NHS FORTH VALLEY. Continuous Positive Airway Pressure (CPAP) Nursing Guidelines

NHS FORTH VALLEY Continuous Positive Airway Pressure (CPAP) Nursing Guidelines Date of First Issue 10/06/2012 Approved 10/06/2012 Current Issue Date 26/11/2014 Review Date 26/11/2016 Version 1.1 EQIA Yes Author / Contact Group Committee Final Approval Stephanie Cahill FV Neonatal Forum Women & Children CG committee This document can, on request, be made available in alternative formats Version 1.1 26 th November 2014 Page 1 of 14

NHS Forth Valley Consultation and Change Record Contributing Authors: Consultation Process: Stephanie Cahill NNU Staff Paediatric Medical Staff/Neonatal Nursing Staff Distribution: NNU FV Intranet Change Record Date Author Change Version 26/09/14 SC Insertions of Indications for use Insertion of when to use CPAP Insertion of Modes on Infant Flow SiPAPTM Insertion of Discontinuation / Weaning from NCPAP 1.1 Version 1.1 26 th November 2014 Page 2 of 14

Continuous Positive Airway Pressure (CPAP) - Nursing Guidelines This guideline is applicable to all medical and nursing staff caring for babies in the neonatal intensive care unit in FVRH. All staff using this device must ensure they have received instruction in the safe use of this device. Contents Aim Background Indications for use When to use NCPAP NCPAP equipment used at FVRH Hazards/Complications of NCPAP Setting up NCPAP Step-by-Step Fixation Technique Monitoring and on-going care of the infant receiving NCPAP Humidification and Suction Mouth care Abdominal distension Feeding Prevention of nasal trauma Positioning and comfort measures Parents Insertion of Discontinuation / Weaning from NCPAP Care while off NCPAP Aim To ensure a safe and effective level of care in the application, monitoring and delivery of CPAP. Background Continuous positive airway pressure (CPAP) is the application of positive pressure to the airways of the spontaneously breathing child throughout the respiratory cycle. Nasal continuous positive airway pressure (NCPAP) is widely used for a range of neonatal respiratory conditions. CPAPs mechanism of action is complex and only partial understood. It is believed to work by increasing oxygenation through the stabilisation and recruitment of collapsed alveoli. The functional residual capacity (FRC) is increased resulting in an increased alveolar surface area for gas exchange and a decrease in intrapulmonary shunt. Endogenous surfactant is conserved. The breathing pattern regularises with stabilisation of the rib cage, reducing recession and increasing efficiency of the diaphragm (Thomson, M 2006). The physiologic effects of CPAP are represented in fig. 1. Version 1.1 26 th November 2014 Page 3 of 14

M.J. Sankar et al CPAP Fig. 1. Effects of CPAP (FRC, functional residual capacity; V/Q, ventilation-perfusion ratio; PVR, pulmonary vascular resistance; PaCO2 & PaO2, partial pressure of carbon-dioxide and oxygen respectively in the arterial blood) In practice NCPAP consists of a controlled flow of gas, (either air or an air and oxygen mixture) administered to the baby using a flow driver to circulate humidified gas through a NCPAP circuit to the larynx or nose. The level of CPAP administered to a baby is measured as a pressure reading of cmh2o. In order to raise or lower the pressure given to a baby the flow of gas in l/min can be increased or decreased. Version 1.1 26 th November 2014 Page 4 of 14

Indications for use Respiratory support- RDS Respiratory drive- apnoea/hypoventilation Upper airway abnormalities (eg infants with Pierre Robin sequence) When to use CPAP? In preterm infants CPAP can be used: At resuscitation From delivery Once the symptoms of RDS have developed Following extubation In term infants CPAP can be used as a form of respiratory support, but a cause of the need for respiratory support must be also sought. The cause of their respiratory distress may be due to airway abnormalities, congenital abnormalities (eg tracheo-oesophageal fistula, diaphragmatic hernia) that might be worsened with the use of CPAP. A pneumothorax may also be the cause of the respiratory distress, or be the consequence of using CPAP. For infants with meconium aspiration syndrome CPAP should also be used cautiously due to the risk of air trapping and pneumothorax NCPAP equipment used at FVRH Infant Flow SiPAPTM This machine can provide simple nasal CPAP and time triggered pressure assists CPAP based on clinician determined inspiratory time, rate and pressure in the BiPhasic mode. The latter mode can also be set in BiPhasic trigger mode with apnoea backup breaths where the pressure assists are delivered when triggered by the baby. Modes on Infant Flow SiPAPTM CPAP CPAP and apnoea (AP) 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 Biphasic 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 Version 1.1 26 th November 2014 Page 5 of 14

