Professional Documents
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PREFACE
Pulmonary surfactant lines the surface of the alveoli in the lung, thereby reducing
surface tension and preventing alveolar collapse. Surfactant deficiency results in
progressive atelectasis of the alveoli, decreased pulmonary compliance, increased
work of breathing, respiratory failure, and lung injury. The earlier the gestational
age, at which birth occurs, the higher the risk that severe respiratory distress
syndrome will develop.
disease (CLD). This lung injury is thought to result from the effect of mechanical
injury due to assisted ventilation, oxygen toxicity, and lung inflammation among
other factors.
The following materials comprise the bubble nasal CPAP Manual. This manual
provides a training tool in the administration of nasal CPAP using a bubble bottle
system, following guidelines established at The Children’s Hospital of New York
at New York Presbyterian Medical Center (Columbia-Presbyterian Medical
Center).
CONTENTS
Introduction
Section 1: Background and Theory
Section 2: Initiation of nasal CPAP
Section 3: Maintenance of nasal CPAP
NCPAP Checklist: Maintaining the nasal CPAP System
Section 4: Complications Associated with nasal CPAP
Section 5: Removal of nasal CPAP
Section 6: Respiratory Failure on nasal CPAP
NCPAP Checklist: Respiratory Failure on nasal CPAP
Section 7: Troubleshooting the nasal CPAP Delivery System
References
Appendix A: Equipment List and Manufacturers
Section 8: Delivery room protocol for the respiratory management of preterm
infants
3
INTRODUCTION
Purpose The purpose of the nasal CPAP Training and Education Manual is to
provide a training tool in the administration of nasal continuous positive airway
pressure (CPAP) using a bubble system following guidelines established at
Columbia-Presbyterian Medical Center in New York.
As you work through this training manual, you will learn the skills to successfully
administer nasal CPAP to premature infants using a bubble system. The sections
outlined below contain information regarding the theory and the application of
the nasal CPAP bubble system.
Section Two: Initiation of nasal CPAP describes the nasal CPAP delivery
system and the steps necessary for stabilization and initiation of NCPAP in the
delivery room. This chapter describes how to determine the appropriate size and
fit of each component in the nasal CPAP delivery system.
SECTION ONE
Physiology of CPAP
Continuous positive airway pressure (CPAP) has been widely used to correct
respiratory insufficiency. CPAP was used in adults as early as 1936. CPAP has
been used in infants with RDS since its introduction in 1971.
CPAP is uniquely suited to address many issues in the pathogenesis of RDS.
Clements and colleagues described the importance of surfactant for the
stabilization of alveoli at low transpulmonary pressures. Harrison and colleagues
recognized the benefit of an increased alveolar pressure during expiration in
infants with respiratory distress syndrome and demonstrated that eliminating the
infant’s ability to grunt by use of an endotracheal tube is associated with a
decrease in Pa02.
CPAP works by maintaining positive pressure in the airway during spontaneous
breathing, thereby increasing functional residual capacity and improving
oxygenation in infants with RDS. CPAP does this by stabilizing airspaces that
have a tendency to collapse during expiration due to surfactant deficiency.
A variety of mechanisms of action of nasal CPAP have been proposed. These
include:
5
Interest in nasal CPAP was renewed by Avery and colleagues, when they
demonstrated that within the NIH score centers, the center that aggressively
utilized NCPAP had the lowest incidence of chronic lung disease. Since the report
of Avery and coworkers, a variety of studies using historical controls have
demonstrated improved outcomes in premature infants with the introduction of
early application of nasal CPAP. Jacobsen and coworkers evaluated non-
asphyxiated very low birth weight infants (VLBW) before and after institution of
a policy of early treatment with nasal continuous positive airway pressure and
minimal handling during stabilization. This “minitouch” regime was introduced
as a routine in 1986. Jacobsen and colleagues compared infants born in 1987
after the policy was instituted, to infants born in 1985, when ventilator treatment
was used initially in all infants with progressive respiratory distress. The
frequency of mechanical ventilation was reduced from 76% in 1985 to 35% in
1987. Intraventricular hemorrhage (IVH) grade II-IV was reduced from 49% in
1985 to 25% in 1987.
