CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) LEARNING …

1 December 2015: Revised January 2020

CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)

LEARNING PACKAGE For the level 3-5 Special Care Nursery

Developed by Caitlin Walker CGHS Revised by Kerrie Venning – Neonatal CNE - LRH

NAME

HEALTH SERVICE

GRCE 4 POINTS


ACKNOWLEDGEMENTS This Self-directed Learning Package was developed Caitlin Walker CGHS and shared with permission across the Gippsland Region. Content has been reviewed and updates by Kerrie Venning LRH Neonatal Educator. Changes were made to ensure that terminology reflects NSQHS Standard 8 - Recognising and Responding to Acute Deterioration. For more information, please refer to PIPER CPAP guideline@ https://www.bettersafercare.vic.gov.au/resources/clinical-guidance/maternity-and-newborn-clinical-network/nasal-continuous-positive-airway-pressure-ncpap-for-neonates

COPYRIGHT Wherever possible permission has been obtained for reproduction of materials and images and the compilers acknowledge the rights of the copyright holder in all reproduced materials which are referenced on the page or in the reference notes. DISCLAIMER The information in this learning package is intended to be a guide only and Health Care Professionals should be aware of the policies and procedures of their employing organisation. However, it should be noted that acting within a guideline or policy statement of an employer, any other organisation or professional group does not relieve them of responsibility for their own acts and may not provide immunity in case of negligence. This learning package consists of current best practice at the time of publication 2020 however it should be noted that changes in the medical and nursing field can occur quite rapidly therefore it is up to the individual to ensure they are accessing current information. NAVIGATION TOOLS &TERMINOLOGY Escalation Protocol “The protocol that sets out the organisational response required for different levels of abnormal physiological measurements or other observed deterioration.” (ACSQHC, 2017) Rapid Response System The protocol set out by organisation in order to obtain emergency assistance in response to severe deterioration it is included as part of escalation protocol. (ACSQHC, 2017)

★Key points & safety

https://www.bettersafercare.vic.gov.au/resources/clinical-guidance/maternity-and-newborn-clinical-network/nasal-continuous-positive-airway-pressure-ncpap-for-neonates




Table of Contents Background................................................................................................................. 4 Aims & Objectives....................................................................................................... 5 Defining CPAP............................................................................................................. 6 How does CPAP work? ……………………………………………………………………. 7 Neonatal Respiratory Distress..................................................................................... 8 Respiratory Assessment............................................................................................. 11 Indications for CPAP................................................................................................... 12 Contraindications for CPAP........................................................................................ 13 Equipment/Resources Required................................................................................. 14 Humidity & CPAP…...……………………………………………………………………… 15 Circuit Setup & Safe Use............................................................................................ 16 Fitting and sizing of prongs/mask…………………………………………………………. 22 Circuit Safety………………………………………………………………………………... 26 Observations & Documentation................................................................................... 27 General Nursing Care.................................................................................................. 30 Main Complications..................................................................................................... 32 Troubleshooting........................................................................................................... 33 Assessing Success/Failure.......................................................................................... 35 Weaning & Discontinuation.......................................................................................... 36 Nutrition/Fluid Requirements....................................................................................... 37 Making a PIPER referral.............................................................................................. 38 Involving Parents......................................................................................................... 39 Quiz Questions............................................................................................................ 41 CPAP Competency Assessment................................................................................. 47 References.................................................................................................................. 49 Appendix……………………………………………………………………………………. 52


Background According to the Australian Institute of Health & Welfare’s (AIHW) most recent 2017 data, 1 in 5 (20%) of all babies born in Australia required admission to either a Special Care Nursery (SCN) or Neonatal Intensive Care Unit (NICU), with respiratory distress cited as the most common reason for admission. Up to 70% of neonates with respiratory distress are born in non-tertiary centres, but in the absence of clinical improvement, many of these infants require transfer to a tertiary NICU for a higher level of care. The implications of transferring a baby are significant & extend beyond financial costs of the health system. It often leads to invasive procedures for the baby, emotional distress & financial burden for families. Considering the number of neonates implicated & an evident need to reduce transfers, non-tertiary SCN’s are increasingly providing higher levels of respiratory support such as Continuous Positive Airway Pressure(CPAP), previously only available in tertiary centres Currently, there are 22 non-tertiary nurseries who provide CPAP throughout Victoria. There are 10 level 3 SCN’s; 9 level 4 SCN’s and 3 level 5 SCN’s. A vast number of clinical trials and review studies have demonstrated the safety & efficacy of CPAP as a therapy for respiratory distress in neonates, even in regional settings. Research has shown that early intervention with CPAP;

reduces the need for intubation & mechanical ventilation

decreases oxygen requirements

reduces the required duration of oxygen therapy

reduces respiratory failure & mortality

reduces the need for re-intubation

decreases the incidence of chronic lung disease in low birth weight infants

decreases length of hospital stay and

reduces the frequency of transfers to tertiary facilities

However, despite being a relatively simple and effective therapy, the administration of CPAP is resource intensive & requires maintenance of a high level of nursing expertise & skills. In non-tertiary settings, there can be a limited availability of trained staff & an evident need for improved educational opportunities. At a minimum, there must be a nurse/midwife appropriately trained & experienced in CPAP available on every shift when treating a baby with this therapy. In addition, there is great need for consistency regarding practices such as saturation targets, thresholds for commencement of CPAP, thresholds for transfer & the development of uniform approaches to care and locally specific guidelines. Consistent & ongoing educational/ training workshops, packages, guidelines and competencies will help to ensure CPAP is used appropriately & safely in the regional or rural SCN. References Buckmaster, 2012; Buckmaster, Arnolda, Wright, & Henderson-Smart, 2007; Hemani, Narayanan, Jeffries-Stokes, & Volkman, 2014; Manley, Owen, Doyle, & Davis, 2012; Resnick & Sokol, 2010


Aims & Objectives This learning package has been designed to assist staff, including nurses and midwives in the management of neonates requiring bubble CPAP in the Level 3-5 SCN setting. The information presented within has been locally adapted & closely informed by Victorian state-wide benchmarks for practice established by PIPER and Safer Care Victoria (SCV). Further content presented in this package is based on additional literature to support evidence-based practices (please refer to reference list). The objective of this educational resource is to provide readers with theoretical information & knowledge so that they will be equipped to:

Define bubble CPAP, understand what this therapy is & when its use is indicated

Understand the physiological effects of bubble CPAP

Identify the signs, symptoms, risk factors for & causes of neonatal respiratory distress

Perform a thorough respiratory assessment on a neonate

Identify indications & contraindications for the use of bubble CPAP, & recognise when there is a need to initiate bubble CPAP

Identify the equipment requirements for a neonate requiring bubble CPAP

Demonstrate competent circuit setup & safe use of bubble CPAP equipment

Understand and accurately document monitoring & observation requirements Manage the general nursing care of a neonate with respiratory distress & requiring bubble CPAP

Readily identify & manage complications of bubble CPAP therapy

Assess the success/failure of bubble CPAP therapy

Undertake troubleshooting of common problems

Understand the fluid & nutritional requirements of a neonate on bubble CPAP, & when & how to commence feeding

Understand when & how to begin weaning/discontinuation of bubble CPAP therapy

Know when a PIPER referral/transfer is indicated & how to make a referral

Assist & facilitate parental involvement in the care of their baby on bubble CPAP

The main aims of this learning package are to:

Increase staff confidence, knowledge, skills & competence in the nursing care and management of neonates requiring bubble CPAP in the Level 3-5 SCN

Improve consistency & quality of care in the management of neonates requiring bubble CPAP


Defining CPAP CPAP is a form of respiratory support that has been used since the year 1971, to assist neonates experiencing respiratory distress It can be described as a non-invasive method for delivering a mixture of air and/or oxygen under a directly measurable, constant & non-varying amount of positive pressure into the lungs of a spontaneously breathing infant (Bonner & Mainous, 2008). The delivery of positive pressure remains at a constant level during both inspiratory and expiratory phases of the respiratory cycle. Pressures commonly delivered to infants in the Level 3-5 Nursery range from 5 to 8cm H2O. CPAP pressures as high as 15cm H2O can be achieved in the NICU setting & whilst rarely needed, do benefit some infants. A CPAP pressure less than 5cm H2O are generally too low to achieve any benefits. CPAP pressures need to be individualised for each infant and vary for each clinical scenario. “But how does Bubble CPAP deliver and generate pressure?” CPAP can be generated by various devices such as a ventilator. However, the bubble CPAP system is a simple, inexpensive and safe way to deliver CPAP. This system has 5 main components:

A blended, humidified gas source

A circuit to run the gas (blue inspiratory & white expiratory circuit tubing)

A patient interface that connects the circuit to the infant (e.g. bi-nasal prongs/nasal mask)

A CPAP generator

Hats & straps to secure the interface.

Simply, the expiratory limb of the breathing circuit is submerged under water. This generates pressure that oscillates in the circuit. The “bubbles” are created as humidified gas flows from the gas source, along the inspiratory circuit, passes the nasal interface to the expiratory limb, and into the water. The amount of CPAP pressure delivered to the infant is determined by the depth of the expiratory tubing below the surface of the water (e.g. 1cm below surface is equivalent to 1cm H2O pressure). Excess pressure build-up in the system is prevented by bubbling the expired air through water. Consistent gentle bubbling indicates that the desired CPAP pressure is being generated (Chan & Chan, 2007; DiBlasi, 2009).

Simple bubble CPAP setup & Components


How does CPAP work?

