breathing frequency at 70 breaths/min inspiratory time of 0.30 s, resistance of 150 cm H2O/L/s, compliance of 0.5 mL/cm H2O, tidal volume of 5 mL, and esophageal pressure of -10 cm H2O. Nasal CPAP prongs, size 4030, newborn and infant RAM cannulas were connected to a nasal airway model and a bubble CPAP system. CPAP levels were set at 4, 5, 6, 7, 8, and 9 cm H2O with flows of 6, 8, and 10 L/min each. Measurements were recorded after 1 min of stabilization. The analysis was performed using SAS 9.4. The Kolmogorov-Smirnov test assessed normality of the data. The Friedman test was used to compare non-normally distributed repeated measures. The Wilcoxon signed-rank test was used to conduct post hoc analysis. All tests were 2-sided, and P values of <.05 were considered as indicating significant differences unless otherwise indicated.
  
  
  RESULTS
  At lower set CPAP levels, 4-6 cm H2O, measured CPAP dropped precipitously with the nasal prongs with the highest flow setting. At higher CPAP levels, 7-9 cm H2O measured CPAP concomitantly increased as the flow setting increased. Statistically significant differences in set and measured CPAP occurred for all devices across all CPAP levels, with the measured CPAP less than set for all conditions, P < .001.
  
  
  CONCLUSIONS
  Set flow had a profound effect on measured CPAP. The concomitant drop in measured pressure with high and low flows could be attributed to increased resistance to spontaneous breathing or insufficient flow to meet inspiratory demand. Clinicians should be aware of the effect that the interface and flow have on CPAP delivery.
authors.affiliation: Simulation Center of Safety and Reliability.
authors.forename: Stephanie A
authors.initials: SA
authors.lastname: Bailes
authors.affiliation: Neonatology Department.
authors.forename: Kimberly S
authors.initials: KS
authors.lastname: Firestone
authors.affiliation: Department of Respiratory Care.
authors.forename: Diane K
authors.initials: DK
authors.lastname: Dunn
authors.affiliation: Rebecca D Considine Research Institute.
authors.forename: Neil L
authors.initials: NL
authors.lastname: McNinch
authors.affiliation: Rebecca D Considine Research Institute.
authors.forename: Miraides F
authors.initials: MF
authors.lastname: Brown
authors.affiliation: Nursing Administration, Akron Children's Hospital, Akron, Ohio. tvolsko@chmca.org.
authors.forename: Teresa A
authors.initials: TA
authors.lastname: Volsko
mesh_terms: D000072601:Cannula; D045422:Continuous Positive Airway Pressure / Q000295:instrumentation*; D004867:Equipment Design; D004947:Esophagus / Q000502:physiology; D006801:Humans; D007231:Infant, Newborn; D007234:Infant, Premature; D008953:Models, Anatomic; D011312:Pressure; D012119:Respiration; D013990:Tidal Volume; D012122:Ventilators, Mechanical
keywords: bubble CPAP; flow dependence; lung model; nasal prongs; noninvasive ventilation; respiratory distress syndrome