Continuous Positive Airway Pressure (CPAP) and Non-invasive Ventilation (NIV)

  • Introduction

    Non-invasive respiratory support is a means of providing ventilatory support to children with either upper airway obstruction or respiratory failure.  Respiratory failure constitutes either failure of ventilation or failure of lung function.
    Non-invasive respiratory support encompasses CPAP and Continuous Bi-level Positive Airway Pressure (BPAP).
    Positive pressure respiratory support is delivered via a mechanical ventilation driver utilizing an external interface such as a nasal mask, nasal pillow, full-face or total-face mask.  

    Medical conditions treatable with CPAP or NIV support include but are not limited to:

    • Altered control of breathing (eg: Congenital Central Hypoventilation Syndrome)
    • Neuromuscular weakness (eg: DMD, SMA,)
    • Upper spinal cord injury (partial)
    • Upper airway obstruction – non-acute (eg: tracheobronchomalacia, some craniofacial abnormalities)
    • Chronic Lung Disease (CLD)
    • Obstructive Sleep Apnoea (OSA) 

    Contraindications include but are not limited to:

    • respiratory arrest
    • unstable cardio-respiratory status
    • un-cooperative patient
    • unable to protect airway
    • oral / facial / oesophageal surgery

    Aim

    This Clinical Guideline is intended to assist in the management of infants and children who require medium to long term respiratory support in the form of non-invasive CPAP, BPAP or NPV, but who are otherwise medically stable, as inpatients within The Royal Children’s Hospital.
    Where an individual patient’s clinical requirements fall outside these guidelines, consensus on patient management must be agreed to by the PICU, Respiratory Medicine and other relevant heads of department.

    This guideline does not refer to the management of CPAP or NIV in the neonatal patient.  Please refer to the Newborn Intensive Care Unit.

    Definition of Terms / Abbreviations

    • NIV: Non-Invasive Ventilation
    • NPPV: Non-Invasive Positive Pressure Ventilation
    • CPAP: Continuous Positive Airway Pressure
    • BPAP: Bi-level Positive Airway Pressure
    • IPAP: Inspiratory Positive Airway Pressure
    • EPAP: Expiratory Positive Airway Pressure
    • Mode: The mode in which the ventilatory device is set (see S, ST, T)
    • S: Spontaneous mode, in which the machine/device assists each spontaneous respiratory effort.
    • ST: Spontaneous Timed, where a spontaneous breath is assisted, or a timed mandatory breath is delivered where no respiratory effort is detected.
    • T: Timed mode, in which mandatory breaths are delivered according to a set rate.
    • BPM: Breaths per Minute
    • Ramp: the amount of time taken for the machine to achieve a set inspiratory pressure 
    • I time (Ti): Inspiratory time
    • I:E: represent the ratio of time spent in inspiration compared to expiration
    • Rise Time: the time taken for the driver to reach the set IPAP
    • TiMin: The Minimum time the driver spends in IPAP
    • TiMax: The Maximum time the driver spends in IPAP
    • OSA: Obstructive Sleep Apnoea
    • EtCO2: End-tidal Carbon Dioxide 
    • TcCO2: Transcutaneous Carbon Dioxide
    • Trigger: sensitivity of device/driver to recognise and respond to an inspiratory breath.  
    • Cycle: allows driver/device to recognise when the inspiratory flow is dropping, ventilator changes to allow expiration.  
    • NGT: Nasogastric tube
    • NJT: Nasojejunal tube
    • NPA: Nasopharyngeal airway

    Management - Acute

    A patient who requires CPAP/NIV for the management of acute respiratory failure will require transfer to the Paediatric Intensive Care Unit.  Initiation of this therapy may occur in the Emergency Department or PICU environment.  Stabilization and ongoing management of this therapy should occur in the PICU environment.

    Management – Non-acute

    CPAP can be initiated on the inpatient units, or in outpatients.  NIV can be initiated on inpatient units only. 

    Administration/application

    • Medical orders for initiation of CPAP/NIV must be completed prior to commencement of therapy
    • Titration or changes to CPAP/NIV should only occur with a written medical order.
    • An inpatient receiving CPAP/NIV must be medically reviewed at least daily or more frequently where their requirement for respiratory support changes.

    In established/long-term CPAP/NIV patients, temporary, and minor changes to settings, or an increase in FiO2, may be required for episodes of minor illness or palliation.

    Assessment / Indications

    See the nursing assessment guideline for additional information.  

    When a patient requires CPAP/NIV support and management, consultation with, and referral to the Department of Respiratory and Sleep Medicine is required.

    The condition of the patient should be stable, without an anticipated requirement for frequent adjustments to mechanical ventilation.  

    However, adjustments may be required in:

    • Recovery from a condition when stable
    • Improvement in underlying illness
    • Consequences of growth and development
    • Planned alterations in respiratory therapy

    Physical Assessment / Observations – during therapy

    Patients should receive a complete nursing respiratory assessment at least once at the commencement of each shift, where the patient’s respiratory status changes, or where CPAP/NIV settings are adjusted.

