Clinical Guideline: Management of a baby on CPAP

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1 Clinical Guideline: Management of a baby on CPAP Authors: EOE Neonatal Benchmarking Group For use in: EoE Neonatal Units Guidance specific to the care of neonatal patients. Used by: For use in neonatal units in the East of England Key Words: CPAP, positive pressure, NCPAP, Date of Ratification: July 2016 Review due: Registration No: July 2019 (or earlier in the light of new evidence) NEO-ODN Approved by: Neonatal Clinical Oversight Group 15 th April 2016 Clinical Lead Mark Dyke Approved Ratified by ODN Board: Date of meeting 6 th July 2016 I confirm that the guideline Management of a Baby on CPAP was approved at the COG on the date above and consequently ratified by the ODN Board on the date stated. S. Rattigan Neonatal ODN Director Audit Standards: Audit will be through annual benchmarking activity and consequent action planning using infant s charts and care plans to assess quality outcomes and guideline adherence. Poor scores may necessitate more frequent audits to ensure progress is being made. Page 1 of 10

2 1. Scope For use in neonatal units in the East of England. 2. Purpose To inform registered practitioners of the safe preparation and evidence based care of a baby requiring Nasal CPAP. 3. Background There are increasing numbers of low birth-weight and premature infants surviving with conditions such as chronic lung disease or bronchopulmonary dysplasia due to complications of assisted mechanical ventilation and other factors. Continuous Positive Airway Pressure (CPAP) has been used as an alternative respiratory treatment to prevent and manage lung disease in preterm infants since its development in the 1970s. 1 Many infants admitted to the neonatal unit are in need of respiratory support. NCPAP reduces the need for ventilation by increasing inspiratory and expiratory pressure reducing airway resistance. 2 The Majority of babies are preferential nose breathers, which facilitates the use of NCPAP. 4. CPAP The anatomy of premature infants places them at a much higher risk for respiratory complications. Their chest wall is very compliant and they are unable to generate enough volume to maintain their own functional residual capacity (FRC) independently, placing them at risk for extrathoracic airway collapse because of the increase in negative pressure. The premature infant's alveoli are unable to remain open and tend to collapse with diaphragmatic distention, increasing atelectasis, and decreasing tidal volumes. 3 The physiologic goal of CPAP is to improve oxygenation of the baby. Many infants who are experiencing respiratory distress tend to have asynchronous breathing, creating a see-saw motion between their chest and their abdomen. When CPAP is applied, it decreases the compliance of the chest wall and allows for synchronous breathing, resulting in decreased effort of breathing, improved gas exchange and improved cardiac function. CPAP increases the FRC by exceeding the closing capacity of the lungs, which stabilizes and prevents the collapse of alveoli. It also provides a splint to the chest wall and airway, resulting in increased lung volumes, recruitment of atelectatic alveoli, and prevention of further atelectasis. With the correct amount of CPAP, the exchange of carbon dioxide and oxygen occurs optimally at the cellular level. 3 Effects of CPAP Increase in functional residual capacity leading to an increase in PaO 2 Increases pulmonary compliance Increases spontaneous tidal volume and reduces respiratory effort Decrease in alveolar-arterial oxygen pressure gradient Prevents alveolar collapse Increases airway diameter Conserves surfactant Splints the airway Splints the diaphragm Reduces mechanical obstruction (e.g. meconium) Page 2 of 10

