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Continuous Positive Airway Pressure (CPAP) - airway management

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Principles of airway management

  • To maintain optimal airway patency
  • Indications
    - Increased secretions
    - Increased respiratory effort
    - Increasing oxygen requirement
    - Increasing respiratory distress
    - Increasing apnoea
  • Equipment required
    - Suction catheter sizes 7, 8 or 10
    - Normal saline (only required for tenacious secretions)
    - Gloves
    - Suction tubing and trap
  • Suction pressure should be set at 100-150mmHg
  • Frequency of suctioning will depend on the condition of the baby
  • Symptomatic infants, on CPAP, suction pre-feed at least 2-4 hourly or more often if required (see indicators).
  • Stable infants, on CPAP, suctioned at least 6 hourly or more if required.
  • After discontinuing CPAP, suction the baby at least 6 hourly or more frequently if symptomatic, for the first 24 hours. Then as required for airway maintenance.

Process

 Step  Action  Management
1
  • Collect all equipment necessary.
  • Attach suction catheter (have saline warmed and opened for use if required).
  • Ensure oxygen supply or anaesthetic bag is within reach if needed. 
Preparation ensures the least time disconnected from CPAP for baby. 
Pre-oxygenate baby if required or give blow-by oxygen during suctioning. Used where baby desaturates rapidly without CPAP. 
Suction mouth first only if required.  Lubricate catheter with oral secretions
  • Measure from nose to pinna of ear.
  • Add half that distance to measurement already obtained. 
This is a rough estimate to ensure the catheter passes far enough into the airway to clear the secretions. 
Remove prongs from nose instill 2 drops or 0.2ml normal saline into each nostril if required for thick secretions.
This is not a routine procedure. 
This helps to loosen secretion and aid suctioning.
No more than required drops are needed, as any excess will only be swallowed by baby or lie in oropharynx. 
  • Suction down each nostril. Go down to predetermined distance.
  • Apply suction and hold there for a few seconds prior to removing, slowly twisting as you come out.
Allows time for secretions to be suctioned.
  • Length of time for each suctioning will depend on the infant's condition.
  • Baby should be suctioned at least twice down each nostril.
Excessive suctioning can cause deterioration in baby's condition. CPAP prongs can be reinserted and suction repeated when baby stable again. 
If there is difficulty passing a catheter into the nasopharynx, the finger port can be used. This should be only placed at the entrance of the nares and the catheter kinked.  Allows for secretions to be removed from the nares clearing sufficiently to allow passage of a suction catheter
Lavage and suctioning can be performed as many times as seen necessary for thick copious secretions. May find easier to remove thick secretions with numerous suctions rather than prolonged suctioning episodes. 
10  After procedures, return the infant to a comfortable position. Hold the infant until vital signs return to normal parameters.  Reduction of stress on the baby and ends procedure with a positive touch. 
11  Consider use of 2 nurses for fragile infants such as:
- ELBW/ VLBW infant
- Infant relying on CPAP pressure
- Infant with increased O2 requirements. 
This optimises the procedure ensuring the infant is supported appropriately. 
12  Documentation of procedure. Note down:
- Colour and consistency of return.
- Quantity
   Minimum - Just in catheter
   Medium - Not up to finger port -
   Copious - Up to and past finger port
- Time of suctioning.
- Documentation in comments column baby's response to suctioning for future reference. 
Aids other staff to ascertain any changes in secretions and frequency required.

Enables other staff to anticipate response of baby and reduce stress. 
13  Where there is difficulty in passing size 7 catheter, a size 6 can be used or use finger port.

Ask CPAP Team for help / support / critique 
Size 6 does not adequately aspirate secretions but may be useful with babies who have inflamed nasal passages. If there is difficulty passing the size 6, use of the finger port initially may be appropriate 

Maintenance of CPAP

 Step  Action  Management
1

Care of the Baby: 
Observe and document a baseline assessment of the infant prior to the commencement of CPAP. This includes:

  • Respiration: rate, effort, breath sounds, signs of distress (tachypnoea, nasal flaring, sternal indrawing, rib retractions, grunting) 
  • Temperature 
  • Cardiovascular: central and peripheral perfusion, blood pressure, auscultation 
  • Neurological: tone, response to stimulation and activity 
  • Gastro-intestinal: specific characteristics (e.g. cleft palate, omphalocoele), abdominal distension, visible loops, bowel sounds 
  • Technical: pre-ductal (preferably right arm) oxygen saturation probe, cardio-respiratory monitor 
Baseline observations are essential to the ongoing assessment and management of the baby. Underlying, contributing conditions may be discovered, e.g. hypothermia, choanal atresia, cardiac murmur, narcotic depression, etc. 

