Infant Flow LP nCPAP system Clinical Training Workbook

Table of contents Infant nasal CPAP...1–6 CPAP overview... 1–3 CPAP modalities...4 Variable flow technology...5 Self assessment...6 Infant Flow® SiPAP driver overview... 7–16 Infant Flow LP system...7 Infant Flow SiPAP configurations...8 Infant Flow SiPAP display screen...9 Infant Flow CPAP and circuit set-up...10 Humidification and nCPAP... 11 Airway temperature probe placement... 11 Infant Flow SiPAP sensor calibration... 12 Infant Flow SiPAP set-up guide... 13–14 Respiratory abdominal sensor... 15 Self assessment...16 Infant Flow SiPAP nCPAP driver... 17–22 Modes of operation... 17–18 BiPhasic mode strategy... 19–20 SiPAP exercises and self assessment... 21–22 Infant Flow LP generator assembly...23–27 Infant Flow LP generator...23 Infant Flow LP interfaces...24–25 Infant Flow LP fixation devices...26 Self assessment...27 Infant Flow LP patient set-up... 28–46 Infant Flow LP interfaces...28–29 Fixation devices...30 Headgear application...31 Generator assembly preparation...32 Generator assembly and interface attachment to headgear...33–34 Bonnet application...35 Generator assembly and interface attachment to bonnet...36–37 Bonnet application (alternative method 1)...38 Bonnet application (alternative method 2)...39 Incorrect application of fixation device and generator assembly...40–41 Incorrect application of generator assembly and interface...42–43 Final inspection of nasal interface placement...44 Self assessment and return demonstration... 45–46 Routine nCPAP care...47–49 Frequently asked questions...50–54 Self assessment...54 Glossary...55–56 References...57

Initiating and maintaining effective nCPAP therapy is a critical step in helping respiratory- compromised infants achieve successful recovery and develop normal respiratory function. When used according to your facility’s treatment protocols and with this training workbook, the Infant Flow LP nCPAP system can effectively deliver nCPAP therapy to help improve patient outcomes.

Infant nasal CPAP

Introduction Worldwide each year, approximately 15 million (1 out of every 10) babies are born prematurely.1 Premature or low-birth weight (LBW) infants are at a high risk for respiratory problems due to underdeveloped lungs. Common neonatal respiratory conditions include apnea of prematurity, respiratory distress syndrome, transient tachypnea of the newborn (TTN), meconium aspiration syndrome, pulmonary edema and post-extubation support. These conditions are often associated with decreased pulmonary compliance and functional residual capacity (FRC).1,2 Several of these infants will require respiratory support. Respiratory distress syndrome (RDS) is a condition that strains normal respiration due to the lack of natural surfactant production. Approximately 50% of neonates born at 26 to 28 weeks gestation and 30% of neonates born at 30 to 31 weeks gestation develop RDS.2

CPAP overview What is surfactant? Surfactant is a phospholipid, which reduces surface tension

compounds problems with premature infants. Given the

to increase lung compliance.

potential complications of intubation, many physicians opt

Artificial surfactant may be given to help reduce surface tension, increase compliance and improve ventilation. Without additional respiratory assistance, many infants have difficulty establishing the adequate functional residual capacity (FRC) required to maintain normal respiration.

for a less invasive approach for spontaneously breathing infants that utilizes continuous positive airway pressure (CPAP). As infants are preferential nose-breathers, nasal CPAP (nCPAP) is the preferred method for treatment delivery. CPAP enhances alveolar recruitment decreasing pulmonary vascular resistance and intrapulmonary shunting,

