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 ID: 9079 Page 4 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

2. Improve oxygenation by improved alveolar gas exchange by recruiting collapsed and poorly ventilated alveoli 3. Improve hypercarbia 4. Reduce time spent in oxygen 5. To avoid fatigue in infants 6. To avoid invasive ventilation 7. Reduce hospital inpatient stay Biochemical aims of CPAP

1. To maintain pH 7.35-7.45 2. To maintain saturations > 95%, PCO2 <6.0 KPa 3. To prevent hypoxia and hypercarbia

Contraindications for use of CPAP

Consider the need for intubation and/or mechanical ventilation as evidenced in the presence of:  Severe cardiovascular instability and impending arrest  Upper airway abnormalities that make CPAP ineffective or potentially dangerous (e.g. Choanal atresia, cleft palate, tracheoesophageal fistula)  Pneumothorax  Older infants do not tolerate the application of CPAP devices well, resulting in restlessness and a labile oxygen requirement.

 PH <7.2 or SpO2 <88% in maximal oxygen therapy may be an indication for ventilation, but CPAP may be tried initially if the child is stable.

Complications of CPAP

 Abdominal distension increasing risk of aspiration.  False pressure readings due to obstruction of nasal prongs, poor fixation, kinking, blockage from mucous plugging or increased resistance created by turbulent air flow through the prongs, artificially maintaining air pressure.  Inadequate gas flow causing fluctuating baseline pressures, resulting in increased respiratory effort by the infant.  Excessive flow preventing incomplete exhalation inadvertently increasing positive end expiratory pressure (PEEP) levels resulting in over-distension.  Impedance of pulmonary blood flow, increase in pulmonary vascular resistance & decrease in cardiac output.  Nasal irritation, septal distortion, pressure necrosis, nasal mucosal damage secondary to inadequate humidification or poor fixation of nasal prongs. 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 5 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

 Skin irritation of the head and neck from improperly secured bonnets.  Lung over-distension causing air leak syndromes i.e. Pneumothorax.  Equipment failure including leaks, tubing blockages, alarm failures, incorrect calibration.  Blockage of nasopharyngeal area and vocal cords with thick secretions.

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 6 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

Conditions Requiring CPAP in infants and young children

Bronchiolitis

This is a common, often serious infectious disease of the lower respiratory tract. It is most common among infants aged 2-12 months with a peak age of 2-8 months usually during the winter months. It is most often due to a viral infection of the bronchioles. The vast majority of cases are caused by the Respiratory Syncitial Virus (RSV), although it is well recognised that many respiratory viruses can cause a similar picture, especially in the winter months. Bronchiolitis results in a combination of increased mucous production, cell debris and oedema causing a narrowing and obstruction of the small airways.

Bronchiolitis is characterised by: mild rhinorrhoea, coughing, decreased feeding, irritability, and occasionally respiratory distress, cyanosis and apnoea. Examination may reveal hyperinflation of the chest, crepitations and/or wheeze with hypoxia. Those infants more at risk of severe disease include the premature, infants with congenital heart disease (CHD) or underlying respiratory diseases.

SIGNS OF MODERATE BRONCHIOLITIS SIGNS OF SEVERE BRONCHIOLITIS Tachycardia Cyanosis Tachypnoea >50 Exhaustion Nasal Flaring Reduced Conscious Level Use of accessory muscles SpO2<92% in spite of O2 therapy Recession Rising PCO2 Head retraction Unable to feed

Post-operative atelectasis

This is an unusual situation that can sometimes occur in young infants causing respiratory distress. It is usually a short term problem requiring a short period of CPAP and physiotherapy.

Chronic Lung Disease

This applies to ex-preterm infants who were ventilated in the newborn period or had a persistent oxygen requirement. These infants often present with an acute on chronic clinical deterioration which is often secondary to an acute viral upper respiratory tract infection. They are at increased risk of needing CPAP if they deteriorate.

