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Infants Requiring Continuous Positive Airway Pressure CPAP JCG0088 V2.2

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Infants Requiring Continuous Positive Airway Pressure CPAP JCG0088 V2.2 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP). A clinical guideline recommended for use Jenny Lind Children’s Hospital (NNUH) and Children’s In: Department at (JPUH) Paediatric and Nursing staff working in Buxton ward and the High Dependency Unit (NNUH) and Paediatric and Nursing By: staff working in ward 10 and the High Dependency Unit (JPUH) Infants with significant respiratory distress who require a For: degree of respiratory support (under 12 months of age) Division responsible for Women and Children’s Division document: Continuous Positive Airway Pressure (CPAP), Bronchiolitis, Key words: Respiratory Distress Syndrome (RDS), High Dependency Unit (HDU) Dr Caroline Kavanagh, Consultant Paediatrician, Names of document Hannah Deacon, Staff Nurse, Buxton Ward, authors: Sarah Burton, Deputy Sister, Buxton Ward Name of document Mary-Anne Morris authors Line Manager: Job title of document Chief of Services for Paediatrics authors Line Manager: Children’s Critical Care Working Group Supported by: Dr John Chapman Consultant Paediatrician (JPUH) Assessed and approved Clinical Guidelines Assessment Panel (CGAP) by the: Chair’s action Date of approval: 13/09/2019 Reported as approved Clinical Safety and Effectiveness Sub-Board (NNUH) and to the: Clinical Governance (JPUH) To be reviewed before: 13/09/2022 To be reviewed by: Dr Caroline Kavanagh Reference and Trustdocs JCG0088 ID No: 9079 ID No: Version No: 2.2 Description of changes: No clinical changes Compliance links: None This guideline has been approved by the Trust's Clinical Guidelines Assessment Panel as an aid to the diagnosis and management of relevant patients and clinical circumstances. Not every patient or situation fits neatly into a standard guideline scenario and the guideline must be interpreted and applied in practice in the light of prevailing clinical circumstances, the diagnostic and treatment options available and the professional judgement, knowledge and expertise of relevant clinicians. It is advised that the rationale for any departure from relevant guidance should be documented in the patient's case notes. The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the quality of healthcare through sharing medical experience and knowledge. The Trust accepts no responsibility for any misunderstanding or misapplication of this document. Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022 Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 1 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP). Contents Page Objective 3 Rationale 3 Background 3 The Bubble CPAP circuit 4 Infant Flow driver circuit 4 Indications for use of CPAP 4 Aims of CPAP 4 Biochemical aims of CPAP 5 Contraindications for use of CPAP 5 Complications of CPAP 5 Conditions Requiring CPAP in infants and young children 6 Bronchiolitis 6 Post-operative atelectasis 6 Chronic Lung Disease 6 Newly diagnosed chronic Respiratory failure 6 Home Non-Invasive Ventilation 7 Initial Management- Quick reference 7 Use the ABCD approach 7 Chloral and CPAP 7 Indication for weaning CPAP 7 Escalation of Care beyond CPAP 8 Organisation and provision of care 8 Clinical audit standards 8 Summary of development and consultation process undertaken 8 before registration and dissemination Distribution list/ dissemination method 9 References/ source documents 9 Appendices Appendix 1 Use of the Bubble CPAP Circuit 10 Quick User Manual reference guidelines for the Bubble 14 CPAP circuit Troubleshooting 21 Appendix 2 Quick reference guidelines for the Infant Flow Driver 23 CPAP Troubleshooting with the infant flowdriver 28 Appendix 3 Care plan 29 Appendix 4 Patient Information leaflet 31 Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022 Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 2 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP). Objective The objective of this guideline is to standardise the care of Infants (children under 12 months old) requiring CPAP via the Bubble CPAP circuit or infant Flow Driver. It is also to ensure safe practice for the required duration of CPAP administration by providing a reference for all staff. Diagrams of the two machines and their individual use can be found in the Appendix. Rationale We have within the paediatric department two different types