Respiratory support

stabilizes FRC and improves oxygenation. By increasing

Several options are available to help the clinician provide

surface area to alveolar gas exchange, CPAP decreases V/Q

respiratory support to the neonatal patient. Historically, the

mismatch. The goal of CPAP therapy is to maintain normal

initial treatment for infants with respiratory problems was

lung volumes and oxygenation, while enabling the infant

mechanical ventilation via an artificial airway. Intubation

to breathe on their own.3,4 Physiologic effects of CPAP are

presents a variety of challenges for any patient but

represented in the organizational chart on page 2. 1

Physiologic effects of nasal CPAP in neonates3–4,10 Infant nasal CPAP

Stretches lung and pleura

Splint open airways

Recruits alveoli and prevents alveoli collapse

Increases FRC and lung volumes

Conserves surfactant

Improves V/Q ratio and increases oxygenation

Increases pharyngeal cross section

Maintains airway patency

Reduces upper airway resistance

Decreases obstructive apnea

Decreases WOB

Stabilizes chest wall and diaphragm

Stimulates the J receptors and HIBR

Improves breathing pattern and decreases WOB

Stimulates lung growth

Reduces central and obstructive apnea

Decreases intrapulmonary shunting

Improves V/Q ratio

Nasal (nCPAP) is associated with improved respiratory mechanics and decreased chronic lung disease (CLD) rate.

What is nasal CPAP (nCPAP)?

Advantages of CPAP

nCPAP is the application of positive pressure to

• Increases FRC

the airways of a spontaneously breathing infant

• Maintains and increases lung volume

throughout the respiratory cycle. nCPAP is a continuous

• Improves lung compliance

flow of gas administered through nasal prongs inserted

• Reduces work of breathing (WOB) and

in the nares or by a nasal mask placed around the perimeter of the nose. The positive pressure, usually

• Provides a noninvasive procedure

4 cmH2O to 8 cmH2O, acts as a splint, which can help

• Allows small airways to develop

prevent alveoli collapse.

• Promotes the use of natural surfactant

BiPhasic CPAP alternates between two levels of CPAP at a set time interval. The infant can breathe at both CPAP settings. The BiPhasic mode helps increase the infant’s tidal volume and may stimulate the respiratory drive center.

2

airway resistance

• Promotes easy application • Provides cost effectiveness • Helps prevent extubation failure in some infants • Stabilizes the airway diaphragm and chest wall • Decreases incidence of chronic lung disease (CLD)

Indications for use 2–5 • Abnormalities on physical examination - Increased WOB - Increased respiratory rate - Intercostal and substernal recession - Grunting and nasal flaring - Pale skin color - Restlessness • Deteriorating arterial/capillary blood gas values (e.g., hypercapnea) • Increased oxygen requirements to maintain a SaO2 greater than 92% with FiO2 > 60% • Atelectasis and infiltration • Clinical conditions - Apnea of prematurity - Chest infections (e.g., pneumonia) - Transient tachypnea of the newborn (TTN) - Mild meconium aspiration • Weaning/Post-extubation support

• Congenital malformations of the upper airway (cleft palate, choanal atresia or tracheoesophageal fistula) • Congenital diaphragmatic hernia or untreated bowel obstruction • Poor respiratory drive unresponsive to CPAP therapy (frequent apnea episodes associated with oxygen desaturation and/or bradycardia) What is work of breathing? WOB describes the amount of effort required to breathe. Any therapy that introduces incoming pressure to a patient’s respiratory system potentially adds imposed WOB. Infants with RDS experience elevated WOB levels, and by expending additional effort to inhale and exhale against pressurized gas, the infant consumes precious calories overcoming the high WOB level. These calories could otherwise be spent on vital recovery and growth processes. In addition to helping the infant conserve energy, a WOB reduction may reduce stress and anxiety levels.