The goal of CPAP is to improve oxygenation in infants with signs & symptoms of respiratory distress. CPAP has various known & proposed mechanisms of action. A good way of understanding how CPAP works (and helping parents understand too) is to use the analogy of the lung as a balloon. The hardest part of inflating a lung, is overcoming the initial opening pressure (just like the first blow on the balloon is always hardest). In other words, a greater amount of pressure is required to open collapsed alveoli than to ventilate already expanded alveoli. CPAP helps to overcome this opening pressure, recruiting previously collapsed alveoli & preventing alveolar & terminal airway atelectasis/collapse at the end of expiration. As long as the airways remain adequately open with the help of CPAP (and the balloon remains partially inflated), breathing (and blowing up the rest of the balloon) thereafter should become much easier (Benitz, 2014).

Physiological Effects Summarised

CPAP provides the opening pressure in a lung.

Splints the chest wall & airways open.

Increases functional residual capacity.

Increases the surface area available for gas exchange.

Improves lung compliance (redistributes fluid in the lungs)

Improves ventilation/perfusion ratios.

Conserves surfactant distribution on the alveolar surface.

Decreases work of breathing & respiratory fatigue for the infant.

Optimises oxygenation & ventilation. Stimulates lung development & growth.

Functional Residual Capacity The volume of air that remains in the lungs at the end of normal expiration. Ventilation/Perfusion Ratios The ratio of the amount of air reaching the alveoli, to the amount of blood reaching the alveoli. Surfactant A complex mixture of phospholipids & proteins that occur naturally in the lungs which spread as a thin film of fluid over the alveolar air-liquid interface, lowering surface wall tension & preventing alveolar collapse at end expiration therefore promoting optimal alveolar inflation on inspiration. Can be given artificially, usually in the form of Curosurf® via an endotracheal tube to neonates who have surfactant deficiency (mostly very preterm neonates who have not developed adequate levels of surfactant)


Neonatal Respiratory Distress Respiratory distress is a general term that can be used to describe a variety of respiratory symptoms that may be indicative of respiratory disease. Symptoms may present immediately after birth, or slightly later in view of the natural history of the disease. SIGNS & SYMPTOMS Tachypnoea Respiratory rate of greater than 60 breaths per minute. The earliest & most common sign of respiratory distress. Breathing at fast rates requires a lot of energy, & is a warning sign that respiratory failure or decompensation is occurring Expiratory grunt An expiratory noise created when the neonate exhales against a partially closed glottis. Considered a form of self-generated positive end expiratory pressure. Grunting maintains a higher residual lung volume and in turn prevents alveoli from collapsing. Chest retractions Occurs due to the increased negative intrathoracic pressure necessary to ventilate a stiff/non-compliant lung. Increased accessory muscle effort results in collapse of soft tissue, called retractions (aka recessions), that can be seen in various locations on an infant’s chest. Types of retractions include; intercostal, subcostal, substernal, suprasternal (aka tracheal tug) & sternal. Nasal Flaring A compensatory mechanism used by the infant to increase the size of the nares, making the passage larger and decreasing resistance of the narrow airways. Cyanosis in Room Air Blueish colour of the skin, lips, nail beds & mucous membranes. Central cyanosis is a late & serious sign of respiratory distress.

★Evidence of 2 or more of the above, persisting for 4 hours or more suggests

respiratory distress


Other Signs and Symptoms Irritability/lethargy, pallor, poor feeding, decreased oxygen saturation, tachycardia or bradycardia, tracheal tug, exhaustion, head bobbing, gasping respirations, apnoea (lasting >20 seconds), periodic respirations, slow or shallow breathing, increased oxygen requirements, desaturation episodes, see-saw breathing, air hunger, diaphoresis.

CAUSES Respiratory distress may arise from various pathologic processes affecting the respiratory system, or indeed another organ system. There are a broad variety of reasons a neonate may develop respiratory distress, but whatever the cause/disease process involved, the final common pathway is always impairment of gas exchange. Cardiac Causes

Heart or great vessel anomalies

Congestive heart failure

Excessive bleeding

Idiopathic pulmonary hypertension

Persistent pulmonary hypertension of the newborn: pulmonary vascular resistance fails to decrease soon after birth as with normal transition

Congenital Causes

Congenital diaphragmatic hernia

Congenital cardiac disease

Syndromes: Pierre Robin Respiratory Causes

Respiratory distress syndrome: structural & functional lung immaturity & surfactant deficiency

Transient tachypnoea of the newborn (TTN): retained fetal lung fluid

Air leaks: pneumothorax

Meconium aspiration syndrome

Aspiration of blood, liquor or feed

Pulmonary haemorrhage

Pneumonia

Airway obstructions (e.g. choanal atresia) Structural lung malformations (e.g. lung hypoplasia)

Diaphragmatic paralysis: phrenic nerve injury

Pulmonary oedema

Chest wall deformities


Neurological Causes

Perinatal asphyxia

Hypoxic ischaemic encephalopathy

Cerebral haemorrhage

Seizures

Depression of the respiratory centre related to drugs

Metabolic & Hematologic Causes

Hypoglycaemia

Hypothermia & cold stress

Polycythaemia

Anaemia

Infection & Sepsis: Group B streptococci, streptococcus pneumoniae, gram negative rods

ABO and Rh incompatibility

Other Contributing Risk Factors from a Midwifery Perspective

Caesarean birth

Assisted delivery

Narcotic administration to mother within 4 hours of birth

Precipitate births

Abnormal amniotic fluid volume

Malpresentations

Uterine tachysystole/ hyper stimulation

Fetal hypoxia, male gender

Maternal diabetes (too much insulin in a baby’s system can delay surfactant production),

Premature birth

Antepartum haemorrhage

Multiple birth

Macrosomia

IUGR

Prolonged rupture of membranes

Maternal fever/infection

Chorioamnionitis


Respiratory Assessment Assessment is a key component of nursing an infant on CPAP. All neonates presenting with signs & symptoms of respiratory distress require timely & consistent assessment.

★Detailed respiratory assessment should be completed: at the time of admission to the

SCN, at the commencement of every shift & whenever the infant’s condition changes. Respiratory assessment should accompany ongoing assessments of other body systems & should include: History

Reason for current admission, diagnosis, relevant history, medications, immunization status, maternal history, antenatal history, delivery type & complications if any, APGAR scores & resuscitation required at delivery.

Inspection/Observation (LOOK)

Observe general appearance of the infant: alert, lethargic, active, agitated, calm, drowsy, irritable, exhaustion (pre-terminal sign), looks well or unwell, and current respiratory support insitu.

Colour (centrally and peripherally): pink, flushed, pale, mottled, diaphoretic, cyanosed, and plethoric.

Respiratory rate, rhythm and depth: shallow, normal, deep, regular, irregular, apnoeic, periodic breathing, tachypnoeic, bradypnoeic, laboured, supported by CPAP.

Respiratory effort/work of breathing: mild, moderate, severe, use of accessory muscles, retractions, head bobbing, nasal flaring, tracheal tug.

Secretions: colour, amount, thick, tenacious, scant, nil.

Symmetry and shape of chest: pigeon/barrel shaped.

Monitor for SpO2 and heart rate, noting any oxygen requirement & delivery mode.

Auscultation (LISTEN)

Listen for absence/quality of breath sounds.

Audible sounds: loud cry, weak cry, wheeze, stridor, grunt, cough.

Auscultate all lung fields for adventitious noises: wheeze, crackles, reduced air entry, transmitted noises from the bubble CPAP.

Silent chest = pre-terminal sign. The more chests you listen to, the better you will get at this skill! Palpation (FEEL)

Feel for bilateral symmetry of chest expansion. Does one side rise more than the other?

Skin condition: temperature, turgor, moisture, capillary refill (central & peripheral) brisk < 2 seconds, or sluggish.

★Ensure your assessments are documented appropriately. Escalate care according to

Hospital Escalation Protocol. Initiate Hospital Rapid Response System in response to severe deterioration in patient condition. (ACSQHC, 2017)


Indications for CPAP As per the 2018 Safer Care Victoria Guidelines and the 2015 ‘Defining levels of care for Victorian newborn services,’ babies should meet all of the following criteria for CPAP to be indicated in a Level 3-5 SCN’s;

Have clinical signs of respiratory distress

Requires FiO2 > 0.25 to maintain saturations between 91-95%

A chest x-ray consistent with mild respiratory distress syndrome or transient tachypnoea.

Be less than 24 hours of age (the use of rescue CPAP in a 2-3-day old baby with

progressive respiratory failure is frequently followed by the need for endotracheal

intubation and aggressive mechanical ventilation).

Weight and gestation based on the SCN’s level of care

With regards to the above indications, the following must also be considered regarding staffing expertise and the level of care which can be provided by the SCN;

Level 3 - ≥ 34 + 0 weeks’ gestation - birthweight ≥ 2,000 grams

Infants on CPAP requiring an ongoing Fi02 of greater than 0.40 for ≥ 4 hours, MUST be discussed with the duty PIPER Consultant


Infants on CPAP requiring an ongoing Fi02 of greater than 0.40 at 48-72 hours MUST be discussed with the duty PIPER Consultant


Infants on CPAP requiring an ongoing Fi02 of greater than 0.50 for ≥ 72 hours MUST be discussed with the duty PIPER Consultant

Guidelines available @ https://www.bettersafercare.vic.gov.au/resources/clinical-guidance/maternity-and-newborn-clinical-network/nasal-continuous-positive-airway-pressure-ncpap-for-neonates and Levels of care @ https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/perinatal-reproductive/maternity-newborn-services/newborn-care-in-victoria




https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/perinatal-reproductive/maternity-newborn-services/newborn-care-in-victoria



Contraindications for CPAP As per the Safer Care Victoria Guidelines (2018) and the ‘Defining levels of care for Victorian newborn services’ (2015), CPAP is contraindicated in Level 3-5 SCN’s in the following instances:

Birth weight and/or gestation less than allowed for your SCN level of care

More than 24 hours of age at time of initiation of CPAP

Insufficient medical/nursing/equipment resources

Infants requiring FiO2 greater than allowed for your SCN level of care

On arterial blood gas: persistent hypercarbia (PaCO2 greater than 60mmHg) with respiratory acidosis (pH less than 7.25)

Apnoea: Infants greater than 1499g and 32 weeks’ gestation rarely have uncomplicated apnoea of prematurity as a reason to require CPAP

Babies who remain dependent on CPAP for greater than 72 hours Please note that CPAP can be initiated on these infants described above, but early discussion with PIPER to arrange transfer to NICU should occur. In addition, neonates with meconium aspiration syndrome, pneumonia, or a history of significant asphyxia can have CPAP initiated BUT are susceptible to significant cardiorespiratory instability & are not suitable for ongoing support on CPAP outside of a NICU. Other contraindications outlined by PIPER include:

Upper airway abnormalities that make CPAP ineffective or dangerous: Choanal atresia, cleft palate, oesophageal atresia (+/- tracheoesophageal fistula)

Congenital abnormalities such as: congenital diaphragmatic hernia, gastroschisis, exomphalous.

