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Queensland Clinical Guideline: Respiratory Distress and CPAP

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Queensland Clinical Guideline: Respiratory Distress and CPAP Queensland Health Clinical Excellence Queensland Maternity and Neonatal Clinical Guideline Respiratory distress and CPAP Queensland Clinical Guideline: Respiratory distress and CPAP Document title: Respiratory distress and CPAP Publication date: June 2020 Document number: MN20.3-V8-R25 The document supplement is integral to and should be read in conjunction with Document supplement: this guideline. Amendments: Full version history is supplied in the document supplement. Amendment date: Full review of original document published in October 2014 Replaces document: MN14.3-V7-R25 Author: Queensland Clinical Guidelines Health professionals in Queensland public and private maternity and neonatal Audience: services. Review date: June 2025 Queensland Clinical Guidelines Steering Committee Endorsed by: Statewide Maternity and Neonatal Clinical Network (Queensland) Email: [email protected] Contact: URL: www.health.qld.gov.au/qcg Cultural acknowledgement We acknowledge the Traditional Custodians of the land on which we work and pay our respect to the Aboriginal and Torres Strait Islander elders past, present and emerging. Disclaimer This guideline is intended as a guide and provided for information purposes only. The information has been prepared using a multidisciplinary approach with reference to the best information and evidence available at the time of preparation. No assurance is given that the information is entirely complete, current, or accurate in every respect. The guideline is not a substitute for clinical judgement, knowledge and expertise, or medical advice. Variation from the guideline, taking into account individual circumstances, may be appropriate. This guideline does not address all elements of standard practice and accepts that individual clinicians are responsible for: • Providing care within the context of locally available resources, expertise, and scope of practice • Supporting consumer rights and informed decision making, including the right to decline intervention or ongoing management • Advising consumers of their choices in an environment that is culturally appropriate and which enables comfortable and confidential discussion. This includes the use of interpreter services where necessary • Ensuring informed consent is obtained prior to delivering care • Meeting all legislative requirements and professional standards • Applying standard precautions, and additional precautions as necessary, when delivering care • Documenting all care in accordance with mandatory and local requirements Queensland Health disclaims, to the maximum extent permitted by law, all responsibility and all liability (including without limitation, liability in negligence) for all expenses, losses, damages and costs incurred for any reason associated with the use of this guideline, including the materials within or referred to throughout this document being in any way inaccurate, out of context, incomplete or unavailable. Recommended citation: Queensland Clinical Guidelines. Respiratory distress and CPAP Guideline No. MN20.3-V8-R25. Queensland Health. 2020. Available from: http://www.health.qld.gov.au/qcg © State of Queensland (Queensland Health) 2020 This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives V4.0 International licence. In essence, you are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute Queensland Clinical Guidelines, Queensland Health and abide by the licence terms. You may not alter or adapt the work in any way. To view a copy of this licence, visit https://creativecommons.org/licenses/by-nc-nd/4.0/deed.en For further information, contact Queensland Clinical Guidelines, RBWH Post Office, Herston Qld 4029, email [email protected]. For permissions beyond the scope of this licence, contact: Intellectual Property Officer, Queensland Health, GPO Box 48, Brisbane Qld 4001, email [email protected], phone (07) 3234 1479. Refer to online version, destroy printed copies after use Page 2 of 32 Queensland Clinical Guideline: Respiratory distress and CPAP Flow Chart: Neonatal respiratory distress and CPAP in babies ≥ 32 weeks gestation Respiratory distress CPAP Signs Capability • Tachypnoea > 60 breaths/minute • Level 4 neonatal service or above • Increased respiratory effort • Appropriate equipment and human No o Audible expiratory grunt CPAP resources available o Recession–sternal, intercostal, indicated? Commence subcostal • CPAP at 7–8 cm H2O; 6–8 L/minute o Nasal flaring • O2 to maintain SpO2 within target • Cyanosis–oxygen needed • OGT 6–8 FG on free drainage Neonatal care Indications for CPAP Yes • Signs of respiratory distress or • Monitor continuously: • O2 requirement ≥ 30% to maintain o SpO2 (sensor preferably right