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  1. blender
  2. flowmeter
  3. flowline
  4. reservoir
  5. tee
  6. lg bore hose
  7. humidifier
  8. humidifier controler
  9. emergency release valve
  10. inspiratory hose
  11. flex hose
  12. pressure line connection
  13. nasal prong
  14. expiratory hose
  15. CPAP control valve
  16. pressure line
  17. pressure line H2O trap
  18. pressure monitor
  19. H2O line
  20. water (H2O)
  21. O2 analyzer
 Neonatal Respiratatory Care

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

 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


 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
 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
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
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


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

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.