Newly diagnosed chronic Respiratory failure

Children with neurodisability may eventually develop chronic respiratory failure. This may present with an acute-on-chronic situation or with a chronic decline in function. These children will in most cases need long term non-invasive ventilation but prior to this may require CPAP in the acute situation. Long term ventilation will be arranged by the respiratory team in conjunction with either Addenbrookes or Great Ormond Street Hospital (if there is pulmonary hypertension present). 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 7 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

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 8 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

Home Non-Invasive Ventilation

More and more children will be commenced on forms of non-invasive ventilation with the improvements in medicine and technology. This is usually arranged by Addenbrookes or Great Ormond Street. When a child on non-invasive ventilation is admitted, refer to manufacturers instructions and leave settings unchanged unless clinically indicated. The child may then require commencement of the Trust’s CPAP devices.

INITIAL MANAGEMENT- Quick reference

Use the ABCD approach.

 Ensure patent airway, suction if indicated.

 Apply facial humidified O2 to achieve saturations >92%.  Continuous monitoring of vital signs and apnoeic episodes.  Nebulisers (Salbutamol or hypertonic saline) may be used, but discontinue if no response.  A blood gas.  Consider Bubble CPAP early for respiratory support if patient unresponsive to initial treatment and/or worsening blood gases.  Size 8 OG Tube to prevent abdominal distension- leave on free drainage.

2  Leave nil by mouth and gain intravenous access and prescribe fluids at /3 of normal maintenance requirements.

The following investigations can be undertaken at some stage but CPAP should not be delayed, if needed:  FBC, U&E, Cultures should be taken if indicated.  Nasopharyngeal Aspirate for virology should be sent if not done so already.  Chest x-ray.

Chloral and CPAP

A small single dose of chloral hydrate to help settle the child while being initiated onto CPAP can be given. It is not to be given if there are signs that the child may deteriorate quickly and is likely to need ventilation. The dose we would advise would be 30mg/kg.

Indication for weaning CPAP

 General physiological condition is stable

 FiO2 <30%

 SpO2 >95%

 CPAP PEEP ≤6cm H2O 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 9 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

 Stabilised blood gases  Minimal increased work of breathing

Once off CPAP infants should remain in HDU on continuous monitoring for 12-24 hours.

Escalation of Care beyond CPAP

If CPAP is ineffective or the infant is unstable and needs further escalation of treatment ventilation is required.  Worsening respiratory distress  Apnoeic episodes  Worsening hypoxia and agitation  Severe cardiovascular instability and impending arrest  Worsening respiratory acidosis If the child weighs <5kg then contact should be made with the neonatal registrar and the neonatal consultant on call regarding ventilation and accommodation.

If the child weigh >5kg contact should be made with the anaesthetic registrar and must be discussed with the Paediatric Anaesthetist on call regarding ventilation and accommodation until CATS are able to retrieve the patient.

Organisation and provision of care

The classification of a sick infant requiring CPAP is high dependency (level 2). The Department of Health (2001) state a nursing ratio of 1:2, increasing to 1:1 if nursed in a side room. All infants therefore receiving CPAP should be treated as a child residing in the High Dependency Unit, even if nursed in a side room. Staff must have adequate training, experience and support to care for infants receiving Bubble CPAP and the Infant Flow Driver.

All children who require CPAP need to be discussed with the consultant on call so that they are aware of the illness of the child being treated.

The registrar should review regularly and observe for any deterioration in the clinical state. The consultant should come and see the child if the registrar is unhappy with their clinical condition.

Inadequate staffing levels (numbers and expertise) or equipment to deliver and monitor safely are indications to consider transfer of the child to another equipped unit within the region.

Clinical audit standards

The indications for use of CPAP and weaning of CPAP can be audited. Staff using CPAP are competent in its use. The management plan can be examined in any patient to see that it was followed correctly. 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 10 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

Summary of development and consultation process undertaken before registration and dissemination

Dr Caroline Kavanagh, Staff Nurse Hannah Deacon and Sister Sarah Burton drafted this guideline on behalf of the children’s critical care working group who has agreed the final content. During its development it was has been circulated for comment to: paediatricians, paediatric anesthetists, paediatric surgeons and neonatologists. All comments were discussed and changes were made if agreed.

This version has been endorsed by the Clinical Guidelines Assessment Panel.

