Introduction Show
Definition of Terms Acute Management Non-Acute Management Assessments/Indications Ongoing Management Follow-up/Review Special Considerations Companion Documents Links Evidence Table References IntroductionNon-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, APAP, Bi-level Positive Airway Pressure (BiPAP). APAP should be considered synonymous with CPAP for the remainder of this document. 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:
Contraindications include but are not limited to:
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 or BiPAP, and who are otherwise medically stable, as inpatients within The Royal Children’s Hospital Melbourne. Where an individual patient’s clinical requirements fall outside these guidelines, consensus on patient management must be agreed to by the PICU, Respiratory and Sleep Medicine Consultant, 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
Management - AcuteA 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-acuteCPAP can be safely initiated on the inpatient units, or as an outpatient. NIV can only be safely initiated on inpatient units due to additional complexity and monitoring requirements. Administration/application
In established/long-term CPAP/NIV patients, temporary and/or minor changes to settings, or an increase in FiO2, may be required for episodes of minor illness, or for palliation. These patients may continue to be safely cared for on their current inpatient unit. Assessment / IndicationsSee 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:
Physical Assessment / Observations – during therapyPatients should receive a complete nursing respiratory assessment at least once at the commencement of each shift, where the patient’s respiratory status changes, where CPAP/NIV settings are adjusted, and/or oxygen requirements change. Monitor patient for and document hourly on EMR Flowsheets under Observations:
Monitor device and document hourly on EMR Flowsheets under Respiratory Support Observations:
Additional device observations may include:
In established/long-term CPAP/NIV patients who are clinically stable, and where ventilation settings do not require adjustment, the frequency of physical assessment may be reduced. Reduction in the frequency of patient physical assessment should be approved
and documented by the treating medical team. Mechanical Driver / Device Assessment / ObservationsAt the commencement of each nursing shift the ventilator settings should be checked against the medical orders and documented on EMR Flowsheets under Respiratory Support Observations. Monitor device each shift or when resuming treatment
Interface assessment
Oxygen therapy
Humidification
Ongoing assessmentThe Respiratory and Sleep Medicine Consultant, or their delegate, is responsible for arranging assessment and documentation of ongoing CPAP/NIV requirements. Inpatient Care Needs
Investigations
Hygiene
Nutrition
Safety
If documented or correlating medical orders are not present, seek medical review and documentation of same prior to commencing CPAP/NIV. Ongoing managementPotential Complications – Clinical
Potential Complications - Mechanical
Complications/troubleshooting
Ongoing management cont.
Follow-up / Review
Special ConsiderationsInfection Control
Patient Safety Alerts
Home Circuits/EquipmentUnless 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 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 DocumentsNursing Competency documents available on the below topics. Sugar Glider staff contact the education team to access the content. • Ventilation - Mechanical (Basic Principles) RCH Staff only - Tracheostomy Learning Package on learning hero. LinksRCH department/wards
Nursing Guidelines
Parent/Carer Information
Evidence TableThe evidence table for this guideline can be viewed here. References
Please remember to read the disclaimer The development of this nursing guideline was coordinated by John Kemp, Clinical Support Nurse/Respiratory Nurse Consultant, Sugar Glider, and approved by the Nursing Clinical Effectiveness Committee. Updated January 2022. Which action will the nurse take first for a client being mechanically ventilated who begins to pick at the bedcovers?A client in the intensive care unit (ICU) who is receiving mechanical ventilation begins to pick at the bedcovers. Which action will the nurse take next? Assess for adequate oxygenation.
Which action would the nurse take to decrease risk for ventilator associated pneumonia in a client who is receiving mechanical ventilation?Proper positioning (keeping the head of the bed between 30–45 degrees) and encouraging early mobility of mechanically ventilated patients aid in the prevention of VAP.
When the low pressure alarm on the ventilator sounds it indicates which of the following?One of the most common alarms is low pressure, caused by airway pressure disconnect, says Malinowski. "Look to see if a tube is dislodged, or if a ventilator is disconnected from the endotracheal tube," he suggests.
Which intervention would the nurse implement for a client admitted for an exacerbation of asthma?The mainstay of treatment during the acute attack is supplementary oxygen, repeated inhaled bronchodilator and systemic corticosteroids (table 5).
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