Respiratory System Disorders Care Guide

- Prepared by

NICU guide

Under supervision

- Prof. Dr. Mohamed Latif, CEO of the Egyptian Health Council

 Dr. Kawthar Mahmoud, Head of the Egyptian Nursing Syndicate - Member of the Senate

 

Prepared by 

Title	Name	NO.
Dean Of Faculty Nursing, Professor of Medical and Surgical Nursing, Tanta University	Dr Afaf Abdel Aziz Abdel Aziz Basal	1
Professor Of Critical Care Nursing	Prof.Dr/Zeinab Hussain Ali	2
Professor And Head of the Department of Medical Surgical Nursing. Faculty-. Benha University	Amal Said Taha Refaie	3
Supervisor Of the Education Sector at Port Said University	Amal Ahmed Khalil Morsy	4
Professor Of Medical Surgical Nursing- Faculty of Nursing- Cairo University	Dr. Hanan Ahmed Al Sebaee	5
Head of central administration on secondment at MOHP	Dr Neveen ab drab al0nabi Mohamed	6
Director Of Primary Health Care Nursing Department at MOHP.	Maysa Hosny Ahmed Tammam	7
Supervisor Of Technical Education- EHA	Nancy Alaa Eldeen Abd-Elbaset Ali	8
Supervisor Of Nursing Services Development- EHA	Sherien Mohamed Saad	9
Assistant Professor of Maternity and Neonatal Health Nursing - Faculty of Nursing- Ain Shams University	Assist.Perof. Dr./Heba Mahmoud Mohammed	10
General manager of general administration of health institutes affairs	Dr Mai Galal Ibrahim Al-Assal	11
Participants
Professor of Obstetrics and Gynecology Nursing	Dr. Nagat Salah Shalabi Salama	12
member of the Nursing administration at EHA, port said branch	Mrs. Shaima Abdel Basset Ibrahim Salim	13
member of the Nursing administration at EHA, port said branch	Mrs. Hoda Al-Sayd Muhammad	14
member of the Nursing administration at EHA, port said branch	Mrs. Walaa Ahmed Ali	15
member of the Nursing administration at EHA, port said branch	Mrs. Omnia Abdel Qader Muhammad	16
member of the Nursing administration at EHA- South Sinai   branch	Mrs. Yasser Abdel Karim Omar Abdel Jawad	17

- Oxygen Therapy

Oxygen is used as an essential treatment for acute respiratory problems and to prevent the harmful effects that may result from inadequate oxygen delivery to the infant’s tissues, particularly the brain. Oxygen is considered a medical therapy for neonates suffering from respiratory distress; therefore, the oxygen flow rate and concentration must be administered strictly according to the physician’s orders. The nurse is responsible for continuous monitoring to prevent complications resulting from either insufficient or excessive oxygen therapy.

Indications for Use:

• Documented hypoxemia based on arterial blood gas (ABG) results.
• Postnatal resuscitation and cardiopulmonary resuscitation.
• Respiratory distress associated with cyanosis.
• Management of functional impairments of body systems resulting from reduced tissue oxygenation (shock).
• Recurrent episodes of apnea.

Signs of Hypoxemia:

• Increased respiratory rate
• Chest retractions
• Grunting during expiration
• Rapid, shallow breathing
• Recurrent episodes of apnea
• Cyanosis (bluish discoloration of the skin)

Methods of Oxygen Administration in Neonatal Care Units:

Oxygen may be administered to neonates using one of the following methods:

• Oxygen incubator
• Head box
• Face mask
• Nasal catheter / nasal prongs
• Nasopharyngeal catheter
• Nasal Continuous Positive Airway Pressure (NCPAP)

• Mechanical Ventilation via an Endotracheal Tube

• Different Methods of Oxygen Administration in Neonatal Intensive Care Units (NICUs), Oxygen Flow Rates (L/min), and the Advantages and Disadvantages of Each Method:  

Nursing Care for Neonates on Oxygen Therapy

• Observe and record skin color, respiratory effort, and vital signs, and notify the physician immediately if any abnormalities occur.
• Continuous monitoring of oxygen saturation (SpO₂) using a pulse oximeter, maintaining levels between 89–93%, or as prescribed by the physician.
• Administer humidified oxygen to prevent drying of the airway mucosa, which can increase secretion viscosity and accumulation.
• Observe and record the oxygen flow rate, the method of oxygen delivery, and the oxygen saturation level.
• Suction the airway as needed, documenting the amount and characteristics of secretions removed.
• Perform arterial blood gas (ABG) analysis to assess oxygenation and acid-base status.
• Monitor oxygen concentration using an oxygen analyzer if available, to prevent complications from excessive oxygen delivery.

