How to deal with Nasal CPAP

[Heather333]

I am wondering how ya'll deal with a kid on NCPAP. I am a GN an just started working in NICU a couple of weeks ago.

Are all kids on NCPAP so crabby? The little one I had yesterday was just miserable. I was trying my hardest to get him comfortable, keep his nose for breaking down anymore, and keep his pressures up. He wouldn't tolerate any other position than prone which just kept squishing his nose on the mask.

He was a 31 weeker who HATED to be touched. It just seemed like a struggle all day long to keep him comfortable and properly maintained.

Any advice would be wonderful!

Heather

[Gompers, BSN, RN]

I'm wondering if the units that still use CPAP have started using Vapotherm or Fisher Paykal's high flow heated humidified nasal cannulas? We haven't used CPAP at all since we got these cannulas and even the micropreemies are tolerating extubation. They're actually doing better because there is less nasal secretions with the cannulas, so less suctioning, and also because the cannula stays taped to their faces, they don't have that "down time" like they do when you're doing CPAP care and switching between masks/prongs. I remember when we used CPAP we had the long prongs and had to suction Q4-6H. Those few minutes were horrible - babies desatting, bradying, etc. Not to mention their swollen, bloody nasal passages! It's been shocking how much better our babies are doing on these cannulas and we're successfully extubating much earlier than we were before. Have your units trialed these systems yet?

[RainDreamer, BSN, RN]

I'm wondering if the units that still use CPAP have started using Vapotherm or Fisher Paykal's high flow heated humidified nasal cannulas? We haven't used CPAP at all since we got these cannulas and even the micropreemies are tolerating extubation. They're actually doing better because there is less nasal secretions with the cannulas, so less suctioning, and also because the cannula stays taped to their faces, they don't have that "down time" like they do when you're doing CPAP care and switching between masks/prongs. I remember when we used CPAP we had the long prongs and had to suction Q4-6H. Those few minutes were horrible - babies desatting, bradying, etc. Not to mention their swollen, bloody nasal passages! It's been shocking how much better our babies are doing on these cannulas and we're successfully extubating much earlier than we were before. Have your units trialed these systems yet?

Are we the only place that doesn't use the Vapotherm or Fisher Paykal? I have never even heard of those except on this forum. I wonder why we don't use those. We do have heated humidified nasal cannula, but I don't think it's the same as what you're describing?

We do wean aggressively as tolerated and extubate as early as we can. I would love it if we were able to just put them on a high flow NC like you describe, because the CPAP is so hard on their nose, but what if they need the extra back-up rate that the CPAP can provide?

[ginger58, ASN, RN]

Heather, I don't like an infant being called a kid, because it just seems disrespectful to a 31 weeker. As an adult I've tried CPAP for sleep apnea and it's not pleasant. Here you have an infant with a developing nervous system you he's in this contraption that's uncomfortable.

Does your NICU have a NIDCAP program? Is there a senior nurse that can work with you on reducing stimuli? Infants console with bringing their hands to their mouth, nesting them, rolling blankets up and putting them around them to cradle them. Try to reduce noise and touch only as necessary.

[Gompers, BSN, RN]

Are we the only place that doesn't use the Vapotherm or Fisher Paykal? I have never even heard of those except on this forum. I wonder why we don't use those. We do have heated humidified nasal cannula, but I don't think it's the same as what you're describing?

We do wean aggressively as tolerated and extubate as early as we can. I would love it if we were able to just put them on a high flow NC like you describe, because the CPAP is so hard on their nose, but what if they need the extra back-up rate that the CPAP can provide?

On our unit, if a baby is having apnea after extubation then it's grounds for reintubation. This is, of course, unless there is something obvious going on like the baby needs blood or isn't on enough caffeine. Reason? If they're so "tired" that they're going apneic, then we're just stressing the baby out with the extubation.

The biggest difference between regular high flow cannulas and the heated humidified ones is the rate at which you can set the flow. For an off-the-wall humidified cannula, you can only go to 2 LPM. If it's heated, though, you can go up to 8 LPM. Plus the humidification with these types of cannulas is so much better than the little bubblers that hook to the wall oxygen/air outputs. We were told the reason is not so much that the baby will get cold without the heater, but that there can be cellular changes in the trachea if the air is too cold and dry. When you listen to the chest of a baby on these high flow cannulas, it sounds like CPAP, very loud rushing of air.

