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GUIDELINE FOR THE USE OF NASAL CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) IN THE MANAGEMENT OF BRONCHIOLITIS IN INFANTS UP TO AGE 6 MONTHS

This guidance does not override the individual responsibility of health professionals to make appropriate decision according to the circumstances of the individual patient in consultation with the patient and /or carer. Health care professionals must be prepared to justify any deviation from this guidance.

Introduction: Continuous Positive Airway Pressure (CPAP) refers to ventilation with a positive pressure that is maintained throughout the respiratory cycle whilst the patient is breathing spontaneously. The important beneficial effect of CPAP is increasing the functional residual capacity (FRC) by increasing transpulmonary pressure that leads to an improved gas exchange. FRC is defined as the amount of air left in the lungs at the end of expiration. CPAP may increase lung compliance by expanding collapsed alveoli, which consequently increases lung volume. Fisher & Paykel’s Bubble CPAP system has been developed based upon 30 years of proven clinical benefits as an effective method of providing respiratory support to neonates. The product is designed to provide a system that is safe, effective, lung protection that is easy to use.

This guideline is for use by the following staff groups : The decision to institute nasal CPAP must be made by experienced paediatric medical and nursing staff. The infant must have been assessed by the Registrar or Consultant, and by a children’s trained nurse who has completed and passed the Level 6 High Dependency module or has significant experience in caring for the sick child. The member of nursing staff allocated responsibility for the patient must have received training and completed the competencies on the Bubble CPAP equipment. The competencies have not been included in this guideline, as they are for the lead High Dependency Nurse to educate the Nursing staff at ward level. This is to ensure the nurse is competent and can demonstrate effective setup of the CPAP, to provide safe, effective, evidence based patient care.

Lead Clinician(s) Karen Haley-Hyde Sister/HDU Lead, Ward One, Alexandra Hospital

Approved by the Paediatric Clinical Governance Committee on: 28th March 2014 Extension approved: 22nd July 2015 This guideline should not be used after end of: 28th March 2017

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Key amendments to this guideline Date Amendment By: 27.09.10 1. Added to the differential diagnosis, the importance of Karen Haley recognising a pnuemothorax in the child on CPAP. 2. To ensure the CPAP pressure is set at no more than 6cm H20 and to only increase the pressures after discussion with the Consultant on call. These patients need to be assessed individually. 3. To ensure staff are competent and assessed by a Lead High Dependency Nurse/Senior member of staff before using the Bubble CPAP. 6/03/2014 Changes to PEEP, allowing Higher PEEP with Consultant K Haley- Instructions Hyde 6/03/2014 Include Care and Comfort Intentional Rounding D.Picken 6/03/2014 Referral made to Bronchiolitis Guideline for further advice V.Harrison 6/03/2014 Using SBAR to escalate concerns D.Picken 5/05/2016 Document extended for 12 months as per TMC paper approved TMC on 22nd July 2015

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Guideline for the use of nasal continuous positive Airway pressure (CPAP) in the management of bronchiolitis in infants up to age 6 months

Introduction

Bronchiolitis is a common seasonal viral lower respiratory tract infection that predominantly affects infants under 12 months of age. Younger infants are often more severely affected and very young infants (under 6 weeks) may present with apnoea before the classical signs and symptoms of bronchiolitis develop. Typical signs include cough, tachypnoea and increased work of breathing, with hyperinflation and widespread crepitations and wheeze on auscultation.

Most cases of bronchiolitis are minor and self-limiting, but approximately 10% of affected infants require hospital admission. In-hospital interventions that have been shown to help include avoidance of oral feeding and provision of supplementary oxygen. Administration of inhaled 2 agonists, ipratroprium, steroids and adrenaline are all unlikely to be of any benefit. Please also see the Bronchiolitis Trust Guideline for further information WAHT-PAE- 089

Nasal CPAP has been shown to be of benefit in moderate and severe cases of bronchiolitis because it helps to restore functional residual capacity and corrects ventilation-perfusion mismatch by recruiting collapsed and poorly ventilated alveoli. Although there are references to its use over 20 years ago, there has been a resurgence in interest because of the ease of administration of CPAP with the infant flow driver. There is increasing but limited evidence that the bubble CPAP system, which is back to basics, is even more effective than the infant flow driver previously used.

