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Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
A clinical guideline recommended for use
In:Jenny Lind Children’s Hospital (NNUH) and Children’sDepartment at (JPUH)
By:
Paediatric and Nursing staff working in Buxton ward and the High Dependency Unit (NNUH) and Paediatric and Nursing staff working in ward 10 and the High Dependency Unit (JPUH)
For:Infants with significant respiratory distress who require adegree of respiratory support (under 12 months of age)
Division responsible fordocument:
Women and Children’s Division
Key words:Continuous Positive Airway Pressure (CPAP), Bronchiolitis, Respiratory Distress Syndrome (RDS), High Dependency Unit (HDU)
Names of document authors:
Dr Caroline Kavanagh, Consultant Paediatrician, Hannah Deacon, Staff Nurse, Buxton Ward, Sarah Burton, Deputy Sister, Buxton Ward
Name of document authors Line Manager:
Mary-Anne Morris
Job title of document authors Line Manager:
Chief of Services for Paediatrics
Supported by:Children’s Critical Care Working GroupDr John Chapman Consultant Paediatrician (JPUH)
Assessed and approved by the:
Clinical Guidelines Assessment Panel (CGAP) Chair’s action
Date of approval: 13/09/2019Reported as approvedto the:
Clinical Safety and Effectiveness Sub-Board (NNUH) and Clinical Governance (JPUH)
To be reviewed before: 13/09/2022
To be reviewed by: Dr Caroline Kavanagh
Reference and Trustdocs ID No:
JCG0088 ID No: 9079
Version No: 2.2Description of changes: No clinical changes
Compliance links: NoneThis guideline has been approved by the Trust's Clinical Guidelines Assessment Panel as an aid to the diagnosis and management of relevant patients and clinical circumstances. Not every patient or situation fits neatly into a standard guideline scenario and the guideline must be interpreted and applied in practice in the light of prevailing clinical circumstances, the diagnostic and treatment options available and the professional judgement, knowledge and expertise of relevant clinicians. It is advised that the rationale for any departure from relevant guidance should be documented in the patient's case notes.
The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the quality of healthcare through sharing medical experience and knowledge. The Trust accepts no responsibility for anymisunderstanding or misapplication of this document.
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 1 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Contents Page
Objective 3Rationale 3Background 3
The Bubble CPAP circuit 4Infant Flow driver circuit 4
Indications for use of CPAP 4Aims of CPAP 4Biochemical aims of CPAP 5Contraindications for use of CPAP 5Complications of CPAP 5
Conditions Requiring CPAP in infants and young children 6Bronchiolitis 6Post-operative atelectasis 6Chronic Lung Disease 6Newly diagnosed chronic Respiratory failure 6Home Non-Invasive Ventilation 7
Initial Management- Quick reference 7Use the ABCD approach 7Chloral and CPAP 7Indication for weaning CPAP 7Escalation of Care beyond CPAP 8Organisation and provision of care 8
Clinical audit standards 8Summary of development and consultation process undertakenbefore registration and dissemination
8
Distribution list/ dissemination method 9References/ source documents 9
Appendices
Appendix 1 Use of the Bubble CPAP Circuit 10
Quick User Manual reference guidelines for the BubbleCPAP circuit
14
Troubleshooting 21
Appendix 2 Quick reference guidelines for the Infant Flow DriverCPAP
23
Troubleshooting with the infant flowdriver 28
Appendix 3 Care plan 29
Appendix 4 Patient Information leaflet 31
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 2 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Objective
The objective of this guideline is to standardise the care of Infants (children under 12 months old) requiring CPAP via the Bubble CPAP circuit or infant Flow Driver. It is also toensure safe practice for the required duration of CPAP administration by providing a reference for all staff. Diagrams of the two machines and their individual use can be found in the Appendix.
Rationale
We have within the paediatric department two different types of machines that are capable of providing CPAP for infants: the bubble CPAP machine and the Viasys Infant Flow drivers. This guideline has been created in order to standardise the care of Infants requiring CPAP using either machine. This ensures that children receive a safe and efficient level of care by practitioners with the knowledge and skill in the safe application, monitoring and delivery of CPAP. This guideline has been composed using an up to date,relevant evidence-base to ensure this required level of care is achieved.
Background
The use of CPAP dates back to 1912, when used by a thoracic surgeon, this prompted much investigation and research into its use. In 1976 Greenbaum et al. reported the use of CPAP successfully in Acute Respiratory Distress Syndrome.