Complications Due to Hypoxia (Low Oxygen):

• Increased pulmonary artery pressure
• Seizures
• Hypoxic encephalopathy
• Cerebral palsy
• Long-term cognitive and behavioral impairments

Complications Due to Hyperoxia (Excess Oxygen):

• Retinopathy of prematurity and potential vision loss, especially in preterm or low-birth-weight neonates
• Oxygen dependency of the lungs and difficulty weaning from oxygen (chronic lung disease)
• Pneumothorax, particularly with NCPAP or mechanical ventilation

- Chest Physiotherapy

Objectives:

• Remove accumulated airway secretions
• Increase airway and lung capacity
• Improve respiratory function through better gas exchange
• Prevent endotracheal tube obstruction
• Reduce the risk of respiratory infections

Techniques and Positions for Chest Physiotherapy:

• Postural Drainage: Positioning the neonate to facilitate drainage of secretions from specific lung segments.
• Percussion: Gentle tapping on the chest wall to loosen secretions.
• Vibration: Manual vibration of the chest to mobilize mucus.
• Airway Suctioning: Removal of secretions from the trachea as needed.

These methods are applied according to the neonate’s condition, with continuous monitoring to ensure safety and effectiveness.

Role of the Nurse in Chest Physiotherapy

1. Assessment and Preparation Before Chest Physiotherapy

The nurse is responsible for evaluating the neonate’s condition and preparing all necessary equipment prior to performing chest physiotherapy:

• Assess the need for chest physiotherapy and select the appropriate technique based on the neonate’s condition.
• Ensure vital signs are stable: temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation.
• Connect the neonate to a monitor.
• Auscultate the chest to identify areas of secretion accumulation.
• Perform a chest X-ray if needed to locate areas of pulmonary secretions.
• Prepare all required equipment depending on the chosen technique, including:
• Padded masks in various sizes suitable for the neonate
• Suction machine
• Vibration device with specifications:
• Battery operated
• Electrically safe
• Smooth surface
• Easy to disinfect between patients
• Suction catheters of different sizes (6, 8, 10 Fr)
• Sterile gloves
• Saline solution
• Sterile dressings
• Small towel
• Oxygen source
• Pulse oximeter or monitor
• Ambu bag
• Stethoscope

2. Steps for Postural Drainage

• Identify the area of secretion accumulation in the lungs and choose the optimal positions to mobilize the secretions.
• Apply postural drainage positions, maintaining the neonate’s posture using a small towel for support, for 10–15 minutes per position or as instructed by the physician.
• Maintain a schedule for changing the neonate’s positions.
• Perform airway suctioning after drainage.

Potential Risks and Complications of Postural Drainage

• Dislodgement of endotracheal tube, umbilical catheter, or chest tube
• Increased intracranial pressure
• Pressure on the diaphragm
• Aspiration of stomach contents into the airway
• Apnea caused by airway obstruction

Examples of Chest Physiotherapy Positions

Chest Physiotherapy Techniques: Vibration and Percussion

Vibration Technique (Vibration)

Steps:

1. Identify the area of secretion accumulation in the lungs.
2. Place the neonate on one side.
3. Place a soft barrier (e.g., cloth) between the skin and the vibration device (electric brush).
4. Apply the device to the back of the neonate, moving in an upward circular motion from bottom to top.
5. Coordinate vibrations with the neonate’s exhalation for effectiveness.
6. Duration: 2–3 minutes per area or as prescribed by the physician.
7. Perform airway suctioning after the session.

Potential Complications:

• Hypoxemia (low blood oxygen)
• Skin abrasions

Percussion Technique (Percussion / Clapping)

Steps:

1. Identify the area of secretion accumulation in the lungs.
2. Place the neonate on one side.
3. Perform gentle percussion using a padded mask, tapping the affected chest area from bottom to top.
4. Duration: 5–10 minutes per area depending on tolerance.
5. Perform airway suctioning after percussion.

Notes for Both Techniques:

• Monitor vital signs and oxygen saturation throughout the session.
• Adjust technique according to the neonate’s tolerance and physician instructions.
• Always have suction equipment ready to clear secretions immediately.