Infants with an unstable respiratory drive with frequent apnoeas resulting in desaturation &/or bradycardia.

Infants with severe cardiovascular instability

★For neonates who fall outside the recommended indications, or if signs of

treatment/respiratory failure become evident for any infant, immediate consultation with PIPER is required to discuss further management and retrieval.

★Escalate care according to Hospital Escalation Protocol. Initiate Hospital Rapid

Response System in response to severe deterioration in patient condition. (ACSQHC, 2017)

Guidelines available @ https://www.bettersafercare.vic.gov.au/resources/clinical-guidance/maternity-and-newborn-clinical-network/nasal-continuous-positive-airway-pressure-ncpap-for-neonates and Levels of care @ https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/perinatal-reproductive/maternity-newborn-services/newborn-care-in-victoria







Equipment/Resources Required Required equipment should be kept within the vicinity of the bedside at all times. As per PIPER guidelines, to safely manage a baby requiring CPAP the following are necessary:

Appropriately trained nursing staff and paediatrician cover 24 hours. When not on hospital grounds, consultants should be contactable by phone immediately.

One on one ratio nursing care is advised. Tertiary centres regard CPAP as an intensive care practice & resource it accordingly.

Pathology & radiology services available 24 hours. Wall medical air and oxygen attached to a blender. Fisher & Paykel Healthcare Neonatal Bubble CPAP Dual Heated Circuit Kit

950N60 which consists of a pressure manifold, humidification chamber, breathing circuit and CPAP generator (if using the older MR850 humidifier you will need the circuit kit MR290)

A bag of sterile water for irrigation A 500ml bottle of sterile water to fill CPAP generator. Fisher & Paykel Healthcare Interface (prongs/mask) & head gear (hat). F&P 950 humidifier base with heater wire (please see appendix for MR850 set

up). Measuring devices to select the appropriate size hat & interface for infant. (the

Fisher & Paykel Healthcare midline CPAP comes with a measuring guide) Cardiorespiratory monitoring (3-lead ECG, respiratory rate, Sp02) with high & low

alarm limits set; non-invasive blood pressure cuffs & monitoring capability, skin temperature probes & per axilla temperature monitoring device.

Equipment for blood gases. Isolette (incubator) or radiant warmer with temperature servo-control Low pressure suction unit at the bedside & suction catheters (size 6, 8 & 10 FG).

Emergency resuscitation equipment including; NeoPuff & bag mask device. Resuscitation drugs: Adrenaline 1:10,000 & 0.9% Sodium Chloride. Intubation equipment: neonatal/infant sized laryngoscope & blades, endotracheal

tubes sizes (2.5, 3.0, 3.5 and 4.0mm), introducers, Magill’s forceps, spare batteries, lubricant, carbon dioxide detector (such as a PediCap) & trouser leg Elastoplast tapes to secure endotracheal tube.

Emergency pneumothorax kit for needle aspiration containing: 21G butterfly needle, 22G cannula, 3-way stopcock, 10 or 20 mL syringe, alcohol swab, sterile cotton swabs, trans illuminator & chest drain equipment (such as a Heimlich valve).

Size 8 FG orogastric tube. Charts with space to record all observations.


Humidity & CPAP When we breathe in air normally it is warmed, filtered and humidified as it travels through the upper respiratory system. On expiration, heat and moisture are recovered. The natural humidification process also provides airway defence mechanisms via the mucociliary transport system to remove pathogens and secretions from the airways. It also preserves energy used for thermoregulation, growth and development. Therefore, we need to ensure the mixture of air & oxygen is heated & humidified to the correct temperature before it is delivered to the lungs. Clinical benefits of optimal humidity are;

Improvement in secretion quality and clearance

Reduces resistance and work of breathing

Maintains lung dynamics

Reduces risk of lung dysfunction

Reduced infection risk

Energy is preserved

F&P 950 Humidifier Base The F&P 950 respiratory humidifier provides heat & humidity to medical gases by passing the gas through a heated water chamber & heated breathing tubes. The amount of heating is controlled based on the gas temperature measured at different parts of the humidifier. Neonatal mode is automatically selected when a neonatal breathing circuit is connected. In this mode of operation the humidifier delivers optimal humidity of 37oC. The F&P Neonatal Bubble CPAP Dual Heated Circuit Kit 950N60 is designed for simple setup and efficient delivery of humidified gases to the neonate. To start setup, open up the circuit package, and ensure contents are laid out on a clean surface.


Circuit Setup Assembling the Fisher & Paykel Bubble CPAP delivery system using the F&P 950 humidifier (please see appendix for instructions if your hospital is using the MR850 set up). Step 1. Insert humidification chamber The humidification chamber can only be inserted one-way into the base, as the Sensor chamber aligns with the ports on the cartridge sensor cartridge attached to the base.

Step 2. Remove yellow cap Once the chamber has clicked into place, the yellow cap can be removed, ensuring part of the yellow cap remains covering the spike until ready for use.


Step 3. Insert circuit into humidifier The end of the blue circuit has a microchip as shown in photo below. This end of the circuit only fits into one part of the humidifier as shown. Ensure the microchip is facing upwards on insertion.

Step 4. Attach pressure manifold Connect pressure manifold to chamber inlet port (either orientation)

Step 5. Connect one end of oxygen tubing to pressure manifold


Step 6. Connect the other end of the oxygen tubing to the oxygen blender.

Step 7. Connect the round end of the expiratory heater wire adapter into the port on the right of the sensor cartridge

Step 8. Connect the other end of the heater Wire adapter into the short end of the Y-piece on the white breathing circuit tubing


Step 9. Fill the CPAP generator Using the small funnel included in the circuit kit, fill the CPAP generator up to the maximum line with the bottle of sterile water

Step 10. Connect the long end of the Y-piece on the white breathing circuit tubing, into the

top of the probe which sits in the CPAP generator

Step 11a. Perform leak test Connect the proximal ends of the blue and white tubing with the yellow test elbow

Step 11b.

Set the oxygen flow to 1Lpm for test.


Step 11c. Observe for gentle audible bubbling. If no bubbles are detected, check the entire system. Check the temperature probes/heater wire are firmly in their ports, & that gas flow is connected securely Run your hands over the tubing to feel for any gas leaks

Step 12. Set desired CPAP level. The number on the CPAP probe just above the lid indicates the CPAP pressure set in cmH2O. The probe can be easily moved up and down to set the prescribed level of CPAP. PIPER advises that CPAP should be commenced at 7cm H2O (as shown in below right picture) & then titrated to each infant’s individual needs. Recommended oxygen flow should be set at 6 – 8Lpm.

Step13. Disconnect yellow elbow Once the elbow is removed, the proximal ends of the blue and white

circuit tubing can now be connected to the flexi-trunk interface.


Step 14. Connect water bag

Hang the water bag on a hook or IV pole, so it is higher than the humidification chamber. Unwind the water feed set and spike the water bag. Gravity should fill the chamber up to the black line.

Screen Navigation Now that your circuit is setup and has been tested for leaks, you can turn on the humidifier. When turning on the humidifier, an audible single beep sound should be heard. Neonatal operating mode is automatically detected and set when a neonatal breathing circuit is connected. The F&P 950 humidifier has visual and audible alarms to warn about interruptions to treatment. These alarms are generated by an intelligent alarm system, which processes information from the sensors and target settings of the unit and compares this information to pre-programmed limits.

CHECKING ALARM SYSTEM FUNCTIONALITY - To check alarm functionality, remove the heated breathing tube at any time while the humidifier is powered on but not connected to a patient. This action should activate the “Disconnection” visual and audible alarms. If either signal is absent, do not use the humidifier. Contact biomedical engineering or your servicing department for assistance.

See manufacturer instructions for further information.


Fitting the appropriate size mask/prong interface Step 1. Measure head circumference Step 2. Choose the correct size hat to match

head circumference, ensuring;

To stretch before application

Is snug fitting

Step 3. Apply hat to infant’s head

Completely cover the ears

Align back edge of hat with

the base of the infant’s neck Align front edge of hat just

above or on the infant’s eyebrows


Step 4. Size the infant for prongs/mask fit

Prongs should fill nares completely without stretching the skin

The mask should not touch the edge of nose, septum or eyes

Step 5. Choose correct size nasal tubing

The clear tubing should not extend over the infant’s forehead

50mm < or equal to 1.5kg 70mm < or equal to 2.5kg 100mm > 2.5kg

Step 6. Connect the prongs or mask to the nasal tubing

Push the end in firmly


Step 7. Remove foam strips as required to adjust the nasal tubing angle to optimise the seal

Tubing should be parallel to infant’s face Step 8. Attach the circuit to the tubing in EITHER

orientation

When circuit connected, place hand close to prongs/mask to see if there is gas flow

Step 9. Secure interface to hat

Hook the clips for the side straps of hat to glider

Pull both straps at same time for central positioning

Affix velcro tabs to blue strap of hat

Use the least tension possible


Step 10. Condensation should not be a problem with the new Dual Heated Circuit Kit 950N60, however, the older MR850 humidifier and circuit kit MR290 can be, in which case, try to keep the circuit below the level of the nasal tubing/interface to minimise condensation build up. You may wish to use a rolled-up towel or cloth nappy to gently support the weight of circuit as shown below, to prevent drag.


