joint trust guideline for the management of infants

Joint Trust Guideline for the Management of Infants requiringContinuous Positive Airway Pressure (CPAP).

A clinical guideline recommended for use

In:Jenny Lind Children’s Hospital (NNUH) and Children’sDepartment at (JPUH)

By:

Paediatric and Nursing staff working in Buxton ward and the High Dependency Unit (NNUH) and Paediatric and Nursing staff working in ward 10 and the High Dependency Unit (JPUH)

For:Infants with significant respiratory distress who require adegree of respiratory support (under 12 months of age)

Division responsible fordocument:

Women and Children’s Division

Key words:Continuous Positive Airway Pressure (CPAP), Bronchiolitis, Respiratory Distress Syndrome (RDS), High Dependency Unit (HDU)

Names of document authors:

Dr Caroline Kavanagh, Consultant Paediatrician, Hannah Deacon, Staff Nurse, Buxton Ward, Sarah Burton, Deputy Sister, Buxton Ward

Name of document authors Line Manager:

Mary-Anne Morris

Job title of document authors Line Manager:

Chief of Services for Paediatrics

Supported by:Children’s Critical Care Working GroupDr John Chapman Consultant Paediatrician (JPUH)

Assessed and approved by the:

Clinical Guidelines Assessment Panel (CGAP) Chair’s action

Date of approval: 13/09/2019Reported as approvedto the:

Clinical Safety and Effectiveness Sub-Board (NNUH) and Clinical Governance (JPUH)

To be reviewed before: 13/09/2022

To be reviewed by: Dr Caroline Kavanagh

Reference and Trustdocs ID No:

JCG0088 ID No: 9079

Version No: 2.2Description of changes: No clinical changes

Compliance links: NoneThis guideline has been approved by the Trust's Clinical Guidelines Assessment Panel as an aid to the diagnosis and management of relevant patients and clinical circumstances. Not every patient or situation fits neatly into a standard guideline scenario and the guideline must be interpreted and applied in practice in the light of prevailing clinical circumstances, the diagnostic and treatment options available and the professional judgement, knowledge and expertise of relevant clinicians. It is advised that the rationale for any departure from relevant guidance should be documented in the patient's case notes.

The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the quality of healthcare through sharing medical experience and knowledge. The Trust accepts no responsibility for anymisunderstanding or misapplication of this document.

Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 of 37


Contents Page

Objective 3Rationale 3Background 3

The Bubble CPAP circuit 4Infant Flow driver circuit 4

Indications for use of CPAP 4Aims of CPAP 4Biochemical aims of CPAP 5Contraindications for use of CPAP 5Complications of CPAP 5

Conditions Requiring CPAP in infants and young children 6Bronchiolitis 6Post-operative atelectasis 6Chronic Lung Disease 6Newly diagnosed chronic Respiratory failure 6Home Non-Invasive Ventilation 7

Initial Management- Quick reference 7Use the ABCD approach 7Chloral and CPAP 7Indication for weaning CPAP 7Escalation of Care beyond CPAP 8Organisation and provision of care 8

Clinical audit standards 8Summary of development and consultation process undertakenbefore registration and dissemination

8

Distribution list/ dissemination method 9References/ source documents 9

Appendices

Appendix 1 Use of the Bubble CPAP Circuit 10

Quick User Manual reference guidelines for the BubbleCPAP circuit

14

Troubleshooting 21

Appendix 2 Quick reference guidelines for the Infant Flow DriverCPAP

23

Troubleshooting with the infant flowdriver 28

Appendix 3 Care plan 29

Appendix 4 Patient Information leaflet 31



Objective

The objective of this guideline is to standardise the care of Infants (children under 12 months old) requiring CPAP via the Bubble CPAP circuit or infant Flow Driver. It is also toensure safe practice for the required duration of CPAP administration by providing a reference for all staff. Diagrams of the two machines and their individual use can be found in the Appendix.