CPAP is the maintenance of a positive pressure throughout the whole respiratory cycle ina spontaneously breathing patient. It improves oxygenation by helping to prevent alveolarcollapse. This is achieved by delivering a continuous oxygen and air mix under gentle pressure. The aim of CPAP is to improve gas exchange and avoid the need for intubation.
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 works by increasing the functional residual capacity of the lungs by exceeding the closing capacity of the lungs, which stabilizes and prevents the collapse of alveoli, making inflating the lungs easier. 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.
For this reason it is particularly effective in the recovery of bronchiolitic infants as it decreases the compliance of the chest wall and allows for synchronous breathing and improved gas exchange.
CPAP can be provided using various machines and circuits. The two methods we have available to us at NNUH are the bubble CPAP circuit and a Viasys infant flow driver circuit. We would recommend using the bubble CPAP circuit preferentially, but if we Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 3 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
have no other machines available we will use the flow driver circuit. This guideline will therefore provide details on the use of both circuits.
The Bubble CPAP circuit
The Bubble CPAP circuit provides pressure using a water chamber. The depth of the tube below the water line controls the amount of positive pressure generated in the system. Bubbles are created when pressure is generated. This system was first introduced in 1974 when Dr. Jen-Tien Wung from New York began looking at CPAP for respiratory support.
Infant Flow driver circuit
The infant Flow Driver is a combined air/oxygen mixer, oxygen analyser, flow meter and manometer with integral alarm systems designed specifically to be used in conjunction with the infant Flow CPAP generator. This circuit provides a virtually constant airway pressure irrespective of patient demand or expiratory flows via the specially designed generator and nasal prongs.
Indications for use of CPAP
CPAP provides an additional therapy between conventional oxygen therapy and controlled ventilation. The decision to initiate must be made by the senior paediatrician on call.
Consider when two or more of the following are present:
Respiratory rate of 60 breaths per minute or greater
Apnoeas, bradypnoea or cyanotic episodes (with or without bradycardia) despite supplemental O2
Severe intercostal recession and worsening signs of respiratory distress (e.g. expiratory grunt, nasal flare, sternal recession)
Need for >2L/min O2 via nasal prongs
Rising PCO2 (>3KPa from baseline)
Respiratory acidosis pH 7.2-7.25 (if pH <7.2 consider intubation)
Exhaustion
Falling level of consciousness
Unable to maintain SaO2 >92% in 50% oxygen
Aims of CPAP
1. Reduce respiratory distress
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 4 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
2. Improve oxygenation by improved alveolar gas exchange by recruiting collapsed and poorly ventilated alveoli
3. Improve hypercarbia
4. Reduce time spent in oxygen
5. To avoid fatigue in infants
6. To avoid invasive ventilation
7. Reduce hospital inpatient stay
Biochemical aims of CPAP
1. To maintain pH 7.35-7.45
2. To maintain saturations > 95%, PCO2 <6.0 KPa
3. To prevent hypoxia and hypercarbia
Contraindications for use of CPAP
Consider the need for intubation and/or mechanical ventilation as evidenced in the presence of:
Severe cardiovascular instability and impending arrest
Upper airway abnormalities that make CPAP ineffective or potentially dangerous (e.g. Choanal atresia, cleft palate, tracheoesophageal fistula)
Pneumothorax
Older infants do not tolerate the application of CPAP devices well, resulting in restlessness and a labile oxygen requirement.
PH <7.2 or SpO2 <88% in maximal oxygen therapy may be an indication for ventilation, but CPAP may be tried initially if the child is stable.
Complications of CPAP
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 positive end expiratory pressure (PEEP) levels resulting in over-distension.
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.
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 5 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
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.
Blockage of nasopharyngeal area and vocal cords with thick secretions.
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 6 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Conditions Requiring CPAP in infants and young children
Bronchiolitis
This is a common, often serious infectious disease of the lower respiratory tract. It is most common among infants aged 2-12 months with a peak age of 2-8 months usually during the winter months. It is most often due to a viral infection of the bronchioles. The vast majority of cases are caused by the Respiratory Syncitial Virus (RSV), although it is well recognised that many respiratory viruses can cause a similar picture, especially in
the winter months. Bronchiolitis results in a combination of increased mucous production,cell debris and oedema causing a narrowing and obstruction of the small airways.
Bronchiolitis is characterised by: mild rhinorrhoea, coughing, decreased feeding, irritability, and occasionally respiratory distress, cyanosis and apnoea. Examination may reveal hyperinflation of the chest, crepitations and/or wheeze with hypoxia. Those infants more at risk of severe disease include the premature, infants with congenital heart disease (CHD) or underlying respiratory diseases.