Other clinical outcomes, including mortality rate, average duration of
hospitalization, number of infants with pneumothorax, patent ductus arteriosus,
need for oxygen at 28 days and number of surviving infants with handicap did
not differ significantly between the two study periods.
The CPAP delivery system consists of three components: the circuit for
continuous flow of inspired gases, the interface connecting the CPAP circuit to
the infant’s airway, and a method of creating positive pressure in the CPAP
circuit. The success involved in delivering CPAP is entirely associated with the
delivery system; the system must fit properly, be lightweight and flexible, be of
low resistance, be easy to apply, remove, and keep connected, and must provide a
minimum of discomfort and trauma to the infant. The CPAP setup is designed to
deliver pressure through a low-resistance system. The resistance in the circuit is
directly proportional to the length of the circuit, and inversely proportional to the
fourth power of the radius of the tubing used. This means that doubling the
length of a tube doubles the resistance of the tube, and halving the radius
increases the resistance (24 = 2x2x2x2, or 16 times). Since the pressure that is
delivered and ultimately reaches the lungs is directly related to the resistance of
the delivery system and patient airway, it is imperative that every effort is made
to minimize this resistance.
Nearly thirty years ago, under the direction and leadership of Dr. Jen-Tien Wung
at Columbia Presbyterian Medical Center in New York, a systematic approach to
the use of the bubble CPAP system was developed. The Columbia approach with
bubble CPAP has been described as a minimal, gentle ventilation approach. This
approach to respiratory care focuses on meticulous attention in providing
consistent and optimal CPAP delivery. At Columbia Presbyterian Medical Center,
premature infants are stabilized in the delivery suite with the application of
Hudson nasal prongs and 5cm of bubble CPAP using a water bottle system.
Meticulous care of the airway including suctioning and placing appropriately
fitting prongs has shown remarkable results. At Columbia Presbyterian Medical
Center 76% of spontaneously-breathing very low birth weight infants < 1250
grams do not require mechanical ventilation.
9
SECTION TWO
INITIATION OF NCPAP
Introduction
1. Step One: Assemble the CPAP Delivery System Follow the steps
outlined below in Sections A and B to assemble the appropriate materials
and set up the CPAP system in the delivery room or stabilization area
(Transitional Nursery-Room 9 in the delivery room) or in the NICU. At
least one bubble bottle CPAP delivery system must be set up and ready to
use for all imminent deliveries of eligible infants. If a delivery system is
already set up, check that the system was assembled appropriately.
Section A: Gather the following equipment:
“Refer to Appendix A for equipment lists and manufacturers”.
Oxygen and air flow sources
Oxygen blender with flow meter
Oxygen or suction tubing to lead from the blender to humidifier
Oxygen analyzer (optional)
Humidifier filled to appropriate level with sterile water
Corrugated circuit tubing with humidifier connections
Humidifier temperature probe
Nasal prong CPAP set (Hudson nasal CPAP set)
Bottle of 0.25% Acetic acid or sterile water, 1000 cc
A 3 cc syringe
A Luer plug/prn adapter (Not required if a ventilator is being used as a flow
source. The pressure tubing can be connected to the opening at the elbow of
the prongs).
4 small safety pins
4 small rubber bands
Tegaderm
Gauze swabs
Soft gauze or soft cast tubing (for chin strap) / or Co-ban tape.
Paper measuring tape
Tape
10
Table 2.1
Procedure to Set Up the Bubble Bottle CPAP System
Procedure Rationale
1. Attach the oxygen tubing to the flow Flow Meter
Flow Meter meter and connect to the humidifier. A flow of 5 to 10 l/m will provide
Set the flow meter to 5 to 10 adequate flow to wash out carbon
liters/minute (l/m). dioxide in the system, compensate for
the normal air leakage from the
tubing connections, and generate
adequate CPAP pressure (verified by
bubbling of the water in the outlet
bottle).