Distribution list/ dissemination method

Trust Intranet

References/ source documents

Ammari, A. et al. (2005) Bubble nasal CPAP manual. Riyadh AL-Kharj Hospital Programme Neonatal Intensive Care. Augey, M. et al. (2009) Nasal continuous positive airway pressure (NCPAP) for the acutely ill infant. Paediatric critical Care Network. Ballarat Health Services. (2010) Clinical Practice Guideline, Nasal CPAP (Paediatric). Bonner, K. M. and Mainous, R. O. (2008) The nursing care of the infant receiving bubble CPAP therapy. Advances in neonatal care. 8, 2, 78-95. CATS (2009) CATS Clinical Guideline, Bronchiolitis. Cockett, A. and Day, H. (2010) Children’s High Dependency Nursing. Wiley-Blackwell: Chichester Department of Health. (2001) High Dependency Care for children- Report of an expert advisory group for Department of Health 2001. The stationary office: London. Dougherty, L. and Lister, S. (2004) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 6th edition. Blackwell Publishing: oxford. Electro Medical Equipment (E.M.E) (1999) The Infant Flow System, Operating Manual. E.M.E: Sussex. Fisher & Paykel. Bubble CPAP Resource Manual. Hockenberry, M. J. and Wilson, D. (2007) Wong’s nursing care of Infants and children. 8th edition. Mosby: Missouri. Hunt, J. (2007) Guidelines for the use of continuous positive airway pressure (CPAP) systems in adults. Royal United Hospital Bath. McDougall, P. (2011) Caring for bronchiolitic infants needing continuous positiveairway pressure. Paediatric Nursing. 23, 1, 30-35.

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 11 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

Ojha, S., McInnes, D. and Dorling, J. (2009) Network Guideline, Continuous Positive Airway Pressure. Trent Perinatal Network, NHS. Resuscitation Council (UK) (2006) EPLS. 2nd edition. London. Scottish Intercollegiate Guideline Network (2006) Bronchiolitis in children, A national clinical guideline. NHS. Upton, C. and Foster, S. (2011) Information leaflet for parents/carers of babies and young children who have bronchiolitis. NNUH.

Appendix1 Use of the Bubble CPAP Circuit

Potential problems caused by Bubble CPAP therapy

 Mouth breathing may result in loss of desired pressure and decrease in delivered oxygen concentration  Increased intrathoracic pressure which causes reduced venous return which may lower cardiac output  Barotrauma leading to surgical emphysema/ pneumothoraces  Sudden deterioration requiring immediate intubation/ventilation  Aspiration  Patient discomfort/intolerance to nasal prongs  Facial sores/ulceration of septum  Reduced ability to feed  Dry mouth/airways  Gastric distension and diaphragmatic splinting  Increased blood level of carbon dioxide due to increase in dead space caused by prongs and tubing. Broad recommendations

Procedure Rationale Initiating Bubble Move to HDU with relevant staffing Ensure safe delivery and monitoring. CPAP Manage infant with facial O2 Reduce further respiratory distress Record baseline observations including Baseline observations are essential CBG, CEWS, O2 requirements prior to to the ongoing assessment and commencing CPAP management of the infant Gather all Manufacturer’s set up instructions. Ensures safe delivery of bubble equipment CPAP required to Bubble CPAP equipment including: deliver Bubble head gear, circuit, O2/air blender, CPAP humidifier, water for irrigation, water for CPAP, saturation probe, orogastric tube, measuring equipment, suction equipment, chin strap/dummy Set up Bubble Follow manufacturer’s instructions and To reduce error and ensure timely

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 12 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

CPAP test the circuit for leaks prior to attaching delivery to the infant to the patient Measure infants Use manufactures measuring device and Correct sizing is essential to prevent nares, septum select appropriate nasal prongs and leakage and damage to the nasal and head head gear septum circumference Fit and connect to CPAP circuit as per Small prongs allow air to leak from instructions the circuit reducing the pressure, if they do not fit snugly movement will cause them to damage the septum Head gear should be lined with eyebrows and be pulled down over the ears and fit snugly to minimise movement of the tubing

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 13 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

Procedure Rationale Turn on CPAP Ensure humidification is set to correct Humidification is pre-set to 37°c setting Adequate humidification prevents drying of secretions