NB: This assessment should be done with the minimum of delay.

The sooner CPAP respiratory support is initiated the better the baby's outcome. If significant symptoms of respiratory distress exist, commence CPAP immediately. Assessment can continue once the acute situation is addressed.
  • Regular observations as outlined above need to be performed.
  • Minimal handling is essential for a sick infant therefore "hands on" intervention should be limited to 2-4 hourly if possible. Initially some fine tuning of the CPAP system may be necessary but limit handling to essentials such as suctioning and core temperature monitoring.
  • Complete blood drawing, IV insertion, X-rays, etc, with the minimum delay.
Decisions regarding ongoing treatment are made on the basis of serial assessments.
Keep the baby's parents informed of what is happening. Answer questions and offer information, as you do with regard to all other aspects of the baby's care. Parents are members of our care team and have the right to understand the care their baby receives.
Once the infant is stable on CPAP and is tolerating handling without compromise or agitation the usual activities of care can be performed.  
Parents can be encouraged to participate by being shown the techniques of soothing and containment. They can perform oral cares, nappy changes, etc. as their confidence and the baby's condition permits. This facilitates attachment and reinforces their role as parent and caretaker.
Change the baby's position 4-6 hourly. Kangaroo care is an ideal variation in position along with it's other tactile emotional advantages.  Changing position is a gentle way to move lung secretions along the airway

Use of Duoderm patches for nasal prong CPAP

  1. Duoderm patchA patch is to be used when a baby needs an improved seal to improve CPAP bubbling. Circumstances may include:
    - A baby who is too small to go up in CPAP size. 
    - A baby who already has size 5 prongs in place and and needs an improved seal. 
  2. Change duoderm patch once a shift or anytime the patch is lifting or dirty. 
  3. Document duoderm patch change on the observation chart. 
  4. Never use a duoderm patch to cover a red septum as this will hide damage, not protect the skin. 
  5. When cutting the opening do a crisscross, don't try and cut a hole.
    Feed prong through the cut prior to placing the patch on the nose.
  6. Always remove the nasal patch when trialling a baby on high/low flow oxygen or air. 
  7. If a duoderm patch has been authorised to be applied, print out the pdf sheet attached here, complete the information and place a baby sticker on the form, and place in the baby's bedside chart.

Kangaroo Care on CPAP

Many infants on CPAP will be considered stable enough to receive Kangaroo care. In general the following guideline should be adhered to:

If the infant requires CPAP and still has an oxygen requirement, they are to remain on CPAP when having Kangaroo care. Infants on CPAP and receiving air (21% oxygen) may be trialed off CPAP for Kangaroo care.

Note: some ELBW infants without an oxygen requirement may not be able to cope off CPAP

All infants should receive appropriate monitoring during Kangaroo care, regardless of whether they remain on or off CPAP

Nasopharyngeal CPAP

Indication

Nasal erosion

Nursing Management

  1. A baby is placed on NP-CPAP either by:
    - CCN (out of hours) 
    - Educator 
    - CPAP Resource Team 

    Note: There should be discussion with the consultant as soon as practicable about why nasopharyngeal CPAP is required. If nasal erosion is significant, enough to require nasopharyngeal CPAP, a Datix report must be completed and clearly documented in baby's notes. 
  2. The ongoing need for NP-CPAP is reviewed daily by the above staff. 
  3. An ET tube 2.5 or 3.0 is inserted 4cm into nasopharynx (5cm if baby >3.5 kg). 
  4. Base tapes are applied to the face with elastoplast patches attached (to allow for ease of tape repositioning). the tube is then taped in place with two separate pieces of leukoplast above the top lip and secures on the cheek. 
  5. The nasopharyngeal (NP) tube shortened to approximately 6cm from nares. Ensure you insert the manifold (non-disposable) into the cut end of the ETT. 
  6. NP tube is removed for suctioning infant as per suction protocol. 
  7. NP tube should be changed 12-hourly (or more frequently if required). 
  8. Print out a pdf copy of this guideline here, fill in the details below, and file in the baby's notes, with a baby sticker placed on this form. 

Date commenced: ______/______/______

Signature: _________________________

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Document Control

  • Date last published: 17 September 2018
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years