2. Turn on the humidifier and set the Humidifier
Humidifier temperature at 36.8-37.3° C and the The temperature selected should be
chamber temp at –2. A higher based on the baby’s size, body
temperature may be used if necessary. temperature, and thickness of
The humidity setting needs to be secretions. Adequate humidity will
adjusted to maintain required gas prevent drying of secretions. The
humidification at or close to 100%. tubing needs to be flexible and not too
Attach one of the lightweight, non- heavy for a small baby’s face. The
kinking, corrugated tubes to the probe will monitor the temperature of
humidifier. Connect the humidifier the inspired gas. If the temperature is
tube temperature probe to the too high it may damage the mucous
corrugated tubing going to the baby. Be membranes; if too low, it can cause
sure the probe remains outside the hypothermia and dry, tenacious
incubator or away from the radiant heat secretions. Other heat sources may
source. lead to inaccurate gas temperature
measurement or excessive rainout.
3. Choose the appropriately sized nasal Nasal Prongs
Nasal prongs and attach them to the tubing Prongs should fit the nares snugly
Prongs coming from the humidifier (refer to without pinching the nasal septum. If
section 2: Determining Appropriate the prongs are too small, there will be
Interface Sizes). Attach the second an increase in airway resistance,
corrugated tube to the other side of the making it harder for the baby to
prongs. Fix the Luer plug/prn adapter breathe. Small prongs also allow more
in place over the small opening in the air to leak from the system, making it
elbow of the prongs (used to measure difficult to maintain the correct
pressure). pressure. If they do not fit snugly, the
excess movement may cause damage
to the mucosa and possible septal
erosion.
11
4. Secure the measuring tape (0-7 cm) to Bubble CPAP Delivery System
Bubble the outlet bottle with the 7 cm mark at The opening at the elbow of the nasal
CPAP the base. Empty the fluid to the 0 mark. prongs is designed to fit a pressure
Delivery Place the end of the corrugated tube tubing connection and can also be
System into the water to a depth of 5 cm to used to maintain CPAP while using
generate 5 cm/H2O of CPAP. Slide the 3 the transport incubator ventilator.
cc syringe (plunger removed) into the The depth of the tubing under the
top of the bottle next to the corrugated water controls the amount of pressure
tubing, and this will fix it in place. Test generated in the system. If bubbling
the system by occluding the ends of the does not occur, systematically check
nasal prongs. You should see active each connection until bubbling
bubbling at the end of the corrugated begins. An obstruction in the system
tubing under water. will occlude the infant’s airway; result
NEVER place the prongs in the baby’s in excessive positive pressure, cause
nose until you have verified that the damage to the airway and lungs, and
setup is fully operational. gastric distention.
Hudson Interface
For using the Hudson nasal prong set, the infant’s birth weight determines the
size of nasal prongs to be used. Refer to Table 2.2 to determine the Hudson nasal
prong size.
Table 2.2
Hudson Interface Nasal prongs’ size
Place the hat on the baby’s head so that the rim is just
over the top of the ears. If using tube-gauze tie the The hat needs to fit snugly to minimize
end with ribbon/tape close to the baby’s head. movement of the tubing.
Cut two pieces of Tegaderm to fit across the prepared Tegaderm provides protection for the
area. skin plus a surface for the Velcro to
adhere.
Cut a strip of Velcro (hook side) to fit the area. It A single Velcro strip provides gentle
needs to be narrow in the center over the philtrum splinting of the area. Two separate
but wider over each cheek. cheek patches may be just as effective in
securing the prongs; each baby’s face is
different, so use whichever works best.
Cut two narrow (~8 mm) strips of soft Velcro to wrap Avoid using the hooked Velcro to wrap
around the area of the prongs that cover the cheeks around the prongs, it may scratch the
skin when disconnected.
Once the mustache and skin are prepared, gently This promotes a dry surface for the
remove the prongs. Wipe away any excess secretions, Velcro mustache to adhere.
and place the Tegaderm followed by the Velcro
mustache in place. Wrap the soft Velcro strips around
each side of the prong cannula, and place the prongs
back in the nose.
During the process of applying the mustache, take the This promotes proper positioning of the
opportunity to suction the nose and mouth. prongs while securing them in place.
SECTION THREE
MAINTENANCE OF NCPAP
Introduction
Continuous positive airway pressure is successful when meticulous attention is
paid to both the infant and to the NCPAP delivery system. This meticulous
attention involves vigilance in continuous monitoring of the infant’s condition,
frequent suctioning to maintain optimal airway care, constant evaluation of the
performance of the delivery system, and prevention of complications which may
arise from the NCPAP delivery system.
