using continuous positive airway pressure (cpap) in an

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1000 mlREF 3K87114ENG Sterile Water for IrrigationUROMATIC container HypotonicNonpyrogenic Not for injectionCautions: — Do not use unless solution is clear and container is undamaged— Discard unused content of opened container— Do not heat this container above 65°CFRA Eau sterile pour IrrigationPoche UROMATIC HypotoniqueApyrogene Ne pas injecterPrecautions: — Utiliser uniqument si la solution est limpide et la poche non — Discard unused content of opened container endommagee— Eliminer toute poche partillement utilsee— Ne pas chauffer le poche a plus de 65°CGER Steriles Wasser zum SpulenUROMATIC Beutel HypotonischPyrogenfrei Nicht fur injektionszweckeAchtung: — Nur verwenden, wenn Losung klar und Beutal intakt ist— Losungsreste von geoffneten Beutein entsorgen— Beutal nicht auf uber 65°C erhitzenITA Aqua sterile per IrrigazioneContenitore UROMATIC IpotonicaA pirogeno Non per iniezioneAvventenze: — Non usare se la soluzione non e limpida e se la sacca e danneggiata— Gettare il contenuto inutillzzato delle sacche aperte— Non riscaldare il contenitore al di sopra di 65°C

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Respiratory CareAdults

Using continuous positive airway pressure (CPAP) in an acute setting (e.g. for COVID-19)

Demonstrated by Gerard Nation, Charge Nurse in Intensive Care, Royal Brompton Hospital, London

©2021 Clinical Skills Limited. All rights reserved

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

Patients who are unable to breathe without assistance, or whose respiratory effort is not sufficient, may benefit from respiratory support. This support may be invasive, via an endotracheal tube, for example, or non-invasive, in which the patient receives air, usually with added oxygen, under positive pressure. One form of non-invasive respiratory support is continuous positive airway pressure (CPAP), in which positive airway pressure is applied throughout the whole respiratory cycle (Nicholson et al., 2020).

CPAP increases pulmonary gas exchange by splinting (holding open) the lower airways in patients with atelectasis (collapsed lung) or hypoxaemic (type 1) respiratory failure who are able to breathe spontaneously. CPAP is also used to splint the upper airway in patients with sleep apnoea (Nicholson et al., 2020).

CPAP is available in both community and acute settings and may be delivered via a ventilator or a CPAP device; the healthcare professional needs to be familiar with the devices used locally, or be supervised by someone who is. The CPAP circuit will include either a humidifier or a heat and moisture exchange (HME) filter; this must be compatible with the ventilator/CPAP device. CPAP is applied via a face mask, nasal mask or helmet, or through an endotracheal or tracheostomy tube. Early application of CPAP may provide a bridge to mechanical ventilatory support, or help in weaning patients from invasive ventilation (NHS England/NHS Improvement, 2020a). These pages show the delivery of CPAP using a ventilator in an acute setting.

Treating patients with COVID-19CPAP is the preferred form of non-invasive respiratory support for COVID-19 patients with hypoxaemic respiratory failure. High-flow nasal oxygenation is not advocated in COVID-19 patients due to lack of evidence for its efficacy, high oxygen consumption and potential infection risk (NHS England/NHS Improvement, 2020b). When using CPAP to treat patients with COVID-19, follow local policy and practice. Ideally, CPAP for such patients should be delivered in a negative pressure room, or failing that a neutral pressure room with air cycling, but this may not always be possible. Ensure that there is a bacterial/viral filter in the circuit between the mask and the oxygen and exhalation ports to reduce droplet spread; regularly check the filter and change it every 24 hours or if it becomes saturated, as this can be mistaken for clinical deterioration (NHS England/NHS Improvement, 2020a). Use heated humidifiers with caution: they can cause rapid saturation of in-line filters (NHS England/NHS Improvement, 2020a; 2020b; MHRA/NHS England, 2015).

It is important to involve experienced clinicians in making an early decision about what the ceiling of care should be, including when/if to offer ventilatory support; the patient and their family must be involved in this discussion (NHS England/NHS Improvement, 2020a). The National Institute for Health and Care Excellence (NICE) recommends using a clinical frailty score, involving palliative care teams, and having a treatment escalation plan (NICE, 2021).