Tools for Performing the Percussion (Clapping) Technique

Potential Complications of the Percussion Technique

• Hypoxemia (low blood oxygen)
• Skin abrasions
• Rib fractures
• Liver or spleen tissue injury
• Pain or discomfort for the neonate

3. Post-Therapy Assessment

After completing chest physiotherapy, the nurse should:

1. Check vital signs:
• Temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation to ensure stability.
2. Auscultate the chest:
• Listen for improved air entry and reduced crackles or wheezes.
3. Palpate the chest:
• Assess for abnormal vibrations or narrowing of airways (tactile fremitus).
4. Chest X-ray:
• If necessary, to confirm clearance of pulmonary secretions.
5. Evaluate response to therapy:
• Determine if the neonate tolerated the session well and if secretions have been effectively mobilized.
• Document improvements or any complications.

Neonate’s Response to Chest Physiotherapy

- Nursing Care for Neonates on Mechanical Ventilation

Mechanical ventilation involves connecting the neonate to a ventilator via an endotracheal tube. The ventilator delivers a mixture of oxygen and compressed air at controlled flow rates and pressures for a specified duration to ensure effective gas exchange. Indications for Mechanical Ventilation in Neonates Severe respiratory dysfunction: Partial pressure of arterial oxygen (PaO₂) < 50 mmHg despite oxygen therapy at 80–100%. Partial pressure of arterial carbon dioxide (PaCO₂) > 60–65 mmHg. Arterial pH < 7.35 (acidosis). Severe respiratory distress: Chest retractions and signs of impending respiratory failure, as assessed by the physician. Apnea: Prolonged apnea or increasing frequency of apnea episodes. Mechanical Ventilation Systems Ventilation Mode Mechanism / How it Works Controlled Mandatory Ventilation (CMV) The ventilator performs all breaths, with no spontaneous effort from the neonate. The neonate must remain calm and sedated to prevent asynchrony. Intermittent Mandatory Ventilation (IMV) Provides mandatory breaths at set intervals per minute, but not synchronized with the neonate’s spontaneous breaths. This may lead to overlap or asynchrony between ventilator and spontaneous breaths. Synchronized Intermittent Mandatory Ventilation (SIMV) Similar to IMV, but the ventilator cycles are synchronized with the neonate’s spontaneous breathing, improving comfort and efficiency. Continuous Positive Airway Pressure (CPAP) Delivers a continuous positive pressure to the airways, keeping alveoli open during exhalation and preventing collapse. Often used before extubating from mechanical ventilation. High-Frequency Ventilation (HFV) Uses small tidal volumes at very high rates via the endotracheal tube to restore lung function in severe respiratory failure. Provides effective oxygenation and ventilation while minimizing alveolar injury compared to conventional modes. Nurse’s Role in Mechanical Ventilation 1. Monitoring and Recording Ventilator Settings and Readings Abbreviation Definition Recommended Setting PIP (Peak Inspiratory Pressure) The maximum airway pressure reached during inhalation. 18–25 cm H₂O PEEP (Positive End-Expiratory Pressure) Positive pressure maintained in the lungs at the end of exhalation; equivalent to CPAP. 4–5 cm H₂O Rate / Frequency Number of breaths delivered per minute as set on the ventilator. 20–40 breaths/min FiO₂ (Fraction of Inspired Oxygen) The percentage of oxygen in the inhaled gas mixture. 21–100% Flow The flow rate of inspired gas, measured in liters per minute. 8–10 L/min 2Assisting with Endotracheal Tube (ET Tube) Insertion – Nursing Role The nurse plays a crucial role in assisting the physician during endotracheal intubation and monitoring the tube after placement. This includes knowing how to select the appropriate tube size, determining the insertion depth, and ensuring proper care. Nurse’s Responsibilities Before ET Tube Insertion 1. Determining the Appropriate ET Tube Size: The tube size is selected based on the neonate’s birth weight and gestational age. ET Tube Size (mm ID) Birth Weight (g) Gestational Age (weeks) 2.5 <1000 <28 3.0 1000–2000 28–34 3.5 2000–3000 34–38 3.5–4.0 >3000 >38 2Preparation of Equipment for Endotracheal Tube (ET Tube) Insertion 1. Required Equipment: Laryngoscope – fully functional, with extra battery available. Laryngoscope blades – straight and curved, sizes 0 and 1. Endotracheal tubes – sizes 2.5, 3.0, 3.5, and 4.0 mm. Suction device. Suction catheters – sizes 5, 6, 8, 10 Fr. Adhesive tape (plaster). Scissors. Stethoscope. Resuscitation bag (Ambu bag) with appropriate mask. Oxygen source. 