Circuit Safety

One bubble CPAP delivery system should be set-up in the SCN & ready to go at all times. Do not spike the water bag until it has been confirmed that an infant will be going onto CPAP. Cover the circuit when not in use.

Check that all connections are tight before use & after any adjustment ALWAYS perform a leak test before commencing an infant on bubble CPAP. NEVER place mask/prongs on infant until you have verified the setup is fully operational.

ALWAYS set the circuit gas flow between 6 - 8 litres/min as recommended by Fisher & Paykel. Optimal gas flow should be maintained to prevent rebreathing of carbon dioxide, increased work of breathing related to insufficient flow available for inspiration, & to compensate for small leakage in the CPAP system (e.g. leak around prongs)

ALWAYS set the humidifier to the invasive setting. This setting will warm the humidifier chamber to 39-40 degrees, but there is an offset of approximately 2 degrees between the chamber and the patient. Thus, the temperature at the patient interface is a comfortable 37 degrees. Inadequate humidification may increase the thickness of secretions, suppress ciliary function, increase the need for suctioning, cause mucosal damage, or even complete blockage of the airway.

At the start of every shift & hourly thereafter, ALWAYS check circuit assembly & settings: FiO2, CPAP level, humidifier temperature and gas flow set at correct rates. FiO2 and CPAP level should align with clearly documented medical orders. Medical orders are required to initiate CPAP, to alter the amount of CPAP/FiO2 delivered & to discontinue CPAP. Check the entire circuit from wall to baby to outlet every hour to ensure that it is functioning correctly.

Is ADVISED that CPAP be commenced at 7cm of H2O as per PIPER guidelines. Starting pressures are ultimately at the discretion of the Paediatrician.

Check the water level in the humidifier chamber HOURLY. Replace the humidification chamber if the water level exceeds the maximum water level marked on the chamber.

Observe the water level in the CPAP generator & overflow container HOURLY. Add more water to the generator if the water level drops below the minimum water level line. Empty the overflow container as needed.

Regularly check the circuit for condensate & drain as required. Placing a reflective sticker (e.g. skin temp dot) covering the circuit temp probe (the one close to the patient) will reduce rainout.

The circuit should be changed WEEKLY.

Ensure circuit tubing is well supported & secure AT ALL TIMES.

MOST IMPORTANTLY, ensure airflow & bubbling is present at all times.

★Although the F&P 950 has alarms that can identify disruption to delivery of

treatment, the Bubble CPAP circuit itself has no audible alarms when pressures are not being delivered. Therefore, the lack of bubbling should also alert staff that the required CPAP pressure is most likely not being achieved.


Observations & Documentation The following table outlines the assessments & observations that should be undertaken & documented when looking after an infant on CPAP. Note, in the initial stabilisation period OR if the infant is unstable, monitoring & documentation should occur more frequently.

= frequency that monitoring/checks should occur & documentation

Observation & monitoring

Start of Shift

Hourly 4 to 6 Hourly

Change in patient’s condition

Continuous/ Ongoing

As ordered

SpO2, HR,RR

Blood pressure

Axilla temp

Skin temp (if on servo)

Cot temp

Pressure area

FiO2

CPAP pressure Gas flow rate

H2O level (bag & base)

Humidifier temp

Bubble activity

Blood gases BSL Activity pattern

Head to toe exam

Respiratory assess

Colour

IV site

Fluid balance

★Escalate care according to hospital escalation protocol in response to variations of

observations & or staff or parental/family concerns. (ACSQHC, 2017)

★Initiate Hospital Rapid Response System in response to severe deterioration in

patient condition. (ACSQHC, 2017)


Vital signs/Assessments

Considerations

SpO2 Target range 91% - 95%

Check monitor alarm limits at start of every shift. Set default alarms at

89% - 95%. When weaned to Fi02 0.21, upper alarm limit may be

increased to 100%

Change sensor site 2-4 hourly

If SpO2 >95% consider weaning Fi02/CPAP pressure

HR Normal range 100-180 (can be as low as 80 when asleep)

Auscultate the apex beat 4 hourly and note rhythm

Bradycardia is a pre-terminal sign in a neonate with respiratory distress

RR Normal range 40-60

Infants on CPAP won’t always be within normal range

Need to count RR for a full minute & never rely on monitor rate

BP Normal values increase with gestation, birth weight and postnatal age.

For a term neonate, normal range is roughly: 50-70 (systolic), 25-45

(diastolic)

Generally, the lower limit of mean BP in mmHg is approximately equal to

gestational age in weeks

If possible, obtain BP measurement during quiet or sleep state.

Why measure BP? Sick lungs can lead to severe haemodynamic

compromise. Lungs & heart work very closely together.

Axilla T Normal range: 36.5o - 37.5o Celsius

Check 30 minutely until stable, then 4-6 hourly

Cold stress increases an infant’s metabolic rate, energy expenditure &

oxygen consumption to produce heat through non-shivering

thermogenesis. Sick neonates don’t have energy & oxygen to spare for

this when in respiratory distress!

Skin T Skin temperature is approximately 0.5 - 1.0 degrees lower than core

body temperature. Therefore, when on servo control, aim for a skin temp

of 36o - 36.5o Celsius and set cot within this temperature range.

Check skin application of skin temp probe frequently. Risk of

overheating infant if not applied correctly or infant lies on temp probe.

Will send incorrect feedback to cot. If unable to get good skin

application, don’t monitor. Probe can cause pressure areas, so re-site to

different area every 4 – 6 hours.


Blood gases It’s good to have an appreciation of normal/abnormal blood gases as

they tell us about acidity, 02 & C02 levels within the blood. Normal

neonatal arterial values are generally: pH 7.35 - 7.45 (<7.35 = acidosis,

>7.45 = alkalosis); pC02 35-45mmHg; p02 55-90mmHg; Bicarbonate

22-26; Base excess -4 - +4. NOTE: do not use venous or capillary blood

gases to interpret oxygenation).

Babies stable/improving on CPAP do not require routine blood gases.

Frequency of blood gases are at Paediatrician’s discretion.

Changes in blood gases over time assist with evaluating medical

treatment & planning care, including respiratory support.


General Nursing Care Airway Management Airway management is perhaps the single most important aspect of improving outcomes & reducing complications in infants receiving CPAP.

Infants on CPAP produce increased amounts of mucous contributed to the presence of prongs/humidified gases passing the nares. Increased mucous production is also characteristic of common disease processes treated with CPAP therapy.

A neonate’s airway is much smaller in diameter than adults. Debris that causes only a mild obstruction in an adult airway causes a disproportionately greater obstruction in the airways of a neonate. Neonates are also obligatory nose breathers & hence dependent on a patent nasal passage for ventilation.

Suctioning of the mouth, nose & nasopharynx ensures airway patency. It assists in the prevention of airway narrowing/mucous obstruction, increased work of breathing, & mucous build-up in the bi-nasal prongs. It may also assist in preventing infection. Frequency of suction depends on the infant’s condition and presence of secretions. Suction should only be carried out PRN or every 6 hours at a minimum

Indications for suctioning include; visible pooling of oral/nasal secretions/vomit, increasing respiratory effort, increasing oxygen requirements or increasing episodes of apnoea.

Document any suctioning undertaken including the time, colour, consistency & quantity of secretions including the infant’s response.

Pressure Area Care

Diligence in monitoring the position of nasal prongs/mask is essential (hourly assessments). Pressure injury to the septum, nares, philtrum and bridge of nose can be prevented.

Prongs should fill the entire nares without causing any skin blanching or pressing against the septum. A 2mm gap between the nares & prong base should be maintained at all times. If blanching or redness occurs, the prongs/mask should be repositioned or changed to a more appropriate size to relieve any pressure/friction.

Remove the prongs/mask & interface every 6 hours to observe skin integrity. The CPAP hat & straps should also be removed at this time to assess for pressure points to the head, ears & neck. Skin irritation from improperly secured hats/straps/interface can occur.

Alternate between prongs and mask to rest pressure areas.

Do not use creams, ointments, gels or dressings on the septum itself. If signs of nasal trauma are visible, keep the area clean & dry. Air is the best cushion between the prongs & the septum.

Care should also be taken to avoid pressure injury related to skin being in contact with monitoring wires/IV lines etc.

Position changes 4-6 hourly with cares

Document assessments and observations of pressure areas on your hospitals Pressure Injury Risk Chart appropriate for neonates.


Mouth & Eye Care

CPAP air flow contributes to mouth dryness & eye irritation. EBM or water can be applied to the end of a swab stick & used to gently clean & moisten the mouth 4-6 hourly.

Regular eye toilets with warm normal saline can help irritated eyes. The use of phototherapy eye shades can assist in preventing flow into the eyes. Ensure mask/prongs are positioned correctly to minimise air flow to the eyes.

Positioning

Neonates on CPAP can be positioned any way that promotes comfort & optimal airway positioning - there are no limitations to positioning.

Be sure to sufficiently support the infant with neck rolls, nesting & positioning aids, keeping alignment of the head & neck & maintaining a flexed position.

If elevating the head of the cot, it should be no more than 30 degrees.

Of all positions, the prone position may be especially beneficial for a neonate on CPAP as it can improve respiratory pattern, lung compliance, decrease work of breathing & oxygen requirements. Long periods of time spent prone can cause pressure injuries to the knees, so be vigilant.

Alternatives such as side lying or lateral positioning have also been found to support oxygenation.

Supine positioning can also be comfortably achieved and is particularly beneficial if wanting to visualise work of breathing.