1. Monitoring the Infant’s Condition
The infant’s condition must be monitored frequently once the NCPAP is applied.
Monitor all infants on NCPAP following our NICU’s current practice guidelines
for monitoring premature infants with respiratory distress.
It is recommended that monitoring the infant’s status while on NCPAP should
include evaluation of the following:
__Respiratory status: respiratory rate, work of breathing;
__Cardiovascular status: central and peripheral perfusion, blood pressure, and
heart rate;
__Gastrointestinal status: abdominal distention, bowel sounds;
__Neurological status: tone, response to stimulation, activity;
__Thermoregulation: infant and environment temperature; and
__Monitor: pre-ductal oxygen saturations, oxygen requirements
It is recommended that the infant be observed every 2-3 hours over the first 4
days of life and every 3-4 hours thereafter while on NCPAP. Any infant that is
experiencing moderate to significant respiratory distress while on NCPAP will
require closer observation of change in condition.
Refer to Table 3.1 for specific guidelines and rationale for monitoring the infant
while on NCPAP.
2. Maintaining Optimal Airway Care
One of the most critical aspects of NCPAP is maintaining an optimal airway
through frequent suctioning of the mouth, nose, and pharynx. We suggest
suctioning the infant at least every 3 hours if the infant has any symptoms of
respiratory distress, or every 4-6 hours if the infant is in room air on NCPAP.
Carefully follow the protocol steps outlined in Table 3.1 for recommendations
regarding suctioning the airway.
3. Preventing Nasal Septal Damage
Damage to the septum arises from friction caused by grazing of the nasal prongs
with the associated continuous pressure, friction or moisture. Avoiding these
contributing factors will maintain an intact septum. Septal injury is preventable
and is not a reason to discontinue using nasal prongs.
It is recommended that the nasal septum and prongs be evaluated every 30-60
minutes. If signs of grazing or erosion are observed, the best treatment is to
remove the cause of pressure, friction, or moisture. Review Table 3.1 for details
regarding interventions to prevent damage to the nasal septum.
16
Table 3.1
Procedure Rationale
1. Monitoring: Monitoring:
Clinical Assessment Clinical Assessment
Suction the mouth, nose and pharynx at least every 3 The presence of excess secretions
hours and prn for symptomatic infants. Use the will narrow the airway and
largest size catheter able to be passed into the naso- increase the effort of breathing. It
pharynx without significant resistance. may cause increased oxygen
requirement, obstructive apnea,
Use a few drops of sterile 0.9% saline solution bradycardia, or pneumothorax.
instilled into the nose to help lubricate the catheter
and loosen dry secretions. Thickening of secretions
indicates the need for increased
Always wear gloves when suctioning, in accordance inspired gas humidity and/or
with universal precaution guidelines. heat. Flecks of blood may suggest
the mucosa is dry.
Table 3.2
Evaluating the CPAP delivery system
Procedure Rationale
1. NCPAP Delivery Circuit NCPAP Delivery Circuit
Check the entire circuit from wall to Changing the circuit weekly prevents growth
baby to outlet every hour to ensure that of bacteria.
it is functioning correctly. Oxygen requirement will vary as the infant’s
Check for leaks and/or broken condition changes.
connections. A flow of 5 to 10 liters/minute will provide
Change the entire CPAP circuit every adequate pressure and prevent carbon
week. dioxide re-breathing.
Check the following:
An adequate water level is required to
__The blender is set at the appropriate maintain inspired gas humidity.
percentage of inspired oxygen.
__The flow meter is set between 5 and The temperature should be based on the
10 liters/minute. infant’s size, body temperature, and the
__The humidifier holds the correct amount and thickness of secretions.
amount of water.
__The inspired gas temperature is Condensation will cause water to accumulate.
appropriate. This needs to be removed in order to prevent
__The corrugated tubing does not water from reaching the infant.
contain water.
__The oxygen analyzer reads the same The oxygen analyzer serves as a double check
as the blender setting (use of an for the blender and needs to be routinely
analyzer is optional). calibrated.
