In this section
Continuous Positive Airway Pressure (CPAP) is a means of providing respiratory support to neonates with either upper airway obstruction or respiratory failure. Respiratory failure constitutes either failure of ventilation or failure of lung function.
CPAP delivers oxygen concentrations and distending airway pressures via the ventilator without the hazards associated with full endotracheal intubation and mechanical ventilation. The delivery of constant positive pressure to the airway of a spontaneously breathing neonate maintains adequate functional residual capacity within the alveoli to prevent atelectasis and improves oxygen and carbon dioxide exchange within the pulmonary circulation.
This guideline is intended to assist in the management of neonates requiring CPAP on the Newborn Intensive Care Unit (Butterfly Ward) at the Royal Children’s Hospital.
This guideline does not include management of a nasopharyngeal tube (NPT) for infants with Pierre Robin Sequence, when the NPT is used to relieve upper airway obstruction. Refer to the separate guideline titled “Nasopharyngeal Tube Modified for Pierre Robin Sequence”.
A medical order is required to initiate CPAP, to alter the amount of CPAP delivered, and to discontinue CPAP. These should be documented by the medical officer.
CPAP commencement and ongoing care is the responsibility of the infant's nurse, with the assistance of a second nurse.
This should be undertaken in discussion with the NICU consultant. The usual range of settings is
5-8cmH2O, however in some clinical conditions (e.g. bronchiolitis, severe chronic lung disease and tracheal issues) higher CPAP up to 12-14cmH2O may be ordered by the NICU consultant. An increase in CPAP may be required from the
initial setting if work of breathing, respiratory rate, oxygen requirement, and underlying lung pathology deteriorate.
Commonly the measured CPAP pressure will be lower than the set pressure because of CPAP attenuation within the interface and leak. In general, both should be documented in the EMR Flowsheets and the delivered pressure should not be targeted beyond the usual care of the patient
(e.g. repositioning the patient or interface, and being aware of leak through the patient’s mouth). If the clinical situation determines that a specific delivered CPAP pressure should be targeted, the medical officer should document this in the CPAP order along with the range for the maximum and minimum CPAP
pressures that are acceptable.
CPAP is usually weaned in increments of 1cmH2O every 12-24 hours. The timing and rate of weaning will be decided by either the NICU consultant or fellow, in discussion with the infant’s nurse. The factors to consider when deciding to wean the CPAP include work of breathing, respiratory rate, oxygen requirement, and underlying lung pathology.
When the infant has demonstrated a stable respiratory pattern on CPAP of 5cmH2O in
<30% FiO2 for 12-24 hours, the CPAP may be removed. In some circumstances it may be appropriate to cease CPAP at a higher CPAP level (e.g. older, larger infants). This decision should be discussed with the NICU medical team before
the CPAP is removed from the infant. At times, the NICU medical staff, in discussion with the nurse, may decide to electively change the infant from CPAP to High or Low Flow Nasal Cannulae Oxygen, if deemed appropriate (this requires a medical order).
CPAP devices used on Butterfly Ward are:
CPAP is not delivered via full endotracheal tube for neonates on the Butterfly Ward.
The decision of whether to use a SNP or FlexiTrunk© is a combined medical and nursing decision. If there are specific clinical indications for a particular interface, medical staff should document this on the CPAP order.
FlexiTrunk©, alternate between nasal prongs and mask
Consider HFNC if appropriate
Reduces attenuation of pressure
Better continuity of CPAP
Better continuity of CPAP
Avoid CPAP (particularly higher settings) if possible. Consider HFNC.
If used SNP may be better tolerated in older infants.
Important Note: In neonates with upper airway
obstruction e.g. neonate with Pierre Robin Sequence (PRS), insertion length
differs in that the tube bypasses the obstruction. Consult medical staff for
clarification if required. A SNP inserted too deeply will cause the infant to
gag or will produce bradycardic episodes from vagal stimulation.
For further information refer to
Nasopharyngeal Tube (NPT) Modified for PRS RCH nursing guideline.
FlexiTrunk© – Infant Interface Set-up Guide
Click here to view the Evidence Table for this guideline.
Please remember to read the
The development of this nursing guideline was coordinated by Sophie Woolger, RN, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated February 2020.