Rationale

We have within the paediatric department two different types of machines that are capable of providing CPAP for infants: the bubble CPAP machine and the Viasys Infant Flow drivers. This guideline has been created in order to standardise the care of Infants requiring CPAP using either machine. This ensures that children receive a safe and efficient level of care by practitioners with the knowledge and skill in the safe application, monitoring and delivery of CPAP. This guideline has been composed using an up to date,relevant evidence-base to ensure this required level of care is achieved.

Background

The use of CPAP dates back to 1912, when used by a thoracic surgeon, this prompted much investigation and research into its use. In 1976 Greenbaum et al. reported the use of CPAP successfully in Acute Respiratory Distress Syndrome.

CPAP is the maintenance of a positive pressure throughout the whole respiratory cycle ina spontaneously breathing patient. It improves oxygenation by helping to prevent alveolarcollapse. This is achieved by delivering a continuous oxygen and air mix under gentle pressure. The aim of CPAP is to improve gas exchange and avoid the need for intubation.

Many infants who are experiencing respiratory distress tend to have asynchronous breathing, creating a see-saw motion between their chest and their abdomen. When CPAP is applied, it decreases the compliance of the chest wall and allows for synchronous breathing, resulting in decreased effort of breathing, improved gas exchange and improved cardiac function.

CPAP works by increasing the functional residual capacity of the lungs by exceeding the closing capacity of the lungs, which stabilizes and prevents the collapse of alveoli, making inflating the lungs easier. It also provides a splint to the chest wall and airway, resulting in increased lung volumes, recruitment of atelectatic alveoli, and prevention of further atelectasis.

For this reason it is particularly effective in the recovery of bronchiolitic infants as it decreases the compliance of the chest wall and allows for synchronous breathing and improved gas exchange.

CPAP can be provided using various machines and circuits. The two methods we have available to us at NNUH are the bubble CPAP circuit and a Viasys infant flow driver circuit. We would recommend using the bubble CPAP circuit preferentially, but if we Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 of 37


have no other machines available we will use the flow driver circuit. This guideline will therefore provide details on the use of both circuits.

The Bubble CPAP circuit

The Bubble CPAP circuit provides pressure using a water chamber. The depth of the tube below the water line controls the amount of positive pressure generated in the system. Bubbles are created when pressure is generated. This system was first introduced in 1974 when Dr. Jen-Tien Wung from New York began looking at CPAP for respiratory support.

Infant Flow driver circuit

The infant Flow Driver is a combined air/oxygen mixer, oxygen analyser, flow meter and manometer with integral alarm systems designed specifically to be used in conjunction with the infant Flow CPAP generator. This circuit provides a virtually constant airway pressure irrespective of patient demand or expiratory flows via the specially designed generator and nasal prongs.

Indications for use of CPAP

CPAP provides an additional therapy between conventional oxygen therapy and controlled ventilation. The decision to initiate must be made by the senior paediatrician on call.

Consider when two or more of the following are present:

Respiratory rate of 60 breaths per minute or greater

Apnoeas, bradypnoea or cyanotic episodes (with or without bradycardia) despite supplemental O2

Severe intercostal recession and worsening signs of respiratory distress (e.g. expiratory grunt, nasal flare, sternal recession)

Need for >2L/min O2 via nasal prongs

Rising PCO2 (>3KPa from baseline)

Respiratory acidosis pH 7.2-7.25 (if pH <7.2 consider intubation)

Exhaustion

Falling level of consciousness

Unable to maintain SaO2 >92% in 50% oxygen

Aims of CPAP

1. Reduce respiratory distress



2. Improve oxygenation by improved alveolar gas exchange by recruiting collapsed and poorly ventilated alveoli

3. Improve hypercarbia

4. Reduce time spent in oxygen

5. To avoid fatigue in infants

6. To avoid invasive ventilation

7. Reduce hospital inpatient stay

Biochemical aims of CPAP

1. To maintain pH 7.35-7.45

2. To maintain saturations > 95%, PCO2 <6.0 KPa

3. To prevent hypoxia and hypercarbia

Contraindications for use of CPAP

Consider the need for intubation and/or mechanical ventilation as evidenced in the presence of:

Severe cardiovascular instability and impending arrest

Upper airway abnormalities that make CPAP ineffective or potentially dangerous (e.g. Choanal atresia, cleft palate, tracheoesophageal fistula)

Pneumothorax

Older infants do not tolerate the application of CPAP devices well, resulting in restlessness and a labile oxygen requirement.

