Royal United Hospital Bath NHS Trust Guidelines For The Use Of Continuous Positive Airway Pressure (CPAP)

Systems In Adults

GUIDELINES FOR THE USE OF CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) SYSTEMS IN ADULTS

Reference Number:

717 2007

Author / Manager Responsible:

Julian Hunt

Deadline for ratification: (Policy must be ratified within 6 June 2010 months of review date)

Review Date:

December 2009

Ratified by:

Director of Nursing

Date Ratified:

June 2007

Related Policies

Author : Julian Hunt Job title: Consultant Nurse Page 1 of 18

Date: December 2006 Version: 2.3.1 Review date: December 2009

Royal United Hospital Bath NHS Trust Guidelines For The Use Of Continuous Positive Airway Pressure (CPAP) Systems In Adults INDEX Section Consultation and Ratification Schedule Policy Procedure Page 3 4 4 4 4 4 5 5 6 6 7 11 11 11 14 16

Introduction Definition Indications Contraindications Relative contraindications

Procedure for Mask CPAP Equipment Important note on humidification -

Procedure for the use of CPAP on an intubated patient Equipment Important note on humidification References -

Consultation Checklist

Author : Julian Hunt Job title: Consultant Nurse Page 2 of 18

Date: December 2006 Version: 2.3.1 Review date: December 2009

Royal United Hospital Bath NHS Trust Guidelines For The Use Of Continuous Positive Airway Pressure (CPAP) Systems In Adults CONSULTATION AND RATIFICATION SCHEDULE

Name and Title of Individual Mark Grover Judith Rollason Victoria Turrell Kerry Joyce Gail Jones Caroline Brown V Masani Kim Gupta Dominic Williamson Richard Krystopik Francesca Thompson Name of Committee Medical Board Surgical Board Specialities Board

Date Consulted December 2006 December 2006 December 2006 December 2006 December 2006 December 2006 December 2006 December 2006 December 2006 December 2006 June 2007 Date of Committee 2007 2007 2007

Author : Julian Hunt Job title: Consultant Nurse Page 3 of 18

Date: December 2006 Version: 2.3.1 Review date: December 2009

Royal United Hospital Bath NHS Trust Guidelines For The Use Of Continuous Positive Airway Pressure (CPAP) Systems In Adults

1. POLICY 1.1. CPAP therapy is a medical intervention with identified complications. It should be prescribed by individuals who have appropriate training and understanding of the complications and contra-indications. 1.2. The use of CPAP involves administration of oxygen, which should also be prescribed. 1.3. CPAP should only be used for patients for whom it is indicated. It should not be used where it is absolutely contra-indicated (See below) 1.4. All patients receiving CPAP require close observation and recording of vital signs assessment and Early Warning Scoring (EWS). Observation should be extra-vigilant in those patients who have relative contra-indications to CPAP.

2. PROCEDURE

2.1 INTRODUCTION 2.2 DEFINITION Continuous Positive Airway Pressure (CPAP) is the maintenance of a positive pressure throughout the whole respiratory cycle (inspiration and expiration), when breathing spontaneously (Keilty and Bott, 1992). The CPAP system is totally closed incorporating a tight-fitting face or nasal mask (or cuffed endotracheal or tracheostomy tube), and a valve, usually at a pressure of 5 - 10 cm H20, against which the patient exhales (Heath, 1993; Simmonds, 1994; Ashurst, 1995). The CPAP valve should be of a low resistance type (Banner et al. 1966). It is possible to deliver high flow CPAP using a flow generator or CPAP via a Non-Invasive Ventilator. These guidelines refer specifically to high flow CPAP 2.3 INDICATIONS CPAP provides an additional therapy between conventional oxygen therapy and controlled ventilation. It helps to prevent atelectasis, reduce the work of breathing and eliminate or reduce hypoxia (Ashurst, 1995). It allows normalisation of the functional residual capacity (Romand and Donald, 1995) (Place, 1997). In the management of pulmonary oedema it can improve cardiac output (Baratz et al., 1992) although in normal volunteers without oedema cardiac performance is reduced (Perkins et al. 1989).
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Royal United Hospital Bath NHS Trust Guidelines For The Use Of Continuous Positive Airway Pressure (CPAP) Systems In Adults