2. Types of Resuscitation Bags (Ambu Bags) and Masks for Neonates: General Characteristics: Bag volume: 200–750 mL. Oxygen delivery capability: 90%–100%. Equipped with a pressure relief mechanism to prevent overinflation. Mask: appropriately sized, cushioned, and suitable for the neonate’s birth weight and gestational age. 3. Determining the Endotracheal Tube Insertion Depth Oral Intubation: Appropriate Depth (cm)=6+Infant’s weight (kg)\text{Appropriate Depth (cm)} = 6 + \text{Infant's weight (kg)}Appropriate Depth (cm)=6+Infant’s weight (kg) Nasal Intubation: Appropriate Depth (cm)=8+Infant’s weight (kg)\text{Appropriate Depth (cm)} = 8 + \text{Infant's weight (kg)}Appropriate Depth (cm)=8+Infant’s weight (kg) Nurse’s Role During Endotracheal Tube Placement Positioning the Infant: Place the infant on their back (sniffing position). Place a folded towel under the shoulders and slightly extend the neck to open the airway. Suctioning: Suction the mouth and nose to remove accumulated mucus, ensuring clear visualization for tube insertion. Monitoring Vital Signs: Observe and document: Skin color Respiratory rate Oxygen saturation (SpO₂) Heart rate Preparing the Resuscitation Bag (Ambu Bag): Connect to an oxygen source. Place an appropriately sized mask over the infant’s chin, mouth, and nose. Secure the mask: Thumb and index finger on the mask Middle finger supporting the lower jaw Slightly extend the chin to maintain airway patency Bag Ventilation: Hold the Ambu bag with the right hand. Squeeze using thumb, index, and middle fingers at a rate of 60 breaths per minute. Adjust the squeeze force according to the infant’s size and condition. Chest Movement Observation: Ensure adequate chest rise with each ventilation and adjust squeeze force as needed. Intubation Timing: Insert the endotracheal tube once the infant’s color improves and SpO₂ stabilizes. Ventilation Rate During Endotracheal Tube Placement Bag Ventilation: Use the Ambu bag to provide approximately 60 breaths per minute. Adjust the squeeze strength to achieve adequate chest rise. Steps for Endotracheal Tube Insertion Open the laryngoscope and hand it to the physician. Slightly extend the infant’s neck to open the airway. Hand the endotracheal tube to the physician. If needed, gently apply pressure on the larynx to facilitate tube passage. Be prepared to suction if secretions obstruct the view. Time the intubation attempt carefully to minimize apnea duration. Nurse’s Role After Tube Placement Connect the Ambu bag to the endotracheal tube and provide manual ventilation. Listen for bilateral breath sounds to confirm proper placement. Insert a nasogastric (Ryle) tube and decompress the stomach. Continuously monitor vital signs and SpO₂. Secure the tube at the calculated insertion depth. Prepare and connect the mechanical ventilator, verifying all settings with the physician.  Airway Suctioning: Remove mucus secretions to prevent airway obstruction and ensure effective mechanical ventilation. Chest X-ray:Perform radiographic imaging as per physician’s instructions to confirm tube placement and assess lung condition. Documentation in the Infant’s Record: Time of endotracheal tube insertion and the size used. Method of insertion (oral or nasal). Depth of tube placement in centimeters. Observations during insertion, including any medications administered. Signs of the infant’s response to mechanical ventilation, such as skin color, respiratory rate, and chest movement. Complications of Endotracheal Tube Insertion and Prevention Strategies Complication Causes Prevention Hypoxemia (low blood oxygen) - Prolonged intubation attempts- Incorrect tube placement - Pre-oxygenate using ambu-bag before intubation- Limit each intubation attempt to ≤20 seconds- Reattempt only if tube position is incorrect Bradycardia or apnea - Stimulation of the vagus nerve during suctioning or laryngoscope insertion - Provide oxygen via ambu-bag before and after intubation Pneumothorax / Emphysema - Overinflation of lung due to tube placed in right bronchus - Confirm correct tube placement- Apply appropriate pressure when squeezing ambu-bag Injuries to tongue, gums, or airway - Forceful insertion or removal of laryngoscope- Using inappropriate size blade - Use proper technique with the laryngoscope- Select blade size appropriate for infant’s weight and gestational age Tube obstruction - Tube bending or blockage - Suction the tube regularly- Replace tube if necessary Infection - Contaminated equipment or hands - Strict infection control measures (hand hygiene, sterile equipment) Routine Nursing Care for a Neonate on Mechanical Ventilation 1. Ventilator Monitoring: Verify that the ventilator settings match the orders recorded in the infant’s chart. Check that all connections are secure. Ensure tubing is free from condensed water; drain if necessary. Respond promptly to ventilator alarms and notify the physician immediately. Types of Ventilator Alarms and Actions: Alarm Type Action to Take High Inspiratory