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Editor—The neonatal unit at St George’s hospital, London, recently reported their findings of nasal trauma associated with nasally applied treatment using continuous positive airway pressure (NCPAP).1 They reported that 20 per cent of the very low birthweight infants treated in this way developed nasal injury. The equipment used was the Infant Flow system.
These figures are shocking and inconceivable. For many years NCPAP has been used extensively with this technique at the neonatal units in our hospitals, the Karolinska Institute, Stockholm, Sweden, and the county hospital in Östersund, Sweden. NCPAP has been given to infants weighing upwards of 430 g at birth. The duration of treatment has varied from a few hours, up to two or three months, in a few cases. One patient has been receiving NCPAP for six months. A total of about 750 infants have been treated (Stockholm 500, Östersund 250), and as yet, we have not experienced any kind of nasal injury. Only very occasionally have we seen minor nasal trauma (< 1%), and this has healed without complications. In fact, one patient (a boy weighing 577 g at birth) transferred from another hospital with a severely swollen mucosal nasal lining that had been caused by a conventional NCPAP device (Argyle cannula). This injury healed completely, even during continued NCPAP treatment, during which the patient was treated using the Infant Flow device.
From our experience, we are convinced that nursing is critical to the handling of NCPAP. No matter how well the equipment is designed, if it is applied with sufficient pressure to the skin to impair the circulation of the underlying tissues, trauma is the inevitable risk. The silastic prongs in the Infant Flow have therefore been designed to seal without applying any major pressure to the nose, provided the right size is chosen—that is, the largest size to fit into the nostrils. However, an varying gas leak through the patient’s mouth and at the nasal attachment is an unavoidable consequence of the method of nasal administration itself. The efficacy of a treatment therefore depends on the capacity of the pressure generator to maintain the CPAP level, even when there is a clinically significant leakage of breathing gas.
The Infant Flow device has been designed to cope with moderate air leaks without significantly altering the level of CPAP.2The positive upper airway pressure can be monitored directly through the device, a fall in pressure due to a major persisting leak can be compensated for by increasing the gas flow in case the nasal attachment cannot be sufficiently sealed with careful adjustment.
NCPAP allowed us to reduce the requirement for mechanical ventilation and so reduce the risk of baro/volutrauma and bronchopulmonary dysplasia.3 In the Stockholm area only about 40% of the very low birthweight infants are mechanically ventilated compared with 70 to 80% in the US and the UK, thanks to NCPAP.