Patients Covered This guideline is for use on The Children’s Wards; Riverbank unit at Worcestershire Royal Hospital and Ward One at The Alexandra Hospital Redditch. This guideline applies to infants up to 6 months of age. If a child who was born prematurely requires CPAP and is older than 6 months old, but is small in weight, then it is the nurse in charge who decides if this is suitable and safe practice.

It applies only to patients with moderate/severe bronchiolitis: i.e. showing signs of poor feeding, lethargy, marked respiratory distress, an oxygen requirement of 60% or more to maintain saturations or Clinical exhaustion with retention of carbon dioxide.

All babies must have a capillary or arterial blood gas analysis prior to commencing CPAP.

INFANTS WITH RECURRENT SEVERE APNOEAS OR MARKED RESPIRATORY ACIDOSIS, (pH < 7.25) WILL REQUIRE DISCUSSION WITH KIDS INTENSIVE CARE AND DECISION SUPPORT (KIDS) as intubation and ventilation may be required.

CPAP may also be instituted for recurrent apnoeas alone in infants under 6 weeks of age regardless of oxygen requirements.

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Guideline

Equipment Overall Infant Delivery System Specification - Fisher – Paykel MR850 Respiratory Humidifier - Fisher – Paykel MR290 Auto feed Humidification Chamber - Fisher – Paykel low flow air-oxygen blender - Fisher – Paykel BC110 Pressure Manifold with option to analyse O2 percentage and PEEP if needed - Fisher – Paykel BC060 Single Heated Breathing Circuit - Fisher - Paykel BC100 CPAP Generator with Non sterile water up to fill line - Short piece of Green Oxygen Tubing - Water for Irrigation

Patient Interface Product Specification - Fisher – Paykel Nasal Tubing in two sizes – BC181 70mm Less than 2.5kg and BC182 More than 2.5kg - Fisher – Paykel Nasal Prongs of which there are 11 sizes - measured by septal and nasal size using caterpillar tool. - Fisher-Paykel Nasal Masks – they come in small, medium and large. - Fisher – Paykel Infant Bonnet which is measured by head circumference and the preferred fixation - Fisher and Paykel Headgear – this can be used if the child has a certain condition i.e. hydrocephalus or needs regular cranial scans

Always try to set up the CPAP machine in advance to allow the machine to heat to 37 degrees Celsius. The baby will then receive instant correct humidification and heat. While the machine is getting to the correct temperature, the baby can be measured for correct prong/mask and bonnet/headgear. Unfortunately in emergency situation this cannot be possible and to attach immediately is acceptable and safe practice in the best interests of the child

Fixation - Select the appropriate size of nasal prongs/Mask using the nose guide provided - Select the largest size prongs that will fit comfortably into the nose and connect to the generator. Always document size on HDU. - Select the appropriate sized bonnet by measuring the head circumference. The size of the bonnet is printed on the front of the bonnet and should sit on the forehead.

Settings - The standard Pressure delivered is usually set between 5-8cm H20 for bubble CPAP These parameters are suggested for safety reasons, although individual cases may need discussion with the consultant on-call, regarding increasing the pressures to avoid/reduce the need for full ventilation. - Set the CPAP pressure by moving the plastic probe into the water in the generator. There can only be whole numbers set for the CPAP, no half number i.e. 6.5. The probe only goes up in whole numbers by the indentations on the probe. - A PEEP of 8cm or more must be discussed with the Consultant on call, who will then needs to physically assess the patient and have a discussion with the nurse in charge. Any Child on a PEEP of 8cm H20 or more is classed as very sick. They will have very little reserve and collapse quickly. There needs to be a clear, documented plan of care in the medical notes by the Consultant on call. The KIDS

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retrieval team also need contacting for advice regarding treatment and possible transfer to a PICU.

- The CPAP generator is the device that creates CPAP with pressure oscillations. This is the container with water where the end expiratory limb is immersed. The number which sits above the line is the CPAP pressure reading. The pressure can be checked by occluding the prongs and seeing the CPAP generator bubbling. Continuous bubbling is necessary to attain the optimum effect of bubble CPAP. - Always set the litres of 02 as the same as the CPAP pressure - Set the oxygen and air blender to the percentage of Oxygen that the individual patient requires. - The respiratory humidifier should be automatically set to invasive ventilation mode (which is the top right hand corner button). The other setting is non invasive if you were administering CPAP via face mask or using High flow. By selecting the invasive mode, the machine automatically sets the temperature to 37 degrees Celsius. The temperature on the display is the temperature that the baby is receiving.

