CLINICAL TEACHING ON BUBBLE CPAP: Introduction, Definition, History of development, Physiology of Bubble CPAP, Principle, Patient interface, equipments for bubble CPAP, indication and contraindication for bubble CPAP, essential of CPAP, CPAP machine, bubble cpap machine application, setting pressure, FiO2, oxygen flow, Monitoring adequacy and complications of bubble CPAP, Monitoring infant condition, weaning for Bubble CPAP, CPAP Failure, complications related to CPAP, Preventing complications, Nursing Care.

1. Presented by:
Ms. Manisha Thakur
Child Health Nursing
M.Sc (N) 2nd Year

2. DEFINITION
 Also called continuous distending pressure (CDP)
 Maintenance of an increased (positive)
transpulmonary pressure during the inspiratory &
expiratory phase of respiration in a spontaniously
breathing baby.
 By which alveoli are kept open which increase the
functional residual capacity(FRC) of the lungs
resulting in better gas exchange.

3. HISTORY
 Harrison 1968: described grunting in neonates as
naturally producing end expiratory pressure
 Gregory et al, 1971: introduced the clinical use of
distending pressure in neonates.(via endotrachial tube or a
head box)
 Kattwinkel reported successful use of nasal prongs in
neonates with RDS.
 Reports of significant lower incidence of chronic lung
disease from columbia university that used more CPAP as
compared to north american centre have led to resurgence
of interest in CPAP over the last 15 years.

4. PHYSIOLOGY OF CPAP
 Increases FRC
 Decreases V/Q mismatch
 Splints upper airway - airway resistance
 Increase tidal volume
 Decrease work of breathing
 Conserves surfectant
 Increase lung compliance

9. Cont.
 Equipment Bubble flow circuit and appropriate size
Hudson CPAP prongs to achieve a snug fit.
 Prongs:
 size 0 < 700 grams
 size 1 700-1250 grams
 size 2 1250-2000 grams
 size 3 2000-3000 grams
 size 4-5 > 3000 grams
 Oxygen-air blender.
 Oxygen high flow meter.
 IV pole/stand.
 Clear combi-stop for outlet port on prongs.
 Humidifier base and temperature probe.
 Sterile water for irrigation.

10. INDICATION OF CPAP
 COMMON
 Respiratory distress syndrome
 Apnea of prematurity (specially obstructive apnea)
 Post-extubation in preterm VLBW infants
 Transient tachypnea of newborn (TTNB)
 OTHER INDICATION
 Pneumonia
 Meconium aspiration/other aspiration syndrome
 Pulmonary edema/pulmonary hemorrhage
 Laryngomalacia/tracheomalacia/bronchomalacia

11. CONTRADICTION OF CPAP
 Progressive respiratory failure with PaCO2 levels
>60 mmhg and/or inability to maintain
oxygenation (PaCO2 <50 mmHg)
 Certain congenital malformation of the airway
(choanal atresia, cleft palate, tracheoesophageal
fistula, congenital diaphragmatic hernia,etc)
 Severe cardiovascular instability (hypotension)
 Poor respiratory drive (frequent apnea and
bradycardia) that is not improved by CPAP.

12. ESSENTIAL OF CPAP

13. CPAP MACHINE
 An ideal CPAP delivery system consists of:
 A continuous supply of warm, humidified, blended gases
at a flow rate of 2-3 times the infant minute ventilation.
 A device to connect CPAP circuit to infants airway.
 Means of creating a positive pressure in CPAP circuit.

14. CPAP DEVICE

15. Nasal CPAP application
 Position the baby in supine position with the head
elevated about 30 degrees.
 Place a small roll under the baby’s neck.
 Put a pre-made hat or stockinet on the baby’s head to
hold the CPAP tubings.
 Choose FiO2 to keep PaO2 at 50-80 mmhg or O2
saturation at 85% – 95%.
 Adjust a flow rate 5-10 Lpm to:
a) provide adequate flow to prevent rebreathings CO2
b) compensate leakage from tubing connectors and
around CPAP prongs
c) generate desired CPAP pressure (usually 5 cmH2O)
 Keep inspired gas temperature at 36-40O C (0 ~ –3)

16. Cont.
 Insert the lightweight corrugated tubing
(preferrably with heating wire inside) in a bottle of
0.25% acetic acid solution or sterile water filled
up to a height of 7 cm. The tube is immersed to a
depth of 5 cm to create 5 cmH2O CPAP as long
as air bubbling out of solution.
 Lubricate the nasal CPAP prongs with sterile
water or saline. Place the prongs curved side
down and direct into nasal cavities.
 Secure tubings on both sides of the hat with
either safety pins and rubber band or velcro.

17. SETTING PRESSURE, FLOW,
FiO2
1. Pressure- regulated by depth of immersion of expiratory
limb(water level being constant).start with 5 cm water in
case of RDS or pneumonia and 4 cm water for apnea
management.(range- 4-8)
2. Flow- it should be minimal to produce bubbling in the
bubble chamber(2-5 L/min is sufficient)
3. FiO2- start with a FiO2 of 40 to 50% and after adjusting
the pressure,titrate FiO2 to maintain SpO2 between 89%
to 94%.

