Big Change for Little Lungs

In the late 1990s, high-tech machines came on the market to deliver continuous positive airway pressure (CPAP) to newborns struggling to breathe, pushing aside the simpler standard of noninvasive ventilation, bubble CPAP. However, over the past several years, some of the largest neonatal ICUs in the country have returned to their roots. Turns out that simpler sometimes is better. These hospitals are now of the belief that aggressive early use of the older bubble CPAP more effectively supports infants in need.

Bubble CPAP supports spontaneous breathing by delivering a continuous, pressurized gas flow to an infant’s airway via nasal cannula or prongs. The gas is humidified and enriched with oxygen. The pressure is controlled by simply adjusting the depth of a partially submerged tube attached to the end of the infant’s breathing circuit. Bubble CPAP provides additional benefits over conventional mechanical CPAP systems because as the gas exits the submerged tube it forms bubbles that create small airway oscillations. The oscillations are transmitted to the patient’s lungs and are thought to improve gas exchange, enhance lung recruitment and reduce work of breathing.

Archive ImageA
Archive ImageA

SKIN-TO-SKIN: (top)Clinical staff was taught to promote skin-to-skin contact as much as possible with parents and their infant when the device is in use. Here a mom holds her infant while Kathy Tigner, RRT (left) and Jeanette Cammarata, RN, check the connections of the bubble CPAP. photo courtesy WakeMed Health& Hospitals NURSERY DUTY: (bottom)Unlike traditional CPAP machines, the bubble CPAP doesn’t have electronic alarms so therapists and nurses have to be nearby to ensure the bubbling never stops. For every shift, a respiratory therapist covers the nursery. Here, Kathy Tigner, RRT, checks the unit while mom and Jeanette Cammarata, RN, check the infant. photo courtesy WakeMed Health& Hospitals

About two years ago, WakeMed Health and Hospitals flagship medical center in Raleigh, N.C., introduced bubble CPAP to nurses and respiratory therapists in its level IV 48-bed NICU. After seeing its success firsthand, Michele Snyder, MD, WakeMed neonatologist, championed for the therapy to be brought to the level III eight-bed NICU within the Special Care Nursery at the health system’s campus in Cary, N.C., where she is the medical director.

“She felt it was important for us to deliver the same level of care as the NICU in Raleigh,” said Andrea Garganese, BSN, RN-C, nurse supervisor and educator in the Special Care Nursery at the Cary campus.

SEE ALSO: Ventilatory Strategies for Newborns

Bruce Handley, MA, MPH, RRT, director of cardiovascular services at Cary, noted it’s rare for a community hospital to implement this therapy. Babies in Raleigh’s NICU are typically more critical and in greater need of support, but having this option in Cary is vital. “Bubble CPAP is now best practice for noninvasive infant ventilation,” he said. “It’s a major shift in theory and practice of how we care for this population, and there are a lot of benefits to this therapy.”

Bubble Benefits

Like other forms of CPAP, bubble CPAP helps to reduce the effort of breathing and improve gas exchange. Bubble CPAP, however, has stood out to its predecessors in studies. Researchers have found with bubble CPAP, there is a reduction in the need for invasive mechanical ventilation, a reduction in the incidence of bronchopulmonary dysplasia, and less of a need the baby would need to be intubated. It’s quieter, and the gentle bubbling pressure of the humidified air causes less damage to the infants’ lungs in the long term.

Bubble CPAP consists of three components and is very inexpensive compared to mechanical systems. All that is needed is nasal prongs or cannula sized for the infant, humidified and blended oxygen, and a column of fluid.

Unlike traditional CPAP machines, the bubble CPAP doesn’t have electronic alarms. Therapists and nurses have to be nearby to ensure the bubbling never stops. The reduction in noise, however, and the gentle bubbling effect allows the infants to sleep soundly.

“For every shift, we have one respiratory therapist covering the nursery,” Handley said. “Therapists and nurses have to be really vigilant when using the bubble CPAP. If it suddenly stops bubbling, we may have to adjust the tubing in the water, or adjust the cannula position, and confirm a patent airway.” Clinicians also have to keep a close eye on the skin around the nasal cannula prongs to ensure there is no breakdown.

Since WakeMed Cary Hospital began using this in January 2014, 10 babies have needed it, the first of whom received it just three weeks after the go-live date. On average, the infants require the CPAP respiratory support anywhere from 24 hours to several weeks.

“This is what I call one of our high-risk, low-volume therapies,” Handley said. “We have to continue practicing it and renewing our knowledge, so when we do have infants who need this, we’re ready for them.”

Staff Education

Last year, to prepare staff to use the four bubble CPAP set-ups, clinical experts were utilized throughout WakeMed. A neonatal nurse practitioner and Cary respiratory therapists helped to educate the staff. Super users from Cary went to Raleigh to observe it being used firsthand and bring back what they learned about the equipment and policies to educate their peers.

Garganese noted education started with mock equipment and an infant training doll set up in the special care nursery. Here, staff learned about the device and worked to become more comfortable with the bubble CPAP, how to maintain it and practice troubleshooting. Quick drills are usually carried out in the nursery to prepare everyone for various circumstances when bubble CPAP may be needed.

In addition, Handley created a new respiratory cart with all bubble CPAP supplies neatly organized for quick access at the bedside. In early July as the nursery staff prepared for a high-risk birth, twins, the cart was ready to be deployed if needed, but the babies were born with normal respiratory rates.

“This was such a team effort between the two campuses and everyone on respiratory and the nursing staff in the nursery,” said Kristin Holmes, BSN, RN, nursery staff nurse. “We really couldn’t do it without the great collaboration.”

Archive ImageA

TEAMWORK: Respiratory therapists and nurses worked together to make the bubble CPAP program a success. From left: Jeanette Cammarata, RN, Karon Sorensen, RN, Jo-Anna Cartwright, NNP, Kathy Tigner, RRT, and Andrea Garganese, RN. photo courtesy WakeMed Health& Hospitals

Family-Centered Care

Holmes and her fellow nurses are also focused on being able to deliver family-centered care while the infants are on bubble CPAP. Clinical staff was taught to promote skin-to-skin contact as much as possible when the device is in use.

“The parents whose babies have needed this are pleased with it,” Garganese said. “We educate them about what the system is and answer any questions they have about it.”

Special Care Nursery staff continue to perfect their skills and expand their knowledge in working with infants on bubble CPAP. The mock set-ups and infant doll haven’t gone into storage, but are nearby to allow therapists and nurses to perfect their skills.

“I was nervous when I first started using it,” said respiratory therapist Kathy Tigner, BS, RRT. “It’s much more labor intensive than mechanical CPAP, but once I started using it and saw how effective it is, I became more comfortable with it and really like it.”

The goal of introducing bubble CPAP to the Cary NICU was to provide the optimum noninvasive ventilation strategy for infants with respiratory distress, explained Angela Newman, MSN, RN, CMSRN, director of the Women’s Health Pavilion.

“This was truly a collaboration of an interdisciplinary team, and hospitals working together to elevate clinical expertise to the next level,” Newman said.

Stacey Miller is a freelance writer.

About The Author