Applying Nasal Interface for Bubble CPAP

Kyonna Moore, RN, MPH and Eileen Ruske, RN
Chinstrap has to be changed every 24 hours or per manufacturer instructionsTo properly apply nasal CPAP prongs and stabilize them on the infant’s head, the following items are required:
  1. Head cap or hat
  2. Nasal Cannulaide
  3. Piece of Velcro
  4. Nasal Prongs
  5. Chin strap
  6. Neck roll
  7. Gastric tube
  8. Adhesive tapes
The above items must be ready and prepared for potential unexpected admissions. Nursing staff should be competent in applying nasal prongs as described below in a timely fashion.

Step 1: Head Cap

A head cap or a hat is needed to conserve the body temperature and to act as an anchor to stabilize the respiratory tubes on the infant’s head.

  1. An appropriate size cap as per manufacturer’s guidelines based on head circumference, or in-house made cap (i.e., from stockinette) may be used.
    Cap needs to be placed properly down over the ears and to the nape of the neck.
  2. The head cap should fit comfortably over the head. It must not be too tight to avoid causing excessive molding but sufficiently snug to stay in place. A loose hat will allow infant’s movement to dislodge the prongs.

Step 2: Nasal Cannulaide

The nasal cannulaide will create a proper seal around the nasal prongs

  1. An appropriate cannulaide size to fit the infant’s nares as per manufacturer guidelines based on head size may be used.
  2. The Velcro-like part on the cannulaide needs to be removed and the cannulaide is to be warmed by hand before use to improve adhesion.
  3. Clean and dry the nose and upper lip, then line up cannulaide holes with nares.
  4. Apply to upper lip then apply over the nose. Cannulaide should adhere to nasal surface without air pockets underneath.
    Cannulaide must be changed at least every 12 hours.

Step 3: Velcro

The Velcro is essential to help keep the prongs in place

  1. Make a “moustache” from the rough side of a piece of white Velcro.
    • Length of moustache needs to be adequate to span the lip from side to side
    • Width of moustache needs to be enough but not to touch nasal septum
  2. Apply the Velcro mustache to the patient’s upper lip on top of the Cannulaide.
    • The Velcro moustache should not touch the nasal septum.
    • The Velcro moustache side ends should NEVER touch the eye area

Step 4: Nasal Prongs

Nasal prongs should fit snuggly in the nasal apertures to create a proper seal and maintain a closed circuit from the gas source to the bubbler.

  1. An appropriate size of nasal CPAP prongs based on the infant’s weight and size of nasal apertures should be used as per manufacture guidelines. Here are a couple of examples for commonly used nasal prongs:

    Nasal Prongs Size

    Infants’ weight Hudson prongs Babi.Plus prongs
    <700g 0 0 – 1
    700g – 1250g 1 2
    1251g – 2000g 2 3
    2001g – 3000g 3 4
    >3000g 4 5 – 7
  2. Attach soft Velcro strips to both ends of the nasal prongs transverse arm at least 0.5 cm from the prongs on either side.
  3. Lubricate the prongs with sterile water, saline or infant’s saliva.
  4. Gently insert the nasal prongs with convex side down into the baby’s nares. Nasal prongs should fit nasal opening snugly:
    • Undersized prongs will fit loosely, air may leak out and no proper seal will be maintained, therefore desired pressure within the circuit will not be achieved.
    • Oversized prongs may overstretch nasal apertures causing blanching of lateral sides of nose or the nasal septum.
    • The bridge between the nasal prongs should be always kept 1-2 mm away from the nasal septum to avoid erosions.
  5. Using proper connectors and adaptors, attach respiratory tubing to either side of the nasal prongs. Blue (see chapter: setting CPAP circuit)
  6. Adjust the angle of the prongs and the position/location of the respiratory tubing until each is correctly positioned over the temporal area away from the eyes, then secure with adhesive tapes to the head cap.
  7. Attach manometer to the pressure port to monitor pressure within the circuit or place cap to close it.
  8. Nasal prongs should be examined frequently to ensure proper placement and good seal. Nasal prongs need to be revised every care and nose to be suctioned to clear secretions. Use less frequent suctioning if infant is stable on 21% FiO2.
  9. Prongs have to be changed every 48-72 hours to avoid over growth of bacteria.

Step 5: Chin Strap

A chin strap may be used to minimize air leak from the mouth and help assure a better seal of the bubble CPAP circuit.

  1. In the following conditions, a chin strap may be indicated to bring the mouth to a natural closed position:
    • infants < 26 weeks gestation
    • infants 26-28 weeks gestation who require FiO2 > 21%
    • infants > 28 weeks gestation who do not exhibit a palatoglossal seal at the open mouth posture based on the bedside assessment.
  2. Use commercially available chin straps or wrap a long piece of stockinette around the infant’s head; starting from the chin, wrap the strap on both sides of the head towards the vertex, then tie in place underneath the corrugated respiratory tubes and pull the jaw forward to close mouth.
  3. Do not tie the strap so tight so that the infant cannot move their jaw..
  4. Chinstrap has to be changed every 24 hours or per manufacturer instructions.
  5. Examine for skin breakdown under the chin straps every care (q 3-4 hours) especially soft tissue of neck below mandibles on both sides and behind both ears.
  6. A pacifier may be used with the chinstrap in place as an option to increase the infant’s comfort level.

Step 6: Neck Roll

A neck roll is essential to put the head in a mild extension position to align the tracheal opening with the upper airway. When neck is flexed gas delivery to the lungs is suboptimal. The neck roll needs to be just the right size under the neck and upper shoulders to avoid flexion or over extension.

  1. The infant needs to be in supine position with the head of bed elevated about 30 degrees.
  2. A commercially available or in house made (i.e., washcloth) neck roll may be used. The neck roll has to be soft.
  3. A gel pillow may be placed around the head for support and to stabilize position.

Step 7: Gastric tube

An orogastric tube is needed to vent the stomach from air and avoid excessive abdominal distention

  1. Place orogastric (OG) tube to desired depth according to infant’s weight and tape in place using adhesive tape or tegaderm.
  2. Leave tube open to vent air from stomach. OG tube may be clamped after bolus gastric feeding, but has to be vented 30 minutes prior to every feeding.

Step 8: Documentation

  1. A new bedside bCPAP checklist should be initiated every day at the beginning of the day shift.
  2. The bedside nurse has to complete the checklist upon initiation and every shift.
  3. 03. Bedside Management Strategies for infants on bubble CPAP05. Setup of Respiratory