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Bubble nasal CPAP manual

Riyadh AL-Kharj Hospital Programme
Neonatal intensive care
2005
Amer Ammari, MB, BS
Fawaz Kashlan, MD
Faisal Ezzedeen, MD
Atyah AL-Zahrani, MD
John Kawas, RRT
M.A. Majeed-Saidan, MB. Ch.B., FRCP
Adapted from the NCPAP Education and training manual
By J.M. Conner, R. de Klerk and A. de Klerk.

PREFACE
Respiratory Distress Syndrome (RDS) is due to a deficiency of pulmonary
surfactant. Seventy one % of very low birth weight infants had RDS, and 35% of
them still required oxygen at 36 weeks adjusted age (Vermont Oxford Network
2001). Along with significant mortality, RDS is associated with significant
morbidity and high costs to society.
Pulmonary surfactant lines the surface of the alveoli in the lung, thereby reducing
surface tension and preventing alveolar collapse. Surfactant deficiency results in
progressive atelectasis of the alveoli, decreased pulmonary compliance, increased
work of breathing, respiratory failure, and lung injury. The earlier the gestational
age, at which birth occurs, the higher the risk that severe respiratory distress
syndrome will develop.
Historically, conventional therapy for this disorder has consisted of continuous
positive airway pressure (CPAP) or mechanical ventilation, along with
appropriate supportive care. In the past decade, surfactant replacement has led
to significant improvements in survival, particularly for infants less than 1000
grams. However, attempts to treat RDS may lead to lung injury, and secondary
complications including bronchopulmonary dysplasia (BPD) and chronic lung

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disease (CLD). This lung injury is thought to result from the effect of mechanical
injury due to assisted ventilation, oxygen toxicity, and lung inflammation among
other factors.
The following materials comprise the bubble nasal CPAP Manual. This manual
provides a training tool in the administration of nasal CPAP using a bubble bottle
system, following guidelines established at The Childrens Hospital of New York
at New York Presbyterian Medical Center (Columbia-Presbyterian Medical
Center).

CONTENTS
Introduction
Section 1: Background and Theory
Section 2: Initiation of nasal CPAP
Section 3: Maintenance of nasal CPAP
NCPAP Checklist: Maintaining the nasal CPAP System
Section 4: Complications Associated with nasal CPAP
Section 5: Removal of nasal CPAP
Section 6: Respiratory Failure on nasal CPAP
NCPAP Checklist: Respiratory Failure on nasal CPAP
Section 7: Troubleshooting the nasal CPAP Delivery System
References
Appendix A: Equipment List and Manufacturers
Section 8: Delivery room protocol for the respiratory management of preterm
infants

INTRODUCTION
Purpose The purpose of the nasal CPAP Training and Education Manual is to
provide a training tool in the administration of nasal continuous positive airway
pressure (CPAP) using a bubble system following guidelines established at
Columbia-Presbyterian Medical Center in New York.
As you work through this training manual, you will learn the skills to successfully
administer nasal CPAP to premature infants using a bubble system. The sections
outlined below contain information regarding the theory and the application of
the nasal CPAP bubble system.
Section One: Background and Theory provides a brief review of the
physiology of continuous positive airway pressure, and pertinent literature
supporting CPAP use in the premature infant.
Section Two: Initiation of nasal CPAP describes the nasal CPAP delivery
system and the steps necessary for stabilization and initiation of NCPAP in the
delivery room. This chapter describes how to determine the appropriate size and
fit of each component in the nasal CPAP delivery system.
Section Three: Maintenance on nasal CPAP describes how to evaluate and
to maintain a properly functioning CPAP system, including the use of the nasal
CPAP Checklist: Maintaining the nasal CPAP System.
Section Four: Complications Associated with nasal CPAP describes
complications that may occur to infants being treated with nasal CPAP.
Section Five: Removal of nasal CPAP describes the steps involved in
determining whether an infant is stable and ready to be removed from the nasal
CPAP system.
Section Six: Respiratory Failure on nasal CPAP describes how to evaluate
and how to troubleshoot the nasal CPAP bubble system in instances where
infants have progressive respiratory failure, including the use of the nasal CPAP
Checklist: Respiratory Failure on nasal CPAP.
Section Seven: Troubleshooting the nasal CPAP Delivery System
focuses on specific common questions and issues arising when using nasal CPAP.

SECTION ONE
BACKGROUND AND THEORY
Introduction
Respiratory Distress Syndrome (RDS) is due to a deficiency or dysfunction of
pulmonary surfactant. Pulmonary surfactant lines the surface of the alveoli in the
lung, thereby reducing surface tension and preventing alveolar collapse.
Surfactant deficiency results in progressive atelectasis of the lung, decreased
pulmonary compliance, increased work of breathing, respiratory failure, and lung
injury.
Since the initial discovery of the role of surfactant deficiency in the pathogenesis
of respiratory distress syndrome, numerous randomized controlled trials have
shown that intratracheal instillation of an exogenous surfactant preparation is
effective in both the prevention and treatment of RDS. To date, over 33
randomized controlled trials of surfactant replacement therapy involving over
6,000 infants have been reported. Meta-analyses of these randomized controlled
trials have shown that, when compared to conventional management without
surfactant replacement, surfactant therapy results in a significant decrease in the
risk of pneumothorax and mortality.
Despite the success of surfactant therapy, a significant number of infants will
develop lung injury, as demonstrated by the persistent high rate of chronic lung
disease seen in extremely low birth weight infants. Nasal Continuous Positive
Airway Pressure (CPAP) may represent a less invasive way to maintain lung
volume and improve oxygenation.
Studies that examined the variation in practice between centers have suggested
that the routine use of nasal CPAP in the stabilization of very low birth weight
infants may reduce the incidence of chronic lung disease.
Physiology of CPAP
Continuous positive airway pressure (CPAP) has been widely used to correct
respiratory insufficiency. CPAP was used in adults as early as 1936. CPAP has
been used in infants with RDS since its introduction in 1971.
CPAP is uniquely suited to address many issues in the pathogenesis of RDS.
Clements and colleagues described the importance of surfactant for the
stabilization of alveoli at low transpulmonary pressures. Harrison and colleagues
recognized the benefit of an increased alveolar pressure during expiration in
infants with respiratory distress syndrome and demonstrated that eliminating the
infants ability to grunt by use of an endotracheal tube is associated with a
decrease in Pa02.
CPAP works by maintaining positive pressure in the airway during spontaneous
breathing, thereby increasing functional residual capacity and improving
oxygenation in infants with RDS. CPAP does this by stabilizing airspaces that
have a tendency to collapse during expiration due to surfactant deficiency.
A variety of mechanisms of action of nasal CPAP have been proposed. These
include:

