Neonatal Respiratory Distress Including
CPAP
Clinical Learning Resource
Response Booklet
January 2015
Neonatal respiratory distress including CPAP: Clinical Learning Resource Response Booklet
Published by the State of Queensland (Queensland Health), January 2015
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Neonatal Respiratory Distress including CPAP: Response Booklet for CLR V2
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Contents
Overview of the resource ................................................................................... 4
How to use this response booklet....................................................................... 4
Assessment ........................................................................................................ 4
Resources required to complete the package .................................................... 5
Unit 1:
Physiology of Respiratory Distress of the Newborn ........................... 6
Activity 1 ..................................................................................................... 6
Unit 2:
Physiology of CPAP .......................................................................... 8
Activity 2 ..................................................................................................... 8
Activity 3 ..................................................................................................... 9
Activity 4 ................................................................................................... 11
Clinical Scenario ................................................................................................ 11
Unit 3:
Humidification of CPAP ................................................................... 15
Activity 5 ................................................................................................... 15
Activity 6 ................................................................................................... 16
Unit 4:
Complications of CPAP ................................................................... 17
Activity 7 ................................................................................................... 17
Clinical Scenario ................................................................................................ 17
Activity 8 ................................................................................................... 19
Activity 9 ................................................................................................... 20
Unit 5:
Nursing Care of the Baby on CPAP................................................. 21
Activity 10 ................................................................................................. 21
Activity 10.1 .............................................................................................. 23
Activity 10.2 .............................................................................................. 25
Activity 10.3 .............................................................................................. 26
Activity 10.4 .............................................................................................. 27
Activity 10.5 .............................................................................................. 28
Activity 11 ................................................................................................. 29
References ....................................................................................................... 33
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Overview of the resource
This Clinical Learning Resource Package Response Booklet is to be used in
conjunction with the Neonatal respiratory distress including administration of CPAP
CLR and response booklet. Please review the contents of the learning resource
package and answer in the appropriate spaces within this response booklet.
How to use this response booklet
To use this response booklet:
 Read through the reading material, including recommended readings and related
policies and guidelines
 Complete written activities within this booklet and discuss your answers with a
resource person
 Complete the clinical skills assessment tool (Appendix 4) on completion of this
package
Assessment
Assessment of this resource package response booklet will be demonstrated through
successful completion of specific activities utilising the resources provided or identified
throughout the CLR, or others available from your Hospital Health Service /Facility.
Resource staff, Clinical Facilitators or Nurse Educators should review and discuss the
responses of all activities listed in the CLR to determine knowledge and awareness of
the specific issues addressed. To gain competency for administering CPAP to
neonates, the following must be completed:
 Completion and assessment of this CLR response booklet
 Successful completion of the Clinical Skills Assessment Tool (CSAT) will be upon
direct supervision by a Resource Person, Clinical Facilitator or Nurse Educator
competent in the care of the baby on CPAP in accordance with the Clinical
Assessment Guidelines within the package.
Completion of this resource package and associated competency is optional for
nurses/midwives with previous experience in the care of the baby requiring CPAP, i.e.
previous completion of an accredited education program in neonatal nursing, including
recent experience in the care of the baby requiring CPAP.
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Resources required to complete the package
 Recommended readings or textbooks
 Access to QHEPS
 Access to Health Service Policy website
 Resource person or Clinical Facilitator or Nurse Educator
 Queensland Clinical Guideline - Neonatal respiratory distress including CPAP
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Unit 1: Physiology of Respiratory Distress of the
Newborn
Activity 1
Utilising the information in your reading and the Queensland Clinical
Guideline Neonatal respiratory distress including CPAP1 answer the
following in your response booklet:
a) Identify the clinical signs of respiratory distress of the
newborn
b) List the major causes of respiratory distress of the newborn
and identify for each cause, rationale for why it happens
1a) Clinical signs of respiratory distress
1b) Major causes of
respiratory distress
Rationale for why it happens
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1b) Major causes of
respiratory distress
continued
Rationale for why it happens
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Unit 2: Physiology of CPAP
Activity 2
Cathy has just started work in the nursery and you are assigned to
preceptor her on her first day caring for a baby on CPAP. Below
please describe how you would teach Cathy the following:
a) The main respiratory issues that CPAP is used for
b) How CPAP reduces babies’ respiratory symptoms
Main respiratory issues and how CPAP reduces symptoms
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Activity 3
Cathy comments that she is unfamiliar with using short bi-nasal
prongs and bubble CPAP. After a demonstration applying these
devices and caring for a baby on these types of CPAP she asks you
about the advantages and disadvantages of each system. Using an
evidence based approach document your response below
Short bi-nasal prongs
Advantages
Disadvantages
Mask CPAP
Advantages
Disadvantages
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Bubble CPAP
Advantages
Disadvantages
Ventilator CPAP
Advantages
Disadvantages
Nasopharyngeal Tube
Advantages
Disadvantages
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Activity 4
Read through the following clinical scenario and answer the
subsequent questions.
Clinical Scenario
Lucy was born in a tertiary referral centre, at 28 weeks gestation via caesarean section,
after her mother’s pregnancy induced hypertension dramatically worsened. Today, five
weeks after birth, she has been transferred to the Level 2 nursery for ongoing care.
The Nurse/Midwife taking over the care of Lucy noted that on the discharge summary
from the tertiary centre, Lucy was ventilated for 7 days and then extubated to nasal
CPAP via an infant ventilator.
4
a)
Using the above scenario, please consider and respond to the following
questions.
Why would you elect to not use ETT CPAP?
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4
b)
Using the above scenario, please consider and respond to the following
questions.
