Home

CPAP AND THE BABY WITH DIFFICULT BREATHING

1. yoajas pezis joajas xoqpeay Joyeqnou peaH ysew aoe 41 CPAP and the Baby with Difficult Breathing 40 03 S 159 eAniugeq uonipuoo eq 10 eseosip JO Suonipuoo 19440 poyeloosse aq uBnoue 10 Addl 10 dVd2O U9UM SJn220 ul ay t O gt Buu PIN uoisuejied uy Axeuowjnd poyeloosse Ke siiBuiueui pue 0045 sisdes 00552 Key 496 2 Se Jose1 u8p vco yeay pezis pue sBun 1ueonj ied u Ke N ui suoisngje esnyjp e A 1e noseA peseedoui pue ABojouyed uo Buipuedep 1ueonjied u jelpseoued syea Jo pys eoeds 90 uomeutuinj Ssuea ui euoo Aje1eyejiq
2. 78 of th OS 79 yan at 79 80 Infection prevention 80 MT 81 The correct technique for suction seen 81 9 7 What if the baby is deteriorating sss 83 Clinical e 83 Possible reasons for deterioration s eee 83 Increasing CPAP settings when the baby deteriorates 84 Maximum settings in ten rien tenia nna 84 Protocol What to do when baby is deteriorating 84 Acute complications of CPAP which may cause deterioration 85 Tube obstruction rhe tete 85 Pneumothotax cesa t e d e ed eh 86 86 Overdistension of the TONGS iuis rt ire absint anti 87 rol 87 CPAP and the Baby with Difficult Breathing 10 11 12 9 8 Weaning and Stopping CPAP essent 90 When to wea CPAP ceti eir i EL rotae rada 90 When to stop the 90 Protocol Stepping CPAP 90 How to make CPAP work well in your hospital eene 92 101 Min
3. ysod ul eixkydsy ejejnonaed jy A eroedse peureis uiniuooe N uolyejndiuew Jnoqe seue4quieul peBuojoud sisdos JO 810109 esuo 101SIH oseosip oeIpJe2 I 1u81sisJ8d ojnsseJd OAIHSOd eixkydsy Jo uondaoseJ pefe eq eixKudsy Qui Buunp 10 019 N ui jo uoneuidsy uonoejut e1eujsod 10 eiuouinaud euueBuo2 Ayanyewaid juejoejns jo Aousioyeq ssesip yeyeuosu Jo sesneo jo 8 9 2 43 CPAP and the Baby with Difficult Breathing 42 1 WHAT IS CPAP PARTB CPAP CONTINUOUS POSITIVE AIRWAY PRESSURE CPAP is a treatment for neonates with apnoea and with respiratory distress CPAP stands for Continuous Positive Airways Pressure it describes both the machine and the treatment using the machine 2 WHY USE CPAP CPAP was first used to treat babies with breathing problems in the 1970 s It lost popularity when mechanical ventilation also referred to as intermittent positive pressure ventilation IPPV was invented and was considered to be a superior treatment Interest in using CPAP returned in
4. salen dVdO 941 dVdO ueeq seu ayNUIW Z uey 1euBiu SMO ye ueB xo seujunoo ul seuesJnu ejeuoeu pesn eq oj s sBuo4d ueB xo siy jo eun sajoyyiod sedeosa ZO ueB xo 604 uBiu eqni 1deoxe qeq eui peo 10uue2 Xoqpeeu 991 jo ued seiqeq Big Alon 0 81209 sexiu pue ejou oeu y edeose ued UBBAXO pepeeu uBiu se ueB xo jo pesn uoB xo ZOD ueB xo 604 yBiy uBiu s qeq ay ouo esoo sede Jo si qeq ji yey SeN eqni Aq 1deoxe eures qeq au peo youueD pepeeu uBiu se ueB xo jo suni ueB xo JO JEWS 00 SI y 4 pesn ueD xo jo eyenbepeul ZOD es eue ue J 604 enseeui uoisuejsip
5. 2 5 B lt 5 a 120 CPAP and the Baby with Difficult Breathing 121 Using a flow of 3L Oxygen and 3L Air gives an FiO2 of 14 CASE SCENARIOS FOR CPAP TRAINING Using a flow of 5L Oxygen and 2L Air gives an FiO2 of doctor has asked for 60 oxygen List different flow combinations that will give approximately FiO2 60 Baby who is deteriorating 11 Apart from monitoring vital signs and the machine list 3 elements of nursing care which site venyimportanton Baby with a possible blocked tube W The baby who is improving There is no bubbling in the expiratory bottle Scenario 1 Baby 1 is 1 7 kg and was born at 31 weeks gestation He was started on CPAP at 12 hours of age because Dr John thought he had RDS of prematurity hyaline membrane disease He had not had any apnoea but had difficult breathing even when he was on face mask oxygen at 6L minute He was started on 5cm CPAP and 30 FiO2 The nurse looking after him had to increase the FiO2 to 40 in the first hour after CPAP started to get the baby s 5 02 to 95 was stable for the rest of the day He began minimum volume feeds of EBM by at 24 hours of age On day 3 it is noted that he has been deteriorating for several hours His work of breathing has increased a lot his respiratory rate and pulse rates have increased significantly his oxygen requirement has increased from 40 to 65 over the preceding
6. 120 13 Pretest posUtesl uisi cem ite e en in ma Go T e ote ite nea 121 14 Case scenarios for CPAP training essere 123 15 Sample timetable for a 1 day CPAP 125 16 Supervision SNEe cccccccccscscssssssssssssessesessesessesscsssecseseesacsesacsesaesessesacsessesessnsansaves 126 17 References eandem 129 18 Annex 1 Oxygen concentration rates essere 132 19 Annex 2 Pretest post test with answers 138 20 Annex 3 Case scenarios for CPAP training with answers 141 Figures Figure 1 S b st rnal TEGBSSIOTTS axaiasasiasiseie Sa iE rip M 22 Figure 2 Nasal flaring source Managing newborn problems WHO 2009 23 Figure 3 Baby receiving oxygen through nasal prongs ses 30 Figure 4 Placement of a single nasal catheter to give oxygen 30 8 CPAP and the Baby with Difficult Breathing Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 Figure 15 Figure 16 Figure 17 Figure 18 Tables Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Table 9 Table 10 Table 11 Table 12 Baby receiving oxygen through a head box cesses senses 31 Poor trace pulse does not match patient 9 esses 35
7. yeo41s Azey esnyq Syee pejeioosse pue uoisuedxejed u seoje Ang 4X2 udeis 10 suoisnye QINH o sells e1oje Iq 10 iun OSNYIP HXO sqems e1ueoe d seunjno SAH PuPu senjno eiueedojAooquioJui Kew OGM Azey Ajesnylq 4X9 suoneBisoeAu sen euuouqe jeuueBuoo poyeloosse uoisnjied pue indino euun 100d AjeBeuiojedeu jndino peonpai jo subig AyeBawoipsesy ses nd juesqe JNWUNW 4 44 uoisnjJed 100d sisouekg epis spunos eJere iun Jo 18840 eueg peureis eooude uonejueAod u uoissaidap SNO 15940 joueg uoisseJdep GND JO pexoous ondes eooude 4 y q Jo 5 suiBeq uoneuluex3 Sf Jereuejue uo eq wou Jeujouu oneqeiq eixkydsy AWH SVIA 9seesip 8uiK jepun uonoes ue AMVE gt
8. 86 CPAP and the Baby with Difficult Breathing Overdistension of the lungs Overdistension of the lungs occurs when inappropriately high CPAP pressures are being used relative to the lung compliance or when lungs are unevenly inflated e g MAS Overdistension may result in hypoxia It may also cause hypotension because overdistended lungs reduce the amount of blood returning to the heart The distensibility of the heart is also reduced 29 A portable CXR can confirm the suspicion of hyperinflation It is diagnosed when more than 9 posterior ribs can be seen and the diaphragms appear flattened Overdistension may be improved by reducing the CPAP pressure and by giving fluid bolus es aliquots of normal saline 10cc kg to optimise blood volume However overdistension may be difficult to reverse particularly if it is localised or uneven such as is often seen in MAS Sepsis Either local skin lung or systemic sepsis may occur as a complication of poor infection prevention practices and or injury to the nasal skin which then serves as a portal of entry for bacteria For signs of systemic sepsis and management of sepsis refer to Managing Newborn Problems WHO 2003 Adhering to strict infection prevention and good care of the nose will greatly reduce the likelihood of complications of sepsis 87 spunos u1eaJq 10 159 0 eui 0 ey 991 Jo eui jo spunos eui spunos 4 soljoigiuy u
9. jo 10 uolyonsysqo Jo ON peuinbei jou pesn jou xoqpeeu pejonJjsqo JOU se aq 15 ueo qeq pue 908 s Aqeq ON ueB xo eui swe M ue 604 enseeui ueg uoisuejsip 2123526 jo 10 Jo ON snf you uBiH uBiu Aq pepeeu yBiy e ued peuinbei jou ueB xo eui swe M you uononasqo 511 ON Apjoinb dn 195 ued uoneasiuiupe ueB xo 1ueBun JO 10 esn jo Oys JO JUBIUBAUOD xoqpeeu Jed sy uBiu UnuulXelA uu 8 1 c uBiu qt e esn 9A147994 ISON Xoqpeeu esn opis Jojeqnoul ui ejou Buigni ueB xo 11989 epeduui 00 ejou Aqeq Big 001 xoqpeeu pezis joajag ueB xo eui sjue eJd YOIUM AeM OUO YPM JIOAJ9SOJ uoB xo ue 98594 ueB xo 001 1 ueo uou ajqejreae ysew
10. 2e ecrire reina CR de Coe ena c fa Ra a di 21 2 Respiratory distress nennen tnnt tnnt 22 2 1 What is respiratory distress essen 22 2 2 Recognising respiratory distress essen 22 el lj Yankan 23 Aetiology of respiratory distress 23 2 3 Evaluating the cause of respiratory distress 25 2 4 Management of established respiratory distress 25 Part B Emergency 25 Ongoing management e 26 Specific audeo is quaii ninna sai Rd 28 2 5 Giving OXYGEN rie Baie ial ehe ede 29 When to give DOCET aate ie kind bia iR Lc 29 How to give OXygen RENI 29 Photographs and illustrations of oxygen administration devices 30 General principles for administering oxygen to 32 When commencing oxygen 32 Making changes to oxygen therapy 33 When to reduce de aa 33 When to stop oxygen 33 2 6 eiui E 34 General instructions for using an oximeter sss 34 2 7 Brief summary of the commonest causes of neonatal res
11. Medical Technology Transfer Services 19 Lane 399 Au Tay Ho Hanoi Vietnam Tel 84 43 766 6521 Fax 84 43 766 3844 Email assistance mtts asia com WWW mtts asia com CPAP AND THE BABY WITH DIFFICULT BREATHING ACKNOWLEDGEMENTS This manual was written by Dr Ingrid Bucens and designed by Mr Andrew EMW is very grateful to the following people for the review and realization of this manual during its development B Dr Priscilla Joe Associate Director Neonatal Intensive Care Unit and Director ECMO program at Oakland Children s Hospital California USA m Dr Stephen Ringer Chief Division of Newborn medicine Brigham and Women s Hospital Boston USA W Associate Professor Trevor Duke Paediatric Intensivist Royal Children Hospital Melbourne Australia Assistant Professor Dr Maneesh Batra Neonatologist m Ms Ester McCall Neonatal Nurse m Mr Bruce Morrison Medical Equipment Specialist National Hospital GVof Dili Timor Leste m Dr Gaston Arnolda M amp E International Director Breath of Life Program East Meets West Foundation m Mr Luciano Moccia International Director Breath of Life Program East Meets West Foundation m Ms Danica Kumara Regional Director for SE Asia Breath of Life Program East Meets West Foundation m Mr Gregory Dajer Director Medical Technology and Transfer Services MTTS Hanoi Vietnam 2 CPAP and the Baby with D
12. 2 is too high The trace is good the pulse matches the baby is pink CPAP and the Baby with Difficult Breathing low alarm sounds because the probe is not attached properly Poor trace pulse does not match baby s pulse 83 vM i Figure 6 Poor trace pulse does not match patient 9 3 82 SEL Figure 7 Good trace pulse matches patient 9 RISKS OF OXYGEN THERAPY Oxygen therapy can be harmful if used incorrectly Both too little and too much oxygen can be harmful Too little oxygen can cause damage to vital organs like the brain and the heart particularly if it is severe or prolonged Eventually too low oxygen will cause permanent damage to these organs and or death Too much oxygen can cause permanent damage to the lungs and in preterm babies to the eyes p 76 This is a brief overview only For a comprehensive review of oxygen therapy the reader is referred to The Clinical Use of Oxygen in Hospitals with limited resources Guidelines for health workers hospital engineers and program managers WHO 2009 9 35 27 Brief summary of the commonest causes of neonatal respiratory distress Hyaline Membrane Disease HMD also called Respiratory Distress Syndrome RDS HMD is with rare exception a condition of preterm babies lt 34 weeks It is the commonest respiratory disease and the commonest cause of mortality in preterm babies The more preterm the baby is the more
13. 51 7 2 Flow Eel 51 How does the EMW CPAP machine work 52 81 Parts of the CPAP machine ciii ieerednktna niu DRE RIAM KR Er NR OA 52 53 Blender and gas eniti men mettra 53 Inspiratory heating bottle 55 Patient circuit tnter eaaa 57 58 Control 59 Front pan l aaa viens dein 59 riii Ebr pe a ais 60 LED c 60 DEDE 60 lateque 60 8 2 Oxygen supply arae gn 62 Oxygen from a cylinder RR Tm 62 Oxygen from a 62 Oxygen Eee m 63 8 3 Patient interfaces sese nn nennen 64 E TREE OPEP TREE 64 Nasal prong SVC CS T 64 Fitted nasal face masks sse 65 Endotracheal tube seen nennen nennen tentes 65 How to use CPAP medical and nursing protocols 67 9 1 When to start CRAP eaa 67 Additional CINE 67 Preter
14. 6 Drug Doses 2010 15th ed Shann F Collective P L ISBN 978 0 9587434 8 8 7 Royal Prince Alfred Hospital Newborn Care Medication Guideline Caffeine Accessed online 28 3 2011 at http www sswahs nsw gov au rpa neonatal 8 Target ranges of oxygen saturation in extremely preterm infants SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Carlo WA Finer NN Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix Das A Poole WK Schibler K Newman NS Ambalavanan N Frantz ID 3rd Piazza AJ S nchez PJ Morris BH Laroia N Phelps DL Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG O Shea TM Bell EF Ehrenkranz RA Watterberg KL Higgins RD N Engl J Med 2010 362 21 1959 69 9 The Clinical Use of Oxygen in Hospitals with limited resources Guidelines for health workers hospital engineers and programme managers Draft version WHO 2009 Available at http www theunion org images stories download OXresources Technicalresources The 20Clinical 20Use 200f 20Oxygen 20in 20Hospitals 20 with 2O0Limited 20Resources pdf 10 Royal Prince Alfred Hospital Newborn Care Guidelines Oxygen therapy Accessed on line at http www sswahs nsw gov au rpa neonatal 11 Vain NE Szyld EG Prudent LM Wiswell TE Aguilar AM Vivas NI Oropharyngeal and nasopharyngeal suctioning of meconium stained neonates before delivery of their shoulders multicentre randomised control
15. Biomedical If present in house then have skills for basic maintenance and trouble maintenance shooting of the CPAP Know when and how to call for external assistance Radiology CXR preferably portable available 24 hours In current times pressures are on hospitals to acquire the latest technologies However prior to deciding to offer CPAP hospital administration and clinicians should review their demand for CPAP Neonatal ward data should be reviewed to determine how many cases of RDS are likely to present each month It has been suggested that as for many practical skills it is difficult to maintain competency in CPAP if a hospital is treating fewer than one case per month 20 Even at these levels skills may need to be maintained by regular rotations to higher level hospitals For hospitals with very low caseloads it is better to focus on improving a referral system to the next level health facility where CPAP is offered 92 CPAP and the Baby with Difficult Breathing CPAP will only be effective in reducing neonatal mortality from RDS when the prerequisites for its safe implementation are fulfilled This is a joint responsibility of hospital administrators clinicians and biomedical as well as those responsible for oxygen supplies Conclusion CPAP cannot save every baby with respiratory distress however provided it is used correctly it will cure to a large number of babies who would otherwise die or require ventilation Use of
16. Gently but firmly restrain the baby s arms 13 Hold the baby s head straight 14 You may choose to hold an oxygen mask over the baby s mouth while you are inserting and securing the tube 15 Gently but firmly insert the tube through one nostril pointing the tube vertically downwards rather than up the nose leaving 3cms of tube outside the nose If there is bleeding or resistance to insertion try the opposite nostril Don t force a tube as this will only provoke bleeding If trying the other nostril does not succeed try the next smallest ETT size Ifthe smallest tube does not seem to fit you can first insert a nasogastric tube with the end cut off size 6 then passing the ETT over the top of the NGT Securing the tube 16 Tie a piece of string firmly around the tube with a double knot The tie should be on the tube at the level where it exits the nostril to indicate depth of insertion 17 If a skin protectant is available then place this on the baby s cheeks before securing the tube with plaster 18 One person should hold each end of the string firmly across each cheek while the other applies the tapes 19 Secure the tube with tapes as shown in the diagram When attaching the tapes be careful NOT to tape so the tube is pressing against the side of the nostril as this may provoke skin damage 20 The tube is ready to connect 12 5 Diagrams of 2 methods of taping tube insert Single tape T piece across nasal b
17. 10 Counsel the parents see separate sheet Attach continuous oxygen saturation monitoring if available Record baseline observations on patient monitoring form a Vital signs PR RR temperature oxygen saturation Respiratory effort retractions grunting flaring Peripheral perfusion BP warmth colour Abdominal distension General condition agitation restlessness alertness Check resuscitation equipment bag mask and suction is available and ready for use next to the baby s bed Ensure adequate oxygen supplies for both the ambu bag and CPAP machine Prepare the nasal catheter See separate protocol as well as a 2 SPARE catheters tapes and ties to have ready at the bedside in case of obstruction Elevate the head of the bed 30 If the bed doesn t move place a pillow or equivalent under the mattress to achieve a similar effect Gently suction the baby s mouth then each nostril with an catheter Insert the patient interface into the baby s nose See separate protocol Connect the CPAP circuit to the patient interface Note the CPAP unit must be turned on all components checked and the settings set before you attach to the baby Observe the water in the expiratory bottle it should bubble as the baby breathes out If there is very little or no bubbling disconnect the circuit from the baby and occlude the circuit a If bubbling returns there is a baby problem apnoea or a leak i Check f
18. 96 If everything is in order then cautiously increase the Observations should be recorded on the patient monitoring form p 120 CPAP support 1 Oxygen FiO2 can be increased in increments of 5 If FiO2 of 60 or more is required to maintain SpO2 the baby has severe hypoxia 2 Pressure can be increased in increments to a maximum of 8cms 3 Increasing flow in increments of 1L min may improve ventilation Neither increasing pressure or flow should be done if the baby may have hyperinflation After making alterations to the settings 1 Obtain a portable CXR if possible 2 Continue to observe until stable see patient monitoring below 3 Ensure all measures are being taken to calm the baby and make the baby comfortable p 78 20 In bigger and or older infants higher pressures may be considered up to 10cms however the baby will need careful monitoring both clinically and by CXR for signs of hyperinflation 70 CPAP and the Baby with Difficult Breathing The frequency of patient monitoring depends upon the patient s condition and should be specified by the doctor Ideally vital signs should be CONTINUOUSLY monitored However in reality continuous electronic patient monitoring may not be available If this case every attempt should be made to monitor vital signs hourly at least during the first 6 12 hours and during periods of instability Alterations in patient observations will alert the staff to the p
19. CPAP and the Baby with Difficult Breathing 4 WHEN CAN CPAP BE USED CPAP is used to treat babies with APNOEA and babies with respiratory distress 4 1 CPAP for apnoea 1 CPAP is a proven treatment for apnoea of prematurity 21 However it is recommended to use CPAP only after a trial of stimulant medication caffeine or theophylline has failed 22 When CPAP is used for apnoea only minimal pressures are needed unless there is accompanying lung disease Oxygen may not be needed at all as the primary problem is immature respiratory drive 2 CPAP may benefit babies who have apnoea due to rare obstructive causes such as reduced airways tone e g laryngotracheomalacia because CPAP increases the diameter of the upper airway 3 CPAP may have some benefit in apnoea due to respiratory fatigue However in these babies CPAP is primarily working to alleviate the respiratory distress and the primary cause of the respiratory distress must also be addressed see below 4 apnoea is severe or recurrent CPAP is unlikely to be effective The baby will require intubation ventilation and treatment of the underlying cause This is often the case in babies who have brain injury e g hypoxic injury haemorrhage meningitis or severe systemic illness such as sepsis See relative contraindications on p 49 4 2 CPAP for Respiratory Distress 1 Respiratory distress is the most common indication for CPAP There are many causes of respir
20. CPAP in the developed world has improved the outcomes of neonatal respiratory distress It has the potential to do the same in low resource contexts providing that due attention is given to the issues that have been highlighted here For hospitals that are considering procuring ventilators for neonatal care first mastering CPAP is excellent preparation before moving to more complex technologies and all of their associated requirements 101 Minimal equipment list for CPAP Basic resuscitation supplies for neonates Ambubags 250 750mls reservoir Face masks neonatal sizes 1 Oxygen tubing Suction catheters sizes 6 8 10 12F Suction wall or portable electronic manual foot operated Oxygen supplies Oxygen source wall oxygen cylinders concentrators Medical oxygen regulators Face masks neonatal size Oxygen hoods Nasal prongs 1mm 2mm internal diameters Saturation monitor with neonatal probes Oxygen analyser optional CPAP CPAP machine 2 EMW CPAP wash bath Interfaces ETT prongs Cleaning solution Bayclin Presept other equivalent Strings tapes for securing tubes Caps tapes if using prongs 93 Support equipment 94 Transilluminator Portable CXR Infection prevention supplies Heating devices radiant warmer Stethoscopes Pneumothorax kit butterfly needle syringe 3 way tap sterile dressing pack Intercostal catheters Underwater drains Fe
21. Care by their parents as soon as they are stable enough FiO2 lt 4096 few apnoea or bradycardia only mild retractions A nurse needs to be present to help move the baby and needs to frequently monitor the baby and help the parent 107 12 1 108 3 Stopping CPAP Indications to stop CPAP Baby stable on 5cm PEEP with normal respiratory rate and minimal or no retractions maintains oxygen saturations of gt 90 in room air and minimal or no apnoea or bradycardia Procedure a Wait until it has been 4 hours since the last OG feed b Ensure the spare cut and tied tube is ready at the bedside if the baby fails c Ensure suction oxygen and ambubag mask are at the bedside and working correctly d Aspirate the stomach and discard any return e Suction mouth and nose well prior to and following removal of the nasal tube f Administer oxygen by nasal prongs or mask g Continue close monitoring of infant s respiratory status with assessment of vital signs work of breathing and oxygen saturations h Do not remove the CPAP circuit from beside the baby s bed until the baby has been stable for at least 4 hours i Hold feeds until the baby has been stable for at least 2 hours off CPAP CPAP and the Baby with Difficult Breathing 12 4 The patient interface preparation insertion and fixation of a cut ETT Preparing the tube for insertion 1 Select the correctly sized ETT the right size is the largest diamete
22. General aspects of each including definitions classification causes and management strategies are addressed The manual is specifically written to accompany the acquisition of the EMW CPAP machine It is not meant to be a comprehensive textbook on neonatal respiratory problems and their management the reader is referred to standard textbooks of neonatology for further details 12 CPAP and the Baby with Difficult Breathing 1 APNOEA 11 Whatis apnoea Apnoea is an abnormally long pause or complete cessation of breathing The precise technical definition of apnoea is A pause in breathing of greater than 20 seconds or a pause in breathing of less than 20 seconds that is associated with bradycardia lt 100 beats min and or cyanosis 1 It is necessary to define an abnormally long pause 20 seconds because it is normal for some babies especially preterms to have intermittent pauses in their breathing This is called periodic breathing In periodic breathing pauses last only 5 10 seconds and are not associated with either bradycardia or cyanosis Periodic breathing is not pathological and does not require treatment Babies who have periodic breathing grow out of it with time 1 2 What causes apnoea There are 3 main causes of apnoea Apnoea due to prematurity Apnoea due to underlying disease Apnoea due to airways obstruction Apnoea of prematurity Apnoea is common in preterm babies The more preterm a ba