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__Increase transpulmonary pressure
__Increase functional residual capacity
__Prevent alveolar collapse
__Decrease intrapulmonary shunting
__Increase lung compliance
__Conserve surfactant
__Increase airway diameter
__Splint the airway
__Splint the diaphragm
__Stimulate lung growth
__High frequency ventilatory effect (with bubble nasal CPAP)
Clinical Research Using nasal CPAP
Interest in nasal CPAP was renewed by Avery and colleagues, when they
demonstrated that within the NIH score centers, the center that aggressively
utilized NCPAP had the lowest incidence of chronic lung disease. Since the report
of Avery and coworkers, a variety of studies using historical controls have
demonstrated improved outcomes in premature infants with the introduction of
early application of nasal CPAP. Jacobsen and coworkers evaluated nonasphyxiated very low birth weight infants (VLBW) before and after institution of
a policy of early treatment with nasal continuous positive airway pressure and
minimal handling during stabilization. This minitouch regime was introduced
as a routine in 1986. Jacobsen and colleagues compared infants born in 1987
after the policy was instituted, to infants born in 1985, when ventilator treatment
was used initially in all infants with progressive respiratory distress. The
frequency of mechanical ventilation was reduced from 76% in 1985 to 35% in
1987. Intraventricular hemorrhage (IVH) grade II-IV was reduced from 49% in
1985 to 25% in 1987.
Other clinical outcomes, including mortality rate, average duration of
hospitalization, number of infants with pneumothorax, patent ductus arteriosus,
need for oxygen at 28 days and number of surviving infants with handicap did
not differ significantly between the two study periods.
Kamper and coworkers studied a cohort of 81 very low birthweight (VLBW)
infants treated with oxygen only (n=11), with early continuous positive airway
pressure (n=68), or mechanical ventilation from birth (n=2). A total of 65 infants
(80%) survived to discharge, 61 of whom were supported solely with CPAP or
oxygen. Nineteen infants (26%) developed IVH, but only four survivors (6%)
developed IVH grade II-IV. No survivors had bronchopulmonary dysplasia.
Gittermann and coworkers evaluated the introduction of early nasal CPAP in
VLBW infants admitted to a tertiary neonatal intensive care unit. All liveborn
VLBW infants admitted to their neonatal intensive care unit in 1990 (historical
control group) and in 1993 (early NCPAP group) were evaluated. Infants in the
later group had NCPAP applied as soon as signs of respiratory distress occurred.
Significantly fewer infants required intubation during the later period, after the

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introduction of early NCPAP (30% vs. 53%). Neither the incidence of
bronchopulmonary dysplasia (32% vs. 30%), nor the incidence of mortality prior
to hospital discharge (10% vs. 7%) was significantly reduced by early application
of NCPAP. Lindner and coworkers studied the effect of delivery room policies on
the rate of endotracheal intubation, mechanical ventilation, and short term
morbidity in extremely low birth weight infants. Until 1994, Lindner and
coworkers intubated extremely low birth weight infants immediately after
delivery when presenting with minimal signs of respiratory distress or asphyxia.
During 1995, the guidelines for respiratory support were changed. In 1996,
continuous (15 to 20 seconds) pressure controlled (20 to 25 cm H2O) inflation of
the lungs using a nasal pharyngeal tube, followed by continuous positive airway
pressure (CPAP 4 to 6 cm H2O) was applied to all ELBW infants immediately
after delivery to establish a functional residual capacity and to avoid intubation
and mechanical ventilation. Of 123 inborn ELBW infants born in 1994 and in
1996, the rate of intubation and mechanical ventilation decreased from 84% in
1994 to 40% in 1996. Twenty-five percent of the ELBW infants were never
intubated in 1996 compared to 7% in 1994.
De Klerk and De Klerk documented the effects of instituting a system of
respiratory support based primarily on the early institution of NCPAP. Outcomes
in premature infants with a birth weight of 1000-1499 grams were compared
retrospectively over a 5-year period; before (period I; n = 57) and after (period II;
n = 59) the introduction of an NCPAP-based approach to respiratory support.
From period I to period II, there was a decline in the number of infants ventilated
(65% vs. 14%) and in the number of infants receiving surfactant (40% vs. 12%). A
decreased incidence of chronic lung disease (CLD) at 28 days (11% vs. 0%) and
death or CLD at 28 days (16% vs. 3%) was also noted. In addition, there was a
decrease in the median days of ventilation (6 vs. 2 days), and the median days on
supplemental oxygen (4 vs. 2 days). Differences in the use of pressor support
(34% vs. 7%), the incidence of necrotizing enterocolitis (11% vs. 0%), the time to
reach full oral feeds (17.3 vs. 13.2 days), discharge weight (2569 vs. 2314 g) and
average length of stay (61 vs. 52.9 days) were noted. There were no differences in
other clinical outcomes.
Although early institution of nasal CPAP is promising, little evidence in support
of this practice is found in randomized controlled trials. A recent Cochrane
Review (Subramaniam 1999) found only one randomized controlled trial of early
application of NCPAP in premature infants (Han 1987).
Han and coworkers (Han 1987) studied 82 infants less than 32 weeks gestation.
Infants were randomized to nasopharyngeal CPAP or supplemental oxygen via
head box. No differences in outcome were noted between the two groups. An
approach that combines aspects of both early surfactant administration and early
stabilization on NCPAP has been tested in the Scandinavian countries.
Verder and coworkers (1999) conducted a multicenter randomized controlled
trial to determine whether early versus late treatment with porcine surfactant
reduced the requirement of mechanical ventilation in very preterm infants

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primarily supported by NCPAP. The study population comprised 60 infants less
than 30 weeks gestation with respiratory distress syndrome who had an arterial
to alveolar oxygen tension ratio (a/APO2) of 0.22 to 0.35. Although the study
does not specifically evaluate the practice of delivery room stabilization, Verder
and coworkers offer support for the practice of early intubation, surfactant
administration, and extubation to NCPAP. Infants who received early treatment
had improved oxygenation six hours after randomization (mean a/APO2 rose to
0.48 in the early-treated infants compared with 0.36 in the late-treated infants).
The need for mechanical ventilation before discharge was reduced from 68% in
the late-treated infants to 25% in the early-treated infants.
CPAP Delivery Systems
The CPAP delivery system consists of three components: the circuit for
continuous flow of inspired gases, the interface connecting the CPAP circuit to
the infants airway, and a method of creating positive pressure in the CPAP
circuit. The success involved in delivering CPAP is entirely associated with the
delivery system; the system must fit properly, be lightweight and flexible, be of
low resistance, be easy to apply, remove, and keep connected, and must provide a
minimum of discomfort and trauma to the infant. The CPAP setup is designed to
deliver pressure through a low-resistance system. The resistance in the circuit is
directly proportional to the length of the circuit, and inversely proportional to the
fourth power of the radius of the tubing used. This means that doubling the
length of a tube doubles the resistance of the tube, and halving the radius
increases the resistance (24 = 2x2x2x2, or 16 times). Since the pressure that is
delivered and ultimately reaches the lungs is directly related to the resistance of
the delivery system and patient airway, it is imperative that every effort is made
to minimize this resistance.
Many techniques are available to deliver CPAP including nasal cannulae,
facemask, nasopharyngeal tube, head-box with neck seal, or endotracheal tube.
For the purposes of this training manual, we will focus on delivering CPAP
through nasal prongs attached to a bubble bottle system.
For the NCPAP system to be effective it must have the following characteristics:
__Be a low resistance delivery system
__Large bore tubing
__Short wide connection to the infant (nasal prongs)
__Fit appropriately and prevent pressure leaks
__Snug fitting nasal prongs
__Well positioned interface
__Chinstrap in place and secure
__Flow through an optimally maintained airway
__Warmed, humidified gas
__Neck mildly extended using a neck roll
__Suctioning q 3-4 hr, and prn.
__Be maintained with meticulous and consistent technique.

