Nasal continuous positive airway pressure (NCPAP) for neonates

A PIPER (Paediatric Infant Perinatal Emergency Retrieval) neonatal consultant is available 24 hours a day on 1300 137 650 to provide clinical advice and support to paediatricians working in level 3-5 newborn services about NCPAP indications, options and management (including indications for retrieval).

NCPAP can be managed in level 3-5 newborn services for selected babies who are assessed by a consultant paediatrician and meet these criteria:

• birthweight more than 1499 g and gestation at 32 weeks
• less than 24 hours old (the use of rescue NCPAP in a two- to three-day-old baby with progressive respiratory failure is often followed by the need for rescue endotracheal intubation and aggressive mechanical ventilation)
• have clinical signs of respiratory distress
• require FiO2 of at least 0.25 to maintain a saturation between 91 and 95 per cent
• a chest radiograph consistent with mild respiratory distress syndrome or transient tachypnoea of the newborn.

Babies of higher acuity (outside the above recommended indications for NCPAP) should be discussed with the duty PIPER neonatal consultant. These babies may well benefit from commencing NCPAP in the referring hospital for stabilisation prior to retrieval.

Babies on NCPAP who require an ongoing FiO2 of > 0.40 should be discussed with the duty PIPER neonatal consultant to determine if transfer is required.

• Birthweight < 1500 g , gestation < 32 weeks
• More than 24 hours old at initiation of NCPAP
• Persistent FiO2 > 0.40 (after commencing NCPAP)
• Persistent hypercarbia (PaCO2 > 60 mmHg) with respiratory acidosis (pH < 7.25)
• Apnoea (babies >1499 g and =32 weeks' gestation rarely have uncomplicated apnoea of prematurity as a reason to require NCPAP)
• Babies who remain dependant on NCPAP for > 72 hours
• Babies with meconium aspiration syndrome, pneumonia, or with a history of a significant asphyxial event. These babies can rapidly develop severe physiological instability with accompanying increased mortality risk.

To help decision making regarding the need for NCPAP, intubation and oxygen requirements, the following should be considered.

Measurement requires a blood gas.

• Arterial sampling is the gold standard for pCO2 measurement. However, repeated arterial stabs are unrealistic and arterial lines are rarely indicated outside a level 6 newborn service.
• A single arterial stab is useful if the result on a venous or capillary sample appears inconsistent with other parameters (oxygen requirements, clinical assessment) AND if confirmed would result in a significant management change (such as intubation and transfer).
• Capillary pCO2 has good agreement with arterial pCO2 and is useful if in the 40-60 mmHg range.
• Venous pCO2 is useful if in the 50-60 mmHg range (which likely indicates that the baby’s ventilation is at least adequate). However, it consistently overestimates arterial pCO2 (PaCO2) and a single high measure cannot be relied on.
• Despite an increasing trend to tolerating respiratory acidosis and hypercarbia in selected circumstances, a pCO2 > 60 mmHg in association with a pH < 7.25 should be discussed with the duty PIPER neonatal consultant.

Points to note:

• Use pulse oximeter placed on right hand.
• Do not use blood gas to assess oxygenation.
• Target range in all babies is SpO2 91-95 per cent.

The commonly used NCPAP interfaces in level 3-5 newborn services are:

• binasal prong techniques (prongs are short, wide tubes that extend approximately -1 cm into the nostrils)
• nasal mask.

Less commonly used methods are single nasopharyngeal prong and face mask.

Commonly used devices to generate NCPAP include:

• bubble CPAP - this is the main mode of delivery of NCPAP
• a mechanical ventilator.

The recommended level for commencement of NCPAP is 7 cm H2O.

The equipment required, both specific and supportive, is similar to that used for stabilisation prior to transfer of babies who need respiratory support.

Find a complete list of equipment required for NCPAP.

