Iowa Neonatology Handbook: Pulmonary

Nasopharyngeal Continuous Positive Airway Pressure (NPCPAP)

A technique of airway management that maintains positive intrapulmonary pressure in the lung during spontaneous breathing.

1. The purpose of Nasopharyngeal CPAP is to reduce the morbidity due to barotrauma and subglottic stenosis from having a neonate intubated and mechanically ventilated because of respiratory failure or apnea.
2. Indications for NPCPAP:
   1. Apnea of Prematurity - obstructive and/or mixed apnea.
   2. Respiratory Distress (i.e., tachypnea, and/or retractions) - RDS, TTN and chronic lung disease (CPIP and BPD).
   3. Weaning from the ventilator.
3. Types of NPCPAP:
   1. Nasopharyngeal Tube - an endotracheal tube whose tip is placed in the nasal pharynx.
      1. Advantages:
         1. May be used on any size infant.
         2. Minimal risk of nasal septum necrosis.
         3. Easy to place infant in any position.
         4. Preferred method at UIHC.
      2. Disadvantages:
         1. May become occluded or plugged with secretions despite suctioning
         2. Higher resistance to spontaneous breathing.
   2. Nasal Prongs:
      1. Advantages:
         1. Easier to apply (less traumatic).
         2. Lower resistance to spontaneous breathing
      2. Disadvantages:
         1. Easily dislodged from nares.
         2. Nasal septal necrosis
         3. Difficult to position infant.
4. Complications of NPCPAP:
   1. Pneumothorax - minimize incidence by using minimal pressure needed to accomplish aims.
   2. Nasal irritation - mucosal swelling or erosion, excessive nasal dilatation or septal necrosis. Minimize by proper positioning of infant and alternating nares every 5 to 7 days.
   3. Abdominal distention and feeding intolerance - Minimize by using continuous drip feeds along with placement of the infant on the stomach or side. Additionally, the placement of an oral gastric tube to straight drain will minimize accumulation of air in the GI tract
5. Management of NPCPAP Pressure - set CPAP at 4-7 cm of H2O pressure, use the previous MAP setting that the infant has been at, before extubation, as a guide (usually 5 cm works well of most infants.)
6. Trouble-shooting while on NPCPAP
   1. Increasing O2 requirement or episodes of desaturation and apnea - "plugged tube." Prevent by routine suctioning,and adequate humidification. If necessary, replace the tube.
   2. Excessive bradycardia with movement - tip of ETT placed in oral rather than nasal pharynx: correct by repositioning tube.
   3. Excessive nasal irritation - move NP tube to the opposite side, change position of infant.
   4. Significant apnea or increasing respiratory acidosis or O2 requirement of 80-100%; NPCPAP failure - intubate and ventilate patient.
7. Weaning off NPCAP:
   1. Oxygen requirement <30%
   2. Decrease CPAP pressure gradually to 4-6 cm and maintain the pressure at this level until tachypnea and retractions have resolved.
   3. If obstructive apnea still occurs after removal of nasal CPAP, you should RESTART the NPCAP and wait until the infant has achieved adequate nutrition with good weight gain and weight is >1000g; if significant apnea reoccurs even on room air, restart NPCPAP and wait a week before weaning off CPAP again.
8. Placement of the NPCPAP tube and care of the neonatal patient on NPCPAP EQUIPMENT:
   • ETT (2.5mm ID)
   • Six Fr suction catheter
   • Water soluble lubricant
   • Adhesive tape - 3/4 or 1 inch wide
   • Hollister spray
   • Stethoscope
   • EKG monitoring equipment
   • O2 source with connecting tube
   • Anesthesia bag
   • Mask
   • Suction source
   1. Procedure:
      1. Insertion:
         1. Prepare equipment:
            1. Thread entire suction catheter through ETT until thumb control is located at the end of the ETT adapter.
            2. Lubricate tip of ETT with water soluble lubricant.
         2. Pass suction catheter nasally as if inserting a nasogastric tube to 10-12 cm. (*See procedure for nasogastric tube placement.) This is to allow for increased ease of nasal ETT insertion. Advance lubricated ETT nasally while maintaining placement of suction catheter.
         3. Depth of placement - Advance ETT to:
            4 cm at naris if weight < 1500 g
            4.5 cm at naris if weight 1500-2000 g
            5 cm at naris if weight > 2000 g
         4. Remove suction catheter, maintaining placement of ETT tube (now called NP tube).
         5. Secure tube with hollister spray and adhesive tape using double "H" technique. One piece over bridge of nose and around tube as an in oral intubation. One piece inverted on lip and around tube. This increases the security of the tube and ensures proper placement; minimizing trauma to mucus membranes.
         6. Connect NP tube to oxygen source per ventilator or anesthesia bag. Per MD order, O2 may be adjusted per oximeter. CPAP setting may be adjusted via blood gas results.
         7. NPCPAP is usually ordered at between 4-7 cm of pressure. Five cm works well for most infants.
         8. Suction NP tubes as indicated (see Endotracheal Tubes, Suctioning of). When ventilating using a resuscitation bag, the infant's mouth must be closed or the mask should be applied to face and infant ventilated/oxygenated per mask.
   2. Precautions, considerations, and observations:
      1. Appropriate NP tube size is usually the same or smaller than that required for intubation.
         < 1500 g = 2.5
         1500-2000 g = 3.0
      2. The above procedure is recommended to increase ease of initial insertion. Subsequent reinsertions may be accomplished the same way or by following procedure for insertion of nasogastric tubes. Placement guidelines should be strictly adhered to in either case.
      3. A physician's order is required to initiate or discontinue NPCPAP. It is recommended that a physician be present for both initial insertion and final removal of NPCPAP tube.
      4. An oral/nasogastric tube should be placed to straight drainage to provide gastric decompression.

References:

Chernick V. Continuous distending pressure in HMD: devices, disadvantages and daring. Pediatrics, 1973;52:114.

Gregory GA, Kitterman JA, Phibbs RH, Tooly WH, Hamilton WK. Treatment of the idiopathic respiratory distress syndrome with continuous positive airway pressure. N Engl J Med, 1971;284:1333.

Higgins RD, Richter SE, Davis JM: Nasal continuous positive airway pressure facilities extubation of very low birth weight neonates. Pediatr 1991;88:999-1003.

Kim EH, Boutwell WC: Successful direct extubation of very low birth weight infants from low intermittent mandatory ventilation rate. Pediatrics, 1987;80:409-414.

Martin RJ, Miller MJ, Carlo WA: Pathogenesis of apnea in preterm infants. J Pediatr, 1986;109:733-741.

Wung JT, Driscoll JM Jr., Epstein RA, Hyman AI. A new device for CPAP by nasal route. Crit Care Med, 1975;3:76.

Kim EH, Boutwell WC. Successful direct extubation of very low birth weight infants from low intermittent mandatory ventilation rate. Pediatrics, 1987;80:409-414.

Higgins RD, Richter SE, Davis JM. Nasal continuous positive airway pressure facilitates extubation of very low birth weight neonates. Pediatrics, 1991;88:999-1003.

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