hand) SpO2 within target o Vital signs (heart rate, respiratory rate, temperature, blood pressure) Assess & monitor o FiO2 Principles of care clinical condition • Record hourly: Vital signs, SpO , work of breathing Oxygenation o 2 (sternal and intercostal recession, • Maintain SpO2 within target grunting, nasal flaring, tachypnoea) o Term baby 92–98% o CPAP—pressure, flow, FiO2 o Preterm baby 90–95% o Humidifier and circuit temperature Monitor and record Water level in humidifier • Monitor continuously SpO (sensor on o 2 • Vigilant surveillance and record hourly right hand), respiratory rate, heart rate CPAP interface positioned correctly • Observe for signs of increasing o Septal columella integrity respiratory distress/work of breathing o o Eyes are clearly visible Blood gas o Securing devices not causing • pCO2 may assist assessment (capillary) indentation, pitting or periorbital Fluids Signs of oedema • Glucose 10% IV at 60 mL/kg/day deterioration/ Yes Signs of deterioration/CPAP failure • Small gavage feeds if stable CPAP failure? • O2 > 50% to maintain SpO2 within Sepsis management target range • Full blood count and blood cultures • A rapid rise in O2 requirement— • Antibiotics: 10% over 2 hours (e.g. an increase from 30% to 40%) o As per local protocol or • o Penicillin or A respiratory acidosis (e.g. pH < 7.25 o Ampicillin and gentamicin No with a normal base excess or o Refer to QCG NeoMedQ) pCO2 > 60 mmHg) • Recurrent apnoeic episodes requiring Chest x-ray to identify: • Respiratory disease stimulation • • Air leak (e.g. pneumothorax) Increased work of breathing • • Congenital diaphragmatic hernia Agitation that cannot be relieved–refer to QCG HIE guideline • Chest masses Signs of No • Cardiomegaly improvement? Signs of improvement • Other anomalies • Decreased Respiratory rate Blood glucose level o Work of breathing • Refer to QCG Hypoglycaemia-newborn o O requirement guideline o 2 • Improved Supportive care o Blood gas • Family centred approach Yes o Chest x-ray • Observe baby unclothed in incubator o Baby comfort • Thermoneutral environment Weaning • Position prone/quarter prone • Commence when: • Developmental care–minimal handling Wean/cease O2 < 25% and SpO2 within target • Skin-to-skin if stable o CPAP o Respiratory distress not present Consult/refer/transfer as indicated o ≤ 3 self-reverting apnoeas, bradycardia, desaturations in Ongoing care as indicated previous 6 hours • Clinical assessment • Wean • Supportive care o O2 until 25% then, • Consult with higher level service for o Pressure incrementally—1 cm as advice or to organise transfer/retrieval tolerated until 5 cm H2O Contact NeoRESQ or ANTS-NQ via o Cease if stable in RSQ phone 1300 799 127 • 21% O2 and CPAP 5 cm H2O • Intubation and mechanical ventilation ANTS-NQ: Advanced Neonatal Transport Service-North Queensland, CPAP: continuous positive airway pressure, FG French gauge, FiO2: fractional inspired oxygen, HIE: Hypoxic-ischaemic encephalopathy, IV: intravenous, NeoRESQ Neonatal Retrieval Emergency Service Southern Queensland, pCO2: partial pressure of carbon dioxide, QCG: Queensland Clinical Guidelines, RSQ: Retrieval Services Queensland, SpO2: peripheral capillary oxygen saturation, >: greater than, ≥: greater than or equal to, <: less than; ≤: less than or equal to Flowchart: F20.3-1-V7-R25 Refer to online version, destroy printed copies after use Page 3 of 32 Queensland Clinical Guideline: Respiratory distress and CPAP Table of Contents Abbreviations ........................................................................................................................................................ 5 Definitions ............................................................................................................................................................. 5 1 Introduction ................................................................................................................................................... 6 1.1 Lung development and respiratory physiology .................................................................................... 6 1.2 Clinical course of respiratory distress .................................................................................................. 6 1.3 Clinical standards ................................................................................................................................ 7 2 Assessment .................................................................................................................................................. 8 2.1 Signs ................................................................................................................................................... 8 2.2 X-rays .................................................................................................................................................
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