Avoids condensation draining into Ensure bubble system and humidifier infants airways are kept lower than the infant Tension on the tubing will put Secure tubing to avoid dragging on the pressure on the nares circuit To be determined by doctor Set gas flow (usually at 6L/min)

Set water pressure (usually 6cmH20) To be determined by doctor Bubbles should appear in the water Set FiO2 blender at required percentage chamber

NEVER PLACE PRONGS IN INFANTS To be determined by doctor. To NARES UNTIL YOU HAVE VARIFIED maintain saturations at acceptable THE SETUP IS FULLY OPERATIONAL level Connect Bubble Place nasal prongs in nares Be mindful of trauma CPAP to infant Secure with Velcro straps attached to Ensuring adequate fit and seal head gear Gain IV access Insert cannula, obtaining bloods and NBM reduces gastric distension and commence commence IVI at 100ml/kg/hr of 0.45% which can impact on work of IVI saline 5% dextrose +/- 10mmol KCL breathing. Feeds can begin when NB.CPAP is not a and make infant NBM infant stable enough contraindication to feeding Insert orogastric Insert size 8fr OGT on free drainage, Helps prevent gastric distension tube gently aspirate as required which can increase the possibility of aspiration and impact on work of breathing

Size 8fr OGT as smaller tubes do not allow the stomach to be vented properly Observations and Infant must be placed on continuous Regular changes of probe site continuous monitoring, change probe site 4 hourly prevent skin breakdown and burns monitoring Record all observations 15 minutes Allows infant to settle on CPAP and after commencing CPAP settings to be changed if necessary

Record observations hourly (more Charts improvement/ deterioration of frequently if required) on CPAP chart infant as well as predicting and on CEWS chart deterioration Sedation Chloral hydrate to be prescribed PRN For use when infant does not according to BNFc tolerate CPAP. If infant does not tolerate CPAP its use will be

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 14 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

ineffective

Procedure Rationale Blood gas Blood gas analysis should be Deteriorating blood gases may monitoring performed prior to and one hour after indicate a need for intubation. commencing CPAP Infants receiving IVI should have electrolyte levels checked to prevent Capillary blood gas monitoring at least hypo/ hyperglycaemia etc 6 hourly until stable

Record on Blood Gas Analysis Chart Suctioning Use size 8fr suction catheter to suction Bronchiolitic infants produce thick Indications for nasopharyngeal or orally secretions that cannot be cleared by suctioning: a smaller bore  Increased secretions Suction pressure set to 100-120mmHg Suction can be traumatic for an  Increased maximum infant so should not be undertaken work of as routine procedure breathing Have facial O2 nearby  Increased Fragile infants may respond with Measure distance from incisor to the bradycardia or apnoeas O2 angle of the lower jaw requiremen Higher pressures will cause trauma t Insert catheter without applying suction to the airways  Increased respiratory Apply suction, withdraw slowly in a distress straight movement without rotating  Increased apnoeas Clear suction tubing with sterile water Mouth care, Use foam mouth swab and sterile water CPAP dries infants airways dummies and regularly chin straps Encourage the use of a dummy Dummies stimulate oral secretions, keeping the mouth moist and encourage a good seal by preventing mouth breathing. Alternatively a chin strap can be applied. NB. Never use a dummy against parental wishes or force one on an infant who does not want it/ tolerate it. Handling/ Elevate cot to 30° Elevated cot will reduce pressure on positioning the babies diaphragm

All cares including repositioning, Constant handling increases the observations, nappy changes and blood infants stress levels, energy gas analysis should be performed expenditure and increases the work together and the infant allowed to rest of breathing

Reposition 4-6 hourly Regular repositioning helps reduce facial oedema, reduce pooling of secretions, and reduce pressure

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 15 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

marks as well as improving oxygenation and reducing respiratory workload

Procedure Rationale Nasal integrity Evaluate infants nares and septum If nasal prongs are ill-fitting it can regularly for signs of pressure or cause erosion of the septum and breakdown nares due to friction Parental Explain infants condition and need for To prepare the family for the information CPAP to parents and update them on a procedure regular basis To ensure family-centred care Gain parental consent prior to commencing CPAP To give parents a better understanding so that they can Allow parents to be as involved as advocate for their child and give condition dictates in their Childs care informed consent