BiPhasic tr 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 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 Fisher&Paykel MR850 Respiratory Humidifier Set to invasive mode. In this mode of operation the humidifier attempts to deliver optimal humidity to the patient (37 C, 100% relative Humidity). See guidelines for Humidification of Inspired Gases. Hazards/Complications of NCPAP The operator should be aware of possible hazards and complications of NCPAP and take all necessary precautions to ensure safe and effective application. Pneumothorax - This hazard must always be considered if a baby on CPAP has a marked or rapid deterioration. In preterm infants with Respiratory Distress Syndrome (RDS) the application of CPAP is associated with benefits in terms of reduced respiratory failure and reduced mortality, but an increased rate of pneumothorax. Pneumothoraces may occur due to the disease process (alveolar over distension with RDS), with CPAP, particularly when the lungs are improving and lung compliance increasing (Ho, JJ 2003) Impedance of pulmonary blood flow with increased pulmonary vascular resistance and decreased cardiac output may occur as a result of increased intrathoracic pressure with the use of inappropriately high CPAP pressure (Morley1999). Abdominal distension In most infants the tone of the lower oesophageal sphincter is sufficient to prevent abdominal distension at the pressures used for CPAP. However some infants do get significant abdominal distension or CPAP belly during CPAP therapy. The risk of distension may be minimised by placement of an orograstic tube (OGT) on free drainage whilst the infant is nil by mouth. Once OGT feeding is commenced, aspirate air prior to each feed. (De Paoli et al 2003). Nasal Trauma Nasal trauma associated with NCPAP is an adverse event with potential short term or long term consequences (McCoskey 2008, Shanmugananda and Rawal 2007). When carefully applied and monitored, the NCPAP device should provide a good seal without causing skin excoriation, pressure necrosis of the nasal tissue or pain. The risk of nasal trauma can be minimised by adherence to the recommended fixation technique and close observation by care givers. Version 1.1 26 th November 2014 Page 6 of 14

Failure to achieve desired CPAP pressures- This can be due to: Inadequate seal by prongs or mask - always select appropriate size prongs/mask. Dislodged prongs check position of prongs. Infant has open mouth use of a dummy to create a better seal. Leak from circuit check connections especially temperature probe site. Infant appears to dislike NCPAP- Some babies become very agitated during NCPAP. This may be due to a combination of the prongs/mask causing discomfort, the high flow of gas through the nose and the noise the gas flow makes in the nasopharynx. This should not be considered a contraindication for NCPAP if the baby clearly has indications for respiratory support. If the use of comfort measures fails to settle the infant, further action should be discussed with medical staff. Setting up NCPAP Step-by-Step Fixation Technique Following this fixation technique closely helps to ensure: Enhanced stability of the Generator Minimal disturbance to the infant Allow effective NCPAP therapy to be administered A quick and easy method for the carer to be able to assess the infant s nasal area WARNING: Do not attach Generator to the patient until User Verification and initial set up into NCPAP mode is complete. Sizing and Fixation Two types of patient interfaces that can be used to deliver NCPAP Nasal prong : small, medium, large Nasal mask: small, medium, large There are differences in how the nasal prongs and the nasal mask create a seal within or around the infant s nose. The nasal prong delivers NCPAP directly into the infant s nares. As gas passes through the circuit into the Generator and prongs, it causes the tip of the prongs to flare out slightly. This will help create a seal within the infant s nose. The nasal mask however, provides a means to deliver NCPAP when: the largest prong is too small the smallest prong is too large when the nares are of an uneven size when pressure relief is required The nasal mask needs to sit evenly on the nose to create a seal. Version 1.1 26 th November 2014 Page 7 of 14