The Columbia Presbyterian NCPAP Approach

Nearly thirty years ago, under the direction and leadership of Dr. Jen-Tien Wung
at Columbia Presbyterian Medical Center in New York, a systematic approach to
the use of the bubble CPAP system was developed. The Columbia approach with
bubble CPAP has been described as a minimal, gentle ventilation approach. This
approach to respiratory care focuses on meticulous attention in providing
consistent and optimal CPAP delivery. At Columbia Presbyterian Medical Center,
premature infants are stabilized in the delivery suite with the application of
Hudson nasal prongs and 5cm of bubble CPAP using a water bottle system.
Meticulous care of the airway including suctioning and placing appropriately
fitting prongs has shown remarkable results. At Columbia Presbyterian Medical
Center 76% of spontaneously-breathing very low birth weight infants < 1250
grams do not require mechanical ventilation.

SECTION TWO
INITIATION OF NCPAP
Introduction
Successful initiation of nasal CPAP involves three critical steps:
Step One: Assemble the CPAP Delivery System
Step Two: Determine the appropriate size of the NCPAP interface
Step Three: Apply the NCPAP system.
1. Step One: Assemble the CPAP Delivery System Follow the steps
outlined below in Sections A and B to assemble the appropriate materials
and set up the CPAP system in the delivery room or stabilization area
(Transitional Nursery-Room 9 in the delivery room) or in the NICU. At
least one bubble bottle CPAP delivery system must be set up and ready to
use for all imminent deliveries of eligible infants. If a delivery system is
already set up, check that the system was assembled appropriately.
Section A: Gather the following equipment:
Refer to Appendix A for equipment lists and manufacturers.
Oxygen and air flow sources
Oxygen blender with flow meter
Oxygen or suction tubing to lead from the blender to humidifier
Oxygen analyzer (optional)
Humidifier filled to appropriate level with sterile water
Corrugated circuit tubing with humidifier connections
Humidifier temperature probe
Nasal prong CPAP set (Hudson nasal CPAP set)
Bottle of 0.25% Acetic acid or sterile water, 1000 cc
A 3 cc syringe
A Luer plug/prn adapter (Not required if a ventilator is being used as a flow
source. The pressure tubing can be connected to the opening at the elbow of
the prongs).
4 small safety pins
4 small rubber bands
Tegaderm
Gauze swabs
Soft gauze or soft cast tubing (for chin strap) / or Co-ban tape.
Paper measuring tape
Tape

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Section B: Procedures to Set up the Bubble Bottle CPAP System:

Follow the steps outlined in Table 2.1 to set up the bubble bottle CPAP system.
Table 2.1
Procedure to Set Up the Bubble Bottle CPAP System

Procedure
1.
Flow Meter

Attach the oxygen tubing to the flow

meter and connect to the humidifier.
Set the flow meter to 5 to 10
liters/minute (l/m).

2.
Humidifier

Turn on the humidifier and set the

temperature at 36.8-37.3 C and the
chamber temp at 2. A higher
temperature may be used if necessary.
The humidity setting needs to be
adjusted to maintain required gas
humidification at or close to 100%.
Attach one of the lightweight, nonkinking, corrugated tubes to the
humidifier. Connect the humidifier
tube temperature probe to the
corrugated tubing going to the baby. Be
sure the probe remains outside the
incubator or away from the radiant heat
source.

3.
Nasal
Prongs

Choose the appropriately sized nasal

prongs and attach them to the tubing
coming from the humidifier (refer to
section 2: Determining Appropriate
Interface Sizes). Attach the second
corrugated tube to the other side of the
prongs. Fix the Luer plug/prn adapter
in place over the small opening in the
elbow of the prongs (used to measure
pressure).

Rationale
Flow Meter
A flow of 5 to 10 l/m will provide
adequate flow to wash out carbon
dioxide in the system, compensate for
the normal air leakage from the
tubing connections, and generate
adequate CPAP pressure (verified by
bubbling of the water in the outlet
bottle).
Humidifier
The temperature selected should be
based on the babys size, body
temperature, and thickness of
secretions. Adequate humidity will
prevent drying of secretions. The
tubing needs to be flexible and not too
heavy for a small babys face. The
probe will monitor the temperature of
the inspired gas. If the temperature is
too high it may damage the mucous
membranes; if too low, it can cause
hypothermia and dry, tenacious
secretions. Other heat sources may
lead to inaccurate gas temperature
measurement or excessive rainout.
Nasal Prongs
Prongs should fit the nares snugly
without pinching the nasal septum. If
the prongs are too small, there will be
an increase in airway resistance,
making it harder for the baby to
breathe. Small prongs also allow more
air to leak from the system, making it
difficult to maintain the correct
pressure. If they do not fit snugly, the
excess movement may cause damage
to the mucosa and possible septal
erosion.

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4.
Bubble
CPAP
Delivery
System

Secure the measuring tape (0-7 cm) to

the outlet bottle with the 7 cm mark at
the base. Empty the fluid to the 0 mark.
Place the end of the corrugated tube
into the water to a depth of 5 cm to
generate 5 cm/H2O of CPAP. Slide the 3
cc syringe (plunger removed) into the
top of the bottle next to the corrugated
tubing, and this will fix it in place. Test
the system by occluding the ends of the
nasal prongs. You should see active
bubbling at the end of the corrugated
tubing under water.
NEVER place the prongs in the babys
nose until you have verified that the
setup is fully operational.

Bubble CPAP Delivery System

The opening at the elbow of the nasal
prongs is designed to fit a pressure
tubing connection and can also be
used to maintain CPAP while using
the transport incubator ventilator.
The depth of the tubing under the
water controls the amount of pressure
generated in the system. If bubbling
does not occur, systematically check
each connection until bubbling
begins. An obstruction in the system
will occlude the infants airway; result
in excessive positive pressure, cause
damage to the airway and lungs, and
gastric distention.

2. Step Two: Determine the Appropriate Size of NCPAP Interface

Once the CPAP bubble bottle system is set up, the next step is to determine
the appropriate size of the interface pieces (nasal prongs and hat). Using
Tables 2.2 determine the correct size of the nasal prongs.

Hudson Interface
For using the Hudson nasal prong set, the infants birth weight determines the
size of nasal prongs to be used. Refer to Table 2.2 to determine the Hudson nasal
prong size.
Table 2.2
Hudson Interface Nasal prongs size

Size 0
Size 1
Size 2
Size 3
Size 4
Size 5

for < 700 g

for 700-1000 g
for 1000-2000 g
for 2000-3000 g
for 3000-4000
for > 4000 g

For infants at the high end of any of the weight ranges, consider using the larger prongs
appropriate

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3. Step Three: Application of the NCPAP System
Correct application of the NCPAP system involves proper positioning of
the infant, ensuring a patent airway, and correct application of the
interface and delivery system.
Table 2.3 outlines each procedural step involved in application of the
NCPAP system.
Table 2.3
Application of the nasal CPAP system.

Procedure
1. Position
Position the baby with the head of the bed elevated
about 30.
Place a small roll under the babys neck/shoulders.
The roll should be firm enough to support the babys
head in the sniffing position.
2. Saturation Probe
A SaO2 probe should be placed on a pre-ductal site,
e.g. right arm or wrist. Maintain this site for the
duration of the oxygen therapy.
3. Suctioning
Gently suction the mouth, nose and pharynx. Use the
largest sized catheter that can be passed into the nose
without significant resistance.
Pass an oro/naso-gastric tube and aspirate the
stomach contents. Remove the tube after aspiration,
if necessary.