PH <7.2 or SpO2 <88% in maximal oxygen therapy may be an indication for ventilation, but CPAP may be tried initially if the child is stable.

Complications of CPAP

Abdominal distension increasing risk of aspiration.

False pressure readings due to obstruction of nasal prongs, poor fixation, kinking, blockage from mucous plugging or increased resistance created by turbulent air flow through the prongs, artificially maintaining air pressure.

Inadequate gas flow causing fluctuating baseline pressures, resulting in increased respiratory effort by the infant.

Excessive flow preventing incomplete exhalation inadvertently increasing positive end expiratory pressure (PEEP) levels resulting in over-distension.

Impedance of pulmonary blood flow, increase in pulmonary vascular resistance & decrease in cardiac output.

Nasal irritation, septal distortion, pressure necrosis, nasal mucosal damage secondary to inadequate humidification or poor fixation of nasal prongs.



Skin irritation of the head and neck from improperly secured bonnets.

Lung over-distension causing air leak syndromes i.e. Pneumothorax.

Equipment failure including leaks, tubing blockages, alarm failures, incorrect calibration.

Blockage of nasopharyngeal area and vocal cords with thick secretions.



Conditions Requiring CPAP in infants and young children

Bronchiolitis

This is a common, often serious infectious disease of the lower respiratory tract. It is most common among infants aged 2-12 months with a peak age of 2-8 months usually during the winter months. It is most often due to a viral infection of the bronchioles. The vast majority of cases are caused by the Respiratory Syncitial Virus (RSV), although it is well recognised that many respiratory viruses can cause a similar picture, especially in

the winter months. Bronchiolitis results in a combination of increased mucous production,cell debris and oedema causing a narrowing and obstruction of the small airways.

Bronchiolitis is characterised by: mild rhinorrhoea, coughing, decreased feeding, irritability, and occasionally respiratory distress, cyanosis and apnoea. Examination may reveal hyperinflation of the chest, crepitations and/or wheeze with hypoxia. Those infants more at risk of severe disease include the premature, infants with congenital heart disease (CHD) or underlying respiratory diseases.

SIGNS OF MODERATE BRONCHIOLITIS SIGNS OF SEVERE BRONCHIOLITISTachycardiaTachypnoea >50Nasal FlaringUse of accessory musclesRecessionHead retractionUnable to feed

CyanosisExhaustionReduced Conscious LevelSpO2<92% in spite of O2 therapyRising PCO2

Post-operative atelectasis

This is an unusual situation that can sometimes occur in young infants causing respiratory distress. It is usually a short term problem requiring a short period of CPAP and physiotherapy.

Chronic Lung Disease

This applies to ex-preterm infants who were ventilated in the newborn period or had a persistent oxygen requirement. These infants often present with an acute on chronic clinical deterioration which is often secondary to an acute viral upper respiratory tract infection. They are at increased risk of needing CPAP if they deteriorate.

Newly diagnosed chronic Respiratory failure

Children with neurodisability may eventually develop chronic respiratory failure. This maypresent with an acute-on-chronic situation or with a chronic decline in function. These children will in most cases need long term non-invasive ventilation but prior to this may require CPAP in the acute situation. Long term ventilation will be arranged by the respiratory team in conjunction with either Addenbrookes or Great Ormond Street Hospital (if there is pulmonary hypertension present).Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 of 37


Home Non-Invasive Ventilation

More and more children will be commenced on forms of non-invasive ventilation with the improvements in medicine and technology. This is usually arranged by Addenbrookesor Great Ormond Street. When a child on non-invasive ventilation is admitted, refer to manufacturers instructions and leave settings unchanged unless clinically indicated. The child may then require commencement of the Trust’s CPAP devices.

