Canberra Hospital and Health Services Clinical



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Purpose

The purpose of this section is to describe the procedure for endotracheal aspirate sampling.

This performed on intubated neonates to detect the presence of microorganisms in the respiratory tract
Procedure Equipment


  • Large sterile container (jar)

  • Sputum trap

  • Sterile suction catheter – open /closed

  • Sterile glove

  • Pathology request form

Competency



  1. Add sputum trap to suction unit

  2. Wash hands

  3. Don gloves

  4. Perform endotracheal suction as per closed/open suction as per Section7 Endotracheal suction – closed system and Section 8 Endotracheal Suction – open system, of this Clinical Procedure

  5. Disconnect sputum trap from suction tubing

  6. Label container and send to pathology.

  7. Explain procedure to parents

  8. Document in progress notes


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Section 15 - Extubation



Purpose

The purpose of Section 14 is to describe the process of extubation and the procedures performed prior to extubation of an infant.


The decision to extubate is made when mechanical ventilator support is considered to no longer be required. This decision is made well in advance of the procedure. Alternative modes of respiratory support i.e. CPAP, low flow oxygen, cot oxygen is determined and organised prior to the procedure.
Equipment

  • Alcohol Based Hand Rub (ABHR)

  • Intubation trolley

  • Suction equipment

  • Neopuff and appropriate size mask

  • Tape removal wipes

  • Equipment for alternative mode of respiratory support.


Procedure

  1. Set up alternative mode of respiratory support so this can be initiated immediately post-extubation

  2. Decision to extubate needs to be made by the senior medical staff

  3. Consult registrar re timing of extubation procedure, to ensure their presence in the unit in case of the need for re-intubation

  4. Ensure that 2 nursing staff members are present for all extubations

  5. Ensure that cardiorespiratory and oxygen saturation monitoring continues before, during and after the procedure

  6. The oral feed should be withheld and/or aspiration of the stomach contents should be performed prior to the extubation if necessary

  7. Consider prophylactic Caffeine medication prior to extubation as required

  8. Intravenous fluids may need to be commenced/ increased for this period

  9. Suction oropharynx/ETT only if necessary. Do not suction ETT if surfactant given within the last 6 hours and only if absolutely necessary

  10. Remove ETT strapping or neobar strapping followed by the ETT

  11. Suction nares and oropharynx prior to applying CPAP or nasal prong O2 as indicated

  12. Position comfortably ensuring airway patency is maintained

  13. Assess and closely monitor respiratory status

  14. Oxygen requirements should be assessed and weaned as indicated

  15. Perform blood gas (arterial or capillary) 1 hour post extubation if requested to assess acid-base status

  16. Post extubation enteral feeds may be recommenced after 1‐2 hours if condition permits.


Outcome

  • The infant's respiratory status is stable as evidenced by:

  • Vital signs maintained within normal limits

  • Lack of nasal flaring

  • No tracheal tug

  • No excessive use of abdominal or intercostal muscles

  • No grunting

  • Oxygen saturation and blood gas results within normal limits

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Section 16 - Bubble CPAP for Neonates



Purpose

The purpose of this Section is to provide instructions on how to deliver continuous positive airway pressure (CPAP) to a Neonate. CPAP is delivered continuously throughout the respiratory cycle ensuring a functional residual capacity and thereby reducing the work of breathing.


Equipment

  • Alcohol Based Hand Rub (ABHR)

  • CPAP circuit

  • Grey wire

  • CPAP cap and accessories

  • Nasal prongs or mask appropriate for the size of the baby

  • Oxygen/Air blender

  1. Grey Wire

  • Humidifier base and water

  • Suction equipment.


Procedure

Collect all equipment



  1. Set up circuit as per directions on CPAP trolley

  2. Set up humidifier base. The MR850 is used for humidification and set on intubation mode

  3. Suction the oropharynx and nares prior to application of the nasal prongs (MAX 4 cms)

  4. Turn the oxygen flow meter to 8L/MIN and check for leaks

  5. Set the CPAP to 5-8 cms of H2O as prescribed by Consultant/Registrar

  6. Place correct size CPAP cap on infant

  7. Attach nasal prongs to snorkel as per manufactures instructions

  8. Insert prongs gently into infant’s nares

  9. Insert Oro Gastric Tube on free drainage

  10. Release the CPAP cap as per manufacturers guidelines 4-6 hourly and massage the infants head and ears

  11. Change the nasal prongs PRN

  12. Wash the nasal prongs with normal saline or sterile water

  13. Suction the oropharynx PRN

  14. Document on the observation chart tube changes and suctioning results

  15. Assess the infant’s respiratory status and document on observation chart

  16. Record on flow chart hourly observations of:

    1. Heart rate

    2. Respiratory rate

    3. Oxygen saturations

    4. PEEP

    5. Flow

    6. Humidifier temperature

    7. Presence of bubbles

  17. Record blood pressure at least 4 hourly for the first 48 hours then once a shift

  18. See Flow chart if the CPAP is not bubbling



Daily management

  1. Management of neonates requiring CPAP should be directed by the treating Consultant Neonatologist

  2. A mask may be used instead of prongs, if the prongs have caused nasal trauma

  3. Neonates requiring CPAP ≥ 6cm H2O should have PEEP maintained during their cares. This is important in order to maintain alveolar expansion