4. Prong placement
Moisten the prongs with sterile water or saline drops
before placing them curve side down into the babys
nose.
Adjust the angle of the prongs and the way the
corrugated tubing is twisted until the correct
positioning is achieved:
__The nasal prongs should fill the nasal opening
completely without stretching the skin or putting
undue pressure on the nares (blanching around the
rim of the nostrils suggests that the prongs are too
large).
__The corrugated tubing will not be touching the
babys skin.
__There will be no lateral pressure on the septum
causing it to be pinched or twisted.
__There will be a small space between the tip of the
septum and the bridge between the prongs.
__The prongs will not be resting on the philtrum.

Rationale
Position
The elevated bed may decrease
intracranial pressure and pressure on
the babys diaphragm.
Slight neck extension helps keep the
airway open.
Saturation Probe
In conditions with right-to-left shunting
it is important to adjust oxygen therapy
based on the pre-ductal SaO2.
Suctioning
Secretions may block the prongs or the
airway beyond, thus increasing airway
resistance. This in turn may worsen the
symptoms of respiratory distress and/or
cause apnea and bradycardia.
The positive pressure generated can
cause air to enter the stomach. A recent
feed or an already distended stomach
may increase pressure on the
diaphragm or result in reflux with
aspiration.
Prong placement
The fluid provides a little lubrication to
aid initial insertion. Do not use creams
and petroleum based ointments, as these
will soften the mucosa, risking
breakdown of the tissues.
Correct positioning reduces the risk of
trauma and ensures the effective
delivery of CPAP.

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5. Securing the Hat (Bonnet)
Use the pre-made hat or make one out of appropriate
sized tube-gauze (or available soft, fine woven tube
bandage). Fold the rim of the hat back approximately
1 inch. If using the tube-gauze fold the edge twice.
The hat must fit firmly.
Place the hat on the babys head so that the rim is just
over the top of the ears. If using tube-gauze tie the
end with ribbon/tape close to the babys head.

Securing the Hat (Bonnet)

The hat holds the prongs and tubing in
place. The rim adds strength and helps
prevent stretching when connecting the
tubing.

The hat needs to fit snugly to minimize

movement of the tubing.

Do not interrupt CPAP delivery during placement of

the hat.
6. Securing the Tubing to the Hat (Bonnet)
The corrugated tubing can now be secured to the hat
at the angle that provides the best prong position.
Hold one of the tubes gently against the side of the
babys head and place two small safety pins, one each
side of the tube, through the rim of the hat. Secure
with the rubber band by threading it around one pin,
over the corrugated tubing, and around the other pin.
The rubber band needs to fit firmly over the tubing to
prevent movement. Tie a knot in the rubber band to
make it shorter if necessary. Repeat the procedure for
the tubing on the other side of the head.

Securing the Tubing to the Hat

(Bonnet)
This will allow the prongs to stay in
place as the babys head moves.

7. Apply the Chin Strap

To prepare the chinstrap use non-elastic tape and
gauze. Cut a piece of tape that will reach from one
side of the hat across under the chin and attach to the
other side of the hat. The tape needs to be backed
with the folded gauze to prevent the adhesive
contacting the skin.

Apply the Chin Strap

An air leak via the mouth will reduce
the effectiveness of the system by
allowing a significant loss of positive
pressure.

Or use Coban tape.

The jaw is gently pulled forward, closing the mouth.
A pacifier may be used with the chinstrap in place if
this will help to settle the baby.

Keeping the design simple is cost

effective and convenient, as the
chinstrap may need replacing every few
hours. It will easily become soiled and
the tape loses its adhesiveness each
time it is detached from the hat for
suctioning or feeding.
The strap will not be so firm as to
prevent the infant from yawning or
crying.

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8. Apply a Mustache (after ~ 4 hours of life)
Gently clean the babys face in the vicinity of the
prongs and cheeks with water. Dry thoroughly using
soft gauze.

Apply a Mustache
This will help keep the prongs firmly in
position. If applied in the first few hours
of life, the mustache will not remain in
place due to excessive secretions during
the first few hours of CPAP.

Cut two pieces of Tegaderm to fit across the prepared

area.

Tegaderm provides protection for the

skin plus a surface for the Velcro to
adhere.

Cut a strip of Velcro (hook side) to fit the area. It

needs to be narrow in the center over the philtrum
but wider over each cheek.

A single Velcro strip provides gentle

splinting of the area. Two separate
cheek patches may be just as effective in
securing the prongs; each babys face is
different, so use whichever works best.

Cut two narrow (~8 mm) strips of soft Velcro to wrap

around the area of the prongs that cover the cheeks

Avoid using the hooked Velcro to wrap

around the prongs, it may scratch the
skin when disconnected.

Once the mustache and skin are prepared, gently

remove the prongs. Wipe away any excess secretions,
and place the Tegaderm followed by the Velcro
mustache in place. Wrap the soft Velcro strips around
each side of the prong cannula, and place the prongs
back in the nose.

This promotes a dry surface for the

Velcro mustache to adhere.

Gently press on the prong cannula until the soft

Velcro strips adhere to the mustache. Some twisting
of the prongs, the connections and corrugated tubing
may be necessary to achieve the correct prong
position.
During the process of applying the mustache, take the
opportunity to suction the nose and mouth.

This promotes proper positioning of the

prongs while securing them in place.

9. Check the NCPAP system

Once the system is applied, check that the prongs are
positioned appropriately and that the CPAP system is
bubbling at 5 cm H20.

Check the NCPAP System

This ensures proper application and
operation of the NCPAP delivery
system.

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SECTION THREE
MAINTENANCE OF NCPAP
Introduction
Continuous positive airway pressure is successful when meticulous attention is
paid to both the infant and to the NCPAP delivery system. This meticulous
attention involves vigilance in continuous monitoring of the infants condition,
frequent suctioning to maintain optimal airway care, constant evaluation of the
performance of the delivery system, and prevention of complications which may
arise from the NCPAP delivery system.
1. Monitoring the Infants Condition
The infants condition must be monitored frequently once the NCPAP is applied.
Monitor all infants on NCPAP following our NICUs current practice guidelines
for monitoring premature infants with respiratory distress.
It is recommended that monitoring the infants status while on NCPAP should
include evaluation of the following:
__Respiratory status: respiratory rate, work of breathing;
__Cardiovascular status: central and peripheral perfusion, blood pressure, and
heart rate;
__Gastrointestinal status: abdominal distention, bowel sounds;
__Neurological status: tone, response to stimulation, activity;
__Thermoregulation: infant and environment temperature; and
__Monitor: pre-ductal oxygen saturations, oxygen requirements
It is recommended that the infant be observed every 2-3 hours over the first 4
days of life and every 3-4 hours thereafter while on NCPAP. Any infant that is
experiencing moderate to significant respiratory distress while on NCPAP will
require closer observation of change in condition.
Refer to Table 3.1 for specific guidelines and rationale for monitoring the infant
while on NCPAP.
2. Maintaining Optimal Airway Care
One of the most critical aspects of NCPAP is maintaining an optimal airway
through frequent suctioning of the mouth, nose, and pharynx. We suggest
suctioning the infant at least every 3 hours if the infant has any symptoms of
respiratory distress, or every 4-6 hours if the infant is in room air on NCPAP.
Carefully follow the protocol steps outlined in Table 3.1 for recommendations
regarding suctioning the airway.
3. Preventing Nasal Septal Damage
Damage to the septum arises from friction caused by grazing of the nasal prongs
with the associated continuous pressure, friction or moisture. Avoiding these
contributing factors will maintain an intact septum. Septal injury is preventable
and is not a reason to discontinue using nasal prongs.
It is recommended that the nasal septum and prongs be evaluated every 30-60
minutes. If signs of grazing or erosion are observed, the best treatment is to
remove the cause of pressure, friction, or moisture. Review Table 3.1 for details
regarding interventions to prevent damage to the nasal septum.