INITIAL MANAGEMENT- Quick reference

Use the ABCD approach.

Ensure patent airway, suction if indicated.

Apply facial humidified O2 to achieve saturations >92%.

Continuous monitoring of vital signs and apnoeic episodes.

Nebulisers (Salbutamol or hypertonic saline) may be used, but discontinue if no response.

A blood gas.

Consider Bubble CPAP early for respiratory support if patient unresponsive to initial treatment and/or worsening blood gases.

Size 8 OG Tube to prevent abdominal distension- leave on free drainage.

Leave nil by mouth and gain intravenous access and prescribe fluids at 2/3 of normal maintenance requirements.

The following investigations can be undertaken at some stage but CPAP should not be delayed, if needed:

FBC, U&E, Cultures should be taken if indicated.

Nasopharyngeal Aspirate for virology should be sent if not done so already.

Chest x-ray.

Chloral and CPAP

A small single dose of chloral hydrate to help settle the child while being initiated onto CPAP can be given. It is not to be given if there are signs that the child may deteriorate quickly and is likely to need ventilation. The dose we would advise would be 30mg/kg.

Indication for weaning CPAP

General physiological condition is stable

FiO2 <30%

SpO2 >95%

CPAP PEEP ≤6cm H2OGuideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 of 37


Stabilised blood gases

Minimal increased work of breathing

Once off CPAP infants should remain in HDU on continuous monitoring for 12-24 hours.

Escalation of Care beyond CPAP

If CPAP is ineffective or the infant is unstable and needs further escalation of treatment ventilation is required.

Worsening respiratory distress

Apnoeic episodes

Worsening hypoxia and agitation

Severe cardiovascular instability and impending arrest

Worsening respiratory acidosis

If the child weighs <5kg then contact should be made with the neonatal registrar and the neonatal consultant on call regarding ventilation and accommodation.

If the child weigh >5kg contact should be made with the anaesthetic registrar and must be discussed with the Paediatric Anaesthetist on call regarding ventilation and accommodation until CATS are able to retrieve the patient.

Organisation and provision of care

The classification of a sick infant requiring CPAP is high dependency (level 2). The Department of Health (2001) state a nursing ratio of 1:2, increasing to 1:1 if nursed in a side room. All infants therefore receiving CPAP should be treated as a child residing in the High Dependency Unit, even if nursed in a side room. Staff must have adequate training, experience and support to care for infants receiving Bubble CPAP and the InfantFlow Driver.

All children who require CPAP need to be discussed with the consultant on call so that they are aware of the illness of the child being treated.

The registrar should review regularly and observe for any deterioration in the clinical state. The consultant should come and see the child if the registrar is unhappy with their clinical condition.

Inadequate staffing levels (numbers and expertise) or equipment to deliver and monitor safely are indications to consider transfer of the child to another equipped unit within the region.

Clinical audit standards

The indications for use of CPAP and weaning of CPAP can be audited. Staff using CPAP are competent in its use. The management plan can be examined in any patient to see that it was followed correctly.Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 of 37


Summary of development and consultation process undertaken beforeregistration and dissemination

Dr Caroline Kavanagh, Staff Nurse Hannah Deacon and Sister Sarah Burton drafted thisguideline on behalf of the children’s critical care working group who has agreed the finalcontent. During its development it was has been circulated for comment to:paediatricians, paediatric anesthetists, paediatric surgeons and neonatologists. Allcomments were discussed and changes were made if agreed.

This version has been endorsed by the Clinical Guidelines Assessment Panel.

Distribution list/ dissemination method

Trust Intranet

References/ source documents

Ammari, A. et al. (2005) Bubble nasal CPAP manual. Riyadh AL-Kharj Hospital Programme Neonatal Intensive Care.

Augey, M. et al. (2009) Nasal continuous positive airway pressure (NCPAP) for the acutely ill infant. Paediatric critical Care Network.

Ballarat Health Services. (2010) Clinical Practice Guideline, Nasal CPAP (Paediatric).