Position changes will also help to shift mucous/secretions & improve ventilation, so ensure you vary an infant’s positioning every 4-6 hours.

The following images demonstrate examples of well positioned neonates.

Prone Supine


Main Complications Circuit Disconnection/Obstruction/Damage Gas flow through the circuit & pressure delivery to the patient may be impeded by circuit disconnection, mucous build up in the circuit/nasal prongs, kinking of the circuit, or damage to the circuit causing air to leak out. If the circuit disconnects or the obstruction/damage is large enough, bubbling in the system will cease. Run your eyes & hands over the entire length of the circuit to detect where the problem is originating from. You may need to replace the circuit if there a damaged segment, reconnect parts that have come apart, or adjust your mask/prong position to improve the seal. Assess the need for suctioning, as this may help reduce the risk of obstruction via mucous build up. It is a good opportunity to thoroughly clean the mask/prongs also when undertaking cares to eliminate any mucous/secretions. Malpositioning of the prongs/mask & Pressure Injury It is an art to position the interface/circuit optimally & takes lots of practice. Malpositioning can cause air leak around the mask/prongs & loss of bubbling in the circuit. Perhaps more concerning is it can contribute to irritation, erosion, distortion & necrosis to the nares, philtrum and septum. Take time to position the hat, mask/prongs & interface, getting someone to help you if needed. Ensure you size your patient correctly when fitting hats/interface/mask/prongs. Prevention of pressure injury is key. Gastric Distension Gastric distention occurs when the infant swallows air. It is a benign finding & does not predispose the infant to necrotizing enterocolitis or bowel perforation. However, all infants on CPAP should have a size 8 FG orogastric tube inserted & care should be taken to aspirate air 4 hourly, as air in the stomach can cause discomfort, & can reduce the infant’s ability for lung expansion. Discard all air aspirated but be sure to replace gastric contents which are important for maintaining normal pH balance. Some infants may require more frequent air aspiration, in which case it may be more appropriate to attach a 10 ml syringe (with plunger removed) allowing air to vent freely from the stomach. The syringe should be positioned above the neonate’s head to encourage gastric fluid to remain in the stomach. Pneumothorax Is a collection of air between the lung & the chest wall that develops when air leaks out of the lung. This usually occurs spontaneously or as a result of an underlying disease processes. It can infrequently occur as a complication of CPAP therapy in < 3 - 5% of cases. Pneumothorax may lead to lung collapse, impedance of pulmonary blood flow, increased pulmonary vascular resistance, decreased venous return, & compromised cardiac output with severe hypotension. Pneumothorax is suspected when neonates on CPAP develop worsening respiratory distress, hypotension, or both. There will also be diminished air entry on the side of the lung affected by the pneumothorax. Chest x-ray provides a definitive diagnosis. If an infant is symptomatic or you suspect a pneumothorax, monitor ABC’s and utilise the NeoPuff if ventilation is required. Escalate care according to your hospital’s escalation protocol (rapid response), as air must be removed promptly from the chest cavity by medical staff via needle aspiration. A chest drain may be placed in-situ to continuously remove air and/or fluid from the chest cavity.


Troubleshooting “The baby won’t settle!”

Infants on CPAP are often irritable & can take time to adjust to therapy. Many factors potentially contribute to their discomfort such as air in the stomach, hunger, poorly positioned nasal prongs, secretions in the airways & respiratory distress itself.

Apply nursing comfort measures: repositioning, swaddling/containment, nappy; using sucrose for painful procedures

Changing or minimising environmental stimuli (e.g. dimming lights, reducing noise), positive touch, talking to the baby, offering a dummy to encourage non-nutritive sucking, or providing the baby with a small amount of EBM for comfort.

Check that the prongs are positioned in the nares appropriately & comfortably & decrease movement & pulling/dragging of the device on the nares.

Assess need for oro-pharyngeal suction. Sometimes, a buildup of secretions can cause considerable distress to a baby whose breathing is already compromised.

Aspirate any excess gastric air; a tummy full of air is never comfortable, especially when you are having trouble breathing.

Cluster cares 4 - 6 hourly and employ a “hands off” approach to care. Adopting cue-based cares may be more appropriate for other babies who are unable to tolerate all cares being undertaken at the same time. Babies may need to be nursed in an isolette (incubator) to remind staff to disturb neonates only when absolutely necessary and to minimise environmental stimulus.

“The baby is foaming at the mouth.”

This is a normal occurrence when a baby is on CPAP & nothing to be alarmed about.

When air is pushed through saliva by the pressure of the CPAP, it causes bubbling. It is a good sign of effective pressure generation.

Gently wipe away bubbles or remove with a suction catheter.

Parents will often comment on it, & some find it quite distressing. Provide simple explanation & give them the opportunity to wipe their baby’s mouth. Reassure them that it is normal.

“Bubbling stops every time the baby opens its mouth”

A loss of desired CPAP pressure occurs as air escapes out the mouth. This is ok for short periods of time, but prolonged periods of mouth opening = prolonged periods without effective CPAP pressures.

Try using a pacifier to encourage the baby to close its mouth. Chin straps can also reduce leak via the mouth. Try repositioning the baby.

“The humidifier keeps alarming and is not heating up”

Low temperature warning alerts user that low temperature level is being delivered to the patient.

This may be suggestive of mechanical failure of the humidification device.

Turn the device off, check that the water level in the humidification chamber is correct. Replace the heater wire & temperature probe wire & turn on again.

If the device continues to alarm or is not heating to the correct temperature, replace the humidifier as soon as possible.


“It’s not bubbling!”

Indicative of loss of air flow or a pressure leak somewhere in the system.

A simple way to check if it’s a circuit problem or a baby problem, is to remove the prongs/mask from the nose & occlude with your fingers/hand. If the system doesn’t bubble, this suggests a problem with the circuit. Systematically check the entire circuit tightening all connections as you go. If the system does bubble when you occlude the prongs, then the leak is at the nose/mouth of the infant. Ensure prongs/mask are correct size & hat is snug. Readjust straps. Try a dummy or a chin strap.

“Air is leaking out around the mask/prongs & it won’t stay in place!”

This is a common problem & often impossible to eliminate leaks around the mask/prongs completely. Provided the CPAP system continues to gently bubble, & mask/prong placement is not contributing to redness/blanching, a small amount of leak can be tolerated.

If the leak is significant & affecting circuit bubbling, you will need to readjust mask/prongs placement to improve the seal. Repositioning the baby may also help.

Check that the mask/prong size is correct, that the hat fits snuggly & the interface is positioned in neutral alignment with the head, with straps secured firmly.

Despite troubleshooting & where a significant leak continues, a Neo-Guard (as shown below) can be used with nasal prongs ONLY.

Neo-Guard

The hydrocolloid is gentle to the skin Prevents the prongs from coming into contact with the baby's nose, so can

minimise septum damage and mucosal irritation Achieves stable CPAP with a constant nasal seal Observation of the condition of the nasal nares and repositioning remains easy Five sizes are available, compatible with all brands of CPAP currently on the

market.


Assessing Success/Failure

Clinical indicators of CPAP therapy success

Reduction in respiratory rate typically by 10 to 20 breaths per minute

Reduction/resolution of work of breathing: e.g. reduced intercostal retraction, resolution of grunting.

Reduction in oxygen requirements needed to maintain oxygen saturation within target range of 91 to 95%

Improved lung volumes & appearance on chest X-rays

Improved patient comfort: a previously irritable, unsettled & tachycardic infant may settle/go to sleep & will appear more comfortable & relaxed in general

Improving/stabilising blood gases (if measured)

Clinical indicators of CPAP therapy failure

A sustained Fi02 requirement of greater than 0.40 on CPAP of 7cm H2O or greater.

Rising oxygen requirements of Fi02 0.10 or greater over a time frame not exceeding 2 hours

Respiratory acidosis on arterial or capillary blood gas with a pH < 7.25 and a rising PaCO2 > 60mmHg

Development of recurrent apnoea requiring stimulation to resolve

Spontaneous episodes of significant desaturation (<91% for >20 seconds)

Increasing tachypnoea, or no reduction in RR after CPAP commencement

Severe work of breathing

Infant agitation unrelieved by simple measures

Development of pneumothorax An Important note Babies that require CPAP are sick & by the very nature of the physiological processes of their illness, prone to deterioration. It is wonderful when CPAP is successful, however this is not always the case, and failure is at times inevitable. Failure is NEVER to be attributed to your colleagues. In almost all instances, failure is related to the pathological processes associated with the infants underlying diagnosis, or as a consequence of complications related to CPAP therapy. Deterioration can be rapid, & it can be severe entailing respiratory/cardiorespiratory arrest. A team approach to stabilising a deteriorating baby is necessitated & this takes many hands, excellent communication between team members, and a manner of calm, & thorough & accurate timing & documentation of events. It is stressful for all team members regardless of the situation, & everyone needs to be looked after & de-briefed post the event. There is often much to be learnt from events, but there is NEVER a time or place for blame or attribution of respiratory failure to your colleagues.


Weaning & Discontinuation The need for support of acute neonatal lung disease can last up to 72 hours. Weaning regimes & CPAP discontinuation is at the discretion of the Paediatrician. It must be noted that there are various methods/ways to undertake weaning, with no one correct method. Often it is a trial & error process, & weaning isn’t always successful the first time. Readiness to wean should be assessed frequently. A baby that was not quite ready to wean yesterday, may be more than ready to wean today! Whilst not a prescriptive weaning regime, PIPER guidelines advise to commence weaning when a baby’s respiratory rate falls below 70 breaths per minute, saturations are consistently within the target range, & the baby’s effort of breathing has reduced.

PIPER Guidelines Suggest Wean oxygen first until FiO2 is

<0.25. Wean in 2-5% increments as tolerated. THEN

Wean pressure by 1cm H2O every 2 to 4 hours until at 5cm H2O

Consider ceasing CPAP when a neonate is stable for several hours on a CPAP of 5cmH2O in a FiO2 <0.25%, with a respiratory rate <70 breaths/minute.