Connecting CPAP - Position bonnet/head gear on the infant’s head , ensuring that the ears are in normal position - Gently insert the prongs into the nostrils to create a seal and deliver required CPAP. The CPAP prongs are anatomically correct and need to be face down. The CPAP generator will start to bubble if the seal is correct and there are no leaks in the circuit. Ensure the prongs are not pressed against the nose. - Attach the nasal masks in the same way, ensuring there is a seal around the whole of the nose. There must not be a Naso Gastric Tube insitu. - Attach the prongs/Mask to the bonnet by the Velcro strapping. Remove section of foam if needed to keep the tubing parallel with the baby’s head. Attach the small white hooks on either side of the blue glider. The blue glider ensures the baby can move freely, without pulling on the nose.

Nursing care

At the start of each shift, and on commencing CPAP, checks and record: - oxygen requirements - CPAP pressure - nasal skin, septum and mucosa for signs of irritation or pressure damage - most recent blood gas result

Each hour check and record: - Oxygen requirements - Oxygen saturation - Respiratory rate - Heart rate - Skin colour - Degree of chest recession - Position of nasal prongs - Condition of the nostrils and nasal septum - Paediatric Early Warning Score (PEWS) - Care and Comfort Intentional Rounding

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PEWS recorded hourly will ensure early signs of deterioration are not missed. Extra scoring should be used for oxygen requirement and worrying condition. The medical team should be informed of any change to the child’s condition. Please use SBAR as your referring tool for consistency in practice. Children who deteriorate are likely to require further intervention and possible intubation. This is better done in a controlled way electively, than because of a respiratory arrest.

Every 4 hours check and record: - A full assessment by loosening the generator straps and tubing - That the nasal skin is clean and dry with no evidence of tissue damage – Suction should also be performed to keep an optimal patent airway. Secretions in the airway will cause the patient to increase their work of breathing. Always wear gloves and an apron when a patient is having suction and use a new catheter each time in accordance with universal precautions to help prevent the spread of infection. These patient will always be cared for in a High Dependency Cubicle. - A size 8 catheter should be used as the secretions are too thick to be cleared by a smaller bore catheter. - If the child is unstable or has an oxygen requirement over 40%, then pre-oxygenate before giving suction is required for a short period. - Be aware that fragile, very sick children may respond to suction, with apnoea’s, bradycardia’s or destauration’s. Therefore, full resuscitation equipment needs to be readily available. In these children it is advisable to have another member of staff present. - If the secretions are dry, ensure saline nasal drops are prescribed to help loosen dry secretions. Thickening of secretions indicates the need for increased inspired gas/humidity or heat. - That the prongs and bonnet fit correctly

Monitoring Babies receiving nasal CPAP should have continuous electronic monitoring of: - heart rate - oxygen saturations - respiration (by apnoea monitor) or ECG Machine

They should also have intermittent monitoring of: - temperature (every 4 hours) - blood pressure (every 8 hours) Baseline observations are essential to the ongoing assessment and management of the sick child. Decisions regarding ongoing treatment are made on the basis of several assessments.

Complications Nursing and medical staff should be aware that, whilst CPAP is a very safe and non-invasive form of respiratory support, complications which can occur include: - necrosis of the nasal septum - this should be avoided by adherence to the nursing guidelines - Pneumothorax - the risk can be minimised by ensuring that pressures above 6 cms are not used without very close supervision of the baby with 1:1 nursing care. Also Guideline for the use of nasal continuous positive airway pressure (CPAP) in the management of Bronchiolitis in infants up to age 6 months WAHT-PAE-033 Page 6 of 12 Version 5.1

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ensuring that the baby is weaned appropriately from CPAP as their condition improves. - A Pneumothorax would become top of the list for differential diagnosis if the child’s clinical condition suddenly deteriorated with a dramatic increase in 02 requirement after starting CPAP, or increasing the PEEP.

Prior to instituting nasal CPAP the infant should have had the following: - insertion of intravenous cannula - intravenous fluids at 75-80% of maintenance requirement Note: glucose or sodium chloride or glucose/sodium chloride infusion fluids - choice and concentration to be determined by the results.

- full blood count and biochemical profile to exclude inappropriate ADH secretion

During CPAP, the baby should have capillary blood gas analysis every 6 hours, although it may be more frequent depending on clinical condition or if there is an increase in oxygen requirement.

Any unexplained increase in oxygen requirement should prompt medical review, which should include physical examination to assess air entry, work of breathing and mental status.