1. Measure for prong/mask size using the nose guide supplied in each generator packet. Connect the prong/mask to the generator. 2. Measure for bonnet size from the middle of the forehead, around the head to the nape of the neck and then back to the middle forehead. DO NOT use a head circumference measurement to determine bonnet size (it is measured in a different way). 3. Loosely weave Generator straps through the buttonholes. Begin from inside the bonnet starting with the lowest colour coded buttonhole. Place the Generator on top of the bonnet above the central Velcro strip. 4. Place the bonnet onto the infant s head, checking that the ears are in a normal position. Ensure the bonnet is pulled well down over the ears and down to the nape of the neck. 5. Lift the Generator from the top of the bonnet and bring towards the nose. Gently insert the nasal prongs/mask into position while supporting the Generator. Secure the Generator straps horizontally across the infant s cheeks. Do not over tighten. 6. Secure all three tubes from the Generator with the central Velcro strip. Split the inspiratory and pressure lines and secure with secondary Velcro strips. Tie the open end of the bonnet if desired. 7. Final check Bonnet well down over the infant s head Ears well covered and flat against head Prongs/mask correctly positioned Nose in normal position not squashed or pulled upwards. Eyes clearly visible Generator is stable and secure Infant receiving required level of NCPAP 8. Every hour it is important to carry out the final check as above. 9. Every 3-4 hours (Increase frequency to 1-2 hourly if any sign of redness) Loosen the generator straps and release the tubes from the central Velcro Strip. The Generator can be lifted away from the infant s face while the nasal area is inspected. The nasal area can be cleaned with warm water if necessary. Do not apply creams or ointments. Ensure that Nasal prongs/mask is not occluded with mucus/water droplets. Wash in warm soapy water as required. Ensure that the nasal prongs/mask and bonnet continue to fit appropriately. Re-apply the generator as described above Version 1.1 26 th November 2014 Page 8 of 14

10. Every 7 days (Infection control measure). Replace circuit and humidification chamber or when visibly soiled or mechanically malfunctioning Re-measure for prong/mask size using manufacturers nose guide. Re-measure for bonnet size using manufacturers colour coded measure. Discard used hat, mask/prong and replace with new ones of correct size Record equipment changes Monitoring and on-going care of the infant receiving NCPAP All infants receiving NCPAP require: Continuous ECG and respiratory monitoring Continuous oxygenation monitoring by pulse oximetry (see guidelines on saturation level) Blood gas analysis as medically indicated. Routine assessment, observation and documentation should include the following:- Information obtained from the Flow Driver and Humidifier CPAP level administered. The percentage of oxygen delivered (FiO2). Temperature reading on heated humidifier, top up water as required. Physiological observations Respiration rate, depth and rhythm (consider trend) Work of breathing, symmetrical chest wall movement, air entry- clear and bilateral. Oxygen saturation levels, note episodes of de-saturation and increases in oxygen requirements Heart rate and rhythm Capillary refill time Skin colour Blood pressure reading (as a baseline reading may be useful) Urine output Temperature The infant s behaviour, tone response to stimuli, activity The condition of the skin around the nasal area Version 1.1 26 th November 2014 Page 9 of 14

