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## Complete Summary

#### GUIDELINE TITLE

Application of continuous positive airway pressure to neonates via nasal
prongs, nasopharyngeal tube, or nasal mask --- 2004 revision & update.

#### BIBLIOGRAPHIC SOURCE(S)

American Association for Respiratory Care. Application of continuous
positive airway pressure to neonates via nasal prongs, nasopharyngeal
tube, or nasal mask\--2004 revision & update. Respir Care 2004
Sep;49(9):1100-8. \[113 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American Association for
Respiratory Care (AARC). AARC clinical practice guideline. Application
of continuous positive airway pressure to neonates via nasal prongs or
nasopharyngeal tube. Respir Care 1994 Aug;39(8):817-23.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Impaired pulmonary function that may occur with:

-   Respiratory distress syndrome

-   Pulmonary edema

-   Atelectasis

-   Apnea of prematurity

-   Recent extubation

-   Tracheal malacia or other similar abnormality of the lower airways

-   Transient tachypnea of the newborn

#### GUIDELINE CATEGORY

Treatment

#### CLINICAL SPECIALTY

Pediatrics\
Pulmonary Medicine

#### INTENDED USERS

Respiratory Care Practitioners

#### GUIDELINE OBJECTIVE(S)

-   To improve the consistency and appropriateness of respiratory care
    and serve as a guide for education and research

-   To provide clinical practice guidelines on the application of
    continuous positive airway pressure to neonates and infants by nasal
    prongs (NCPAP), nasopharyngeal tube (NP-CPAP), or infant nasal mask
    (NM-CPAP)

#### TARGET POPULATION

Neonates and infants requiring the application of continuous positive
airway pressure

#### INTERVENTIONS AND PRACTICES CONSIDERED

The application of continuous positive airway pressure to neonates and
infants by nasal prongs (NCPAP), nasopharyngeal tube (NP-CPAP), or
infant nasal mask (NM-CPAP) administered with a commercially available
circuit used in conjunction with a continuous-flow source, infant
ventilator, or a suitably equipped multipurpose ventilator

#### MAJOR OUTCOMES CONSIDERED

Therapeutic efficacy of CPAP

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Consultants to the Working Group may review the initial draft of the
guideline. After completion by the Working Group, the draft is reviewed
by the entire Steering Committee and then by a Review Panel (i.e.,
persons engaged in all facets of the delivery of respiratory care who
have volunteered to review drafts of the Guidelines before publication).

The 2004 update was approved by the 2003 Clinical Practice Guideline
(CPG) Steering Committee.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Procedure**

The application of continuous positive airway pressure to neonates and
infants by nasal prongs (NCPAP), nasopharyngeal tube (NP-CPAP), or
infant nasal mask (NM-CPAP) administered with a commercially available
circuit used in conjunction with a continuous flow source, infant
ventilator, or a suitably equipped multipurpose ventilator

**Description/Definition**

Continuous positive airway pressure (CPAP) is the application of
positive pressure to the airways of the spontaneously breathing patient
throughout the respiratory cycle. For the most part, neonates are
preferential nose breathers, which easily facilitates the application of
nasal CPAP. This is accomplished by inserting nasopharyngeal tubes,
affixing nasal prongs, or fitting a nasal mask to the patient. The
device provides heated and humidified continuous or variable flow from a
circuit connected to a continuous gas source, mechanical ventilator
designed for neonates, or a suitably equipped multipurpose ventilator,
set in the CPAP mode.

CPAP maintains inspiratory and expiratory pressures above ambient
pressure, which should result in an increase in functional residual
capacity (FRC) and improvement in static lung compliance and decreased
airway resistance in the infant with unstable lung mechanics. This
allows a greater volume change per unit of pressure change (i.e.,
greater tidal volume for a given pressure change) with subsequent
reduction in the work of breathing and stabilization of minute
ventilation (V~E~). CPAP increases mean airway pressure, and the
associated increase in FRC should improve ventilation-perfusion
relationships and potentially reduce oxygen requirements. Additionally
CPAP may expand, or stent, upper airway structures preventing collapse
and upper airway obstruction.

**Settings**

NCPAP, NP-CPAP, and NM-CPAP are applied by trained personnel in acute
and subacute care hospitals.