23. OR 2 Choose to intubate ventilate from the outset babies who have particularly severe RDS e g severe RDS and FiO2 gt 70 who are unlikely to respond to CPAP The decision will depend upon various factors including staff skills staff numbers and patient load When blood gas analysis is available pCO2 and pH may also be used to guide the decision of when to choose ventilation e g unable to maintain paO2 gt 50mmHg and or paCO2 gt 60mmHg 13 23 CXR If CXR is available this may assist in confirming the cause of the RDS and the severity of HMD CXR is not needed prior to starting CPAP unless there is strong clinical suspicion of congenital diaphragmatic hernia tracheo oesophageal fistula or pneumothorax 19 Generally this would include babies 28 30 weeks of gestation 68 CPAP and the Baby with Difficult Breathing 9 2 How to start CPAP CHECKLIST FOR STARTING CPAP Get the CPAP machine and check it is ready for use 96 Turn it on and dial the machine settings you want to use Prepare the tube prongs 109 Prepare the baby 103 Insert the tube prongs and attach the baby to the CPAP m Remain with the baby and observe the baby s response to CPAP m Adjust the settings if needed 104 If possible get a portable CXR and do an ABG A CXR is useful to confirm the underlying cause of the RDS however availability will determine use ABG is only recommended if ventilation is al
24. Wo1qefe sou uolsua sip pue 19nJ1Sqo 10 os eqni 991 oiu jueujeoe dsip qg DO esn Jo eqni ON ueB xo eui Aue uey U9 SUOO 1981 lea eouejsip eui eqni uiesu LON 48 esf JOU jeuonippe jou e ie SuoneJoes eseu e qissoduu x g 15281 ye sBuoud uee 2 Jo 10 e seu qeq esn pe4eisiunupe ueB xo eoe ueB xo eui 1s luM pee UD ejqejs ueuAM 16 s Aqeq A eunoes Ayoyes eoue eq 1Seg se sBunjes ul BuiwiB 104 MOT P99N joe4109 16 0 wazad POUJOW 16 O J 1ue1suoo sBuo4d pezis 1991109 esf JOU jews jesen Big sBuoud 2218 4991109 Buueisiurupe jo 7 9192 may very unwell born with congenita
25. assisted and regularly encouraged to express her breast milk 5 Care of the nose and suction a C When doing patient observations check for pressure areas on the nostril and check position of prongs tube If there is any redness remove the tapes and ensure there is no tension on the tube Gently but securely retape Change the tube to the other nostril if the redness persists after you remove the tapes If using prongs check the size and position are correct before reinserting Apply antibiotic ointment to the affected area tid Suction the nose if audible or visible secretions are present or if the baby shows signs of deterioration Suction the mouth at the same time Record the suction on the monitoring form Report any bleeding from the nose to the doctor 6 Care of the nasal ETT prongs and suction 106 a There is no need for routine suctioning too much or too vigorous suctioning may cause bradycardia and desaturation and may provoke secretion production Suction only if i There are obvious secretions ii There are signs of possible obstruction desaturation increased work of breathing less bubbling apnoea When a suction is done record it on the patient monitoring form Retape the nasal tube remove old tapes and replace with new ones or change the tube if tapes become loose due to secretions or poor taping technique Always be careful to remove the tapes gently when doing this soak the tape first with a
26. cause serious deterioration in a baby s condition 5 Oxygen should not be disrupted for feeds If anything babies require more oxygen during feeding because the work of breathing is increased by the effort of sucking 32 CPAP and the Baby with Difficult Breathing Therefore babies who are breastfeeding will need either prong catheter oxygen Most babies on oxygen are fed by nasogastric tube For babies on low flow oxygen nasal catheters or prongs there should always be a mask close by eg hung on oxygen cylinder so in case of sudden deterioration a higher concentration of oxygen can be administered quickly When commencing oxygen therapy Ensure equipment set up is correct Ensure the oxygen source is working check it is flowing by feeling for flow out the end of the tubing Ensure baby s airway is patent need to suction nose and mouth Insert or attach device Start at the minimum of the recommended flow table 5 p 31 Continue to increase concentration increase flow to maximum possible with the particular device table 5 until cyanosis is resolved baby is pink and or the saturations are in the target range IF unable to obtain normal saturations on maximum flow consider changing to a device which can administer higher concentrations see table 5 OR consider if CPAP is indicated If saturations are normal however respiratory distress is severe consider CPAP Making changes to oxygen therapy Only m
27. determined by the medical reason for the ie by the underlying disease In practise all babies with RDS on CPAP should be treated with antibiotics Ampicillin and Gentamicin at least until infection can be ruled out This is because it is difficult to exclude pneumonia as the cause of RDS and in low resource contexts microbiology may not be readily available or of reliable quality Nystatin should be used if the babies are on antibiotics Babies with apnoea should be treated with IV aminophylline or caffeine depending on availability p 18 Paracetamol may be used for fever or pain see below See Managing Newborn Problems WHO 2003 or The Pocket Book of Hospital Care for Children WHO 2005 for standard neonatal drug doses Sedative drugs should NOT be used for babies on CPAP because sedatives may depress respiratory drive Feeding fluids Babies on CPAP should be fed providing it is medically safe to do so see below Feeds should be given 2 3hrly via orogastric tube depending on the baby s size Refer to Managing Newborn Problems WHO 2008 for recommended feeding regimes for sick neonates Providing feeds in the recommended regimen will also help prevent hypoglycaemia which can cause apnoea and deterioration in a baby s condition If the baby does not tolerate the OGT keeps trying to expel it with his tongue then a nasogastric tube can be used OGTs are preferred because babies are obligate nose breathers they
28. in the mouth and below the nose with the nasal tube in situ 4 Kangaroo Mother Care KMC can be used provided the baby is stable and the oxygen requirement is not very high e g lt 4096 KMC will also assist in maintaining breast milk supply and may make the parents feel more involved in their baby s care Care of the nose Care of the nose is a very important part of nursing care on CPAP because the nostril may be damaged by pressure from the nasal tube or prongs This is most likely when a tube is tied incorrectly or is changed infrequently It may also occur if prongs of incorrect size are used i e too large or if they are badly positioned Pressure from the tube prongs can cause inflammation and may result in skin breakdown Bacteria may enter through damaged nasal skin and may result in local or systemic sepsis Skin damage may result in permanent nasal deformity Figure 12 Nasal erosions caused by CPAP patient interfaces Accessed on line fn bmj com Original in Fischer C Bertelle V Hohlfeld J Forcada Guexl M Stadelmann Diawl C Tolsal J Nasal trauma due to continuous positive airway pressure in neonates Arch Dis Child Fetal Neonatal Ed doi 10 1136 adc 2009 179416 Good nursing care can prevent this complication Care must be taken to ensure the tube is tied and changed according to protocol p 104 that the correct sized prongs are used and that prongs are positioned correctly p 109 If any redness is seen on the
29. increase if suspect hyperinflation g Urgent CXR if possible Scenario 2 Nurse is caring for a 1 5kg baby 32 weeks gestation who is on CPAP The baby is 2 days old and was started on CPAP on day 1 of life for RDS He is doing well on CPAP on a pressure of 5 cms 2 45 The settings have been stable since was started on CPAP his SpO2 has been kept between 88 and 93 on these settings Suddenly half an hour after his observations had been stable the baby desturates to 7596 He appears agitated and has increased recessions respiratory rate and pulse rate Maria quickly checks the circuit and machine and all connections are intact and the settings flows pressure are as ordered There is still bubbling in the expiratory bottle Auscultation of the chest is equal on both sides 142 CPAP and the Baby with Difficult Breathing 1 What could be the problem The likely problem is either a blocked tube or an acute deterioration in lung disease such as a pneumothorax or aspiration 2 What should Nurse Maria do First she should increase the oxygen by 1096 Then she should exclude a blocked tube To do this she should suction the tube if the catheter does not easily pass to the full length of the tube then she should quickly remove and replace the tube with a new one If the suction catheter does easily pass through the tube but the baby remains desaturated then the baby may have a pneumothorax or an acute aspiration The
30. increasingly used as first line respiratory support for babies with respiratory distress How and when to use CPAP is discussed in detail in the second part of this manual 28 CPAP and the Baby with Difficult Breathing 2 5 Giving Oxygen When to give oxygen Oxygen should be given to all babies with hypoxia as determined by SpO2 monitoring box Where oximetry is not available clinical signs must be used as a proxy for hypoxia Babies with cyanosis and or moderate severe respiratory distress RR gt 70 severe retractions head nodding grunting or inability to feed as well as babies with depressed level of consciousness should be given oxygen 9 m n very preterm babies X32 weeks or lt 1 5kg give oxygen if 5 02 lt 85 m In term babies with specific conditions including sepsis asphyxia meconium aspiration or pulmonary hypertension oxygen should be given when SpO2 lt 95 9 10 m Inall other babies Oxygen should be given when SpO2 lt 90 How to give oxygen Devices for administration There are several ways that free flow oxygen can be administered Nasal Prongs also called nasal cannulae Single nasal catheter Face mask Head box Incubator free flow into incubator Bag mask ventilation Babies who have inadequate breathing hypoventilation gasping or apnoea as well as hypoxia need to have bag mask support to breathing with oxygen Other methods of oxygen administration are unsuitab
31. kg dose od term 274 47 wks 7 5mg kg dose od Cloxacillin flucloxacillin 25 50mg kg dose bd 1 wk or tid 2 4 4 wks 25 50mg kg daily 1 wk bd 2 wks 25 50mg kg bd preterm 1 wk tid qid 2 4wks Of these 2 cefotaxime is preferred in neonates as ceftriaxone may exacerbate jaundice 3 Abdominal decompression An oro or nasogastric tube should be inserted and left open on free drainage This prevents gastric distension which will further compromise respiration 4 Suggestions of staphylococcal disease include associated pustular skin lesions bullae or effusions on CXR 26 CPAP and the Baby with Difficult Breathing 4 Thermal control Both hyperthermia and hypothermia can worsen a baby s respiratory status and may cause apnoea Temperature monitoring and keeping the baby s temperature in the normal range reduces metabolic demands which in turn minimises oxygen requirement and keeps the baby more stable See the manual on the EMW radiant warmer 5 IV Fluids Most babies with respiratory distress should receive IV fluids until their respiratory status is stable improving and they can be safely fed It is normal to use IV fluids and withold feeds in babies with respiratory rates gt 70 minute and or other signs of significant respiratory distress A guide to IV fluid volumes which depend on weight and age can be found in Managing Newborn Problems WHO 2003 In respiratory distress high volumes of IV fluids s
32. mouth e g Pierre Robin syndrome down to the lower airways eg tracheo bronchomalacia are prone to apnoea due to narrowing and or collapse of airway passages particularly during sleep 13 Whyis apnoea a problem If apnoea is prolonged and not treated it will cause hypoxia and bradycardia If unrelieved apnoea can be fatal 1 Babies who still require oxygen to maintain saturations in normal range at 36 weeks corrected gestation 14 CPAP and the Baby with Difficult Breathing Table 2 List of underlying diseases which may cause apnoea UNDERLYING DISEASE Hypoxia Hypothermia Sepsis Shock Severe anaemia Systemic condition Polycythaemia Cardiac failure Cardiac Patent ductus arteriosus Hypoglycaemia Electrolyte disturbance Na Ca etc Rare congenital diseases Metabolic problem Asphyxia Meningitis ae Haemorrhage Brain disease 3 Seizures Congenital malformation Drugs causing CNS depression diazepam morphine Any cause of respiratory distress resulting in FATIGUE eg pneumonia HMD Bronchiolitis RSV infection Pertussis infection Lung disease Severe gastro oesophageal reflux Gastro intestinal Aspiration Necrotising enterocolitis Choanal atresia Micrognathia Airways obstruction Macroglossia Tracheomalacia Apnoea in premature babies must never be assumed to be due to prematurity Other pathologic causes must be excluded before attributing apnoea to prematuri
33. of air and of oxygen will be provided 15 In this situation 10096 oxygen will still be supplied because the oxygen supply is not reliant on electricity 53 On the front of the blender there is a table which tells the user what concentration of oxygen FiO2 is being delivered when differing combinations of flows of oxygen and air are set The proportion of oxygen vs air in the mixed gas determines the FiO2 The user selects both the oxygen concentration and the flow rate he wishes to use eg 3L oxygen and 3L air provides FiO2 of 61 5L oxygen and 1L air provides FiO2 of 87 etc There are exercises on this later in the manual p 121 54 CPAP and the Baby with Difficult Breathing Air 21 L min TEE Bran Bonam a 57 54 5 87 77 6 89 80 7 90 82 The gases are mixed blended and leave the common gas outlet a thin clear plastic tube on the back side of the blender The common gas outlet takes the gas into the inspiratory bottle Oxygen flow 100 O L min 2 lt x gt o o 2 x o Oxygen IN Common gas flow outlet Mixed gas OUT Figure 8 back of the blender Inspiratory heating bottle The inspiratory bottle is the bottle which sits in the posterior ring of the metal hanger on the left side of the CPAP device The metal plates surrounding
34. of lung volume AND the baby is stable then try to manage conservatively and follow progress with a repeat CXR Reduce the CPAP pressure slowly towards bcm and maintain FiO2 as high as needed to keep SpO2 in required range In term babies 10096 oxygen may facilitate resolution of the pneumothorax in preterm babies do not use more oxygen than is required to keep the saturations in the normal range Take off CPAP as soon as baby meets criteria to do so Figure 15 CXR showing large right sided pneumonthorax in an intubated baby http img medscape com pi emed ckb pediatrics cardiac 973235 976801 815 jpg Draining a pneumothorax with butterfly needle Needle aspiration is best reserved only for emergencies when the baby s clinical condition does not allow you to wait for a portable CXR and placement of a proper ICC If the doctor is very experienced and can quickly and competently place an ICC even without a CXR this is the preferred option It is also acceptable to use this technique if the operator doesn t have the skills and or resources to place an ICC however the procedure carries a risk of CAUSING a pneumothorax Equipment Butterfly needle 23 25G 10 20cc syringe way stop cock Sterile gloves Sterile dressing pack cotton wool swabs antiseptic solution 70 alcohol can be used Preparation Monitoring vital signs ideally use continuous oximetry Support oxygenation and ventilation as needed Counse
35. oxygen may be increased further to try and improve saturations The doctor should be urgently called The baby will need to be transilluminated to check for pneumothorax the pressure may need to be increased and a CXR should be urgently ordered if possible Scenario 3 Nurse Jo is caring for baby Carlos a 1 3kg baby of 30 weeks gestation He has been on CPAP for 5 days since he was 8 hours of age when he developed significant RDS probably due to HMD At his sickest he needed CPAP 7cms and 70 oxygen He is now on 25 oxygen and pressure of bcm is stable tolerating his milk feeds by and does not have any apnoea episodes He is on aminophylline iv 1 What is the appropriate management regarding the CPAP at this stage The baby is ready for a trial off CPAP 2 What steps do you need to do Hold the feeds Explain that you will try the baby off CPAP to the parents and what this will involve Ensure you have prepared resuscitation equipment and a spare pre cut tube and tapes next to the bed in case the baby fails trial off Prepare an oxygen mask or nasal prongs or headbox to use immediately after taking off the CPAP After 2 hours off feeds suction the tube the other nostril and the mouth You are ready to trial the baby off Scenario 4 Nurse Anna is doing her routine observations of a baby 1 9kg on CPAP who had RDS from probable neonatal pneumonia She does her checks on the baby and doesnt find any problem however when
36. prevention ensuring SpO2 is in required range calling a doctor if suspected deterioration 140 CPAP and the Baby with Difficult Breathing 20 3 CASE SCENARIOS FOR CPAP TRAINING WITH ANSWERS m Baby who is deteriorating m Baby with a possible blocked tube m The baby who is improving There is no bubbling in the expiratory bottle Scenario 1 Baby 1 is 1 7 kg and was born at 31 weeks gestation He was started on CPAP at 12 hours of age because Dr John thought he had RDS of prematurity hyaline membrane disease He had not had any apnoea but had difficult breathing even when he was on face mask oxygen at 6L minute He was started on 5cm CPAP and 30 FiO2 The nurse looking after him had to increase the FiO2 to 40 in the first hour after CPAP started to get the baby s SpO2 to 95 was stable for the rest of the day He began minimum volume feeds of EBM by at 24 hours of age On day 3 it is noted that he has been deteriorating for several hours His work of breathing has increased a lot his respiratory rate and pulse rates have increased significantly his oxygen requirement has increased from 40 to 65 over the preceding 6 hours His perfusion is not very good and he has had several apnoeas all responding to stimulation He is less active 1 List possible reasons for his deterioration If a baby deteriorates after having been stable or improving on CPAP it may be due to a machine circuit problem
37. rate 132 CPAP and the Baby with Difficult Breathing Flow rate of 100 mL min Weight kg 1 25 1 5 1 75 20 oss oss Respiratory rate Flow rate of 150 mL min Weight kg 1 25 1 5 1 75 2 2 5 20 100 093 0 83 0 78 0 69 0 62 40 Respiratory rate 133 Flow rate of 200 mL min Weight kg 1 25 1 5 1 75 2 2 5 3 3 5 20 100 100 100 093 0 78 069 0 62 0 98 0 85 076 0 69 078 0 69 0 62 40 Respiratory rate Flow rate of 250 mL min Weight kg 1 25 1 5 134 CPAP and the Baby with Difficult Breathing Respiratory rate Flow rate of 300 mL min Weight kg 1 25 1 5 gt c Q N a Flow rate of 400 mL min Weight kg 1 25 1 5 Respiratory rate Flow rate of 600 mL min 135 Weight kg 1 25 1 5 Respiratory rate Flow rate of 800 mL min 800 Weight kg 1 25 1 5 Respiratory rate Flow rate of 1000 mL min Weight kg 1 25 1 5 136 CPAP and the Baby with Difficult Breathing c gt Q N a 1 Hyaline membrane dise
38. results in distal collapse and areas of hyperinflated lung Babies with MAS have respiratory distress their chest may appear barrel shaped due to the hyperinflated lung They may have severe hypoxia which may be worsened by secondary pulmonary hypertension They may also have central nervous system asphyxia mild to profound depending upon the severity of asphyxia Severe asphyxia may cause hypoventilation gasping or apneoa at birth and later seizures hypotonia and or unresponsiveness This may of course result in permanent neurological deficit Management of MAS remains a challenge even in countries with no resource limitations There is little that can be done for the central nervous system asphyxia and the management of the respiratory distress is difficult because of the frequent occurrence of pulmonary hypertension and air leak syndromes Good obstetric care is critical to minimise asphyxia and to reduce incidence and severity of asphyxia Delivery room management includes direct visualisation and suction through the cords using endotracheal tube meconium aspirator or other suction device in babies who have respiratory depression at birth Subsequent management of MAS includes surfactant lavage inhaled nitric oxide and a variety of ventilatory strategies including high frequency oscillation CPAP may be useful in milder cases Transient Tachypnoea of the Newborn TTN TTN is also a condition largely of term babies It present
39. she checks the CPAP machine she notices there is no bubbling in the expiratory bottle 1 Is this a problem If yes why is it a problem Yes this is a problem It is a problem because no bubbling means that the CPAP is not working 143 2 What could be the reasons It could be a problem with the baby or a problem with the machine circuit Problems with the baby could be a a leak around the interface or out the mouth or b apnoea Problems with the machine could be a a disconnection or leak somewhere in the circuit b no gas flow due to power failure disconnection or running out of oxygen c a kink in the tubing 3 What should she do to try and fix the problem Firstly she needs to try and determine whether it is a baby problem or a machine circuit problem She should check if the baby is breathing or if there is apnoea If there is apnoea the baby should be stimulated and the oxygen increased If the baby does not immediately begin to breathe she should be disconnected from the CPAP and the nurse should bag mask the baby and call the doctor If there was no apnoea the baby should be disconnected from the circuit and the nurse should occlude the end of the circuit with her hand If bubbling returns then there is a problem of leaking at the baby s nose mouth Reconnect the baby Check the interface is correctly inserted Gently extend the baby s neck Try closing the mouth by hand or with a dummy or with a gauze chin strap See
40. the baby s nose Inside the inspiratory arm there is a thick black wire The wire is a heating element that is plugged into the back panel of the control unit The temperature of the wire is determined by the set temp knob on the front of the control box There is a sensor at the end of the wire close to the baby s nose The sensor measures the temperature of the gas at this point and transmits this information back to the CPAP control box The measured temperature is displayed on the lower LCD screen on the front of the control unit When the measured temperature reaches the set temperature the CPAP automatically reduces the heating to the wire If the temperature at the sensor is too high the CPAP will alarm and will automatically reduce the set temp see below alarms section This mechanism helps protect the baby from exposure to overheated gases and reduces condensation of water in the tubing Patient interface This is not part of the CPAP device It is a separate unit and is discussed below It transmits the gas from the inspiratory arm of the circuit INTO the baby s airway and transmits the gases that the baby breathes OUT back into the expiratory arm of the circuit It is described in the next section Expiratory pressure bottle The expiratory bottle sits on the most anterior of the 2 metal rings on the bottle holder the ring without any heating plates The expiratory bottle is differentiated from the inspiratory bottle by the ce
41. very closely for apnoea If respiratory rate drops below 20 minute if the hypoventilation is associated with hypoxia or if there are gasping breaths then support with bag and mask and oxygen It is very likely CPAP or ventilation if available will be required Ongoing management Supportive care Elements of supportive care are very important in care of the baby with respiratory distress Paying careful attention to supportive care increases the effectivess of CPAP and other specific therapies 1 Oxygen Giving oxygen directly increases blood oxygen levels It further increases blood oxygen because it increases blood flow to the lungs by decreasing pulmonary vascular resistance Oxygen should be given and continued to keep SpO2 in the desired range above 2 Antibiotics Antibiotics should be given to cover possible infection Begin with Ampicillin Benzyl Penicillin Gentamicin In very severe cases or in babies who may have staphylococcal disease it is better to use Cloxacillin Gentamicin or Ceftriaxone Cefotaxime Antibiotics should be continued until infection can be excluded on clinical grounds there is another clear explanation for the respiratory distress or after investigations exclude infection normal wbc negative cultures Ampicillin 50mg kg iv bd 1 wk or qid 275 4 wks BenzylPenicillin 60mg kg dose bd 1 wk or qid 2 4 4 wks lt 30wk 2 5mg kg dose od ud 30 35wk 3 5mg kg dose od term 1st wk 5mg
