Nasal CPAP (Paediatric)

Transcription

1 CLINICAL PRACTICE GUIDELINE SCOPE (Area): SCOPE (Staff): Nasal CPAP (Paediatric) Paediatrics & Special Care Nursery (SCN) Nursing & Medical Staff BACKGROUND Nasal CPAP is a management option for treatment of neonates & infants with respiratory problems. It can be used to stabilise them prior to transfer to a tertiary hospital or to manage the respiratory problem within the hospital environment. DESIRED OUTCOME/OBJECTIVE To provide continuous positive pressure oxygenation to neonates/infants with respiratory problems in an effective and safe manner. DEFINITIONS CPAP: Continuous Positive Airway Pressure the application of a constant positive pressure to the airways during both inspiration and expiration in a spontaneously breathing neonate/infant. Bronchiolitis: Inflammation of the bronchioles, the airways that extend beyond the bronchi and terminate in the alveoli. Bronchiolitis is due to viral infections. NETS: Neonatal Emergency Transport Service PETS: Paediatric Emergency Transport Service INDICATIONS Criteria for Special Care Nursery neonates: Birthweight >1500gm and gestation >31.6 weeks. Usually less than 24hrs old Worsening clinical signs of respiratory distress. Increasing oxygen requirements Criteria for Paediatric & Adolescent Unit infants: Age < 12months Worsening clinical signs of respiratory distress Increasing oxygen requirements ISSUES TO CONSIDER The decision to commence CPAP must be made by the paediatrician on call. Each neonate/infant should be discussed with NETS/PETS prior to commencement of CPAP so they are aware of any outlying unwell infants (possibility of transfer). At least one daily update to NETS/PETS is recommended. CPG/N030: Nasal CPAP (Paediatric) (2010) Page 1 of 5

2 CPAP can still be used for neonates under the prescribed weight and gestation for stabilisation prior to transfer to tertiary hospital. For older infants sedation may be useful to increase effectiveness of CPAP consult with NETS. Staffing These infants require one-to-one nursing. Before commencing CPAP: The Unit Coordinator and the Patient Flow Coordinator must be consulted The availability of appropriately trained staff must be assessed. - Ensure that there are enough nursing staff available for the predicted duration of CPAP (average 48-72hrs). - Medical staff, with a neonatal background, must be available for the duration of CPAP. - If either of these conditions cannot be met then the baby must be transferred to a tertiary hospital. EQUIPMENT Set-up instructions Compressed air/ O 2 with blender OR ability to mix with connecter/ O 2 analyser Pulse oximeter for continuous monitoring Bubble CPAP equipment - circuit, headgear, nasal prongs & tubing Humidifier base Water for irrigation Tape measure for head circumference Low pressure suction Suction catheters (8fg & 10fg) Gastric (feeding) tube to decompress the stomach (6fg & 8fg) & dressing to secure Emergency intubation/resuscitation equipment Chest Drain insertion & set-up equipment PROCEDURE 1. Manage neonate s/infant s condition with Neopuff/headbox while Nasal CPAP is being set-up 2. Obtain IV access if appropriate. a. Collect blood for gases and glucose, FBE if requested. b. Commence intravenous fluids. 3. Set-up circuit according to flip chart. CPG/N030: Nasal CPAP (Paediatric) (2010) Page 2 of 5

3 4. Measure neonate/infant for appropriate equipment: a. Measure the nares and septum with the guide from the circuit to ensure correct fitting of nasal prongs. i. Correct sizing is essential to prevent leakage and damage to the nasal septum b. Measure head circumference to get correct bonnet/headgear size. i. Ensure hat covers head well and pull down over ears, make sure not too tight. ii. Numbers go to top of forehead. 5. Turn on CPAP circuit a. Ensure humidification is set on intubation setting. i. Humidification is pre-set at 37 C (Humidifier default = ventilator set-up) ii. Ensure the bubble system & humidification are always kept lower than the baby to avoid condensation draining into infants airway. b. Secure tubing to avoid any dragging on the circuit i. Use the grooves in the Resuscitair or sand bags can be used. ii. Make sure there is no tension on the tubing as this will put pressure on the baby s nares. c. Set gas flow from the wall; usually start at 5 litres (determined by paediatrician). d. Set water pressure; usually start at 6cm of water (determined by paediatrician). i. There should be bubbles evident that resemble a moderate boil. 6. Connect Nasal CPAP to neonate/infant: a. Place nasal prong in nares, ensure snug fit. b. Be mindful of trauma to nares and septum c. Secure with side tapes with equal tension on each side. 7. Insert oral gastric tube on free drainage, may gently aspirate 3-4 hourly, or as required. a. This helps prevent gastric distension which can increase the possibility of aspiration and impact on work of breathing. 8. Monitor vital signs and assess breathing regularly. Ensure set up continues to function effectively. a. May place free drainage onto bag or syringe with plunger removed. b. These neonates/infants will be nil orally until review. c. Add chin strap to neonate/infants where air leaks are evident, or use a dummy. 9. Consider portable CXR. 10. Ensure minimal handling as this will decrease the neonate s/infant s energy requirements. a. Position changes 4-6 hourly. b. Ideally neonates/infants should be nursed prone (improves circulation and blood flow to the lungs). CPG/N030: Nasal CPAP (Paediatric) (2010) Page 3 of 5

