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Policy & Procedure Manual page 1 of 3
Nasal CPAP (Continuous Positive Airway Pressure)
1 Indications for CPAP
1.1 Mild RDS (HMD)
1.2 Pulmonary edema
1.3 PDA
1.4 Mild to moderate oxygen requirement, mild CO2retention secondary
to grunting, flaring,
and retracting
2 Procedure:
2.1 Obtain physician's order. for FIO2 & CPAP pressure
2.2 Observe the infant.
2.2.1 Watch the infant's rate and depth of respiration, retractions.
Observe t color.
2.3 Obtain a baseline abdominal girth.
2.3.1 Infants have the tendency to swallow air while on nasal
CPAP. If their girth does
increase, they may need an orogastric tube in place.
2.4 Check the patency of the infant's nares and the size of them.
2.4.1 The nasopharynx needs to be patent for the CPAP to be effective.
Observe the
nares for the use of appropriate size of nasal prongs.
2.5 Prior to initiation and intermittently after initiation of nasal
CPAP, give the infant inflating or
sigh breaths with the flow-inflating bag.
2.5.1 This may aid in opening up or recruiting_partially collapsed
alveoli, before the infant is placed on nasal CPAP.
2.6 Obtain the proper equipment.
2.6.1 A conventi setup (x-small, small, or large), allowing
for a comfortable, snug fit
2.7 Remove the patient wye from the ventilator circuit and place it
in a plastic bag. Tape it to the side of the ventilator.
2.7.1 This piece should be saved so that it can be used if the baby
requires intubation
later.
2.8 Attach the nasal CPAP set up to the inspiratory and expiratory
sides of the ventilator circuit.
2.8.1 Make sure that the pressure monitor tubing is_attached
to the inspiratory (blue)
side of the circuit.
2.9 Set the ventilator flow rate initially at 5-6 lpm.
2.9.1 This is the minimally accepted flow rate to meet the infant's
inspiratory demands
and to prevent the re-breathing of CO2. If the infant deflects
the needle more than
+/-2cm of H2O, the flow rate_should be increased.
Brigham & Women’s Hospital Neonatal Respiratory Care Dept.
Policy & Procedure Manual page 2 of 3
CPAP
2.10 Turn the ventilator on the CPAP mode.
2.10.1 CPAP is provided in the off mode on
Sechrist Ventilators
2.11 With a sterile 2x2 gauze pad, occlude the nasal_prongs and adjust
the expiratory pressure knob on the ventilator to set
an initial CPAP level.
2.11.1 This level is set before placing the prongs on_the patient,
so that you know how much pressure_the ventilator
is delivering.
2.12.1 You want the headstraps to fit snugly to assure_a proper
fit. Refer to the diagram
that comes with the initial nasal CPAP set up.
2.12 Apply a small amount of lubafax to the prongs before_placing
in the infant's nares.
2.13.1 This lessens the initial irritation of the prongs on the
nares.
2.14 Gently slide the prongs into the infant's nares and_adjust the clips on the headstraps.
2.15 Observe the CPAP level on the ventilator manometer.
2.15.1 Unless you have a very good fit, with no leaks,you
are probably not observing the
CPAP level_that you initially set on the ventilator.
2.16 With the prongs still in the infant, readjust the_CPAP level,
using the expiratory pressure
knob, until_you reach the desired level of CPAP. Observe
the_pressure on the ventilator
manometer.
2.16.1 You may have to adjust the CPAP level by 2-4 cm H2O to
achieve the CPAP level
that you actually_want.
2.17 Take the prongs off the infant and occlude them, observing
the CPAP level on the ventilator
manometer.
2.17.1 It is important to know how much pressure the ventilator
is set for to deliver the
actual CPAP level.
2.18 Reapply the prongs to the infant, again observing the CPAP
level on the ventilator
manometer.
2.18.1 Watch for some inflection of the black needle on the manometer
with each infant
breath. Set the red needle appropriately.
2.18.2 The black
needle should cross the red needle with each infant breath.
2.19 If you are still unable to maintain an adequate CPAP level,
try repositioning the infant
and/or the prongs until you get an adequate and consistent CPAP level.
2.19.1 The infant needs to by lying flat on his back_& his
mouth should not be wide open.
2.20 Turn the Ventilator Alarm Monitor on and place it in the CPAP mode.
2.21 Set the disconnect delay alarm on the ventilator for 20 seconds.
Brigham & Women’s Hospital Neonatal Respiratory Care Dept.
Policy & Procedure Manual
page 3 of 3
CPAP
2.22 Write down the settings on the ventilator check card.
2.22.1 Note the CPAP level set by occlusion of_the prongs and
the CPAP level observed
when on the patient.
2.23 Set the FiO2 as ordered on the ventilator blender. Observe the
FiO2 on the oxygen analyzer.
2.23.1 If there is a discrepancy between the blender and
analyzer, the analyzer should be
recalibrated.
2.24 Observe and adjust the humidity and temperature in the circuit
as needed.
2.24.1 If the flow is low (5-8 lpm), the amount of humidity in the
tubing should be
adjusted to avoid excessive rainout in the tubing.
2.25 Continue to observe the infant for toleration of the set up.
2.25.1 Watch for apnea or extreme agitation or intolerance of the set
up
.
2.26 Obtain an arterial blood gas in approximately 20 minutes.
2.27 Once the results are obtained, it should be_determined by the physician,
respiratory therapist, and nurse if the nasal CPAP is effective.
2.27.1 The nasal CPAP level can be increased by increments of 2 cm
H2O to be more
effective. A minimum of 5 cm H2O and a maximum of 10 cm H2O_are
generally
used. If the baby fails nasal_CPAP, the next step is intubation.