Bonner, K. M. and Mainous, R. O. (2008) The nursing care of the infant receiving bubble CPAP therapy. Advances in neonatal care. 8, 2, 78-95.

CATS (2009) CATS Clinical Guideline, Bronchiolitis.

Cockett, A. and Day, H. (2010) Children’s High Dependency Nursing. Wiley-Blackwell: Chichester

Department of Health. (2001) High Dependency Care for children- Report of an expert advisory group for Department of Health 2001. The stationary office: London.

Dougherty, L. and Lister, S. (2004) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 6th edition. Blackwell Publishing: oxford.

Electro Medical Equipment (E.M.E) (1999) The Infant Flow System, Operating Manual. E.M.E: Sussex.

Fisher & Paykel. Bubble CPAP Resource Manual.

Hockenberry, M. J. and Wilson, D. (2007) Wong’s nursing care of Infants and children. 8 th

edition. Mosby: Missouri.

Hunt, J. (2007) Guidelines for the use of continuous positive airway pressure (CPAP) systems in adults. Royal United Hospital Bath.

McDougall, P. (2011) Caring for bronchiolitic infants needing continuous positiveairway pressure. Paediatric Nursing. 23, 1, 30-35.



Ojha, S., McInnes, D. and Dorling, J. (2009) Network Guideline, Continuous Positive Airway Pressure. Trent Perinatal Network, NHS.

Resuscitation Council (UK) (2006) EPLS. 2nd edition. London.

Scottish Intercollegiate Guideline Network (2006) Bronchiolitis in children, A national clinical guideline. NHS.

Upton, C. and Foster, S. (2011) Information leaflet for parents/carers of babies and young children who have bronchiolitis. NNUH.

Appendix1 Use of the Bubble CPAP Circuit

Potential problems caused by Bubble CPAP therapy

Mouth breathing may result in loss of desired pressure and decrease in delivered oxygen concentration

Increased intrathoracic pressure which causes reduced venous return which may lower cardiac output

Barotrauma leading to surgical emphysema/ pneumothoraces

Sudden deterioration requiring immediate intubation/ventilation

Aspiration

Patient discomfort/intolerance to nasal prongs

Facial sores/ulceration of septum

Reduced ability to feed

Dry mouth/airways

Gastric distension and diaphragmatic splinting

Increased blood level of carbon dioxide due to increase in dead space caused by prongs and tubing.

Broad recommendations

Procedure RationaleInitiating BubbleCPAP

Move to HDU with relevant staffing Manage infant with facial O2

Record baseline observations including CBG, CEWS, O2 requirements prior to commencing CPAP

Ensure safe delivery and monitoring.Reduce further respiratory distressBaseline observations are essential to the ongoing assessment and management of the infant

Gather all equipment required to deliver Bubble CPAP

Manufacturer’s set up instructions.

Bubble CPAP equipment including:head gear, circuit, O2/air blender, humidifier, water for irrigation, water for CPAP, saturation probe, orogastric tube, measuring equipment, suction equipment, chin strap/dummy

Ensures safe delivery of bubble CPAP

Set up Bubble Follow manufacturer’s instructions and To reduce error and ensure timely



CPAP test the circuit for leaks prior to attaching to the patient

delivery to the infant

Measure infantsnares, septum and head circumference

Use manufactures measuring device andselect appropriate nasal prongs and head gear

Fit and connect to CPAP circuit as per instructions

Correct sizing is essential to prevent leakage and damage to the nasal septum

Small prongs allow air to leak from the circuit reducing the pressure, if they do not fit snugly movement will cause them to damage the septum

Head gear should be lined with eyebrows and be pulled down over the ears and fit snugly to minimise movement of the tubing



Procedure RationaleTurn on CPAP Ensure humidification is set to correct

setting

Ensure bubble system and humidifier are kept lower than the infant

Secure tubing to avoid dragging on the circuit

Set gas flow (usually at 6L/min)

Set water pressure (usually 6cmH20)