Setting up the CPAP system

The CPAP device or ventilator provides a defined flow of air and oxygen to the patient, which is warmed and humidified before passing through to the face mask, where the patient breathes it in. When the patient breathes out, the CPAP device or ventilator maintains a specified positive pressure to prevent the patient breathing out fully. When initiating therapy, set up the system according to the manufacturer’s instructions and local policy, making sure that all connections are secure. Do not use any equipment that is overdue for maintenance. Make sure that you are familiar with the equipment you are using and that you know whether it has alarms or if you will need to carry out regular checks for malfunctions.

The �lter at the patient end should be not an HME if using a humidi�er.

Respiratory Care

Adults

Using CPAP in an acute setting (e.g. for COVID-19)

Page 2 of 8


Use pic 2 and 3 from page at LHS to create more explanatory/graphic account of how pulmonary gas exchange works

At sea level, the partial pressure (concentration) of oxygen is 13.7 kPa in the alveolar air. In the arriving capillary blood, it is 5.3 kPa. The alveolar wall is only 0.5 micrometres thick, presenting very little barrier to diffusion, so oxygen diffuses down the concentration gradient from the air into the blood. More than 98 per cent of the oxygen binds to haemoglobin in the red blood cells. The rest dissolves in the blood plasma. Carbon dioxide passes in the opposite direction, from the blood to the alveolar air. In the arriving capillary blood, the partial pressure of carbon dioxide is 5.9 kPa. In the alveolar air, the partial pressure of carbon dioxide is 5.3 kPa, so the carbon dioxide diffuses down the concentration gradient from the blood into the air.

For pulmonary gas exchange to take place efficiently, the amount of air reaching the alveoli per minute (ventilation or V) must match the required amount of blood reaching the alveoli per minute (perfusion or Q). The relative amounts are known as the V/Q ratio, and this ratio is normally about 0.8 (1:1.25). A V/Q mismatch occurs when perfusion of the lung tissue is normal, but part of the lung is not ventilated. For example, atelectasis (the collapse of all or part of a lung) reduces ventilation because fewer alveoli are available for gas exchange; this causes a V/Q mismatch.

Capillaries

Venous (deoxygenated) blood

Alveolar sac

Alveolar duct

CO2

O2

Oxygenated blood

For oxygen to be breathed in and carbon dioxide to be breathed out, two requirements must be met: ventilation and perfusion. During ventilation, air must enter and then leave the alveoli, as a result of inspiration and expiration. Secondly, red blood cells must perfuse the basket-like mesh of blood capillaries that surrounds each alveolus. As a result, the red blood cells can release the carbon dioxide bound to their haemoglobin molecules and bind with oxygen instead.

13.7 kPa5.3 kPa

OxygengradientCarbon

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Oxygen moleculeCarbon dioxide moleculeAlveolar space Alveolar wallAlveolusBronchiole

Alveolar wall

Capillary

Capillary

Requirements for pulmonary gas exchange

V/Q ratio and V/Q mismatch

How pulmonary gas exchange takes place

Respiratory Care

Adults


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Trachea

Intercostal muscles

Bronchi

Pleura

Ribs

Collapsedlung

Atelectasis is usually most pronounced in the left lower lobe and it may affect as much as 30–70 per cent of basal lung tissue. Atelectasis is a common feature following cardiothoracic surgery/cardiopulmonary bypass. The risk of atelectasis increases with length of time of surgery, opening of the pleura, postoperative diaphragmatic dysfunction, postoperative immobility and postoperative pain.

Atelectasis and other indications for CPAP

Pulmonary shunting: a result of V/Q mismatch Pulmonary oedema

A V/Q mismatch can cause deoxygenated blood to flow from the right side of the heart to the left, without taking part in gas exchange in the pulmonary capillaries. This is known as intrapulmonary shunting, and is the main cause of hypoxaemic respiratory failure.

In pulmonary oedema, fluid collects in the pulmonary capillary network and in the lung tissue and alveoli. This fluid puts pressure on the alveolus, which starts to collapse. As with atelectasis, pulmonary oedema reduces the surface area for gas exchange. Oxygenation of the blood is reduced.

