Presentation1 CPAP VK [Autosaved].pptx

Pumani B cpap

1. PUMANI BUBBLE CPAP PRESENTED BY V.KHONJE TO 2023 COHORT

2. LEARNING OUTCOMES Describe what BCPAP IS Explain the background of CPAP Describe the indications for CPAP Explain the contraindications for CPAP Demonstrate skills in initiating and weaning an infant/child on CPAP Demonstrate skill in monitoring a baby on CPAP

3. What is bCPAP ? bCPAP = bubble continuous positive airway pressure. It is a constant pressure applied to the airway, generated by continuous, consistent flow of air with the aim of opening collapsed lung segments and maintaining patency in already opened air spaces.

4. What is bCPAP ? bCPAP = bubble continuous positive airway pressure. It is a constant pressure applied to the airway, generated by continuous, consistent flow of air with the aim of opening collapsed lung segments and maintaining patency in already opened air spaces.

5. Global Burden of Prematurity & RDS CPAP has been widely used to respiratory insufficiency Used in adults from 1936 and introduced to treat RDS in infants from 1971 In Malawi CPAP began to be experimented at Queen Elizabeth Central Hospital in Blantyre , in mid 2000. In 2008, Rice University students, in collaboration with Baylor College of Medicine, developed an affordable, low-tech version of the bubble CPAP system

6. The Pumani bCPAP was developed at Rice University & Texas Children’s Hospital and evaluated at QECH Pumani bCPAP: low cost, effective innovation

7. How does bCPAP help? On inspiration, bCPAP drives air with additional pressure into collapsed alveoli and opens them. This process is sometimes called ‘recruitment’. The pressure is maintained even when the patient breathes out, therefore the alveoli do not collapse at the end of expiration. The lung expands easily thus improving oxygenation and reducing the need for increased work of breathing.

8. Indications for CPAP RDS: respiratory distress syndrome TTN: transient tachypnea of the newborn Pneumonia/sepsis MAS: meconium aspiration syndrome PPHN: persistent pulmonary hypertension of the newborn Bronchiolitis Upper airway obstruction Apnea of prematurity

9. Baby is breathing. HR greater than 100, Weight more than 1 kg Tone is poor Baby is floppy Tone is good Baby is active No CPAP Put on O 2 1 L/min if saturation is less than 90% in room air Weight between 1kg and 1.3 kg . Premature less than 30 weeks EARLY CPAP Weight is more than 1.3 kg. RR greater than 60 . Saturation less than 90% in room air. Retractions or grunting (with or without) CPAP Start O 2 1 L/min After 15 minutes: Is saturation less than 90% on O 2 1 L/min? Which Patient is to be put on CPAP? R Y T Tone is good Respiratory Distress : Pulse ox less than 90% on O 2 1LPM Yes for HR greater than 100 TRY CPAP! Always perform ABC assessment and resuscitation as needed BEFORE beginning TRY CPAP

10. When is bCPAP not be effective : Severe birth asphyxia Upper airway abnormalities Choanal atresia, cleft palate, tracheoesophageal fistula Severe cardiovascular instability and impending arrest Unstable respiratory drive Ventilator failure

11. Clinical trial was conducted at QECH to ensure that the equipment is robust and effective Pilot Study - 2012

12. bCPAP Increased Survival at QECH

13. p= 0.006 Results for RDS and Sepsis

14. Setting Up a Patient on CPAP Ensure proper indication for CPAP (RDS, Apnea Prepare necessary equipment cpap machine Infant size mask or nasal interface Head gear Oxygen source Safety pin OGT Syringes Rubber bands

15. Setting Up a Patient on CPAP Appropriate location Warm area High care area/corner to ensure close monitoring Close to nursing station if possible Keep bCPAP patients close together

16. Setting Up a Patient on CPAP Nasal Patency Prime importance If the nares are obstructed air cannot enter the lungs, but bubbling will be forceful Suction secretions and blood as needed Avoid trauma/observe for irritation Insert an oral gastric tubes