SIGNS OF MODERATE BRONCHIOLITIS SIGNS OF SEVERE BRONCHIOLITISTachycardiaTachypnoea >50Nasal FlaringUse of accessory musclesRecessionHead retractionUnable to feed
CyanosisExhaustionReduced Conscious LevelSpO2<92% in spite of O2 therapyRising PCO2
Post-operative atelectasis
This is an unusual situation that can sometimes occur in young infants causing respiratory distress. It is usually a short term problem requiring a short period of CPAP and physiotherapy.
Chronic Lung Disease
This applies to ex-preterm infants who were ventilated in the newborn period or had a persistent oxygen requirement. These infants often present with an acute on chronic clinical deterioration which is often secondary to an acute viral upper respiratory tract infection. They are at increased risk of needing CPAP if they deteriorate.
Newly diagnosed chronic Respiratory failure
Children with neurodisability may eventually develop chronic respiratory failure. This maypresent with an acute-on-chronic situation or with a chronic decline in function. These children will in most cases need long term non-invasive ventilation but prior to this may require CPAP in the acute situation. Long term ventilation will be arranged by the respiratory team in conjunction with either Addenbrookes or Great Ormond Street Hospital (if there is pulmonary hypertension present).Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 7 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 8 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Home Non-Invasive Ventilation
More and more children will be commenced on forms of non-invasive ventilation with the improvements in medicine and technology. This is usually arranged by Addenbrookesor Great Ormond Street. When a child on non-invasive ventilation is admitted, refer to manufacturers instructions and leave settings unchanged unless clinically indicated. The child may then require commencement of the Trust’s CPAP devices.
INITIAL MANAGEMENT- Quick reference
Use the ABCD approach.
Ensure patent airway, suction if indicated.
Apply facial humidified O2 to achieve saturations >92%.
Continuous monitoring of vital signs and apnoeic episodes.
Nebulisers (Salbutamol or hypertonic saline) may be used, but discontinue if no response.
A blood gas.
Consider Bubble CPAP early for respiratory support if patient unresponsive to initial treatment and/or worsening blood gases.
Size 8 OG Tube to prevent abdominal distension- leave on free drainage.
Leave nil by mouth and gain intravenous access and prescribe fluids at 2/3 of normal maintenance requirements.
The following investigations can be undertaken at some stage but CPAP should not be delayed, if needed:
FBC, U&E, Cultures should be taken if indicated.
Nasopharyngeal Aspirate for virology should be sent if not done so already.
Chest x-ray.
Chloral and CPAP
A small single dose of chloral hydrate to help settle the child while being initiated onto CPAP can be given. It is not to be given if there are signs that the child may deteriorate quickly and is likely to need ventilation. The dose we would advise would be 30mg/kg.
Indication for weaning CPAP
General physiological condition is stable
FiO2 <30%
SpO2 >95%
CPAP PEEP ≤6cm H2OGuideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 9 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Stabilised blood gases
Minimal increased work of breathing
Once off CPAP infants should remain in HDU on continuous monitoring for 12-24 hours.
Escalation of Care beyond CPAP
If CPAP is ineffective or the infant is unstable and needs further escalation of treatment ventilation is required.
Worsening respiratory distress
Apnoeic episodes
Worsening hypoxia and agitation
Severe cardiovascular instability and impending arrest
Worsening respiratory acidosis
If the child weighs <5kg then contact should be made with the neonatal registrar and the neonatal consultant on call regarding ventilation and accommodation.
If the child weigh >5kg contact should be made with the anaesthetic registrar and must be discussed with the Paediatric Anaesthetist on call regarding ventilation and accommodation until CATS are able to retrieve the patient.
Organisation and provision of care
The classification of a sick infant requiring CPAP is high dependency (level 2). The Department of Health (2001) state a nursing ratio of 1:2, increasing to 1:1 if nursed in a side room. All infants therefore receiving CPAP should be treated as a child residing in the High Dependency Unit, even if nursed in a side room. Staff must have adequate training, experience and support to care for infants receiving Bubble CPAP and the InfantFlow Driver.
All children who require CPAP need to be discussed with the consultant on call so that they are aware of the illness of the child being treated.
The registrar should review regularly and observe for any deterioration in the clinical state. The consultant should come and see the child if the registrar is unhappy with their clinical condition.
