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Continuous Positive Airway Pressure (CPAP)

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CPAP Baby1Continuous positive airway pressure (CPAP) is used to maintain continuous positive pressure during both inspiratory and expiratory phases when the infant is breathing spontaneously.

Its effects include:

  • Increase in functional residual capacity leading to an increase in PaO2
  • Increases pulmonary compliance
  • Increases spontaneous tidal volume and reduces respiratory effort
  • Decrease in alveolar-arterial oxygen pressure gradient
  • Prevents alveolar collapse
  • Increases airway diameter
  • Conserves surfactant
  • Splints the airway
  • Splints the diaphragm
  • Reduces mechanical obstruction (eg. meconium)

Indications for CPAP

The following infants should be considered for continuous positive ariway pressure

  • Any signs of significant respiratory distress:
    Nasal Flaring
    Subcostal or intercostal retractions
    O2 requirement
  • Diseases with low functional residual capacity (FRC):
    Respiratory distress syndrome
    Transient Tachypoea of the newborn
    Pulmonary oedema
  • Meconium Aspiration Syndrome

 CPAP is commenced in discussion with a doctor/NS-ANP


  • CPAP is to be applied by newborn nursing staff who have undertaken CPAP training
  • CPAP pressure is to be discussed with the medical team, 6cm is the default, greater than 8cms is a consultant decision
  • Gas flow between 6-10 litres, enough to generate a bubble. Consider 6 litres for ELBW infants and 8-10 litres for larger infants

 Applying the CPAP Cap

Choose an appropriate size CPAP Cap for the baby's head circumference

Step  Action
 1 Place cap around back (nape) of neck, over ears and across forehead
 2 Ensure cap is placed in the middle of the forehead, so it's not sitting down on the eyebrows
 3 Ensure some overlap of cap. No overlap means the cap is too small. If tab crosses the stitched red line then cap is too large. Vary the overlap position at each cares, avoiding ears or lying on overlap
 4 Fit the cap snuggly, not tightly, to avoid pressure areas
 5 Gather top of cap and feed into toggle. Slide toggle down to infants crown, creating a snug fitting cap 
 6 Apply wide Velcro to each corrugated CPAP tubing, secure with thin leucoplast around circumference 
 7 Secure chin strap in place with short fasteners
 8 Place a roll under the infant's neck to give slight extension
 9 Apply Duoderm with Velcro (rough side) attached, as base tapes to cheeks

Select appropriate size Prongs

Infant Size Prong Size
<700g 0
700-1250g 1
1250-2000g 2
2000-3000g 3
>3000g 4
>4000g 5
  • Blanching of the nostrils suggests prongs are too large
  • Pinching of the septum suggests prongs are too small
11 Wrap Velcro (soft side) around prongs, secure with thin leucoplast around circumference

Suctioning in NICU is not a routine procedure.

Consider suctioning if the infant has excessive secretions, increasing oxygen requirement or worsening RDS. Record colour and volume of return. Suction should be set at 100-150mmHg

Minimum - Just in the catheter
Moderate - Up to finger port
Copious - Past finger port

13  Gently insert prongs that fit nares snuggly, without causing pressure

Ensure you have a minimum 2mm space between the prongs and septum AT ALL TIMES

14 Secure inspiration (blue) and expiration (white) tubing to the CPAP hat with the long fasteners, secure tubing where it naturally lies
15  Once tubing is secured in place, re-check prong placement,  ensuring 2mm space between prongs and septum
16 Attach the yellow sticker to the humidifier chamber with date the circuit needs to be changed

Care of the infant and documentation on CPAP

  • Vigilant monitoring that prongs are a minimum of 2mm off septum At ALL TIMES
  • CPAP is to be applied by newborn nursing staff, who have undertaken CPAP training
  • If any septal damage, seek advice from CPAP team member, CCNs or Educators (Duoderm is NOT to be applied). If NP CPAP is required, this is a medical team decision and a Datix is to be completed, and clearly documented in the baby's notes
  • Suctioning is not a routine procedure, only suction as appropriate
  • Visually check prongs sizes are correct for infants weight
  • Visually check prongs sizes are correct for infants weight
  • Ensure prongs are changed with weight increase, as per guide
  • Calibrate oxygen analyser each shift
  • 12 hourly blood pressure (minimum)
  • Allow baby to rest, using minimal handling and cue based cares
  • Ensure optimum prone positioning - if necessary see CPAP team, Educators, Senior Staff
  • Change CPAP cap weekly, unless visibly soiled
  • Put CPAP cap, chin strap and toggle out for CPAP washing. Discard all velcro
  • Document: in comments section of observation chart when CPAP cares are done, hat released and if suctioning was required. On back of nursing chart, record prong size and integrity of septum

Use of Duoderm Patch

A Duoderm patch may be used if a baby reuqires an improved seal to optimise CPAP. A patch needs to be approved by a CPAP team member, CCN or Educator.