16
4. Positioning while on NCPAP
Infants may be positioned side lying or prone while on NCPAP. We recommend
that when the infant is placed prone a firm chest support is placed underneath
the infant to allow the chin to drop slightly forward allowing for optimal
positioning of the airway.
Refer to Table 3.1 for specific details regarding positioning while on NCPAP.
5. Feeding while on NCPAP
Nasal continuous positive airway pressure is not a contraindication to feeding.
Infants on NCPAP are expected to have mild abdominal distention associated
with swallowing air while on NCPAP. An infant on NCPAP who is being fed may
require the placement of an 8 French oro-gastric tube to aspirate air prior to
feeding. The oro-gastric tube should be aspirated every 3 hours or more
frequently as needed. If abdominal distention persists, it may be necessary to
leave an indwelling oro-gastric tube to allow for continuous removal of
abdominal air. If the indwelling oro-gastric tube prevents closure of the mouth
and therefore allows NCPAP pressure to escape, it should be removed and
inserted as needed. Or a chinstrap may be used to maintain closure of the mouth.
Review Table 3.1 for specific details regarding nasal CPAP and feeding.
Table 3.1

Procedure

Rationale

1. Monitoring:
Clinical Assessment

Monitoring:
Clinical Assessment

Perform a baseline assessment of the infant prior to

commencement of NCPAP.

Baseline observations are

essential to the ongoing
assessment and management of
the infant.

Observe and document the condition of the infant

every 2-3 hrs for the first 4 days of life.
Thereafter, monitor the infants condition every 3-4
hrs.
Assessment should include:
__Respiration: rate, effort, breath sounds, signs of
distress.
__Cardiovascular: central and peripheral perfusion,
blood pressure, and auscultation.
__Gastro-intestinal: bowel sounds, abdominal
distention, visible bowel loops.
__Neurological: tone, response to stimulation,
activity.
__Thermoregulation: infant and environmental
temperature.
Monitor: pre-ductal saturations, oxygen requirement,
trends and changes in saturations and oxygen
requirements.

Observations are essential to the

ongoing management of the
infant. Decisions regarding status
and ongoing treatment are made
on the basis of serial
assessments.

Some mild abdominal distention

is expected with CPAP. Careful
observation will differentiate this
from distention associated with
gastro-intestinal disorders such
as obstruction, perforation, or
infection.

17
2. Airway Care: Suctioning

Airway Care: Suctioning

Suction the mouth, nose and pharynx at least every 3

hours and prn for symptomatic infants. Use the
largest size catheter able to be passed into the nasopharynx without significant resistance.

The presence of excess secretions

will narrow the airway and
increase the effort of breathing. It
may cause increased oxygen
requirement, obstructive apnea,
bradycardia, or pneumothorax.

Use a few drops of sterile 0.9% saline solution

instilled into the nose to help lubricate the catheter
and loosen dry secretions.
Always wear gloves when suctioning, in accordance
with universal precaution guidelines.

3. Preventing Damage to the Nasal Septum

Septal injury is absolutely preventable and is not a
reason to discontinue using the nasal prongs.
__Use the correct prong size.
__Secure the prongs in place with a snug fitting hat
and correctly placed tubing.
__Use a mustache if necessary.
__Do not allow the bridge of the prongs to press up
against the septum.
__Avoid twisting the prongs with resultant lateral
pressure against the septum.

__Do not use creams, ointments, gels, or products

such as Duoderm on the septum itself.
__Frequent observation of the site and prong
position every 30-60 minutes is essential.
__If signs of grazing or erosion are observed,
reposition the prongs to remove the pressure, friction,
or moisture.
4. Positioning with NCPAP
Change the infants position every 3-6 hours.
When positioning an infant supine or side lying,
always support the airway position using a neck roll.
When the infant is positioned prone remove the neck
roll and place a chest pad under the infant. Make a
firm pad using linen, that is the same size as the
length from the infants clavicle to lower ribs and
width between the shoulders. Do not use beanbags or
gel pillows under the chest, as these will not provide
appropriate support.

Thickening of secretions
indicates the need for increased
inspired gas humidity and/or
heat. Flecks of blood may suggest
the mucosa is dry.
Avoiding contact with blood and
body fluids prevents the spread of
infection.
Preventing Damage to the
Nasal Septum
The septum will become grazed
and erode within a few hours if it
is subjected to continuous
pressure, friction, and or
moisture. Avoiding these
contributing factors will maintain
an intact septum.

The best protective cushion

between the bridge of the prongs
and the septum is air.
Moist skin is compromised skin,
so the area must be kept clean
and dry.

Positioning with NCPAP

Regular position change is
essential to skin care and
neurological development and
facilitates adequate observation
of the infant by care providers.
A clear well-supported airway
will assist the infants respiratory
effort.
Raising the chest slightly will
allow the chin to fall slightly
forward and thereby correctly
support the airway.

18
5. Feeding with NCPAP
Nasal CPAP is not a contraindication to enteric
feeding.
It may be necessary to pass an oro-gastric (OG) tube
to aspirate excess air before feeds. Naso-gastric tubes
are contraindicated in an infant receiving NCPAP.
An 8 French oro-gastric tube may be left indwelling
to allow continuous removal of air. If the indwelling
OG- tube prevents closure of the mouth and allows
CPAP pressure to escape, then it should be removed
and inserted prn. A chinstrap may also be used to
keep the mouth closed.
Infants whose acute respiratory symptoms are well
controlled on NCPAP may be breast-fed or
nipple/bottle fed. These infants will need to be
observed closely for signs of distress during feeding
with NCPAP in place.
6. Phototherapy with NCPAP
Phototherapy eye patches may be placed gently over
the eyes and secured with soft paper tape to the
corrugated CPAP tubing.
Do not allow the eye patches to touch the nasal
septum or prongs or obstruct your view of the nasal
septum and prongs.

Feeding with NCPAP

Swallowing of air while on CPAP
can cause air to enter the
stomach. A recent feed or an
already distended stomach may
increase pressure on the
diaphragm or result in reflux
with aspiration.

Phototherapy with NCPAP

The eye patches will obstruct
your view of the nasal septum
and could put pressure on the
prongs and septum leading to
septal injury.

6. Evaluating the Performance of the nasal CPAP Delivery System

In addition to monitoring the infants condition and maintaining an optimal
airway, the CPAP system must constantly be evaluated for optimal performance.
This involves checking the CPAP delivery circuit beginning with the nasal prongs
and ending with the bubble bottle system. Carefully review the procedures in
Table 3.2 for evaluating the CPAP delivery system.
It is recommended that the CPAP delivery system be evaluated every 2 to 3 hours
for performance, in addition to the daily use of the Checklist for Maintaining
CPAP Form.