2.4 It is a well known therapy appropriate for: Patients who are hypoxic but not exhausted. A list of conditions where CPAP may be appropriate includes: Pneumonia, infective exacerbation of COPD (Non-Invasive Ventilation may be more appropriate if respiratory acidosis is present, but note that many NIV machines do not deliver high oxygen concentrations), fibrotic lung disease, Mild to moderate Adult Respiratory Distress Syndrome, sleep apnoea and cardiogenic pulmonary oedema. Patients being weaned from ventilation with Positive End Expiratory Pressure (PEEP) to obtain re-opening of atelectatis areas of the lung. Patients who may be hypoxaemic following extubation. (Tonneson, 1996; Keilty and Bott, 1992; Iapichino et al., 1991; Branson, 1988; Dehaven et al. 1985, 1989; Simmonds, 1994; Lindberg et al. 1992 Yap and Fleetham, 2001; Shochat et al., 2001: Johnson, 1999).

2.5 CONTRAINDICATIONS 1. Recurrent pneumothoraces / untreated pneumothorax - may contribute to barotraumas. 2. Severe post-operative pulmonary air leak. 3. Central Apnoea 4. Epistaxis 5. Any condition where an elevated Intracranial Pressure is undesirable or where reduction in cerebral blood flow is inappropriate (Kolbitsch et al., 2000). 6. Any situation where there is already significant lung over-distension 7. Unstable facial fractures, extensive facial surgery or lacerations and facial burns. 8. Laryngeal trauma, recent tracheal anastamosis. 9. Recent ear, nose and throat surgery. 10. Basilar skull fracture - at risk of pneumocephalus. (Note: The last four contraindications listed are specific to mask CPAP)

2.6 RELATIVE CONTRA-INDICATIONS CPAP is not contraindicated but should be used with caution in patients who have: Hypotension. Hypovolaemia.
Date: December 2006 Version: 2.3.1 Review date: December 2009

Author : Julian Hunt Job title: Consultant Nurse Page 5 of 18

Royal United Hospital Bath NHS Trust Guidelines For The Use Of Continuous Positive Airway Pressure (CPAP) Systems In Adults Chronic Obstructive Pulmonary Disease Asthma. Recent oesophageal anastamosis Lung abscess / active tuberculosis. Bronchial tumour. Haemoptysis (may be absolute contra-indication) Reduced conscious level (For CPAP by mask airway protection by the patient must be possible) Hypercapnia and/or hypoventilation patient may require bi-level positive pressure ventilation (BiPAP). (Tonneson, 1996; Ashurst, 1995; Keilty and Bott, 1982; Moore and Haenel, 1991).

3. PROCEDURE FOR MASK CPAP 3.1 In the ward setting CPAP pressures of +5 or +7.5 are likely to be suitable. Choice will be determined by assessment of the relative contraindications, the patients lung condition and the degree of hypoxia, or oxygen requirement, associated with assessment of cardiovascular filling (Higher CPAP settings (+10 cms) may be required where obstructive sleep apnoea is being managed,) 3.2 The prescription of CPAP should be guided by an oxygen requirement of greater than 60% and evidence of atelectasis or pulmonary oedema. In the latter case CPAP has been shown to improve cardiac output. Use of CPAP should be regularly reviewed and the need for its continuation assessed. 3.3 In the Critical Care setting, for intermittent physiotherapy, and occasionally in the Emergency Department or Coronary Care Unit a higher rated valve may be appropriate. 3.4 All patients requiring CPAP require close observation. This requirement is increased with higher rated valves and high-inspired oxygen percentages. Mask CPAP at greater than 7.5 cms of H2O pressure greatly increases the chances of gastric distension (aerophagia). 3.5 EQUIPMENT Flow generator with variable flow (Vital Flow 100) CPAP mask (Two port type) with securing straps. Bacterial-Viral filter (NOT an HME) Aerosol tubing Oxygen analyser and T piece CPAP valve of prescribed level Higher rated CPAP valve (+20 cm of water) and T piece Pressure gauge (Optional) Hot water bath (heated wire) humidifier (Optional: See note below)