Humidification and Suction The aim of humidification is to prevent damage to the respiratory tract, keeping the airway/secretions moist to prevent the formation of thickened secretions and mucus plugs (See Guidelines for the humidification of inspired gases). Care should be taken to ensure the tubes from the humidifier to the infant are free from condensate as this may impede the gas flow to the infant causing deterioration in the infant s condition. Water accumulating in the tubes should be drained back into the humidifier. It is also important to drain the CPAP circuit before repositioning the infant to prevent condensate draining into the generator. Nasal and/or oro-pharyngeal suction may be necessary if baby has a lot of secretions. Any of the following may indicate the need for suction and the infant will need careful assessment: - Increased oxygen requirement Increased work of breathing Increased recession Snuffly If suction does not improve baby s condition within a few minutes then medical review is indicated. Mouth Care The mouth may become very dry due to the high gas flow and mouth care should be performed regularly. The use of a pacifier helps create a better seal for the NCPAP and also encourage non-nutritive sucking in the pre-term or tiny infant. Abdominal Distension Leave oro-gastric tube (OGT) on free drainage whilst baby is nil by mouth. Once OGT feeding is commenced, aspirate air prior to each feed. Feeding NCPAP should not, in itself, be considered a contraindication to enteral feeding, however, medical and nursing staff will need to assess each infant individually when introducing feeds, devising a regime depending upon the infant s ability to tolerate enteral feeds and overall condition. Prevention of nasal trauma Recent studies have shown the incidence of moderate to severe nasal trauma is common and can be as high as 50% in infants receiving nasal CPAP (Alsop et al 2008, Fischer et al 2010). The nasal prongs tend to cause nasal wall and septum trauma, whereas, the nasal mask tends to cause trauma low on the septum at the base of the philtrum and on the bridge of the nose. The most effective way of maintaining skin integrity is to get babies off CPAP as soon as possible. When medically indicated, even short periods off NCPAP can be beneficial in the prevention of nasal trauma, however, CPAP works by increasing alveolar recruitment and preventing atelectasis. If the infant develops atelectatic areas, then the last 4 to 8 hours of NCPAP benefits have been undone during the time off NCPAP. Version 1.1 26 th November 2014 Page 10 of 14

The infants most susceptible to pressure damage are: Those less than 28/40 (the risk increases with increasing prematurity because of the fragility of the skin) Those on CPAP for a long time, particularly if they cannot manage any time off (Alsop et al 2005, Fischer et al 2010, Squires and Hyndman 2009). Aim to keep the skin clean and dry and avoid pressure and friction. Assess skin integrity hourly. If infant has blanching erythema, change generator from prong to mask or mask to prong. Note how long since last change and plan to change earlier next time i.e. if blanching erythema seen after 4 hours then alternate between prong and mask 3 hourly. If infant has non-blanching erythema, ideally no further pressure should be placed on that area until it has recovered. In practice that may be difficult, so alternating hourly may be the only option. Duoderm (or any other skin dressing that obscures direct visualisation of the underlying skin) should not be applied to the skin routinely; it does not relieve or protect from pressure damage. It makes observation of the skin and detection of damage more difficult. Sterile Duoderm dressing should only be applied to any broken areas to protect from infection and promote healing. If Duoderm is applied to any areas of the nose, pressure relief is still the most important part of the healing process. Do not apply creams or ointments to the nasal area. NCPAP tubing should be positioned on the hat following the manufacturer s recommendations. It should not press against the skin or pull upwards on the nasal septum. Observe to ensure absence of a brow furrow, which indicates excessive pressure on the nasal septum. Any areas of redness or breaks in the skin should be documented. Positioning and Comfort Measures Appropriate positioning can help reduce nasal damage, maintains a clear airway and promote comfort. Furthermore it has been shown that positioning is important in terms of the infant s neurological development. (See Developmental Care Guidelines NHS Forth Valley) The infant can be positioned in the prone, lateral, or supine position although the position selected will be determined by many factors other than the use of NCPAP. If a baby is very active, optimal positioning for the delivery of NCPAP may be difficult. Factors such as hunger, cerebral oedema, over-handling, drug withdrawal and other environmental factors can lead to excessive spontaneous motor activity. Use of comfort measures such as swaddling, use of a pacifier, decreasing light and noise stimulation, use of positioning aids and containment holding may help to settle a very active distressed infant. Co-ordinate care to minimise disturbance of the infant and maintain therapeutic periods of CPAP as much as possible. Handling should be kept to a minimum to reduce the work of breathing. Version 1.1 26 th November 2014 Page 11 of 14

