CPAP Continuous Positive Airway Pressure Introduction: Premature baby’s lungs lack surfactant and that leads to Respiratory Distress Syndrome (RDS). The lungs of such premature baby have decreased lung compliance – “ stiff lungs”. The alveoli of such lung tends to collapse, reducing overall lung volume. This leads to areas that are poorly ventilated and unable to participate in gas exchange. Babies attempt to compensate by exaggerated use of accessory muscles of breathing in order to pull air into the lungs during inspiration & also by expiring against close glottis which generates a characteristic ‘grunt’. Applying CPAP keeps alveoli open and increases FRC and improves oxygenation. CPAP also helps in reducing apnea in such babies . Thus Continuous positive airway pressure (CPAP) is a simple, inexpensive and gentle mode of respiratory support in preterm very low birth weight (VLBW) infants. Indication: Respiratory distress, such as tachypnea, flaring, grunting, retractions, cyanosis, atelectasis, and increased oxygen requirements. Diseases with low FRC, such as RDS Transient tachypnea of the newborn. Pulmonary edema, Meconium aspiration syndrome, Airway closure diseases such as BPD and bronchiolitis, Apnea and bradycardia of prematurity, Weaning from mechanical ventilation, Tracheomalacia, and Diaphragmatic paralysis Bubble CPAP is a unique, simple, inexpensive way of providing continuous positive pressure to infants Items required: (Basic parts of CPAP) : Bubble CPAP setup demonstrating what a completed bubble CPAP circuit looks like, minus the connections to a flow meter and an oxygen blender. Used with permission from Karla Ferrelli,Vermont Oxford Network. PROCEDURE: Set Up and Care for an Infant on Bubble CPAP Using the Hudson Prongs Set up a disposable humidifier bag. Set temperature at 34-37 degree C. Attach oxygen tubing to flow meter and connect it to the humidifier. Adequate humidity prevents drying of nasal secretion. Deliver 6–10 L/min flow via a blender. 6–10 L/min flow provides enough pressure to generate bubbles in the bottle at the specified pressure; wash out carbon dioxide Set a pressure relief valve. NewbornServices Clinical Guidelines recommends 15 cm H2O pressure. Safety precaution only Attach lightweight corrugated tubing to humidifier. Tubing needs to be flexible so it is not too heavy for the infant Choose appropriate size nasal prongs and attach them to corrugated tubing Prongs should fit snugly without pinching the nasal septum Prongs too small: Increase airway resistance, increase air leaks, excess movement can cause damage to mucosa and septal erosion. Size 0: Infants < 700 g Size 1: Infants 700–1250 g Size 2: Infants 1250–2000 g Size 3: Infants 2000–3000 g Size 4: Infants >3000 g Size 5: Infants >3500 g Attach second corrugated tubing to opposite side of prongs and occlude pressure line connection port with Luer plug or pressure tubing. Opening is designed to fit pressure tubing and manometer Secure measuring tape to outlet bottle with 0 cm at the water level and 7 cm at the bottom of the outlet bottle. Set CPAP pressure, submerge expiratory limb to the appropriate depth. Vermont Oxford Network recommends 5 cm H2O pressure, Newborn Services Clinical Guidelines recommends 6 cm H2O pressure. Continuously monitor to ensure that proper CPAP is being administered. Adjust the expiratory limb as need to account for evaporation or a change in pressure Test the system by occluding the ends of the nasal prongs. Ensures that all the connections are secure and there are no leaks in the system Perform initial assessment: Respiratory, cardiac, and neurological. Baseline observations are essential to the management of the infant. Underlying conditions may be discovered. Elevate the head of the bed by 30 degree. Place the infant’s head in optimal position; if supine, place roll under the neck. Allows for optimal airway Ensure that the infant monitored via a pulse oximetry, preferably preductal. It is import to adjust oxygen according to the preductal saturations because of a possible right-to-left shunting Gently suction the infant’s mouth and nose. Use the largest size catheter, ie, 8-French OG tube. Clears secretions. Ensures that the nares are clear and helps maintain patent nares Place a snug fitting hat with a 1-in brim on the infant’s head. The hat holds the prongs in place. Moisten prongs with sterile water or saline drops before placing them curve side down into the infant’s nose. The prongs should fit snugly—adjust the angle of the prongs and the tubing. Curve side down is anatomically correct. The tubing should not be touching the infant’s face and the bridge of the prongs should not be touching the septum The prongs should not go all the way in the nares, just enough to occlude them. Pass an 8-French OG tube. The OG tube would keep the stomach decompressed and increase the infant’s comfort. Secure the CPAP tubing to the hat. Vermont Oxford Network recommends using safety pins and rubber bands rather than foam and a strap, decreases molding and keeps the prongs in the nares more securely. This allows the prongs to stay in place during the infant’s head movement. Position a chin strap, made from soft gauze