Babies with respiratory distress on whom NCPAP is initiated are usually tachypnoeic, grunting and require mild to moderate inspired oxygen concentrations.
The indications of a positive response to NCPAP include:

• a reduction in the respiratory rate typically by 10-20 breaths/min
• stabilisation or reduction in FiO2 (babies who commence CPAP in FiO2 > 0.40 should show a clear reduction in oxygen requirements within two hours of commencement)
• resolution of grunting
• reduction in the degree of sternal and intercostal recession.

Failure of NCPAP is indicated by one or more of the following:

• a sustained requirement for a FiO2 > 0.40 on CPAP of 7 cm H2O
• absolute rise in FiO2 of 0.10 or greater over a timeframe not exceeding two hours
• respiratory acidosis pH < 7.25 with a rising PaCO2 > 60 mmHg on an arterial or capillary sample
• development of recurrent apnoea requiring stimulation
• development of spontaneous episodes of significant desaturation (<91 per cent for > 20 seconds)
• increased recession and tachypnoea
• agitation not relieved by simple measures (comforting, repositioning)
• development of a pneumothorax.

A PIPER neonatal consultant (1300 137 650) is available to provide clinical advice and support and to discuss further management including indications and process for retrieval.

Health services need to plan staffing around meeting requirements for NCPAP including ongoing availability of staff with NCPAP experience and expertise. This needs to be regularly reviewed against the baby’s progress.

Buckmaster (2012) states ‘at the minimum, there must be a nurse or midwife appropriately trained and experienced in NCPAP available on every shift when treating a baby with NCPAP’. His 2007 study ‘assumed a nurse to patient ratio of 1:2’.

While the acute collapse of a baby on NCPAP is uncommon, access to medical, nursing and midwifery staff with appropriate skills and training to recognise and manage severe deterioration should be readily available.

Regular review of specific procedures in relation to complications (for example, pneumothorax, nasal trauma) is suggested.

A comprehensive learning package and competency assessment checklist

Babies receiving NCPAP require specific clinical care, assessment and monitoring.

Support services

24-hour access to pathology/I-STAT and radiology services should be available.

Nutrition and hydration

Babies who receive NCPAP for acute respiratory indications in the first 24 hours after birth are kept nil by mouth until:

• their respiratory rate is < 70 breaths/min
• the FiO2 is < 0.25
• their work of breathing (as evidenced by grunting, intercostal recession) has improved significantly.

Maintenance IV fluids are required (60 mL/kg/day 10 per cent glucose)

Once the baby is stable and improving, feeds can be commenced cautiously at 15-30 mL/kg/day).

If risks for necrotising enterocolitis (NEC) exist (for example, early compromise or severe growth restriction), discussion with the duty PIPER neonatal consultant is suggested.

If feeds cannot be commenced by 96 hours of age due to ongoing respiratory distress, total parenteral nutrition (TPN) will usually be required. These babies will require discussion with a neonatologist.

Monitoring components of baby on NCPAP

Patient interface

• Care of nasal prongs - prevention, diagnosis and management of blocked prongs
  • care with strapping and changing prong(s)
• Observe for any signs of nasal trauma
• Nasal airway is clear
• Mouth is closed
• Orogastric tube in situ and correct placement

CPAP system

• Regular hourly assessment of the ventilator circuit and equipment
• Check system for leaks
• Drain any excess H2O build up in tubing.

Staff caring for a baby on NCPAP must understand the system and have the ability to problem solve issues in relation to equipment associated with delivery of NCPAP.

Patient position

• Neck slightly extended to maintain airway
• Support and position neonate to promote developmental care and comfort

Vital signs

• Continuous oxygen saturation monitoring, target 91-95 per cent regardless of gestation and postnatal age
• Continuous cardiorespiratory monitoring
• Monitor temperature four- to six-hourly once stable or with servo control
• Six-hourly blood pressure monitoring (non-invasive or invasive)

Blood gas analysis

Babies on NCPAP who have stabilised or improved and whose FiO2 is < 0.40 do not require routine blood gas monitoring. There is no place for ‘four-hourly’ or ‘six-hourly blood gas’ orders.

• Weaning should be managed on clinical grounds.

Blood glucose monitoring

• Blood glucose as per unit guideline or as ordered by medical officer.