**Indications**

-   Abnormalities on physical examination\--the presence of increased
    work of breathing as indicated by an increase in respiratory rate of
    \>30% of normal, substernal and suprasternal retractions, grunting,
    and nasal flaring; the presence of pale or cyanotic skin color and
    agitation

-   Inadequate arterial blood gas values\--the inability to maintain a
    P~aO2~ greater than 50 torr with F~IO2~ of [\<]{.underline}0.60
    provided V~E~ is adequate as indicated by a P~aCO2~ level of 50 torr
    and a pH [\>]{.underline}7.25

-   The presence of poorly expanded and/or infiltrated lung fields on
    chest radiograph

-   The presence of a condition thought to be responsive to CPAP and
    associated with one or more of the clinical presentations described
    above:

    -   Respiratory distress syndrome

    -   Pulmonary edema

    -   Atelectasis

    -   Apnea of prematurity

    -   Recent extubation

    -   Tracheal malacia or other similar abnormality of the lower
        airways

    -   Transient tachypnea of the newborn

-   Early intervention in conjunction with surfactant administration for
    very low birth weight infants at risk for developing respiratory
    distress syndrome

-   The administration of controlled concentrations of nitric oxide in
    spontaneously breathing infants

**Contraindications**

Refer to the \"Contraindications\" field or see the original guideline
document.

**Hazards/Complications**

Refer to the \"Potential Harms\" field or see the original guideline
document.

**Limitations of Device**

-   NCPAP, NP-CPAP, and NM-CPAP applications are not benign procedures,
    and operators should be aware of the possible hazards and
    complications and take all necessary precautions to ensure safe and
    effective application.

-   Mouth breathing during NCPAP, NP-CPAP, and NM-CPAP may result in
    loss of desired pressure and decrease in delivered oxygen
    concentration.

-   NCPAP harnesses and attachment devices are often cumbersome and
    difficult to secure and may cause agitation and result in
    inadvertent decannulation.

-   Excessive head rotation or neck extension may alter the position of
    NP-CPAP tube placement or obstruct upper airway structures resulting
    in diminished or altered pressure, flow, and effective CPAP.

-   Severe respiratory distress syndrome (RDS), septicemia during NCPAP
    administration, and pneumothorax are risk factors associated with
    NCPAP failure.

**Assessment of Need**

Determination that valid indications are present by physical,
radiographic, and laboratory assessments

**Assessment of Outcome**

CPAP is initiated at levels of 4-5 cm H~2~O and may be gradually
increased up to 10 cm H~2~O to provide the following

-   Stabilization of F~IO2~ requirement [\<]{.underline}0.60 with P~aO2~
    levels \>50 torr and/or the presence of clinically acceptable
    noninvasive monitoring of oxygen (P~tcO2~), while maintaining an
    adequate V~E~ as indicated by P~aCO2~ of 50-60 torr or less and pH
    [\>]{.underline}7.25

-   Reduction in the work of breathing as indicated by a decrease in
    respiratory rate by 30-40% and a decrease in the severity of
    retractions, grunting, and nasal flaring

-   Improvement in lung volumes and appearance of lung as indicated by
    chest radiograph

-   Improvement in patient comfort as assessed by bedside caregiver

-   Clinically significant reduction in apnea, bradycardia, and cyanosis
    episodes

**Resources**

-   Equipment

    -   Endotracheal tubes (positioned in the nasopharynx and secured by
        taping, with placement verified by laryngoscopy or palpation) or
        commercially available nasal prongs, bilateral nasopharyngeal
        tubes, or specially designed nasal masks with accompanying
        harness and accessories may be used for CPAP administration

        -   Unilateral nasopharyngeal prongs may be less effective in
            preventing extubation failure than bilateral short prongs.

    -   Continuous flow air-oxygen gas source; commercially available
        continuous-flow infant ventilators equipped with CPAP mode; CPAP
        flow driver with fluidic nasal interface, or suitably equipped
        multipurpose ventilator, with integrated or adjunct low and high
        airway pressure alarms, oxygen concentration analyzer with low
        and high alarms, loss of power and gas source alarms.

        -   A continuous gas flow source requires a mechanical pressure
            limiting device, or a flow or threshold resistor, which
            includes the use of an underwater threshold resistor (e.g.,
            Bubble CPAP).