Feeding One of the most problematic issues with CPAP is its effect on the gastrointestinal system. The continuous flow of oxygen and related increased swallowing of air, can lead to gastric distension, causing an increase in abdominal girth and dilated bowel loops.

The distended abdomen results in increased pressure on the diaphragm, which may result in a compromised respiratory state. However, these problems can be reduced with insertion of an orogastric (OG) tube, left on free drainage.

If a baby has become so unwell that it needs CPAP support, it should remain nil by mouth, until it’s condition improves and it becomes more stable.

A size 8 orogastic tube should be passed to allow the aspiration of air and stomach contents. Smaller tubes do not allow the stomach to be vented properly, therefore, all infants regardless of their size should have a size 8 OG tube.

While Nil by Mouth, the infant should have blood sugars monitored once a day.

A strict fluid balance record should be kept to monitor the urinary output and ensure that the baby excretes a minimum of 2ml/kg per hour and maintains a reasonable fluid balance.

Occasionally some infants become so unsettled on CPAP that a small amount of milk via the OG tube is necessary to settle. This must be done only by instructions by a senior medical doctor.

The use of soothers (dummies) has been shown to promote the suck/swallow reflex, minimise the accumulation of air in the stomach, and decrease energy expenditure. It can also help to maintain CPAP pressures if the baby tends to lie with the mouth open. However, do not force a dummy on a baby who does not want it or tolerate it. Re-positioning the baby will help with mouth breathing. Guideline for the use of nasal continuous positive airway pressure (CPAP) in the management of Bronchiolitis in infants up to age 6 months WAHT-PAE-033 Page 7 of 12 Version 5.1

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Sucrose can also be used on the dummy as a soother and should be tried before giving comfort 5-10mls of milk via the OG tube.

Positioning The aim of positioning is to nurse the infant in a position that gives optimal respiratory function. In a hospital setting where physiological stability is required for a sick infant, prone positioning is recommended. Regular re-positioning helps to reduce facial oedema. This should happen every 3-4 hours, with all cares included to reduce stress to the infant and breathing effort.

Weaning off CPAP The decision to wean an infant off CPAP will be a joint medical and nursing decision, taking into account respiratory effort, oxygen requirements, blood gases, apnoeas and how the baby tolerates nursing cares.

Assuming that the oxygen requirements are reducing to below 40% and blood gases are satisfactory, weaning should begin by dropping the CPAP pressures to 4 cms. Next, the baby’s condition should be assessed during cares, and especially when the CPAP is disconnected to inspect the nose. If the baby is stable he may be left off CPAP for gradually increasing periods or by being transferred to high flow or headbox oxygen.

Indications to reinstate CPAP would include tiredness, increasing respiratory effort, increasing oxygen requirements or deteriorating blood gases.

Once off CPAP the baby should be closely monitored over the next 24 hours to ensure the child does not get tired and to return to CPAP. Only clinical deterioration would prompt the nursing/medical staff to repeat a blood gas. The OG tube should be replaced by a naso gastric tube and feeds should resume at 100mls/kg, divided into hourly feeds, then increased as tolerated in volume and hours between feeds.

Parental involvement Parents should be encouraged to participate fully in their child’s care. This should include holding/comforting the baby whilst on CPAP. This will help reduce the baby’s stress and is likely to comfort the parents.

Parents should also be provided with information (including written information) about bronchiolitis.

Parents should also be informed of the severity of their baby’s illness and be prepared for further intervention and the possibility of being transferred to a Paediatric Intensive Care Unit for further support.

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Monitoring Tool How will monitoring be carried out? The nursing staff will complete competencies based on CPAP set up.

Who will monitor compliance with the guideline? The lead High Dependency Nurse will carry out audits on this practice and ensure the nursing staff are assessed yearly to perform safe, effective care.

STANDARDS % CLINICAL EXCEPTIONS All children’s trained nurses to have received 100 None training in use of the Bubble CPAP system % All infants to have been reviewed by senior 100 None paediatrician before starting CPAP % All infants to have blood gas estimation 95% Babies where it is deemed more before starting CPAP important to institute CPAP first, prior to obtaining gases

References

 Blease, J. (1997). Nasal CPAP via the infant flow system. Clinical Training Manual. EME Ltd. Brighton

 Centre for Maternal and Child Health (2008) Why Children Die: A Pilot Study 2006. Children and Young People’s Report.http://tiny.cc/1xpal

 Fisher. W. Paykel M. (2008) Bubble CPAP System. Neonatal group. New Zealand

 McDougall P (2011) Caring for Bronchiolitic infants needing continuous positive airway pressure. Paediatric Nursing. 23, 1, 30-35.