17. Setting the machine Attach oxygen tubing to the flow meter and connect to the humidifier Set the flow rate 3L/ min, 6cm H2O, and Choose appropriate mask or nasal interface and connect to the tubing from the humidfier Test if its working before securing nasal interface on the baby Test by occluding the tubing and see if there is bubling of water in the bottle

18. PROCEDURE Put child in with head of bed elevated at 30 degrees For neonates, put in sniffing position Put a small roll under the infants neck to support baby's head and maintain the sniffing position keep the Check baby’s saturation and keep pulse oximeter throught the process.

19. Gently suction the mouth, nose and pharynx to relieve any obstruction and allow proper flow of air and reduce resistance Pass an oro -gastric tube for feeding. Moisten the prongs with sterile water or saline drops before placing them into the baby’s nose . Adjust the angle of the prongs until the correct positioning is achieved

20. nasal prongs should fill the nasal opening completely without stretching the skin or putting undue pressure on the nares Securing the Tubing to the Hat (Bonnet) Place the hat on the baby’s head so that the rim is just over the top of the ears. Secure the corrugated tubing to the hat at the angle that provides the best prong position.

21. Hold one of the tubes gently against the side of the baby’s 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

22. Monitoring Patients on CPAP Require more than average monitoring 1 st hour after starting CPAP, Review for response (heart rate, respiratory rate, oxygen saturation, signs of distress, general clinical condition) ¼ hourly then ½ hourly in the next hour. Reassess after 2 hours then every 4 hours C heck CPAP settings **Remember each time you review a patient on CPAP to look in the nostrils for signs of nostril blockage

23. Consequences of Poor Monitoring

24. Escalating Support Babies on CPAP require more support than 3LPM oxygen, 6LPM total flow After placing baby on CPAP, assess vital signs saturations, breathing pattern, heart rate ¼ hourly for the 1 st hour then half hourly the next hour. 2. Adequate CPAP should begin to decrease work of breathing and improve oxygen saturation

25. Escalating Support 3. If oxygen saturation is less than 90%, check all connections and suction nares Re-assess saturation: If saturation is less than 90%, increase O 2 to 4 LPM If after this increase oxygen saturation is less than 90% and work of breathing is high– increase O 2 to 5LPM and CPAP water level gradually to 8cm.

26. Escalating Support This is often necessary for babies with severe RDS If saturation is still less than 90%, increase O 2 to 6LPM and call for assistance Do not increase CPAP to more than 8cm H 2

27. Increasing CPAP Treatment **Always Check Connections before increasing treatment : Is the water bubbling? Suction baby once more. Baby is responding to treatment. Continue management. Increase settings : Oxygen to 5 L/min CPAP water level to 7 cm Blended Flow to 7 L/min Yes No CPAP water level: 6 cm Oxygen: 3 L/min Blended Flow: 6 L/min Is O 2 saturation greater than 90% Increase Oxygen by 1 L/min After 4 hours: Is O 2 saturation greater than 90%? No Start Substantial in-drawing, recessions, retractions, work of breathing? Increase Oxygen to 5 L/min, consider increasing CPAP water level to 7 cm, and blended flow to 7 L/min. Reassess for complications or alternative diagnosis Yes Yes Increase oxygen to 6 and CPAP to 8cm of water if it is not already, then call for assistance. CPAP cannot be increased past 8cm of water without discussing with seniors. Reassess for complications or alternative diagnosis O 2 Saturation greater than 90% No No

28. Weaning a Patient off CPAP ‘ Clinical respiratory stability’ is the main criteria, but as a guide, the following must be achieved: Patient has been on bCPAP at least 24 hours RR less than 60/minute for at least 6 hours (for neonates) Oxygen saturation consistently > 90% for at least 6 hours No significant grunting, recessions, nasal flaring, apnoea or bradycardia for at least 6 hours