and taped using nonelastic tape to the sides of the hat. A pacifier can also be used in its place, keeping the mouth gently closed. The strap should not prevent infant yawning or crying. An open mouth is the biggest reason for air leaks in the bubble CPAP system. The baby would still be able to open his or her mouth and yawn. The strap is removed for feedings and for oral care. 4–6 h after having bubble CPAP on, apply a Velcro mustache (the hook side) on top of Tegaderm (or thin DuoDerm) on the upper lip. It should be thin across the upper lip and wider on each cheek. Then place 2 thin strips of Velcro (the soft side) on either end of the Hudson prongs. After 6 h, the amount of oral secretions would start to decrease, making it easier to keep the Velcro mustache on. The Velcro mustache acts as a stabilizer for the Hudson prongs. Ongoing assessments of respiratory, cardiac, neurological, integumentary, and gastrointestinal tract systems. Provides information for decision relative to the infants care. Able to help predict as the infant is improving or decompensating. Airway care, including positioning, and suctioning every 3 hrs. Gentle suctioning of the mouth, nose, and pharynx helps maintain an open airway. Settle the infant by proving boundaries, containment, pacifiers, swaddling, clearing his or her airway, and/or aspirating gastric air; hands off. A quiet infant is less distressed. Feeding an infant on bubble CPAP is not contraindicated. Infants may require to have gastric air aspirated before bolus feeds or intermittently during continuous feedings. Infants are also allowed to receive oral feedings by breast or bottle. Aspirating air removes excess gastric air, removing pressure from the diaphragm. Infants on bubble CPAP should be repositioned every 2–4 hrs. May be positioned prone, supine, or side-lying with appropriate support. Changing the infant’s position is essential to maintaining skin integrity and neurological development. Troubleshooting bubble CPAP. Systematically check the system from the wall to the outlet bottle. Being familiar with the working of bubble CPAP would enable the nurse to problem solve issues that arise. Hudson prongs attached to corrugated tubing to make up the bubble CPAP circuit. It is essential that the prongs be of the correct size before placing them in the infant’s nares. Used with permission from Karla Ferrelli, Vermont Oxford Network. Water bottle setup with measuring tape on the side of the bottle demonstrating how the outlet bottle with the measuring tape would appear. Notice the level at which the expiratory limb rests dictates the level of CPAP the infant receives, not the volume of water in the bottle. Used with permission from Karla Ferrelli, Vermont Oxford Network. Premature infant with the Hudson prongs in place. Notice how the bridge of the prongs do not touch the nasal septum and are supported by the Velcro mustache. In addition, the infant’s hat is snug and the corrugated tubing is secured with the safety pins and rubber band. Used with permission from Dr Jen-Tien Wung, Department of Pediatrics, Columbia University Medical Center. Monitoring the Infant’s Condition • Once NCPAP is applied, the infant’s condition must be monitored frequently • Observe the infant 1 hrly over the first 4 hours of life, and then 3-4 hrly thereafter while on NCPAP. • Any infant experiencing significant respiratory distress while on NCPAP requires closer observation for change in condition. Recommended monitoring: • Respiratory status (RR, work of breathing) • Pre ductal oxygen saturation. Right hand. • Cardiovascular status (HR, BP, perfusion) • GI status (abdominal distention, bowel sounds) • Neurological state (tone, activity, responsiveness) • Thermoregulation (temp) Maintaining Optimal Airway Care: Suctioning • Suction the mouth, nose and pharynx 3 hrly • For symptomatic infants more frequent suctioning may be needed • Moisten the nares with normal saline or sterile water to lubricate the catheter and loosen dry secretions.It may be necessary to pass the suction catheter more than once to ensure adequate airway clearance. Maintaining Optimal Airway Care: Humidification • Maintain adequate humidification of the circuit to prevent drying of secretions. • Adjust settings to maintain gas humidification at or close to 100%. • Set the humidifier temperature to 36.8-37.3 degree C. COMPLICATIONS: Prevent complications Complications associated with bubble nasal CPAP ● Pneumothorax / PIE - more in the acute phase - not a contraindication for continuing CPAP ● Nasal obstruction - Remove secretions and check for proper positioning of the prongs ● Nasal septal erosion or necrosis - Keep prongs away from the septum ● Gastric distension Intermittent or continuous aspiration of the stomach ● Feeding intolerance Preventing Complications: Nasal Septal Injury • Septal injury is preventable • Damage to the septum arises when poorly fitted or mobile prongs cause pressure and/or friction. • Excess moisture from gels, lubricants or duoderm-like products undermines the skin integrity. • Avoiding these factors will maintain an intact septum To prevent damage to the nasal septum: • Evaluate the nasal septum every 30-60 