42. 0mg 25mL 2mg caffeine base infuse over Oral 10mg ml IV 50mg 5ml ORAL give with feeds 19 Care whilst on medication Babies being treated with aminophylline should have serum levels monitored in order to titrate the dose and avoid side effects Side effects include tachycardia jitteriness irritability feed intolerance vomiting and hyperglycaemia If given too quickly serious cardiac arrhythmias may occur Unfortunately serum aminophylline levels are rarely available in low resource contexts Instead clinicians must observe closely for the presence of side effects especially tachycardia which would suggest possible toxicity and may warrant a reduction in dose In order to avoid medication errors and to reduce the risk of infection associated with IV medication administration stimulant medications should be given orally as soon as it is safe to do so This usually means when the baby is stable on full oral feeds Stopping medications Medications for apnoea either aminophylline or caffeine can be stopped when the baby has reached a gestational age of 34 weeks and when the baby has had no apnoea for at least one week Ideally babies should continue to be monitored with electronic monitoring for one week after stopping medication As this is not a reality in low resource contexts parents should be taught the signs of apnoea or cyanosis and should know how to stimulate the baby and to call for help Babies sho
43. 6 hours His perfusion is not very good and he has had several apnoeas all responding to stimulation He is less active 1 List possible reasons for his deterioration 2 List a series of actions that are needed to help work out the actual reason for his deterioration Scenario 2 Nurse Maria is caring for a 1 5kg baby 32 weeks gestation who is on CPAP The baby is 2 days old and was started on CPAP on day 1 of life for RDS He is doing well on CPAP on a pressure of 5cms FiO2 45 The settings have been stable since he was started on his SpO2 has been kept between 88 and 93 on these settings Suddenly half an hour after his observations had been stable the baby desturates to 75 He appears agitated and has increased recessions respiratory rate and pulse rate Maria quickly checks the circuit and machine and all connections are intact and the settings flows pressure are as ordered There is still bubbling in the expiratory bottle Auscultation of the chest is equal 122 CPAP and the Baby with Difficult Breathing 123 on both sides 1 What could be the problem 2 What should Nurse Maria do Scenario 3 Nurse Jo is caring for baby Carlos a 1 3kg baby of 30 weeks gestation He has been on CPAP for 5 days since he was 8 hours of age when he developed significant RDS probably due to HMD At his sickest he needed CPAP 7cms and 7096 oxygen He is now on 25 oxygen and pressure of bcm He is stable tolerating his mil
44. C This may be due to excess external heat eg from a radiant warmer or due to machine malfunction No gas flow detected Monitoring frequency Disconnect the baby from the CPAP and occlude the circuit with your palm If bubbling returns then the problem is with the baby apnoea or mouth leak If there is still no bubbling it is a machine problem Check the gas flow is ON Tighten the bottle lids and check the circuit connections Ensure the tube set is connected properly to the CPAP unit Try changing the heater wire If this doesnt fix it change machines and call BME Disconnect the patient provide CPAP with bag mask if needed or swap to another CPAP unit and circuit Turn off the CPAP for 10 minutes and check if the sensor cools down hold under a fan or AC if available If the sensor cools reconnect the baby and try to use the CPAP again Observe carefully If the problem recurs change to another machine and report the problem to BME Check gas is on Check for leaks in the circuit air compressor oxygen supply common gas tubing Fix any disconnections or kinks in circuit If problem continues change machine and inform BME The main objective of regular patient monitoring is to detect and respond to problems early so to prevent more serious Complications from occurring In low resource contexts human resources may be insufficient relative to the number of sick babies The ideal frequency of moni
45. CC Equipment Sterile drapes Dressing pack Cotton swabs Antiseptic solution e g 70 alcohol Sterile gloves Sterile gown ICC size 25 Small curved artery forceps mosquito type artery forceps longer straight Scalpel blade Lignocaine 1 Drawing up needle 21G 25G needle 2cc syringe Heimlich valve or underwater drain system Sterile water drain tubing with tunnel connector including adaptors functioning suction Silk or nylon suture 2 0 3 0 or 4 0 with needle needle holder dressings clear plastic tape 25 IF an ICC is unavailable it is possible though not ideal to use a 12 or 14G intravenous catheter and to tape it securely in situ Attach to a 3 way tap and syringe Insert as per butterfly needle technique Leave in situ and aspirate regularly Beware the catheter falling out or kinking because it is much softer than an ICC 117 Preparation Monitoring vital signs ideally use continuous oximetry Support oxygenation and ventilation as needed Use local anaesthetic cream patch on the skin if available Administer rectal paracetamol Counsel the parents Open and set up the underwater drain if using this and tubing leaving the cap on the end of the tubing Fill the drain with water and marked Open the dressing pack and open the ICC instruments including scalpel needles and syringes and Heimlich valve if using this
46. Good trace pulse matches patient 9 sse 35 Back of the blender M 55 the iai Eon ko dial 61 eue 61 A typical oxygen concentrator aA Ald 63 Nasal erosions caused by CPAP patient interfaces 79 Prone nursing C M 81 Secretions around the end of a cut ETT it is easy to see how they may cause complete obstruction sss tette 86 CXR showing large right sided pneumonthorax in an intubated baby 115 Draining pneumonthorax with a butterfly 117 Heimlich valve ice eco nbn a ea ient 119 Correct placement and taping of an intercostal catheter 119 Relationship between gestational age and incidence of recurrent apnoea 13 Causes of neonatal 15 Dosing regimens for 6 and Caffeine 7 19 Causes of respiratory distress in neonates sse 24 Different oxygen concentrations that are delivered at the specified flow tates toa 5kg 31 SourceS Of ONY SIT sisira 32 Different methods of administering oxyge
47. RACTERISTICS OF CPAP THAT MAKE IT SUITED FOR USE IN LOW RESOURCE CONTEXTS CPAP is a simpler technology than IPPV so less training and supervision is required to 10 Barotrauma refers to the lung damage that is caused in IPPV due to the positive pressure inflations 44 CPAP and the Baby with Difficult Breathing 45 achieve competency in its use The simpler technology also means CPAP is cheaper and is easier to repair than ventilators CPAP is also safer to use than IPPV The baby does NOT need to be intubated so neither the skills to intubate nor to manage an intubated baby are required by the user Although CPAP can be administered to an intubated baby it is not recommended see p 65 In addition with CPAP there is no risk of ventilator associated pneumonia These characteristics make CPAP particularly well suited to low resource contexts where even when modern ventilators are provided by well intentioned donors the machines often fail to be used to potential due to biomedical issues or lack of staff skilled in their use CPAP has greater potential than IPPV for safe and successful use in these situations Table 9 Important differences between IPPV and CPAP IPPV CPAP Intermittent positive pressure Constant positive pressure No breathing through a straw Less safe Safety Risk of ventilator associated pneumonia Need Yes intubation 11 This should not downplay the importance of close patient monitoring 46
48. ablished respiratory distress The management of respiratory distress includes the following steps 1 Emergency management 2 Ongoing management a supportive care b specific therapies Emergency management 1 Correcting hypoxia Ifa saturation monitor is available all babies with respiratory distress should have their oxygen saturation SpO2 checked and oxygen should be given to try and return SpO2 to normal i Very preterm babies lt 32 weeks or lt 1 5kg are at risk of eye damage from oxygen treatment This is further explained on p 29 In these babies give oxygen if SpO2 is lt 85 and keep SpO2 85 93 8 ii In term babies who have suspected asphyxia sepsis meconium aspiration or pulmonary hypertension give oxygen if SpO2 lt 95 and keep SpO2 gt 95 9 10 iii In all other babies give oxygen if SpO2 is lt 90 and keep SpO2 90 95 b If SpO2 monitoring is not available and the baby has central cyanosis or severe respiratory distress 270 severe retractions head nodding inability to feed or depressed conscious state oxygen should be given c How to give oxygen is further explained below See GIVING OXYGEN 25 2 Correcting hypoventilation gasping or apnoea baby with respiratroy distress may develop hypoventilation respirations lt 30 per minute gasping or apnoea due to fatigue If apnoea is present this must be immediately managed as above If a baby has hypoventilation observe
49. acerbate apnoea iv Give oxygen if needed to keep SpO2 in safe range p 76 v Maintain temperature in normal range vi Avoid hypoglycaemia Intermittent blood glucose checks if possible Ensure appropriate glucose intake with IV fluids or feeds vii Feed when it is safe to do so Feeds should be witheld if apnoea is frequent or severe and the baby will need IV fluid until he is stable It is safer to feed using og ng tube if apnoea is ongoing the baby is unstable or the baby is on CPAP viii Nurse in prone position or Kangaroo Care unless contraindicated as this will help reduce apnoea of prematurity 3 ix Consider blood transfusion if Hct lt and recurrent apnoea 1 5 Specific management for apnoea Aside from specific treatments for any underlying conditions there are two treatments for apnoea 1 medications 2 respiratory support Medication is the first line treatment for apnoea of prematurity unless the baby has apnoea that is very severe or prolonged For apnoea of other causes CPAP or ventilation is the treatment of first choice 3 For details refer to Managing Newborn Problems WHO 2003 or other relevant text Medications Two medications aminophylline and caffeine are used in the management of apnoea They work by stimulating breathing and diaphragmatic contraction Both medications are effective and safe in the management of apnoea of prematurity 2 They also reduce apnoea after extubation in babies wh
50. achine fails Simple to operate cleaning High cost at initial set up Needs oxygen machine Constant source Needs maintenance Piped oxygen m at site Doesn t need electricity Need flow regulator at each outlet General principles for administering oxygen to neonates 1 Only administer oxygen where there is a genuine indication hypoxia apnoea or severe respiratory distress and stop as soon as oxygen is no longer required 2 Monitor the baby s clinical condition and response to oxygen therapy When the vital signs are checked also check if possible or presence of cyanosis Other signs of difficult breathing 3 Monitor the supply delivery of oxygen Is the baby getting the amount of oxygen that is prescribed flow concentration Is the method of delivering the oxygen being applied used appropriately are the tapes loose is the mask falling off is the baby slipping out of the headbox etc Is the delivery system patent Is the cylinder near empty These things should be checked at the same time as the patient observations The frequency of monitoring will depend upon the severity of the baby s condition and will be ordered by the doctor 4 Do not disconnect the oxygen for cares procedures transfers etc If the baby requires oxygen it must be administered continuously If the baby must be moved eg for X ray arrange for a portable form of oxygen Sudden interruption of oxygen supply could
51. ake SMALL changes to the flow at a time If high flow change by 1L time Jf moderate to low flow change by 0 1 0 5L at a time Always wait to observe the effect of the change for 15 minutes after the change If signs of breathing difficulty increase return after the change the saturations reduce cyanosis returns or other signs of breathing difficulty increase return the oxygen treatment to its earlier quantity After stopping oxygen therapy babies should be observed closely still for at least 24 hours When to reduce oxygen saturations in target range improvement in signs of difficulty breathing When to stop oxygen saturations normal no signs of difficulty breathing A low flow flow meter range of flow 0 2L minute is needed to do this accurately 33 2 6 Do not forget the importance of supportive for babies receiving oxygen p 26 Oximetry Oximetry is the only way to accurately detect hypoxia and the only way to detect hyperoxia Both hypoxia and hyperoxia are dangerous For this reason all facilities offering oxygen therapy should have at least one working oximeter in the neonatal care area When oximetry is available it may be used for continuous or intermittent assessment of oxygen saturation SpO2 Continuous monitoring is preferable because it gives an instant reading and it requires less handling of the baby However this will depend on the number of babies on oxygen treatment and the a
52. amp Sensor Distilled Distilled Water HEATER Water CONTROL UNIT Set PEEP by depth of Set temperature set humidity monitor tube under temperature and heater percentage water Figure 10 CPAP circuit 17 Diagram developed and provided by Mr Bruce Morrison 61 8 2 Oxygen supply An oxygen source is not part of the EMW CPAP device A separate oxygen supply must be provided and connected to the CPAP Oxygen is connected to the CPAP device via the blue hose which enters the back of the blender THERE ARE 3 OPTIONS FOR PROVIDING OXYGEN TO THE CPAP Oxygen from a cylinder Wall outlet oxygen and Oxygen from an oxygen concentrator 4 Oxygen from cylinder Oxygen provided from a cylinder is the most common scenario in low resource countries The oxygen cylinder must be fitted with a medical oxygen regulator The regulator sits between the oxygen cylinder and the CPAP machine The regulator is also known as a reducing valve because it reduces the pressure of the gases inside the cylinder to allow the flow of gas to be controlled 9 When attaching the CPAP to the oxygen cylinder you will need to ensure the end of the CPAP oxygen hose and the regulator connection are compatible If not they won t join and another solution will need to be found Never connect the CPAP to the oxygen cylinder without a regulator When using an oxygen cylinder a spare cylinder must alwa
53. ase is also often referred to as Respiratory distres syndrome however so as to prevent confusion with other causes of respiratory distress in this manual we use only the term HMD to refer to lung disease of prematurity presenting with respiratory distress 2 Developed world settings recommend nurse patient ratios of 1 1 this has been modified to acknowledge the human resource realities of developing nations 137 19 138 2 PRETEST POST TEST WITH ANSWERS List 3 neonatal conditions that can be treated with CPAP apnoea RDS HMD pneumonia aspiration wet lung TTN pulmonary oedema postextubation List 2 conditions where CPAP is unlikely to be useful very severe RDS severe apnoea Severe cardiac instability sepsis How does CPAP help a baby to breathe keeps lungs alveoli from collapsing increases lung volume functional residual capacity stimulates breathing What is the correct SpO2 range for a baby on CPAP Give answers for both preterm and term babies Preterm 88 93 Term 90 95 95 98 if asphyxia meconium aspiration sepsis or pulmonary hypertension Write 3 things on the CPAP machine that you must check regularly while it is in use on the baby oxygen supply circuit connections machine settings set temperature vs temperature reading on control box rain in tubing humidity bubbling water level in bottles Write 3 things on th
54. asing oxygen requirement e g gt 40 or prophylactically for babies at risk of severe disease e g lt 27 30 wks gestation Many units use a strategy called INSURE which is a combination of surfactant and CPAP Babies at risk of severe disease are intubated given surfactant and then quickly extubated to nasopharyngeal CPAP This has been shown to reduce the need for ventilation 28 However economic constraints seriously limit the availability of surfactant in low resource contexts so hospitals must determine their own policies regarding use Surfactant is not discussed further in this manual Bigger babies RDS in bigger babies is rarely due to HMD and the criteria for when to start CPAP for non HMD RDS are less clearly defined Some causes of RDS in bigger babies such as TTN may resolve spontaneously even if oxygen requirements increase beyond 30 In addition bigger babies do not tolerate CPAP as well as smaller babies Therefore a higher oxygen threshold e g requires FiO2 gt 50 is suggested for starting CPAP in these babies Ventilation This manual does not attempt to cover neonatal ventilation however some hospitals that provide CPAP will also have ventilators In these hospitals CPAP criteria will need to be modified to take into account the option of ventilation One of 2 approaches can be used 1 Try CPAP in all cases of RDS using the above criteria Stop CPAP and intubate ventilate only if CPAP fails p 75
55. ason in resource limited contexts it is reasonable to begin stimulant medication in all preterm babies eg 32 weeks or lt 1 5kg to try and prevent apnoea and its consequences The risk of starting the medication side effects medication errors is balanced by the risk of unwitnessed apnoea and its consequences How For maximum effectiveness both aminophylline and caffeine require a loading dose table 3 Regular dosing is then continued twice daily bd for aminophylline or if using caffeine only once a day 18 CPAP and the Baby with Difficult Breathing Table 3 Dosing regimens for Aminophylline and Caffeine Side effect monitoring c o 5 E 5 e Regular dose preparations IV 0 4ml of If available 10mg kg iv 12 hr later Aminophylline Observe for tachycardia prior to administration 250mg 10ml solution 1 wk 2 5mg kg over 60mins diluted in 40 80 mmol L added to 4 6ml normal 250mg 10ml saline gives 2mg ml 2 9 wk 4mg kg dose bd normal saline If HR gt 180 per minute at sample taken mid dose or rest consider witholding the gt 2 wk 5mg kg slow bolus 10mins Can use iv solution orally once on full Not necessary IV dilute 50mg 5mL ampoule with 24 hr later 20mg kg iv o Caffeine citrate 5mg kg od oral or iv 2mg caffeine 20ml water for over 30mins no need to citrate 1 mg injection Solution 5
56. asures Concern that the tube needs to be changed Any concern about the CPAP machine alarm situations In some hospitals nurses may change the nasal tube independently this needs to be a policy decision at local level and will depend upon the skills of nurses the number of nurses and how sick the individual baby IS 75 9 6 Regular patient This section describes the medical and nursing aspects of which are important when a baby is being treated with CPAP For medical issues not covered in detail here refer to Managing Newborn Problems WHO 2003 and other standard textbooks of neonatology Several of the areas addressed here are also formatted into bedside job aides later in this chapter p 95 Oxygen saturations SpO2 Adjusting the pressure during CPAP is a medical responsibility However adjusting the FiO2 is a medical and a nursing responsibility as changes may have to be made often Oxygen saturation monitoring is very important during CPAP especially for preterm babies especially those lt 32 weeks or lt 1250g who are at risk of retinopathy of prematurity ROP ROP is a disease of the retina which is caused by high blood levels of oxygen ROP may cause irreversible eye damage and blindness In developed countries all preterm babies who receive oxygen therapy will be checked by an ophthalmologist who can detect and treat ROP with laser therapy if needed These services may not be available at all in
57. at the bedside and working correctly Aspirate the stomach and discard any aspirate Suction the mouth the free nostril and the tube Explain what you will do to the parents including the possibility that the baby may not cope with coming off the CPAP and may have to be put back on Remove the tube and quickly suction the nose and the mouth again Give oxygen by mask 6L min nasal prongs 2L min or headbox 10L min 90 CPAP and the Baby with Difficult Breathing Place the baby in the prone position if possible only if oxygen saturation monitoring is available and nursing staff to remain with the baby Remain with the baby and observe closely for at least an hour after taking the baby off Watch closely for apnoea increasing work of breathing deterioration of vital signs Monitor SpO2 continually if possible Withhold feeds Neither a CXR nor is essential to trial off CPAP Clinical criteria can be used to guide the trial and to determine whether the baby is able to remain off CPAP or whether the baby needs to return to CPAP for a further period of treatment before trying again If a baby fails a trial off CPAP wait at least another 24 hrs before attempting off again If a baby is stable after 4 hours off CPAP it is unlikely the baby will need to go back on Feeds can be restarted Observations should be done hourly for the first 4 hours off CPAP After that time if the baby is well and has minimal res
58. atory distress in neonates see box below and many babies with these conditions will respond to CPAP In practice CPAP is most beneficial in babies under 35 weeks and the most common indication is hyaline membrane disease HMD 2 Meconium Aspiration Syndrome MAS Special mention is made of MAS as it is a common cause of RDS in low resource contexts where obstetric care is often poor and because MAS may be difficult to treat Although some cases of MAS do well with CPAP there are many other cases where CPAP is not effective This may be because Babies with MAS have been asphyxiated so they may have hypoxic ischaemic brain injury with severe apnoea CPAP is unlikely to be effective in this situation the baby requires intubation ventilation if available MAS may cause localised areas of lung hyperinflation and this may be exacerbated by CPAP particularly if high pressures are used Hyperinflation may cause hypoxia and hypotension and can be difficult to manage 47 3 4 3 48 Babies with MAS may have persistent pulmonary hypertension with severe hypoxia which does not respond well to CPAP These cases are very difficult to manage even in developed countries and treatments such as surfactant lavage nitric oxide inhalation and modern ventilation techniques are used These options are rarely available in low resource contexts It may not always be possible to determine the specific cause of neonatal respiratory distress part
59. by the more likely it is to have apnoea of prematurity table 1 Most babies lt 30 weeks gestation have apnoea of prematurity Table 1 Relationship between gestational age and incidence of recurrent apnoea Gestational age Incidence of recurrent apnoea lt 80 weeks Apnoea of prematurity is due to immaturity of the central nervous system The part of the brain that controls the drive to breathe is not fully developed Apnoea of prematurity can therefore be considered to be physiological or part of a normal developmental process However apnoea of prematurity can cause hypoxia so it must be treated Apnoea of prematurity usually starts on day 1 or day 2 of life Apnoea that begins within hours of birth 19 more than 1 week after birth is unlikely to be apnoea of prematurity Babies grow out of apnoea of prematurity as they mature Most cases have resolved by 34 36 weeks It is rare for apnoea to continue at term however babies with chronic lung disease may take longer to outgrow their apnoea Apnoea due to underlying disease Apnoea is a common symptom of many different diseases that occur in the neonatal period table 2 Any of these conditions may cause apnoea in both term and preterm babies In preterm babies any one of these conditions may worsen underlying apnoea of prematurity Apnoea due to airways obstruction This is the least common cause of apnoea Babies who have abnormal airways anywhere from the