  4. When caring for a neonate on CPAP please document if the neonate is meeting the following criteria for “Guide to cease CPAP”, as this will assist in decision making for cessation of CPAP

  5. In general, weaning CPAP pressure to a PEEP of 5cm H2O then ceasing is the preferred method. Alternative methods of weaning may be used for individual neonates as directed


Guide to cease CPAP (All 6 need to be present)

  1. CPAP ≤5cm H2O

  2. Oxygen requirement <30% and not increasing (or as directed by treating Consultant Neonatologist)

  3. Average respiratory rate (RR) <60 bpm

  4. Apnoeas requiring tactile stimulation ≤2 episodes over 6 hours

  5. Average saturation ≥88%

  6. Tolerate 15-30 mins off CPAP with appropriate oxygen provided during several care sessions over a 24 hour period


Guide to recommence CPAP (2 or more need to be present)

  1. Increased work of breathing (average RR >75 for 4-6 hours)

  2. Apnoeas requiring tactile stimulation ≥4 episodes over 6 hours

  3. Major apnoea and/or bradycardia requiring resuscitation

  4. Increase in oxygen requirement >10% above the level when CPAP ceased

  5. Neonate has non-specific clinical deterioration


If the neonate has two or more of the above Criteria then the neonate should be:

  1. Reviewed by the registrar

  2. Placed back on CPAP

  3. The timing of next cessation of CPAP will be decided by the consultant on service (Minimum of 48 hours) and when criteria to “cease CPAP” are present


Back to Table of Contents

Section 17 - Continuous Positive Airway Pressure (CPAP) via Nasal Tube



Purpose

This section lists the equipment required and the procedure on how to deliver CPAP via a Nasal Tube.


This is a system whereby mono nasal CPAP is delivered by a shortened endotracheal tube which is placed 2-3 cms into a nare. It is attached to a ventilator circuit to deliver a required level of peak end expiratory pressure (PEEP). This system is mainly used during transport following delivery/resuscitation of a baby.
Equipment

  • Suction equipment

  • Resuscitation equipment

  • ETT - refer to table below (x2 - one spare)

  • 1cm wide leucoplast - strapping nasal tube see diagrams for option 1a or 1b

  • Scissors

  • Duoderm ®

  • Barrier wipes

  • Water-based lubricant

  • Ventilator - Stephanie or Drager with ventilator circuits/equipment

  • Oxygen/air source - wall outlet

  • Gastric tube

  • Equipment for provision of oral sucrose administration (sucrose, dummy and 1ml syringe) - refer to SOP sucrose Pain relief

  • Parent information leaflet

  • Alcohol based hand rub (ABHR).


Endotracheal Tube Size

TUBE SIZE (mm)

(INSIDE DIAMETER)

WEIGHT (g)

GESTATIONAL AGE (wk)

2.5

<1000

<28

3.0

1000-2000

28-34

3.5

2000-3000

34-38

3.5-4.0

>3000

>38



  1. Collect equipment

  2. Set up ventilator per SOP - set parameters as prescribed by the Neonatologist

  3. Set humidifier temperature for the MR 730 at 40oC -3

  4. Check the resuscitation and suction equipment

  5. Apply barrier wipe - cheeks (avoiding the eyes and lips) and allow to dry

  6. Strapping – see diagram below

  7. If neonate unstable - involve 2 personnel

  8. Short ETT to approx 6cms reduce dead space

  9. Suction the oropharynx and nares prior to insertion of nasal tube

  10. Oral sucrose during procedure as required see

  11. Gently insert nasal tube 2-3cm in baby's nare - ensure blue line on tube is towards the septum, i.e. bevel of nasal tube pointed away from the septum; prevent occlusion

  12. Check nasal tube is correct size - if blanching of nares occurs try a smaller size

  13. Secure the nasal tube in place using either option 1a or 1b

  14. Check nasal tube and taping is secure, and not traumatising the nose or face

  15. Connect to ventilator circuit

  16. Monitor blood gas as requested by Neonatologist

  17. Document on observation chart and progress notes

    1. Nasal tube changes

    2. Which nostril used

    3. Condition of nares

  18. Include in hourly observations documentation; parameters on the ventilator (PEEP, Fi02 and flow), humidifier temperature and rainout in circuit; position of nasal tube at nares, strapping, nares condition and need for suction

  19. Change nasal tube 12 hourly or more frequently if required (5) especially if the assessment of infant indicates blocking of nasal tube by

    1. Sudden increase in oxygen requirements

    2. Increase in number of apnoea and bradycardia or desaturation - if 'episodes' clustered this indicates and acute change

    3. Occlusion (or partial) of one nostril

    4. Reduced air entry on auscultation and increased work of breathing (7)

  20. Suction 'free' nare and oropharynx PRN and document suctioning results


ALERT

Do not irrigate nasal – tube remove the tube if blocked. Suction the nares and replace tube in other nare. If the infant is CPAP dependant a second nurse should apply PEEP via the Neopuff throughout the procedure.
Outcome

  • CPAP equipment is secure and not traumatizing the nose or causing excessive flexion/extension or rotation of head and neck of the neonate (4)

  • Any change in neonate's condition has been reported to the medical officer




Option 1a Strapping Using X2 Trouser Legs













Figure 1




Figure 2




Figure 3



Option 1b Strapping Using 1x Trouser Leg


















Figure 1




Figure 2




Figure 3




Figure 4
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