Contraindications for use 2– 5 • Severe cardiovascular instability • Respiratory failure defined as pH < 7.25 and PaCO2 > 60 mmHg torr

Potential problems associated with CPAP therapy3,5,6 Clinicians should be aware of the possible hazards and complications associated with CPAP, and take the necessary precautions to ensure safe and effective applications, such as: • Possible loss of prescribed pressure and decreased FiO2 due to mouth breathing • Increased intrathoracic pressure reducing venous return, which may lower cardiac output

Columella necrosis

• Barotrauma leading to surgical emphysema/ pneumothoraces • Aspiration • Deterioration in the respiratory condition, requiring immediate ventilation • Patient discomfort from prong/mask intolerance • Nasal septal injury (e.g., columella necrosis) • Blanching of the nares • Dry mouth and airways • Gastric inflation

Nasal dilation

3

CPAP modalities What are the treatment options? A variety of technologies have been employed in nCPAP

provides the most stable pressure, even in the presence of

delivery throughout the years.

leaks up to 6 LPM.

Conventional CPAP (V-CPAP): Utilizes a traditional mechanical

Pandt and Associates demonstrated that the Infant Flow

ventilator to deliver a constant flow of gas. CPAP is created

variable flow technology delivered a consistent level of

by changing the expiratory port orifice size. The ventilator

CPAP with little fluctuations. In contrast, the conventional

equipment is comprehensive and expensive.

CPAP did not reach the desired level of 5 cmH 2O, and

Bubble CPAP (B-CPAP): Utilizes a constant flow of heated

the pressure fluctuated significantly throughout the

and humidified gas. The level of pressure is controlled by

breath cycle.9

the depth of the exhalation tube inserted into a water

Using a variable flow generator with a dedicated CPAP

container. The pressure can increase if condensate collects

driver provides a measurable therapy with system alarms

in the tubing, the flow rate changes or the water evaporates

to help ensure safe and effective therapy.

from the container. B-CPAP lacks system alarms and imposes a higher WOB due to the constant flow and inability to entrain flow during inspiration.(16,18,19) High flow nasal cannula (HFNC): Has not been cleared by the FDA for nasal CPAP delivery. HFNC utilizes a constant

Infant Flow 8 Lts flow, 5 cmH2O System pressure 5 cmH 2 O

flow of heated, humidified gas that potentially delivers a positive distending pressure. The level of therapy cannot be measured and fluctuates depending on body position, oral leaks, nasal secretions and the size and weight of the

0 cmH 2 O

Time

patient. HFNC does not contain critical alarms that ensure the safe delivery of therapy.

Conventional CPAP 17 Lts flow, 5 cmH2O with 5 Lts reservoir bag

Variable flow CPAP (VF-CPAP): Incorporates a generator that redirects the heated and humidified gas flow away from the

System pressure 5 cmH 2 O

patient during exhalation and allows air entrainment during periods of high inspiratory effort. By redirecting the gas, VF-CPAP offers a lower imposed WOB and less expiratory resistance compared to other

0 cmH 2 O

Time

nCPAP technologies. Because the pressure is created and measured at the nares, the variable flow technology

Moa, G., Nilsson, K. et al. Crit Care Med, 1988, 16(12):1238–1242.

Infant Flow variable flow Inspiration: Gas flow converted

Expiration: Gas flow

to pressure reducing the WOB

flipped away from the nasal

and maximizing the pressure

prongs to the expiratory

stability at the patient interface.

tube. The residual gas pressure provided by the continuous gas flow creates a stable CPAP throughout the respiratory cycle.

4

Variable flow technology Inhalation

Exhalation Exhaust tube

Dual jets

Fluidic flip

Vortice shedding

Flow direction

Flow direction

Patient nare

Patient nare

What is variable flow technology?10,11

What is vortices technology? 1 0 , 1 2

The Infant Flow LP patented dual-jet variable flow

The patented Infant Flow LP generator is a new form of

generator utilizes fluidic technology to deliver a

variable flow that uses vortices technology to reduce the

constant CPAP at the airway proximal to the infant’s

imposed WOB during inhalation. Similar to the single- jet

nares. Without moving parts or valves, the generator

technology, the flow entrainment reduces the WOB

provides consistent performance. The level of CPAP

on inhalation by meeting the patient’s inspiratory flow

created is proportional to the flow provided by the

demand and during exhalation gas flow flips away from

driver; for example, 9 LPM creates approximately

the patient reducing resistance.