60. by is being fed check to see whether a feed is due and that the feeds being prescribed are of adequate volume Hypoxia worse RDS Hypoxia can be checked with SpO2 If the baby has hypoxia turn up the oxygen 5 If there are signs of worsening respiratory status check the machine and circuit and check the baby for signs of complications p 84 Use the protocol to check for a cause and to start to treat the problem Pain A doctor should check the baby for sources of pain e g abdominal disease pressure sores If a cause is found then treatment specific to the cause should be given Paracetamol may be given for analgesia The dose is 15mg kg by OGT or rectally up to 4 times per 24 hrs 6 If none of these things appear to be the cause of the discomfort then the baby should be managed with the following simple interventions each of which may help 1 Swaddling with firm wraps 2 Nesting 22 To make sucrose solution mix 33g of sugar with 100ml of heated drinking water sterile water and stir until dissolved http www livestrong com article 284024 how to prepare sucrose solutions Do not store the solution beyond 24 hours as it is an ideal medium for bacterial growth 78 CPAP and the Baby with Difficult Breathing 3 Offer a dummy which may be dipped in milk nystatin or sucrose solution A dummy may also help reduce any CPAP leak via the mouth The top half of the dummy support may need to be cut in order for it to fit
61. close by in case of power failure 4 7 Figure 11 A typical oxygen concentrator Much more detailed information regarding oxygen supplies and systems for clinicians administrators and biomedical engineers alike can be found in the recent publication The Clinical Use of Oxygen in Hospitals with Limited Resources Guidelines for health workers hospital engineers and program managers WHO 2009 Note if oxygen is not provided or available the CPAP device will still function however it can provide only air This may still be effective for treating apnoea of prematurity however the majority of cases treated with CPAP need oxygen as well as pressure support 63 8 3 Patient Interfaces The patient interface is the part that connects the baby to the CPAP circuit It transmits the gas from the inspiratory arm of the circuit INTO the baby s airway and transmits the gases that the baby breathes OUT back into the expiratory arm of the circuit Several different patient interfaces are available Each device together with its advantages and disadvantages for use is depicted in table 10 They are discussed in turn Cut ETT A cut ETT is the cheapest interface and is therefore the most practical option in low resource countries It is also the most secure interface because a reasonable length is inside the nose A disadvantage is that it may exacerbate secretion production especially after it has been in for a few days so tube care is pa
62. ctions vi cleaning the CPAP machine after use vii using the CPAP monitoring form 1545 1630 Case scenarios 3 small groups 1630 1700 Post test 10 questions 125 16 SUPERVISION SHEET This sheet is prepared as a GUIDE to what could be reviewed during a supervision exercise to a hospital where CPAP is used and as a follow up after training A suggested scoring system is listed below Use the protocols policies and checklists in the manual as your standard against which to assign scores If there are no babies on CPAP during the visit you can use medical records and mannequins and hypothetical scenarios to determine the skills competencies of the staff The purpose of the exercise is to have an idea of how competently the CPAP is being implemented to discover areas that need strengthening in care and to help target areas which may need better focus in training It is always a good idea to compare serial supervision assessments against one another in order to detect improvement deterioration in care over time HOSPITAL SCORE COMMENTS Has 24 hour CXR Has reliable oxygen supply Has safe ratio of nurses to babies in neonatal area Has 24 hour medical cover with staff trained in CPAP Number of babies who have been treated with CPAP month and number of months CPAP has been in use supplies for CPAP Babies in nursery on CPAP at time of visit have suction equipment and equipment fo
63. dimensions in preterm infants J Perinatol 2001 21 521 4 De Paoli AG Davis PG Faber B Morely CJ Devices and pressure sources for adminsitration of nasal continuous positive airways pressure NCPAP in preterm neonates Cochrane Database of Systematic Reviews Reviews 2008 1 CD002977 SO Subramaniam Prema Henderson Smart David J Davis Peter G Prophylactic nasal continuous positive airways pressure for preventing morbidity and mortality in very preterm infants Cochrane Database of Systematic Reviews 2005 3 CD001243 Sweet D Bevilacqua G Carnielli V Greisen G Plavka R Didrik S et al 2007 European consensus guidelines on the management of neonatal respiratory distress syndrome Journal of Perinatology Medicine 35 175 186 29 Tittley JG Fremes SE Wiesel RD Christakis GT Evans PJ Madonik MM et al Haemodynamic and myocardial metabolic consequences of PEEP Chest 1985 Oct 88 4 496 502 131 18 ANNEX 1 OXYGEN CONCENTRATION RATES Varying oxygen concentrations FiO2 that can be delivered via nasal flow oxygen up to 1L minute according to the baby s weight and respiratory rate These are only accurate when low flow meters are used These tables were provided by personal communication Dr Gaston Arnolda Flow rate of 50 mL min Weight kg 1 25 1 5 Respiratory rate Flow rate of 75 mL min 75 Weight kg Weight 0 64 Respiratory
64. due to a machine circuit problem or it may be a patient problem A BABY MAY DETERIORATE WHILE ON CPAP BECAUSE OF Amachine circuit problem circuit disconnection nasal tube blockage oxygen supply run out or turned off A baby problem Recurrent Apnoea Underlying lung disease is worsening Complication of CPAP lung overdistension pneumothorax gastric distension aspiration Development of a new problem such as sepsis pneumonia PDA A stepwise action protocol for what to do when a baby is deteriorating is found on p 84 Following the protocol will enable the health worker to determine a probable reason for the deterioration as well as to institute steps to fix the problem and improve the baby s condition The first step is to increase the oxygen supply and the second is to check for apnoea The oxygen supply the CPAP circuit and machine are checked next Finally the tube is checked If no problem is found then the baby has deteriorated either because the underlying lung disease is worse because of an acute complication of CPAP pneumothorax lung over distension or aspiration or due to the development of another medical problem The health worker should always call for help if a reversible problem is not found quickly Table 12 lists the clinical signs to diagnose each of these possibilities as well as the appropriate actions to manage them A portable CXR is very useful to help to differentiate bet
65. dy 0 MOH uomnejuted u YXD uonisod 12900 ueo pue djeu Aew e qeie4 sanse uic UXO epis jo 9 eqm eui jo ujBue eut uBnouu isee ssed seop uonong spuooes oc 20 eui sisouBeip 0 jou SI subis eixod H uoisue1od H uoisnyjed jeueudiued 1004 jou SI d ydo subis uoisuejsip jeuruopqy spunos peonpes jou SI subis Builqqnq 1ueuleA oui 1s8uo peonpes 18 ui spunos jou SI 5 subis eimoq y jqqnq ou si 2194 jou si Aqeg 94 si Aqeg zi asiom s eseosip Bun sBun jo uoisuejsip1aAQ uome4idsy jeq dWdO 4 uononisqo eqn 5 89 CPAP and the Baby with Difficult Breathing 88 9 8 Weaning and Stopping CPAP When to wean CPAP Weaning means reducing the support that is being provided to the baby from the CPAP Weaning can be done when the baby s respiratory effort is improving RR reducing minimal retractions no grunt or flare and SpO2 is normal pre
66. e If your baby is well enough they may organise for him to rest on your chest in a position we call Kangaroo Care This will help him settle and is also good for your milk supply The nurses can explain this more 6 Is there anything shouldn t do It is important that you do not touch the CPAP machine Be careful when you are near the bed not to bang into the machine In no circumstances should you touch any of the machine controls If you have any worries about your baby at any time please call a nurse or doctor to help you 12 8 Pneumothorax protocol Signs that suggest a possible pneumothorax The baby deteriorates AND uneven breath sounds in the chest one side decreased relative to other may be hyperinflation of one side apex beat of the heart may be displaced subcutaneous emphysema crepitus of air under the chest skin RARE The deterioration may be sudden and severe or more gradual Smaller pneumothoraces may be aymptomatic Large pneumothoraces may be under tension with secondary reduction in cardiac output blood pressure it is a medical emergency Management of pneumothorax Increase oxygen to try and obtain saturations in the desired normal range Give IV fluid bolus 10cc kg of normal saline if the baby s perfusion is poor Confirm diagnosis Ifyou have a transilluminator turn off all lights and place the light against each side of the chest in turn If a significant pneumothorax is p
67. e visible alarm It flashes for an alarm condition The button on the right side controls the audible alarm The audible alarm can sound only when the right side button is pushed IN The audible alarm sounds beeps for a few seconds when the machine is first turned on It also sounds whenever an alarm condition occurs and the left hand alarm is flashing If the button is OUT the alarm is muted Alarm conditions include 1 the heater wire sensor is disconnected 2 the sensor in the inspiratory arm records a temperature that is too high or too low See later p 98 for further explanation Back panel The back panel has the connection for the heater element wire of the inspiratory circuit the 60 CPAP and the Baby with Difficult Breathing connections for the air compressor and additional power outlet diagnostic buttons for use by biomedical engineers who are servicing the machine power supply cord and fuse diagnostic buttons depending on version Additional power outlet only on early models Heater element wire of inspiratory circuit Power outlet for air compressor 220v power cord Figure 9 Back panel of the CPAP The block diagram illustrates the circuit of the CPAP as is described in text above To Patient OXYGEN FLOWMETER From cylinder Inspiratory Expiratory or wall suppl PATIENT MIXER AIR FLOWMETER Humidified air oxygen Exhaust AIR mixture COMPRESSOR Hose Heater
68. e baby that you must check while he she is on CPAP vital signs respiratory effort peripheral circulation general condition settledness gastric distension secretions nasal skin tube security and placement CPAP and the Baby with Difficult Breathing Can you feed a baby while he she is on CPAP If yes describe how yes byOGT 2 8 hourly feeds of EBM if possible leave end of open except for 2 hour after feed List 3 things that must be set on the CPAP machine pressure flow of oxygen and air humidity set temperature of inhaled gas What is the usual starting pressure setting for CPAP for a 1 5kg baby who has RDS How many cms water 10 Look at the picture of the blender graph Compressor air flow litre minute 5 x gt En o o gt x o Using a flow of 3L Oxygen and 3L Air gives an FiO2 of 61 Using a flow of 5L Oxygen and 2L Air gives an FiO2 of 77 9o doctor has asked for 60 oxygen List different flow combinations that will give approximately FiO2 60 3 3 61 4 4 61 4 3 66 Apart from monitoring vital signs and the machine list 3 elements of nursing care whch are very important on CPAP 139 of the nose tube care including suction if you think it is blocked positioning swaddling and ensuring comfort feeding infection
69. e hourly observations 9 Blood monitoring Ideally babies on IV fluids should have daily monitoring of electrolytes and haemoglobin should be checked twice weekly Electrolyte abnormalities must be corrected If a baby requires oxygen blood should be transfused to keep Hb gt 8g dl if respiratory distress is severe keep Hb gt 10g dl Blood glucose should be checked twice a day until it is stable and the baby is on feeds it may need to be checked more often if there is any hypoglycaemia IF blood gas monitoring ABG is available and if there is facility to offer ventilation to babies with respiratory failure then ABG should be checked daily and during periods of instability 10 General nursing Positioning the baby with the head raised by 30 may improve 27 respiratory status Use pillows under the mattress or raise the bed head if possible Using the prone position may also help respiration and may reduce apnoea be careful not to obstruct the baby s face Handle the baby for cares procedures as little as possible because activity will increase oxygen requirement Specific therapies When babies have hypoxia that does not respond to oxygen and other supportive care or apnoea or increasingly severe respiratory distress they need further support to breathing This can be temporarily provided with bag mask ventilation but if ongoing support is needed then the baby requires either CPAP or intubation and ventilation CPAP is
70. e kinking The catheter should not cross the midline pull it back if it does Ongoing analgesia until ICC removed Figure 17 Heimlich valve http www arrowintl europe com webcat user bilder 1058946749 Al 01500 E 2 jpg Figure 18 Correct placement and taping of an intercostal catheter http archive student bmj com issues 05 07 education images view 7 jpg 12 9 Bedside monitoring chart for babies on CPAP 13 PRETEST POST TEST 1 List 3 neonatal conditions that can be treated with CPAP E HEHERHERHEHERHUHEHER HG b i B 2 List 2 conditions where CPAP is unlikely to be useful i BH z 1 3 How does help baby to breathe 3 2 t 4 Whatis the correct SpO2 range for a baby on CPAP Give answers for both preterm EE and term babies 1 5 Write 3 things on the CPAP machine that you must check regularly while it is in use ME oH the baby Pio 6 Write things on the baby that you must check while she is on 7 Can you feed baby while she is on If yes describe how 8 List 3 things that must be set on the CPAP machine i 9 What is the usual starting pressure setting for CPAP for a 1 5kg baby who has RDS How cms water 10 Look at the picture of the blender graph i fl S Compressor air flow litre minute t T ET 5 E A
71. e meconium aspiration or pulmonary hypertension or sepsis unable to keep saturations gt 94 on maximal oxygen flows via non invasive means 9 20 W After extubation in very low birth weight neonates Assuming the baby has no contraindication to CPAP p 49 Additional points Preterm babies 1 A lower oxygen requirement is recommended for starting CPAP in preterm babies because research has shown that babies with HMD do better when CPAP is begun early in the course of their disease 21 Fewer babies later require intubation and ventilation Beginning CPAP early prevents further lung collapse which is difficult to reverse once established 2 Using the same logic some neonatal units in the developed world use prophylactic CPAP in very small 1kg babies who are at high risk of developing HMD CPAP is initiated at birth before they have signs of RDS There is no good evidence that this results in better outcomes and there is some concern about potential side effects from the CPAP 27 It is not recommended in low resource contexts 23 3 Surfactant has revolutionised the outcome of babies with RDS over the past 20 years It reduces the need for ventilation reduces the incidence of pneumothorax and reduces mortality in preterm babies with RDS 28 Neonatal units in the developed world routinely administer surfactant to preterm babies with RDS It is used either as treatment 67 for babies with established RDS and an incre
72. eding tubes sizes 6 8 10 12F CPAP and the Baby with Difficult Breathing 10 2 Job aides bedside protocols These protocols are meant to be able to be hung and used at the bedside List of protocols included here The machine Using and Caring for CPAP m checking the machine before use turning on and adjusting the controls for operation care in use turning off the CPAP machine cleaning assembling reassembling The patient Nursing protocols 1 2 3 4 Starting the baby on CPAP Caring for the baby on CPAP Stopping CPAP Preparing the patient interface tube or prongs Medical protocols 1 2 How to manage a deterioration on CPAP Pneumothorax detect manage Counseling for parents 95 11 USING AND CARING FOR THE EMW CPAP UNIT CPAP is Continuous Positive Airway Pressure Tube to warm and administer into patient Tube to send air into pressurized thermos bottles Light and alarm Off button for alarm Humidifier thermos Display screen Temperature selection button Pressure thermos Moisture selection display light Moisture selection button On Off switch Air compressor 11 1 Checking the machine before use 1 Remove the cloth cover and check the machine is clean If it is not clean wipe it over with a damp cloth soaked in alcohol 2 Check the mains cable and plug make sure there are no breaks in the cable and that the plug is not s
73. ee some humidity or vapour in the ICC as it enters the pleural space Advance it so all holes in the side of the tube are inside the chest Attach either the Heimlich valve or the tubing underwater drain system You should see flapping of the Heimlich valve or swinging of the water if the drain is correctly placed in the pleural space If there is no swinging gently advance the drain until swinging is seen Secure the drain with a suture around the entry site and tied to the ICC Secure again with tapes in a bridge plasters to each side of the chest next to the tube then a third piece between each of these and across the Cover with clear dressings e g tegaderm in a sandwich to seal the tube entry site Anchor the tubing to the patient s chest so it can t pull out 118 CPAP and the Baby with Difficult Breathing If using a Heimlich valve ensure the valve balloon is flapping if it isn t then the position of the drain may need to be adjusted If using an underwater drain connect to gentle suction 10 15cm and ensure the water is bubbling and swinging in the tube Continue suction until the bubbling ceases for 24hrs and the pneumothorax is resolved on CXR Stop the suction and repeat CXR again in 24hrs remove the tube if no reaccumulation of air Use a single stitch to close the wound and cover with a tegaderm or equivalent dressing Post procedure CXR to confirm position both AP and lateral and exclud
74. egins in the expiratory bottle If no bubbling begins check the gas flow is on and check for leaks in the circuit 11 3 Care use 1 When patient observations are performed also check a The machine settings are as ordered Sometimes settings are inadvertently moved b The circuit is secure bottle lids and all connections are tight c The oxygen oylinder is not approaching empty or if connected to a wall oxygen outlet that the pressure gauge on the wall supply outside shows that the external cylinders are not approaching empty If the pressure gauge shows nearly empty change over the cylinders and report the empty cylinder to the Oxygen Technician d The water in the expiratory bottle is bubbling If there is no bubbling disconnect the baby from the circuit and occlude the end of the circuit If bubbling recommences there is a problem with the baby apnoea or a leak from the mouth If there is still no bubbling there is a machine problem Check the gas flow is on check all circuit connections looking for a leak If you cannot resolve the problem quickly change the machine e The water level in the inspiratory bottle is up to the red line Because heated water evaporates very quickly check the level every couple of hours and top up distilled or sterile water as needed f The circuit tubing for rain out excess water collecting in the base of the tube and empty it back into the bottle by lifting the tubing and
75. erity of HMD In low resource contexts prevention of disease is particularly important Every attempt should be made to provide steroids to a mother in preterm labor even if she may receive only one dose prior to delivery Surfactant is expensive so hospitals must determine whether or not it is an affordable option and must develop policies for judicious use The use of CPAP for HMD is discussed in the next part of this manual Ventilation strategies are not covered here Meconium Aspiration Syndrome MAS Unlike HMD meconium aspiration syndrome MAS is a disease of term or post term babies It is rare before 36 weeks As suggested by the name MAS is a condition where meconium is aspirated into the lungs 8 Aside from preventing HMD antenatal steroids also reduce neonatal mortality necrotizing enterocolitis and intraventricular hemorrhage 36 CPAP and the Baby with Difficult Breathing Meconium is produced by the fetal bowel It may be released into the amniotic fluid if the fetus experiences intrauterine asphyxia Meconium stained liquor is present in 15 of all deliveries however meconium aspiration syndrome occurs in only 5 to 10 of all babies with meconium stained liquor Aspiration of meconium may occur in utero asphyxia may cause the fetus to gasp or during delivery Meconium is an irritant and toxic to the lungs producing inflammation and affecting surfactant production It also causes obstruction of the small airways which
76. ery devices differs Prongs catheters and masks are not able to give 100 oxygen because when the baby is breathing the oxygen supplied through the device is mixed with ambient room air which the baby breathes in alongside the oxygen delivery device The inspired oxygen concentration also varies according to size respiratory rate and effort the seal of the device and the oxygen flow rate Table 5 below illustrates this The figures in this table have been calculated for a baby of 5kg and using flow rates recommended for the individual devices More detailed tables showing percent of oxygen delivered at different flow rates and for babies of different weights are included for completeness as an annex p 132 Table 5 Different oxygen concentrations that are delivered at the specified flow rates to a 5kg baby Oxygen Flow l minute Oxygen that is delivered Delivery system 1 Nasal catheter Simple Mask Head box 31 Table 6 Sources of oxygen Oxygen can be sourced from cylinders concentrators or pipes wall outlets Special Advantages Disadvantages considerations E 2 Does not need Limited source suppl Oxygen Backup cylinder must iij electricity to run runs out cylinder always be available Transportable Flow regulator needed Backup oylinder Very cost effective after Needs reliable electricity Oxygen concentrator needed in case power initial purchase Needs regular maintenance or m
77. evices are found in the section on patient care 65 Table 10 Patient interfaces DT Advantages Disadvantages Nasopharyngeal tube cut ETT Exacerbates secretions so obstruction a common problem Cheap Easy to kink Availability Nasal trauma Securest fixation Significant leak through other nostril Tape can cause skin trauma on face Double nasal prongs Hudson prongs Probably the most effective ac Difficult to secure require quite adds complex fixation devices More comfortable for the Expensive Nasal trauma Argyle prongs V E 4 Fitted face mask Difficult to maintain a seal Minimal nasal trauma Cost unavailability in low resource contexts Difficult for baby to breathe through s due to small diameter None to justify If obstructs no alternative airway available NOT RECOMMENDED recommending its use 66 CPAP and the Baby with Difficult Breathing 9 _ HOW TO USE CPAP MEDICAL AND NURSING PROTOCOLS 9 1 When to start CPAP CPAP SHOULD BE CONSIDERED IN THESE SCENARIOS preterm baby lt 35wks 18009 who has recurrent or severe apnoea that does not respond to stimulant medications A term baby who has recurrent apnoea baby term or pre term with respiratory distress unable to keep saturations gt 90 9 20 on maximal oxygen flows via non invasive means p 31 baby with respiratory distress due to probabl
