When to start CPAP vs. blow by 02 vs. PPV?

  1. 0
    Hello all,
    I am new to the NICU and I just recently took my NRP and I feel as though I have an ok grasp of what to do when a baby is experiencing 100% apnea but I find myself getting confused when it comes to situations such as this:

    I had a patient the other day who gets "very tired" when bottle feeding and has trouble pacing so she did very well for the first bit and the pacing helped her saturations return to 100% when they would go down to high 80's, low 90's. At one point, however, her saturations kept going lower and lower until eventually they reached the 20's. By this point and her heart rate started slowing down. For some reason I decided to put her prone and "stimulate" her by gently rubbing her back- although looking back, don't know if this mattered because she wasn't experiencing apnea. I guess it was my instinct to just stimulate her to breathe more? I have no idea why I did that. And then after a few seconds of seeing no improvement, I provided blow-by oxygen and she eventually came back up and had no problems for the rest of the shift.

    What would have been the proper thing to do in this situation? I kept thinking back to NRP as I saw her heart rate drop to below 100... first I thought "PPV" but then realized, she wasnt experiencing apnea and wasnt gasping. Then I thought "CPAP" because of her low 02, but I'm thinking that would be something more in the "long run"... if she kept up the low 02 for a long time and didn't come up with blow-by oxygen.

    I still feel SO confused!!! Was using blow-by oxygen ok in this situation?

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  2. 12 Comments...

  3. 0
    I'm a bit confused. You let this baby's sats reach the 20's before you intervened? Placing a child in the prone position does not promote oxygenation. Neither does rubbing the back. If the child had decreased saturations with bradycardia then the initial intervention is to provide oxygen.

    I'm PICU, but we see little babies a lot. I don't take NRP, but I do take PALS. Symptomatic bradycardia due to poor oxygenation requires manual ventilation to attempt to increase the oxygenation and the heart rate.

    I'm glad blow by worked, but I would have intervened much faster than waiting for the sats to drop to 20. If her normal is 100%, and normal when feeding is high 80's-90's I would have been concerned and giving blow by when they reached the 70's. By the 20's I would have been bagging. I'm not sure why you allowed them to reach the 20's in the first place, and then wasted time trying to stimulate her before giving oxygen.
  4. 1
    Were you feeding her when this happened? Was she refluxing? It is hard to tell what what was going on when this occurred,but give that kiddo some blowby and stim her so she cries. If that doesn't work then PPV, esp if the sat was truly in the 20's. You have to look at the full picture: Kid eating, desats, stop feed, cont to desat, get out the blowby and stim her, cont to desat, call for help and PPV that kid, esp if she is sating that low. She could have refluxed, she could have aspirated. This is a learn from situation, that is for sure.
    karnicurnc likes this.
  5. 0
    Since she was feeding at the time, it's likely that she was sucking on the bottle too fast without taking a break and/or refluxing. In the first instance, you have to force her to take breaks by tipping the bottle down or taking it out (lol, have to do this sometimes as the kid will keep on sucking!), in the other instance, you need to beat on her back to help clear her airway. But after you have beat on her back a few seconds and she is still not coming up, then I would give her some blow-by and progress to PPV.

    Waiting to the 20s is very low and you should be bagging by the 50s at the very latest. Unfortunately this kind of thing is very baby dependent and how they react. The problem is that you have to balance with bagging and filling their little bellies up with air which already have milk in them and then having them throw up and aspirating more.

    You can also ask the docs if you can give her some supplemental O2 during feeds and be able to titrate up as needed, but you do still need to force the baby to have breaks as you don't want to use excessive FiO2 due to the ROP risks as most of these kids you are feeding with these issues are ex-preemies...
  6. 2
    First of all, stop feeding when her sats start to drop. if she doesn't recover quickly, but keeps on dropping, then CPAP or PPV would be appropriate. To me, any baby that desats like that with feedings even when paced is getting tired. At that point gavage feeding is necessary. There is no point in wearing her out. We do cue-based feedings, and this little one is telling you something.

