PS1006 SARASOTA MEMORIAL HOSPITAL DEPARTMENT POLICY TITLE: NON-INVASIVE VENTILATION FOR THE Job Title of Reviewer: EFFECTIVE DATE: REVISED DATE: Director, Respiratory Care Services 126.685 (neo) 3/26/15 3/18 1of 7 PURPOSE: POLICY STATEMENT: EQUIPMENT: INDICATIONS: DEFINITIONS: EXCEPTIONS: To provide safe & appropriate respiratory support for infants receiving nasal intermittent positive pressure ventilation (NIPPV). This policy will provide the RT or RCP with a guideline for the setup, management and weaning of patients on NIV (non-invasive ventilation.) Drager v500 or Evita XL ventilator with adaptable CPAP interface or non-invasive nasal cannula (Ram Cannula). To support breathing of infants that present with respiratory distress, apnea of prematurity, and/or early treatment of RDS. Early treatment of respiratory distress syndrome to prevent intubation Post extubation management preventing re-intubation Achieve and maintain adequate pulmonary gas exchange Minimize the risk of lung injury Reduce patient work of breathing (WOB) Optimize patient comfort Non-invasive ventilation (NIV) is the delivery of positive airway pressure to assist breathing without the application of an artificial airway. Continuous positive airway pressure (CPAP) and nasal intermittent positive pressure ventilation (NIPPV) are both considered forms of NIV. CPAP applies continuous distending pressure throughout the respiratory cycle, maintaining alveolar inflation during expiration preventing atelectasis. NIPPV combines CPAP with superimposed pressure cycled ventilator breaths. The breaths are not synchronized with the baby s spontaneous breaths. NIPPV may be contraindicated in patients with the following conditions: Poor respiratory drive, severe cardiovascular instability, congenital malformations of the upper airway (T_E fistula, choanal atersia, cleft palate), congenital diaphragmatic hernia, bowel Prepared by: Wanda Turner c:\users\reynoldp\appdata\local\microsoft\windows\temporary internet files\content.ie5\h07jjllb\126_685.doc 3/9/2018
2 obstruction, oomphalocele or gastroschisis. Interface: Babies less than 1000 grams should be initiated on NIPPV using NIV interface alternating between the mask and nasal prongs a minimum of every 12 hours or as ordered. Babies greater than 1000 grams can be initiated on NIPPV using a non-invasive cannula. (RAM cannula) GUIDELINES for NIPPV: Initial settings: Rate 25-40 PIP 20-24 cmh20 PEEP 4-8 cmh20 Inspiratory Time 0.4-0.5 sec Titrate Fi02 to keep Sa02 in target range Adjustments: After initial settings, adjustments should be made to maintain ABG/CBG results within ordered target ranges, considering clinical assessment, including response to therapy, and chest x-ray results. POSSIBLE COMPLICATIONS: PROCEDURE: For apnea, increased work of breathing, and/or PC02>60 increase rate by 5 up to 45 bpm or increase PIP by 2, up to 24 cmh20. (Babies requiring higher than 24cm H2O should be brought to the attention of the physician.) For Fi02 requirements >35%, increased work of breathing, low-lung volume or atelectasis: Increase PEEP by 1cm H20 up to 8cmH20 and/or increase PIP by 1-2 cm, H20 up to 24 cmh20 or increase rate by 5 up to 40/min. If Fi02 requirements <25%, consider weaning PEEP by 1cm H2O to as low as 4cm H2O and/or wean PIP by 2cm H2O at a time to maintain. If chest x-ray shows lung inflation > 9 ribs and/or flattened diaphragm, consider weaning PEEP and/or PIP. If Fi02 requirements are consistently >.60 and/or PC02 is >65 with a ph <7.20 consider intubation with volume ventilation and/or surfactant administration. Nasal septal irritation and necrosis, gastric distension, pneumothorax, increased intracranial pressure, difficulty keeping nasal prongs or mask in place, over-distention of the lungs, mucous obstruction of the airway. Respiratory Care: Obtain physician order for NIPPV including parameter settings and pulse oximeter parameters Perform hand hygiene and use standard precautions as needed 2
3 Throughout procedure. Identify patient via patient identification band according to SMH policy using two identifiers; Name and DOB. Bring assembled equipment to bedside Connect ventilator to electrical, oxygen and air outlets. Turn power switch to ON Perform ventilator flow sensor calibrations and leak test Turn ventilator to neonatal noninvasive mode and set ordered parameters. Remove the Neoflow sensor and turn neoflow to OFF Connect ventilator circuit to appropriate sized patient interface or CPAP cannula Carefully place interface or use CPAP cannula on baby per manufactured guidelines Check the position of the prongs regularly Document NIPPV settings and respiratory assessment approximately every 4 hours in patient medical record Check integrity of nares, nasal septum and skin on facial area approximately every 4-6 hours, per attached nasal assessment score guidelines, and document in SCM on Respiratory Care flow sheet. Alternate nasal prongs with nasal mask as needed to prevent breakdown. This should be done at a minimum of once Q 12 H. Document in EMR (electronic medical record) on Respiratory Flow Sheet. Suction nares