    -   Lightweight CPAP or ventilator circuits with servo-regulated
        humidification system

    -   Continuous noninvasive oxygenation monitoring by pulse oximetry
        or transcutaneous monitor with high and low alarm capabilities
        is recommended (continuous transcutaneous CO~2~ monitoring may
        also be utilized).

    -   Continuous electrocardiographic and respiratory rate monitor,
        with high and low alarm capabilities, is recommended.

    -   Suction source, suction regulator, and suction catheters for
        periodic suctioning to assure patency of nasal passages and of
        endotracheal tubes used for NP-CPAP are necessary.

    -   Resuscitation apparatus with airway manometer and masks of
        appropriate size should be available.

    -   Gastric tube for periodic decompression of stomach and chest
        tubes should be available.

-   Personnel: The application of NCPAP, NP-CPAP, and NM-CPAP should be
    performed under the direction of a physician by trained personnel
    who hold a recognized credential (e.g., CRT, RRT, RN) and who
    competently demonstrate:

    -   Proper use, understanding, and mastery of the technical aspects
        of CPAP devices, mechanical ventilators, and humidification
        systems

    -   Knowledge of ventilator management and understanding of neonatal
        airway anatomy and pulmonary physiology

    -   Patient assessment skills, with an understanding of the
        interaction between the CPAP device and the patient and the
        ability to recognize and respond to adverse reactions and
        complications

    -   Knowledge and understanding of artificial airway management,
        training in the procedures of placing endotracheal tubes in the
        nasopharynx

    -   The ability to interpret monitored and measured blood gas values
        and vital signs

    -   The application of Standard Precautions

    -   Proper use, understanding, and mastery of emergency
        resuscitation equipment and procedures

    -   The ability to assess, evaluate, and document outcome

**Monitoring**

-   Patient-ventilator system checks should be performed at least every
    2 to 4 hours and should include documentation of mechanical
    settings, alarms, and patient assessments as recommended by the
    American Association for Respiratory Care Clinical Practice
    Guideline (AARC CPG) Patient-Ventilator System Checks (MV-SC) and
    the CPG Humidification during Mechanical Ventilation (HMV).

-   Oxygen and carbon dioxide monitoring, including:

    -   Periodic sampling of blood gas values by arterial, capillary, or
        venous route

    -   Continuous noninvasive blood gas monitoring by transcutaneous
        O~2~ and CO~2~ monitors

    -   Continuous noninvasive monitoring of oxygen saturation by pulse
        oximetry

-   Continuous monitoring of electrocardiogram and respiratory rate

-   Continuous monitoring of proximal airway pressure (P~aw~), positive
    end-expiratory pressure (PEEP), and mean airway pressure (P~aw~)

-   Continuous monitoring of F~IO2~

-   Periodic physical assessment of breath sounds and signs of increased
    work of breathing (see \"Indications\" section above)

-   Periodic evaluation of chest radiographs

-   Periodic assessment of nasal septum

**Frequency**

NCPAP, NP-CPAP, and NM-CPAP are intended for continuous use and are
discontinued when the patient\'s clinical condition improves as
indicated by successful outcome assessments (see \"Assessment of
Outcome\" section above).

**Infection Control**

No special precautions are necessary, but Standard Precautions as
described by the Centers for Disease Control and Prevention should be
employed.

-   Disposable nasal CPAP kits are recommended and are intended for
    single-patient use.

-   Routine disposable circuit changes are unnecessary for infection
    control purposes when the humidifying device is other than an
    aerosol generator.

-   External surfaces of ventilator should be cleaned according to the
    manufacturer\'s recommendations when the device has remained in a
    patient\'s room for a prolonged period, when soiled, when it has
    come in contact with potentially transmittable organisms, and after
    each patient use.

-   Sterile suctioning procedures should be strictly adhered to.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Appropriate utilization of continuous positive airway pressure
    (CPAP) in neonates and infants

-   Improved pulmonary function and clinical status with application of
    continuous positive airway pressure

#### POTENTIAL HARMS

Hazards and complications associated with equipment include the
following:

-   Obstruction of nasal prongs from mucus plugging or kinking of
    nasopharyngeal tube may interfere with delivery of continuous
    positive airway pressure (CPAP) and result in a decrease in F~IO2~
    through entertainment of room air via opposite naris or mouth.