Author : Julian Hunt Job title: Consultant Nurse Page 6 of 18

Date: December 2006 Version: 2.3.1 Review date: December 2009

Royal United Hospital Bath NHS Trust Guidelines For The Use Of Continuous Positive Airway Pressure (CPAP) Systems In Adults (If humidifier is used a patient section and 1 litre bag of water for inhalation will be required) In some departments a complete circuit is available with all of the disposable items provided in one kit). 3.6 Assemble the equipment as illustrated. In the Emergency Department and CCU the circuitry may be used without the humidifier section. 3.7 IMPORTANT NOTE. CPAP should not be used without humidification for longer than four hours 3.8 Ensure that the circuitry is working properly before attachment to the patient. 3.9 When setting up the equipment ensure that it works properly before use. Pay particular attention to the outflow of gas. The Vital Flow 100 has a safety valve on the expiratory port which under some circumstances will allow gas to blow out through the air entrainment port. 3.10 Always check that gas flows through the tubing and mask, by feeling for gas flow at the level of the patient mask 3.11 IMPORTANT NOTE ON HUMIDIFICATION Where CPAP therapy is being used intermittently and for short periods, then humidification need not be used. As a general rule if CPAP is going to be continued for more than four hours then a high specification (heated-wire) humidifier should be added to the circuit.

Author : Julian Hunt Job title: Consultant Nurse Page 7 of 18

Date: December 2006 Version: 2.3.1 Review date: December 2009

Royal United Hospital Bath NHS Trust Guidelines For The Use Of Continuous Positive Airway Pressure (CPAP) Systems In Adults

Author : Julian Hunt Job title: Consultant Nurse Page 8 of 18

Date: December 2006 Version: 2.3.1 Review date: December 2009

Royal United Hospital Bath NHS Trust Guidelines For The Use Of Continuous Positive Airway Pressure (CPAP) Systems In Adults 4. ACTION RATIONALE 4.1. Monitor and assess the To provide some baseline patient's vital signs. Ideally an observations and allow future arterial blood gas should be detection of changes in the patient's checked prior to instituting CPAP condition; to facilitate early detection therapy of deterioration in clinical condition. 4.2. Set the flow generator to deliver an appropriate flow and percentage of oxygen, using the oxygen analyser. A Wrights respirometer is not routinely used, but the flow generator must be set to administer a flow that sufficiently drives the CPAP valve. To ensure that oxygen percentage and gas flow are as prescribed. For true CPAP the flow rate of delivered gas must be greater than the peak inspiratory flow of the patient (Taylor et al, 1989). Excessive flow is desiccant to lung tissue and may exceed the rated flow of the CPAP valve.

4.3. Humidification is required for high flow gas therapy, except for short term use in the Emergency Department. Intermittent CPAP treatment for physiotherapy does not require humidification 4.4. Medical gas mixed with room air is desiccant to lung tissue. Humidification should be provided if CPAP therapy is continued beyond four hours.. 4.5. Consider placing a nasogastric tube, particularly if the use of CPAP is sustained or if CPAP > 5 cms of water is used. The nasogastric tube should be on free drainage and aspirated regularly (at least three hourly). 4.6. If a patient is being fed via a naso-gastric tube this may be continued, but it should be regularly aspirated. The feed should be stopped if rapid deterioration in respiratory condition is anticipated.

If a humidifier is used it should be of heated wire type and set at the appropriate temperature (33.5 35.5 degrees Centigrade) to prevent spurious alarming of humidifiers.

To optimise lung condition.

Mask CPAP may enhance the swallowing of air, resulting in gastric dilatation and vomiting. The presence of a naso-gastric tube ensures the gas is removed. (Ashurst, 1995).