Antibiotic therapy

• Babies with no other risk factors for sepsis who have respiratory distress for more than six hours should be commenced on antibiotics if not already prescribed.

Indications to commence weaning include:

• respiratory rate falls below 70 breaths/min
• FiO2 is <0.25
• the baby is breathing with less effort.

There is no clear evidence about approaches to wean babies from CPAP. Current advice from expert opinion supports the following:

• The CPAP should be reduced by 1 cm H2O every two to four hours until at 5 cm H2O.
• A trial off NCPAP is undertaken once the baby is stable for several hours on a CPAP of 5 cm H2O in a FiO2 < 0.25 with a respiratory rate < 70 breaths/min.
• It is common to see a mild increase in respiratory rate (10-20 breaths/min) as well as a small increase in inspired oxygen concentration (for example, FiO2 0.25 to FiO2 0.30) in the first hour after discontinuation of NCPAP.

Complications of NCPAP may include:

• pneumothorax
• agitation
• continued deterioration
• nasal trauma (irritation, ulceration, distortion of the septum).

Equipment required to administer NCPAP in level 3-5 newborn services:

Thermal maintenance

• Resuscitaire with servo-controlled radiant heater
• Incubator

Mechanical ventilator system/bubble CPAP system

• Continuous flow mechanical ventilator set in the CPAP mode with high and low pressure, loss of power and gas alarms or bubble CPAP system with air/oxygen blending capacity
• Humidifying chamber
• Sterile water (bottle or bag and feed set)
• Lightweight ventilator tubing or NCPAP tubing
• Temperature probe for the circuit
• Medical air and oxygen outlets

Monitoring equipment

• Cardiorespiratory monitor
• Pulse oximeter
• Non-invasive blood pressure monitor
• Equipment for collecting blood gases
• Transilluminator for rapid clinical diagnosis of pneumothorax

Equipment to connect the ventilator tubing or CPAP circuit to the airway

• Binasal prongs or nasal mask and recommended fixation device (for example, the NCPAP cap, Fisher & Paykel infant bonnet or nasal CPAP mask)
• Hydrocolloid dressing (such as Comfeel, extra-thin DuoDERM) [optional]
• Suction apparatus
• Fg 5 or 6 and 8 suction catheters
• T piece device/self -inflating bag and face mask
• Intubation equipment

Equipment for gastric decompression

• Orogastric tube of appropriate size
• Tape for securing
• Container to collect gastric drainage
• 10 mL syringe

Resuscitation equipment

Keep this resuscitation equipment cotside at all times:

• suction apparatus
• suction catheters Fg 5, 6 and 8
• hand ventilation system and face mask (T piece device or self-inflating bag)
• intubation equipment
• thoracocentesis equipment:
  • 21 gauge butterfly needle or 22 gauge cannula
  • three-way stopcock
  • 10 or 20 mL syringe
  • alcohol swab
  • sterile cotton swab
• equipment to insert an intercostal catheter.

Documentation

In general, the following parameters should be documented to one-hourly or as ordered by MO:

• FiO2
• CPAP pressure/measurement/setting/level
• gas flow rate
• water level in humidifying chamber
• humidifier and circuit temperature
• activity of bubbles in Bubble CPAP system.

• Buckmaster A, Arnolda G, Wright I, Foster J. Continuous positive airway pressure therapy for infants with respiratory distress in nontertiary care centers: a randomized, controlled trial, 2014. Paediatrics, 2007, 120:509-518
• Buckmaster, A. Nasal continuous positive airway pressure for respiratory distress in non-tertiary care centres: What is needed and where to from here? Journal of Paediatrics and Child Health, 2012,48(747-752)3.
• Todd DA et al, Methods of weaning preterm babies <30 weeks gestation off CPAP: a multicentre randomised controlled trial. Archives of disease in Childhood - Fetal & Neonatal Edition, 2012, 97(236-240
• Defining levels of care in Victorian newborn services, Department of Health & Human Services, November 2015.
• Department of Health, 2010. Capability framework for Victorian maternity and newborn services