78. f CPAP 20 It may result in sudden and severe deterioration of the baby s condition Pneumothorax is especially likely to occur when high pressures are being used It is also more likely in babies with HMD during the recovery phase when the baby s oxygen requirement is decreasing and lung compliance is improving Staff caring for babies on CPAP must be competent in recognition and management of pneumothorax Hospitals with CPAP should have a transilluminator available in the neonatal ward and 24 hour facility for portable CXR to enable prompt diagnosis of pneumothorax A pneumothorax kit p 94 must be readily available in areas where babies are being treated with CPAP A pneumothorax protocol is included p 114 Gastric distension Gastric distension on CPAP is commonly referred to as CPAP belly It is a common complication It refers to distension of the abdomen due to passive entry of gas flow into the stomach during CPAP It is worse when higher flows are used It can usually be prevented or contained by using an orogastric tube on free drainage while babies are on CPAP the tube is closed only for 1 2 hour after a feed Nursing the baby PRONE may also help prevent or reduce CPAP belly Gastric distension can worsen a baby s respiratory distress by compressing the lungs and reducing lung volume Aspiration of stomach contents is more likely to occur when a baby has CPAP belly and may significantly worsen oxygenation and respiratory status
79. f how to insert and fix nasal prongs is shown on p 112 Fitted nasal face masks Soft fitted nasal face masks have been developed for neonatal CPAP in order to try to reduce nasal trauma so often a complication of nasal prongs These masks are effective however it can be difficult to maintain a seal In addition they are costly and as yet not available in low resource contexts Endotracheal tube CPAP can be administered through a regular ETT i e to an intubated baby This method is sometimes used when testing to see whether a ventilated baby is ready for extubation The ETT is left in place the baby is switched from ventilation to CPAP The baby is observed before deciding whether to extubate to nasopharyngeal CPAP or to return to ventilation Providing CPAP through a ETT however has 2 serious problems Firstly breathing through a long ETT is very difficult for the baby As mentioned above the resistance of breathing through a long tube is very high so work of breathing will be increased The second and VERY IMPORTANT issue is that in case of tube blockage the baby has no alternative airway tube blockage may result in severe hypoxia and or death ETT CPAP should ONLY ever be used as a very temporary measure for a few minutes only and it is essential that the baby has CONTINUOUS nursing observation throughout that period in case of tube obstruction Protocols on how to connect apply and how to care for each of these interface d
80. g problem p 15 If ventilation is an option then this should be considered at this point The decision about whether or not to proceed at this point will depend upon the availability of local resources to manage an intubated baby and must be made by the most senior clinician available As mentioned earlier if available blood gas analysis may also be used to help make this decision Protocol what to do when a baby is deteriorating 1 Increase the FiO2 by 10 20 or more if needed 2 Quick Check for apnoea a If present stimulate the baby b If the baby does not begin breathing within 20 30 seconds take off CPAP and ambubag mask with oxygen 3 Quick Machine Check a Connections intact 23 It is not possible to include here discussion of the possible new medical problems that are not specifically related to the CPAP Here we have focused on those specifically related to the CPAP treatment 84 CPAP and the Baby with Difficult Breathing b Oxygen on and cylinder full c Settings correct PEEP oxygen flow rate d Bubbling i Fix any problem immediately ii If no improvement continue 4 Quick clinical assessment a Auscultation pneumothorax i If unsure transilluminate or order portable CXR b Hypotension reduced cardiac output i Try bolus of fluid 10cc kg normal saline 5 Check the tube obstruction a Suction the tube and airway b Change the tube if you have any concern that it is blocked lf th
81. he list of items that require regular monitoring for a baby on CPAP and for the machine Scoring Clinical standards good care meets standards order some need for improvement to reach standard care some missing or broken Supplies equipment all present and in working 127 marked need for improvement to reach standard care many items missing or broken 17 REFERENCES Majority all not t care provided or harmful practices b 1 American Academy of Paediatrics Policy Statement Apnoea Sudden Infant Death Syndrome and Home Montioring Committee on Fetus and Newborn Paediatrics 2003 111 914 917 Accessed online 28 3 2011 at http pediatrics aappublications org cgi reprint 111 4 914 pdf 2 Royal Prince Alfred Hospital Newborn Care Clinical Guideline Apneoa and Bradycardia Accessed online 28 3 2011 at http www sswahs nsw gov au rpa neonatal 3 Heimler R Langlois J Hodel DJ Nelin LD Sasidharan P Effect of positioning on the breathing pattern of preterm infants Arch Dis Child 1992 67 312 4 4 Schmidt B Roberts RS Davis P Doyle LW Barrington KJ Ohlsson A et al Caffeine therapy for apnea of prematurity Engl Med 2006 354 2112 21 5 Davis PG Schmidt B Roberts RS Doyle LW Asztalos E Haslam R Sinha S Tin W Caffeine for Apnea of Prematurity Trial Group Caffeine for Apnea of Prematurity trial benefits may vary in subgroups J Pediatr 2010 Mar 156 3 382 7
82. he top LED screen 2 Humidifier This dial determines the amount of heat output 45 70 supplied to the heater elements next to the inspiratory bottle The set amount of heat is shown by the LED display column immediately above the dial Note that whilst the CPAP is warming up for the first 45 minutes after turning the CPAP on the heat output to the humidity heater elements is fixed cannot be changed to 100 Increasing the heat increases humidification of the gases LED displays The top display shows the set temperature between 35 and 39 The bottom display has 2 lines The upper line shows the temperature recorded at the sensor in the metal wire hose inside the inspiratory circuit arm The measured temperature is displayed as Sensor in blue The second line shows the amount of power the heater is using to provide in order to reach the set temperature It is expressed in 96 from 0 to 100 For example if the CPAP has just been switched on the heater output will be 100 as it tries to heat up quickly to reach the set temperature When the heater reaches the set temperature the heater output will begin to drop below 100 The heater output power will then constantly fluctuate as it tries to maintain the temperature at the required level This is normal It may also drop in alarm conditions see below Alarms There is one audible and one visible alarm on the top of the front panel The alarm on the left side is th
83. his table is to remind the clinician that fast or difficult breathing is not always due to primary lung disease The commonest of these conditions are discussed in more detail on the following page 24 CPAP and the Baby with Difficult Breathing 2 3 Evaluating the cause of respiratory distress Clinical assessment history and examination together with a limited set of investigations when available help determine the likely cause of respiratory distress Knowing the probable cause influences management to some degree and enables the clinician to predict the likely course of illness Important features of history and examination which help to differentiate between common lung problems are shown in table 4 p 24 Wherever possible babies with RDS should have a chest Xray CXR and a sepsis screen FBC including haematocrit blood cultures A CXR is the most helpful investigation It is diagnostic of some conditions and is useful in confirming the severity of some conditions It is the only reliable means of diagnosing a pneumothorax CXR may not be readily available in some resource poor countries portable CXR even less so Portable CXR is the safest X ray to do if a baby is very sick because very sick babies often deteriorate with the handling involved in transport If portable CXR is not available and a baby is very sick then it is often safer to begin treatment and to delay the CXR until the baby is more stable 2 4 Management of est
84. hould be avoided 6 Feeding It is important to feed babies as soon as it is safe to do so preferably with expressed breast milk However when a baby has respiratory distress it is safest to withhold feeds because of the risk of aspiration The mother should express and store or discard her milk and the baby should be given IV fluids When the baby is stable and respiratory distress is not severe small volume feeds can be started usually by og or ng tube They are gradually increased as tolerated and according to the baby s respiratory status Large volume feeds should be avoided until the baby s respiratory status is normal it is safer to feed small amounts more frequently For a guide to feeding see Managing Newborn Problems WHO 2003 7 Suctioning It is important to maintain a clear airway however suction must be done cautiously and using correct technique Suctioning too frequently or too vigorously can cause apnoea and bradycardia Suction only when secretions are present or if the baby has deteriorated Suction must be brief and catheters must not be inserted too deeply See p 79 for suctioning protocol 8 Vital signs monitoring Ideally babies with respiratory distress requiring treatment should have continuous electronic monitoring of vital signs and oximetry This is unrealistic in low resource settings and must be replaced with frequent nursing observations in a frequency determined by the doctor Very sick babies requir
85. hourly for the first 3 4 hours or until the baby is stable Subsequently record observations 2 4 hourly depending on doctor s instructions Any baby with severe respiratory distress needs ongoing close monitoring hourly vital signs If the baby deteriorates a Call for help Increase FiO2 10 20 to try and get SpO2 in required range Quick check oxygen supply connections machine settings Check for apnoea and treat if present Quick patient assessment for pneumothorax Check if the tube is blocked p 81 suction protocol Doctor will decide whether to increase pressure transilluminate order a CXR or other management o 9oo20c APNOEA episodes record any apnoea episodes on the patient monitoring form When the baby has an apnoea 105 a Stimulate the baby b If no response remove tube and bag mask with oxygen c CALL the doctor 4 Feeding a Feed the baby via an b i Begin feeding as soon as the baby is stable ii After a feed close the tube for 30 minutes only then reopen iii Suspend the open end of the by taping it to a pole on the baby s cot This allows the milk to be slowly absorbed and excess gas can still escape iv Before each feed check the position of the OGT is correct if you think it has moved or could be out replace and aspirate If there is gt 25 of the last feed returned or if the aspirate contains blood or bile hold a feed and call the doctor The mother should be
86. howing any exposed wires brown blue green black or white 3 Lockthe wheels with the brake 4 Make sure the 4 rubber feet of the air compressor are sitting in place on the air 96 CPAP and the Baby with Difficult Breathing compressor stand so that the compressor is secure Check all the other components are correctly connected see cleaning aide a Check the gas hoses are correctly connected b Check the bottles are correctly set up c Check the patient circuit is correctly set up Fill the thermos bottles with distilled or sterile water to the top red line on each bottle Screw the blue lid on each bottle firmly 11 2 Turning on and adjusting the controls for operation 1 Turn the unit on at the wall and turn on the ON switch on the CPAP a The lights on the front panel should all come on and the alarm will sound briefly b The base of the posterior thermos bottle and the inspiratory arm of the patient circuit should begin to heat It will take about 5 minutes to be able to feel this temperature increase c The air should begin to bubble through the inspiratory bottle and the compressor should be making a noise If this does not happen check the air compressor is plugged in and or try changing the air compressor with another d If none of these things happen unplug the unit and check the wall power outlet is working by plugging in another electric device In any other case contact Biomedical Engineering Dia
87. i En Ce 108 12 4 The patient interface preparation insertion and fixation of a cut 109 Preparing the tube for insertion eee 109 Insertingthe TG 110 Securing th tube siistisi ne enses iude di a 110 12 5 Diagrams of 2 methods of taping tube 110 12 6 The patient interface example fixation of nasal prongs 112 12 7 Counseling sheet for parents of babies on 113 12 8 Pneumothorax protocol essen 114 Signs that suggest a possible 114 Management of 114 Definitive edu ander pd 115 Draining pneumothorax with butterfly 115 EqQuUIDMON ma aaa 116 Prepatation Ai 116 POCO QUPC P 116 Inserting an intercostal catheter ICC 117 M 117 iss 118 Post uicit foie deii e 119 12 9 Bedside monitoring chart for babies on
88. icularly when portable X rays are not available to confirm the diagnosis Thus in practice CPAP can be tried for any neonate with RDS provided no contraindications exist Neonatal conditions which may respond to CPAP membrane disease Apnoea Pneumonia Pulmonary haemorrhage Pulmonary oedema due to cardiac conditions Aspiration meconium or other types Post extubation Transient tachypnoea of the newborn Airways obstruction due to abnormalities that predispose to airways collapse eg laryngomalacia tracheomalacia CPAP and the Baby with Difficult Breathing 5 WHEN SHOULD CPAP NOT BE USED 5 1 Contraindications 1 In tracheo oesophageal fistula and diaphragmatic hernia CPAP is contraindicated because it can cause gastric distension which can further compromise respiratory function If these babies require respiratory support then they need intubation ventilation and other specialised care which is not covered here 2 In choanal atresia or severe cleft palate the anatomical abnormality makes application of the CPAP ineffective 3 In bowel obstruction or necrotising enterocolitis CPAP is contraindicated because it will exacerbate the gastric distension 5 2 Situations where CPAP is unlikely to work There are 3 situations where CPAP is unlikely to work These are not absolute contra indications however experience has shown that CPAP is often ineffective in these situations 1 Severe and
89. if bubbling returns If not try increasing the flow by 1 2L minute If this doesn t work call the doctor If bubbling did not return when the baby was disconnected and the circuit occluded then there is a circuit machine problem Provide the baby with facemask oxygen Check the circuit and machine for kinks or disconnections Check the gas flows are on the air compressor is on and the oxygen supply is on If no problem can be found and the bubbling does not continue change machines 144 CPAP and the Baby with Difficult Breathing 145
90. ifficult Breathing TABLE OF CONTENTS List of FIGUFIGS rodeo tede EUR o 8 EisEof Tables aces EH thee ieee i ea estes 9 Abbrevialioris snaran cetera seta dere neha ween ear REIR 10 Part A Babies with difficult breathing sess nnne 12 1 NN 13 11 What is 2 13 1 2 What causes 13 Apnoea of prematurity essent nnne 13 Apnoea due to underlying 14 Apnoea due to airways obstruction eene 14 1 3 Why is apnoea a problem essent nnns 14 1 4 Managmenet of sss nennen nennen nennen nnns 16 Immediate the FLUR 16 Determine the cause cccscsccsssscsssessssrcesessssssscessessssecsesersesaesessassnsessnsans 16 Ongoing management 16 1 5 Specific management for 17 MediGatlonguss 18 Starting medications cusa a ned a ac ud 18 Care whilst on medication essere 20 Stopping medications NM 20 Respiratory support essent tenete entente nennen inten nn 20 1 6 Apnoea algorithim
91. imal equipment list for CPAP esee 93 Basic resuscitation supplies for neonates sss 93 Oxyg n Supple S 93 a 93 Support 94 10 2 Job aides bedside protocols esee 95 The te ca niacin ers arua crecen ata aro iaer 95 The 95 Medical protocol rete i en etn 95 Counseling for parents acce 95 Using and caring for the EMW CPAP unit 96 11 1 Checking the machine before 96 11 2 Turning on and adjusting the controls for operation 97 11 3 Care Ini USC i n iei base nce ten Exe 98 13 4 etienne 98 11 5 Turning off the machine 99 11 6 of the CPAP unit between 99 Cleaning the CPAP s ao petet 99 Assembling reassembling the CPAP 102 Nursing protocols eh i cen i rr rgo ie mia ne oc d 103 121 Starting the baby on CPAP sese nnne 103 12 2 Care of the baby on 104 12 3 Stopping CPAP ean
92. is does not resolve the problem continue 6 Increase the settings a Oxygen 5 increments b Pressure increments 1cm up to a maximum of 8 do not increase if suspect hyperinflation or pneumothorax 7 Urgent CXR if possible Call for help if you do not quickly find a reversible problem Acute complications of CPAP which may cause deterioration Tube obstruction This is a common problem and all health workers working with CPAP must be competent in detecting and managing tube obstruction Obstruction may cause sudden and severe deterioration in the baby s condition It can be prevented by close observation for early signs of obstruction table 12 and good tube care When CPAP is used for more than a couple of days the presence of the tube tends to provoke secretion production Obstruction becomes more likely at this time If a blocked tube is suspected the tube should be suctioned If this improves the baby s condition no further action is needed If the catheter does not pass readily or easily the tube may be blocked remove it and change for a new one 85 4 Figure 14 Secretions around end of a cut As tube obstruction is a common and potentially life threatening problem two spare cut and tied tubes should always be at the bedside one the same size one half a size down in case the same size tube will not insert in an emergency Pneumothorax Pneumothorax is an important and potentially very serious complication o
93. k feeds by and does not have any apnoea episodes He is on aminophylline IV 1 What is the appropriate management regarding the CPAP at this stage 2 What steps do you need to do Scenario 4 Nurse Anna is doing her routine observations of a baby 1 9kg on CPAP who had RDS from probable neonatal pneumonia She does her checks on the baby and doesnt find any problem however when she checks the CPAP machine she notices there is no bubbling in the expiratory bottle 1 Is this a problem If yes why is it a problem 2 What could be the reasons 3 What should she do to try and fix the problem 124 CPAP and the Baby with Difficult Breathing 15 SAMPLE TIMETABLE FOR A 1 DAY CPAP TRAINING 0830 0845 Introduction Welcome 0845 0930 Pretest 10 questions CLINICAL theory presentation 0930 1015 What is CPAP i What are the indications for using CPAP j How is CPAP implemented BIOMEDICAL theory presentation 1030 1100 DIM i How does the CPAP machine work NURSING theory presentation 1100 1200 Nursing care of the baby on CPAP Nursing care of the CPAP machine Demonstration and group practice 3 scenarios 30mins each D ae i setting up the CPAP machins to use ii using the CPAP machine changing settings alarms monitoring iii preparing and inserting a nasopharyngeal NP tube 1430 1445 Demonstration and group practice 3 scenarios 20mins each ASIRAR v changing a NP tube recognising signs and correct a
94. l pneumonia preterm birth manipulation in labour chorioamnionitis due to prolonged rupture of membranes or at any time in the days or weeks at birth with respiratory distress and or apnoea especially if there is concomitant sepsis or meningitis Infection may alternatively be acquired during birth especially if there is maternal after birth The consequences of neonatal pneumonia may be devastating in particular if associated with sepsis septic shock or meningitis Treatment includes specific antibiotic therapy There is a wide variety of possible causative organisms including bacteria viruses and respiratory support oxygen CPAP or ventilation and other supportive care and maternal carriage of group B streptococcus all predispose to neonatal pneumonia syphilis and relative prevalence varies between countries For more comprehensive information and for information about the other causes of refer to standard textbooks of neonatology Maternal infection prolonged rupture of membranes respiratory distress transplacental infection These babies 39 CPAP and the Baby with Difficult Breathing 38 eJeu pessnosip 0 SI Sjxojuoo ui peipnis Ajayenbape 191 Jou seu pue Mou 15 s poujeu siu sy KEM ui pesn qal aiWnH pue peuuew eq snw y YONW Mou eejnuueo y 1 991 pue qeq y ezis y 0
95. l the parents Open the dressing pack using aseptic technique and drop the opened needle syringe and 3 way tap onto the plastic drape Fill the pot with antiseptic solution Wash hands and put on sterile gloves Procedure Attach the butterfly to 3 way and to syringe Nurse to firmly hold the baby in the supine position Clean the skin over the anterior hemithorax with antiseptic Pierce the skin of the 279 or 3 intercostal space in the midclavicular line with the butterfly at 90910 the skin take care to avoid the nipple area Gently aspirate the needle as you go you will probably feel a change in resistance as you enter the pleural space Decrease the angle of the needle slightly Once you are in the pneumothorax pleural space gas should freely enter the syringe as you aspirate Continue to aspirate and expel the air using the 3 way until no further gas is aspirated the leak has stopped or until you are ready to place an ICC If gas just continues to fill the syringe then the butterfly will definitely need to be replaced with an ICC Remove the needle either when gas has stopped aspirating or when a ICC is placed Doa CXR after the procedure to confirm the air leak has resolved 116 CPAP and the Baby with Difficult Breathing Figure 16 Draining pneumothorax with a butterfly needle http t3 gstatic com images q tbn ANd9GcQVCG_GRhgR4M FDF_6rKWBKBjQvxXpGi1 SfN_ SIKgqOOPX2H 5 Inserting an Intercostal catheter I
96. l up the desired oxygen concentration FiO2 by adjusting the flow meters for air and oxygen according to the label on the blender Unless the doctor instructs otherwise begin with a combined flow air oxygen of 6L min The flow may need to be adjusted after the baby is connected and the baby s condition and the amount of bubbling is observed Set the temperature of the inspired gas The possible range is between 35 C and 39 First check the electronic display goes down to 359C and up to 39 when the knob is moved to the extreme left and the extreme right The usual starting temperature is 36 37 5 C The temperature may need to be higher for small or sick babies the doctor may modify this Set the humidity of the inspired gas it is usual to begin at 50 but this will need to be adjusted in use depending on the rain amount of water droplets that form in the inspiratory arm Humidity requirements will also vary according to the ambient temperature and humidity If the ambient temperature is cold and dry AC in use more humidity may be required Set the level of PEEP by adjusting the height of the metal leg in the expiratory thermos bottle measured against the cm readings on the side of the bottle The usual starting PEEP is 5cm HO This may need adjusting depending on the baby s condition and response to CPAP 97 6 Occlude the patient connector on the end of the patient circuit with your thumb and check that bubbling b
97. le Table 5 p 31 lists the advantages and disadvantages of each of these modes of oxygen delivery The method selected for delivering oxygen to a particular baby needs to take these issues into account and will depend upon the availability of delivery devices In resource limited settings oxygen supply is often limited If oxygen supply is limited prongs and catheters should be used instead of masks headboxes and incubator oxygen as these 3 methods all use high flows and waste oxygen unnecessarily Prongs and catheters also have 5 Nasopharyngeal catheters have also been used to deliver oxygen to neonates however their use is not included here due to the significant safety hazards associated with their use These hazards make it difficult to recommend their use in low resource contexts 29 the advantage of delivering some PEEP like CPAP as well as administering oxygen In low resource settings considering patient safety and cost as priorities nasal prongs are the preferred method of administering oxygen in most circumstances Photographs and illustrations of oxygen administration devices Figure 3 Baby receiving oxygen through nasal prongs Figure 4 Placement of a single nasal catheter to give oxygen 9 6 PEEP positive end expiratory pressure 30 CPAP and the Baby with Difficult Breathing Figure 5 Baby receiving oxygen through a headbox The concentration of oxygen that can be supplied using different deliv