4 11. Monitor vital signs (including a respiratory assessment), blood gases, blood glucose and set-up regularly. (See Monitoring chart for further details) a. The following monitoring equipment is required: i. 3-lead cardio ii. Sa0 2 Monitor place this on the right arm or wrist for neonates to obtain a preductal reading. iii. Servo temp control if available, otherwise axilla temperature 12. Document all information, including time CPAP commenced. a. Observations and breathing assessment 15 minutely, then hourly when stable. i. Vital signs ii. Percentage of oxygen, and any changes iii. Water pressure in centimetres (cms) of water and presence of bubbles, note any changes to these iv. Any tests and results v. Any other care given to neonate. 13. Discontinuation of Nasal CPAP (As per NSAC) a. When infant s respiratory rate falls below 70/min, the FiO 2 is <0.3 and the baby is breathing with less effort, reduce CPAP by 1cm H 2 O every 6 hours until at 5cm H 2 O b. Once the baby is stable for 6-12 hours on a CPAP of 5cm H 2 O in an FiO 2 <0.3 with a respiratory rate < 70, a trial off CPAP can be undertaken. c. It is not uncommon to see a mild increase in respiratory rate as well as an increase in inspired oxygen concentration (eg. 25% to 35%), in the first hour after discontinuation of CPAP. 14. Circuits must be changed weekly; this reduces the incidence of nosocomial infections. (However, at BHS we do not keep infants on nasal CPAP for that length of time). APPENDIX Appendix 1: Monitoring neonates/infants on Nasal CPAP REFERENCES Neonatal services Advisory Committee Victoria. (2003). Administration of nasal CPAP in nontertiary level 2 nurseries. Retrieved 6 July, 2006, from Neonatal Emergency Transport Service. (2001). Care of an infant requiring nasal continuous positive airway pressure (CPAP) whilst awaiting transfer via NETS. Education Handout. Neonatal Emergency Transport Service. (2006). NCPAP and Level 2 nurseries. Education Handout. Reg. Authority: CEO, Executive Directors Nursing/Residential Services, Medical, Subacute/Community & Psychiatric Services. Clinical Director & DON Women & Children s Health Review Responsibility: Midwifery & PA&U Date Effective: September 2006 Date Revised: Apr 2010 Date for Review: Apr 2013 Original Author: Clinical Educator - Midwifery Updated by: Midwifery Project Worker, NUM P&U Unit, Clinical Educator Midwifery (2010) CPG/N030: Nasal CPAP (Paediatric) (2010) Page 4 of 5

5 APPENDIX 1 Monitoring neonates/infants on Nasal CPAP Neonate (SCN) Infant (P&AU) SaO 2. Aim at 88-92% if premature Aim > 90% (providing no cardiac Aim at >90% for term babies anomalies Heart Rate (Baseline) beats per minute beats per minutes Respiratory Effort Rate breaths per minute Rate breaths per minute Document any: Document any: Retraction Retraction Grunting Grunting Nasal flaring Nasal flaring Tracheal Tug Tracheal Tug Head bob Temperature 36.5 Celsius Celsius Colour Observe colour of skin and any changes: Pink Cyanosis Pale Mottling Auscultation of breath Listen for bilateral breath sounds under the axilla sounds Blood gases Can be peripheral or arterial Range for arterial: Range for peripheral: PaCO mmHg PaCO mmHg PaO mmHg PaO 2 not useful Frequency of the blood gases at the discretion of the Paediatrician depending on clinical picture. Usually: Before commencement of CPAP. Then 1hour after. Then as condition dictates. Blood Glucose Levels Monitor as ordered by paediatrician Keep BGL > 2.6mmols Check nose Observe for pressure areas or trauma, can lead to necrosis and septal damage. Blanching will usually indicate incorrect sizing you may need to go to a smaller size. Position & patency of Can easily dislodge or plug up with secretions. prongs Tubing / condensation Avoid expanding the corrugated tubing, closest to baby Frequent emptying of the corrugated tubing is required, when condensation occurs. Activity of bubbles Aim for continuous moderate boil You will lose pressure if the baby cries, is mouth breathing or when they are not as compromised and become more active Dummies or a chin strap can be used. Infants can be swaddled to help settle them. Water pressure level of Usually commences at 6mm H2O CPAP As per paediatrician order Gas Flow 5-8lts blended oxygen/air CPG/N030: Nasal CPAP (Paediatric) (2010) Page 5 of 5