of machines that are capable of providing CPAP for infants: the bubble CPAP machine and the Viasys Infant Flow drivers. This guideline has been created in order to standardise the care of Infants requiring CPAP using either machine. This ensures that children receive a safe and efficient level of care by practitioners with the knowledge and skill in the safe application, monitoring and delivery of CPAP. This guideline has been composed using an up to date, relevant evidence-base to ensure this required level of care is achieved. Background The use of CPAP dates back to 1912, when used by a thoracic surgeon, this prompted much investigation and research into its use. In 1976 Greenbaum et al. reported the use of CPAP successfully in Acute Respiratory Distress Syndrome. CPAP is the maintenance of a positive pressure throughout the whole respiratory cycle in a spontaneously breathing patient. It improves oxygenation by helping to prevent alveolar collapse. This is achieved by delivering a continuous oxygen and air mix under gentle pressure. The aim of CPAP is to improve gas exchange and avoid the need for intubation. Many infants who are experiencing respiratory distress tend to have asynchronous breathing, creating a see-saw motion between their chest and their abdomen. When CPAP is applied, it decreases the compliance of the chest wall and allows for synchronous breathing, resulting in decreased effort of breathing, improved gas exchange and improved cardiac function. CPAP works by increasing the functional residual capacity of the lungs by exceeding the closing capacity of the lungs, which stabilizes and prevents the collapse of alveoli, making inflating the lungs easier. It also provides a splint to the chest wall and airway, resulting in increased lung volumes, recruitment of atelectatic alveoli, and prevention of further atelectasis. For this reason it is particularly effective in the recovery of bronchiolitic infants as it decreases the compliance of the chest wall and allows for synchronous breathing and improved gas exchange. CPAP can be provided using various machines and circuits. The two methods we have available to us at NNUH are the bubble CPAP circuit and a Viasys infant flow driver circuit. We would recommend using the bubble CPAP circuit preferentially, but if we Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022 Available via Trust Docs Version: 2.2 Trust Docs ID: 9079 Page 3 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP). have no other machines available we will use the flow driver circuit. This guideline will therefore provide details on the use of both circuits. The Bubble CPAP circuit The Bubble CPAP circuit provides pressure using a water chamber. The depth of the tube below the water line controls the amount of positive pressure generated in the system. Bubbles are created when pressure is generated. This system was first introduced in 1974 when Dr. Jen-Tien Wung from New York began looking at CPAP for respiratory support. Infant Flow driver circuit The infant Flow Driver is a combined air/oxygen mixer, oxygen analyser, flow meter and manometer with integral alarm systems designed specifically to be used in conjunction with the infant Flow CPAP generator. This circuit provides a virtually constant airway pressure irrespective of patient demand or expiratory flows via the specially designed generator and nasal prongs. Indications for use of CPAP CPAP provides an additional therapy between conventional oxygen therapy and controlled ventilation. The decision to initiate must be made by the senior paediatrician on call. Consider when two or more of the following are present: Respiratory rate of 60 breaths per minute or greater Apnoeas, bradypnoea or cyanotic episodes (with or without bradycardia) despite supplemental O2 Severe intercostal recession and worsening signs of respiratory distress (e.g. expiratory grunt, nasal flare, sternal recession) Need for >2L/min O2 via nasal prongs Rising PCO2 (>3KPa from baseline) Respiratory acidosis pH 7.2-7.25 (if pH <7.2 consider intubation) Exhaustion Falling level of consciousness Unable to maintain SaO2 >92% in 50% oxygen Aims of CPAP 1. Reduce respiratory distress Guideline for: Management of Infants requiring Continuous Positive Airway Pressure (CPAP) Author/s: Dr Caroline Kavanagh , S/N Hannah Deacon , D/S Sarah Burton Approved by: CGAP Date approved: 13/09/2019 Review date: 13/09/2022 Available via Trust Docs Version: 2.2 Trust Docs
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