 Thia et al. (2008) Randomised controlled trial of nasal continuous positive airways pressure (CPAP) in bronchiolitis. Archives of Diseases in Children; 93: 45-7.

 Yanney, M. Vyas, H. ( 2008) The treatment of bronchiolitis. Archives of the Diseases of Children. 93: 793-798

 Zuzanna,J. Kubick, J. Limauro, J. Darnell, R (2007) Heated, Humidified High-Flow Nasal Cannula : Yet Another Way to Deliver Continuous Positive Airway Pressure? . American Academy of Pediatrics. 121: 82-88

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Contribution List

Key individuals involved in developing the document Name Designation Sr Karen Haley-Hyde Sister/HDU Lead

Circulated to the following individuals for comments Name Designation Patti Paine Divisional Director of Nursing and Midwifery Cathy Garlick Divisional Director of Operations Dr J Scanlon Consultant Paediatrician Dr L Harry Consultant Paediatrician Dr M Hanlon Consultant Paediatrician Dr V Weckemann Consultant Paediatrician Dr B Kamalarajan Consultant Paediatrician Dr A Mills Consultant Paediatrician Dr P Van-Der-Velde Consultant Paediatrician Dr N Ahmad Consultant Paediatrician Dr M Ahmed Consultant Paediatrician Dr T Bindal Consultant Paediatrician Dr M Ayaz Consultant Paediatrician Dr C Onyon Consultant Paediatrician Dr T Dawson Consultant Paediatrician Dr M McCabe Anaesthetics WRH Dr T Smith Anaesthetics Alex Nell Pegg Ward Manager, Riverbank Lara Greenway Ward Manager, Ward One Wendy Hubbard Ward One Sister Sharon Lownsbrough Ward One Sister Melanie Chippendale Paediatric Advanced Nurse Practitioner Victoria Harrison Respiratory Specialist Nurse Christina De-Cothi Respiratory Specialist Nurse Gail Bradford Sister A+E Worcester Michele Aston Riverbank Sister Natalya Moore Riverbank Sister Sarah Weale Riverbank Sister Rebecca Delves Riverbank Sister Natalie Meddings Sister A+E Alexandra Sarah Scott Julian Berlet Consultant Anaesthetist/Divisional Manager

Circulated to the following CD’s/Heads of dept for comments from their directorates / departments Name Directorate / Department Dr A Short Consultant Paediatrician/Medical Divisional Director Dr A Gallagher Consultant Paediatrician/Clinical Director Dana Picken Paediatric Modern Matron Janice Kerr Directorate Manager

Circulated to the chair of the following committee’s / groups for comments Name Committee / group Dr Andrew Gallagher Paediatric Clinical Governance Group

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Supporting Document 1 - Equality Impact Assessment Tool

To be completed by the key document author and attached to key document when submitted to the appropriate committee for consideration and approval.

Yes/No Comments

1. Does the policy/guidance affect one group NO less or more favourably than another on the basis of:

 Race NO

 Ethnic origins (including gypsies and NO travellers)

 Nationality NO

 Gender NO

 Culture NO

 Religion or belief NO

 Sexual orientation including lesbian, NO gay and bisexual people

 Age NO

2. Is there any evidence that some groups are NO affected differently? 3. If you have identified potential N/A discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to NO be negative? 5. If so can the impact be avoided? N/A 6. What alternatives are there to achieving the N/A policy/guidance without the impact? 7. Can we reduce the impact by taking N/A different action?

If you have identified a potential discriminatory impact of this key document, please refer it to Human Resources, together with any suggestions as to the action required to avoid/reduce this impact.

For advice in respect of answering the above questions, please contact Human Resources.

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Supporting Document 2 – Financial Impact Assessment

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Yes/No Title of document:

1. Does the implementation of this document require any additional NO Capital resources 2. Does the implementation of this document require additional NO revenue

3. Does the implementation of this document require additional NO manpower

4. Does the implementation of this document release any NO manpower costs through a change in practice 5. Are there additional staff training costs associated with NO implementing this document which cannot be delivered through current training programmes or allocated training times for staff

Other comments:

If the response to any of the above is yes, please complete a business case and which is signed by your Finance Manager and Directorate Manager for consideration by the Accountable Director before progressing to the relevant committee for approval

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