19

Table 3.2
Evaluating the CPAP delivery system

Procedure
1. NCPAP Delivery Circuit
Check the entire circuit from wall to
baby to outlet every hour to ensure that
it is functioning correctly.
Check for leaks and/or broken
connections.
Change the entire CPAP circuit every
week.
Check the following:
__The blender is set at the appropriate
percentage of inspired oxygen.
__The flow meter is set between 5 and
10 liters/minute.
__The humidifier holds the correct
amount of water.
__The inspired gas temperature is
appropriate.
__The corrugated tubing does not
contain water.
__The oxygen analyzer reads the same
as the blender setting (use of an
analyzer is optional).
__The outlet bottle is bubbling.
__The tubing in the outlet bottle is
fixed at 5 cm of water.

Rationale
NCPAP Delivery Circuit
Changing the circuit weekly prevents growth
of bacteria.
Oxygen requirement will vary as the infants
condition changes.
A flow of 5 to 10 liters/minute will provide
adequate pressure and prevent carbon
dioxide re-breathing.
An adequate water level is required to
maintain inspired gas humidity.
The temperature should be based on the
infants size, body temperature, and the
amount and thickness of secretions.
Condensation will cause water to accumulate.
This needs to be removed in order to prevent
water from reaching the infant.
The oxygen analyzer serves as a double check
for the blender and needs to be routinely
calibrated.
The bubbling indicates that the desired CPAP
pressure is being generated. Vigorous
bubbling is not necessary; consistent, gentle
bubbling is adequate. Some infants with mild
respiratory distress may tolerate intermittent
bubbling.
A CPAP of 5 cm of water will deliver 5cm of
pressure to the infant. Higher than
physiologic PEEP (2-3 cm H2O) recruits more
alveoli for gas exchange and increases
functional residual capacity. Higher CPAP
pressure will cause pressure to pop off from
the mouth.

2. Interface (Nasal Prongs)

Check the following:
__Prongs fit snuggly within the nares.
__The infants mouth is closed.

Interface (Nasal Prongs)

Prongs that are too small will allow air to
escape, and increase resistance to breathe.
Pressure will be lost through an open mouth.

20

Checklist for maintaining CPAP

This list may be used daily to check the performance of the nasal
CPAP delivery system

Criteria

Criteria
met/not met

Additional
information

CIRCUIT AND BUBBLER:

Blended air/oxygen gas supply
Flow between 5-10 liters/min
Humidifier temperature correct (36.837.3 C)
Humidifier water level correct
Oxygen analyzer correctly set
Corrugated tubing correctly placed
Excess rainout (afferent tubing) drained
Excess rainout (efferent tubing) drained
Gas bubbling continuously
Water level at 5 cm H2O
INTERFACE:
Nasal prong size correct
Nasal prongs positioned correctly
Hat fits snugly
Mustache suitable and effective (if > 4
hr of age)
Chin strap correct size and position
Septum intact
POSITIONING:
Head position correct (if prone)
Neck roll correct size and position if
supine or side lying
MONITORING/SUCTIONING:
Pre-ductal oxygen saturation probe
Documentation in nurses record of q36 hourly nasal/oral suction as
appropriate

Notes: -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

21

SECTION FOUR
COMPLICATIONS ASSOCIATED WITH NCPAP
Although the risks associated with NCPAP administration are minimal, there
may be complications that arise during delivery of NCPAP. Careful attention to
detail in management of the NCPAP delivery system and the infant while on
NCPAP may minimize the risk of adverse events.
1. Pneumothorax
If a pneumothorax occurs it is more likely to occur in the acute phase of
respiratory distress. A pneumothorax is NOT a contraindication to continuing
NCPAP therapy.
2. Nasal Obstruction
Nasal obstruction occurs from secretions or improper position of the NCPAP
prongs. To avoid obstruction, the nares should be suctioned frequently and the
prongs checked for proper placement.
3.Nasal Septal Erosion or Necrosis
Pressure or friction to the nasal septum will result in nasal septal erosion or
necrosis. This can be avoided by maintaining a small cushion of air (2-3 mm)
between the bridge of the prongs and the septum. Choosing the proper size snugfitting nasal prongs, use of a Velcro mustache to secure the prongs in place, and
avoiding pinching of the nasal septum, will minimize the risk of septal injury.
Septal erosion is not a contraindication for the use of nasal prongs. If an injury
has occurred due to pressure or friction, the simple solution is to strictly avoid
further pressure injury. It is not necessary to apply any creams or dressings to the
area. Significant nasal septal erosion may require a consult with the ENT or
Plastic Surgery team.
4. Gastric Distention
Gastric distention occurs from swallowing air. Gastric distention is a benign
finding and does not predispose the infant to necrotizing enterocolitis or bowel
perforation. This occurs more often in the chronic phase of respiratory distress
than in the acute phase. Gastric distention can be treated by intermittent
aspiration of stomach contents. For severe distention an indwelling orogastric
tube may be inserted. It is important to ensure patency of the orogastric tube,
because secretions will block the tube and lead to distention.

22

SECTION FIVE
REMOVAL OF NCPAP
Introduction
When an infant has met clinical criteria to be removed from NCPAP, the NCPAP
delivery system is removed completely. It is not recommend that the NCPAP
system be weaned from a pressure of 5cm of H20 to a lower pressure prior to
removal.
1. Indications for removal from NCPAP are:

__Infant is > 72 hours post extubation

__Infant is stable in room air with oxygen saturations >88%
__Infant has no evidence of tachypnea or retractions
__Infant has minimal to no apnea or bradycardia events
2. Procedures for removal of NCPAP
It is recommended that the infants nose and mouth be suctioned thoroughly
prior to, and after removal of NCPAP. The infant should be carefully monitored
after removal of the NCPAP for evidence of tachypnea, retractions, or increased
apnea and bradycardia. The infant should be suctioned every 6 hours for the first
24 hours after the removal of NCPAP.
3. Indications for reintroducing NCPAP
If the infant develops frequent apnea and bradycardia episodes, tachypnea or
retractions, the NCPAP should be reintroduced.

23

SECTION SIX
RESPIRATORY FAILURE ON NCPAP
Introduction
If an infant develops symptoms of respiratory failure on routine NCPAP (CPAP of
5 cm H20), the CPAP is not sufficient and intubation and mechanical ventilation
may need to be considered. Prior to intubation, you may increase the nasal CPAP
pressure to 7 cm of H20 for a trial period.
1. Symptoms of Respiratory Failure
The symptoms of respiratory failure on NCPAP include:

__ Significant apnea
__ Respiratory failure (PCO2 >65 mm Hg or 8.5 Kpa)
__ Progressive hypoxemia
__ Severe respiratory distress
2. Procedures Prior to Intubation and Mechanical Ventilation
It is important that prior to intubation and mechanical ventilation specific
procedures are followed.
The following steps should be taken PRIOR to intubation.
__Evaluate the infants clinical condition: Is the clinical condition compatible
with the blood gas evaluation?
__Check the NCPAP delivery system for proper functioning: Is the system
bubbling properly? Are air leaks by mouth and nose minimized?
__Suction the infant and reposition the nasal prongs: Are the nares obstructed?
Are the prongs the correct size and position?
__Increase the CPAP to 7 cm H20: Does the infant respond to higher pressure?
If after these procedures, the infant continues to show evidence of
respiratory failure, THEN the infant has met the indications for
intubation.