as needed for excessive secretions or airway obstruction Obtain ABG or CBG as ordered and PRN. NURSING CARE: Excessive patient movement increases the risk of nasal irritation. Providing comfort measures and swaddling is helpful in minimizingmovement and drag on circuit. A pacifier may help comfort, encourage suck and prevent pressure loss from mouth. Place appropriate sized oral gastric (OG) tube and keep vented to prevent abdominal distention. Assess abdomen for distension and rigidity. Assess/reassess the patient every 4 hour for: vital signs, respiratory status and comfort level. Document in SCM Nursing Flow Sheet. Check integrity of nares, nasal septum and facial skin. Consult with RT any concerns. RESPONSIBILITY: It is the responsibility of the Respiratory Care Team 3
4 Leaders/Director to assure that this policy is understood and adhered to by all hospital staff. It is the responsibility of the Clinical Managers/Directors to assure that this policy is understood and adhered to by all hospital staff. REFERENCES: Diblasi, R.M. (2011) Neonatal Noninvasive Ventilation Techniques: Do We Really Need to Intubate? Respiratory Care, 56(9), 1273-1297, doi:10.4187/respcare.01376 Davis, P.G., Morley, C.J., & Owen, L.S. (2009). Non-invasive respiratory support of preterm neonates with respiratory distress: Continuous positive airway pressure and nasal intermittent positive pressure ventilation. Seminars in Fetal and Neonatal Medicine, 14(1), 14-20, doi: 10.4187/respcare.01376 Owen, LS, Manley, BJ. Nasal intermittent positive pressure ventilation in preterm infants: Equipment, evidence, and synchronization. Semin Fetal Neonatal Med. 2016. Lemyre B, Laughon, M. Bose, C. Davis PG., Early nasal intermiitent positive pressure ventilation (NIPPV) versus early nasal conituous positive airway pressure (NCPAP) for preterm infants. Cochrane Database Syst Rev. 2016 Dec 15;12:CD005384. Doi: 10.1002/14651858.CD005384.pub2. AUTHOR(S): Kathleen Duffy, RRT, NPS Team Leader Heike Bucken, RNC-NIC, CLC, NICU Clinical Coordinator ATTACHMENT(S): 2 Respiratory Support Guidelines for NIPPV (page 6) Nasal Assessment Score (page 7) APPROVALS: Signatures indicate approval of the new or reviewed/revised policy Title: Pam Beitlich, Director, Women s and Children s Date 3/6/18 3/2/18 Title: Mark Pellman, Director Respiratory Care Services 4
5 Title: Title: Committee/Sections (if applicable): Clinical Practice Council 3/1/18 Vice President/Administrative Director (if applicable): Name and Title: 3/8/18 Name and Title: Connie Andersen, VP/CNO Non invasive Positive Pressure Ventilation (NIPPV) Respiratory Support Guidelines for NIPPV Interface- Babies less than 1000 grams should be initiated on NIPPV using NIV interface alternating mask and prongs a minimum of every 12 hours. Babies greater than 1000 grams can be initiated on NIPPV using Ram Cannula. Initial Settings- Rate: 25-40 PIP: 20-24 PEEP: 4-8 cmh2o Inspiratory Time: 0.4 to 0.5 seconds Adjustments-After initial settings, adjustments should be made based on clinical assessment, including response to therapy, ABG/CBG results and CXR results. 5
6 For persistent apnea, increased work of breathing and/or PCO2 > 60, increase rate by 5 up to 45 bpm or increase PIP by 2 up to 24 cm H2O. For FiO2 requirements > 35%, increased work of breathing, low lung volume, or atelectasis; increase PEEP by 1 cm H2O up to 8 cm H2O and/or increase PIP up to 24 cm H2O. For FiO2 requirements < 25%, consider weaning PEEP by 1 cm H2O down to 4 cmh2o or wean PIP by 2 cm H2O. If lung inflation on CXR reveals greater than 9 ribs and/or flattened diaphragm, consider weaning PEEP and/or PIP. If FiO2 requirements are consistently > 60% and/or PCO2 > 65 with a ph of less than 7.20, consider intubation with volume ventilation or Surfactant administration (See re-intubation criteria). Nasal Assessment Score o Nasal assessment should be done every 4 to 6 hours and documented in SCM on Respiratory Care flow sheet. 6
7 Nasal Assessment for Nasal CPAP/NIPPV Signs Score Action Nasal bridge, septum and nares 0 No action required appear healthy without redness Alternate the use of mask and prongs a or breakdown minimum of every 12 hours. Slight redness noted around Nares, septum and/or bridge of nose Area appears painful to touch Some indentation noted Any of the following evident: Marked indentation Painful to touch Tissue breakdown 1 Ensure the baby is wearing the correct size hat/mask/prong as per NICU guidelines and that all are correctly positioned. Apply skin barrier prep per NICU guidelines. Review assessment with RT, RN and Neonatologist; If a change in mask or prongs is needed, consider changing interface. Ensure mask and prongs are being alternated per guidelines and increase frequency as needed. Document score and action taken on NICU Respiratory Care Flow sheet. 2 Notify Neonatologist for recommendations and consider consultation with plastic surgeon. Remove mask /prongs immediately ensuring Baby s breathing remains supported. Decide on appropriate alternative respiratory Support. Document score and action taken on NICU Respiratory Care flow sheet. 7