CPAP

CPAP, or continuous positive airway pressure,(non invasive) is a treatment that uses mild air pressure to keep the airways open. Through Continuous Positive Air Pressure treatment, pressurized air is delivered to the childs lungs which assist the child in breathing. CPAP does not breathe for the patient, but it helps the patient to breathe. Continuous positive airway pressure (CPAP) is the use of continuous positive pressure to maintain a continuous level of positive airway pressure. It is functionally similar to PEEP, except that PEEP is an applied pressure against exhalation and CPAP is a pressure applied by a constant flow. The ventilator does not cycle during CPAP, no additional pressure above the level of CPAP is provided, and patients must initiate all of their breaths. INDICATIONS Respiratory distress in preterm neonates Post extubation After surfactant administration AOP(Apnea of prematurity) Pulmonary edema or haemorrhage PDA Tracheomalacia and airway instability MAS PPHN DEVICES FOR ADMINISTRATION VARIABLE FLOW DEVICES Infant flow devices (flow drivers) and devices using Benveniste valve

CONTINUOUS FLOW DEVICES Bubble CPAP Ventilator CPAP Indigenous bubble CPAP (not much reliable)

BUBBLE CPAP Bubble CPAP (continuous positive airway pressure) is a procedure that doctors use to help promote breathing in premature newborns. The key to the procedure is the bubbles, which are created in a water column that is mixed with humidified air to increase a newborn's respiration. It is considered a much safer device to help newborns breath than a mechanical respirator and can aid a newborn's lung development. The first thing to do is to hook up the machinery to the infant; although it looks complicated, the setup is actually pretty simple. There is a ventilator and a humidifier in the Bubble CPAP system, with air flowing from the ventilator to the humidifier and then to the patient. The system is hooked to the patient through a mask, tube or nasal prongs, with the prongs being most recommended for newborns due to fit and freedom of air flow into the newborn's lungs.

The flow of air begins in the ventilator. An air blender or a flow driver can also be used. The air flows from the ventilator to the humidifier, which is heated. While in the humidifier, the air is heated to a temperature between 36.5 and 37.2 degrees Celsius. The humidifier is one of the keys to the bubble CPAP. The humidified air is then fed into a water column, which creates vibrations and pressure (or the bubbles), which combine to open the newborn's lungs and promote breathing. The bubbles don't actually flow into the baby's respiratory system. They just create the pressure needed to promote breathing.

The vibration and pressure created by the combination of the humidified air and water column is why doctors like the CPAP system. A newborn's lungs are sensitive organs and can be easily damaged by a mechanical ventilator. The CPAP opens the lungs without the use of the pressure created by the mechanical ventilator. The CPAP creates only the pressure needed to open the baby's lungs for proper air flow and, unlike a mechanical ventilator; it doesn't force a newborn to breathe. CPAP treatment involves a CPAP machine, which has three main parts:

A mask or other device that fits over nose or nose and mouth. Straps keep the mask in place while wearing it.

A tube that connects the mask to the machine's motor. A motor that blows air into the tube.

The gas passes from the reservoir to the tube passed through one side valve .The valve is designed in such a way that it opens when the child inhales, and closes when the child

exhales. The gas is delivered through tube that can extend to babys nose or inserted in the trachea. Generally, the preferred method of delivery is through nasal prongs, but endotracheal tube or face mask are also used based on requirement. The pressure is set according to the patients need and the gas flow can be regulated.

STARTING OF CPAP Initial pressure: Lung disease: 5-6 cms H2O Central problems(apnea): 4 cms H2O Initial FiO2 (fractional oxygen percentage) FiO2 is used to represent the percentage of oxygen
participating in gas-exchange.: Depending upon the oxygenation status. As a rule of thumb, the

FiO2 requirement should go hand in hand, with the distending pressure( eg.30-40% at 4 cms H2O And 40-50% at 5-6 cms H2O

TRACHEOSTOMY CARE
A tracheostomy is needed for a child with birth complications such as a narrow airway, disorders that affect swallowing or extreme prematurity. A child might also need a tracheostomy for prolonged help with breathing, leaving the mouth and nose free from tubes. Nurses who care for pediatric tracheostomy patients are highly trained in the specialized treatment of these children.

SELECTION OF TRACHEOSTOMY TUBE The following ctiteria on pediatric tracheostomy tube sizes, determined on the basis of patient age and weight:

Premature neonates or babies who weigh less than 1000 g - 2.5 mm Babies who weigh 1000-2500 g 3 mm Neonates aged 0-6 months 3-3.5 mm Infants aged 6 months to 1 year - 3.5-4 mm Infants aged 1-2 years 4-4.5 mm Children older than 2 years (age [years] + 16)/4

The appropriate inner and outer diameters could be conveniently calculated by means of the following formulas:

Inner diameter (mm) = (age [years]/3) + 3.5 Outer diameter (mm) = (age [years]/3) + 5.5 The inner and outer diameters of the tracheostomy tube correlated well with patient weight, as follows :

Inner diameter (mm) = (weight [kg] 0.08) + 3.1 Outer diameter (mm) = (weight [kg] 0.1) + 4.7

IDENTIFICATION A tracheostomy, often referred to as a trach, is a tube placed in an opening in a child's neck that ends in the trachea. It helps the patient breathe. A trach might be connected to a ventilator for continuing oxygenation or it might be kept in place with a cap in a child who is learning to breathe on his own. A trach is not necessarily a permanent fixture, and many children eventually outgrow them.