3. Checklist for Evaluating the CPAP Delivery System during

Respiratory Failure
This checklist may be used for infants receiving bubble bottle NCPAP who
experience severe respiratory distress and meet criteria for intubation due to
respiratory failure.

24

Checklist for evaluating CPAP delivery system

during respiratory failure
Complete this checklist for infants receiving bubble nasal CPAP who are
experiencing respiratory distress and failure. Must be completed before removing
the infant from CPAP.

Criteria

Criteria
met/not met

Additional
information

Nasal prongs size correct

Nasal prongs positioned correctly
Hat fits snugly
Corrugated tubes are correctly placed
Mustache suitable and effective
Neck roll of correct size and position if in
the supine position or side lying.
Chin strap correct size and position
Head position correct (if prone)
Gas bubbling continuously
Airway suctioned
CPAP increased to 7 cm H2O
Infants clinical condition consistent with
definition of respiratory failure AFTER
these measures taken
Oxygen requirements:
Blood gas values:
Date/time

FiO2 ------------------PH --------------------PaO2 -----------------PaCO2 ----------------Time ------------

Notes: ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

25

SECTION SEVEN
TROUBLESHOOTING THE NCPAP DELIVERY SYSTEM
Introduction
This section focuses on specific aspects in troubleshooting problems with the
nasal CPAP delivery system. These are common questions and issues that arise
with staff who are new to using the bubble bottle nasal CPAP system.
If you have a question or problem that is not addressed here, please discuss it
with one of the NICU consultants or the respiratory therapist on call.
Troubleshooting
1. Its not bubbling!
This indicates loss of airflow or a pressure leak somewhere in the system. A
simple way to check if it is a circuit problem or a baby problem is to remove the
prongs from the nose and occlude them with your fingers. If the system doesnt
bubble, it means the problem is with the circuit. Systematically check the circuit,
as outlined above, tightening all connections as you go.
Troubleshoot the system beginning at the wall and ending at the outlet bottle. If
the system does bubble, when you occlude the prongs with your fingers, then the
pressure leak is occurring within the nares or via an open mouth. Air will escape
if the prongs are too small or if they are not curved down into the nose and fitting
snugly. The suggested sizes are only a guide, as babies nose sizes do vary. A firm,
effective chinstrap is essential to the delivery of consistent positive pressure.
2. The prongs wont stay in place!
A. Are they the right size?
Nasal prongs should be the largest size that will fit snugly in the nares without
allowing excessive leak around the prongs, or causing persistent blanching of the
nares. Prongs that are too small are more likely to move around causing friction,
trauma, and inconsistent CPAP pressure. The correct size prongs are more
effective, more comfortable, and more stable than prongs that are too small. It is
acceptable to create a nose seal using duoderm to cover the entire nose and to
limit air leakage around the prongs.
B. Does the hat fit snugly?
The hat is the anchor for the prongs, so a loose hat will allow any head movement
to dislodge the prongs.
C. Are the corrugated tubes fixed firmly in place on the sides of
the hat and are they at the correct angle to keep the prongs in place?

26
If there is rotating pressure on the prongs they may twist out of the nose. If in
doubt, try undoing the rubber bands and, with the prongs correctly positioned in
the nose, allow the tubing to sit naturally in place. Reposition the pins and rubber
bands as necessary.
D. Would a Velcro mustache help or does the existing one need
replacing?
See instructions for applying a mustache under Table 2.3 Protocol Steps for
Initiation of NCPAP.
3. The baby wont settle!
Does the baby need suctioning? This may seem a contradiction when suggesting
ways to settle a baby down, but a build up of secretions can cause considerable
distress to a baby whose breathing is already compromised. Aspirate any excess
gastric air and/or remove the oro-gastric tube unless it is really necessary. Try
positioning the baby prone, as this can help relieve abdominal distention and
diaphragmatic pressure. Once you are sure the airway is clear, try the usual
calming techniques of containment, linen nesting, swaddling, and pacifier. Often,
just "hands off" will allow the baby to slowly settle, especially in the early hours as
he/she adjusts to the CPAP.
4. How can we avoid septal damage?
Prevention is the key. Tissue will break down if it is subjected to continuous
pressure, friction and or moisture. Avoiding these contributing factors will
maintain an intact septum: Use the correct sized prongs as outlined in the
application instructions.
__ Secure them in place with a snug fitting hat, correctly positioned pins and
rubber bands over the corrugated tubing.
If necessary use a Velcro mustache for extra security (make sure it doesnt press
up against the septum).
Dont allow the bridge of the prongs to press up against the septum.
Avoid twisting the prongs with resultant lateral pressure against the septum.
Do not use creams, ointments or gels (use saline drops to moisten the nares for
initial prong insertion or during suctioning if necessary).
Frequent observation of the site and prong position is essential.
Be wary of eye pads that cover the nose on babies under phototherapy as these
can obstruct your view of the septum. If an injury has occurred, reviewing the
above guidelines will avoid further damage and promote healing. It is not
necessary to apply creams or dressings to the injured area. Covering the septum
with Duoderm or similar product may lead to further skin break down and will
limit the ability to assess healing or any further damage.

27
5. There is a lot of foaming at the babys mouth.
This often occurs during the first few hours after the initiation of CPAP. It is
saliva that the baby is not swallowing that is being pushed out of the mouth by
the pressure of the CPAP and is actually a good sign of effective pressure
generation. It can be gently wiped away with a soft gauze pad or removed with a
suction catheter. Parents often comment on it, and some will find it quite
distressing. A simple explanation and the opportunity to wipe their babys mouth
with the soft gauze will often relieve the associated anxiety. The amount of
bubbling saliva generally diminishes over the first four to six hours of CPAP.

REFERENCES
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membrane disease. American Journal of Diseases of the Child 1959; 97: 517-523
2. Avery ME, Tooley WH, Keller JB, et al . Is chronic lung disease in low birth
weight infants preventable? A survey of eight centers. Pediatrics 1987; 79: 26-30.
3. Boyle MH, Torrance GW, Sinclair JC, Horwood SP. Economic evaluation of
neonatal intensive care of very-low-birth-weight infants. New Engl J Med 1983;
308:1330-1337
4. Clements, J.A., Brown, E.S., and Johnson, R.P. Pulmonary surface tension and
the mucus lining of the lungs: Some theoretical considerations. Journal of
Applied Physiology, 1958; 12:262.
5. De Klerk AM, De Klerk RK. Nasal continuous positive airway pressure and
outcomes of preterm infants. J Paediatr Child Health 2001 Apr;37(2):161-7
Farell PM and Avery ME. Hyaline membrane disease. Am Rev Resp Dis 1975; 111:
657-688
6. Gittermann MK, Fusch C, Gitterman AR, Regazzoni BM, Moessinger AC. Early
nasal continuous positive airway pressure treatment reduces the need for
intubation in very low weight infants. Eur J Pediatr 1997; 156: 384-388.
7. Gregory, G.A., Kitterman, J.A., Phibbs, R.H., Tooley, W.H., Hamilton, W.K.
Treatment of the idiopathic respiratory-distress syndrome with continuous
positive airway pressure. New England Journal of Medicine, 1971; 284:13331340.
8. Guyer B, MacDorman MF, Martin, JA, Peters KD, Strobino DM. Annual
summary of vital statistics-1997. Pediatrics 1998; 102:1333-1349