    Monitor patient for and document hourly on EMR, in the Ventilator Pressures row, under Observations:

    • Level of consciousness
    • Breath rate, pattern, and effort
    • Heart rate
    • Use of accessory muscles
    • Oxygen requirement
    • Pulse oximetry
    • Compliance/comfort with therapy
    • Patient respiratory synchronization with bi-level ventilation

    Mechanical Driver/Device Assessment / Observations

    At the commencement of each nursing shift the ventilator settings should be checked against the medical orders and documented on EMR, in the Ventilator Pressures row, under Observations.

    Monitor device each shift or when resuming treatment

    • Ventilation Settings:
      • Mode
      • Inspiratory Pressure
      • Expiratory Pressure
      • Rate
      • Inspiratory Time
      • TiMin / TiMax
      • Trigger
      • Ramp
      • Cycle
    • Alarm settings
    • Synchronization of device with patient respirations when on bi-level NIV in S, T and ST mode
    • Battery back-up (as required)
    • Secondary driver/device back-up (as required)

    Oxygen therapy

    • Oxygen supply appropriately connected
    • FiO2 / Oxygen flow rate
    • Nasal prong oxygen for patients receiving NPV
    • Oxygen Analyzer calibrated to FiO2 of 0.21 (low) and 0.50 (high)
    • Interface and Circuit
    • Mask fit  and leak
    • Curaiss/Collar fit  and leak
    • Pressure areas from mask / strapping
    • CO2 exhalation port present and patent
    • Anti-asphyxiation port insitu and patent full face and total face mask
    • Circuit patency

    Humidification

    • Humidifier settings
    • Humidifier alarms
    • Heat adaptor wire and temperature probe (MR850 only)
    • Device specific humidifier
    • Humidifier chamber water level
    • Excess condensation in circuit (‘rain out’)

    Ongoing assessment

    The Respiratory and Sleep Medicine Consultant, or their delegate, is responsible for arranging assessment and documentation of ongoing CPAP/NIV requirements.

    Inpatient Care Needs

    • All NIV must be initiated and supervised by competent medical and nursing staff. 
    • All NIV inpatients should receive care coordination from a nurse care manager.
    • Allied health providers should be engaged dependant on individual patient requirements.

    Investigations

    • Blood gas analysis may need to be performed PRN.
    • TcCO2 or EtCO2 monitoring may need be performed as clinically indicated
    • Downloadable pulse oximetry PRN.
    • Sleep studies in select patients prior to discharge, and in most patients after discharge, with timing to be determined by treating physician.

    Hygiene

    • Increased need for regular oral hygiene.
    • Increased need for pressure area assessment and skin care.

    Nutrition

    • Enteral feeds can be administered during periods of CPAP/NIV. However carers should be mindful of the increased risk of abdominal distension and need for increased venting/aspiration of nasogastric (NGT) or other gastrostomy tubes.
    • Time spent on NIV may impinge on the patient’s ability and opportunity to take adequate nutrition and/or fluids orally. Therefore alternate feeding methods may need to be used.

    If the patient has an NGT, a nasojenunal tube (NJT) or a nasopharyngeal airway (NPA) insitu there is an increased risk of pressure area formation and leak. 

    Safety

    • The patient receiving any form of CPAP/NIV needs to be medically assessed for their capacity to self ventilate adequately in case of ventilator, circuit or interface failure.  Where a patient cannot self ventilate adequately there should be provision for the immediate availability of a backup mechanical device/driver, battery, circuit and interface.
      • Document start of shift primary and secondary patient survey
      • Complete standard bedside safety checks
      • Check that ventilator settings correlate with documented medical orders
      • Familiarize yourself with equipment checklist at the start of shift 

    If documented or correlating medical orders are not present, seek medical input. 

    Ongoing management

    Potential Complications – Clinical

    • Pneumothorax
    • Decreased cardiac output
    • Gastric distension
    • Mucus plugging
    • Secretion build up inside mask
    • Oral and Nasal dryness
    • Eye irritation from air leak
    • Nasal congestion
    • Aspiration
    • Abdominal distension
    • Pressure areas from mask, tubing and strapping
    • Pressure areas from nasogastric tubing

    Potential Complications - Mechanical

    • Inadequate ventilation (ie: hypoxaemia, hypercapnoea)
    • Overventilation (ie. hypocapnoea) 
    • Mechanical failure of ventilation delivery device
    • Mechanical failure of humidification device
    • Non ‘synchronisation’ with device
    • Interface leak, damage and misfit
    • Circuit leak and damage
    • Inadequate humidification
    • Change in FiO2 related to leak or change in minute volume

    Complications/troubleshooting

    • Assess patient for adequacy of airway and breathing / ventilation
    • Troubleshoot interface, circuit and device
    • Seek medical review when necessary
    • During hours contact on-call respiratory fellow, respiratory consultant, respiratory nurse, or clinical technologist.
    • After hours contact on-call respiratory fellow, after hours clinical support nurse, respiratory consultant on call, or PICU medical staff/clinical technologist.