18. MONITORING ADEQUACY AND
COMPLICATION OF CPAP
CPAP IS CONSIDERED ADEQUATE IF THE
BABY IS:

19. MONITORING INFANT
CONDITION
 Recommended monitoring:
• Respiratory status (RR, work of
breathing)
• Pre ductal oxygen saturation
• Cardiovascular status (HR, BP,
perfusion)
• GI status (abdominal distention, bowel sounds)
• Neurological state (tone, activity,
responsiveness)
• Thermoregulation (temp)

20. WEANING FROM CPAP
 It is considered when clinical condition for
which CPAP was indicated is passive.
 e.g. in case of RDS we have to see for
improvement in Silverman Anderson score
i.e. if score is less than 4 we can try weaning

21. CONT…
 CPAP for apnea may be removed after 24 -48 hrs
of apnea
 free interval.
 If the baby is stable on CPAP,first wean off the
oxygen in steps of 5% and then wean PEEP to
minimum of 4cm in step of 1cm/change.
 When baby is in FiO2<30%, PEEP 4cm, with
normal saturation and minimal retraction CPAP
can be removed.

22. CPAP FAILURE
 CPAP failure is considered if FiO2 required is
>60% and PEEP required is > 7cm of water.
 If PaO2<50%, SpO2<85%, and PaCO2>60% on
CPAP with FiO2>60% and PEEP >7cm of water
is also considered for mechanical ventilation.
 If the baby is continued to have retraction,
grunting and apnea then, it is considered for
mechanical ventilation.

23. BEFORE CONSIDERING CPAP
FAILURE CONSIDER FOLLOWING:

24. COMPLICATIONS RELATED TO
CPAP
 Pneumothorax / PIE
more in the acute phase
not a contraindication for continuing CPAP
 Nasal obstruction
Remove secretions and check for proper positioning of the
prongs
 Nasal septal erosion or necrosis
Keep prongs away from the septum
 Gastric distension
Intermittent or continuous aspiration of the stomach
 Feeding intolerance

25. PREVENTING
COMPLICATIONS
GASTRIC DISTENTION
To prevent gastric distention:
• Assess the infant’s abdomen regularly
• Pass an oro-gastric tube to aspirate excess air
before feeds q 2-4 hr
• An 8 Fr oro-gastric tube may be left indwelling
to allow for continuous air removal

26. NURSING CARE
 Setting up the system.
 Monitoring of the patient: respiration, heart rate,
bloodpressure, oxygen saturation.
 Care of airway: frequent suctioning, oxygen therapy.
 Prevention of abdominal distention: OG insertion and
is kept open.
 Prevention of nasal irritation: by applying oil, keeping
cotton pad.
 Skin of the baby.
 Check for downes and silverman score in order to
know respiratory status.
 Monitor intake and output of the patient.
 Monitor daily weight of the patient.

27. Cont…
 Optimal positoning:
 Positioning infants on bubble CPAP is an art. It is
recommended that infants be repositioned at least
every 3 to 6 hours.
 The prone position is often the preferred position by
many nurses in an attempt to improve oxygenation
and decrease the frequency of desaturation
episodes.
 Airway care:
 Airway care for an infant on bubble CPAP means
ensuring the airway is cleared of secretions and the
nasal septum is protected from damage.
 Suctioning

28. Cont…
 Feeding consideration:
 The infant on bubble CPAP can be fed using bolus,
continuous, or when stable, oral feedings.
 It may be necessary to aspirate air from the OG
tube before feedings to decrease the gastric
distention.
 An infant is receiving continuous feedings, routine
aspiration of gastric air is recommended. This can
be done with assessments every 2 to 4 hours to
allow optimal sleep time for the infant.
 Positioning the infant prone after feedings, with the
knees up toward the chest, will facilitate the passing
of stool and flatulence.

29. Cont….
 Trouble shooting bubble CPAP:
 If the infant begins to experience desaturations,
there are several areas that may be problematic:
 Check the placement of the prongs to determine
whether they are in the nares properly.
 Ensure the prongs are of the correct size for the
infant and the appropriate size has been chosen
according to the infant’s current weight.
 Prongs of the correct size will fit into the nares
snuggly without excessive movement or blanching
of the nares. If the prongs are too small, they would
not remain in the nose.

30.  Ensure that the infant’s airway is clear and positioned midline.
 Ensure that the blender is set to the appropriate percentage of
oxygen. Infant oxygen requirements may fluctuate, leading to
changes in the percentage of oxygen required.
 Bubbling consideration: can be due to any kink in the apparatus.
 Safety consideration:
 fit of the prongs in the nares and the condition of the septum must
be constantly monitored.
 when positioning the infant, never allow the infant to rest directly
on the corrugated tubing. This could cause molding, pressure
sores, or even burns from the heated tubing.
 Weaning consideration:
 As infants recover from the acute phase of RDS, their oxygen
requirement will decrease and their blood gases will begin to
improve.
 Weaning may be performed based on blood gas values until the
infant reaches a CPAP of 4 with a minimal oxygen requirement.