NON-INVASIVE VENTILATION

Transcription

1 POLICY This interdisciplinary practice support document is intended to give an overview of the management of infants using non-invasive respiratory support. Non-invasive respiratory support (NIV) is used for infants who require increasing respiratory support with or without supplemental oxygen therapy. In cases of acute respiratory deterioration, non-invasive respiratory support could be used to avoid intubation. Primary Indications: Respiratory compromised patients not requiring full invasive respiratory support. Prevention of deterioration in respiratory status Maintenance of Functional Residual Capacity (FRC) To avoid intubation Secondary Indications: Initiation of NIV only occurs with this patient population in collaboration with the infant s physician to determine appropriateness. Upper airway abnormalities such as choanal atresia, cleft palate Cardiovascular instability Respiratory failure demonstrated by arterial blood gas: ph <7.25; PaCO2 > 60 mmhg; Pa02 < 50 mmhg with FiO2 > 60% Tracheoesophageal fistula (TEF) Pre-Op esophageal atresia Small bowel obstruction Pneumothorax Necrotizing enterocolitis (NEC) Hyperinflation Pulmonary interstitial emphysema (PIE) Congenital pulmonary airway malformation (C-PAM) Post-Op intestinal surgeries Contraindications: Tension pneumothorax Congenital Diaphragmatic Hernia Gastroschisis pre-op Omphalocele pre-op The infant s physician is responsible for ordering the initiation of non-invasive respiratory support, its ongoing management and discontinuation. The Registered Respiratory Therapist is responsible for device set-up, monitoring, escalation, weaning and discontinuation of therapy, as per orders. Every three hours, the RRT completes a clinical respiratory assessment, checking the functional operation of the device (inclusive of site to source) and documenting findings on the respiratory therapy (RT) flow sheet. The RRT serves as the non-invasive respiratory support resource person for the health care team and family. The bedside Registered Nurse (RN) is responsible for completing hourly infant skin assessments of skin located below the mask or prongs interface, ensuring the correct placement of an orogastric tube, ensuring Page 1 of 5

2 adequate interface seal, and that equipment is positioned correctly during parental/infant cuddles. See - Appendix 1- Guidelines for maintaining non-invasive respiratory support During all intra-hospital transports, the infant must be accompanied by a RRT and RN. The RRT will manage the non-invasive respiratory support device throughout the transport except when care is provided by an anesthesiologist. Non-invasive respiratory support delivery devices must never be turned off unless an RRT is present at the bedside. PURPOSE Non-invasive respiratory support uses a specific medical device to deliver positive airway pressure(s) to the infant s airway through a mask or nasal prongs interface. The prescribed positive airway pressure(s) supports functional residual capacity (FRC), improves gas exchange, redistributes lung fluid, decreases intrapulmonary shunting, reduces work of breathing, reduces oxygen requirements and increases lung compliance. The prescribed parameters of non-invasive respiratory support are determined by assessment of the patient s respiratory status as evaluated by clinical signs, radiographs, blood gases, oximetry and also by patient tolerance of this treatment modality. PRACTICE LEVEL/COMPETENCIES Set-up and management of non-invasive respiratory support is a foundational competency for RRTs. Nursing Care of the infants requiring non-invasive respiratory support is considered a Neonatal nursing competency. It is practiced only after the RN has successfully completed the non invasive ventilation workshop and has had his/her learning validated at the bedside by the appropriate clinical support person. EQUIPMENT Non-invasive respiratory support device capable of supporting the infant s individualized respiratory needs with the functional operational capabilities to deliver the parameters as prescribed by the physician. Mask or prongs interface based upon the infant s individual needs. Securing head gear for mask/prongs Humidification device to provide patient with humidified gas Temperature probes Circuit PROCEDURE Respiratory Therapy: Set up and Management 1. CHECK infant s chart for prescriber orders and target saturations for non-invasive ventilation Rationale Ensures appropriate infant targets and goals of administration are set Page 2 of 5