Set FiO2 blender at required percentage

NEVER PLACE PRONGS IN INFANTSNARES UNTIL YOU HAVE VARIFIED THE SETUP IS FULLY OPERATIONAL

Humidification is pre-set to 37°c

Adequate humidification prevents drying of secretions

Avoids condensation draining into infants airways

Tension on the tubing will put pressure on the nares

To be determined by doctor

To be determined by doctorBubbles should appear in the water chamber

To be determined by doctor. To maintain saturations at acceptable level

Connect Bubble CPAP to infant

Place nasal prongs in nares

Secure with Velcro straps attached to head gear

Be mindful of trauma

Ensuring adequate fit and seal

Gain IV access and commence IVINB.CPAP is not a contraindication to feeding

Insert cannula, obtaining bloods and commence IVI at 100ml/kg/hr of 0.45% saline 5% dextrose +/- 10mmol KCL and make infant NBM

NBM reduces gastric distension which can impact on work of breathing. Feeds can begin when infant stable enough

Insert orogastric tube

Insert size 8fr OGT on free drainage, gently aspirate as required

Helps prevent gastric distension which can increase the possibility of aspiration and impact on work of breathing

Size 8fr OGT as smaller tubes do notallow the stomach to be vented properly

Observations andcontinuous monitoring

Infant must be placed on continuous monitoring, change probe site 4 hourly

Record all observations 15 minutes after commencing CPAP

Record observations hourly (more frequently if required) on CPAP chart and on CEWS chart

Regular changes of probe site prevent skin breakdown and burns

Allows infant to settle on CPAP and settings to be changed if necessary

Charts improvement/ deterioration ofinfant as well as predicting deterioration

Sedation Chloral hydrate to be prescribed PRN according to BNFc

For use when infant does not tolerate CPAP. If infant does not tolerate CPAP its use will be



ineffective

Procedure RationaleBlood gas monitoring

Blood gas analysis should be performed prior to and one hour after commencing CPAP

Capillary blood gas monitoring at least 6 hourly until stable

Record on Blood Gas Analysis Chart

Deteriorating blood gases may indicate a need for intubation. Infants receiving IVI should have electrolyte levels checked to prevent hypo/ hyperglycaemia etc

SuctioningIndications for suctioning:

Increased secretions

Increased work of breathing

Increased O2 requirement

Increased respiratory distress

Increased apnoeas

Use size 8fr suction catheter to suction nasopharyngeal or orally

Suction pressure set to 100-120mmHg maximum

Have facial O2 nearby

Measure distance from incisor to the angle of the lower jaw

Insert catheter without applying suction

Apply suction, withdraw slowly in a straight movement without rotating

Clear suction tubing with sterile water

Bronchiolitic infants produce thick secretions that cannot be cleared by a smaller bore

Suction can be traumatic for an infant so should not be undertaken as routine procedure

Fragile infants may respond with bradycardia or apnoeas

Higher pressures will cause trauma to the airways

Mouth care, dummies and chin straps

Use foam mouth swab and sterile waterregularly

Encourage the use of a dummy

CPAP dries infants airways

Dummies stimulate oral secretions, keeping the mouth moist and encourage a good seal by preventingmouth breathing. Alternatively a chin strap can be applied.NB. Never use a dummy against parental wishes or force one on an infant who does not want it/ tolerate it.

Handling/ positioning

Elevate cot to 30°

All cares including repositioning, observations, nappy changes and bloodgas analysis should be performed together and the infant allowed to rest

Reposition 4-6 hourly

Elevated cot will reduce pressure on the babies diaphragm

Constant handling increases the infants stress levels, energy expenditure and increases the work of breathing

Regular repositioning helps reduce facial oedema, reduce pooling of secretions, and reduce pressure



marks as well as improving oxygenation and reducing respiratoryworkload

Procedure RationaleNasal integrity Evaluate infants nares and septum

regularly for signs of pressure or breakdown

If nasal prongs are ill-fitting it can cause erosion of the septum and nares due to friction