To detect gastric dilatation noted above. Gastric dilatation and continued feeding will predispose to aspiration of gastric contents

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Date: December 2006 Version: 2.3.1 Review date: December 2009

Royal United Hospital Bath NHS Trust Guidelines For The Use Of Continuous Positive Airway Pressure (CPAP) Systems In Adults ACTION RATIONALE 4.7. Hold the mask in position for a To allow the patient to adjust to the short while before securing, with a feel of the mask, preventing anxiety head strap. Explain the procedure and panic at the initial increased fully and reassure the patient work of breathing. appropriately

4.8. When securing the mask use a 20 ml syringe to partially empty and then fill the seal of the face mask.

To ensure mask comfort, allow the mask seal to contour to the shape of the patients face and to minimise pressure symptoms. To ensure that volume of gas delivered at least matches peak inspiratory flow, and ensures that true CPAP is maintained.

4.9. Ensure that the diaphragm on the CPAP valve barely closes on inspiration and that the pressure meter (if used) records the pressure level of the valve in use. (Flow rate will normally be in the range of 40 70 litres a minute, but may be higher in a patient who is working hard to breathe). 4.10. Ensure that there is no gas leakage around the seal of the mask (Keilty and Bott, 1992). 4.11. Record and assess respiratory rate appropriately and continually assess respiratory status. 4.12. Check oxygen percentage of delivered gas and CPAP pressure from pressure gauge (if used), after every adjustment of the flow generator, and every hour. Record information on vital signs chart hourly. 4.13. If a pressure gauge is not used the establishment of true CPAP can be assured by ensuring that the CPAP valve remains slightly open or only just closes throughout the respiratory cycle. This can be done by visually inspecting the valve in use or by feeling the gas flow into the ball of the hand.
Author : Julian Hunt Job title: Consultant Nurse Page 10 of 18

To guarantee that the patient is receiving CPAP. To prevent desiccation of cornea. To observe and monitor for signs of respiratory distress and fatigue. To ensure that CPAP therapy is maintained as prescribed. Failure to do so may result in marked changes in gas flow delivery that may impact on a patients condition, through rebreathing of expired gas.

Too little flow results in a circuit that will increase hypoxia. Too much flow will exceed the design range of the CPAP valve and the humidifier and result in uncontrolled airway pressures and desiccation of lung tissue.

Date: December 2006 Version: 2.3.1 Review date: December 2009

Royal United Hospital Bath NHS Trust Guidelines For The Use Of Continuous Positive Airway Pressure (CPAP) Systems In Adults RATIONALE ACTION To minimise panic and anxiety. To 4.14. If the patient cannot tolerate try and ensure continued the system and condition allows let compliance from the patient. To the patient to rest from the mask. allow mouth care (Iapichino et al, Oxygen can be administered with 1991).Close observation is required an ordinary aerosol mask and the when the patient is rested from the high flow circuit. system. To allow verbal communication by patient and thereby assist in maintaining morale. To allow for expectoration 4.15. Alter the position of the mask and strapping at regular intervals. The face mask is particularly claustrophobic (Ashurst, 1995). Avoid securing straps too tight. To prevent discomfort and forehead trauma (Iapichino et al, 1991). To ensure mask is comfortable. Particular attention should be devoted to behind the ears and the bridge of the nose. To prevent or minimise peri-orbital oedema and subconjunctival haemorrhage. Nasal and cheek sores have been recorded (Iapichino, 1991).

Author : Julian Hunt Job title: Consultant Nurse Page 11 of 18

Date: December 2006 Version: 2.3.1 Review date: December 2009

Royal United Hospital Bath NHS Trust Guidelines For The Use Of Continuous Positive Airway Pressure (CPAP) Systems

5. PROCEDURE FOR THE USE OF CPAP ON AN INTUBATED PATIENT 5.1 Equipment Flow generator with variable flow (Vital Flow 100) Bacterial filter Aerosol tubing (two pieces) Oxygen analyser and T piece CPAP valve of prescribed level (Vital Signs) CPAP valve of higher rated value than prescribed. (Vital Signs) Hot water humidifier (Fisher and Paykel or Vital Signs) Heated wire tubing One litre bag of water for inhalation 5.2 The circuitry for a patient with a tracheal tube is essentially the same as for mask CPAP. The connection from aerosol tubing to tracheal tube is made with a T piece with a standard 15mm connector on the side. A catheter mount should not be used as it will create an unnecessary dead space of the circuitry. If tube comfort is an issue swivel connector between T piece and tracheal tube will suffice. 5.3 Important note on humidification Humidification is essential if a patient with a tracheal tube is set up for CPAP.