In atelectasis and pulmonary oedema, the alveoli tend to collapse on expiration, making it more difficult to inflate them when the person breathes in again. CPAP supplies oxygen under pressure, so that not all the air leaves the alveoli on expiration. As a result, the person can more easily inhale on the next breath—just as it is much easier to blow up a balloon that is already blown up a little than one that is completely deflated (Pierce, 2006; Pierce, 1995). The pressure remaining in the alveoli at the end of expiration is known as the positive end expiratory pressure (PEEP). During CPAP, the PEEP will be set at a higher than normal level, depending on the patient’s oxygenation. As a result, the patient’s work of breathing is dramatically reduced, the alveoli do not collapse, and gas exchange is improved.

This is the caption for this image as used on previous version and follows on from previous image on Pulmonary oedema but suggest we edit the image to tie in woth thr caption below, wdyt?

move contraindications here if possible (currently on page 4)

• Undrained pneumothorax;• Surgical emphysema;• Severe facial injuries/burns;• Fracture to the base of the skull or elevated intracranial pressure; • Paralytic ileus or abdominal distension (without a nasogastric/ orogastric tube);• Recent upper gastrointestinal surgery;• Unstable cardiovascular state;• Altered level of consciousness/inability to protect the airway;• Life-threatening hypoxaemia;• Anxiety/confusion.

Contraindications for CPAP

• Atelectasis (collapsed lung) following cardiothoracic surgery;• Hypoxaemic (type 1) respiratory failure, e.g. due to COVID-19;• Chronic congestive heart failure;• Weaning from invasive ventilation;• Sleep apnoea; and • Pre-existing respiratory disease.

Indications for CPAP

Positive end expiratory pressure = 0

Positive end expiratory pressure = +10

Engorged capillary

Collapsed alveolus

How CPAP helps to reduce the work of breathing

Confirm that the patient has a prescription for oxygen. Check the target oxygen saturation value (inset) (O’Driscoll et al., 2017). (Refer also to the relevant clinicalskills.net procedures on “Oxygen therapy”.) Select the flow rate and oxygen concentration prescribed by medical staff.

STOP

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RESPIRATORY PRECAUTIONS

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SMALL MEDIUM LARGE Negative aspects of CPAP treatment• Cough suppression;• Drying of the airways if humidification is inadequate, and subsequent increased risk of nosocomial infection, tissue damage, discomfort;• Claustrophobia;• Pressure sore development (on the bridge of the nose, ears, etc.);• Air entrainment into the stomach and subsequent increased risk of vomiting/aspiration. Insertion of a nasogastric tube may help, in order to decompress the stomach;• Exacerbation of pneumothorax;• Increased agitation and distress;• Interference with activities of daily life, such as eating, drinking, communicating and mobility;• CPAP using higher levels of PEEP has the potential to reduce venous return/preload and cardiac output.

Procedure: decontaminate hands and select PPE Explain the procedure to the patient

Target Saturation:94Route:InhaledIndication:

Prescribing Info:Start with low dose oxygen (usually 1-4litres nasal) and titrate to keep saturations in target range. In oxygen sensitive patientsuse 24% or 28% Venturi (blue/white) and repeat blood gas at 30 minutes or any time that oxygen concentration is increased

98 %To: Unit:

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First NameLast NamePrescription Date Prescribing Provider29/05/2021

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001 SHMELLY AIREY

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Discuss concerns and gain consent Record observations before starting CPAP

Perform hand hygiene. Select the personal protective equipment (PPE) you will need according to your risk assessment. CPAP is an aerosol-generating procedure, so if the patient is known or suspected to have COVID-19, you will need to use the appropriate PPE. (See also clinicalskills.net procedure, “Putting on and taking off PPE for COVID-19”.)

Explain CPAP to the patient and what the treatment involves. Discuss the benefits and drawbacks (see above), the possible duration of treatment and the possible outcomes, including what may happen if it is necessary to escalate care.

Record a full set of observations, including oxygen saturations, before starting CPAP (see next page), and record these on a National Early Warning Score 2 (NEWS2) chart (RCP, 2017).

Discuss any concerns and agree how to communicate once the mask is on: a notepad and pen may be useful (inset). Gain consent. Make sure the patient has a call bell in working order within easy reach.