Circumstances may include:

  •  A baby who is too small to go up in CPAP prong size.
  • A baby who already has size 5 prongs in place and needs an improved seal.

Never use a duoderm patch to cover a red septum, as this will hide damage, NOT protect the skin.

If a Duoderm patch has been approved for use, print out this pdf  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.


  • If the infant requires CPAP and still has an oxygen requirement, they are to remain on CPAP while having Kangaroo care.
  • Some ELBW infants without an oxygen requirement may not cope off CPAP

Nasopharyngeal CPAP


Nasal erosion

Nursing Management

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

  • There should be discussion with the medical team as soon as possible. A Datix report must be completed and clearly documented in baby's notes.
  • The ongoing need for NP-CPAP is reviewed daily on the ward round.  

If an infant requires Nasophanygeal CPAP Print out this pdf form, complete the details, label and file in the baby's bedside chart


 "It's not Bubbling!"

This indicates loss of air flow or a pressure leak somewhere in the system. A simple way to check if it is a 'circuit' problem or a 'baby' problem is to remove the prongs from the nose and occlude them with your fingers.

If the system doesn't bubble it means the problem is with the circuit. Systematically check the circuit, tightening all connections as you go.

If the system does bubble, when you occlude the prongs with your fingers then the pressure leak is at the nose or mouth. Air will escape if the prongs are too small or if they are not curved down into the nose and fitting snugly. Prong sizes are based on weight, this is usually very accurate, occasionally a smaller size is required for 12-24hrs, reassess regularly. Any pinching of the septum will cause pressure damage. Adjust chin strap position to reduce any leak via the mouth. A dummy may help an unsettled baby.

A Duoderm Patch may be applied to nares for problems with a seal / no bubbling, following assessment by a member of the CPAP Team. Before using a Duoderm patch, please check the prong size is correct for the weight of the baby. Duoderm patch paperwork must be signed and dated by the person approving the patch and kept in the nursing chart.

"The prongs won't stay in place!"

  • Are they the right size?
  • Does the hat fit snugly? The hat is the anchor for the prongs a loose hat will allow any movement of the head to dislodge the prongs.
  • Are the corrugated tubes fixed firmly in place on the side of the hat and are they at the correct angle to keep the prongs in place? If there is rotating pressure on the prongs they may twist out of the nose. If in doubt, remove the long fasteners and with the prongs correctly positioned in the nose, allow the tubing to sit naturally in place. Reposition the prongs, tubing and the long fasteners as necessary. Ensure that the base tapes are secure on the face. Do the existing ones need replacing?

"The baby won't settle!"

  • Are the prongs positioned in the nares appropriately and comfortably?
  • Assess nares for any redness or pressure areas
  • Does s/he need suctioning? This may seem a contradiction when suggesting ways to settle a baby, but a build up of secretions can cause considerable distress to a baby whose breathing is already compromised.
  • Once you are sure the airway is clear and the prongs are appropriately positioned, try the usual calming techniques of containment, nesting, swaddling, pacifier with a drop of  expressed breast milk, if a parent is available encourage kangaroo care.
  • Aspirate any excess gastric air and vent OG tube to free drainage if necessary.
  • Try positioning the baby prone, this can help relieve abdominal distension and diaphragmatic pressure.
  • Often just "hands off" will allow the baby to slowly settle, use baby led/cue based care.

"How can we avoid septal damage?

Prevention is the key.Vigilant nursing care is paramount for the prevention of pressure areas to septum and nares. Tissue will break down if it is subjected to continuous pressure, friction and/or moisture. Avoiding these contributing factors will maintain an intact septum:

  • Use the correct sized prongs 
  • Secure in place with a snug fitting hat, correctly positioned with long fasteners over the corrugated tubing
  • Use velcro base tapes to secure the prongs to the face
  • Don't allow the bridge of the prongs to press up against the septum
  • Avoid twisting of the prongs with resultant lateral pressure against the septum
  • Do not use creams, ointments or gels
  • Frequent observation of the septum and prong position is essential. Be wary of eye pads that cover the nose on babies under phototherapy as these can obstruct your view of the septum.

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Document Control

  • Date last published: 29 November 2018
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years