29. Weaning Procedure Procedure: Reduce CPAP pressure by 1 cm every 6 hours until 5 cm is reached Once 5 cm is reached, start reducing oxygen flow by 1 LPM every 6 hours until 1 LPM is reached After 6 hours on 1 LPM or less, and patient is stable, remove CPAP and place patient on 2 LPM of oxygen Once off CPAP, review baby at 1 hour, then at 6 hours, then every 12 hours

30. Weaning a Patient from CPAP Weaning Criteria: Patient is clinically stable as below: 1. Patient has been on bCPAP at least 24 hours 2. RR less than 60/minute for at least 6 hours 3. O 2 saturation consistently greater than 90% for at least 6 hours 4. No significant grunting, recessions, nasal flaring, apnoea or bradycardia for at least 6 hours Keep on CPAP Does patient meet weaning criteria? No Yes Start Reassess patient after 1, 6 and 12 hours . If meets criteria for CPAP again at any point, restart CPAP and discuss patient with seniors. Water level is at 5cm O 2 is at 1 L/min Blended flow is at 6 L/min Take patient off CPAP and place on 2 L/min O 2 Water level is more than 5cm O 2 is more than 1 L/min Blended flow is more than 6 L/min Water level is at 5cm O 2 is at 1 L/min Blended flow is at 6 L/min for 6 hours and patient is stable Take patient off CPAP and place on 2 L/min O 2 Decrease water by 1 cm every 6 hours if patient continues to meet weaning criteria. Until a water level of 5cm is reached Decrease O 2 by 1 L/min every 6 hours if patient continues to meet weaning criteria until O 2 reaches a minimum of 1 L/min

31. NOTE Weaning is NOT stopping or removing baby from CPAP!!!! It is the gradual reduction of CPAP settings to the minimum levels while making sure that the child is coping.

32. Complications of CPAP Blocked nostrils Nasal irritation and necrosis Distended abdomen Nose bleeding Pneumothorax

33. CPAP Alone Does Not Assure Success Remember the basics: Temperature stability Glucose homeostasis Optimal positioning and airway clearance of secretions Adequate caloric intake for continued growth Prevention and treatment of infection

34. Cont… 6. Skin care 7. Caregiver and baby interaction (bonding) 8. Provide support to care givers and family

35. Temperature Stability cover neonate with a warm, dry, blanket Place in a warm environment Place a hat Monitor temperature on an ongoing basis Maintain neutral thermal environment

36. Glucose Homeostasis Assess glucose in: Symptomatic babies Babies at risk for hypoglycemia Infant of diabetic mother Small for gestational age babies Large for gestational age babies All babies admitted to special care areas

37. Positioning Place in the “sniff” position to optimize air exchange Assess Color (saturation if possible) Heart rate Respirations

38. Adequate caloric intake Babies need 100-120 kcal/kg/day --Equivalent to 180ml/kg/day of human milk These amounts are when baby is in a neutral thermal environment Significantly more calories are required when baby is cold stressed

39. Prevent and Treat Infection Hand hygiene is everyone’s responsibility Check HIV and VDRL status Not all babies need antibiotics Obtain appropriate cultures and check results Use most appropriate narrow spectrum antibiotics when feasible Stop antibiotics when no longer neeed

40. Skin care Keep baby’s skin clean and dry. Turn baby every 2 hours and when necessary. Instill nasal drops every 2 hours to prevent dryness of nostrils and bleeding.

41. Care giver and baby interaction Encourage caregiver to hold baby in arms and talk to child. Allow caregiver to participate in care like feeding through OGT, cleaning baby, changing clothes etc

42. Support to caregivers and family CPAP is stressful to caregivers and family members. Provide information before, during and after procedure. Answer all question from caregiver. Allow family members to visit.

43. CPAP Works But only when attention is given to the basics of neonatal care