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Nasal Continuous Positive Pressure Ventilation (nCPAP)

Management guidelines for students, interns and registrars on a variety of routine and emergency situations in our neonatal service at Tygerberg Children’s Hospital. Published in 2014.

Indications

Contraindications

Failure of nCPAP

Dangers (Complications)

Components of nCAP apparatus

Setting up the Apparatus

Observation of Baby

Weaning

Indications

  1.  Mild to moderate respiratory distress as a result of i.e.:
    •  Respiratory distress syndrome (HMD)
    •  Wet lung syndrome
    •  Meconium aspiration syndrome
    •  Pneumonia
  2.  Apnoea of prematurity
  3.  Post extubation
  4.  Atelectasis (and also small lung volumes)

Contraindications   

  1.  Upper airway abnormalities e.g. cleft palate, Pierre Robin
  2.  Recurrent apnoea with bradycardia
  3.  Severe cardio-respiratory instability
  4.  Essential intubation and mechanical ventilation

Failure of nCPAP

  1.  Recurrent apnoea with bradycardia
  2.  Severe rib retraction
  3.  Severe grunting
  4.  PaCO2 > 7.5 kPa
  5.  FiO2 ≥ 0.6 (60% O2)
  6.  pH < 7.25 (or Base excess >-10)
  7.  O2 saturation < 90% with FiO2 ≥ 0.6
  8.  a/A ratio < 0.22

Dangers (complications)

  1.  Nasal obstruction (and apnoea) as a result of secretions or displaced nasal prongs
  2.  Nasal prongs displacement
  3.  Nasal irritation, septum and mucosal erosion/necrosis
  4.  Nasal decannulation
  5.  Water accumulation in circuit and nose
  6.  Pneumothorax

Components of nCPAP apparatus  (See photographs below)

  • Oxygen-air blender
  • Humidifier
  • Circuit (pipes)
  • Nose-piece (“generator”) with correctly sized nasal prongs
  • Tapes for stabilisation of nose-piece
  • Cap for head



Nose-piece and tapes attached to woollen cap


Nose-piece (generator) with prongs

Oxygen humidifier

1. Pressure meter  2. Oxygen-air blender  and  3. Flow meter      

Setting up the Apparatus

Commence nCPAP as quickly as possible

  1. Place baby supine in overhead radiant heater bed (open incubator) with small rolled up nappy under the shoulders
  2. Keep baby nil per os initially with orogastric tube on open drainage
  3. Begin intravenous infusion
  4. Put snug-fitting woollen cap on baby’s head (low down over forehead)
  5. Stick Granuflex strips over nose, nasal septum (outside) and cheeks.  This decreases pressure necrosis.  1 strip between upper lip and nostrils; 1 strip over nasal bridge (above nostrils) and cheeks, and 1 strip over nasal septum.
  6. Choose correct size of nasal prongs so as to fit comfortably into nostrils.
    • Insert without pressing on nasal septum.
    • 3 sizes to choose from viz. small, medium, large.
  7. Connect correct size of nasal prongs to the nose-piece (“generator”) and place in baby’s nostrils. The prongs should fit snugly without pressing on the nasal septum.
  8. Tie the tapes of the nose-piece to the woollen cap with sticking plaster
  9. Stick the small gauge oxygen tube to the top of the baby’s head so that the nose-piece fits comfortably into the nostrils
  10. Do not tape the thick corrugated expiratory tube to the woollen cap
  11. Check that there is sterile water in the humidifier and set the temperature to 37°C
  12. Oxygen is heated to 36°C
  13. Commence initial oxygen flow of 6-8 litres/minute or 4-5 cm H2O pressure.
  14. Adapt oxygen concentration (FiO2) according to saturation:
    Aim to maintain O2 saturation 92 - 95% in term baby
    Aim to maintain O2 saturation 85 - 90% in preterm baby <1.5kg or <32 weeks corrected age
    Aim to maintain O2 saturation 88 - 92% in preterm baby 33 – 36 weeks corrected age
  15. Observe baby and document saturations
  16. Prescribe the nCPAP, pressure and O2 saturation range/criteria on the patient’s prescription chart

Observation of Baby

  1. As the nasal prongs can easily become dislodged and the baby then may become hypoxic, a baby on nCPAP must be observed continually by the nurse
  2. Observations must be documented half hourly:
    • Respiratory rate
    • Heart rate
    • Retraction
    • Grunting
    • Colour
    • Apnoea
    • Are nasal prongs correctly positioned in the nostrils? (must not slip out or press against the nasal septum)
  3.  Check water level (fill/empty)
  4.  Check humidification temperature
  5.  Remove excess water from the nCPAP circuit every hour (clear rain-out)
  6.  Check sterile water level in the humidifier every hour
  7.  Oxygen in apparatus must automatically be heated (37°C) and humidified
  8.  Suction the nose and mouth as necessary. (Routine suctioning is not indicated)
    • Suction apparatus must not exceed the following pressures:
          -80 to -100mm Hg, or  -130 mbar,  -13 kPa,  -0.13 bar,  -4 inches Hg
    •  [Conversion:  1 mm Hg = 0.133 kPa  or  0.0013 bar  or  1.33 mbar or 1.36 cm H2O  or  0.039 mm Hg]
  9.  Baby to be on continuous transcutaneous oxygen monitoring
  10.  Measure and document oxygen saturations hourly
    •  Maintain oxygen saturations at appropriate levels for preterm and term babies.
    •  If oxygen requirements exceed 60 % O2 (FiO2 >0.6), or baby develops severe retraction, or apnoea or grunting, then the doctor must be notified immediately
  11.  If oxygenation is low, increase pressure by 1cm H2O as necessary
    •  Maximum pressure 8cm H2O. 
  12. Do blood gases and acid-base as necessary.  If PaCO2 rises (because of over distension of lungs), decrease pressure.  Maintain pH > 7.25 and PaCO2 < 7.5 kPa.
  13.  Keep stomach tube open if baby is nil per mouth
  14.  As soon as baby is stable, consider feeding through stomach tube
  15.  Baby may be turned onto back, stomach or side. (Do not place baby on stomach if umbilical catheter is in situ)
  16.  Change the circuit and nasal prongs every week
  17.  Do CXR if no clinical improvement (look for air leaks, small lung volumes)

Weaning

  1. Wean FiO2 and pressure according to clinical improvement, blood gases, O2 saturation and acid-base.
  2.  Decrease FiO2 by 0.05 (5% O2) at a time.  If FiO2  <0.25, decrease CPAP pressures by 0.5 - 1cm H2O every 4 hours.
  3.   Discontinue nCPAP and remove device once FiO2 = 0.21 (21 % O2) for 24 hours with pressures
     ≤ 2cm H2O and no grunting or severe retraction present
  4.  If the baby still requires supplementary oxygen, administer oxygen with oxygen-air blender through nasal cannulae with a maximum flow of 1 – 2 litres O2 per minute.    
    Aim to maintain  O2 saturation 92 - 95% in term baby
    Aim to maintain O2 saturation 85 - 90% in preterm baby <1.5kg/<32 weeks
    Aim to maintain O2 saturation 88 - 92% in preterm baby 33 – 36 weeks                                             
  5.  Kangaroo mother care can be administered if baby is stable
  6.  Observe baby




NeoHealth® ID 17155 · updated 9/15/2021