98. led trial Lancet 2004 364 9434 597 602 12 Avery ME Tooley WH Heller JB 15 chronic lung disease in low birth weight infants 128 CPAP and the Baby with Difficult Breathing 129 13 14 15 16 17 18 19 20 21 22 23 24 130 preventable A survey of eight centers Pediatrics 1987 79 26 30 Morely CJ COIN Trial collaborators Nasal CPAP or ventilation for very pretem infants at birth A randomised trial The COIN Trial Ped Res E PAS2007 61 6090 1 Lindner W Vossbeck S Hummler H and Pohlandt F Delivery room management of extremely low birthweight infants spontaneous breathing or intubation Pediatrics 103 1999 961 967 Ho JJ Subramaniam P Henderson Smart DJ Davis PG Continuous distending pressure for respiratory distress in preterm infants Cochrane Database of Systematic Reviews 2002 Issue 2 Art No 002271 DOI 10 1002 14651858 CD002271 Ho JJ Henderson Smart DJ Davis PG Early versus delayed initiation of continuous distending pressure for respiratory distress syndrome in preterm infants Cochrane Database of Systematic Reviews 2002 2 CD002975 Davis PG Henderson Smart DJ Nasal continuous positive airways pressure immediately after extubation for preventing morbidity in preterm infants Cochrane Database of Systematic Reviews 2003 Issue 2 Art No CD000143 DOI 10 1002 14651858 CD000143 Belenky Orr RJ Woodrum DE Hodson WA 15 continuous t
99. likely it is to have HMD about 5096 of babies born lt 30 weeks will have HMD membranes are a histological change seen by microscope They are fibrous layers formed by sloughed cells and exudate which line the alveoli in HMD HMD is caused by a deficiency of surfactant a natural substance which facilitates inflation of alveoli by reducing the forces surface tension which make alveoli prone to collapse Surfactant production is incomplete before 34 weeks gestation Surfactant insufficiency means that the terminal air spaces alveoli are prone to collapse Collapse reduces the volume of lung available for gas exchange reduced functional residual capacity and makes the lungs stiff HMD presents with increasing respiratory distress within hours of birth It worsens as collapse becomes more widespread Typically the disease is at its worst at 24 48 hours If the baby survives then improvement and resolution occurs 72 96 hours after birth A spontaneous diuresis marks this change The management of established HMD aims to support the baby through this time and to limit further lung injury Big progress in management has occurred over recent decades with resulting improved preterm survival The 2 key postnatal interventions are the administration of surfactant p 67 and improved ventilatory strategies including CPAP Prenatal administration of steroids to women in preterm labour has also significantly reduced the incidence and sev
100. low resource contexts so every effort possible must be made to prevent ROP ROP is prevented by trying to prevent hyperoxia by strictly monitoring and maintaining SpO2 levels within the safe range SpO2 for preterm babies should be maintained between 85 93 at all times Oxygen saturation monitor alarm limits should be set to reflect this set lower limit 83 and upper limit 95 8 Preventing ROP implies that SpO2 monitoring is available If SpO2 monitors are unavailable then this becomes an impossible task Clinical assessment cannot detect or prevent hyperoxia It can be argued that CPAP should not be used where frequent SpO2 monitoring at least hourly is not possible Term babies 35 weeks or more are not at risk of SpO2 need not be so tightly controlled However unnecessarily high oxygen levels should still be avoided as there may be other side effects of too much oxygen and it is wasteful of oxygen SpO2 should be maintained gt 95 but oxygen should be weaned if SpO2 is gt 98 If a baby may have pulmonary hypertension e g MAS and severe hypoxia then saturations should be kept higher preferably gt 97 10 76 CPAP and the Baby with Difficult Breathing In term babies SpO2 should be kept gt 90 If a baby is thought to have pulmonary hypertension sepsis or asphyxia then they should be kept gt 95 Medications There are no medications that are needed just because a baby is on CPAP Medications are
101. m babies te aes ies ite todo 67 Bigger DADIOS itte eet ad a eh pee edid 68 VIELE 68 e dl T EDT TUI 68 9 2 How to start dd 69 5 6 9 3 How to care for babies being treated with 70 Immediate response eessesseeeseneeenn teet nnnetenn ntn 70 The baby who is not responding daria aiias 70 After making alterations to the settings iik enitn 70 9 4 Regular patient monitoring essent 71 The baby what I6 MONItOT 71 CPAP What to a ato 72 Treublesshaoting the machine HG HG dpi 73 Monitoring or tdi cx ioa 73 9 5 When to call the dOGLOTF iniezci dokn ncbnod indice ed aid 75 Baby pablo capi D Md 75 Machine problem 75 9 6 Regular Patient 76 Oxygen Saturations cedat uice toate 76 Medication Sirenia gib he tud ese rs 77 Feeding m 77 Patient ane ae 78 BVOl 78 e EM 78 Hypoxia worse RDS Mn 78
102. mperature in the patient circuit is too high The bottom screen will display a warning message Some reasons for temperature too high could be i Temporary overshoot This is to be expected sometimes as a normal part of controlling the temperature This overshoot should not last longer than 3 minutes ii Sudden change in ambient conditions For example presence of an air conditioner or vent ii Blockage somewhere in the patient circuit iv Machine failure c Depending on the reason for temperature being too high you may need to take the following actions disconnect the patient provide CPAP with bag mask if needed or swap to another machine circuit Turn off the CPAP for 10 minutes and check that the sensor cools down hold under a fan if available Provided the sensor cools turn the machine back on and try to use it again Observe carefully If the problem recurs change the baby to another machine and report the problem to biomedical engineering 11 5 Turning off the machine When the baby is ready to be trialed off CPAP see patient indications disconnect the baby from the patient circuit and turn off the machine on the front of the control panel The oxygen flow will need to be turned off as well 11 6 Care of the CPAP unit between uses 1 2 3 The CPAP unit and circuit must be washed after use and before storing After the machine is washed and cleaned reassemble the machine fully cover with a clean cloth and st
103. n to neonates 9 39 DDx of select common causes of neonatal respiratory distress 42 Important differences between IPPV and 46 Patient Interfaces eter tede Reine t ta dl edd ehe nat ta 66 Suggested start settings for CPAP for various conditions 69 Baby Reuter 88 ABBREVIATIONS Int ittent iti pressure ventilation Bid bd Twice daily Intraventricular haemorrhage Biomedical engineering Kangaroo Mother Care syndrome Medical Technol Transf Services Blood sugar level tube Carbon dioxide Og OGT Orogastric tube Continuous Positive Airways Oxygen Pressure Chest Xray Patent ductus arteriosus Positive end expirator pressure Four times daily Respiratory distress Respiratory distress syndrome Endotracheal tube East Meets West Transient tachypnoea of the 4 newborn Hyaline Membrane Disease Ultrasound Co o o o Breath of Life Light emitting diode Tid TN 10 CPAP and the Baby with Difficult Breathing INTRODUCTION This manual CPAP and the Baby with Difficult Breathing has been written with the intention of assisting doctors and nurses to understand and to use the Breath of Life BOL CPAP machine The manual is in 2 parts The first part The Baby with Difficult Breathing gives an overview of the two clinical indications for CPAP in neonates apnoea and respiratory dist
104. nostril during patient observations the tube prongs should be removed If using a single nasal tube move it to the opposite side If using prongs check they are the correct size and reposition carefully ensuring no pressure on the nares Topical antibiotic ointment may be used for skin breakdown to try and prevent infection Suctioning Suctioning is another important part of nursing care on CPAP Appropriate suctioning will 79 help to prevent tube blockage and subsequent deterioration However suctioning is not without risks to the baby Suctioning may upset the baby It may cause bradycardia and desaturation if it is done too often for too long or too vigorously It may also cause bleeding from the nose For these reasons routine suctioning of a nasopharyngeal tube is NOT recommended Tubes should only be suctioned if there are signs of deterioration or signs of excess secretions rattly sounds visible secretions Nasal prongs do not need to be suctioned If blocked prongs are suspected or if there are audible visible secretions or signs of deterioration gently remove the prongs from the nose and wipe them clean While the prongs are out gently suction each nostril according to protocol Replace the prongs and suction the mouth Thermoregulation Thermoregulation is an important part of care of all sick and small babies Thermoregulation means paying care to a baby s temperature and ensuring he she is neither too cold hy
105. ntimeter markings on the side of the bottle The baby s expired gas enters the expiratory bottle through a hollow metal tube which connects to the expiratory circuit above the bottle lid As the baby expires gas enters the water and bubbles are formed The depth of the metal tube in the bottle determines the pressure provided by the CPAP this is also called end expiratory pressure which supports the baby s breathing For example if the leg is submerged to 7cms then 7cms H20 of pressure is being delivered The deeper the tube is submerged the greater the pressure provided to the baby Expiratory gases escape from the water to the atmosphere through a small hole in the lid of the bottle 58 CPAP and the Baby with Difficult Breathing Expiratory circuit am going to the patient Hole for expiratory gas to Metal tube immersed in distilled water Control box The control box is the electronic part of the CPAP device It contains the user controls display screens and alarms Front panel The front panel has 2 display screens an on off switch 2 control knobs and 2 alarm buttons 59 Controls The 2 controls need to be set by the user These include 1 Set temp This knob determines the temperature of the inspired gas by heating the wire inside the inspiratory arm of the patient circuit The possible set temperature ranges between 35 and 39 The set temperature is shown in red in t
106. o qeq nsuq esneo 0 eseesip 1291 c33ad 10 9sn njeJe7 DO jews sy Bulsinu uo DO Aqeq y deay GWH ueeA s nss d uBiu piony d33d Jo esn uoneoyipiunu ejeiadouddy KjrejnBou 5 egni poop Buisunu euoJg 81 9 seiqeq 104 98 01 Sqooqixei KBojoreuoeu ees e1eu JOU sisdes se sesneo peje euun 910 pepeeu se ZOld snjog nje1eo eonpey pepeeu se 6084 sBunies eseejou Spe9J e1numu 18 Bulsinu euoug uo 90 ALL d DO uep 18949 01 d33d Ssiwiuiw pduo4d yeosy eseeJou MAU eoe doeJ pue eqni UBU ssed jouueo eqni eui eseeJou ueB xo ysew Beqnquie pue dvdo eip1eo pejq 10 eixod u pue esuodseai ou j qeq eui ejejnung eseeJou 91 8 jooojo1d eeou
107. o have been ventilated Apnoea of other causes and apnoea in term babies is unlikely to respond to these medications Aminophylline and caffeine are equally effective however caffeine is preferred as it is safer and simpler to use Compared with aminophylline caffeine causes fewer side effects only needs to be administered once a day and it does not require blood monitoring of drug levels 4 Caffeine also reduces overall neonatal mortality long term disability and chronic lung disease in preterm babies who were ventilated 5 Unfortunately caffeine is not routinely available in low resource countries Starting medications When In wealthy countries stimulant medications are started when babies are recognised to have apnoea of prematurity Commonly medication is started when 1 a baby lt 30 weeks gestation has any apnoea 2 a baby gt 30 weeks has 2 or more apnoea requiring stimulation Medications are also used prior to extubating preterm babies Medications are not used prophylactically However in developed country settings all preterm babies lt 34 weeks are continuously monitored with electronic devices and apnoea is quickly detected and treated In resource limited settings electronic monitoring equipment is rarely available Human resources are also limited so patient observation is infrequent Prophylactic and safe monitoring is not the reality Babies develop apnoea unseen sometimes with severe consequences For this re
108. onto the tray Fill the pot with antiseptic solution Wash hands Gown up and put on sterile gloves Attach the 25G needle 2cc syringe and draw up 0 5cc of lignocaine Remove the stylet from the ICC Clamp the ICC with the straight artery forceps several cms down the ICC Nurse to firmly secure the baby in the supine position rolled with the affected side elevated 60 using a towel arm held above head Wash the area over the anterior and lateral chest with antiseptic Drape Locate the landmarks the nipple the anterior axillary line the 4 or 5 intercostal space and estimate the length of ICC needed inside the chest distance from incision site to midclavicle Infiltrate the skin and subcutaneous tissues through to pleura with the lignocaine Make a small incision 2 5mm through the skin and the immediate sub cutaneous tissues with the scalpel Place the small mosquito forceps over the cut and gently push and split blunt dissection the tissue by slowly opening closing the forceps Stay as close to the upper edge of the rib below the cut as you can this is difficult to discern in a small baby Do this until you feel a give in resistance as you enter the pleural space Remove the forceps and then holding the tip of the ICC with the curved artery forceps pass the clamped ICC up through the opening you have just created directing it towards the head and mid clavicle You should s
109. or APNOEA If apnoeic stimulate If no response remove the tube bag mask with oxygen and call the doctor ii There may be a leak if the baby s mouth is open Try closing the baby s mouth lift the chin to see if this resolves the problem If it does this confirms a leak is the problem 1 Place a small roll under the baby s shoulders to extend the neck a little 103 2 Use dummy or a gauze chin strap to stop the leak 3 Increasing the gas flow eg 6L to 8L may improve the bubbling and compensate for a leak out the mouth however call a doctor before doing this b Ifthere is still no bubbling when you occlude the circuit there is a machine problem i Check again the gas flow is turned ON ii Check for a circuit leak check nothing is disconnected and that the bottle lids are closed firmly 11 Secure the circuit with tape onto the side of the baby s bed so that it doesn t pull the nasal tube out a Be sure that the circuit arms are lower than the baby so that water droplets that precipitate in the tube don t run down into the baby but run back down into the humidifier bottle b Ensure the CPAP tubing is not pulling up against the baby s nostrils but following a downward position An upward pulling position will cause pressure areas and nasal damage 12 Insert OGT size 8F or larger and aspirate then leave it open this is to prevent CPAP belly 13 Wrap nest the baby securely so that his arms cannot pull
110. or it may be a patient problem a A Machine circuit problem i circuit disconnection ii nasal tube blockage iii oxygen supply run out or turned off b A Baby problem i Recurrent Apnoea ii Underlying lung disease is worsening iii Complication of CPAP a lung overdistension pneumothorax b gastric distension aspiration 141 iv Development of a new problem such as a sepsis pneumonia b PDA 2 List a series of actions that are needed to help work out the actual reason for his deterioration a Call for help consider whether to b Increase the FiO2 by 10 20 or more if needed i Check for apnoea ii If present stimulate the baby iii If the baby does not begin breathing within 20 30 seconds take off CPAP and ambubag mask with oxygen c Quick Machine Check i Connections intact ii Oxygen on and cylinder full iii Settings correct PEEP oxygen flow rate iv Bubbling a Fix any problem immediately b If no improvement continue d Quick clinical assessment i Auscultation pneumothorax a If unsure transilluminate or order portable CXR ii Hypotension reduced cardiac output a Try bolus of fluid 10cc kg normal saline e Check the tube obstruction i Suction the tube and airway ii Change the tube if you have any concern that it is blocked iii If this does not resolve the problem continue f Increase the settings i Oxygen 5 increments ii Pressure increments 1cm up to a maximum of 8 do not
111. ore The inlet and outlet air filters on the air compressor will need to be intermittently checked and cleaned or replaced by BME as needed Cleaning the CPAP unit 1 2 Ensure the CPAP is turned off and the power cord is disconnected from the wall Take the heating wire out of the patient circuit and check it for breaks or kinks It is not necessary to disconnect the wire from the back of the unit to do this However 2 people are required One person holds the circuit out straight while the other takes out the wire If there are breaks or kinks in the wire it cannot be used call Biomedical Engineering 99 7 Place the bottles and circuits in the washer bath The bottles stand in the brackets Plug the small clear tubing from the bath into the common gas inlet on the inspiratory bottle Plug the open ports in the bottle lids with the plugs supplied These plugs seal the 2 bottles and tubing together so that the water sterilizing agent will reach all inner surfaces Note 2 sets of brackets allow 2 bottle sets to be washed at one time 3 Wipe the heating wire with alcohol then leave it hooked over the machine whilst the patient circuit and bottles are disinfected 4 Disconnect the common gas tube from the lid of the inspiratory bottle and then lift both bottles and the patient circuit off the machine 8 Turn ON the switch on the bath and allow the wash to run for 2 hours 5 Wash the bottles and the circuit with dishwa
112. osed vocal chords in an attempt to make its own CPAP to try and keep the lungs open during expiration Severity When respiratory distress becomes severe babies become tired and their respiratory muscles FATIGUE The baby s respiratory drive may be affected Babies may begin to have periods of hypoventilation respiratory rate lt 30 minute gasping slow deep abnormal breaths or apnoea Apnoea associated with severe respiratory distress occurs in both term and preterm babies Aetiology of respiratory distress Respiratory distress may be caused by a wide variety of conditions Most commonly it is caused by lung conditions however it may also be present in various extra pulmonary conditions see table 23 Table 4 Causes of respiratory distress in neonates Respiratory system Hyaline Membrane disease HMD Pneumonia Meconium Aspiration syndrome Other aspiration Transient tachypnoea of the newborn TTN also called wet lung Pulmonary haemorrhage Congenital malformations eg cystic abnormalities Pulmonary hypoplasia Pneumothorax Pleural space Pleural effusion Airways obstruction Extrapulmonary Cardiac failure with pulmonary oedema Cardiac Persistent pulmonary hypertension PPHN Congenital diaphragmatic hernia CDH Gastrointestinal Tracheo oesophageal fistula Sepsis Shock Systemic process Hypoglycaemia Hypothermia Muscle disease myopathy The purpose of including t
113. ossible presence of complications 71 CPAP what to monitor 12 m Machine settings pressure FiO2 flow are they as ordered Circuit connections are they correct and intact m Oxygen level is the cylinder approaching empty m Water Does it need filling Is it bubbling m Humidity is there water droplets in the tubing to empty m Temperature reading is the reading close to the set temp m Alarms is the alarm light on Equipment checks can be done at the same time as patient observations Equipment checks should also be recorded on the patient monitoring form They should be done at east 4 hourly but it is preferable to check each time patient observations are performed Equipment checks can be done very quickly with practice Checking equipment and responding to problems early will prevent later complications and problems with the baby CPAP and the Baby with Difficult Breathing Troubleshooting the machine No bubbles in expiratory bottle ALARMS display says sensor off and no tubeset ALARMS display says check temp sensor or check set temp ALARMS display says no flow Gas turned off or disconnected A leak in the system a bottle lid is not sealed or a tube disconnected Baby apnoeic Large leak out baby s mouth mouth open Heater wire disconnected Electrical malfunction The sensor in the patient circuit measures a temperature gt 40
114. out the tube and so that he is comfortable 14 Perform another set of observations at 15 minutes after starting See care of the baby on CPAP 12 2 Care of the baby on CPAP 1 Monitoring Immediate response to CPAP 15 mins after starting CPAP do another set of observations i If SpO2 gt 95 reduce FiO2 by 5 continue to reduce FiO2 by 5 every 15 minutes until SpO2 in correct range 85 9396 for preterms 90 95 98 for term babies 104 CPAP and the Baby with Difficult Breathing Patient observations 1 Tube tapes are secure prongs are in i If SpO2 lt 90906 increase FiO2 by 5 and observe response if saturations remain lt 90 call doctor PEEP and or flow may need to be increased A CXR may be needed b Routine observations should include Machine observations Vital signs SpO2 RR HR 1 Machine settings pressure FiO2 flow are they as ordered Respiratory effort retractions grunting flaring Circuit connections are they correct and intact Peripheral perfusion colour warmth urine output Oxygen level is the cylinder approaching empty General level of comfort Water Does it need filling Is it bubbling place Humidity is there water rain in the tubing to empty Secretions need suctioning Nasal skin for redness Temperature reading is the reading close to the set temp Abdominal distension Alarms is the alarm light on Record observations
115. p parents understand CPAP because many parents will find the machinery and attachments frightening It is very important they understand what they can and shouldn t do while their baby is on CPAP Explaining these things to them helps them feel more involved in their baby s care 1 Why your baby needs CPAP Your baby is going to be treated with a machine we call CPAP This machine helps your baby with its breathing The baby is getting oxygen as well as other support through the machine and the tubes that attach to the baby s nose The doctors have decided to use the CPAP for your baby because his her breathing is very difficult and if we dont use the CPAP he will get sicker The CPAP helps your baby breathe and helps him get better more quickly 2 How long will my baby be on CPAP Some babies need CPAP for only one day others need it for several days How long your baby is on CPAP will depend upon how sick your baby is Every day the doctors will check to see whether your baby can have less CPAP than the day before and whether he is ready to stop the CPAP or not 3 What are the possible problems for the baby on CPAP Most babies have no problems on the CPAP machine Some babies get some swelling of the abdomen due to gas from the machine entering the stomach The nurses can manage this Very rarely a baby will have a problem in the lung due to the CPAP machine This is called a pneumothorax IF this happens a doctor will discuss it with