Pressure - Check that all tubing connections are free from kinks or obstruction. - Ensure the endotracheal tube is patent and not blocked by secretions or bent. Low Inspiratory Pressure - Verify that all connections are secure with no leaks. - Inspect tubing for defects or disconnections. Low PEEP/CPAP - Assess the neonate’s respiratory status. - Observe for increased spontaneous respiratory rate due to crying, resisting the ventilator, or waking. Low Air Pressure - Check hospital central air supply pressure. - Ensure the ventilator’s air inlet is properly connected. Insufficient Expiratory Time - Evaluate the neonate’s respiratory condition. - Observe for increased spontaneous breathing rate or resistance t 1. Arterial Blood Gas (ABG) Sampling Neonates on mechanical ventilation require continuous monitoring of their overall condition and respiratory function. This is achieved by analyzing arterial blood gases (ABG), which provide information about: Oxygenation status (PaO₂) Carbon dioxide levels (PaCO₂) Acid-base balance (pH) These results are compared with normal reference values to guide adjustments in ventilator settings according to the neonate’s needs. Normal Blood Gas Values in Neonates Blood Gas Parameter Acceptable Range pH (Blood Reaction) 7.35 – 7.45 PaO₂ (Partial Pressure of Oxygen in Arterial Blood) 50 – 70 mmHg PaCO₂ (Partial Pressure of Carbon Dioxide in Arterial Blood) 45 – 50 mmHg HCO₃⁻ (Sodium Bicarbonate) 22 – 28 mEq/L SaO₂ (Oxygen Saturation) 89 – 93 % Blood Gas Sampling in Neonates on Mechanical Ventilation Timing of Sampling: A blood gas sample should be obtained and analyzed within 10–15 minutes of starting mechanical ventilation. Routine blood gas analysis is performed every 6 hours or as per physician instructions, unless there is a sudden change in the neonate’s condition. Blood gas should be analyzed every 10–15 minutes whenever ventilator settings or positions are adjusted. Method for Obtaining a Blood Gas Sample from the Heel Heel sampling can be used as an alternative to arterial blood gas. The following precautions must be observed to ensure accurate results: Warm the Site: Wrap a cotton pad soaked in warm water (~42°C) around the heel for 5 minutes before sampling. Avoid Over-Milking: Do not excessively squeeze the heel to prevent contamination of the sample. Disinfect: Clean the sampling site with alcohol and allow it to dry completely. Puncture Site: Prick one side of the heel, avoiding the center. Discard First Drop: Remove the first drop of blood to avoid tissue fluid contamination. Fill the Capillary Tube: Collect the sample without introducing air bubbles. Send Immediately: Send the sample to the laboratory immediately after collection. Apply Pressure: Press on the puncture site after sampling to prevent bleeding.  Care for Neonates on Mechanical Ventilation and Nasal CPAP 1. Endotracheal Tube (ETT) Care Ensure the tube is securely fixed with minimal tape, without pulling or stretching the lips or nose. Inspect the skin around the lips and nose for irritation or wounds. Change the fixation site daily from right to left to prevent skin breakdown. Check that the tube is not blocked due to kinking or thick secretions. Suction the ETT every 3–4 hours or as needed. Auscultate breath sounds bilaterally every 2–4 hours. Watch for signs of accidental tube dislodgement: cyanosis, decreased oxygen saturation, sudden deterioration, abdominal distension, audible crying, reduced chest movement, or bradycardia. 2. Monitoring Vital Signs Connect the neonate to cardiorespiratory monitoring. Record vital signs every 3 hours, focusing on respiratory effort and blood pressure. Observe skin color and oxygen saturation. 3. Chest Physiotherapy and Suctioning Perform chest physiotherapy as indicated. Suction as needed to maintain airway patency. 4. Nutrition Neonates may receive nutrition via an orogastric or nasogastric tube as per physician instructions. 5. Repositioning Reposition the neonate every 2 hours (side, back, or prone) to prevent secretion accumulation while ensuring proper tube fixation. Weaning from Mechanical Ventilation Gradually reduce ventilator settings (pressure, oxygen concentration, respiratory rate) to encourage spontaneous breathing before extubation. Extubation Procedure Stop tube feeding 2 hours before extubation. Perform chest physiotherapy and suction immediately prior to tube removal. Remove the ETT during inhalation. Closely monitor breathing after extubation. Perform a blood gas analysis 30 minutes after extubation. Notify the physician of any complications. Potential Complications of Mechanical Ventilation ETT obstruction due to secretions or kinking. Accidental extubation. Pneumothorax or emphysema from excessive pressure. Reduced cardiac output due to high intrathoracic pressure.