3 Types There are many different varieties of CPAP, each having advantages and disadvantages NCPAP - Nasal CPAP refers to a continuous fixed positive airway pressure Level applied by the machine. For example a CPAP of 5 cmh2o, delivers a pressure of 5 cm H2O continuously Assisted CPAP- Infant flow SIPAP provides bi-level nasal CPAP for the spontaneously breathing neonate through the delivery of sighs above a baseline CPAP pressure. These sighs may be timed, at a rate specified by clinicians, or triggered by patients own inspiratory efforts. Infant flow SIPAP offers a comprehensive selection of modalities to provide non-invasive ventilatory support to the neonatal patient. Certain patients may benefit from a non-certain non-invasive approach incorporating bi level nasal CPAP and avoid the need for intubation. Still others may be effectively weaned from invasive ventilation earlier with a bi level approach. There are several modes of operation: CPAP CPAP and Apnoea Trigger Biphasic Biphasic Biphasic and apnoea Bubble CPAP - Bubble CPAP is unique in that it has no audible alarms to indicate a leak in the system; it appears to generate oscillations in the premature infant's chest, which mimic the vibrations of the high-frequency oscillator. Some controversy exists about the effectiveness of these oscillations on the exchange of oxygen, respiratory rate, and work of breathing. Also, it can be modified and made mobile, allowing it to be placed on the neonate in the delivery room, thereby optimizing its use. Bubbling is created as humidified air flows at the rate of 6-10 L/min from the gas source, passes the nasal prongs to the expiratory limb, and into the water. The amount of CPAP that is administered is determined by the depth of the expiratory tubing: 1 cm is equivalent to 1 cm H 2 O pressure. Possible indications for CPAP The ultimate decision for commencement of CPAP lie with the attending medical team however, the following list provides a number of examples of when CPAP might be appropriate Significant signs of respiratory distress: o o o o o tachypnoea expiratory grunting intercostal recession, sternal recession and nasal flaring increased oxygen requirements (i.e. FiO2 >30% or 1lt/min on nasal cannula oxygen) deteriorating blood gases (i.e. ph <7.25 with evidence of CO2 retention. Apnoea & bradycardia of prematurity Atelectasis shown on x-ray Pulmonary oedema Post extubation Transient Tachypnoea of the Newborn Tracheo-malacia or other abnormality of the lower airways. Page 3 of 10

4 Contra-indications Known pneumothorax Facial and nasal abnormalities e.g., choanal atresia, cleft palate, tracheoesophageal atresia. Diaphragmatic Hernia. Larger babies often do not tolerate application of CPAP devices well, resulting in restlessness and labile oxygen requirement Complications 5. Equipment Abdominal distension increasing risk of aspiration. False pressure readings due to obstruction of nasal prongs, poor fixation, kinking, blockage from mucous plugging or increased resistance created by turbulent air flow through the prongs, artificially maintaining air pressure. Inadequate gas flow causing fluctuating baseline pressures, resulting in increased respiratory effort by the infant. Excessive flow preventing incomplete exhalation inadvertently increasing PEEP levels resulting in over-distension. Aspiration Impedance of pulmonary blood flow, increase in pulmonary vascular resistance & decrease in cardiac output Nasal irritation, septal distortion, pressure necrosis, nasal mucosal damage secondary to inadequate humidification or poor fixation of nasal prongs. Skin irritation of the head and neck from improperly secured bonnets. Lung over-distension causing air leak syndromes i.e. Pneumothorax Equipment failure including leaks, tubing blockages, alarm failures, incorrect calibration. NCPAP machine, NCPAP tubing and humidifier chamber. Bag/bottle of sterile water. Correctly sized hat using head circumference and manufacturers sizing tool. Correctly sized prongs/mask using manufacturers sizing tool. Monitoring equipment to detect heart-rate, saturations, respirations and blood pressure. Observation chart. Resuscitation equipment available Gastric Tube Page 4 of 10