Is nasal CPAP immediately after extubation in preterm infants necessary?
(Refer to the Cochrane Library for the most recent systematic review). Write
your conclusions here:
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Reference
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Reading further into Lucy’s discharge summary, it is noted that a couple of days after
having her CPAP ceased, she was recommenced on CPAP for apnoea of prematurity.
4
c)
Using the above scenario, please consider and respond to the following
questions.
Referring back to Reading 2 and 4, identify how CPAP may reduce apnoea in
infants with this condition.
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Unit 3: Humidification of CPAP
Activity 5
Inadequately humidified ventilatory gases delivered to intubated
babies can cause significant respiratory morbidity. Explain seven
(7) respiratory changes that occur as a result of poor humidification.
Seven respiratory changes due to poor humidification
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Activity 6
Consider the management of humidification for ventilation of gases in
your nursery. Review your nursery’s policy and practices and examine
the configuration of the circuit used in the nursery. Using your
readings and appendix 3, answer the following questions.
Where is/are the heater
wire/s located?
Where is the gas
temperature probe
positioned? Why?
Which of the inspiratory and
expiratory limbs is positioned
uppermost at the manifold?
Why?
Set temperature for water
chamber/inspiratory gas? Is
there a deliberate
differential? Why?
Is rain-out ever a problem
with the configuration used
in the nursery? Identify the
circumstances (i.e.
environmental temperatures)
when this occurs and how
this could be corrected.
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Unit 4: Complications of CPAP
Activity 7
Read through the following clinical scenario and answer the
subsequent questions.
Clinical Scenario
Daisy was born in a regional hospital at 41 weeks gestational age via caesarean
section. Daisy’s mother had reported decreased fetal movements and upon
examination was found to have poor CTG readings leading to an emergency
caesarean section. Daisy was born in poor condition with Apgar’s of 3 at 1 minute and
7 at 5 minutes. She required bag and mask intermittent positive pressure ventilation
(IPPV) and by ten minutes of age was pink and active.
Though Daisy was breathing, she had moderate chest recession, nasal flaring, and
occasional grunting. Daisy was commenced on CPAP with additional oxygen and was
taken to the Special Care Nursery. Shortly after, she was commenced on IV antibiotics
for her respiratory distress. One hour later, Daisy’s pulse oximetre was alarming and
suggested sudden desaturation into the 70’s. Upon closer inspection, the nurse
observed that though Daisy was still breathing, she had cyanotic lips and a general
dusky appearance. The nurse suctioned Daisy’s mouth and increased her oxygen.
Daisy’s oxygen saturations did not improve; the nurse pressed the emergency alarm
and the paediatrician attended. A chest x-ray was ordered while the doctor examined
Daisy. Auscultation showed decreased breath sounds on the right side, and a slight
chest asymmetry. Chest x-ray confirmed the diagnosis of tension pneumothorax and
insertion of an intercostal catheter (ICC) was performed using a sterile technique.
Daisy was later weaned back to 21%FiO2 and two days later had the ICC removed.
Reflecting on the above scenario, please answer the following questions.
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7
Identify eight (8) clinical signs of a pneumothorax
a)
7
b)
Discuss the required nursing care of Daisy after insertion of an ICC.
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Activity 8
Consider the current nursing management of abdominal distension
and the prevention strategies used in your nursery.



How often do babies in your nursery have gastric aspirates?
Is gastric venting a routine procedure?
How do you differentiate between CPAP belly and signs of
NEC?
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Activity 9
Consult the Queensland Clinical Guideline: Neonatal respiratory
distress including CPAP1 and complete the activity below.
9
Identify the signs of failure of CPAP as described in the guideline and the
nursing actions that would be initiated
a)
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Unit 5: Nursing Care of the Baby on CPAP
Activity 10
Utilising your readings and local resources, list the measurements
needed to determine the appropriate equipment size to minimise
trauma and maximise efficacy of CPAP (Prior to application)
CPAP type
Measurements needed prior to CPAP application
HudsonTMProng CPAP
Mask CPAP
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Fisher & PaykelTM
Midline or ‘snorkel’
CPAP
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Activity 10.1
In an effort to minimise nasal trauma, how do you ensure the
following?
a) Right sized prongs (fit)
b) Position prongs
appropriately
c) Prongs are secure (bonnet
size)
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d) Infant positioned for
comfort and containment
e) Prevent ‘drag’ on nares by
circuit tubing
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Activity 10.2
In order to address airway patency, how would the following
strategies be addressed?
a) Removal of nasal
secretions
(frequency/technique)
b) Prevention of drying of
secretions
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Activity 10.3
In order to maintain mean airway pressure, how will the following
strategies will be addressed?
a) Maintain prongs in nares
b) Prong size prevents air
leak
c) Minimise and address
oral air leaks
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Activity 10.4
In an effort to reduce gastric distention, how would you address the
following?
a) Nursing assessment of
the baby’s abdomen
b) Gastric decompression
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Activity 10.5
Despite the increased pressure Jack shows no signs of
improvement. Outline below why higher levels of CPAP may not
improve Jack’s condition.
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Activity 11
In your response booklet, formulate a nursing care plan based on
Jack’s scenario. Utilise the QCG, local policy, readings provided
within this package and nursing experience to formulate a plan of
care for baby Jack. Some ideas have been put in below to get you
started……
CPAP Cares (frequency,
equipment required)
Frequency of positioning
changes
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Skin assessment
Cardiorespiratory
assessment
Kangaroo cuddle
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Communication with family
Suction
Feeds
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Analgesia
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References
1. Queensland Clinical Guidelines. Neonatal respiratory distress including CPAP. 2014:1-21.
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