Position the infant with the head of the bed elevated approximately 15-30 degrees. Place a small roll under the infant’s shoulders maintaining a “sniffing” position to keep the airway open
An Orogastric tube (OG) is always in place when an infant is on any NIV form of ventilation because the OG tube vents/removes excessive air delivered from the NIV devices from the stomach
If an Orogastric tube (OG) is incorrectly placed or not placed at all and infant is on any form of NIV, it can lead to:
Decrease digestion of food
Stomach distension
Increase of residual feed from the stomach
Compression of the lungs
Increase work of breathing
Increase chance of NEC (Necrotizing Enterocolitis)
Signs and/or symptoms of an infant not tolerating NIV CPAP or NIV CPAP with a rate:
Increased heart rate
Increased respiratory effort
Increased oxygen requirement
Increased retractions
Increased apnea
Increased feeding residual
Decreased CPAP “roar”
Increased stomach distension
Selecting Flex Trunk Size
The CPAP Flex Trunk SHOULD NOT extend pass the infant’s head
CPAP Bonnet or Headgear
Obtain the infant’s FOC (Frontal-Occipital Circumference)
CPAP hat or headgear changes usually occur on Sunday night shift
The bonnet should rest at the infant’s brow line
Make sure that the infant’s ears are lying flat against the head
Tie the top of the bonnet once in place. This will prevent the bonnet from slipping on down the infants head
Selecting Prong Or Mask Size
Use the sizing guide
The nasal prongs should be large enough to create a seal without causing blanching
Nasal prongs should fit snuggly in the nares curved side down
Avoiding direct pressure on the front of the septum and the upper lip area. Prongs should maintain”floating” position
The extra risers in the Flexi trunk kits can be used to maintain proper prong placement
After placement, check the infant’s skin for redness or blanching and assess CPAP sounds
You should hear a CPAP “roar” should be heard throughout both lung fields when listening to an infant on NIV CPAP or NIV CPAP with a rate
Chin Straps
Can be used to aid with the keeping the infant’s mouth closed with CPAP ventilation
Posey ties in the NICU neo mart can be cut down to fit the infant’s face
Key Points with Chin Straps:
Avoid over tightening of the Posey chin strap
More air will go to the infant’s stomach when using a chin stap, venting the stomach is very important
Assess the infant stomach. Look for “loopy” bowels and note if the stomach is firm, alert the nurse as necessary
Chin straps DO NOT prevent apnea. If apnea is excessive despite dosing with caffeine, consult the nurse and notify the Neonatologist or Nurse Practitioner
Draeger
NIV modes of ventilation
SPN-CPAP
PC-CMV
To change Draeger ventilator from an invasive mode of ventilation to a NIV mode of ventilation
The infant is taken off the ventilator
The ventilator is placed in the Standby mode
From the Standby screen select NIV. The parameter will highlight dark green
At the top of the ventilator screen, tap the word Standby in the orange highlight section of the ventilator screen
Key Points
Maximum flow rate on the Draeger ventilator in the NIV mode is 30 LPM
Draeger is an UNCOMPENSTATED ventilator, what you set is what you get so confirm ventilator settings and the infant’s return PIP
Example: 20/6x20= PIP 20
In the NICU, PC-CMV NIV CPAP with the Draeger ventilator is used rather than NIV Pressure Control on Servo-I because:
The Draeger ventilator has an external flow sensor which is removed from the ventilator circuit when utilizing the NIV modes of ventilation. Without the flow sensor in place the ventilator cannot trigger on infant’s respiratory effort
The Servo-I utilizes an internal flow sensor. When the infant is on the NIV Pressure Control mode of ventilation, because of the internal sensor, the ventilator will trigger a breath on the infant’s respiratory effort
Servo-I
NIV modes of ventilation on the Servo-I ventilator
Nasal CPAP
NIV NAVA
NIV PS
NIV Pressure Control
To change Servo-I ventilator from an invasive mode of ventilation to a Nasal CPAP mode of ventilation:
The infant is taken off the ventilator
The ventilator is placed in the Standby mode
Select NIV
From the NIV selection screen select Nasal CPAP
Key Points
The patient should not be on NIV Pressure Control, if they are inform the MD/NNP:
The incorrect mode of ventilation on the Servo-I is being used. The mode change is Invasive SIMV Pressure Control + Pressure Support for NIV ventilation should be ordered
The flow sensor is located internally because of this the ventilator will support every breath from the infant
If the Infant breaths between 40-60 times a minute an inadvertent, severe decrease in CO2 could occur
SIMV Pressure Control+Pressure Support (Invasive mode)is used for NIV ventilation with a backup rate on the Servo-I in the NICU
The Servo-i is a COMPENSATED ventilator, (do the math)