- Nasal Continuous Positive Airway Pressure (Nasal CPAP)

Nasal CPAP is a non-invasive, safe ventilatory support system that does not require an endotracheal tube. It delivers a continuous positive pressure of oxygen-enriched air to keep alveoli open and prevent collapse during exhalation. It can be delivered via mask, nasopharyngeal catheter, or endotracheal tube, though nasal CPAP is the most commonly used.

Indications

• Respiratory distress from Hyaline Membrane Disease in preterm neonates due to surfactant deficiency, to improve lung efficiency and reduce the need for invasive ventilation.
• PaO₂ < 50 mmHg despite oxygen therapy ≥60% using simpler methods.
• Moderate respiratory distress: tachypnea (>60 breaths/min), grunting, or subcostal retractions, such as:
• Transient neonatal tachypnea
• Meconium aspiration
• Apnea of prematurity in low birth weight infants.
• Post-weaning from mechanical ventilation.

Contraindications

• Respiratory failure requiring invasive ventilation.
• Persistent apnea with bradycardia unresponsive to CPAP.
• Upper airway malformations (cleft palate, nasal obstruction).
• Diaphragmatic hernia.
• Severe, unstable cardiac disease.

Nasal CPAP Components

1. Gas Source: Provides a humidified mixture of oxygen and compressed air.
2. Pressure Generator: Creates continuous positive airway pressure.
3. Interface: Connects the circuit to the neonate’s airway (nasal prongs or mask).

Circuit Components

• Gas Delivery Circuit:
• Oxygen and compressed air inlets.
• Oxygen blender to mix oxygen and air to the required FiO₂.
• Flowmeter (8–10 L/min) and manometer to monitor pressure.
• Humidifier: Heats and humidifies the inspired gas with a temperature sensor.
• Pressure Generator: Maintains continuous positive pressure at the end of exhalation to keep alveoli open.

Positive Pressure Generator (CPAP Generator)

Other Methods to Generate Positive Pressure (Bubble–CPAP)

• Immerse the free end of the exhalation tube under the water surface to a depth of 5 cm to generate the desired positive pressure in the alveoli.
• Attach a graduated measuring tube to the outer wall of the sterile water bottle.
• Fill the bottle with sterile water until the water level reaches 7 on the measuring tube.
• Immerse the tube end under the water to 5 cm, leaving a 2 cm gap between the tube end and the bottom of the bottle to prevent excessive alveolar pressure.
• Ensure the appearance of air bubbles after connecting the neonate and starting the CPAP device.
• Connect the device’s exhalation tube to a valve.

Nasal Prongs (Double-Prong Catheter)

• Connection: Attaches to the end of the generator to deliver the inhaled gas circuit to the infant.

Device Connections

• Short Corrugated Tube: Connects the flow meter (on the oxygen blender) to the humidifier.
• Inhalation Tube: A long corrugated tube carrying the humidified inhaled gas from the humidifier to the positive pressure generator and the double-prong nasal tube, delivering warm, moist air to the infant.
• Exhalation Tube: A corrugated tube connecting the double-prong nasal tube to the positive pressure generator at the back, connected to a manometer to monitor the generated pressure.

