Procedure
The application of continuous positive airway pressure to neonates and infants by nasal prongs (NCPAP), nasopharyngeal tube (NP-CPAP), or infant nasal mask (NM-CPAP) administered with a commercially available circuit used in conjunction with a continuous flow source, infant ventilator, or a suitably equipped multipurpose ventilator
Description/Definition
Continuous positive airway pressure (CPAP) is the application of positive pressure to the airways of the spontaneously breathing patient throughout the respiratory cycle. For the most part, neonates are preferential nose breathers, which easily facilitates the application of nasal CPAP. This is accomplished by inserting nasopharyngeal tubes, affixing nasal prongs, or fitting a nasal mask to the patient. The device provides heated and humidified continuous or variable flow from a circuit connected to a continuous gas source, mechanical ventilator designed for neonates, or a suitably equipped multipurpose ventilator, set in the CPAP mode.
CPAP maintains inspiratory and expiratory pressures above ambient pressure, which should result in an increase in functional residual capacity (FRC) and improvement in static lung compliance and decreased airway resistance in the infant with unstable lung mechanics. This allows a greater volume change per unit of pressure change (i.e., greater tidal volume for a given pressure change) with subsequent reduction in the work of breathing and stabilization of minute ventilation (VE). CPAP increases mean airway pressure, and the associated increase in FRC should improve ventilation-perfusion relationships and potentially reduce oxygen requirements. Additionally CPAP may expand, or stent, upper airway structures preventing collapse and upper airway obstruction.
Settings
NCPAP, NP-CPAP, and NM-CPAP are applied by trained personnel in acute and subacute care hospitals.
Indications
- Abnormalities on physical examination--the presence of increased work of breathing as indicated by an increase in respiratory rate of >30% of normal, substernal and suprasternal retractions, grunting, and nasal flaring; the presence of pale or cyanotic skin color and agitation
- Inadequate arterial blood gas values--the inability to maintain a PaO2 greater than 50 torr with FIO2 of <0.60 provided VE is adequate as indicated by a PaCO2 level of 50 torr and a pH >7.25
- The presence of poorly expanded and/or infiltrated lung fields on chest radiograph
- The presence of a condition thought to be responsive to CPAP and associated with one or more of the clinical presentations described above:
- Respiratory distress syndrome
- Pulmonary edema
- Atelectasis
- Apnea of prematurity
- Recent extubation
- Tracheal malacia or other similar abnormality of the lower airways
- Transient tachypnea of the newborn
- Early intervention in conjunction with surfactant administration for very low birth weight infants at risk for developing respiratory distress syndrome
- The administration of controlled concentrations of nitric oxide in spontaneously breathing infants
Contraindications
Refer to the "Contraindications" field or see the original guideline document.
Hazards/Complications
Refer to the "Potential Harms" field or see the original guideline document.
Limitations of Device
- NCPAP, NP-CPAP, and NM-CPAP applications are not benign procedures, and operators should be aware of the possible hazards and complications and take all necessary precautions to ensure safe and effective application.
- Mouth breathing during NCPAP, NP-CPAP, and NM-CPAP may result in loss of desired pressure and decrease in delivered oxygen concentration.
- NCPAP harnesses and attachment devices are often cumbersome and difficult to secure and may cause agitation and result in inadvertent decannulation.
- Excessive head rotation or neck extension may alter the position of NP-CPAP tube placement or obstruct upper airway structures resulting in diminished or altered pressure, flow, and effective CPAP.
- Severe respiratory distress syndrome (RDS), septicemia during NCPAP administration, and pneumothorax are risk factors associated with NCPAP failure.
Assessment of Need
Determination that valid indications are present by physical, radiographic, and laboratory assessments
Assessment of Outcome
CPAP is initiated at levels of 4-5 cm H2O and may be gradually increased up to 10 cm H2O to provide the following
- Stabilization of FIO2 requirement <0.60 with PaO2 levels >50 torr and/or the presence of clinically acceptable noninvasive monitoring of oxygen (PtcO2), while maintaining an adequate VE as indicated by PaCO2 of 50-60 torr or less and pH >7.25
- Reduction in the work of breathing as indicated by a decrease in respiratory rate by 30-40% and a decrease in the severity of retractions, grunting, and nasal flaring
- Improvement in lung volumes and appearance of lung as indicated by chest radiograph
- Improvement in patient comfort as assessed by bedside caregiver
- Clinically significant reduction in apnea, bradycardia, and cyanosis episodes
Resources
- Equipment
- Endotracheal tubes (positioned in the nasopharynx and secured by taping, with placement verified by laryngoscopy or palpation) or commercially available nasal prongs, bilateral nasopharyngeal tubes, or specially designed nasal masks with accompanying harness and accessories may be used for CPAP administration
- Unilateral nasopharyngeal prongs may be less effective in preventing extubation failure than bilateral short prongs.
