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BUBBLE NASAL CONTINUOUS POSITIVE AIRWAY PRESSURE (bCPAP) Nationwide Childrens Hospital NICU Introduction Nasal CPAP is used in spontaneously breathing patients, and provides a constant positive pressure to the airway throughout the respiratory cycle. Nasal CPAP is used to increase transpulmonary pressure and functional residual capacity, particularly in preterm patients with compliant chest walls. By increasing transpulmonary pressure and FRC with nasal CPAP, alveolar collapse is prevented, intrapulmonary shunting is decreased and lung compliance is improved. There may also be beneficial effects of nasal CPAP on surfactant function, splinting of airways, and diaphragmatic function. Nasal CPAP may have beneficial effects on lung growth (Zhang, 1996). Finally, bCPAP may provide oscillatory ventilation to the patient, which may decrease work of breathing and improve minute ventilation (Lee, 1998). The indications for bCPAP include: 1) lung diseases with low FRC; 2) apnea of prematurity; 3) airway closure; 4) tracheomalacia; 5) respiratory support after extubation; and 6) paralysis of a hemidiaphragm. By increasing alveolar pressure and thereby alveolar diameter, alveolar stability is improved. LaPlaces Law relates alveolar pressure to surface tension divided by alveolar radius, thus with a larger radius the alveolus is stabilized even at higher surface tensions such as seen with RDS. Furthermore, there is an increasing body of evidence that demonstrates that by using bCPAP mechanical ventilation can be avoided resulting in a lower incidence of BPD (deKlerk, 2001; Kamper, 2004; Narendran, 2003). Therefore, although bCPAP is more labor intensive than is mechanical ventilation, bCPAP is the preferred form of respiratory support for the preterm patient. In fact, in the Nationwide Childrens Hospital NICU bCPAP is the recommended form of nasal CPAP delivery for patients <2500 grams (see CPAP Protocol). Apparatus The apparatus for delivering bCPAP will consist of a variable oxygen source, a flow meter, a humidifier, and a bottle containing 0.25% acetic acid in which to submerge the expiratory limb to generate the desired airway pressure. A pressure-monitoring device will no longer be utilized. The humidifier will be placed in line, with one temp probe at the humidifier and one downstream of the humidifier. The prongs will be placed as discussed in detail below. The expiratory

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limb of the ventilator tubing will be submerged to the desired distance below the surface of the 0.25% acetic acid solution to generate the ordered pressure. A tape measure will be affixed to the outside of the bottle. The bottle will be filled to no more than 10 cm of the 0.25% acetic acid solution (thus, the highest pressure that could be generated is 10 cmH 2O). It will be necessary to monitor the height of the water in the bottle, as rain out will increase the amount of fluid in the bottle, and if the height of the water is >10 cm then water is suctioned out until the level is at 10 cm again. It should be noted that there are no alarms for this apparatus, indeed the primary end-point for bCPAP is the patients condition. If the patient is doing well, then it is recommended that the patient be left alone. On the other hand, if the patient has desaturation, apneic, and/or bradycardic episodes then bubbling should be checked first, and if not present then measures should be taken to promote bubbling. Prongs Hudson prongs are utilized to deliver bCPAP. The prongs should be sized as shown below: Body weight (grams) <700 ~1000 ~2000 ~3000 ~4000 Prong size 0 1 2 3 4

Note that when the prongs are upsized, not only is the radius of the prongs increased but also the distance between the prongs is increased. Thus, a prong size greater than one or two sizes above the recommended should probably not be used due to the increased length of the prongs and increased distance between the prongs. In rare cases, duoderm may be wrapped around the prong to increase its outer diameter (Note: size 0 prongs should never be wrapped with duoderm). The duoderm should only cover about 2/3rd of the prong and the last 1/3 rd of the prong should not be wrapped.

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Application Position the patient in the supine position with the head elevated. Place a small roll under the patients neck. Nesting and comfortable positioning account for 50% of successful application of bCPAP. Place a pre-made hat (stockinet) on the patients head to hold the bCPAP tubing. Adjust flow rate through circuit to 5 10 lpm. Lower flow rates are more important with size 0 and size 1 prongs due to the high resistance with the small internal diameter of the prongs. Maintain gas temperature at 38 40C. Insert expiratory limb in a bottle of 0.25% acetic acid filled to a height of no more than 10 cm; place a tape measure on side of bottle. Using the appropriate sized prongs, moisten them with water or saline, and then place the curved side down into the nares. Secure tubing on both sides of the hat with safety pins and rubber bands, tie the rubber bands in the middle. Please note the safety pins should go through both layers of the hat, e.g. through the brim and the hat, and that the safety pins should clasp at the top of the head (see Figure 1). There should always be a cushion of air between the prongs and the nasal septum. FIGURE 1. Bubble nCPAP application.