Inadequate staffing levels (numbers and expertise) or equipment to deliver and monitor safely are indications to consider transfer of the child to another equipped unit within the region.
Clinical audit standards
The indications for use of CPAP and weaning of CPAP can be audited. Staff using CPAP are competent in its use. The management plan can be examined in any patient to see that it was followed correctly.Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 10 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Summary of development and consultation process undertaken beforeregistration and dissemination
Dr Caroline Kavanagh, Staff Nurse Hannah Deacon and Sister Sarah Burton drafted thisguideline on behalf of the children’s critical care working group who has agreed the finalcontent. During its development it was has been circulated for comment to:paediatricians, paediatric anesthetists, paediatric surgeons and neonatologists. Allcomments were discussed and changes were made if agreed.
This version has been endorsed by the Clinical Guidelines Assessment Panel.
Distribution list/ dissemination method
Trust Intranet
References/ source documents
Ammari, A. et al. (2005) Bubble nasal CPAP manual. Riyadh AL-Kharj Hospital Programme Neonatal Intensive Care.
Augey, M. et al. (2009) Nasal continuous positive airway pressure (NCPAP) for the acutely ill infant. Paediatric critical Care Network.
Ballarat Health Services. (2010) Clinical Practice Guideline, Nasal CPAP (Paediatric).
Bonner, K. M. and Mainous, R. O. (2008) The nursing care of the infant receiving bubble CPAP therapy. Advances in neonatal care. 8, 2, 78-95.
CATS (2009) CATS Clinical Guideline, Bronchiolitis.
Cockett, A. and Day, H. (2010) Children’s High Dependency Nursing. Wiley-Blackwell: Chichester
Department of Health. (2001) High Dependency Care for children- Report of an expert advisory group for Department of Health 2001. The stationary office: London.
Dougherty, L. and Lister, S. (2004) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 6th edition. Blackwell Publishing: oxford.
Electro Medical Equipment (E.M.E) (1999) The Infant Flow System, Operating Manual. E.M.E: Sussex.
Fisher & Paykel. Bubble CPAP Resource Manual.
Hockenberry, M. J. and Wilson, D. (2007) Wong’s nursing care of Infants and children. 8 th
edition. Mosby: Missouri.
Hunt, J. (2007) Guidelines for the use of continuous positive airway pressure (CPAP) systems in adults. Royal United Hospital Bath.
McDougall, P. (2011) Caring for bronchiolitic infants needing continuous positiveairway pressure. Paediatric Nursing. 23, 1, 30-35.
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 11 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Ojha, S., McInnes, D. and Dorling, J. (2009) Network Guideline, Continuous Positive Airway Pressure. Trent Perinatal Network, NHS.
Resuscitation Council (UK) (2006) EPLS. 2nd edition. London.
Scottish Intercollegiate Guideline Network (2006) Bronchiolitis in children, A national clinical guideline. NHS.
Upton, C. and Foster, S. (2011) Information leaflet for parents/carers of babies and young children who have bronchiolitis. NNUH.
Appendix1 Use of the Bubble CPAP Circuit
Potential problems caused by Bubble CPAP therapy
Mouth breathing may result in loss of desired pressure and decrease in delivered oxygen concentration
Increased intrathoracic pressure which causes reduced venous return which may lower cardiac output
Barotrauma leading to surgical emphysema/ pneumothoraces
Sudden deterioration requiring immediate intubation/ventilation
Aspiration
Patient discomfort/intolerance to nasal prongs
Facial sores/ulceration of septum
Reduced ability to feed
Dry mouth/airways
Gastric distension and diaphragmatic splinting
Increased blood level of carbon dioxide due to increase in dead space caused by prongs and tubing.
Broad recommendations
Procedure RationaleInitiating BubbleCPAP
Move to HDU with relevant staffing Manage infant with facial O2
Record baseline observations including CBG, CEWS, O2 requirements prior to commencing CPAP
Ensure safe delivery and monitoring.Reduce further respiratory distressBaseline observations are essential to the ongoing assessment and management of the infant
Gather all equipment required to deliver Bubble CPAP
Manufacturer’s set up instructions.