116. piratory distress 36 Hyaline membrane disease HMD sse 36 Meconium Aspiration Syndrome MAS sss 36 Transient Tachyphnoea of the Newborn 37 CER CE Ek d AR ER RR 37 CPAP Continuous Positive Airway Pressure eene 44 What CPAP cusan ot herr 45 Why use ri card 45 Characteristics of CPAP that make it suited use in low resource COMTEXT S ed on Da oC EO FEE dt e prre n Ede 45 When can CPAP be used eene tenter tenete tnit tenta 47 4 1 CPAP for apnoea terit cenb nhe dr ra Fa daa to dt na epa Rasen 47 4 2 CPAP for respiratory distress sss 47 4 3 Neonatal conditions which may respond to 48 When should CPAP not be 7 sese 49 5 1 Contraindications sse tnter nnne trate 49 5 2 Situations where CPAP is unlikely to 49 CPAP and the Baby with Difficult Breathing 5 3 CPAP for older nda Sx rx dr anis 49 How does EEN 50 How is CPAP IVen iniecit nite Dae Fee ke E trees ER aea 51 7 1 Pressure driven CPAP uode Dro
117. piratory pressure bottle B Inspiratory heating bottle Front panel of control box Back panel of control box li ti I Patient circuit p 52 CPAP and the Baby with Difficult Breathing Air compressor The air compressor is a pump which extracts air from the atmosphere by suction and drives it into the CPAP machine at pressure 400kPa The air is cleaned by a filter and then travels from the compressor to the blender The air compressor requires electricity to work In case of power failure the pump will not work and no air will be supplied to the CPAP device Blender and gas flows The blender controls measures and mixes gas flow before it is sent through the CPAP system receives gas from the air compressor and from the external oxygen supply An oxygen source is NOT part of the CPAP device and must be provided separately This is discussed later p 62 Air gt There are 2 separate compartments inside the blender one for the air and one for the oxygen Each chamber has a separate flow meter air on the right oxygen on the left which can deliver flow from O 10L minute However combined flow rates of more than 8L are rarely used The flow meter contains a ball float which rises up as the flow valve is turned on The set flow is measured by the level of the middle of the ball float against the markings on the side of the flow meter The user determines how many litres
118. piratory distress then observations can be reduced to 4 hourly 91 10 HOW TO MAKE CPAP WORK WELL IN YOUR HOSPITAL Hospitals who decide to make CPAP available must understand the issues that determine its safe and effective implementation Certain prerequisites must be met these are summarised in the table below The responsibility for effective implementation of CPAP lies across hospital disciplines Responsibilities Prerequisites Ensuring the necessary staff numbers skills medical and nursing biomedical radiology are available to care for CPAP babies Ensuring staff are sufficiently skilled through training and ongoing competency checks Ensuring the hospital has written policies and procedures for safe use of Administration outlining how when and where it will be used Ensuring the availability of the necessary equipment and supplies to run CPAP Ensuring access to biomedical support for CPAP Hospitals without ventilators should also have policies for when to refer to other centres for a higher level of care if available 24 hour in house cover Medical staff Trained and competent in using CPAP including recognising and managing complications 24 hour in house cover Minimum nurse patient ratio of 1 3 Nursing staff is Trained and competent in using CPAP including recognising when to call medical staff Owe Guaranteed reliable supply m Maintenance of oxygen supply system is readily available
119. pothermic nor too hot febrile Sick and small babies are not good at controlling their own temperature and are easily affected by problems with the environment e g drafts warmers set at inappropriately high temperatures They frequently need to be cared for under a radiant warmer or if available in an incubator to assist with thermoregulation If babies become either too hot or too cold their general condition may deteriorate More information can be found in Managing Newborn Problems WHO 2003 Infection Prevention Infection prevention is an extremely important part of care of all newborns Sepsis can cause serious deterioration or even death Important aspects of infection prevention for babies on CPAP include Strict handwashing Use of aseptic technique for procedures including preparing a nasal tube for CPAP and suctioning Use of aseptic technique for handling IV fluids drips and medications Correct isolation practices Correct cleaning and disinfecting of equipment i e the CPAP p 99 Changing the bottles and patient circuits as recommended Using only sterile or disinfected water to fill the bottles Strict attention to preventing injury to the nose Maintaining breastfeeding Again for more information refer to Managing Newborn Problems WHO 2003 80 CPAP and the Baby with Difficult Breathing Positioning Positioning is an important but often forgotten part of patient care Prone positioning ma
120. prefer to breathe through their nose so if one nostril is occluded with a CPAP tube then it is better to leave the other unoccluded If a baby cannot be fed then IV fluids must be provided Again refer to Managing Newborn Problems WHO 2003 A baby on CPAP should not be fed if Severe or worsening RDS FiO2 gt 60 severe retractions Moderate or severe CPAP belly and or more than 2 gastric aspirates of gt 25 of the previous feed or bile stained gastric aspirate Other GI complication such as GI bleeding or vomiting Anticipating a trial off CPAP in next 4 hours Patient comfort Patient comfort is important If a baby is uncomfortable on CPAP it is distressing for everyone Equally importantly if the baby is unsettled it will interfere with oxygenation the CPAP may be less effective more secretions are produced and there is a greater risk of pneumothorax Reasons a baby may appear uncomfortable include pain hunger fever hypoxia worsening respiratory status Fever Fever is easily checked If febrile the baby should be examined to determine a cause for fever Antibiotics may be required and paracetamol can be given to help reduce the fever and improve comfort Fever may be caused by external heating devices If a baby is under a warmer reduce the set temperature Hunger If a baby cannot be fed for medical reasons sucking a dummy dipped in sucrose solution may calm him If the ba
121. r tube change ready at bedside Written protocols for CPAP exist and readily available Job aides for CPAP exist and readily available ee Babies in nursery on CPAP at of review have correct indication for CPAP CPAP being used correctly machine set up correct oxygen use correct for babies in nursery on CPAP at time of visit 126 CPAP and the Baby with Difficult Breathing No babies in nursery who need CPAP who are not receiving CPAP at the time of visit Babies in nursery on CPAP are having regular monitoring observations done and recorded MEDICAL STAFF Know indications for starting CPAP Knows correct start settings for CPAP Knows correct oxygen ranges for babies treated with CPAP Knows differential diagnosis for why a baby may be getting worse on CPAP Know indications for stopping CPAP Know signs a baby is deteriorating Knows what to check on the machine and on the baby when a baby is deteriorating Knows correct actions for the problems with the CPAP machine see table p 73 Can correctly explain how the CPAP works and the individual components of the machine NURSING STAFF Know signs a baby is deteriorating Knows what to check on the machine and on the baby when a baby is deteriorating Can correctly demonstrate how to set up the CPAP machine Demonstrates correct suction technique Demonstrates correct technique for inserting and or changing CPAP nasal tube Knows t
122. r sets the pressure A common type of pressure driven CPAP is known as Bubble CPAP so called because bubbles are created when the baby breathes out and the expired gas enters the water out the end of the expiratory limb of the CPAP circuit see diagram p 61 7 2 Flow driven CPAP These machines use changes in the flow of gases to determine how much pressure is generated The user sets only the flow rate These machines tend to be more expensive than bubble devices and require more technical expertise to operate They may be slightly more effective for some conditions They are not described further in this manual The EMW CPAP machine is an example of bubble CPAP How it works is explained in detail on the following page 51 8 DOES THE EMW CPAP MACHINE WORK Here is a simplified explanation of how the EMW CPAP works As this manual is meant for use by a wide variety of health workers technical terms have been kept to a minimum Further biomedical detail for engineers can be found in the EMW biomedical maintenance manual The diagram illustrates the EMW CPAP device and names its main components The purpose and function of each of the components is briefly described The parts are described in series beginning with the gas compressor The control box is described last A block diagram illustrates the functional circuit of the CPAP system 8 1 Main parts of the CPAP machine Air compressor _ o d Blender SN Ex
123. r that will comfortably fit into the baby s nostril without significant resistance Suggested sizes are Baby Weight lt 1250 grams 1250 2000 grams gt 2000 grams 2 Wash hands and put on a pair of gloves 3 Prepare on a clean cloth or tissue a ETT take it out of the wrap b String cut a piece c Tape d Scissors e Lubricant if available 4 Cutthe tapes which will be used to fix the tube 5 Remove the connector from the end of the tube 6 Measure the distance to cut the tube To do this place the ETT against the side of the baby s face and measure the distance from the baby s external nostril and the ear lobe Add 3cms which is the distance of tube that should protude from the nose 7 Using sterile scissors cut the ETT to the measured length with an oblique cut to the tube 8 Reattach the connecting end of the ETT to the cut ETT 9 Preserve the other part of the ETT by placing it back in the sterile wrapper It can be used later when the tube is changed a single ETT can make 2 3 cut tubes 10 Tie a piece of string firmly around the tube with a double knot The tie should be on the tube at the level where it exits the nostril This is used to later help to know how far the tube sits in the nose It also helps secure the tapes 11 Lubricate the end of the cut ETT with the baby s saliva or glycerine KY gel 109 2 people are needed to insert and secure the tube Inserting the tube 12
124. ranspulmonary pressure better than conventional respiratory management of hyaline membrane disaese A controlled study Pediatrics 58 1976 800 808 Durbin GM Hunter NJ Mclntosh N Reynolds EO Wimberley PD Controlled trial of continuous inflating pressure for hyaline membrane disease Arch Dis Child 51 1976 163 169 Buckmaster AG Arnolda GR Wright IM Henderson Smart DJ CPAP use in babies with respiratory distress in Australian special care nurseries Paediatr Child Health 2007 43 376 382 Polin RA Sahni R Continuous Positive Airways Pressure Old questions and new controversies J Neonatal Perinatal Medicine 1 2008 1 10 Henderson Smart DJ Subramaniam P Davis PG Continuous positive airway pressure versus theophylline for apnea in preterm infants Cochrane Database of Systematic Reviews Reviews 2001 4 CD001072 All India Institute of Medical Sciences Division of Neonatology Clinical Protocols Protocol for Administering Continuous Positive Airway Pressure in Neonates DRAFT Accessed 28 3 2001 at http www newbornwhocc org pdf cpap 310508 pdf Wyszogrodski Kyei Aboagye Taeusch HW Jr Avery ME Surfactant inactivation by hyperventilation conservation by end expiratory pressure J Appl Physiol 1975 38 461 466 CPAP and the Baby with Difficult Breathing 25 26 27 28 Rehan VK Laiprasert J Nakashima JM Wallach M McCool FD Effects of continuous positive airway pressure on diaphragm
125. reathing patient When a baby being treated with CPAP breathes OUT the pressure generated by the machine helps to keep the baby s alveoli and small airways open and prevents them from collapsing In technical terms functional residual capacity FRC of the lungs is maintained This increases the amount of lung which is available for gas exchange and is the main way that CPAP improves breathing CPAP has additional effects on the alveoli and other components of the respiratory system which also improve a baby s breathing 23 splinting open the upper airway protecting surfactant 24 reducing the amount of fluid oedema in the alveoli stabilising the chest wall 25 Stretching the lungs and pleura allowing more blood to flow through the lungs These effects all work towards increasing blood oxygen reducing the work of breathing and reducing apnoea CPAP improves oxygenation reduces the work of breathing and reduces apnoea 13 reduces ventilation perfusion mismatch 14 reduces pulmonary vascular resistance 50 CPAP and the Baby with Difficult Breathing 7 HOW IS GIVEN CPAP can be given either via a conventional ventilator which has both regular ventilation and CPAP modes or via a stand alone CPAP device There are 2 main types of stand alone CPAP devices 74 Pressure driven CPAP These machines use a constant flow of gas and another mechanism determines the pressure The use
126. recurrent apnoea Babies who have severe or recurrent apnoea have inadequate drive to breathe to benefit from CPAP 21 This is common in severe perinatal asphyxia or brain infections 2 Severe cardiovascular instability Babies with cardiovascular instability e g severe sepsis do not usually do well on CPAP CPAP often exacerbates the hypotension found in these situations 3 Severe and progressive respiratory failure Babies who have very severe lung disease where oxygen saturations are very low despite high inspired oxygen eg FiO2 gt 60 and respiratory distress is very severe may require more support than can be provided by CPAP In these situations and where the necessary skills and resources are available intubation ventilation is the treatment of choice If this is not an option there is little to be lost in a closely observed trial of CPAP However families should understand that the outcome may not be successful 5 3 CPAP for older babies CPAP may also be used for older infants with RDS especially bronchiolitis or pneumonia with airway problems and after extubation This is not discussed further in this manual as the focus is on neonatal care 12 Maybe defined in terms of blood gas analysis as an inability to keep paO2 gt 50mmHg paCO2 lt 60mmHg or pH gt 7 25 20 22 49 6 HOW DOES CPAP WORK CPAP works by providing a constant pressure with a variable amount of oxygen to the airway of a spontaneously b
127. resent the affected side will glow like 24 Procedural protocol adapted from protocols at Department of Neonatology Children s Hospital amp Research Center Oakland California USA provided by Dr Priscilla Joe and Royal Children s Hospital Melbourne Australia medical guideline Chest tube insertion www rch org au 114 CPAP and the Baby with Difficult Breathing a lantern and is clearly different from the other side If you suspect a pneumothorax on transillumination AND the baby is managing to keep SpO2 gt 85 on the increased oxygen try and get a portable CXR to confirm the size and position of the pneumothorax a lateral decubitus CXR will confirm the air as anterior or posterior If you suspect a pneumothorax on transillumination AND the baby is NOT managing to keep SpO2 gt 85 on the increased oxygen or the pneumothorax is causing tension severe respiratory distress displaced apex reduced blood pressure drain the pneumothorax using a butterfly needle see below Get a portable CXR as soon as possible Definitive management Once CXR confirms pneumothorax f pneumothorax is gt 20 of the lung volume or the baby is on positive pressure ventilation or if the baby is on CPAP and the baby has moderate respiratory distress or oxygen requirement or the pneumothorax has caused a deterioration then it will need to be drained with an intercostal catheter ICC Insert according to protocol f pneumothorax is lt 20
128. ress The second part CPAP focuses on the machine itself and the treatment of neonates with CPAP A detailed index is on the following page SPECIFIC CHAPTER LEARNING OBJECTIVES m understand how to recognise babies with apnoea and babies with respiratory distress m To know how to correctly manage babies with apnoea and babies with respiratory distress m Tounderstand what CPAP is m To know how the CPAP machine works To understand when to use CPAP To be able to safely and correctly use CPAP To be able to safely and correctly care for the baby being treated with CPAP The material in this manual can be used in various different ways either for individual or group learning with or without a facilitator Material is presented in text form as protocols and bedside Job aides There are also practical exercises and supervision tools Sufficient materials are provided for a complete training and follow up exercise __ I IULLULLIULEGIOIGILoc USOGLTUIadcU cOC L GLUuLLL LILGEG z e wl PARTA BABIES WITH DIFFICULT BREATHING Sick neonates often have difficulty breathing It may signal primary lung problems or may be a sign of other diseases or conditions It is important that clinical staff working with neonates are competent in recognising and correctly managing babies with these problems within the limits of available resources In this manual both apnoea inadequate breathing and respiratory distress are considered
129. ridge and both legs wrap around the tube Two trouser leg tapes Top of trousers one cheek and split legs one above and one below one around tube and the other straight across to other side Mirror image 3 whole tape with hole across all Much more difficult to change or remove 110 CPAP and the Baby with Difficult Breathing 12 6 The patient interface example fixation of nasal prongs Preparing the prongs for insertion 1 Select the correctly sized prongs the right size is the largest diameter that will comfortably fit into the baby s nostril without significant resistance 2 Suction the nostrils as per protocol 3 Gently insert into the baby s nose being sure to angle the prongs down and back Ensure the prongs are not tight in the baby s nostrils 4 Use fixations that come with the prongs or makeshift as in the diagram Choose an adult cotton sock Mark 3 4 lines with a pencil according to the required size 4 Cut along the dotted line One end has to be stitched for the other 2 pieces 4 Stitch the edges to make them smooth 4 Make two holes at the sides to attach the tapes 4 Attach tapes to these holes 4 Fix the cannula using the tapes as shown 112 CPAP and the Baby with Difficult Breathing 12 7 Counselling sheet for parents of babies on CPAP This sheet can be given to parents to read or can be read with them It is important to spend the few minutes it takes to hel
130. rticularly important It can be less comfortable for the baby than softer shorter nasal prongs How to prepare insert and fix a cut ETT is shown on p 109 A single ETT can be cut into 2 or 3 smaller lengths to enable 2 3 uses Note it is very important that the ETT is cut to the correct length An uncut ETT must NOT be used the resistance to breathing is too high and work of breathing is greatly increased Correct Incorrect Nasal prong devices CPAP with nasal prongs has been shown to be more effective than CPAP delivered through a single nasopharyngeal tube cut ETT 26 As the prongs are short there is minimal resistance to flow so pressure is transmitted more effectively to the lungs Various devices are available Each is designed with an adaptor to allow them to connect to the CPAP circuit Many also come with fixation devices such as caps velcro tapes and ties Fixation is the biggest disadvantage of these devices As the prongs are only inserted into the anterior part of the nares it is easy for them to dislodge Once the prongs are dislodged the CPAP is ineffective The prongs may also cause nasal trauma There are fewer problems 64 CPAP and the Baby with Difficult Breathing with secretion production compared with longer prongs However these devices may not be affordable or readily available in low resource contexts Commonly used brands include Hudson Argyle and Inca prongs Images are included in the table An example o
131. s as respiratory distress in the first few hours after birth It is thought to be due to delayed removal of fetal lung fluid which is usually largely removed during delivery It occurs most often in caesarean deliveries and precipitate or breech births The lack of a normal labour process impedes the usual clearance of fluid The respiratory distress of TTN is typically not severe it is rare for oxygen requirements to go beyond 40 free flow oxygen so it is rare for babies with TTN to need treatment other than free flow oxygen A few will need CPAP or even ventilation Pneumonia Pneumonia is a common cause of neonatal respiratory distress particularly in low resource contexts where infections make up a large proportion of morbidity at all ages Pneumonia may occur together with sepsis and or meningitis The infection may begin in utero due to 9 A recent multicentre randomised controlled trial found there was no advantage in oral and pharyngeal suction as the head delivers 11 37 XG 15291 ye pue S sou eq 0 pe4eisiunupe BuiiB 10 MOT P99N 16 0 xoeq 1S lUM peo ueo 1 y ON PINOYS 1
132. s broken kinked Forcefully disconnecting the wire may damage the wire 3 Connect the clear air hose to the air outlet on the back of the oxygen blender 4 Connect the blue oxygen hose to the wall oxygen outlet or oxygen cylinder regulator 5 Place the bottles in the bracket on the side of the unit a The inspiratory bottle is the humidifying bottle It sits in the posterior bracket b The expiratory bottle is the pressure bottle the bottle which provides the PEEP It has the numbers 1 10 in cms printed on the side in addition to the 400cc markings which both bottles have This bottle sits in the anterior bracket 6 Connect a disinfected patient circuit to the unit Insert the clean heating wire in the inspiratory limb Attach the ends of the patient circuit to the thermos bottle lids The white connector end of the inspiratory arm of the circuit attaches to the lid of the humidifier thermos bottle The black connector end of the expiratory arm of the circuit plugs into the lid of the pressure thermos bottle Rest the neck of the circuit on the metal support clips on the arm of the CPAP unit 7 Connect the small clear tubing from the back of oxygen blender the common gas flow to the small knob on the top of the inspiratory humidifier thermos bottle lid 8 Cover the whole unit with a cloth It is ready for use 102 CPAP and the Baby with Difficult Breathing 12 NURSING PROTOCOLS 124 Starting the baby on CPAP 1
133. se are available and if indicated from history and examination Ongoing management Ongoing management involves general supportive care as well as care specific to apnoea and its cause a Specific i If apnoea of prematurity start stimulant medication below ii Provide any treatment specific to the cause 2 CPAP is unlikely to be effective if there is no spontaneous breathing after a prolonged apnoea Intubation ventilation may be considered earlier depending upon the skills of available personnel availability of equipment and the safety of ongoing ventilation 16 CPAP and the Baby with Difficult Breathing ii Give glucose if hypoglycaemic BSL lt 2 5mmol or if unable to exclude hypoglycaemia unable to quickly check blood glucose iv Give antibiotics ampicillin penicillin and gentamicin or in severe cases cefotaxime ceftriaxone unless sepsis can be excluded v Start CPAP if no response to medication apnoea continues vi Intubate ventilate if this is an option if spontaneous respiratory drive doesn t return if apnoea is prolonged or severe or if CPAP fails b Supportive care i Monitor for further apnoea desaturation and bradycardia with electronic monitoring SpO2 monitor if available If this is not an option close nursing observation is essential ii Teach parents to observe for apnoea how to give tactile stimulation and to call for help if their baby has apnoea Avoid vigorous suction which may ex
