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232 Section VI ■ Respiratory Care

a. Short binasal prongs

b. Velcro (to make attachment circles and moustache

for upper lip)

c. DuoDERM (to make nasal septum protective layer)

d. CPAP head cap

e. Adhesive tape

E. Technique (See Procedures Website

for Video)

1. Starting b-CPAP

Nonventilator-derived b-CPAP apparatus involves

making a simple water seal device that can be put

together in neonatal units. It consists of a container of

water, through which the expiratory gas from the baby

is bubbled at a measured level below the surface (e.g.,

5 cm below the surface = 5cm H2O CPAP). The lower

the level of the tip of the expiratory tubing below the

surface of the water, the higher the CPAP (Fig. 35.1). It

is important to fix the water bottle to an IV pole at or

below the level of the baby’s chest to avoid any accidental displacement or water spills. The recent, commercially available, preassembled circuits rely on the same

basic principle.

a. Before attaching the device to an infant

(1) Position the infant with the head of the bed elevated 30 degrees.

(2) Gently suction the mouth, nose, and pharynx.

Whenever possible, use size 8-Fr suction

catheter. Smaller-sized catheters are not as efficient.

(3) Place a small roll under the infant’s neck/shoulder.

Allow slight neck extension to help maintaining

the airway open.

(4) Clean the infant’s upper lip with water.

(5) Place a thin strip of DuoDERM (or Tegaderm)

over the upper lip. That should also cover the

nasal columella and both sides of nasal apertures (Fig. 35.2).

(6) Cut a Velcro moustache and fix it over the

DuoDERM.

(7) Cut two strips of soft Velcro (8 mm width) and

wrap them around the transverse arm of the

device, about 1 cm away, on each side, from the

nasal prongs.

b. Placing nasal prongs into infant’s nostrils (Figs. 35.2

and 35.3)

(1) Use appropriate-size CPAP prongs. The correct

size nasal prongs should snugly fit the infant’s

nares without pinching the septum. If prongs

are too small, they will increase airway resistance and allow air to leak around them, making it difficult to maintain appropriate pressure.

If prongs are too large, they may cause mucosal

and septal erosion.

(2) Curve prongs gently down into the infant’s

nose.

(3) Press gently on the prong device until the soft

Velcro strips adhere to the moustache.

(4) Make sure of the following points

(a) Nasal prongs fit well in the nostrils

(b) Skin of nares is not stretched (indicated by

blanching of the rim of the nostrils)

(c) Corrugated tubes are not touching the

infant’s skin

(d) There is no lateral pressure on the nasal septum

(e) There is a small space between the nasal

septum and the bridge between the prongs

(f) Prongs are not resting on the philtrum

5

4

3

2

1

Manometer

Distal

tubings

Flowmeter

Oxygen

blender

The

CPAP

bottle

Nasal

CPAP

canula Proximal

tubings

Thermometer

Heated

humidifier

Fig. 35.1. Bubble CPAP circuit. This simplified

diagram demonstrates the components of the b-CPAP

device that is either assembled at the bedside or commercially manufactured. Gas mixture flows to the

infant from the wall source after it is warmed and

humidified. The free expiratory limb of the tube is

immersed under the surface of sterile water to produce

the required CPAP (usually 5 cm H2O).