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Date: December 2006 Version: 2.3.1 Review date: December 2009

Royal United Hospital Bath NHS Trust Guidelines For The Use Of Continuous Positive Airway Pressure (CPAP) Systems ACTION 6.1. Monitor and assess the patient's vital signs. Ideally arterial blood gases should be checked prior to and after initiating CPAP therapy. RATIONALE To provide baseline observations so that changes in the patient's condition can be detected, and signs of deterioration observed.

6.2. A nasogastric tube is not specifically required (unless it is required for airway protection i.e. to prevent aspiration of gastric contents).

Dilatation of the stomach and vomiting are not specifically associated with CPAP administered via a tracheal tube

6.3. Set the flow generator to deliver an appropriate volume of flow and percentage of oxygen, using the oxygen analyser.

To ensure that oxygen percentage and gas flow are as prescribed. For true CPAP the flow rate of delivered gas must be greater than the peak inspiratory flow of the patient (Taylor et al, 1989). To ensure that volume of gas delivered at least matches peak inspiratory flow. Although the flow is not measured with a respirometer the movement of the valve is a sufficient way of monitoring. If the valve is widely open and the noise of the flow generator too great, it indicates high flows that are beyond the design specification of the valve. To guarantee that the patient is receiving CPAP, the air seal around the cuff must be complete. At high CPAP pressure a perfect seal may not be achievable. To observe and monitor for signs of respiratory distress and fatigue.

6.4. Ensure that the diaphragm on the CPAP valve barely closes on inspiration. (Flow rate will normally be in the range of 40 70 litres a minute but may be higher in large adults who are making a lot of effort to breathe).

6.5. Ensure that the tracheal tube cuff is appropriately pressurised by using a cuff pressure gauge.

6.6. Record and assess respiratory rate hourly and continually assess respiratory status.

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Date: December 2006 Version: 2.3.1 Review date: December 2009

Royal United Hospital Bath NHS Trust Guidelines For The Use Of Continuous Positive Airway Pressure (CPAP) Systems ACTION 6.7. Monitor oxygen percentage of delivered gas continually. Also regularly inspect the CPAP valve is working appropriately. RATIONALE To ensure that CPAP therapy is maintained appropriately. Failure to do so may result in marked changes in gas flow delivery that may impact on a patients condition. Flow generators are capable of generating dangerously high airway pressures in a well-sealed circuit, (hence the need for an exhaust or safety valve) (Medical Devices Agency, 2000).

6.8. Ensure that the end of the CPAP valve is not occluded, and that the exhaust valve is appropriately placed.

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Date: December 2006 Version: 2.3.1 Review date: December 2009

Royal United Hospital Bath NHS Trust Guidelines For The Use Of Continuous Positive Airway Pressure (CPAP) Systems