134. shaking GENTLY Be careful not to dislodge the tube from the baby s nose while you do this g The measured temperature of the inspired gas shown on the lower screen is the same as the set temperature If there is a difference of more than 1 degree check there is enough water in the inspiratory bottle If there is enough water and the problem remains call Biomedical Engineering 11 4 Alarms The alarm on the CPAP unit has both a LIGHT and a SOUND For the sound to work the orange button must be pushed IN The sound can be turned off by pushing the orange button OUT When there is an alarm condition the alarm light will always be on The RED alarm light will illuminate and the orange buzzer will sound if 98 a The temperature in the patient circuit is too low The bottom screen will display a warning message Note that the patient circuit can take a little while to reach the set temperature During this time the temperature too low alarm may start This is normal and no action is required However in other circumstances Check the gas CPAP and the Baby with Difficult Breathing flow is turned on Check for leaks in the circuit are the air compressor and the oxygen supply and the common gas tubing all connected correctly Are any of the tubes disconnected or bent Check if air conditioning or vents are blowing across the patient circuit If no correctable problem is found change machines and call Biomedical Engineering b The te
135. shing detergent and cold water Then rinse 9 Remove the bottles circuits and rinse in sterile bottled water off the detergent 10 Allow the bottles and tubing to drip dry or dry using the air compressor or other similar device in a very humid environment it will take a long while to completely dry the 6 There are 2 versions of the MTTS washer bath tubing without using a drying device a Stainless steel bucket Fill with 20L of disinfectant solution Bayclin 0 5 solution mix 18L water with 2L 5 Bayclin sodium hypochlorite 11 When the components are dry reassemble the machine b Plastic bucket Fill with 13L of disinfectant solution Bayclin 0 5 solution mix 11 7L water with 1 3L 5 Bayclin sodium hypochlorite NOTE After prolonged use you may see white calcium appearing inside the bottle and tube 100 CPAP and the Baby with Difficult Breathing 101 To get of it you should 3 liters of vinegar and 3 liters of hot water mixed together Soak the bottle set and silicone tube inside the basin There is no need to run the water pump in this case Leave the bottle set and silicone tube to soak overnight Next day the calcium will have disappeared Assembling reassembling the CPAP unit 1 Plug the cable from the air compressor into the 220V power socket on the back of the CPAP unit 2 Plug and screw the heater wire into the back of the CPAP unit never disconnect the heater wire from the back of the unit unless it i
136. so available and if ABG results are used to determine when to stop CPAP and to use IPPV Table 11 Suggested start settings for CPAP for various conditions N APNOEA Non HMD Post ventilation Bigger baby LUN 6L minute combined flow oxygen air 6L choose a combination of flows to give the desired FiO2 50 in dryer climates set at 80 These start settings are a guide only Although they may suit many babies it is imperative that the doctor and nurse remain with the baby to observe the baby s immediate response to the CPAP They must decide whether the baby is responding and whether the settings require adjustment The recommended start FiO2 levels are very empiric On very sick babies you may begin with 100 This is acceptable as long as you remain with the baby to reduce the FiO2 69 towards the more appropriate level according to saturations p 76 Babies with apnoea 4 IF ventilation is an option it should be considered for babies who require gt 8cms may not any supplementary oxygen pressure FiO2 gt 70 If analysis is available this may help to decide when to use ventilation e g unable to maintain paO2 gt 50mmHg paCO2 gt 60mmHg pH 7 25 21 However ABG analysis is rarely readily available as to be useful for decision making in low resource contexts 9 3 How to care for babies being treated with CPAP Immediate response 9 4 Regular patient monitoring Whether CPAP is helping the baby is
137. term babies 88 93 term babies gt 90 The general principals of weaning from CPAP are as follows wean only one thing at a time i e pressure or 102 wean gradually do not be tempted to wean quickly Wait at least 6 hours in between changes of pressure FiO2 can be weaned more quickly depending on baby s condition always observe a baby for at least 30 minutes following a change to settings don t wean if you cannot stay around to observe the effect of the changes Oxygen FiO2 should be weaned before pressure if FiO2 is gt 50 UNLESS the baby s problem was pneumothorax or overdistension In this case wean pressure first until it is 5 or 6 cms then reduce FiO2 Reduce FiO2 in steps of 5 Pressure Pressure should be weaned 1cm at a time Reduce pressure to 5cm there is NO benefit in reducing pressure to lt When to stop the CPAP In general terms a baby can be tried off CPAP when The baby is stable for at least 48 hours The FiO2 is 35 or less for at least 12 hours PEEP is 5 at least 24hrs consider stopping when PEEP 6cm in a bigger baby if the FiO2 is satisfactory There is no apnoea The baby is haemodynamically stable and no other medical problem Protocol for stopping CPAP Withold feeds for 4 hours prior to trying the baby off Prepare a spare cut and tied nasal tube to be used in case the baby fails the trial off Ensure suction oxygen and ambubag mask are
138. the 81 baby s head and the CPAP tube during the suction Nurse 1 passes the suction catheter into the tube to the predetermined distance do not pass it further it will irritate the mucosa Apply suction 80 100cmH20 while withdrawing the catheter using a circular motion Suction lt 6 seconds in total Note vital signs Only repeat the procedure if there were a lot of secretions 2nd nurse reconnects the baby Suction the other nostril and the mouth you may change to an 8F catheter Suction a little sterile water into the tube to clean the tubing removes the catheter and discards Turn off suction remove gloves and wash hands Document suction result of suction amount and consistency and colour of secretions and response of baby to suction did vital signs improve If the baby requires suction and a 2 nurse is unavailable the 1 nurse detaches the tube from the CPAP with one hand steadies the tube using the same hand and inserts the catheter using the other clean hand Care is especially required to steady the ETT and infant s head to ensure the tube doesn t accidentally come out 82 CPAP and the Baby with Difficult Breathing 9 7 Whatif the baby is deteriorating Clinical signs The signs that a baby is deteriorating are the same as the signs that the CPAP is not working p 75 Possible reasons for deterioration If a baby deteriorates after having been stable or improving on CPAP it may be
139. the late 1980 s when it was seen as a potential way of avoiding chronic lung disease bronchopulmonary dysplasia BPD which had emerged as a complication of IPPV As CPAP was known to cause less barotrauma than IPPV it was hoped BPD would occur less frequently if babies could be treated more with CPAP and less with IPPV Research has since confirmed that CPAP reduces the incidence of BPD in preterm babies 12 13 14 It has also proven that 1 CPAP reduces mortality in preterm neonates 12 15 2 CPAP reduces the need for ventilation IPPV especially when used early for babies with HMD 12 15 16 3 Extubating babies from ventilation to CPAP reduces the need for reventilation 12 15 17 18 19 4 Using CPAP at nontertiary centres in a developed country setting reduces the need for up transfer of neonates with RDS of mixed causes to tertiary centres for ventilation 20 These advantages make CPAP attractive for neonatal care in both developed and less developed countries The reduction in BPD has been the main motivation for its use in the developed world where CPAP is increasingly used as first line treatment for neonatal respiratory problems especially for very low birth weight babies 21 Other features of CPAP make it particularly suited for use in low resource contexts where staff numbers monitoring and biomedical maintenance facilities are limited and where other treatments may not be available due to cost 3 CHA
140. this bottle contain heater elements This heats the water in the bottle according to how much heat is set by the user Heat is set with the humidity knob on the front of the control box for the first 45 minutes 55 after the CPAP is turned on the amount of power delivered to these heater elements is set to 100 After this the heat can be set from 45 70 see below Increasing the heat increases the humidification of the gas Gases enter the inspiratory bottle via the common gas tube which enters the lid of the inspiratory bottle The force of the gas flow entering the water creates bubbling in the bottle The gas picks up both heat and moisture as it passes through the water so the gas leaving the bottle is heated and humidified The gas leaves the inspiratory bottle through a hollow metal tube which is not submerged in the bottle and which comes out through the lid 21 100 Air inta patient 16 The inspiratory bottle could equally be called the heater bottle or the humidity bottle 56 CPAP and the Baby with Difficult Breathing Patient circuit The patient circuit is the long light blue corrugated silicone tubing which connects the CPAP bottles to the patient interface at the baby s nose There are 2 arms to the circuit inspiratory and expiratory 57 The inspiratory arm arises from the hollow metal tube in the inspiratory bottle It carries the gas from the inspiratory bottle to the interface at
141. toring may not be possible as nurses are too busy There needs to be a balance between what is safe and the reality Hospitals who commit 73 74 to offering CPAP must be responsible and ensure a minimum nurse ratio for safe patient care Monitoring frequency will vary a little according to how unwell the babies are A ratio of 1 nurse to 3 CPAP should be the ABSOLUTE maximum patient load With this ratio patient observations can be performed 1 2 hourly CPAP and the Baby with Difficult Breathing 9 5 When to call the doctor A nurse should call for medical assistance when he she is concerned a baby has deteriorated or may have a problem that needs medical attention The following list is a guide of specific circumstances when a doctor should be notified It cannot cover every possibility a good principal is if you are worried or unsure then call Baby problem 1 2 3 ja PRU e A need to increase FiO2 gt 10 or more in a 4 hour period 5 02 lt 90 even after increase FiO2 by 10 More than 3 apnoeas or 1 apnoea that does not respond to stimulation and requires bag mask ventilation Concern the baby has a pneumothorax sudden deterioration in respiratory status Abdominal distension or feed residuals more than 2596 of feed or bile or vomiting Signs of inflammation of the nose Bleeding from the nose Machine problem 1 2 3 21 No bubbling in expiratory bottle and cannot resolve it with simple me
142. tory rate of gt 60 breaths minute When counting respiratory rates it is important to count for a full minute when the baby is settled Counting for shorter times can over or underestimate the real rate Cyanosis Cyanosis is a blue discolouration of the central mucous membranes lips gums and indicates hypoxia However cyanosis is generally only detectable when oxygen saturations are below 90 Therefore it is a late sign of hypoxia Lesser degrees of hypoxia may not be detected unless SpO2 monitoring is available Recessions Recessions are indrawings of soft tissues on or around the chest during inspiration They occur because disease makes the lungs stiff less compliant and the baby has to use the extra muscles and tissues to help inflate the lungs to breathe Figure 1 Sub sternal recessions 22 CPAP and the Baby with Difficult Breathing Reproduced from the CD of the Pocket Book of Hospital Care for Children WHO 2005 Head Nodding up down movement of the head in time with respiration caused by accessory use of the suprasternal muscles Nasal flaring Nasal flaring refers to movement of the external nares with each breath Breathing IN Breathing OUT gt gt aA a Figure 2 Nasal flaring source Managing Newborn Problems WHO 2003 Grunting Grunting is an expiratory noise which occurs when a baby s lungs are stiff It is caused because the baby is forcing air through partly cl
143. ty Babies who are stable on treatment for apnoea of prematurity may deteriorate if they develop an intercurrent condition that can cause apnoea in its own right 15 14 Management of apnoea THERE ARE 3 COMPONENTS TO THE MANAGEMENT OF APNOEA m Immediate emergency management m Determining the cause Ongoing treatment medication respiratory support Immediate management Immediate management of apnoea focuses on reversing and preventing hypoxia The steps are as follows a tactile stimulation 10 seconds only b clear suction and position the airway c if no immediate response ventilate with bag mask use oxygen if SpO2 lt 90 and call for help d if spontaneous breathing does not recommence after 15 minutes of bag mask ventilation consider intubation ventilation Determine the cause As soon as the baby is stable review the history for risk factors for causes of apnoea examine the baby for signs of any of the causes of apnoea and perform basic investigations if possible a History Consider risk factors gestation sepsis risk birth asphyxia drugs other b Examine For signs of disease temperature anaemia signs of sepsis signs of neurological disease such as bulging fontanelle and seizures congenital abnormalities cardiac problem respiratory distress etc c Investigations Check blood glucose FBC Hct electrolytes and blood cultures if possible Consider urinalysis CXR AXR USS head ABG if the
144. uld never be discharged from hospital on stimulant medications They must have been well and free of apnoea for at least one week before discharge Respiratory support Both CPAP and intubation ventilation where available have a place in the management of apnoea The role of CPAP for treating apnoea and how to use CPAP for apnoea is discussed in detail in the second part of this chapter 20 CPAP and the Baby with Difficult Breathing 1 6 Apnoea Algorithm APNOEA Emergency Treatment stimulate clear position airway ventilate O2 if SpO2 90 Evaluate Cause History Exam Investigate Apnoea of Prematurity Apnoea of Other Cause Aminophylline or Caffeine Cause Specific Treatment Consider antibiotics until CPAP sepsis excluded Medication if preterm 1 Week IPPV if Available Add CPAP 21 2 RESPIRATORY DISTRESS 21 What is respiratory distress Respiratory distress is the term used to describe a combination of clinical signs that commonly occur when a baby has difficulty breathing tachypnoea grunting recessions intercostal subcostal suprasternal sternal nasal flaring cyanosis 2 2 Recognising respiratory distress Most readers of this manual will be familiar with recognising the signs of respiratory distress Explanations are included here for completeness Tachypnoea Tachypnoea is abnormally fast breathing In a neonate this is defined as a respira
145. usually apparent within half an hour Although CPAP is simpler to use than IPPV this does not mean that babies on CPAP should receive less vigilant care CPAP is an intensive care treatment Clinical signs that Parameter CPAP is working CPAP is not working SpO2 Improves to normal range Respiratory rate Reduces towards normal Respiratory effort retractions Red educes or none i grunt flare No change or worse even if Babies on CPAP may deteriorate at any time due to their underlying respiratory problem or due to a complication of CPAP Complications in particular pneumothorax and tube blockage may occur suddenly and catastrophically Adhering to the care principals outlined here will reduce the likelihood of these occurrences increase FiO2 Pulse rate Reduces towards normal The baby what to monitor Peripheral perfusion 1 Vital signs SpO2 RR HR General condition 2 Respiratory effort retractions grunting flaring None fewer than before Same number or more than 3 Peripheral perfusion colour warmth urine output starting before starting 4 Secretion production 5 Nasal skin for redness 6 Abdominal distension 7 Feed tolerance The baby who is not responding 8 Level of comfort assuming appropriate sized BP cuffs available If the baby is not improving after starting CPAP check the machine is set up correctly and the connections are intact p
146. vailability of oximeters Priority should be given to the sickest babies and the smallest babies because oxygen treatment may be toxic in small babies General instructions for using an oximeter 1 34 Select correct sized probe using probes which are too big on a neonate will make it difficult to secure and to get a good trace Disinfect the probe before use Attach probe securely to foot finger ear If too loose the monitor will not detect the pulse accurately If too tight or left on for long periods the probe can cause skin breakdown If using continuous monitoring you need to change the probe site every few hours Read the oxygen saturation from the machine First ensure the machine is detecting the saturation correctly Is signal good Does the pulse reading on the oximeter match the baby s pulse Ifthe answer to either of these is no then reattach the probe before reading Chart the result Adjust the oxygen if the result is too low or too high If using the oximeter for continuous monitoring set alarm limits before use Set the too low alarm at 83 in preterm babies and at 88 in term babies Setthe too high alarm at 9596 in preterm babies and 9896 in term babies If the alarm sounds respond immediately Assess the baby to determine why the alarm is sounding Determine if The baby s SpO2 is really too low The trace is good the pulse matches the baby may be cyanosed baby s 5
147. ween the possibilities A transilluminator is very useful in quickly confirming a 83 pneumothorax Each of the individual causes of acute deterioration is also discussed in more detail on the following page Note other medical problems such as PDA NEC IVH which may all cause general deterioration are not covered here refer to Managing Newborn Problems WHO 2003 Increasing CPAP settings when the baby deteriorates Oxygen should be increased as the immediate first step when a baby has deteriorated The oxygen is increased while the health worker is trying to determine the cause of the problem Pressure PEEP may also need to be increased at least temporarily in managing a deterioration see table However this must be done with caution f pneumothorax or lung overdistension is suspected pressure should not be increased In these situations the doctor should try to see whether decreasing the PEEP improves the baby s condition Ideally CXR will have been obtained first Maximum settings Oygen may potentially be increased up to 100 i e 6L oxygen OL air however if a baby is requiring gt 70 oxygen then the baby has very severe hypoxia This signals that the CPAP may not be sufficient to help the baby Pressure should not normally be increased beyond 8cms On occasion 9cms may be used on a bigger baby If a baby does not respond to high oxygen and maximum pressure then CPAP may not be enough to treat the underlying lun
148. wet cotton swab to avoid hurting the baby and causing skin trauma Change the nasal tube for a new one when there are signs of possible obstruction Change the tube regularly if there are a lot of secretions especially in term babies Always change to the other nostril when you insert a new tube unless there is already injury to that nostril CPAP and the Baby with Difficult Breathing Positioning Change the baby s position every 4 8 hours front back each side Move unstable babies less frequently Be sure to move the baby s head to the other side each time a Prone position lying on the baby s front is best for digesting feeds unless there specific concerns about the baby s abdomen It may also improve respiratory effort and help reduce apnoeas Care must be taken to ensure the baby s face is turned to the side b 2 people may be needed for position changes in order to prevent tube disconnections or the tube falling out Comfort a Ifa baby appears agitated first check that he does not have signs of deterioration p 83 or fever Call a doctor if signs of deterioration or fever b If it is just that he is unsettled by the tube or the treatment try swaddling nesting and repositioning Offering a dummy to suck Ensure a feed has been given according to schedule Paracetamol may also be given 15mg kg dose 6 hourly by OGT Kangaroo Care may also help settle the baby Babies on CPAP may be nursed in Kangaroo
149. y benefit respiratory drive and improve oxygenation 2 9 However it should only be used where patient observation is guaranteed and where it is not otherwise contraindicated e g abdominal distension Regular changing of position with patient cares will also avoid pressure sores which can result in secondary infection and in pain UD Figure 13 Prone nursing on CPAP Providing close attention to all the elements of supportive care will help to minimise complications due to CPAP and complications due to other medical problems that commonly affect preterms e g PDA NEC and sepsis The correct technique for suction Suction equipment should a ways be available at the bedside of a baby on CPAP Equipment functioning suction sterile suction catheter of correct size and clean non sterile gloves ETT Size mm Suction Catheter Size 3 0 3 5 6 7FG The suction catheter should be pre measured against the nasal CPAP tube adaptor The length that the suction catheter should be passed is the same length as the cut tube plus adaptor Mark this distance somewhere to serve as a reference e g on the observations sheet Procedure use 2 nurses if possible Note baseline vital signs HR RR SpO2 1 nurse washes hands and puts on gloves picks up sterile catheter and attaches to suction tubing without allowing the catheter to touch anything else 2 nurse holds and disconnects the ETT adaptor from the CPAP tubing and holds
150. you and will also explain the treatment which is the placement of a small drain tube into the baby s chest 4 Feeding holding touching and caring for your baby When your baby is on CPAP he cannot suck from the breast However he will be given milk through a tube which passes directly into his stomach It is very important that the mother is taught how to express her breastmilk by hand or with a pump so that the milk can be given to the baby through the tube Breastmilk is the best milk for the baby s health even when the baby is on CPAP You can touch your baby while he is on CPAP It is very important that your baby knows you are close you can speak or sing to him hold his hand caress him When he is well enough the doctors and nurses will help you nurse him in Kangaroo Care see below Your baby will still need you to change his wet or dirty clothes wraps The nurses will show you how you can do this gently by lifting the baby s bottom or legs As long as you don t move your baby s head or chest changing the cloths will not disturb the 5 Does CPAP hurt my baby CPAP does not hurt your baby or cause your baby pain Some bigger babies find it frustrating having the tube in their nose and may appear unsettled If you think your baby is uncomfortable then let the nurse or doctor know There are various ways they may help your baby settle such as wrapping him snuggly giving him a dummy to suck or a small dose of medicin
151. ys be available Oxygen from a wall outlet This will usually only be found in larger hospitals as it is a costly instillation and requires a lot of maintenance Where wall oxygen is available the oxygen hose from the CPAP screws directly onto the wall outlet In wall oxygen set ups the oxygen outlet is regulated to 400kPa A separate regulator is not needed As with the cylinder set up the CPAP oxygen hose and the wall outlet connectors must be compatible 18 Contact MTTS BME to discuss if there is no locally available biomedical expertise to solve the problem 62 CPAP and the Baby with Difficult Breathing Oxygen concentrators These are economic and portable devices which in a similar way to the CPAP air compressor extract oxygen from the atmosphere Oxygen concentrators can provide oxygen in flow rates up to 8L minute which is sufficient for the vast majority of neonates who require CPAP It may not be adequate for an older infant The oxygen concentrator is a low pressure oxygen system so no regulator is required The oxygen hose of the CPAP machine will need to be connected to the flow meter outlet of the oxygen concentrator and compatible connections are again required The humidifier on the oxygen concentrator could be removed when connecting the CPAP as the humidifier is built into the CPAP The oxygen concentrator requires electricity in order to function Therefore it is good practice to have a back up oxygen cylinder regulator

CPAP AND THE BABY WITH DIFFICULT BREATHING

Contents

Download Pdf Manuals

Related Search

Related Contents