SUCTIONING A child with a trach is prone to mucous buildup, which requires frequent suctioning to keep the airway open. Before suctioning, a catheter must be measured to let the nurse know how deep to suction the trach to avoid injuring the airway. The suction catheter is connected to a machine and the catheter is inserted into the trach tube to the determined depth. The nurse turns on the suction and slowly draws out the catheter, which removes mucous and drainage. Suction pressures should be kept to a minimum; as a general guide pressures should not exceed 60-80mmHg for neonates/ small infants and up to 120mmHg for older children, below is an approximate but more specific guide Excessive pressures can cause trauma, hypoxaemia and atelectasis .

Age of child

Approx tube size

Suction pressures

Pre - term - 1 month

3.0

60 - 75 mmHg

0 - 3 yrs

3.5 - 5.0

75 - 90 mmHg

3 - 10 yrs

5.0 - 6.0

90 - 112 mmHg 112 - 150 mmHg

10 - 16 yrs

6.0 - 7.0

CLEANING The opening of the skin for the trach tube is known as the stoma. The skin around the stoma is prone to irritation and infection because of the placement of the trach tube, as well as frequent secretions and mucous buildup. The Medical University of South Carolina recommends nurses clean around the trach site daily by gently swabbing the area with a mixture of half peroxide and half water to remove crusting. Daily cleaning reduces redness, drainage and odors from the stoma site. TIES The trach tube is held in place by a pair of ties that circle the neck. Trach ties can become soiled easily and should be changed daily. The nurse removes the ties and threads new ones through a plate that holds the trach tube in place, securing them with Velcro. Changing trach ties reinforces the placement of the trach and allows the nurse to assess its position.

RESPIRATORY SUPPORT A child with a trach is unable to make sounds while crying because of the location of the tube. A child who has a trach and is having difficulty with breathing may become agitated. She might show an increase in breathing rate and have noisy breathing, with sounds similar to grunting or wheezing. Also, her skin might appear blue or pale. Nurses must be trained in CPR to respond to a child who is not breathing by establishing an airway and giving oxygen while help is on the way.

'Trache' Poster

APPLICATION OF ORO PHARYNGEAL AIRWAY An oropharyngeal airway (also known as an oral airway, OPA or Guedel pattern airway) is a medical device called an airway adjunct used to maintain a patent (open) airway. It does this by preventing the tongue from covering the epiglottis, which could prevent the person from breathing. When a person becomes unconscious, the muscles in their jaw relax and allow the tongue to obstruct the airway.

An OPA is indicated if the jaw thrust manoeuvre has failed to correct airway obstruction.

An OPA acts by establishing an opening between the tongue and the posterior pharyngeal wall and can make a difficult airway much easier to manage.

OPAs may not be tolerated by semi-conscious patients

Oropharyngeal airways come in a variety of sizes, from infant to adult, and are used commonly in pre-hospital emergency care and for short term airway management post anaesthetic or when manual methods are inadequate to maintain an open airway. INDICATIONS Oropharyngeal airways are indicated only in unconscious people, because of the likelihood that the device would stimulate a gag reflex in conscious or semi-conscious persons. This could result in vomit and potentially lead to an obstructed airway. Nasopharyngeal airways are mostly used instead as they do not stimulate a gag reflex. In general

oropharyngeal airways need to be sized and inserted correctly to maximise effectiveness and minimise possible complications - such as oral trauma. INSERTION

The correct size OPA is chosen by measuring from the middle of the persons mouth to the angle of the jaw. The airway is then inserted into the persons mouth upside down. Once contact is made with the back of the throat, the airway is rotated 180 degrees, allowing for easy insertion, and assuring that the tongue is secured. An alternative method for insertion, the method that is recommended for OPA use in children and infants, involves holding the tongue forward with a tongue depressor and inserting the airway right side up. The device is removed when the person regains swallow reflex and can protect their own airway. Simply remove by pulling on it without rotation. Procedure

Pre-lubricate with either the patient's own saliva or a small amount of lubricating jelly. Insertion: >8 years: like an adult: concave side up; pass to the back of the hard palate, then rotate 180o to concave side down

<8 years: insert under direct vision, concave side down, using a tongue depressor

USE Use of an OPA does not remove the need for the recovery position and ongoing assessment of the airway and it does not prevent obstruction by liquids (blood, saliva, food, cerebrospinal fluid) or the closing of the glottis. But can facilitate ventilation during CPR (cardiopulmonary resuscitation) and for persons with a large tongue.

RISK FACTORS The mains risks of its use are:

if the person has a gag-reflex they may vomit when it is too large, it can close the glottis and thus close the airway improper sizing can cause bleeding in the airway

ENDOTRACHEAL TUBE SIZE Diameter: Neonate - 3.0 mm 0-6 months -3.5mm 6-12 months -4.0 mm Then use (Age in years / 4) + 4 = size of endotracheal tube (ET) mm Newborn 1 yr 2 yr 3 yr 4 yr 6 yr 8 yr 10 yr 12 yr | | | | | | | | | 10 cm 11cm 12 cm 13 cm 14 cm 15 cm 16 cm 17 cm 18 cm

Formula for length (at lips) of oral tube is Age/2 + 12