NOTE: Physiological PEEP (the neonate’s self-generated version of CPAP) is 3-4cm H2O in the neonatal lung. Thus, there is no need to wean CPAP pressures to less than 5cm H2O.

After cessation, it is common to see a mild increase in respiratory rate (10 - 20 breaths/minute), as well as a small increase in FiO2 requirements (e.g. FiO2 0.25 increasing to FiO2 0.30). Maintain continuous oximetry & cardiorespiratory monitoring for some time post cessation & continue to monitor work of breathing closely. Do not dress an infant that has come off CPAP until you are convinced that their respiratory status is stable.

CPAP may need to be recommenced if there is increased work of breathing or a significant increase in oxygen requirements.


Nutrition/Fluid Requirements Early nutrition is an important aspect of the care plan for all infants with respiratory distress. Infants with respiratory distress have increased metabolic demands & greater energy requirements (because they are using all their energy just to breathe!), meaning that they in fact have greater nutritional requirements than a well-baby. Furthermore, if nutrition is not optimised early, lung function can actually worsen as respiratory muscle strength weakens, & immune function becomes impaired. In addition, early nutrition is vital for enhancing maturation & function of the gastrointestinal tract, weight stabilisation & growth. The preferred mode of nutrition is always enteral, and the preferred milk source always breast milk. IV maintenance fluids/parenteral nutrition in place of enteral feeding poses great potential for malnutrition, greater than normal neonatal weight loss OR fluid overload, & fluid & electrolyte imbalances (Sweet et al., 2010; Taylor, Kiger, Finch, & Bizal, 2010). Unfortunately, infants with respiratory distress cannot always tolerate enteral feeding & must be fed very cautiously. Having a stomach full of milk puts pressure on the diaphragm impairing the lungs ability to expand & contributing to an exacerbation of work of breathing. Furthermore, bottle feeds are not appropriate when an infant is requiring CPAP as they will tire the infant who needs to reserve all energy for breathing. However, in light of previously discussed reasons, small “trophic” orogastric feeds should be commenced as soon as possible. Review studies have demonstrated there is no increase in the risk of necrotizing enterocolitis with early trophic feeding (Sweet et al., 2010). PIPER recommends the following:

Keep babies on CPAP nil by mouth until:

Respiratory rate is < 70 breaths/minute

FiO2 < 0.25

Work of breathing (grunting & intercostal retraction) has improved significantly.

When these parameters are met, trophic feeds can be commenced cautiously (<15ml/kg/day). Trophic feeds can be administered hourly or 2-3 hourly as tolerated by the baby.

Whilst infants remain nil by mouth & on trophic feeds, maintenance IV fluids are required. 10% Dextrose should be commenced at 60mL/kg/day on day 1. Dextrose 10% is the fluid of choice for meeting neonatal energy requirements. At a rate of 60mL/kg/day, 4-6mg/kg/min of glucose is delivered, meeting an infant’s basal metabolic requirements. Remember that a neonate with respiratory distress may have increased metabolic demands & requirements, & increased insensible loses when nursed under a radiant warmer. Fluid rate should be titrated as per the Paediatrician and infants may require a little more than the usual fluid rates. Infants requiring IV maintenance fluids require DAILY electrolyte checks, & may require the addition of sodium & potassium if needing fluids for more than 24 hours (Taylor et al., 2010). If feeds cannot be commenced by 96 hours of age due to ongoing respiratory distress, parenteral nutrition (TPN & lipids) will usually be required & the baby should be transferred to a tertiary centre.


Making a PIPER Referral The PIPER duty Consultant should be contacted by the PAEDIATRICIAN as soon as an infant goes onto CPAP in the SCN. This is not only to access clinical advice & support, but also to alert the referral team that a Level 2 baby is unwell & may require future retrieval. This is especially important for neonates that fall outside recommended indications, or show signs of respiratory/CPAP therapy failure: in these instances, PIPER contact is mandatory and should occur immediately. In all emergency situations, PIPER should be contacted by the PAEDIATRICAN.

24 hr. PIPER Emergency Number 1300 137 650

When calling the emergency number, a clinical coordinator will require the following information:

Name of referrer, hospital you are calling from, your direct telephone number, name, date of birth and gender of patient.

The coordinator will then transfer your call into a ‘conference room’ and a PIPER neonatologist and PIPER transport staff will join the call. You should have the following information at hand as required by the PIPER consultant:

Reason for referral, birth history, condition of the baby, vital signs, treatment received/receiving, IV access points, medications administered, blood results, chest x-ray findings, resources at your health service

Stabilisation advice will be given & a PIPER team activated to come & retrieve the patient. Upon arrival the PIPER team will require:

240v power access, oxygen & medical air, space for PIPER cot, signed consent for transfer (2 copies), completed perinatal history sheet, photocopies of paperwork (obs charts, medication charts, fluid charts, nursing notes), x-rays, green ‘health & development’ record with birth history/immunisation record filled out.

24 hr. PIPER Non-emergency/ elective transfer/advice Line

1300 659 803

PIPER Education Enquiries: 1300 662 434

[email protected]

PIPER Website http://www.rch.org.au/piper/

mailto:[email protected]

http://www.rch.org.au/piper/


Involving Parents Last but absolutely not least, we must acknowledge the parents as the main caregivers. Having a baby in the SCN is a very stressful time for parents. Witnessing their baby connected to numerous wires, tubes, monitors & machines can be frightening, eliciting many feelings such as guilt, self-blame, anger, sadness, anxiety, agitation, confusion & even jealousy. Parents may be hesitant to participate in the care of their baby, feeling that they lack understanding of their baby’s needs, fearing that they may interfere with equipment, or believing their baby is too fragile to interact with. There are many ways you can help parents interact with & care for their infant on CPAP. Siblings Parents may need assistance in deciding whether or not to bring a sibling in to see the baby & how to talk to a sibling about the sick baby. Suggest developmentally appropriate ways of communicating the situation to siblings. Prepare parents for their well child’s questions & reactions. Suggest age appropriate books & other material to prepare siblings for what they might see and hear. Maintain a child friendly atmosphere, encourage parents to keep sibling visits brief, use age appropriate language, encourage questions, debriefing after visits, & always respect decisions not to visit. Positive touch Assist parents in finding the form of touch most comforting to their infant. Never tell a parent not to touch their baby, or suggest that their baby’s vital signs are negatively affected by their touch. If an infant is very unsettled & a ‘hands off’ approach is warranted, remind parents that sick infants can be more sensitive to their environment & find touching stressful, & that the baby might just need some quiet time to preserve energy for getting better. Instead of patting, stroking or running fingers over the infant’s skin, encourage comfort holding – pretend hands are like the uterus walls & cup them on the baby’s head, feet, bottom or back & hold them in place with constant pressure. Remind hesitant parents that touching will help their baby feel calm, cared for & loved. (Duhn, 2010) Participation in cares You are facilitator of this process, educating parents about their baby’s needs & condition, so as to ensure parents feel confident in their ability to provide care for their baby. Some parents want to participate but are not sure of their role & what they can do. Others are simply terrified of the thought of participating in cares. It is your job to allay fears by offering assistance, educating & showing them how they can be involved. Nurturing actions (talking, singing, reading, comforting, & nappy changing) should be encouraged. Other activities parents can be involved in are mouth & eye care, general hygiene activities, & tube feeds. (Kearvell & Grant, 2009) Communication Casual ‘chatting,’ provision of emotional support, & providing parents with education & regular updates on their baby’s illness & progress are key factors in helping a parent feel involved, relaxed & confident around their sick infants. Share complete, honest, & unbiased information with parents.


Kangaroo Care Rarely is a baby too sick for skin-to-skin with the parents - even intubated infants can have skin-to-skin contact! It is however best to avoid whilst initially stabilising a baby, or if a baby is medically unstable. Staff need to ensure that if a baby on CPAP is having Kangaroo Care, that nursing staff are within close proximity to quickly respond, should any complications arise. Skin-to-skin has been proven to assist in stabilising temperature, BSL, HR, work of breathing & oxygenation. Additional benefits include, parental feelings of intense connectedness to the infant, enhanced parental confidence, increased positive interactions and sensitivity to baby’s cues, facilitation of attachment, feelings of participation in care & decreased levels of anxiety and maternal depression. There is no such thing as too much kangaroo care for a baby on CPAP, facilitate it wherever possible. (Chia & Sellick, 2005) Breastfeeding “Can I still breastfeed?” is a commonly asked question. The answer is “Yes, absolutely.” Provide unconditional positive breastfeeding support & education. Engage in positive gentle encouragement, highlight the benefits of breast milk & breastfeeding for the sick baby & the mother. Providing early guidance, including not only verbal education, but also ‘showing’ of correct breast stimulation & expressing techniques have a positive impact on the breastfeeding experience. Ensure portable expressing pumps are available to mothers, with additional facilities at the bedside to promote expressing in the presence of the sick baby (e.g. privacy curtains, comfortable chairs). Put the baby to the breast as soon as well enough to do so. (Boucher et al., 2011)

Download the F&P 950 app This interactive learning tool is designed to help clinicians become more confident with using the F&P 950. It features a simulator of the user interface, education modules, a step-by-step setup guide, a guide to the alarms, cleaning instructions, and frequently asked questions (FAQs).


