Bubble CPAP

A bubble CPAP (continuous positive airway pressure therapy) system is a noninvasive ventilation method in which CPAP is delivered to a spontaneously breathing newborn to maintain lung volume during expiration. In this, blended and humidified oxygen is delivered via short binasal prongs or nasal mask. Pressure in the circuit is maintained by immersing the distal end of the expiratory tubing in water. The depth to which the tubing is immersed underwater determines the pressure generated in the airways of the infant. As the gas flows through the system, it bubbles out and prevents the buildup of excess.

Purposes

• To maintain positive airway pressure
• To provide optimum humidification
• To increase functional residual capacity of neonate’s lung
• To improve oxygenation
• To prevent atelectasis

Mechanism of Action

The bubble CPAP system helps in breathing of infants requiring respiratory support.

It is incorporated with unique feature of humidification technology and air/oxygen blender CPAP works by maintaining positive pressure in the airway during spontaneous breathing, thereby increasing functional residual capacity and improving oxygenation in infants with RDS. CPAP does this by stabilizing airspaces that have a tendency to collapse during expiration due to surfactant deficiency.

Salient Features of Bubble CPAP

• Consistent and accurate delivery of CPAP
• Servo-controlled humidifier
• Bubble generator
• Easy to operate

Types of CPAP Device

1. The F&P Bubble circuit: Preferred for infants of all gestations and for all causes of respiratory distress.
2. The Drager Babylog 8000 ventilator: Used for near-term and term babies with a birth weight > 1,250 g.
3.  The Stephanie ventilator with Argyle prongs: Used for near-term/term babies who been extubated and continue to need respiratory support.
4. The EME Flow Driver: Used for babies who have birth weight of <1,250g.

Procedure

• Perform hand hygiene.
• Wear gloves.
• Set the gas supply flow rate as required in the flowmeter
• Set the FiO2percentage on the dial knob (21-100%)
• Set the humidifier by selecting desired mode using mode key select the heater wire on /off by using heater wire key.
• Set the positive end expiratory pressure (PEEP) to the positive airway pressure (PAP)Valve. Adjust PEEP knob clockwise or anticlockwise to the desired PEEP level in the PAP valve.
• Remove the lid from the jar and fill the water reservoir. Fill the jar to the fill line with sterile water. Replace the lid close the jar.
• To attach the PAP valve to a mounting clam, slide the equipment into the corresponding equipment mount holder. This will help to keep the device in vertical position.
• Connect the exhalation port by rotating the PAP adjustment lever to the full anticlockwise position. Adjust the gas flow to the desired level and connect the expiratory end of the breathing circuit to the gas inlet connector.
• PAP should be set using clockwise rotation, adjust the device to the desired back pressure.
• Fix the patient interface.
• Confirm the circuit is correctly set up.
• Turn on the gas flow.
• Choose the appropriate hat size (22-25, 25-29, 29-36 and> 37 cm) to provide snug fit. Select an appropriate size prongs and connect it to the circuit. Position the prongs gently in the nares and secure with lateral tapes to the hat. The prongs should rest approximately 2-3 mm from the nares and should not be in contact with the columella (end of septum).

