Tasmanian Health Organisation - North

NEONATAL UNIT LGH SDMS Id No.: P2012/0451-001 Procedure No: 4.26/12WACS

Nasal Continuous Positive Airway Pressure (NCPAP) for Neonates and Infants Procedure
Application: Approved by: Effective Date: Custodian and Review Responsibility: Review Date: Version: Registered/Enrolled Nurses/Medical Staff, QVMU Director of Paediatrics, LGH 2 August 2012 Quality and Clinical Improvement Nurse Paediatrics/Neonates

2 August 2015 Version No. 1 Policy No: 4.26

Background
Tasmanian infants from 30 weeks gestation are currently able to be managed at the Launceston General Hospital (LGH) in accordance with the Neonatal and Paediatric ICU, Tasmania Admission Guideline. NCPAP is used as one of the modalities for the management of respiratory distress of neonates and it is the purpose of this document to provide guidelines for NCPAP at the LGH, with input from the Neonatologists at the RHH. The use of NCPAP in a level 2 unit such as the LGH reduces the need for transfer, but is relatively resource intensive in regards to equipment, medical staff availability and skilled nursing care. This guideline will cover 3 main areas: 1 A clinical protocol with indication, contraindications, technique, assessment of success/failure, discontinuation, complications, and monitoring requirements. Medical staff resources Nursing staff resources

2 3

This document will NOT describe the total care related to a sick baby, but only aspects of care relevant to NCPAP.

Procedure
Causes of respiratory distress in neonates
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Respiratory distress syndrome (HMD) Transient tachypnoea of the neonate (TTN)

Congenital pneumonia (carefully evaluate suitability of ongoing NCPAP at LGH, depending on clinical course as these babies are at an increased risk of requiring intubation and ventilation) Meconium aspiration (carefully evaluate suitability for NCPAP) Pneumothorax (not suitable for NCPAP) Congenital abnormalities (not suitable for ongoing NCPAP at LGH, discuss with RHH) o o o o Pulmonary hypoplasia Diaphragmatic hernia Airway obstruction Congenital cardiac disease

Indications for NCPAP at LGH

Infants should meet the following criteria: Gestation > 30 weeks Clinical signs of respiratory distress (nasal flare, tachypnoea, grunt, recession) Oxygen requirement of >30% to keep oxygen saturation 92-96% A CXR consistent with respiratory disease

Contraindications
Gestation < 30 weeks (does not preclude using NCPAP as a pretransfer modality for these babies) Insufficient medical or nursing resources Rising FiO2 > 0.4 (i.e. 40%oxygen) (discuss with RHH) Significant apnoea

Technique and monitoring required

The recommended starting level of NCPAP is 5-7cm H20 and titrated to patients condition. The maximum level of NCPAP pressure is 8cm H20. Maintenance intravenous fluids are required Expressed colostrum can be given at the discretion of the paediatrician Continuous pulse oximetry and oxygen saturation monitoring Indwelling arterial line for BP and intermittent blood gas estimations if FiO2 > 0.4 is recommended
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Note: PLEASE DESTROY PRINTED COPIES. The electronic version of this Procedure is the approved and current version and is located on the departments intranet. Any printed version is uncontrolled and therefore not current.

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Standard cardio respiratory monitoring including blood pressure Regular inspection of the ventilatory circuit and equipment which includes 1 2 3 4 prong position and orientation the need for a chin strap water in circuit is the expiratory limb bubbling?

Assessment of failure of NCPAP

FiO2 rising above 0.4 Ongoing respiratory acidosis ph < 7.25, PaCO2 > 50 mmHg Recurrent apnoea requiring stimulation Recurrent episodes of significant desaturation (<90% for >20 sec) Worsening sternal and intercostal recession/grunt/tachypnoea Agitation not relieved by simple measures (comforting, paracetamol) Development of pneumothorax.

An immediate medical assessment and CXR is required and the consultant notified. Consideration should be given to notifying the RHH neonatologist of the babys condition. A positive response to NCPAP includes a reduction in respiratory rate, resolution of grunting, stabilization or reduction of FiO2, and reduction in recession.

Discontinuation
Once a babys respiratory rate falls below 60/minute, the Fi02 is < 0.3 and the baby is breathing with less effort, the CPAP and FiO2 can be weaned and stopped. There is no clear evidence as to the best weaning strategy, but once the FiO2 is 0.210.23 the CPAP could be reduced by 1 cm H2O every 6-12 hours, until stable at 5 Cm H2O, and then trialled off. It is not uncommon to see a slight increase in respiratory rate and FiO2 in the 1st hour after discontinuation.

Complications
Pneumothorax Agitation Continued deterioration Nasal trauma Abdominal distension

Documentation
Observation chart for hourly recording of: Vital signs and work of breathing

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FiO2 CPAP pressure Gas flow Humidifier and circuit temperature Water level in humidifier

Medical resources
A baby should not be started on NCPAP without the involvement of the Consultant Paediatrician. 24 hour registrar cover must be available on site or within 10 minutes

The registrar must have recognised neonatal resuscitation training Knowledge about the indications for NCPAP Knowledge about the complications of NCPAP Knowledge about the expected course of neonates on NCPAP The Consultant Paediatrician must be immediately contactable by phone, and no more than 30 minutes away, experienced in the use of CPAP and able to manage the complications ie: drainage of pneumothorax, intubation and ventilation.

Nursing Resources
Completed LGH resuscitation education The nurse to patient ratio should be 1:1 and able to be maintained for duration of care There needs to be agreement between the nursing and medical staff that 1:1 nursing would be available for the patient on NCPAP (typically for 24-72 hours) Competent in care of baby with CPAP Knowledgeable of the indications for and contraindications of commencing a neonate on CPAP Knowledgeable of the expected course of neonates on CPAP

When should NETS (RHH) be notified:

Any baby not following the expected course on NCPAP Failure of NCPAP as above Babies under 30 weeks gestational age Babies not managing enteral nutrition and requiring parental nutrition

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There is the potential for babies over 30 weeks gestational age, from the North West Regional Hospital and Mersey Community Hospital with respiratory distress, to be managed with NCPAP at the LGH. This would need to be in discussion with both the LGH Paediatrician as well as the RHH Neonatologist, as the risk that they might need ventilation and thus further retrieval to RHH needs to be assessed.

Responsibilities/Delegations
Nursing and Medical Staff Neonatal Nursery LGH, QVMU.

Related Documents/Legislation
1 http://www.health.vic.gov.au/neonatal/nasalcpapguidelines.pdf
Dr Ingrid Els Malcolm Gulliver Chris Coker Chris Bailey Consultant Paediatrician Position Title Nurse Unit Manager Paeds Exec 6348 8991 6348 7374 6348 8944 6348 8974 June 2012 June 2012 June 2012 2 August 2012 Prepared by Through Through Cleared by

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