5 6. Process The decision to commence NCPAP must be medically led. 1. Inform parents of need to commence NCPAP and provide written information and document. 2. Measure head circumference to determine correct hat/head gear size, using manufacturers sizing tool. 3. Ensure a snug fit. 4. Use sizing tool included within the CPAP tubing, to measure nares for correct prong/mask size:- o Prongs should fill the nares completely without stretching the skin. o Use the biggest possible size and closest septum gap. o It may be necessary to choose a smaller nares size to accommodate septum gap. o To confirm size place the prongs in the infants nostrils (briefly), prior to attaching to the nasal tubing. 5. Attach the prongs to the nasal tubing 6. Ensure machine is plugged in and gases connected and turn on. 7. Attach/open sterile bag/bottle of water to humidification unit and turn on. 8. Attach NCPAP to the baby, as per manufacturer s instructions avoiding excessive pressure on the nose, cheeks and base of neck. 9. Increase flow to achieve required pressures within manufacturer s guidelines. 10. Check NCPAP sounds can be heard in the lungs by auscultation with a stethoscope. 11. Measure and pass a gastric tube; record size, length and position of gastric tube in accordance with ward guideline. 12. Place an open syringe onto the end of the gastric tube and leave open to the air or aspirate tube hourly. 13. Record observations of: heart rate, respirations, saturations, FiO2, humidity, pressures and flow hourly. 14. Visually check position of CPAP hourly to detect dislodgement 15. Monitor blood pressure as clinical condition dictates, at least 12hrly. 16. Aspirate OGT 4-6hrly or more frequently if clinically indicated. 17. Assess and score skin condition as per unit guidelines. 18. Check nasal septum for alterations in condition. 19. Record hourly whether mask or prong and alternate use as per unit guideline. 20. Report deviations to Dr and Nurse in Charge and document in notes as per escalation policy. 21. Check air entry with position changes/cares or with any increases in oxygen requirements or respiration rates 22. Observe for secretions and need for oral/nasal suctioning. 23. Give mouth care as needed in line with mouth care assessment tool and document 24. Adjust in accordance with blood gases and overall condition. Page 5 of 10

6 25. CPAP tubing must be changed every 7 days or in line with hospital infection control guidelines. 26. Any CPAP equipment not in use must be decontaminated and tubing discarded. 7. References 1. AARC Clinical Practice Guideline. Revised by Czervinske. M. (2004) Application of Continuous Positive Airway Pressure to Neonates via Nasal Prongs or Nasopharyngeal Tube Respiratory Care 49(9): Original publication Respiratory Care 1994; 39(8): Sweet, D.G, Carnielli,V., Greisen, G., Hallman, M., Ozek, E., Plavka, R., Saugstad, O.D., Simeoni, U., Speer, C.P., Vento, M., Halliday, H.L. (2013) European consensus guidelines on the management of neonatal respiratory distress syndrome in preterm infants update. Neonatology, 103(4) pg doi: / Jollye, S. & Summers, D. in Boxwell. G. Neonatal Intensive care Nursing. (2010) Chapter 6: Management of respiratory disorders. 8. Bibliography Fischer, C. Bertello, V., Hohlfeld, J. Forcada-Guex, M., Stradelmann-Diaw, C., Tolsa, J. (2010) Nasal trauma due CPAP in neonates. Arch Dis Child Fetal Neonatal Ed. 95, F447-F451. McCoskey, L. (2008) Nursing care guidelines for the prevention of nasal breakdown in neonates receiving NCPAP. Advances in Neonatal care. 8(2) pg Sanker, M.J., Sankar, J., Agarwal, R., Paul, V.K. & Deorari, A.K. (2008). Protocol for administering continuous positive airway pressure in neonates. Indian Journal of Pediatrics. May: 75(5) pg doi: /s x. Squirrel, A. & Hyndman, M. (2009) Prevention of nasal injuries secondary to NCPAP application in the ELBW infant. Neonatal Network. 28(1) pg Appendices 1. Assisted CPAP modes. Page 6 of 10

7 Appendix 1 ASSISTED CPAP In this mode it is possible to give additional PIP above baseline CPAP pressure at a rate set by clinician (Biphasic) or as triggered (Biphasic tr.) by neonate Equipment Infant Flow SiPAP, Viasys Respiratory Care Inc. A flow-driven machine, where pressure is directly related to flow used Indications Respiratory stabilisation in neonates born at <30 weeks Post-extubation in neonates born at <30 weeks Respiratory decompensation whilst on CPAP, with persistent tachypnoea, pco 2 >8.3 kpa, ph<7.25, FiO2 >0.4 Recurrent apnoea and desaturations requiring manual breaths/ippv CLD patients may be extubated onto biphasic CPAP from a higher MAP Modes on Infant Flow SiPAP CPAP and apnoea Biphasic CPAP with added advantage of apnoea monitoring via a sensor attached to abdomen Apnoea alarm triggered when no breaths detected within set time-out period Bi-level pressure respiratory support Timed higher level (PIP) pressure rise above baseline CPAP, delivered intermittently at pressure and rate set by clinician Not synchronised with respiratory effort Can be set at variable rate (R) and with varying inspiratory times (Ti) Can be used with or without apnoea monitoring Biphasic trigger Bi-level pressure respiratory support Higher level (PIP) pressure rise above baseline CPAP, at rate in synchrony with baby s respiratory effort sensed through an abdominal sensor Page 7 of 10