Nurse’s Responsibility in Caring Neonates with Bubble CPAP

• Observation and documentation: Monitor the heart rate, respiratory rate, SpO2, percentage, axillary temperature as per protocol and record it nurse’s chart. Mention whether nasal prongs/mask are used, its size, water level, suction, etc. in nurse’s chart. Neonate’s condition, including response to handling and changes in skin also, should be documented.
• ABG analysis: Arterial blood sample should be collected, and the results should be notified to the neonatal intensivist.
• Medications: Administer the medications round the clock; maintain fluid and electrolyte balance.
• Airway management: Ensure that gases are delivered at core temperature (37°C) with adequate humidification. This will facilitate mucociliary action, clear secretions, optimize gas exchange, and reduce the chance for infection. Confirm the patency of nasal prongs, humidification, infant position, feeding techniques, etc.
• Suction: Suctioning may be done when there is severe apnea, less response to tactile stimulation, or increase in oropharyngeal secretions.
• Positioning: The newborn should be positioned to facilitate comfort and optimize respiratory effort. Prone, supine, and lateral positions can be used alternately to promote upper airway stability, reduce work of breathing, facilitate physiological flexion of the trunk and limbs, and enhance normal growth and development.
• Skin care and prevention of injury: Provide meticulous skin care, oral care, and umbilical cord care. Skin-to-skin contact (kangaroo mother care) can be facilitated once the condition of baby is stable.
• Family-centered care: The parents should be kept informed about the infant’s progress from time to time. When the infant is able to tolerate minimal handling, involve the parents in daily care. Demonstrate and discuss the common NICU procedures in care of newborns to the parents.
• Prevention of complications:  1)Pneumothorax: Assess the infant for signs of pneumothorax such as respiratory distress, increased work of breathing, severe apnea, desaturation of oxygen, decreased air entry, and asymmetrical movement. If suspected, support the baby and inform the neonatal intensivist. (2) Retinopathy of prematurity (ROP): Judiciously use oxygen therapy and comply with oxygen protocols. Ensure that oxygen saturation and transcutaneous monitor alarms are set at correct limits. (3) Gastric distension: All infants who are on CPAP require nasogastric (NG) tube insertion (size—6 Fr) to prevent over distension of the stomach. Always check for the positioning of NG tube. Feeding should be given as per order. Gastric decompression can be done to enhance venting of air from the stomach. (4) Injury to nasal septum and nares: To prevent friction injury to the nasal septum and nares, we must limit excessive movement of the nasal prongs through good positioning and alignment of prongs. Always use appropriate size prongs or mask. Do not use any lubricants except normal saline for insertion of prongs. Ensure that the hat remains fitted over the glabella to anchor prongs/mask effectively. Release the prongs/masks as well as chin strap every 2 hours and gently massage the nares, cheeks, and chin. If there is any redness or injury to nares, mask can be used alternatively.
• Monitor the oxygen concentration using calibrated oxygen measuring unit.
• Maintain the water level between minimum and maximum lines without the drop tube beneath the surface of the water. Adjust the water level through water level adjustment port. Remove the Luer cap and connect a syringe to the port for adding or removing water as required.
• Airway pressure should be monitored continuously using a manometer and adjust the device accordingly.
• Regularly monitor the humidification chamber for water level. Replace the chamber if water level exceeds.
• Check whether all the connections are tight before use and after adjustment.
• Ensure that airflow is present at all times if there is an interruption in airflow.
• Constantly observe the circuit for condensate, drain as needed.
• Regularly assess the PAP valve for bubbling.
• Check for any leakage of air in the system as well as at the patient end. If air leaks are minimized, increase the airflow to maintain continuous bubbling.
• Monitor the newborn’s oxygen level.
• Check the water level in the PAP valve, refill it if it drops below the minimum level.
• Verify whether the baby is receiving prescribed CPAP level.

Managing the Troubleshooting and Maintenance of Bubble CPAP

• Loss of bubbling: If there is regular/ intermittent loss of pressure, reposition the baby and use a chin strap to achieve optimal seal.
• Clean the outer sides of bubble CPAP and gas supply line using damp cloth and mild soap and water or isopropyl alcohol. Dry all the surfaces with soft cloth or paper towel.
• Follow operational safety measures as per manufacturer guidelines.
• Check the working condition of the device after cleaning and before using for patients.
• Humidifier can be autoclaved to prevent infection.
• Other parts of the equipment should be disinfected using prescribed disinfectant agents. Dry the parts before reassembling them.

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
4. Marcia London, Ruth Bindler, Principles of Paediatric Nursing: Caring for Children, 8th Edition, 2023, Pearson Publications, ISBN-13: 9780136859840
5. Naveen Bajaj, Rajesh Kumar, Manual of Newborn Nursing, 2nd Edition, 2023, Jaypee Publishers, ISBN:978-9354659294
6. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

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