The Science Journal of the American Association for Respiratory Care

2005 OPEN FORUM Abstracts

A NEW STANDARD OF CARE IN THE DELIVERY ROOM AND NICU

Sandra McClanahan RRT, CPFT, Pamela Krieg, RN, University Hospital, Cincinnati, Ohio

Background: CPAP has been used to treat surfactant deficiency in preterm infants for many years. Recently, interest has arisen concerning early Bubble CPAP's role in the delivery room and its effect in reducing ventilator induced lung injury and BPD. Our improved outcomes following the use of Bubble CPAP have been published (Narendaren V, et al; Journal of Perinatology 2003;00:1-5). The bubble effect is theorized to provide an oscillatory vibration inside the infant's chest and facilitates better gas exchange. We conducted a questionnaire survey with our staff after 3 years of experience with the Bubble CPAP.

Method: Prior to July 2000, our standard of care was to intubate infants < 1000 gms in the delivery room. We changed our standard of care so that spontaneously breathing infants < 1000gms received Bubble CPAP using nasal prongs in the delivery room. We also used the same technique for transport and long- term maintenance of CPAP in the NICU. The transport CPAP system consists of nasal prongs, headgear, and a circuit attached to a rolling oxygen tank with gauge. The expiratory limb of the circuit is placed in a water seal canister containing 10 cm of 0.25% acetic acid. Once in the NICU, infants are transferred to a permanent Bubble CPAP system without loss of continuous distending pressure. This change of practice occurred following a brief educational session for the respiratory and nursing staff. With experience, we improved our techniques for positioning infants, maintaining adequate CPAP, septal protection and weaning to nasal cannula, among other improved areas. A questionnaire was distributed to doctors, nurses, and respiratory care practitioners to ascertain ease and effectiveness of this new standard of care.

Results: After adopting Bubble CPAP as our new standard of care, the NICU staff completed a survey. 100% of DRs, 100% of RCPs, 93% of RNs believed that bubble CPAP was easy to use in the delivery room. 75% of DRs, 75% of RCPs, 70% of RNs believed that compared to intubation, Bubble CPAP made it easier for mother/baby bonding. 100% of DRs, 100% of RCPs, 98% of RNs believed that Bubble CPAP is less traumatic to the baby than intubation. 75% of RCPs, 65% of RNs believed that the infection rate of Bubble CPAP infants has decreased, 90% of DRs stated they didn't know. 90% of DRs, 50% of RNs believe bubble CPAP is less time consuming than intubation, while 75% of RCPs believe Bubble CPAP is more time consuming. 100% of DRs, RCPs, and RNs believe that Bubble CPAP is better for the baby than intubation. The top 5 main concerns from all staff members about maintenance of Bubble CPAP: septal erosion, head contouring, maintaining proper pressure, ability to keep prongs in place, and air leak.

Conclusions: The success of our Bubble CPAP program has definitely been a TEAM effort. As with many other NICUs, we have adopted a more gentle approach to respiratory care when treating the premature infant. We primarily use CPAP and initiate it early, tolerate higher CO2 values, and have learned that patience does have its rewards. The survey has shown we need continuing education monthly to include all new residents and staff. It also helped identify staff concerns that need to be considered. Our change of practice has made us become resourceful, develop new techniques/tools, and to find tricks/tips to help us be more effective. We hope to share the information we have learned to help others answer Bubble CPAP questions and develop a Standard of Care for an effective CPAP program in their delivery room and NICU.

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