7. REFERENCE DOCUMENTS Ashurst S (1995). Oxygen Therapy. British Journal of Nursing. 9: 508 - 516. Banner M, Lampotang S, Boysen P et al. (1966). Flow Resistance of Expiratory Positive-Pressure Valve Systems. Chest. 90 (2): 212-217. Baratz D, Westbrook P, Shah P et al. (1992). Effect of nasal continuous positive airway pressure on cardiac output and oxygen delivery in patients with congestive heart failure. Chest. 102 (5): 1397 1401. Branson R, (1988). PEEP without endotracheal intubation. Respiratory Care. 33: 598. Dehaven C, Hurst J, Branson R, (1989). Post Extubation Hypoxaemia treated with continuous positive airways pressure mask. Critical Care Medicine. 13(1): 46 - 48. Heath M, (1993). Management of Obstructive Sleep Apnoea. British Journal of Nursing. 2 (16): 802 - 804. Iapichino G, Gavazzeni V, Mascheroni D,et al. (1991). Combined use of mask CPAP and minitracheostomy as an alternative to endo-tracheal intubation. Intensive Care Medicine. 17: 57 - 59. Johnson M (1999). Acute Pulmonary Edema. Current Treatment Options in Cardiovascular Medicine. 1 (3): 269 276. Keilty S, Bott J, (1992). Continuous positive airways pressure. Physiotherapy 78(2): 90 - 92. Kolbitsch C Lorenz I, Horman C et al., (2000). The impact of increased Mean Airway Pressure on contrast-enhanced MRI measurement of regional blood flow, regional blood volume, regional mean transit time and regional cerebrovascular resistance in human volunteers. Human Brain Mapping. 11 (3): 214 222. Lindberg P, Gunnarsson L, Tokics E et al. (1992). Atelectasis and lung function in the postoperative period. Acta Anaesthesiol. Scand. 36: 546 553. Medical Devices Agency (2000). Continuous Positive Airway Pressure (CPAP) Circuits: Risk of misassembly. Safety Notice. MDA. London. Crown Copyright.
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Royal United Hospital Bath NHS Trust Guidelines For The Use Of Continuous Positive Airway Pressure (CPAP) Systems Moore F, Haenel J, (1991). Flail Chest and Pulmonary Contusion. Cited in: Parson P, Wiener-Kronish J, Critical Care Secrets. Hanley and Belfus Inc., Philadelphia. Perkins M Dasta J and DeHaven B (1989). A model to decrease hepatic blood flow and cardiac output with pressure breathing. Clinical Pharmacol. Ther. 45 (5): 548 552. Place B (1997). Using Airway Pressure. Nursing Times. 93 (31): 42-44. Romand J and Donald F (1995). Physiological effects of continuous positive airway pressure (CPAP) ventilation in the critically ill. Care of the Critically Ill.11 (6): 239 242. Shochat T, Loredo J and Ancoli-Israel S. (2001). Obstructive Sleep Apnea: Sleep Disorders in the Elderly. Current Treatment Options in Neurology. 3(11): 19 - 36 Simmonds S, (1994). Non-invasive respiratory support. British Journal of Intensive Care. 4(7): 235 - 241. Taylor A, Rehder K, Hyatt R, et al., (1989). Clinical Respiratory Physiology. W B Saunders Company, Philadelphia. Tonneson (1996) Critical Care Handbook: Respiratory System. Departments of Aneshesiology & Surgery. University of Texas Medical School. Houston. (Website) Yap W and Fleetham J (2001). Central Sleep Apnea and Hypoventilation Syndrome. Current Treatment Options in Neurology. 3 (1): 51 56

ACKNOWLEDGEMENT This policy is adapted from one originally produced by Nottingham City Hospitals NHS Trust, specifically Sue Bowler.

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Date: December 2006 Version: 2.3.1 Review date: December 2009

Royal United Hospital Bath NHS Trust Guidelines For The Use Of Continuous Positive Airway Pressure (CPAP) Systems CONSULTATION CHECKLIST Author, please attach this to each copy of the policy being sent to a meeting for comments. Dear Chairman, please would you review this policy at your committee and return any amendments / comments to ____________________________ by _____ / _____ / _____ Title of meeting ______________________________________ Date of meeting Name of policy Name of author ______________________________________ ______________________________________ ______________________________________ Yes Are there any elements of this policy which present operational issues that require further discussion? If yes, please provide a contact name for the author. ___________________________________ Is the policy referenced? Does the policy include a training plan? If you are the appropriate forum, have the necessary resources been agreed to implement this policy? Is there a plan for policy implementation? Does your meeting recommend further consultation with groups or staff other than listed at the front of the policy? Other comments from meeting. No N/A

Policy accepted without further comment. (Please circle) Yes / No Policy needs further amendment. (Please circle) Yes / No Name of Chair __________________________ Signature ________________________ Date _____ / _____ / _____

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Date: December 2006 Version: 2.3.1 Review date: December 2009