5 cmH 2O CPAP. The variable flow generator uses

Four low-momentum jets (two per nare) impinge inside

Bernoulli’s Principle via injector jets directed toward

the generator to create a consistent and measurable

each nare. If the infant pulls additional flow, the

positive airway pressure within the generator head.

venturi action of the injector jets entrains additional

During inhalation, the dual jets entrain flow to meet

flow from either the source gas or exhalation tube

the patient’s inspiratory demand. During exhalation, the

reservoir. During exhalation, the incoming gas flow

jets easily deflect to disrupt the gas flow. This disruption

redirects away from the infant. This action is referred

of flow creates vortice shedding that spirals outwardly,

to as the “fluidic flip.” By redirecting the gas, variable

combining with the exhaled breath to create an

flow nCPAP reduces the imposed WOB. The infant

organized, efficient flow path toward the exhaust ports.

can exhale freely and conserve precious calories for development. In summary, the direction of gas flow in variable flow devices depends on the patient’s respiratory cycle. The flow “flips” away from the nares when the infant exhales and then, “flips” back as the exhalation phase ends. The response is almost

Exhaust tube

instantaneous as it occurs at the patient’s nares.

Drive line Pressure line

Impinging jets

Patient 5

Self assessment

1. Describe RDS:

8. Match the generator parts to the diagram: Pressure line Impinging jets Exhaust tube Drive line Patient

2. List three indications for nCPAP therapy:

c

d b

3. List three benefits of nCPAP therapy:

a

e

4. List three potential complications to nCPAP therapy:

5. State four methods used to deliver nCPAP therapy:

6. Discuss the advantage of variable flow technology compared to other CPAP modalities:

7. Discuss the importance of low work of breathing:

6

Notes:

Infant Flow SiPAP driver overview

Infant Flow LP system The Infant Flow LP nCPAP system is a comprehensive system for delivering unique nCPAP therapy. The system consists of: • Infant Flow SiPAP driver • Infant Flow LP generator assembly • Infant Flow LP fixation-bonnet or headgear • Infant Flow LP nasal interfaces-mask or prongs This chapter discusses the set-up and operation of the Infant Flow SiPAP Plus driver.

Alarm LED Indicates alarm situation as visual and audible notification color varies according to alarm level

Power LED Indicates power on and AC connection

Note: Refer to the Infant Flow SiPAP operator manual for additional instructions on the set-up, operation and maintenance of the Infant Flow SiPAP Plus driver.

Transducer LED Indicates transducer connected.

Touch screen display Adjusts settings and displays patient parameters and alarms.

% O2 blender control Adjusts FiO2. Pressure low flow meter Adjusts low CPAP level. CPAP supplied to patient directly relates to flow rate from the nCPAP driver.

Transducer connection Connects to transducer interface.

Pressure high flow meter Adjusts high CPAP level. CPAP supplied to patient directly relates to flow rate from nCPAP driver.

Patient circuit connection Connects patient breathing circuit to gas outlet port.

Pressure line connection Connects patient pressure line to device. 7

Infant Flow SiPAP configurations The Infant Flow SiPAP driver is sold globally and is available

In select areas, additional languages or an international icon

in different configurations. The two main models are Infant

overlay may be used in place of the English text. The operation

Flow SiPAP Plus and Infant Flow SiPAP Comprehensive.

and maintenance of the Infant Flow SiPAP driver is the

The Comprehensive model offers an additional ventilation

same regardless of the specific configurations. Refer to the

mode, BiPhasic trigger, which is not available in the U.S.

Infant Flow SiPAP operator manual for more specific details.

Description Press to access the user calibration menu and language options.*

Press to return to the start-up screen.

Press to switch between the graphical and numerical monitoring screen.

Press to change the operation mode.

Press to deliver a manual breath. The breath delivers at the pressure high setting for the set time high duration. Indicates user should refer to the operator manual for additional information.