    Education (patient, parent and care-giver)

    • NIV and CPAP via tracheostomy: Education for patients and caregivers will be coordinated by the Clinical Technologist.
    • Mask CPAP: Education for patients and caregivers will be coordinated by the Respiratory Nurse Consultant.
    • Reinforcement of education for parents and caregivers will be provided by suitably competent ward nurses, supporting the education programmes of the Clinical Technologist and Respiratory nurse.  

    Education needs (Nurse)

    • Nurses caring for patients on NIV should have successfully completed The Royal Children’s Hospital Mechanical Ventilation and NIV Ventilation competencies or their equivalent.

    Discharge planning and community-based management

    • Weekly ventilation group meetings.
    • Education from Respiratory Nurses or Clinical Technologists.
    • Referral to Complex Care support.

    Follow-up / Review 

    • Daily medical review by home team with consultation as required by the Respiratory Team
    • Ventilation orders should be medically reviewed daily
    • Parent/Carer should be given a hard copy of CPAP/NIV medical order prior to discharge.

    Special considerations

    Infection Control

    • Change / clean circuit weekly or PRN
    • Clean mask daily or PRN
    • Refresh water daily (wash & air dry humidifier reservoir on applicable drivers as per home care plan)
    • Use bottled sterile water for irrigation or 1 litre I.V.I. sterile water

    Patient Safety Alerts

    • Presence of CO2 exhalation port on interface
    • Presence of anti-asphyxiation valve on full and total face masks
    • Patient ability to self ventilate in event of power, device, circuit or interface failure

    Home Circuits/Equipment

    Unless otherwise indicated, patients who are managed on CPAP/NIV in the home environment will use reusable ventilation circuits.
      
    If patients are to be discharged home on CPAP/NIV they should use the home (reusable) circuit for at least one to two nights prior to discharge in order that compliance and efficacy can be assessed.  

    When managed as inpatients, unless otherwise indicated, patients receiving CPAP/NIV should be managed on disposable circuits.

    Where patients who are established on long-term NIV are readmitted they should use their home driver and equipment, unless otherwise clinically indicated.

    Companion documents

    RCH Nursing Competency documents

    Links

    Nursing Guidelines and Clinical Practice Guidelines (CPG)

    Parent/Carer Information

    References

    • Annane D, Orlikowski D, Chevret S, Chevrolet J, & Raphaël J. (2007). Nocturnal mechanical ventilation for chronic hypoventilation in patients with neuromuscular and chest wall disorders. Cochrane database of systematic reviews. Issue 4. Art No: CD001941.
    • Bhalla, A., Newth, C., and Khemani, R.  (2015)  Respiratory Support in Children. Paediatrics and Child Health 25:5 pp214-221
    • Dehlink, E and Tan, H. (2016).  Update on Paediatric Obstructive Sleep Apnoea. Journal of Thoracic Disease. Feb 8(2):224-235
    • Fauroux, B., Aubertin, G., Lafaso, F.  (2008) European Respiratory Monograph, 41, 272-286.
    • Hammer, J. (2013) Acute Respiratory Failure in Children.  Paediatric Respiratory Reviews 14, pp64-69
    • Kaditis et al.  (2016).  Obstructive Sleep Disordered Breathing in 2 to 18 Year Old Children:  Diagnosis and Management.  European Respiratory Journal.  Jan:47(1):69-94 
    • Marcus, CL. Radcliffe, J. Konstantinopoulou, S. Beck, SE. Cornaglia, A. Traylor, J. DiFeo, N. Karamessinis, LR. Gallagher, PR. Meltzer, LJ. (2012) Effects of positive airway pressure therapy on neurobehavior outcomes in children with obstructive sleep apnea. American Journal of Respiratory Critical Care Medicine 185(9):998-1003.
    • Pham, L. and Schwartz, A. (2015).  The Pathogenesis of Obstructive Sleep Apnoea.  Journal of Thoracic Disease. Aug: 7(8) pp1358-72
    • Ventilatory Support at Home for Children (2008).  A Consensus Statement from the Australian Paediatric Respiratory Group.  The Thoracic Society of Australia and New Zealand.
    • Wallis, C. Patton, JY. Beaton, S. Jardine, E. (2011) Children on long term ventilatory support: 10 years of progress. Archives of Disease in Childhood. 96(11):998-1002.


    Evidence table 

    The evidence table for this guideline can be found here. 


    Please remember to read the disclaimer


    The development of this nursing guideline was coordinated by John Kemp, Clinical Nurse Facilitator, Sugar Glider, and approved by the Nursing Clinical Effectiveness Committee. Updated October 2018.