__The outlet bottle is bubbling.
__The tubing in the outlet bottle is The bubbling indicates that the desired CPAP
fixed at 5 cm of water. pressure is being generated. Vigorous
bubbling is not necessary; consistent, gentle
bubbling is adequate. Some infants with mild
respiratory distress may tolerate intermittent
bubbling.
Criteria Additional
Criteria
met/not met information
CIRCUIT AND BUBBLER:
Notes: ---------------------------------------------------------------------------------------
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21
SECTION FOUR
2. Nasal Obstruction
Nasal obstruction occurs from secretions or improper position of the NCPAP
prongs. To avoid obstruction, the nares should be suctioned frequently and the
prongs checked for proper placement.
4. Gastric Distention
Gastric distention occurs from swallowing air. Gastric distention is a benign
finding and does not predispose the infant to necrotizing enterocolitis or bowel
perforation. This occurs more often in the chronic phase of respiratory distress
than in the acute phase. Gastric distention can be treated by intermittent
aspiration of stomach contents. For severe distention an indwelling orogastric
tube may be inserted. It is important to ensure patency of the orogastric tube,
because secretions will block the tube and lead to distention.
22
SECTION FIVE
REMOVAL OF NCPAP
Introduction
When an infant has met clinical criteria to be removed from NCPAP, the NCPAP
delivery system is removed completely. It is not recommend that the NCPAP
system be weaned from a pressure of 5cm of H20 to a lower pressure prior to
removal.
SECTION SIX
Introduction
If an infant develops symptoms of respiratory failure on routine NCPAP (CPAP of
5 cm H20), the CPAP is not sufficient and intubation and mechanical ventilation
may need to be considered. Prior to intubation, you may increase the nasal CPAP
pressure to 7 cm of H20 for a trial period.
Complete this checklist for infants receiving bubble nasal CPAP who are
experiencing respiratory distress and failure. Must be completed before removing
the infant from CPAP.
Criteria Additional
Criteria met/not met information
Nasal prongs size correct
Nasal prongs positioned correctly
Hat fits snugly
Corrugated tubes are correctly placed
Mustache suitable and effective
Neck roll of correct size and position if in
the supine position or side lying.
Chin strap correct size and position
Head position correct (if prone)
Gas bubbling continuously
Airway suctioned
CPAP increased to 7 cm H2O
Infant’s clinical condition consistent with
definition of respiratory failure AFTER
these measures taken
Notes: ----------------------------------------------------------------------------------------------------------
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25
SECTION SEVEN
Troubleshooting
If there is rotating pressure on the prongs they may twist out of the nose. If in
doubt, try undoing the rubber bands and, with the prongs correctly positioned in
the nose, allow the tubing to sit naturally in place. Reposition the pins and rubber
bands as necessary.
See instructions for applying a mustache under Table 2.3 Protocol Steps for
Initiation of NCPAP.
Don’t allow the bridge of the prongs to press up against the septum.
Avoid twisting the prongs with resultant lateral pressure against the septum.
Do not use creams, ointments or gels (use saline drops to moisten the nares for
initial prong insertion or during suctioning if necessary).
Frequent observation of the site and prong position is essential.
Be wary of eye pads that cover the nose on babies under phototherapy as these
can obstruct your view of the septum. If an injury has occurred, reviewing the
above guidelines will avoid further damage and promote healing. It is not
necessary to apply creams or dressings to the injured area. Covering the septum
with Duoderm or similar product may lead to further skin break down and will
limit the ability to assess healing or any further damage.
27
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APPENDIX A:
EQUIPMENT LIST AND MANUFACTURERS
Section eight
C. Infants who are more than 28 wks, more than 1000 g and
not spontaneously breathing after proper stimulation and
resuscitation are to be intubated (no surfactant to be given),
and admitted to the NICU.
They are to be evaluated in the first 2 hrs of life.
1. They can be extubated to bubble nasal CPAP if they are
spontaneously breathing, requiring less than 30% FiO2 to
keep the preductal saturation 92% and above and their CXR
is showing only a mild RDS picture.
Humidifier
Temperature should be 36.8-37.2°C.
(1)
40
(2)
41
The chinstrap