CPAP in NICU

Overview:

Continuous Positive Airway Pressure (CPAP) is a crucial respiratory support therapy commonly used in the NICU to help premature or critically ill neonates maintain adequate oxygenation and improve lung function. CPAP works by delivering a continuous flow of air or oxygen through the infant's airways, helping to keep the alveoli open and preventing atelectasis (lung collapse). It is typically used for conditions such as respiratory distress syndrome (RDS), apnea of prematurity, or transient tachypnea of the newborn (TTN). CPAP can be delivered via various interfaces, including nasal prongs, nasal masks, or endotracheal tubes, and helps reduce the need for more invasive interventions like intubation and mechanical ventilation, promoting better outcomes and reducing the risk of long-term respiratory complications.

1. Non-Invasive Respiratory Support in the NICU: 

  Purpose and Goals: The primary goal of non-invasive respiratory support is to provide respiratory assistance to neonates without the need for invasive interventions like endotracheal intubation. Minimizing lung injury, supporting alveolar stability, and preventing the need for mechanical ventilation are key objectives. 

a. Mask CPAP: 

Overview:  Mask CPAP involves the delivery of a continuous positive pressure to the airways mask.

It is often used as an initial intervention for infants with mild to moderate respiratory distress. 

Technique and Implementation: Proper mask selection is crucial for an effective seal, preventing

air leaks. Continuous monitoring of vital signs and respiratory parameters is essential. Mask should

fit over the bridge of the nose but not extend over the eyes. The lower portion of the mask should

fit completely over the mouth but not over the chin. Mask CPAP is typically started at 5 cmH20 and

titrated from there based off patient assessment. The 02 flowmeter is usually set at 8-10 lpm to keep

the bag inflated when using a flow inflating bag. 

Challenges: Achieving a consistent mask seal can be challenging, particularly in very low birth

weight infants.  

b. Nasal CPAP: 

Overview: Nasal CPAP delivers a continuous positive pressure through prongs placed in the infant's nostrils.

It is a widely used and effective method for managing respiratory distress in the NICU. 

Technique and Implementation: Proper positioning of nasal prongs is crucial to prevent nasal trauma.

Humidification is often employed to maintain mucosal integrity. Continuous monitoring of CPAP pressure

and respiratory parameters is essential. 

Advantages: Provides stable and well-tolerated respiratory support.  Reduces the need for intubation

and mechanical ventilation. Allows for oral feeding in many cases. 

Challenges: Risk of nasal septal injury or necrosis with prolonged use. Prongs may become displaced,

leading to air leaks. Injuries behind the ears may arise from prolonged use. 

2. Indications:

Respiratory Distress Syndrome (RDS):

• Common in premature infants due to lack of surfactant, nasal or mask CPAP helps maintain lung expansion and prevent atelectasis.

1. Apnea of Prematurity:

   • In preterm infants, CPAP supports airway patency and reduces episodes of apnea (temporary cessation of breathing).

2. Transient Tachypnea of the Newborn (TTN):

   • CPAP is used to help with mild respiratory distress in infants born by cesarean section or those who may have retained lung fluid.

3. Meconium Aspiration Syndrome (MAS):

   • If the infant shows signs of respiratory distress after inhaling meconium, CPAP can help open airways and prevent atelectasis.

4. Pulmonary Hypertension:

   • CPAP is helpful in infants with pulmonary hypertension to improve oxygenation and support pulmonary blood flow.

5. Post-Extubation Support:

   • After weaning from mechanical ventilation, CPAP can provide non-invasive respiratory support to avoid re-intubation.

6. Prevention of Intubation:

   • In some cases, early use of CPAP can prevent the need for endotracheal intubation in infants with moderate respiratory distress.

7. Non-invasive Respiratory Support in Stable Infants:

   • In full-term infants with mild respiratory distress, CPAP (nasal or mask) is used to provide gentle support while maintaining respiratory function.

8. Congenital Diaphragmatic Hernia (CDH):

   • CPAP is sometimes used to stabilize infants with CDH prior to surgical intervention, as it helps maintain oxygenation and reduces the work of breathing.

3.Mask vs. Nasal CPAP:

• Nasal CPAP: Often used for preterm infants or those requiring lower levels of respiratory support. It is more comfortable and less invasive.

• Mask CPAP: Sometimes used for infants who require higher pressures or have more severe respiratory distress. It may provide a better seal for infants who do not tolerate nasal prongs.

4. Skin Integrity:

When using CPAP devices (nasal prongs or mask) in neonates, maintaining skin integrity is crucial to prevent pressure sores, abrasions, and other skin-related complications. Here are the key factors to watch out for and how to address them:

a. Pressure Sores and Nasal Trauma

• Nasal prongs or masks can create pressure on the skin, especially around the nares, cheeks,

  and forehead.

• Signs to watch for: redness, indentations, skin breakdown, or sores at the contact points.

• Prevention:

  • Ensure the prongs or mask are the correct size for the neonate to avoid excessive pressure.

  • Reposition the CPAP device regularly to avoid prolonged pressure on the same area.

  • Use soft, breathable materials (e.g., gauze or soft cloths) around the nares or forehead to

    provide cushioning.

  • Monitor skin closely at the pressure points, especially for infants on CPAP for prolonged

    periods.

b. Nasal Passage Obstruction or Irritation

• Prolonged use of nasal prongs can cause nasal irritation, dryness, or mucosal damage in the nostrils.

• Signs to watch for: redness, swelling, or bleeding in the nasal passages.

• Prevention:

  • Use humidified air to keep the airway moist and reduce irritation.

  • Monitor the nasal prongs for proper fit and avoid overtightening, which can contribute to irritation.

  • Consider using nasal saline drops or gels to lubricate the nostrils if recommended.

c. Facial Skin Breakdown from Mask CPAP

• Masks, especially full-face masks, can cause pressure ulcers or skin breakdown on the nose, forehead, and cheeks.

• Signs to watch for: red marks, skin blanching, or any skin breakage under the mask.

• Prevention:

  • Ensure the mask is properly fitted to avoid excessive pressure on the face.

  • Use moisture-wicking materials under the mask to reduce friction and moisture buildup.

  • Rotate mask positioning or use soft padding to distribute pressure evenly.

  • Clean the skin regularly to remove any moisture or secretions that can cause irritation.

d. Ear and Head Positioning

• Nasal prongs, especially when secured with tape, can cause pressure on the ears and head if the infant is positioned improperly.

• Signs to watch for: redness or irritation on the ears or scalp.

• Prevention:

  • Reposition the infant frequently to relieve pressure on the ears or head.

  • Use soft, flexible tape or straps that don’t apply excessive pressure.

  • If a nasal mask is used, make sure it fits snugly but not too tight, as a tight fit can contribute to ear or head pressure.

Why is it important for an RT to understand CPAP in NICU?

Understanding CPAP in the NICU is essential for respiratory therapists because it is a key non-invasive therapy used to support neonates with respiratory distress, particularly those born prematurely or with conditions like RDS, apnea of prematurity, and TTN. CPAP helps prevent atelectasis, improves oxygenation, and reduces the need for more invasive interventions like intubation and mechanical ventilation. Proper use and monitoring of CPAP can significantly improve outcomes for neonates, promote lung health, and reduce complications, making it a critical aspect of neonatal respiratory care.