Indicates battery status and turns red if the battery charge is less than 40%. Indicates the screen is locked. Press to unlock the screen.

Adjust the low flow rate setting for the baseline CPAP level. Adjust the high flow rate setting for BiPhasic high CPAP level. *Language option not available on all SiPAP models.

8

English text

ICON symbol

Infant Flow SiPAP display screen Mode, control settings and function buttons

Alarm priority/alarm silence indicator

Operational information

Mode indicator

Battery charge

Pressure/Time graphics or monitored parameters display

Monitored parameters FiO2

Control/Setting indicators

Soft key color code

Alarm management

White letter

High priority

Key enabled

• Series of 10 tones sound every 10 seconds • Parameters display, and limits flash red

Faded letter

Medium priority

Key inactive

• 3 audible tones sound every 15 seconds • Parameters display, and limits flash yellow

Yellow letter

Low priority

Solid: Pending confirmation

• 2 audible tones sound every 30 seconds

Flashing: Low-priority alarm

• Parameters display, and limits change to yellow

Red letter Flashing: High-priority alarm Solid: Reduction in another parameter caused by an adjustment

9

Infant Flow SiPAP and circuit set-up Circuit set-up 1. Gather the nCPAP supplies: • Infant Flow SiPAP driver • Single-limb, heated breathing circuit • Infant Flow LP generator kit • Infant Flow LP fixation device • Humidifier and chamber • Sterile water bag 2. Attach the water chamber to the humidifier and connect it to the water feed system. Follow the manufacturer instructions for the proper set-up.

I

V

3. Connect the gas delivery tubing (A) to the flow driver outlet port (I) and humidifier chamber port (II).

A

4. Connect the elbow connector on the heated breathing circuit (B) to the humidifier chamber.

II

III

Insert the heater wire plug into the wire socket. Securely insert the temperature probe in the port on the circuit elbow (III). Insert the second temperature probe (IV) into the airway port at the distal end of the breathing circuit.

B

E

5. Connect the non-heated section (C) to the drive line of the generator assembly (D). 6. Connect the proximal pressure line (E) to the proximal port on the driver (V) and the pressure

IV

line on the generator. C

Temperature probe When inserting the temperature probe into the circuit, ensure the probe tip is in the middle of the gas stream. This allows the gas temperature to be measured accurately. If the probe is not properly seated, the temperature measurement accuracy may be compromised, leading to excessive condensation. Cover the temperature probe with a reflective shield when used under a radiant warmer or bilirubin light.

10

D

Humidification and nCPAP Humidification Heated humidification is recommended for nCPAP therapy.

practice guidelines recommend gas temperature

The normal functions of the nose and air passages of

between 34 and 41 °C to provide a humidity level of

the respiratory tract are too warm, moisten and filter

33 to 44 mgH2O/L with artificial airways.14 Be cautious

the inhaled gases before they reach the lungs. In normal

using higher temperatures, as condensation may reduce

respiration, the nasal mucosa and upper airways provide

the mucous viscosity and interfere with the mucous

75% of the heat and moisture supplied to the smaller

clearance. Extended exposure of gas temperatures over

airways and alveoli. By the time air reaches the alveoli,

41 °C may cause cellular damage to the airways.14

the inspired gas warms to 37 °C at 100% relative humidity

The higher temperature settings may not be required to

(RH).13 With nCPAP, the upper airways are not bypassed,

deliver adequate humidification, since an artificial airway

but the high gas flows may be drying to the airways,

is not used with nCPAP. Start with a temperature setting

especially to a neonate’s underdeveloped lung. Adequate

of 36 °C to 37 °C and adjust the humidifier settings to

humidification is essential to maintain airway clearance,

maintain adequate humidification; if condensate occurs,

optimize ventilation and improve patient comfort.

reduce the humidifier temperature setting.