(Bubble CPAP)

Nurse’s Role:

The device must always be ready for use at any time in the neonatal care units, with all necessary connections available, including all sizes of double-prong nasal catheters according to the infant’s weight and gestational age.

Preparing the Infant for Connection to the Device

• Infection Control: Follow strict infection control measures to prevent respiratory infections and ensure the device functions efficiently:
• Wash hands thoroughly before handling the device, catheter, or infant.
• Wear sterile gloves during airway suctioning.
• Keep all tubing off the floor or away from contamination sources.
• Device Setup:
• Connect the oxygen and air supply to the oxygen blender, adjusting the oxygen flow rate to 8–10 L/min.
• Set the oxygen concentration to the required percentage.
• Connect the short corrugated tube to the oxygen humidifier and insert the temperature probe into the designated port.
• Fill the humidifier with sterile water to the marked level, turn on the device, and set the temperature to 37°C.
• Select the appropriate cap size for the infant’s head.
• Select the correct nasal catheter size by measuring the infant’s nostrils; proper fit is crucial:
• Too small → leakage, difficult to maintain pressure.
• Too large → nasal mucosal injury.
• Attach the nasal catheter to the generator and temporarily cover with a finger to check that the manometer shows the correct pressure (5 cm H₂O).

Connecting the Infant to the Device

• Wash hands or use alcohol rub.
• Ensure no obstruction in the infant’s posterior nasal passages (congenital defect in some cases).
• Connect the infant to the monitoring system (oxygen saturation and vital signs).
• Wear gloves.
• Suction the nose, mouth, and pharynx using the largest catheter that can pass without resistance.
• Positioning: Raise the bed 30°, place a folded sheet under the infant’s shoulders, slightly extend the neck to keep the airway open.
• Place the appropriately sized cap, bending its edge 2–3 cm above the ears.
• Insert the double-prong nasal catheter and secure with the cap’s attached strings, ensuring:
• Catheter fills both nostrils completely.
• Skin around the nose is not under tension.
• Catheter does not press on the nasal septum.
• Space between the septum tip and the catheter bridge.
• Catheter does not rest on the upper lip.
• Secure the exhalation corrugated tube to the forehead via cap straps.
• Insert a gastric feeding tube for stomach suction, connecting it to a syringe to release excess air.
• Clean the upper lip and cheeks with warm water, dry, and apply prescribed moisturizer to prevent pressure sores.

Monitoring the Infant on the Device

• Check every 2–4 hours:
• Respiratory status: rate, nasal flaring, chest retractions, breath sounds.
• Body temperature.
• Circulation: capillary refill, blood pressure, heart rate.
• Neurological status: activity, movement, reflexes.
• Gastrointestinal: abdominal distention.
• Monitor devices for proper function.
• Suction as needed (nose, mouth, pharynx, stomach). Shorter suction intervals (<2 hours) may be needed if:
• Increased respiratory effort.
• Higher oxygen requirements.
• Apnea or bradycardia episodes.
• Record volume and color of secretions.
• Verify device function via checklist.
• Reposition infant every 4–6 hours to prevent secretion accumulation.
• Drain and dispose of condensation in tubing regularly.

Weaning from Nasal CPAP

Indicators for weaning:

• Overall improvement in the infant’s condition.
• Spontaneous, comfortable breathing.
• Reduced respiratory rate, absence of chest retractions, improved color.

Weaning Steps:

• Gradually reduce oxygen concentration by 2–5% at a time until reaching 21%, guided by pulse oximetry or arterial blood gas analysis.
• Temporarily remove the nasal catheter and observe:
• Increased breathing rate.
• Chest retractions.
• Decreased oxygen saturation.
• Apnea episodes.
• Cyanosis.
• If any signs appear → weaning fails; resume CPAP and attempt again after 24 hours.
• Do not attempt weaning if alveolar collapse is likely, as prevention is better than treatment.

Feeding During Nasal CPAP

• If stable, feed via the gastrointestinal tract using gravity or syringe pump.
• Suction excess stomach air before feeding.

Potential Complications of Nasal CPAP

• Nasal septum injuries from prolonged catheter pressure.
• Skin injuries from device straps.
• Abdominal distention.
• Increased secretions.
• Pneumothorax.

Checklist for Neonatal NCPAP Monitoring (Filled by Responsible Nurse Each Shift)

Checklist for Preparing the Neonatal Continuous Positive Airway Pressure (NCPAP) System