-   Inactivation of airway pressure alarms

    -   Increased resistance created by turbulent flow through the small
        orifices of nasal prongs and nasopharyngeal tubes can maintain
        pressure in the CPAP system even when decannulation has
        occurred. This can result in failure of low airway
        pressure/disconnect alarms to respond.

    -   Complete obstruction of nasal prongs and nasopharyngeal tubes
        results in continued pressurization of the CPAP system without
        activation of low or high airway pressure alarms.

-   Activation of a manual breath (commonly available on infant
    ventilators) may cause gastric insufflation and patient discomfort
    particularly if the peak pressure is set inappropriately high.

-   Insufficient gas flow to meet inspiratory demand resulting in a
    fluctuating baseline pressure and an increase in the work of
    breathing

-   Excessive flow results in overdistension from increased work of
    breathing due to incomplete exhalation and inadvertent positive
    end-expiratory pressure (PEEP) levels.

-   Decannulation or malpositioning of prongs or nasopharyngeal tubes
    causing fluctuating or reduced CPAP levels

-   Aspiration or accidental swallowing of small pieces of the
    detachable circuit or nasal device assembly

-   Nasal excoriation, scarring, pressure necrosis, and septal
    distortion

-   Skin irritation of the head and neck from improperly secured bonnets
    or CPAP head harnesses

Hazards and complications associated with the patient\'s clinical
condition include:

-   Lung overdistension leading to:

    -   Air leak syndromes

    -   Ventilation-perfusion mismatch

    -   CO~2~ retention and increased work of breathing

    -   Impedance of pulmonary blood flow with a subsequent increase in
        pulmonary vascular resistance and decrease in cardiac output

    -   Gastric insufflation and abdominal distention potentially
        leading to aspiration

    -   Nasal mucosal damage due to inadequate humidification

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   Although application of continuous positive airway pressure to
    neonates and infants by nasal prongs (NCPAP), nasopharyngeal tube
    (NP-CPAP), and infant nasal mask (NM-CPAP) have been used in
    bronchiolitis, this application may be contraindicated.

-   The need for intubation and/or mechanical ventilation as evidenced
    by the presence of

    -   Upper airway abnormalities that make NCPAP, NP-CPAP, or NM-CPAP
        ineffective or potentially dangerous (e.g., choanal atresia,
        cleft palate, tracheoesophageal fistula)

    -   Severe cardiovascular instability and impending arrest

    -   Unstable respiratory drive with frequent apneic episodes
        resulting in desaturation and/or bradycardia

    -   Ventilatory failure as indicated by the inability to maintain
        P~aCO2~ \<60 torr and pH \>7.25

-   Application of NCPAP, NP-CPAP, or NM-CPAP to patients with untreated
    congenital diaphragmatic hernia may lead to gastric distention and
    further compromise of thoracic organs.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness\
Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

American Association for Respiratory Care. Application of continuous
positive airway pressure to neonates via nasal prongs, nasopharyngeal
tube, or nasal mask\--2004 revision & update. Respir Care 2004
Sep;49(9):1100-8. \[113 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1994 Aug (revised 2004 Sep)

#### GUIDELINE DEVELOPER(S)

American Association for Respiratory Care - Professional Association

#### SOURCE(S) OF FUNDING

American Association for Respiratory Care (AARC)

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Author*: Mike Czervinske, RRT-NPS, University of Kansas Medical
Center, Kansas City, Kansas

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American Association for
Respiratory Care (AARC). AARC clinical practice guideline. Application
of continuous positive airway pressure to neonates via nasal prongs or
nasopharyngeal tube. Respir Care 1994 Aug;39(8):817-23.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American Association for Respiratory Care (AARC) Web
site](http://www.rcjournal.com/contents/09.04/09.04.1100.pdf).

Print copies: Available from the American Association for Respiratory
Care (AARC), CPG Desk, 11030 Ables Ln, Dallas, TX 75229-4593; Web site:
[www.aarc.org](http://www.aarc.org/).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on November 30, 1998. The information
was verified by the guideline developer on December 15, 1998. This NGC
summary was updated by ECRI on March 22, 2005.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

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Date Modified: 11/3/2008