min. • Use correct prong size • Secure prongs in place correctly • Use Velcro mustache To prevent damage to the nasal septum: • Maintain distance of 2-3 mm between bridge of prongs and septum • Avoid twisting of prongs • Do not use creams, gels, ointments or adhesive barriers on the septum Preventing Complications: Gastric Distention • NCPAP is not a contraindication to enteric feeding. • Infants may experience mild abdominal distention during NCPAP delivery from swallowing air. To prevent gastric distention: • Assess the infant’s abdomen regularly • Pass an oro-gastric tube to aspirate excess air before feeds 2-4 hrly • An 8 F oro-gastric tube may be left indwelling to allow for continuous air removal • If feeding continuously consider venting the tube 2hrly. • Place the infant prone with knees under the chest to relieve gastric pressure and encourage passing of stools and flatus. Preventing Complications: Pneumothorax • Pneumothorax, if occurs, is likely to occur during the acute phase of respiratory distress • Pneumothorax is usually not due to NCPAP and is not a contraindication to continuing NCPAP Positioning While on NCPAP • The infant on NCPAP may be positioned supine, prone, or side lying • When positioning supine or side lying support airway alignment with a neck roll. • When positioning prone place a chest pad under the infant. • Make a firm pad using linen which is the same size as the infant’s chest • Do not use beanbags or gel pillows under the chest as these will not provide adequate support Phototherapy While on NCPAP • The infant may receive phototherapy while on NCPAP • Place the eye patches over the eyes and secure them with paper tape to the tubing or hat • Do not allow the eye patches to obstruct your view of the nasal septum and prongs Evaluating the Performance of the NCPAP Delivery System • The NCPAP system must be evaluated for optimal performance • From the flow meter to the nasal prongs to the bubble bottle; check the entire delivery circuit • Evaluate the system 2-3 hrly. • Use a bedside Checklist that lists the key points necessary to maintain effective CPAP. Weaning Considerations: There is a lack of empirical evidence on how to wean an infant from bubble CPAP. As infants recover from the acute phase of RDS, their oxygen requirement will decrease and their blood gases will begin to improve. Weaning may be performed based on blood gas values until the infant reaches a CPAP of 4 with a minimal oxygen requirement. At this time, the infant may be ready to be placed on a nasal cannula. This weaning process will vary based on the severity of the disease and the guidelines of the institution. The most important variable is infant status. Infant behavior will dictate need. Contraindications: Need for ventilation because of ventilatory failure- Inability to maintain oxygenation and arterial PaCo2 < 8kPa and pH > 7.25 Upper airway abnormality like cleft palate, choanal atresia Tracheo-esophageal atresia Diaphragmatic hernia Sever cardiovascular instability KEY POINTS FOR MAINTAINING OPTIMAL NCPAP • Correctly set up and maintain low resistance delivery circuit • Securely attach interface • Assure minimal pressure leaks • Maintain optimal airway • Prevent nasal septal injury • Provide meticulous attention to detail • Resist the temptation to ‘improve’ the system • Encourage committed and skilled caregivers References: The Nursing Care of the Infant Receiving Bubble CPAP Therapy Krista M. Bonner, RNC, MSN, NNP,1 and Rosalie O. Mainous, RNC, PhD, NNP2 Advances in Neonatal Care April 2008 Volume 8 Number 2 Pages 78 – 95. with due acknowledgement the main material is from this article. Accessed on advancesinneonatalcare.org earlybubblecpap Hamilton B, Martin J, Ventura S, Sutton P, Menacker F. Division of Vital Statistics. Births: Preliminary Data for 2004. Atlanta, GA: Centers for Disease Control and Prevention; 2005. Report No. 54.2. Zukowsky K. Respiratory distress. In: Verklan M, Walden M, eds. Core Curriculum for Neonatal Intensive Care Nursing. 3rd ed. St. Louis, MO: Elsevier Saunders; 2005:487—523.3. Avery ME, Tooley WH, Keller JB, et al. Is chronic lung disease in low birth weight infants preventable? A survey of eight centers. Pediatrics. 1987;79:26—30.4. Van Marter LJ, Allred EN, Pagano M, et al. Do clinical markers of barotraumas and oxygen toxicity explain interhospital variation in rates of chronic lung disease? Pediatrics. 2000;105:1194—1201. Woodgate PG, Davies MW. Permissive hypercapnia for the prevention of morbidity and mortality in mechanically ventilated newborn infants. Cochrane Database Syst Rev.. 2001. mrw.interscience.wiley. com.proxy.library.vanderbilt.edu/cochrane/clsysrev/articles/CD002061/frame.html. Accessed July 17, 2006. Jobe AH, Kramer BW, Moss TJ, Newnham JP, Ikegami M. Decreased indicators of lung injury with continuous positive expiratory pressure in preterm lambs. Pediatr Res. 2002;52:387—392. Lee KS, Dunn MS, Fenwick M, Shennan AT. A comparison of underwater bubble continuous positive airway pressure with ventilator-derived continuous positive airway pressure in premature neonates ready for extubation. Biol Neonate. 1998;73:69—75.
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