Parental information

Explain infants condition and need for CPAP to parents and update them on aregular basis

Gain parental consent prior to commencing CPAP

Allow parents to be as involved as condition dictates in their Childs care

Ensure parents receive a Parental information leaflet

To prepare the family for the procedure

To ensure family-centred care

To give parents a better understanding so that they can advocate for their child and give informed consent



Quick User Manual reference guidelines for the Bubble CPAP circuit



Troubleshooting



APPENDIX 2

Quick reference guidelines for the Infant Flow Driver CPAP



Appendix 3



CPAP

PARENTAL INFORMATION LEAFLET

WHAT IS CPAP, WHY IS IT USED?

CPAP stands for Continuous Positive Airway Pressure and is used in hospital to provide constant gentle pressure through the airways to the lungs. This pressure keeps the airways open to aid your child’s breathing, allowing them to rest. The amount of pressure and oxygen can be adjusted accordingly helping them get better.

The CPAP is delivered through two tubes which attach to prongs, which fit snugly in the nostrils and are secured to a bonnet as illustrated in the picture above. These tubes connect to the CPAP machine. You will then see bubbles in the water chamber.

CONTINUOUS MONITORING

Whilst your baby is receiving CPAP, they will be cared for in the High Dependency Unit (HDU) on Buxton Ward. This is so that they can receive closer observation. You are welcome to stay with your baby next to the cot throughout. An Oxygen Saturation Probe (Sats Probe) will be placed on your baby’s foot or toe displaying how much oxygen is in the bloodstream and the baby’s heart rate. Other observations, such as the respiratory rate and temperature, will also be monitored frequently.

OROGASTRIC TUBE

This is a small tube inserted into your baby’s stomach, via the mouth and secured to the cheek or chin. This tube will allow the air and contents of the stomach to be drained, giving the lungs more room to expand. Your baby may be Nil By Mouth for a period of time, as digestion takes a lot of energy, which can be used instead for breathing.Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 of 37


CANNULAS AND IV FLUIDS

If your baby needs to be Nil By Mouth, a cannula will be inserted and Intravenous fluids will be given to keep your baby hydrated. The doctors will do this and they maytake a small amount of blood at the same time for a blood test.

BLOOD GAS ANALYSIS

The amount of oxygen and carbon dioxide in the blood needs to be measured frequently. This is done by pricking the baby’s heel with a lancet and filling a small glass tube with blood. It is much less blood than it looks but this may need to be done quite often until the levels stabilise.

SEDATION

If your baby does not tolerate the CPAP machine very well, they can be given a sedative called Chloral Hydrate. This allows the baby to relax, once your baby gets used to the CPAP, they will not need to have the sedative any more.

SUCTION

Suction is used to clear the airways of excess mucous so your baby can breathe better. A thin suction catheter is inserted into the nose or mouth. Sometimes a larger Yanker Sucker is used in the mouth to clear excessive secretions.

POSITIONING, HANDLING AND COMFORTING

When your baby is on CPAP they can still be touched and comforted by you. They may need to stay in the cot while they adapt to being on CPAP, but after a time you will be able to take them out of the cot and give them a cuddle. The nurses will makethe baby a ‘nest’ for them to lie in while they are in the cot to provide comfort and support. The cot will also be tilted so keep your baby upright, helping them to breathe. Their position will be changed regularly to help naturally clear the chest andrelieve pressure on their skin. You are welcome to help the nurses with this if you like. You can put some teddies and toys in the cot and provide your own blankets to make your baby feel more relaxed if you want to.

If your baby usually sucks a dummy, they can continue to do this while on CPAP. This will also prevent the baby breathing through their mouth, which will prevent air and pressure from the CPAP escaping.

COMING OFF CPAP

When your babies’ breathing has improved, they will be taken off CPAP, but may still require a little oxygen. Your child will be monitored closely for the first few hours after coming off CPAP to make sure they are still breathing normally; however in some cases, it may be necessary to place them back on CPAP again until they have completely recovered.


joint trust guideline for the management of infants

Documents