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Figure 2. Anatomy of the nose.

Maintenance Observe the babys vital signs, oxygenation, and activity. If the baby is fine, then there is no need to adjust the bCPAP apparatus or prongs even if there is no bubbling as long as the prongs are not touching the septum. Check bCPAP prong position, the prongs should never touch the septum. Remember there should always be a cushion of air between the prongs and the nasal septum! Systematically check the bCPAP apparatus with scheduled cares and if the patient is having desaturation, apneic and/or bradycardic episodes. Pay particular attention to the inspired gas temperature, and whether air is bubbling into the acetic acid solution. A snug hat is used to securely hold the tubing in place and maintain prong position. Self-adhesive Velcro can be used to keep the prongs away from the septum if necessary. If Velcro is used, then put the fuzzy Velcro right next to the prongs and the rough or the hook Velcro should be placed right underneath the nares not under the septum (see Figure 1). A chinstrap can be employed if there is no bubbling and the patient is decompensating, but remember that it should be relatively loose fitting and tied over the top of the head. Remember to change the babys position; it is recommended to use side lying and supine position.

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The head of the bed is raised 15. An extra large blanket roll placed in a circle can be used as a combination nest and neck/chest roll for side lying and prone positioning to elevate the circuit and prongs above the bed. Change the hat, prongs, and Velcro daily with the first care of the dayshift to be done by the nurse and respiratory therapist. Change the bCPAP circuit and the acetic acid bottle weekly. Baths, cares and weights should be done with the bCPAP on the patient.

Suctioning The patient on bCPAP should be suctioned q 3-4 hours (q 6hrs for infants on Small Baby Guidelines I) with every care, and as needed. Moisten the nares with a few drops of saline prior to inserting the suction catheter. Use the largest size suction catheter that passes easily. The suction catheter should be inserted to a depth of the nose-to-ear measurement + that distance. The suction tubing should be aimed straight back (see Figure 2). Aspirate the OG tube to empty the stomach of air before every feeding. The most common complications of bCPAP include: 1) nasal obstruction from secretions; 2) improper prong placement; 3) gastric distension from swallowed air; and 4) nasal septum erosion or necrosis. Thus, suctioning, proper prong placement, and vigilance by the entire health care team are the mainstay of successful bCPAP therapy. Weaning Premature patients are maintained on bCPAP until the patient is breathing easily on room air with little apnea and bradycardia. Thus, the length of bCPAP therapy depends on each individual patient, although many extremely premature infants may require bCPAP until ~32 weeks post-conceptual age. There is some evidence that CPAP may augment lung growth in preterm infants (Zhang, 1996). When patients are weaned off bCPAP they should not require supplemental oxygen by nasal cannula, and therefore should be placed in room air. Patients weaned off bCPAP who then develop an oxygen requirement to maintain SpO 2 >85%, and/or increased apnea and bradycardia need to be placed back on bCPAP.

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Developmental Care It is okay to kangaroo patients on bCPAP It is okay to feed patients on bCPAP, even to PO feed these patients Cares should include attention to positioning with emphasis on side-lying and supine positioning References
de Klerk AM, de Klerk RK. Nasal continuous positive airway pressure and outcomes of preterm infants. J Paediatr Child Health 37: 161-167, 2001. Kamper J, Feilberg-Jorgensen N, Jonsbo F, Pedersen-Bjergaard L, Pryds O; Danish ETFOL Study Group. The Danish national study in infants with extremely low gestational age and birthweight (the ETFOL study): respiratory morbidity and outcome. Acta Paediatr 93: 225-32, 2004. Lee KS, Dunn MS, Fenwick M, Shennan AT. A comparison of underwater bubble continuous positive airway pressure with ventilator-derived continuous positive airway pressure in premature neonates ready for extubation. Biol Neonate 73: 69-75, 1998. Narendran V, Donovan EF, Hoath SB, Akinbi HT, Steichen JJ, Jobe AH. Early bubble CPAP and outcomes in ELBW Preterm Infants. J Perinatol 23: 195-199, 2003. Zhang S, Garbutt V, McBride JT Strain-induced growth of the immature lung. J App Physiol 81: 1471-1476, 1996.

These guidelines were drafted by the bCPAP Group: Lori Alexander, Tom Preston, Letitia Wiltshire, Emily Brinkman, Michele Crane, Lisa Mollica, Tria Shadeed, Ed Shepherd, Randy Rose, Susan Frazier, Brandon Kuehne, Jon Wisp, Leif Nelin, and Steve Welty. These guidelines are based on the approach to bCPAP used at Columbia University and the Morgan Stanley Childrens Hospital.