Bubble CPAP equipment including:head gear, circuit, O2/air blender, humidifier, water for irrigation, water for CPAP, saturation probe, orogastric tube, measuring equipment, suction equipment, chin strap/dummy
Ensures safe delivery of bubble CPAP
Set up Bubble Follow manufacturer’s instructions and To reduce error and ensure timely
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 12 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
CPAP test the circuit for leaks prior to attaching to the patient
delivery to the infant
Measure infantsnares, septum and head circumference
Use manufactures measuring device andselect appropriate nasal prongs and head gear
Fit and connect to CPAP circuit as per instructions
Correct sizing is essential to prevent leakage and damage to the nasal septum
Small prongs allow air to leak from the circuit reducing the pressure, if they do not fit snugly movement will cause them to damage the septum
Head gear should be lined with eyebrows and be pulled down over the ears and fit snugly to minimise movement of the tubing
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 13 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Procedure RationaleTurn on CPAP Ensure humidification is set to correct
setting
Ensure bubble system and humidifier are kept lower than the infant
Secure tubing to avoid dragging on the circuit
Set gas flow (usually at 6L/min)
Set water pressure (usually 6cmH20)
Set FiO2 blender at required percentage
NEVER PLACE PRONGS IN INFANTSNARES UNTIL YOU HAVE VARIFIED THE SETUP IS FULLY OPERATIONAL
Humidification is pre-set to 37°c
Adequate humidification prevents drying of secretions
Avoids condensation draining into infants airways
Tension on the tubing will put pressure on the nares
To be determined by doctor
To be determined by doctorBubbles should appear in the water chamber
To be determined by doctor. To maintain saturations at acceptable level
Connect Bubble CPAP to infant
Place nasal prongs in nares
Secure with Velcro straps attached to head gear
Be mindful of trauma
Ensuring adequate fit and seal
Gain IV access and commence IVINB.CPAP is not a contraindication to feeding
Insert cannula, obtaining bloods and commence IVI at 100ml/kg/hr of 0.45% saline 5% dextrose +/- 10mmol KCL and make infant NBM
NBM reduces gastric distension which can impact on work of breathing. Feeds can begin when infant stable enough
Insert orogastric tube
Insert size 8fr OGT on free drainage, gently aspirate as required
Helps prevent gastric distension which can increase the possibility of aspiration and impact on work of breathing
Size 8fr OGT as smaller tubes do notallow the stomach to be vented properly
Observations andcontinuous monitoring
Infant must be placed on continuous monitoring, change probe site 4 hourly
Record all observations 15 minutes after commencing CPAP
Record observations hourly (more frequently if required) on CPAP chart and on CEWS chart
Regular changes of probe site prevent skin breakdown and burns
Allows infant to settle on CPAP and settings to be changed if necessary
Charts improvement/ deterioration ofinfant as well as predicting deterioration
Sedation Chloral hydrate to be prescribed PRN according to BNFc
For use when infant does not tolerate CPAP. If infant does not tolerate CPAP its use will be
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 14 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
ineffective
Procedure RationaleBlood gas monitoring
Blood gas analysis should be performed prior to and one hour after commencing CPAP
Capillary blood gas monitoring at least 6 hourly until stable
Record on Blood Gas Analysis Chart
Deteriorating blood gases may indicate a need for intubation. Infants receiving IVI should have electrolyte levels checked to prevent hypo/ hyperglycaemia etc
SuctioningIndications for suctioning:
Increased secretions
Increased work of breathing
Increased O2 requirement
Increased respiratory distress
Increased apnoeas
Use size 8fr suction catheter to suction nasopharyngeal or orally
Suction pressure set to 100-120mmHg maximum
Have facial O2 nearby
Measure distance from incisor to the angle of the lower jaw
Insert catheter without applying suction
Apply suction, withdraw slowly in a straight movement without rotating
Clear suction tubing with sterile water
Bronchiolitic infants produce thick secretions that cannot be cleared by a smaller bore
Suction can be traumatic for an infant so should not be undertaken as routine procedure
Fragile infants may respond with bradycardia or apnoeas
Higher pressures will cause trauma to the airways
Mouth care, dummies and chin straps
Use foam mouth swab and sterile waterregularly
Encourage the use of a dummy
CPAP dries infants airways
Dummies stimulate oral secretions, keeping the mouth moist and encourage a good seal by preventingmouth breathing. Alternatively a chin strap can be applied.NB. Never use a dummy against parental wishes or force one on an infant who does not want it/ tolerate it.