Quiz Test Your Knowledge 1. Physiological effects of CPAP include all of the following EXCEPT: a). Increases functional residual capacity b). Conserves surfactant distribution on the alveolar surface c). Decreases lung compliance d). Increases surface area available for gas exchange 2. For every 1 cm that the expiratory limb of the breathing circuit is submerged under water, ____ cm of water pressure is generated. a). 2 b). 1 c). 0.5 d). 3 3. Functional residual capacity refers to: a). The volume of air that remains in the lungs, at the end of normal expiration b). The volume of air that is inhaled into the lung with every breath c). The total lung ventilation per minute d). The air that can be forcibly inhaled after the inspiration of a normal tidal volume 4. CPAP is indicated in the Level 2 SCN in which of the following clinical situations: a). an infant’s chest x-ray is consistent with severe respiratory distress syndrome b). an infant is displaying respiratory distress & has a birth weight of 1200 grams c). a baby of 34 weeks’ gestation, less than 24 hours old, with signs of respiratory distress d). a term infant requiring an FiO2 greater than 0.8 to maintain saturations 5. All of the following are contraindications for CPAP in the Level 2 SCN EXCEPT: a). More than 24 hours of age at the time of initiation of CPAP b). Birth weight less than 1500 grams c). Infants with unstable respiratory drive & frequent apnoea’s d). An FiO2 requirement of 0.40 to maintain saturations between 91-95% 6. Circuit leak tests should be performed before commencing a baby on CPAP. To perform a circuit leak test: a). Set the CPAP probe to 1cm H2O, & the flow rate to 10L/min & observe for audible bubbling. b). Set the CPAP probe to 10cm H2O & the flow rate to 1L/min & observe for audible bubbling c). Set the CPAP probe to any level, & the flow rate to any level &observe for audible bubbling. d). Set the CPAP probe to 10cm H2O, & the flow rate to 10L/min & observe for audible bubbling.


7. Recommended circuit flow rate using the Fisher & Paykel bubble CPAP system is: a). 6 to 8 litres/minute b). 10 litres/minute c). 15 litres/minute d). 8 to 10 litres/minute 8. Target oxygen saturation levels for a neonate on CPAP are: a). 95% or above b). 88-95% c). 91-95% d). 90-96% 9. An arterial blood gas reveals a pH of 7.37. This pH is: a). Within normal neonatal values b). Alkalotic c). Not compatible with life d). Acidotic 10. Baby Charlie has been on CPAP for 6 hours, when a blood gas is performed and it is revealed that his pH is 7.23 and PaCO2 is 74. He is requiring a FiO2 of 50% to maintain saturations. His respiratory rate before going on to CPAP was 66, and it is now 80. This represents: a). CPAP therapy success b). Respiratory arrest c). CPAP therapy failure & a need for PIPER referral & transfer d). CPAP therapy failure, no need for PIPER referral & transfer just yet. 11. An appropriate weaning regime for bubble CPAP as suggested by PIPER is: a). Wean oxygen first until FiO2 <0.25, then wean pressure by 1cm H2O every 2 to 4 hours until at 5cm H20 b). Wean oxygen first until FiO2 <0.25, then wean pressure by 1cm H2O every 6-8 hours until at 5cm H2O c). Wean oxygen first until FiO2 <0.25, then wean pressure by 1cm H2O every 2 to 4 hours until at 2cm H2O d). Wean oxygen first until FiO2 <0.25, then wean pressure by 1cm H2O every 12 hours until at 4cm H2O


12. Infants requiring CPAP should be commenced on trophic feeds: a). As soon as CPAP is ceased b). As soon as respiratory rate is <70 breaths/minute, FiO2 < 0.25, & work of breathing improved significantly. c). As soon as respiratory rate is <40 breaths/minute, FiO2 0.21, & work of breathing improved significantly d). As soon as respiratory rate & work of breathing have normalised, and CPAP weaning has begun. 13. When parameters are met, trophic feeds can be commenced at a rate of: a). <15ml/kg/day b). 20-30ml/kg/day c). 1ml/hour d). 2 mls every 3 hours 14. For all infants on CPAP kept nil by mouth & on IV maintenance fluids, electrolytes should be checked: a). on commencement of CPAP therapy b). twice weekly c). 2nd daily d). daily 15. Kangaroo care for a baby on CPAP: a). Should be limited & the baby allowed to rest. b). Can cause a baby to become unstable, particularly with their work of breathing & oxygenation c). Assists in stabilising heart rate, work of breathing & oxygenation. d). Has few proven benefits. 16. Gastric distension is a common complication of CPAP therapy. To reduce gastric distension & associated patient discomfort, when CPAP is commenced a size 8 FG orogastric tube should be inserted &: a). Air aspirated & discarded hourly, with gastric fluids returned to the patient. b). Air aspirated & discarded 4 hourly, with gastric fluids returned to the patient. c). Air aspirated & discarded hourly, with gastric fluids discarded. d). Air aspirated & discarded 4 hourly, with gastric fluids discarded.


17. For neonates requiring CPAP, blood pressure should be checked: a). Hourly b). 4-6 hourly, & whenever there is a change in the patient’s condition c). Never. Blood pressure is not relevant in an infant with respiratory illness d). When symptomatic of cardiovascular compromise 18. When undertaking hourly humidifier observations, nursing staff must check & document: a). Humidifier water level & humidifier temperature. b). Humidifier temperature & circuit temperature at the patient. c). Humidifier water level, humidifier temperature, & circuit temperature at the patient. d). Humidifier temperature 19. As per PIPER guidelines, it is recommended that CPAP pressures are commenced at: a). 5cm H2O b). 6cm H2O c). 7cm H2O d). 8cm H2O 20. CPAP should be ceased when: a). A neonate is stable for several hours on a CPAP of 5cm H2O, in an FiO2 <0.25, with a respiratory rate < 70 breaths/minute b). A neonate is stable for several hours on a CPAP of 4cm H2O, in an FiO2 <0.25, with a respiratory rate < 70 breaths/minute c). All physiological parameters return to normal values d). A neonate is stable for several hours, on a CPAP of 5cm H2O, in an FiO2 0.21, with a respiratory rate < 60 breaths/minute 21. Can you identify 10 signs & symptoms of respiratory distress? ๏_________________________ ๏_________________________ ๏_________________________ ๏_________________________ ๏_________________________ ๏_________________________ ๏_________________________ ๏_________________________ ๏_________________________ ๏_________________________


22. Can you list 5 causes of respiratory distress related to the respiratory system? ๏__________________________ ๏__________________________ ๏__________________________ ๏__________________________ ๏__________________________ 23. Can you list 4 complications of NCPAP therapy? ๏ __________________________ ๏___________________________ ๏___________________________ ๏___________________________ 24. Can you describe the steps you would take if you noticed bubbling had ceased in the CPAP generator? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 25. Can you describe how you would respond to a parent that is concerned about bubbling from the mouth of her baby on CPAP? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 26. Can you describe steps you may implement to try & help an unsettled baby on CPAP? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 27. Can you list the ‘start of shift’ checks/observations/assessments that must be undertaken when caring for a baby on bubble CPAP? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________


28. Describe how you can involve parents in the care of their infant’s on CPAP. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 29. When PIPER is activated to retrieve a baby, what will they require? upon arrival that you should have considered/prepared? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 30. What is the 24-hour PIPER emergency number?


CPAP Competency Assessment Assessment Pre-requisite Observation

Use of bubble CPAP in the Level 2 SCN

Bubble CPAP learning package pre-reading Date:________________

Assessments performed under observation Date_________________ Date_________________

Performance Criteria The candidate must be able to discuss & demonstrate

Yes No

Identify 5 clinical signs & 5 major causes of respiratory distress in a neonate

Perform a thorough respiratory assessment on a neonate

Demonstrate assembly of equipment & leak test prior to connection to patient

Demonstrate sizing & application of CPAP hat/interface to patient

Demonstrate the removal of prongs/mask/hat/interface and undertake pressure area assessment.

Demonstrate supine, prone & lateral positioning of the infant on CPAP

State other equipment that should be readily available for a baby on CPAP

Describe bubble CPAP & explain how it helps treat respiratory distress in neonates

Describe what is meant by ‘functional residual capacity’

Discuss why adequate humidification of gas is important when administering bubble CPAP

When would it be appropriate to commence an infant on bubble CPAP in the Level 2 SCN? List indications

When would it would be inappropriate to commence an infant on bubble CPAP in the Level 2 SCN? List contraindications

Discuss 3 potential complications of bubble CPAP

Discuss how you would troubleshoot a cessation of bubbling in the CPAP generator

Discuss the general nursing care of a baby on CPAP including frequency of observations

Discuss how parents can be involved in the care of their baby on CPAP

Discuss the importance of nutrition for an infant on CPAP & when trophic feeds can be commenced.