3 2. Determine & OBTAIN appropriate noninvasive ventilation device 3. Determine & OBTAIN appropriate sized mask, and/or nasal prongs and hat specific to the non-invasive respiratory device selected and to the individualized needs of the infant. 4. CONNECT the circuit to the non-invasive respiratory device 5. CONNECT Humidification probe and heater wire by aligning the colour coded ends & ports Heater wire - yellow to yellow located on the side of the humidifier assembly & inserted into the inspiratory limb Heater probe - blue to blue located on the side of the humidifier assembly Note: Ensure temp probe is inserted completely into the inspiratory limb The humidifier will preset temperature, is servo controlled and should always be in invasive mode Ensures that the prescribed physician orders can be delivered to the infant Ensures accurate functionality of the device and comfort for the infant. Ensures adequate humidification is delivered to the infant 6. CONNECT Non-invasive respiratory support Prepares system device to power source 7. TURN ON the non-invasive respiratory support device set appropriate mode and settings 8. SECURE a second person to assist with applying device to patient 9. ENSURE functional operation of the device 10. MONITOR Sp02, breath sounds, respiratory rate (RR), heart rate (HR) every 3 hours or more often as clinically indicated. SUCTION as needed. 11. SUCTION as needed Assists in maintaining a patent airway 12. Wean as per the appendix for the specific non-invasive respiratory device in use in conjunction with the physician orders. adhered to. 13. Discontinue therapy as per the appendix for the specific non-invasive respiratory device in use in conjunction with the physician orders. 14. Upon discontinuation of therapy the RRT will remove the device from the infant s bedside so that it can be cleaned and a new circuit put on. RRT or RN helps to maintain developmental care positioning and is less traumatic for the infant. Allows early identification and prompt intervention for patient deterioration. Ensures a team approach to weaning of therapy and ensures that guidelines for specific devices are Ensures a team approach to discontinuation of therapy. Ensures availability of device at all times. Page 3 of 5

4 Respiratory Therapy: Intra-hospital Transports Rationale 1. OBTAIN transport stand equipped with Ensures availability of oxygen/air throughout blender, Neopuff & mask transport Check regulators for contents 2. TURN ON system Ensure medical gases are flowing 3. SET parameters on the Neopuff to mimic Ensure consistency of care parameters set on the non-invasive respiratory device 4. Connect Neopuff to infant and assess infant s response to transport device. 5. DISCONNECT non-invasive respiratory device from wall connections 6. UNPLUG heater from wall outlet 7. TRANSPORT patient - constantly monitoring patient s respiratory status 8. SETS UP & MANAGES the non-invasive respiratory device during infant s procedure (exception: when infant is in the operating room as care is handed over to anaesthetist ) 9. Transport the patient back to the NICU using the above stated procedure. DOCUMENTATION Ensures patient clinical stability on the transport device Ensures safe transport of patient. Allows early identification and prompt intervention for patient deterioration. RRT remains with the infant throughout procedure to ensure safe consistent care Respiratory Therapy: Document on appropriate records (RT flowsheet) Date and time non-invasive ventilation was initiated Type of non-invasive ventilation device selected FiO2 and pressures (set and measured) Clinical assessment (breath sounds, Heart Rate, Respiratory Rate, Oxygen saturation) every three hours Patient s response to therapy Plan as per prescribed orders from physician. Family teaching Medical Team teaching Nursing: Document on appropriate records (patient care flowsheet, RN notes) Type of non-invasive ventilation device initiated FiO2 and pressures Clinical assessment ( Heart Rate, Respiratory Rate, Oxygen saturation) hourly Blood Pressure, temperature, every 4 hours and when needed. Oxygen delivery system check hourly Patient s response to therapy Family teaching Any other pertinent actions or observations Page 4 of 5

5 REFERENCES 1. BCWH Newborn Care Program; Respiratory Score document; October Page 5 of 5