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9. Han VKM, Beverley DW, Clarson C, Sumabat WO, Shaheed WA, Brabyn DG,
Chance GW. Randomized controlled trial of very early continuous distending
pressure in the management of preterm infants. Early Human Dev 1987;15:21-32.
10. Harrison, V.C., Heese, HdeV, Klein, M. The significance of grunting in hyaline
membrane disease. Pediatrics, 1968; 41:549.
11. Horbar, J.D., Carpenter, J., Kenney, M. Vermont Oxford Network 2000
Database Summary. 2001.
12. Jacobsen T, Gronvall J, Petersen S, Andersen GE. "Minitouch" treatment of
very low-birth-weight infants. Acta Paediatr 1993; 82: 934-938.
13. Jobe AH. Pulmonary surfactant therapy. New England Journal of Medicine
1993; 328: 861-868
14. Kamper J, Wulff K, Larsen C, Lindquist S. Early treatment with nasal
continuous positive airway pressure in very low birth weight infants. Acta
Paediatr 1993;82:193-7.
15. Kraybill E, Runyan D, Bose C, Khan J. Risk factors for chronic lung disease in
infants with birth weights of 751 to 1000 grams. J Pediatrics 1989;1115:115-20.
16. Lidner W, VoBbeck S, Hummier H, Pohlandt F. Delivery Room Management
of Extremely Low Birth Weight Infants: Spontaneous Breathing or Intubation.
Pediatrics 1999;103(5):961-967.
17. OBrodovich HM, Mellins RB. Bronchopulmonary dysplasia. Unresolved
neonatal acute lung injury. Am Rev Respir Dis 1985; 132: 694-709
17. Poulton, E.P., and Oxon, D.M. 1936. Left sided heart failure with pulmonary
edema: Its treatment with the pulmonary plus pressure machine. Lancet,
231:981.
19. Robertson PA, Sniderman SH, Laros RK, Cowan R, Heilbron D, Goldenberg
RL, Iams JD, Creasy RK. Neonatal morbidity according to gestational age and
birth weight from five tertiary care centers in the United States, 1983 through
1986. Am J Obstet Gynecol 1992; 166:1629-1645
20. Schwartz RM, Luby AM, Scanlon JW, and Kellog RJ. Effect of surfactant on
morbidity, mortality, and resource use in newborn infants weighing 500 to
1500g. NEJM 1994; 330(21): 1476-80.
21. Soll RF, McQueen MC. Respiratory Distress Syndrome. In Sinclair JC,
Bracken MB (eds): Effective Care of the Newborn Infant. Oxford University
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29
22. St. John EB, Nelson KG, Cliver SP, Bishnoi RR, and Goldenberg RL. Cost of
neonatal care according to gestational age at birth and survival status. Am J
Obstet Gynecol 2000 Jan; 182(1Pt1): 170-5.
23. Subramaniam P, Henderson-Smart D, and Davis PG. Prophylactic nasal
continuous positive airways pressure for preventing morbidity and mortality in
very preterm infants (Cochrane Review). Cochrane Library Issue 3, 1999. Update
Software.

APPENDIX A:
EQUIPMENT LIST AND MANUFACTURERS
Acetic Acid Solution, 1000 ml Manufacturer: Baxter Healthcare Address:
Deerfield, IL 60015 Product No: 2F 7184, NDC 0338-0656-04 (not available at
RKH hospital)
Respiratory Circuit and tubing Allegiance Healthcare Corporation Address:
McGaw Park, IL 60085 Product No: Customized kit (Kit, Respiratory, 20/CS)
which includes: Airlife U/Connect-it Oxygen Tubing (cat. number 001350) Fisher
& Paykel humidification chamber (product number MR250) Airlife Respiratory
Transfer Set (cat. number 2C7103) Airlife Isothermal breathing circuit, Infant
Respiratory Circuit Heated (cat. number 7431-4S2). Contents include 1 heated
circuit, 2 connectors, 1 trache tie, and 1oxygen tubing connector)
Sterile Water, 1000 ml Manufacturer: Baxter Healthcare Address: Deerfield,
IL 60015 Product No: 2F 7114, NDC 0338-0004-04
Stockinette (hat) Manufacturer: Alba Health, Health Products Division, AlbaWaldensian Inc. Address: 425 North Gateway Ave, Rockwood TN 37854 Product
No: 081220 (2 x 25 yards (5cm x 2.9m)) Product No: 081320 (3 x 25 yards
(8cm x 22.9m))

30

Section eight
Delivery room protocol for the
respiratory management of preterm
infants
A. Infants less than 1000 g or less than 28 wks gestation
whether breathing spontaneously or not, need to be
intubated and given exogenous surfactant in the delivery
room unless judged clinically to not require intubation.
They are to be evaluated within 2 hours for the possibility of
extubation to bubble nasal CPAP.
Criteria for extubation:
1. Spontaneously breathing.
2. No significant apneic episodes.
2. Requiring less than 30% FiO2 to maintain a preductal
saturation of > 92%.
3. Cardiopulmonary stability (Stable BP, HR and
perfusion).
4. Mild RDS on their initial CXR.
B. Infants who are 28 wks or more, 1000 g or more and
spontaneously breathing are to be put on bubble nasal
CPAP (5 cm H2O, with a FiO2 to maintain a preductal
saturation of 92-96%).
Criteria for intubation;
1. Significant apnea (requiring bag and mask ventilation or
associated with bradycardia, pallor or cyanosis).
2. Requiring more than 60% FiO2 to maintain a preductal
saturation of 92% or more.

31

3. Significant respiratory distress (Significant retractions

and poor air entry).
4. PCO2 >60-65 mmHg (8KPa) and a PH <7.25
C. Infants who are more than 28 wks, more than 1000 g and
not spontaneously breathing after proper stimulation and
resuscitation are to be intubated (no surfactant to be given),
and admitted to the NICU.
They are to be evaluated in the first 2 hrs of life.
1. They can be extubated to bubble nasal CPAP if they are
spontaneously breathing, requiring less than 30% FiO2 to
keep the preductal saturation 92% and above and their CXR
is showing only a mild RDS picture.
2. They can be given exogenous surfactant and maintained
on mechanical ventilation if their oxygen requirements are
above 30-40%, requiring higher ventilatory support, are
still not breathing spontaneously and their CXR is showing
moderate to severe RDS picture.

32

Bubble nasal CPAP circuit and interface

Flow meter and blender assembly

33

The flow should be at 5-10 L/min

(Usually 7 L/min).

34

Humidifier
Temperature should be 36.8-37.2C.

The Hudson Prongs interface

35

An infant on Hudson Prongs nasal CPAP

36

Suctioning of both nostrils with 8.0FG

suction catheter as shown here.

Use normal saline prior to suctioning of both

nostrils.

37

Chinstrap in place (it will keep the mouth closed to

prevent pressure escape). Co-Ban can be used
instead.

Use appropriate sized feeding tube to vent the

stomach.

38

Bottle feeding an infant on bubble nasal CPAP.

Infants can be nursed prone or side lying.

39

Phototherapy and eye patches

Home made hat

(1)

40

Home made hat

(2)

41

Safety pins and 2 rubber bands are used to attach

the corrugated tubes to the hat, as shown.

Making of a mustache and chin strap

42

43

The chinstrap