Ensure parents receive a Parental information leaflet

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 16 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

Quick User Manual reference guidelines for the Bubble CPAP circuit

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 17 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

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 18 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

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 19 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

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 20 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

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 21 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

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 22 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

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 23 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

Troubleshooting

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 24 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

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 25 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

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 26 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

APPENDIX 2 Quick reference guidelines for the Infant Flow Driver CPAP

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 27 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

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 28 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

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 29 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

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 30 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

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 31 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

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 32 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

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 33 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP). Appendix 3

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 34 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

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 35 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

CPAP

PARENTAL INFORMATION LEAFLET

WHAT IS CPAP, WHY IS IT USED?

CPAP stands for Continuous Positive Airway Pressure and is used in hospital to provide constant gentle pressure through the airways to the lungs. This pressure keeps the airways open to aid your child’s breathing, allowing them to rest. The amount of pressure and oxygen can be adjusted accordingly helping them get better. The CPAP is delivered through two tubes which attach to prongs, which fit snugly in the nostrils and are secured to a bonnet as illustrated in the picture above. These tubes connect to the CPAP machine. You will then see bubbles in the water chamber. CONTINUOUS MONITORING Whilst your baby is receiving CPAP, they will be cared for in the High Dependency Unit (HDU) on Buxton Ward. This is so that they can receive closer observation. You are welcome to stay with your baby next to the cot throughout. An Oxygen Saturation Probe (Sats Probe) will be placed on your baby’s foot or toe displaying how much oxygen is in the bloodstream and the baby’s heart rate. Other observations, such as the respiratory rate and temperature, will also be monitored frequently. OROGASTRIC TUBE This is a small tube inserted into your baby’s stomach, via the mouth and secured to the cheek or chin. This tube will allow the air and contents of the stomach to be drained, giving the lungs more room to expand. Your baby may be Nil By Mouth for a period of time, as digestion takes a lot of energy, which can be used instead for breathing. 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 36 of 37 Joint Trust Guideline for the Management of Infants requiring Continuous Positive Airway Pressure (CPAP).

CANNULAS AND IV FLUIDS

If your baby needs to be Nil By Mouth, a cannula will be inserted and Intravenous fluids will be given to keep your baby hydrated. The doctors will do this and they may take a small amount of blood at the same time for a blood test.

BLOOD GAS ANALYSIS

The amount of oxygen and carbon dioxide in the blood needs to be measured frequently. This is done by pricking the baby’s heel with a lancet and filling a small glass tube with blood. It is much less blood than it looks but this may need to be done quite often until the levels stabilise.

SEDATION

If your baby does not tolerate the CPAP machine very well, they can be given a sedative called Chloral Hydrate. This allows the baby to relax, once your baby gets used to the CPAP, they will not need to have the sedative any more.

SUCTION

Suction is used to clear the airways of excess mucous so your baby can breathe better. A thin suction catheter is inserted into the nose or mouth. Sometimes a larger Yanker Sucker is used in the mouth to clear excessive secretions.

POSITIONING, HANDLING AND COMFORTING

When your baby is on CPAP they can still be touched and comforted by you. They may need to stay in the cot while they adapt to being on CPAP, but after a time you will be able to take them out of the cot and give them a cuddle. The nurses will make the baby a ‘nest’ for them to lie in while they are in the cot to provide comfort and support. The cot will also be tilted so keep your baby upright, helping them to breathe. Their position will be changed regularly to help naturally clear the chest and relieve pressure on their skin. You are welcome to help the nurses with this if you like. You can put some teddies and toys in the cot and provide your own blankets to make your baby feel more relaxed if you want to.

If your baby usually sucks a dummy, they can continue to do this while on CPAP. This will also prevent the baby breathing through their mouth, which will prevent air and pressure from the CPAP escaping.

COMING OFF CPAP

When your babies’ breathing has improved, they will be taken off CPAP, but may still require a little oxygen. Your child will be monitored closely for the first few hours after coming off CPAP to make sure they are still breathing normally; however in some cases, it may be necessary to place them back on CPAP again until they have completely recovered.

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 37 of 37