Fig. 35.3. An infant with CPAP properly attached to the head.

(1) Head cap (cap fit well on head covering down to eye brows,

almost entire ears and back of head); (2) breathing circuit tubes

attached to side of hat while avoiding both eyes; (3) three-way

elbow on expiratory limb allows the attachment of pressure

manometer or could be capped to preserve pressure within circuit;

(4) orogastric tube attached to lower lip and chin with Tegaderm;

(5) neck roll allowing slight neck extension (sniff position); (6)

nasal prongs applied to baby—prongs inserted into nares allowing

a space between the transverse arm of the nasal prongs and nose to

avoid damage to nasal columella; (7) supporting chin strip.

Infant should be assessed during the trial for any

tachypnea, retractions, oxygen desaturation, or

apnea. If any of these signs are observed, the trial is

considered failed. Infant should be restarted immediately on CPAP, for at least 24 hours, before

another trial is undertaken.

b. There is no need to change the level of positive pressure during the weaning process. Infant is either on

b-CPAP 5-cm H2O or off CPAP.

c. Do not wean the infant off b-CPAP if there is any

likelihood of respiratory compromise during the

weaning process. It is wise to anticipate and prevent

lung collapse, rather than risk having to manage collapsed lungs.

d. Do not wean infants off b-CPAP if they require supplemental oxygen. (13)

4. Potential Complications

a. Nasal obstruction: From secretions or improper

positioning of b-CPAP prongs. To avoid obstruction,

nares should be suctioned frequently and prongs

checked for proper placement. Never use a nasal–

pharyngeal tube to supply b-CPAP, because of significant risk of nasal airway obstruction.

b. Nasal septal erosion or necrosis: Due to pressure

on the nasal septum. This can be avoided by maintaining a small space (use DuoDERM 2 to

3 mm) between the bridge of the prongs and the

septum. Choosing the proper-sized snug-fitting

nasal prongs, using a Velcro mustache to secure

the prongs in place, and avoiding pinching of the

nasal septum, will minimize the risk of septal

injury. Significant nasal septal erosion may require

consultation with the ENT or Plastic Surgery

team.

c. Gastric distention: From swallowing air. Gastric distention is a benign finding and does not predispose

the infant to necrotizing enterocolitis or bowel perforation (14). It is important to ensure patency of the

indwelling orogastric tube because secretions may

block the tube and lead to distention.

d. Pneumothorax: During the first 2 days of life, premature infants usually will require intubation for this

complication.

e. Unintended increase/decrease in positive end pressure: The tubing that is placed under water to provide positive end pressure must be firmly fixed in

place so that it cannot be displaced to produce

unwanted pressure changes.

Acknowledgement

We thank Aser Kandel, MD for drawing the illustrations in

this chapter.