When medically stable, Kangaroo Care should be promoted. When transferring the infant from the incubator to the parent's arms ensure that the circuit is supported and continues to be positioned correctly. Parents The use of NCPAP should be explained to parents using appropriate terminology including risks and benefits, plan for weaning and clinical observations. Where possible, contemporary information should be available for parents. The administration of NCPAP should not interfere with parental contact or holding/handling their baby, (when medically stable), Ensure the family is involved in the care of their baby, update regularly on progress and treatment and promote attachment. Parents should be supported to provide individualised developmentally appropriate care for their baby whilst on NCPAP. Discontinuation / Weaning from NCPAP This is usually based on the following criteria: The general physiological condition is stable. FiO2 requirements are minimal. CPAP levels are minimal. Blood gas values are within normal or acceptable limits. Weaning may be by time off CPAP (cycling) or by weaning pressure. The plan for weaning should be discussed with medical staff and documented in the medical and nursing notes. Recently, Humidified High Flow Nasal Cannula (HHFNC), Vapotherm, has been used as a step down from CPAP support or as an alternative to CPAP see HHFNC guideline. Care while on time-off CPAP Whilst the infant is off NCPAP observe for increased work of breathing; he may tolerate less time off than was planned. A combination of one or more of the following may indicate the baby needs to go back on CPAP: Increasing incidents of apnoea/bradycardia/desaturation Increasing respiratory rate Increasing oxygen requirement Head bobbing, nasal flaring, and increasing recession Version 1.1 26 th November 2014 Page 12 of 14

References Alsop E., A., Cooke, J., Gupta, S., Sinha, S., K. Nasal trauma in preterm infants receiving continuous positive airway pressure. Arch Dis Child 2008; 93: n23 De Paoili A.G., Morley C., Davis P.G. Nasal CPAP for neonates: what do we know in 2003, Archives of Diseases in Childhood Fetal & Neonatal Edn. 2003; 88 F168 Fischer, C., Bertelle, V., Hohlfeld, J., Forcada-Guex, M., Stadelmann-Diaw, C., Tolsa, J. Nasal trauma due to continuous positive airway pressure in neonates. Arch Dis Child Fetal Neonatal Ed 2010; 95 F447-F451 doi:10.1136/adc.2009.179416 Ho JJ, Subramaniam P, Henderson-Smart DJ, Davis PG. Continuous distending pressure for respiratory distress in preterm infants. Cochrane Database of Systematic Reviews 2002, Issue2. Art. No. CD002271 doi: 10.1002/14651858.CD002271. McCoskey L. Nursing care guidelines for the prevention of nasal breakdown in neonates receiving nasal CPAP. Advances in Neonatal Care 2008; 8 (2), 116-124 Morley, C. Continuous distending pressure. Arch Dis Child Fetal Neonatal Ed 1999; 81 F152-F156 Sanker, M., J., Sanker, J., Agarwal, R., Paul, V., K., Deorrari, A., K. Protocol for administering continuous positive airway pressure in neonates. Indian Journal of Pediatrics 2008; 75 471-478 Shanmugananda, K., Rawal, J. Nasal trauma due to continuous positive airway pressure in newborns. Arch Dis Child Fetal Neonatal Ed 2007; 92 F18 doi: 10.1136/adc.2006.095034 Squires, A., J., Hyndman, M. Prevention of nasal injuries secondary to NCPAP application in the ELBW infant. Neonatal Network 2009; 28 (1) 13-26 Thompson, M., A., The prevention of bronchopulmonary dysplasia. Is there synergy between early nasal CPAP and surfactant? Infant 2006; 2 (2), 48-52 Chen, S., J., Boo, N., Y. Yong, S., C., Incidence of nasal trauma associated with nasal prong versus nasal mask during continuous positive airway pressure treatment in very low birth weight infants: a randomised control study Arch Dis Child Fetal Neonatal Ed 2005; 90 F480 doi:10.1136/adc.2004.069351 Version 1.1 26 th November 2014 Page 13 of 14

Publications in Alternative Formats NHS Forth Valley is happy to consider requests for publications in other language or formats such as large print. To request another language for a patient, please contact 01786 434784. For other formats contact 01324 590886, text 07990 690605, fax 01324 590867 or e-mail - fv-uhb.nhsfv-alternativeformats@nhs.net Version 1.1 26 th November 2014 Page 14 of 14