[Love_2_Learn]

We use 5% USP Lidociaine ointment at my NICU to place on the baby's nose septum just inside the nares; seems to work pretty well. We also have found that using a short nasal prong which is large enough in diameter to fit inside the nose so as to not allow excess air to escape between the prong and inside edge of the nare works terrific and allows the proper pressures without having to apply any pressure on the tip of the nose to cause snubbing. Each NICU should have a wide variety of different companies prongs so you can choose the proper one which has large enough nare diameter without being too close so as to cause thinning of the nasal septum. We have found that having the proper fitting prongs can make a world of difference in how babies tolerate their NCPAP. Along with the other suggestions mentioned earlier this is another one I thought should be added. Our unit also alternates between the prongs & mask as well as between the NCPAP and nasal cannula however our docs don't give more than 1 liter pressures and we have unfortunately never tried the wonderful sounding Vapotherm, etc.

[lovemyjob]

On our unit, if a baby is having apnea after extubation then it's grounds for reintubation. This is, of course, unless there is something obvious going on like the baby needs blood or isn't on enough caffeine. Reason? If they're so "tired" that they're going apneic, then we're just stressing the baby out with the extubation.

.

i wsh our docs would see it this way. The kid has to be near dying every minute before they will reintubate. We had a little one who had to be bagged back from the light 12 times in a 24 hour period and we still didnt reintubate. I understand the risks involved and the dangers of reintubating a BPDer, but sometimes the risks outweigh the benefit.

I dont think there is anything wrong with calling the babe a kid, kiddo, tyke, little one... whatever. It would be disrespectful if the term was derogatory or culturallly insensitive. But its not. What makes it so inappropriate?

[TiffyRN, BSN, PhD]

We use mostly NPCPAP. Now the kids really hate that; they fight it like mad. But since Vapotherm came around we started using high flow cannulas much more. Of course vapotherm went away for a while so we started using the fisher-paykel and that's what's used most of the time though we have a few vapotherms around now. The Fisher-Paykels get so much rain-out in the tubing then it shoots up the kids noses and drowns them; literally; like A&B's with severe desats (yea, turns out our kids are not part fish and cannot breathe water!). Vapotherms are WAY superior.

Having said all that; either system is better than the NPCPAP. We generally extubate to Hi flow of some sort and then go to NP if they fail the cannula. We can give a back-up rate of up to 20 with NPCPAP because it's run off one of our regular vents. As far as nasal damage; the NP doesn't so much seem to cause septum issues as just general nasal trauma; lots of bleeding, and if it's in the same nostril for very long; unequal nostril size (that's not attractive). Often the "unused" nostril gets too swollen from suctioning and the only way to suction the infant is through the NP tube. But that can't be done very well at all if they have a 2.5 size so the tube must be pulled then reinserted for each suctioning; further exacerbating the nasal trauma. I hate NPCPAP.

And. . .

I don't get the whole "kid" as an offensive or demeaning term. But each to their own. Everyone has their personal opinions. But I've never heard anyone else say they felt that way.

[dawngloves, BSN, RN]

Heather, I don't like an infant being called a kid, because it just seems disrespectful to a 31 weeker. As an adult I've tried CPAP for sleep apnea and it's not pleasant. Here you have an infant with a developing nervous system you he's in this contraption that's uncomfortable.

Does your NICU have a NIDCAP program? Is there a senior nurse that can work with you on reducing stimuli? Infants console with bringing their hands to their mouth, nesting them, rolling blankets up and putting them around them to cradle them. Try to reduce noise and touch only as necessary.

I'd say your all wasting your breath since this post is 5 years old and the OP hasn't posted anything in in 4 years.

[lovemyjob]

Hah, I didnt even see that......

Why would someone be so bored as to comment/look through posts from 2002???

[RainDreamer, BSN, RN]

Well if you do a search on a topic, then all kinds of threads come up in which that topic was mentioned ..... new or old. Not so much boredom, but just people getting more information.

Disrespectful to call a baby a kid? Never heard that one before. We all call our babies our kids at work. Oops!

[lovemyjob]

Thats fine if you are searching for info, but to reply to one is a bit strange...

[Gompers, BSN, RN]

Disrespectful to call a baby a kid? Never heard that one before. We all call our babies our kids at work. Oops!

We call them "kids" sometimes too. I actually like it - makes them seem less sick for some reason.