Handling/ positioning
Elevate cot to 30°
All cares including repositioning, observations, nappy changes and bloodgas analysis should be performed together and the infant allowed to rest
Reposition 4-6 hourly
Elevated cot will reduce pressure on the babies diaphragm
Constant handling increases the infants stress levels, energy expenditure and increases the work of breathing
Regular repositioning helps reduce facial oedema, reduce pooling of secretions, and reduce pressure
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 15 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
marks as well as improving oxygenation and reducing respiratoryworkload
Procedure RationaleNasal integrity Evaluate infants nares and septum
regularly for signs of pressure or breakdown
If nasal prongs are ill-fitting it can cause erosion of the septum and nares due to friction
Parental information
Explain infants condition and need for CPAP to parents and update them on aregular basis
Gain parental consent prior to commencing CPAP
Allow parents to be as involved as condition dictates in their Childs care
Ensure parents receive a Parental information leaflet
To prepare the family for the procedure
To ensure family-centred care
To give parents a better understanding so that they can advocate for their child and give informed consent
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 16 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Quick User Manual reference guidelines for the Bubble CPAP circuit
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 17 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 18 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 19 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 20 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 21 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 22 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 23 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Troubleshooting
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 24 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 25 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 26 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
APPENDIX 2
Quick reference guidelines for the Infant Flow Driver CPAP
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 27 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 28 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 29 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 30 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 31 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 32 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 33 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Appendix 3
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 34 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 35 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
CPAP
PARENTAL INFORMATION LEAFLET
WHAT IS CPAP, WHY IS IT USED?
CPAP stands for Continuous Positive Airway Pressure and is used in hospital to provide constant gentle pressure through the airways to the lungs. This pressure keeps the airways open to aid your child’s breathing, allowing them to rest. The amount of pressure and oxygen can be adjusted accordingly helping them get better.
The CPAP is delivered through two tubes which attach to prongs, which fit snugly in the nostrils and are secured to a bonnet as illustrated in the picture above. These tubes connect to the CPAP machine. You will then see bubbles in the water chamber.
CONTINUOUS MONITORING
Whilst your baby is receiving CPAP, they will be cared for in the High Dependency Unit (HDU) on Buxton Ward. This is so that they can receive closer observation. You are welcome to stay with your baby next to the cot throughout. An Oxygen Saturation Probe (Sats Probe) will be placed on your baby’s foot or toe displaying how much oxygen is in the bloodstream and the baby’s heart rate. Other observations, such as the respiratory rate and temperature, will also be monitored frequently.
OROGASTRIC TUBE
This is a small tube inserted into your baby’s stomach, via the mouth and secured to the cheek or chin. This tube will allow the air and contents of the stomach to be drained, giving the lungs more room to expand. Your baby may be Nil By Mouth for a period of time, as digestion takes a lot of energy, which can be used instead for breathing.Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 36 of 37
Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).
CANNULAS AND IV FLUIDS
If your baby needs to be Nil By Mouth, a cannula will be inserted and Intravenous fluids will be given to keep your baby hydrated. The doctors will do this and they maytake a small amount of blood at the same time for a blood test.
BLOOD GAS ANALYSIS
The amount of oxygen and carbon dioxide in the blood needs to be measured frequently. This is done by pricking the baby’s heel with a lancet and filling a small glass tube with blood. It is much less blood than it looks but this may need to be done quite often until the levels stabilise.
SEDATION
If your baby does not tolerate the CPAP machine very well, they can be given a sedative called Chloral Hydrate. This allows the baby to relax, once your baby gets used to the CPAP, they will not need to have the sedative any more.
SUCTION
Suction is used to clear the airways of excess mucous so your baby can breathe better. A thin suction catheter is inserted into the nose or mouth. Sometimes a larger Yanker Sucker is used in the mouth to clear excessive secretions.
POSITIONING, HANDLING AND COMFORTING
When your baby is on CPAP they can still be touched and comforted by you. They may need to stay in the cot while they adapt to being on CPAP, but after a time you will be able to take them out of the cot and give them a cuddle. The nurses will makethe baby a ‘nest’ for them to lie in while they are in the cot to provide comfort and support. The cot will also be tilted so keep your baby upright, helping them to breathe. Their position will be changed regularly to help naturally clear the chest andrelieve pressure on their skin. You are welcome to help the nurses with this if you like. You can put some teddies and toys in the cot and provide your own blankets to make your baby feel more relaxed if you want to.
If your baby usually sucks a dummy, they can continue to do this while on CPAP. This will also prevent the baby breathing through their mouth, which will prevent air and pressure from the CPAP escaping.
COMING OFF CPAP
When your babies’ breathing has improved, they will be taken off CPAP, but may still require a little oxygen. Your child will be monitored closely for the first few hours after coming off CPAP to make sure they are still breathing normally; however in some cases, it may be necessary to place them back on CPAP again until they have completely recovered.
Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 37 of 37