- Continuous flow air-oxygen gas source; commercially available continuous-flow infant ventilators equipped with CPAP mode; CPAP flow driver with fluidic nasal interface, or suitably equipped multipurpose ventilator, with integrated or adjunct low and high airway pressure alarms, oxygen concentration analyzer with low and high alarms, loss of power and gas source alarms.
- A continuous gas flow source requires a mechanical pressure limiting device, or a flow or threshold resistor, which includes the use of an underwater threshold resistor (e.g., Bubble CPAP).
- Lightweight CPAP or ventilator circuits with servo-regulated humidification system
- Continuous noninvasive oxygenation monitoring by pulse oximetry or transcutaneous monitor with high and low alarm capabilities is recommended (continuous transcutaneous CO2 monitoring may also be utilized).
- Continuous electrocardiographic and respiratory rate monitor, with high and low alarm capabilities, is recommended.
- Suction source, suction regulator, and suction catheters for periodic suctioning to assure patency of nasal passages and of endotracheal tubes used for NP-CPAP are necessary.
- Resuscitation apparatus with airway manometer and masks of appropriate size should be available.
- Gastric tube for periodic decompression of stomach and chest tubes should be available.
- Personnel: The application of NCPAP, NP-CPAP, and NM-CPAP should be performed under the direction of a physician by trained personnel who hold a recognized credential (e.g., CRT, RRT, RN) and who competently demonstrate:
- Proper use, understanding, and mastery of the technical aspects of CPAP devices, mechanical ventilators, and humidification systems
- Knowledge of ventilator management and understanding of neonatal airway anatomy and pulmonary physiology
- Patient assessment skills, with an understanding of the interaction between the CPAP device and the patient and the ability to recognize and respond to adverse reactions and complications
- Knowledge and understanding of artificial airway management, training in the procedures of placing endotracheal tubes in the nasopharynx
- The ability to interpret monitored and measured blood gas values and vital signs
- The application of Standard Precautions
- Proper use, understanding, and mastery of emergency resuscitation equipment and procedures
- The ability to assess, evaluate, and document outcome
Monitoring
- Patient-ventilator system checks should be performed at least every 2 to 4 hours and should include documentation of mechanical settings, alarms, and patient assessments as recommended by the American Association for Respiratory Care Clinical Practice Guideline (AARC CPG) Patient-Ventilator System Checks (MV-SC) and the CPG Humidification during Mechanical Ventilation (HMV).
- Oxygen and carbon dioxide monitoring, including:
- Periodic sampling of blood gas values by arterial, capillary, or venous route
- Continuous noninvasive blood gas monitoring by transcutaneous O2 and CO2 monitors
- Continuous noninvasive monitoring of oxygen saturation by pulse oximetry
- Continuous monitoring of electrocardiogram and respiratory rate
- Continuous monitoring of proximal airway pressure (Paw), positive end-expiratory pressure (PEEP), and mean airway pressure (Paw)
- Continuous monitoring of FIO2
- Periodic physical assessment of breath sounds and signs of increased work of breathing (see "Indications" section above)
- Periodic evaluation of chest radiographs
- Periodic assessment of nasal septum
Frequency
NCPAP, NP-CPAP, and NM-CPAP are intended for continuous use and are discontinued when the patient's clinical condition improves as indicated by successful outcome assessments (see "Assessment of Outcome" section above).
Infection Control
No special precautions are necessary, but Standard Precautions as described by the Centers for Disease Control and Prevention should be employed.
- Disposable nasal CPAP kits are recommended and are intended for single-patient use.
- Routine disposable circuit changes are unnecessary for infection control purposes when the humidifying device is other than an aerosol generator.
- External surfaces of ventilator should be cleaned according to the manufacturer's recommendations when the device has remained in a patient's room for a prolonged period, when soiled, when it has come in contact with potentially transmittable organisms, and after each patient use.
- Sterile suctioning procedures should be strictly adhered to.