Tick if saturation not indicated

(Saturation is indicated in almost all casesexcept for palliative terminal care)

88-92% 94-98% Other

Circle target oxygen saturation

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Respiratory Care

Adults


Page 4 of 8

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.O

2

Set PEEP to the correct pressure on the ventilator/CPAP device. For some CPAP devices, you will need to connect the appropriate PEEP valve to the mask (inset), according to the clinician’s directions and local policy. Follow the manufacturer’s instructions.

ARNING:

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Check that the circuit is functioning correctly, by holding the mask against your gloved hand to feel for gas flow. Either ask the patient to hold the mask against their face, or hold it to their face and press gently, while reassuring them.

Any patient requiring oxygen therapy is dependent on a reliable oxygen and air supply. As part of the safety checks, ensure the oxygen and air hoses are securely plugged into the correct wall outlets (or gas cylinders) and that flow meters are in working order for alternative oxygen delivery during breaks from CPAP (see clinicalskills.net series on “Medical gases”).

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Fit and secure the mask

Continuous monitoring: (a) Cardiac monitoring

Check that the mask is the correct size for the patient. Once the patient has become used to the feel of the mask, secure it in position using the head straps. Avoid securing the straps too tightly, to prevent discomfort and trauma to the facial skin, particularly behind the ears and on the bridge of the nose.

Check the seal on the mask and that there are no leaks. The patient may be able to tell you if gas is escaping from around the mask. If necessary, use padding around the mask to help it fit snugly. Make the patient comfortable; reassure the patient that you will be checking on them frequently. The screen on the CPAP machine will show the selected PEEP, e.g. 5 cm H2O.

It is vital to ensure that the patient is never connected to the system without gas flow, as this could increase the work of breathing, with a potential risk of suffocation.

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Carry out continuous pulse oximetry monitoring (NHS England/NHS Improvement, 2020a). Monitoring should be reviewed every 24 hours and will continue until the patient is able to tolerate significant periods without CPAP. Check that the patient’s SpO2 shows an improving trend.

(b) Pulse oximetry

Respiratory Care

Adults

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Using CPAP in an acute setting (e.g. for COVID-19) Page 5

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Patients receiving CPAP in the acute setting will require continuous monitoring, with appropriate alarm settings to alert staff to any changes that may occur. Carry out continuous cardiac monitoring and review this every 24 hours, until the patient is able to tolerate significant periods without CPAP.

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†ONLY use Scale 2 under the direction of a qualified clinician

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(c) Arterial blood gas measurements Record cardiorespiratory observations

Additional observations

Check that the patient is comfortable Provide appropriate nursing care

Obtain arterial blood gas measurements in patients at risk of hypercapnia, and as guided by local policy. Many patients in the intensive care unit will have an arterial line, making it easy to obtain an arterial sample for blood gas analysis. If available, obtain an arterial blood gas sample 1 hour after starting CPAP, or follow local policy.

In addition to routine observations on the NEWS2 chart (RCP, 2017), assess chest wall movement and accessory muscle use; coordination of respiratory effort with the CPAP machine; chest pain or other indicators of myocardial ischaemia; and mental state. Check the colour of the patient’s mucous membranes and lips (inset).

Regularly check that the CPAP system is working correctly, following the manufacturer’s instructions. In addition, check regularly that the system is free from obstruction, that there are no leaks, and that all visible parts are working correctly. Check for accumulation of water in water traps (left inset) or kinks in tubing (right inset); these checks would normally form part of the hourly check of all devices in ICU.

Record full cardiorespiratory observations 15 minutes after starting therapy to assess response, then at 15-minute intervals for the first hour, every 30 minutes for the next 4 hours, and hourly for the next 12 hours, or follow local policy. Record the patient’s respiratory rate, work of breathing, saturation of peripheral oxygen (SpO2), heart rate and blood pressure.

Provide nursing care for the patient as appropriate. Consider positioning, chest physiotherapy, eye care and mouth care. Where possible, provide personal care during breaks from CPAP therapy (see page 7).

Check frequently that the patient is comfortable. Check the mask regularly to ensure that it is delivering the optimal flow of oxygen at the required pressure.