8 PIP and CPAP are set by clinician Inspiratory time (Ti) and back-up rate (Rb) can be varied, but back-up rate only comes into function if baby apnoeic or spontaneous breaths less than back-up rate Apnoea monitoring built into this model Available settings NCPAP/low flow meter 0-15 L/min Pressure generated is directly related to flow (Figure 1) a flow of 8 L/min will generate a pressure of 5 cm H2O PIP/high flow meter: additional flow 0-5 L/min FiO2 : % Maximum CPAP pressure that can be delivered 11 cm H 2 O (on CPAP and Biphasic mode) Maximum MAP that can be delivered 10 cm H 2 O (on Biphasic tr. mode) Default setting Set ranges Apnoea alarm delay 20 sec 10, 15, 20, 25, 30 sec Ti 0.3 sec sec R (unsynchronised PA) 30/min 1-120/min Rb (trpa) 10/min 10-30/min Biphasic settings Set CPAP pressure at 5 cm HO or above based on clinical problem For neonates with mild RDS CPAP of 5-6 cm HO should be adequate For moderate to severe CLD use higher CPAP, may need to use up to 10 cm HO Set PIP at 3-4 cmho higher over CPAP and begin with a rate of 30 breaths/min Keep Ti and apnoea alarm delay at default setting If CO retention, increase rate If necessary, increase PIP to give a maximum MAP 10 cm H 2 O Avoid over-distension and keep PIP to minimum for optimum chest expansion Wean by pressure and rate If rate >30 bpm, wean to 30 bpm Reduce MAP, by reducing PIP by 1 cm H 2 O every hr When baby breathing above 30 bpm change to Biphasic tr mode Once MAP down to 5-6 cm H 2 O change to CPAP Page 8 of 10

9 Biphasic tr settings In spontaneously breathing neonates it is advisable to use this mode as each breath is synchronised with the machine and each breath of baby is supported Set CPAP and PIP pressure as indicated in Biphasic mode Keep Ti and apnoea alarm delay at default setting Set back-up rate at 10 bpm Maximum MAP delivered at this mode might be higher, up to 10 cm H 2 O depending on baby s vigour. Reduce set PIP/MAP to avoid over-distension in these cases Wean by pressure only Reduce MAP, by reducing PIP by 1 cm H 2 O every hr Once MAP down to 5-6 cm H 2 O change to CPAP If at any point during weaning, baby develops recurrent apnoea requiring manual breaths/further IPPV, assess baby and switch to Biphasic mode at rate 30 bpm or higher to ensure adequate support Once baby re-establishes good spontaneous breathing change back to Biphasic tr mode The document must not incur alteration that may pose patients at potential risk. The East of England Neonatal ODN accepts no legal responsibility against any unlawful reproduction. The document only applies to the East of England region with due process followed in agreeing the content. Page 9 of 10

10 Exceptional Circumstances Form Form to be completed in the exceptional circumstances that the Trust is not able to follow ODN approved guidelines. Details of person completing the form: Title: Organisation: First name: contact address: Surname: Telephone contact number: Title of document to be excepted from: Rationale why Trust is unable to adhere to the document: Signature of speciality Clinical Lead: Signature of Trust Nursing / Medical Director: Date: Hard Copy Received by ODN (date and sign): Date: Date acknowledgement receipt sent out: Please form to: mandybaker6@nhs.net requesting receipt. Send hard signed copy to: Mandy Baker EOE ODN Executive Administrator Box 93 Cambridge University Hospital Hills Road Cambridge CB2 0QQ Page 10 of 10

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