Discuss an appropriate weaning regime for a baby on bubble CPAP

Adapted from PIPER Neonatal Education NCPAP Competency Assessment Checklist (2013)


CPAP Competency Assessment Assessment Results COMPETENT/NOT YET COMPETENT Assessors Name: ______________________________________________ Assessors Signature: ______________________________________________ Candidates Name: ______________________________________________ Candidates Signature: ______________________________________________

Feedback: ______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________


References

Ammari, A., Kashlan, F., Ezzedeen, F., Al-Zahrani. A., & Kawas, J. (2005). Bubble nasal CPAP manual. Retrieved from http://earlybubblecpap.com/downloads/CPAP%20Educational%20Files/CPAP_Manual.pdf Augey, M., Brown, V., Clancy, L., Daniel, L., Jefferson, S., & Milner, M. (2009). Nasal continuous positive airway pressure (NCPAP) for the acutely ill infant. Resource package. Retrieved from http:/mypicu.org/file.php/1/CPAP…/NCPAP_Resource_Package.pdf Australian Commission on Safety & Quality in Health Care (ACSQHC) (2017). National Consensus Statement Essential elements for recognising and responding to clinical deterioration. Second Edition http://www.safetyandquality.gov.au/wp-content/uploads/2017/01/national_consensus_statement.pdf Australian Institute of Health and Welfare (AIHW). (2019). Australia’s mothers and babies data visualisations. Australian Government Aylott, M. (2006). Observing the sick child: part 2a: respiratory assessment. Paediatric Nursing, 18, 38-44. Aylott, M. (2007). Observing the sick child: Part 2b Respiratory palpation. Paediatric Nursing, 19, 38-45. Aylott, M. (2007). Observing the sick child: part 2c: respiratory auscultation. Paediatric Nursing, 19, 38-45. Benitz, W. (2014). Mechanical ventilation. Retrieved from https://lane.stanford.edu/ portals/cvicu/HCP_Respiratory-Pulmoanry_Tab_2/Mechanical_Ventilation.pdf Bonner, K.M., & Mainous, R.O. (2008). The nursing care of the infant receiving bubble CPAP therapy. Advances in Neonatal Care, 8, 78-95. Boucher, C.A., Brazal, P.M., Graham-Certosini, C., Carnaghan-Sherrard, K., & Feeley, N. (2011). Mothers’ breastfeeding experiences in the NICU. Neonatal Network, 30, 14-20. Buckmaster, A. (2012). Nasal continuous positive airway pressure for respiratory distress in non-tertiary care centres: What is needed and where to from here? Journal of Paediatrics and Child Health, 48, 747-752. Buckmaster, A., Arnolda, G., Wright, I.M.R., Foster, J.P., & Henderson-Smarts, D.J. (2007). Continuous positive airway pressure therapy for infants with respiratory distress in non−tertiary care centers: A randomized, controlled trial. Pediatrics, 120, 509-518.

http://earlybubblecpap.com/downloads/CPAP%20Educational%20Files/CPAP_Manual.pdf

http://earlybubblecpap.com/downloads/CPAP%20Educational%20Files/CPAP_Manual.pdf

http://www.safetyandquality.gov.au/wp-content/uploads/2017/01/national_consensus_statement.pdf

http://www.safetyandquality.gov.au/wp-content/uploads/2017/01/national_consensus_statement.pdf


Buckmaster, A., Arnolda, G.R.B., Wright, I.M.R., & Henderson-Smart, D.J. (2007). CPAP use in babies with respiratory distress in Australian special care nurseries. Journal of Paediatrics and Child Health, 43, 376-382. Buckmaster, A.G., Wright, I.M.R., Arnolda, G., & Henderson-Smart, D.J. (2007). Practice variation in initial management and transfer thresholds for infants with respiratory distress in Australian hospitals. Who should write the guidelines? Journal of Paediatrics and Child Health, 43, 469-475. Chan, K.M., & Chan, H.B. (2007). The use of bubble CPAP in premature infants: local experience. Hong Kong Journal of Paediatrics, 12, 86-92. Chia, P., & Sellick, K. (2005). The attitudes and practices of neonatal nurses in the use of kangaroo care. Australian Journal of Advanced Nursing, 23, 20-27. Department of Health and Human Services (DHHS). (2015). Defining levels of care for Victorian newborn services. Victorian Government. DiBlasi, R.M. (2009). Nasal continuous positive airway pressure (CPAP) for the respiratory care of the newborn infant. Respiratory Care, 54, 1209-1235. Discenza, D. (2009). Gently encouraging breastfeeding in the NICU. Neonatal Network, 28, 269-270. Duhn, L. (2010). The importance of touch in the development of attachment. Advances in Neonatal Care, 10, 294-300. Duke, T. (2014). CPAP: a guide for clinicians in developing countries. Paediatrics and International Child Health, 34, 3-11. Fisher & Paykel Healthcare Limited (2011). Bubble CPAP system set-up guide. Retrieved from https://www.fphcare.com.au/products/bubble-cpap-system/ Fisher & Paykel Healthcare Limited (2011). Infant interface set-up guide. Retrieved from https://www.fphcare.com.au/products/flexitrunk-midline/ Gardner, S.L., Carter, B.S., Enzman-Hines, M., & Hernandez, J.A. (2016). Merenstein & Gardner’s handbook of neonatal intensive care (8th ed.). St Louis: Mosby Elsvier. Girvin, L., Wang, W., & Plummer, V. (2018). CPAP for infants in rural and metropolitan special care nurseries: Perspectives of nurse unit managers. Journal of Neonatal Nursing, 24, 336-339. Hemani, R., Narayanan, M., Jeffries-Stokes, C., & Volkman, T. (2014). Successful nasal continuous positive airway pressure for newborn respiratory distress in a regional setting. Journal of Paediatrics and Child Health, 50, 85-86. Kearvell, H., & Grant, J. (2009). Getting connected: how nurses can support mother/infant attachment in the neonatal intensive care unit. Australian Journal of Advanced Nursing, 27, 75- 82.

https://www.fphcare.com.au/products/flexitrunk-midline/


Manley, B.J., Owen, L., Doyle, L.W., & Davis, P.G. (2012). High-flow nasal cannulae and nasal continuous positive airway pressure use in non-tertiary special care nurseries in Australia and New Zealand. Journal of Paediatrics and Child Health, 48, 16-21. Meeks, M., Hallsworth, M., & Yeo, H. (Eds.) (2010). Nursing the neonate (2nd ed.). West Sussex: Blackwell Publishing Ltd. Pattie, S., & Lim, C. (2014). Continuous positive airway pressure CPAP - nursing care in the Neonatal Intensive Care Unit (Butterfly ward). Clinical Guidelines (Nursing).

Retrieved from http://www.rch.org.au/clinicalguide/ PIPER (2013). Guideline for the administration of nasal CPAP in Victorian non-tertiary Level 2 nurseries. Retrieved from http://www.rch.org.au/piper Queensland Maternity and Neonatal Clinical Guidelines Program (2009). Management of neonatal respiratory distress incorporating the administration of continuous positive airway pressure (CPAP). Retrieved from https://www.clinicalguidelines.gov.au/ Resnick, S., & Sokol, J. (2010). Impact of introducing binasal continuous positive airway pressure for acute respiratory distress in newborns during retrieval: Experience from Western Australia. Journal of Paediatrics and Child Health, 46, 754-759. Sweet, D.G., Carnielli, V., Greisen, G., Hallman, M., Ozek, E., Plavka, R., Halliday, H.L. (2010). European consensus guidelines on the management of neonatal respiratory distress syndrome in preterm infants - 2010 update. Neonatology, 97, 402-417. Taylor, S.N., Kiger, J., Finch, C., & Bizal, D. (2010). Fluids, electrolytes, and nutrition: minutes matter. Advances in Neonatal Care, 10, 248-255. The Royal Children’s Hospital Melbourne (2011). Continuous positive airway pressure (CPAP) in neonates. Competency Statement. Retrieved from http:// www.rch.org.au/uploadedFiles/Main/Content/mcpc/CPAP__Neonates_.pdf Safer Care Victoria (2018). Maternity and Newborn Clinical Network. Nasal continuous positive airway pressure (NCPAP) for neonates. Retrieved from https://www.bettersafercare.vic.gov.au/resources/clinical-guidance/maternity-and-newborn-clinical-network/nasal-continuous-positive-airway-pressure-ncpap-for-neonates Wiseman, N. (2014). PIPER-Neonatal Education learning resource package and competency based assessment for nasal CPAP in level 2 special care nurseries in Victoria. Retrieved from www.rch.org.au/piper/education/ PIPER_learning_packages/ * Images used within this learning package retrieved from Google Images & Flikr. * Images of humidifier bases and circuit equipment used with permission from Fisher & Paykel for teaching purposes only.

http://www.rch.org.au/clinicalguide/

http://www.rch.org.au/piper

https://www.clinicalguidelines.gov.au/

http://www.rch.org.au/uploadedFiles/Main/Content/mcpc/CPAP__Neonates_.pdf





Appendix Circuit Setup using MR850 Humidifier Assembling the Fisher & Paykel Bubble CPAP delivery system (Information retrieved from www.fphcare.com.au) Step 1. Insert humidification chamber

Slide chamber on to

Remove blue caps

Step 2. Connect water bag

Hang the water bag, unwind water feed set and spike the water bag

Open vent on the vented spike

The humidification chamber should fill with water. If not, check the bag is spiked correctly & feed tube not kinked or blocked. Gently squeeze bag to promote water flow

http://www.fphcare.com.au/


Step 3. Fill bubble CPAP generator

Use the funnel provided to fill the chamber with sterile water until water flows into the overflow container.

Set the CPAP probe to 10cm H2O ready for the leak test.

Ensure CPAP generator & humidifier are mounted below the patient

Step 4. Connect CPAP pressure manifold & breathing circuit

Connect oxygen tubing from gas source to pressure manifold

Connect pressure manifold to chamber inlet port (either orientation)

Connect blue inspiratory tubing to chamber port (either orientation)

Install temperature probe & heater wire at the correct ports

Connect the white expiratory tubing to the top of the CPAP probe

Connect blue & white tubing with test elbow


Step 5. Leak Test

Set the CPAP probe to 10 cmH2O & the flow rate to 1L/min.

Observe for gentle audible bubbling. No bubbling indicates a leak in the circuit

If no bubbles are detected, check the entire system. Check the temperature probes/heater wire are firmly in their ports, & that gas flow is connected securely Run your hands over the tubing to feel for any gas leaks

Step 6. Set correct flow rate

Recommended flow is 6 to 8 L/min


Step 7. Set CPAP level

The number on the CPAP probe above the lid indicates the CPAP pressure set in cmH2O

Set the CPAP probe at the prescribed level. PIPER advises CPAP be commenced at 7cm H2O & then titrated to each baby.

Step 8. Connect CPAP circuit to infant interface

Remove test elbow & connect the circuit to the interface using instructions provided with the interface


Step 9. Set the humidifier

Turn device on & ALWAYS set to invasive mode (37 degrees)

The face with the ET tube should be illuminated, NOT the face with the mask

Step 10. Attach interface to infant


Circuit set-up requires a working knowledge of circuit components. Please label the following diagrams;


CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) LEARNING …

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