Check the CPAP system regularly



Page 6 of 8


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ID Label or

Name

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Date of Birth Date Fluid requirement/fluid restriction=

FLUID BALANCE CHART

Fluid Input Fluid Output

TIME Enteral/Oral intake Urine Bowel Gastric Drain ml mlIntravenous meds/

fluids Cumulativebalance+/-

Runningtotal(IN)

Runningtotal

(OUT)07:0008:0009:0010:0011:0012:0013:0014:0015:0016:0017:0018:0019:0020:0021:0022:0023:0024:0000:0001:0002:0003:0004:0005:0006:00TOTALS

Jones, R 758901 20/03/52 02/05/2021

20 mL water

20 mL water

100 mL water

50 mL water

20 mL 35 mL 200 mL

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Provide regular breaks from CPAPBe alert to when you may need to remove the mask

Cluster personal care during breaks

Administration of medication Monitor fluid balance

Consider the need for regular breaks from CPAP to allow the patient to have nursing care, meals, drinks, medication and physiotherapy. Always have a high-flow oxygen mask to hand, monitor the oxygen saturations during these breaks, and replace the CPAP promptly if the patient’s condition deteriorates following its removal.

During breaks from CPAP, cluster care together, such as mouth care, and providing drinks and food, to minimise the patient’s time off the mask.

Check for red areas of skin caused by pressure of the mask: use pressure-relieving material and skin creams to relieve or reduce the risk of skin damage caused by prolonged full face mask usage. It may be appropriate to involve a tissue viability nurse, or consider a hood as an alternative to a face mask.

Check the fit of the mask

Monitor the patient’s oral and dietary intake, using a fluid balance chart to assist with hydration assessment.



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Remove the mask immediately if the patient develops claustrophobia or finds wearing the mask intolerable, or develops respiratory arrest, abdominal distension, nausea, vomiting or pneumothorax, or if intubation is required for advanced life support. Have a high-flow oxygen mask ready, and apply it if you can. Monitor oxygen saturations. Call for help in an emergency.

Interrupt CPAP temporarily to give prescribed medication, including inhaled medication such as bronchodilators. The clinician may prescribe low doses of benzodiazepines to treat anxiety in patients who are distressed by the treatment and not responding to psychosocial support measures (WHO, 2021). Consider non-pharmacological and pharmacological measures for dyspnoea that is refractory to treatment of the underlying cause (WHO, 2021).

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Patient Notes ? X

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General Notes

Bedside safety checks completed at start of shift.Mr Jones has been started on CPAP as a result of arterial blood gas analysis showing hypoxaemia. His chest X-ray shows that he does not have a pneumothorax. His response to CPAP has been documented on the observations chart. Mr Jones tolerates up to 10 minutes off CPAP for drinks and eating and mouth care. High flow oxygen mask provided to tolerate being off CPAP during this time.Mr Jones is tolerant and comfortable, and his progress will be reviewed at 11am or sooner if clinically indicated.

Allergy Notes



Check the oxygen supply when restarting CPAP Psychological care

Duration of therapy Weaning

Documentation

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After each episode of care, remove your PPE and dispose of it according to local policy. Decontaminate your hands. Throughout, record the care given in the patient’s notes.

If the patient’s condition is not improving or is deteriorating, the doctor may want to consider ventilation with endotracheal intubation instead. The full face mask should be kept in place right up to the point of endotracheal intubation, if possible, to maximise oxygenation. The decision not to intubate should be taken by a consultant (NHS England/NHS Improvement, 2020a).

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Consideration of intubation

Improvements in respiratory rate, heart rate, neurological state and arterial blood gas parameters may be evident within 4 hours of starting therapy, depending on the severity of the patient’s condition (NHS England/NHS Improvement, 2020a). However, CPAP therapy will continue until the underlying cause is starting to reverse. Pneumonitis takes over a week to resolve, and CPAP for this duration may be challenging for the patient.

CPAP therapy in acute situations will usually continue for a few days to a week or more. A trial of weaning CPAP to conventional oxygen therapy can be considered when the oxygen concentration needed to achieve target oxygen saturation falls below 40%. Patients may still require CPAP at night for a few days.

Check the oxygen supply is reconnected correctly when removing the oxygen mask and restarting CPAP.

Psychological care is very important: monitor the patient for signs of anxiety and provide reassurance. Try to encourage the patient by explaining how the treatment is helping them. High-quality nursing care, involvement of psychological support services, and pharmaceutical agents, can all help the patient to tolerate therapy, reducing the risk that endotracheal intubation may become necessary.

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