    Try side-lying for feedings, sometimes they will feed better in that position. At times, we do use supplemental O2 during feedings, too.
    karnicurnc and prmenrs like this.
  7. 0
    Almost ALL babies in the NICU require very close monitoring and supervision when bottle feeding. You have to watch them constantly. Learn to pace them appropriately. Use the correct nipple and be mindful of the nipple flow. Yes, some nipples have a faster flow than others. Only fill the nipple about 1/2 way with milk. Feeding in a side-lying position is also helpful as it allows the baby to have more control over the bolus of milk. Use BBO2 if needed to keep sats within parameters. Monitor their breathing. The baby should take no more than a few sucks before stopping to breathe. Based on your narrative, it sounds like the baby sucked too much, stopped breathing and became apneic, which was quickly followed by bradycardia. Don't let it even get to that point. Proper pacing is the key. Intervene immediately by stopping the feeding and patting (kind of aggressively) or rubbing her back, until she cries. After she recovers she may be too wiped out to continue. The PO attempt is over. Watch what other nurses do while PO feeding and how they react to situations.
  8. 4
    Quote from karnicurnc
    patting (kind of aggressively) or rubbing her back, until she cries.
    I see a lot of newer nurses that will be feeding a baby, know the infant is having a "moment", stop the feeding, then sit there and stare at the infant who is apneic and getting bluer by the moment, as they carefully watch the monitor (and the infant) slowly lose their sats and HR.

    I'm on the other side of the room (screaming in my head), would you pat the kid, or pinch it's toe, make that baby cry!! That's a lot less invasive than bagging or cpap. Depending on the kid, this may be the signal that we're done here for now, time for the tube (NG) but for some kids. . . I mean, being that aggressive should not be routine with any given kid, but in the moment, it's appropriate.

    With some kids, you do the aggressive back pat, then the toe pinch and all you get is a little grimace, then it's game over, back to the bed, pull out the ambu, call the charge nurse and RT, and oh, by the way, your nippling attempt is concluded for now.

    I also agree with the previous poster, appropriate pacing is the key, but some of these little ones are sneaky. Sometimes you can hear a certain suck and you know immediately that this kid just "bit" off more than they can handle and you immediately tilt that bottle out of their mouth, change their position a little and let them have a little time to figure out what to do with that mouthful of milk.
    HazelLPN, karnicurnc, umcRN, and 1 other like this.
  9. 0
    Quote from TiffyRN

    I also agree with the previous poster, appropriate pacing is the key, but some of these little ones are sneaky. Sometimes you can hear a certain suck and you know immediately that this kid just "bit" off more than they can handle and you immediately tilt that bottle out of their mouth, change their position a little and let them have a little time to figure out what to do with that mouthful of milk.
    It's as if you can read my mind because that is one of the things I tell my orientees to be aware of.
  10. 0
    In this situation you describe I would have never let her sats drop lower than the mid 80's before intervening. The first intervention when in the 80s would be to remove bottle- stim the feet something to make her cry, if that doesnt work and she's dropping lower on sats and bradying I would CPAP and bag if in the 20s!! I wonder if she really was that low or if you were moving her around and her oximeter wasn't picking up.... The prone position would make it more difficult to intervene so I would not recomend doing that, plus it does not promote oxygenation.
  11. 0
    In an emergency situation, PPV is your best friend. A baby does NOT need to be apneic before you start PPV. Decreased O2 sats with color change and bradycardia = too late. CPAP is a form of PPV. In an emergency, you hand bag the baby. If the heart rate is below 100 you bag the baby. If the heart rate drops below 60 and keeps dropping, you make it a quick 30 seconds of PPV and start compressions. Eventually you'll get to know your babies and know what they respond to and how to fix them, but you will never get dinged in a court of law for going by NRP. You will get dinged in a court of law for proning your baby and patting them while they are further decompensating.

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