The International Organization for Standardization (ISO) and American Association for Respiratory Care (AARC) clinical

Airway temperature probe placement Open bed or crib

Isolette or incubator

When the infant is placed on an open bed warmer or

When the infant is in an isolette or incubator, the

crib, it is recommended to remove the unheated section.

non-heated section should be used with the temperature

This places the temperature probe next to the

probe placed outside of the isolette. Make sure that the

generator assembly.

rest of the unheated section remains in the isolette.

If the infant is under a radiant warmer or bilirubin light,

If condensation is observed, remove the non-

the temperature probe should be covered with a light

heated (A) section and place the temperature probe

reflective shield to prevent heating the probe. If the probe

inside the isolette.

is not covered, it could interfere with the operation of the humidifier and cause excessive condensation to form.

A

11

Infant Flow SiPAP sensor calibration Two-point oxygen sensor calibration Two-point oxygen sensor calibration should be performed

9 LPM prior to turning on the Infant Flow SiPAP driver on.

before initially using the Infant Flow SiPAP driver and with

When the Infant Flow SiPAP driver is turned on, a power on

each circuit change. To avoid unwanted alarms, occlude the

self-check automatically performs.

prongs or mask and set the low pressure flowmeter to

To perform two-point calibration: 1. Press the CAL button to enter the calibration menu. Infant Flow SiPAP NCPAP/ Pres Low L/min

Infant Flow SiPAP NCPAP/ Pres Low L/min

Pres High L/min

2. Set the pressure low flowmeter to 9 LPM and the pressure high flowmeter to 2 to 14

50

40

12 10

60

5

70

80

90

30

21

4

4

manual breath button.

window to stabilize.

50

40

12 10 8

60

70

XDCR

PPROX

21

L/min

5

14

4

100

3

4. Press the flashing question mark button located under the 21% icon. The question 4

100

90

4 3

2

2

2

10

1

PPROX

XDCR

Pres High L/min

50

60

5

70

40

12

6

21

Infant Flow SiPAP NCPAP/ Pres Low L/min

80 90

30

80

2

3. Adjust the oxygen control to 21%. Allow time for the reading in the oxygen display 14

40

4

2 1

Pres High

5

70

6

2

Infant Flow SiPAP NCPAP/ Pres Low L/min

8

3

60

30

10

100

6

L/min 50

12

3 LPM. Note: The pressure high flowmeter must be set during set-up to enable the 8

Pres High

14

80 90

30

8

21

4

100

3

6 4

2

2

mark changes to a static hourglass. When calibration is complete, a static green 1

1

P check mark icon appears and the oxygen window reads 21%. XDCR display

PPROX

XDCR

PROX

Infant Flow SiPAP

5. Adjust the oxygen control to 100%. Allow time for the reading in the oxygen display window to stabilize.

NCPAP/ Pres Low L/min

Pres High L/min

14

50 40

12 10 8

60

5

70 80 90

30

21

3

6

6. Press the flashing question mark button located under the 100% icon. The question

4

2

2

mark changes to a static hourglass icon. When calibration is complete, the hourglass icon changes to a static checkmark. The oxygen display window reads 100%. 7. If oxygen calibration fails, a red X displays on the button of the screen, the alarm sounds and an Error code displays on the top-left corner. Turn the driver off and then, back on. Repeat the calibration procedure.

Disable the oxygen sensor The internal oxygen sensor may be disabled by pressing the O2 disable button on the calibration screen. This disables oxygen monitoring and the audible oxygen alarm. An error code displays to indicate the oxygen monitor is inoperative. An external oxygen monitor must be used whenever the oxygen sensor is disabled.

Leak test While occluding the patient interface, set a flow of 9 LPM on the pressure low flowmeter. A CPAP of 5 cmH2O ± 1 should display on the SiPAP screen. If pressure is not reached, check the system for leaks. Release the occlusion, and the displayed pressure should be ≤ 2 cmH2O. Wait for 15 seconds, and a disconnect alarm should sound. If the pressure does not fall, check the circuit for occlusions. 12

4

100

1

XDCR

PPROX

Infant Flow SiPAP set-up guide Set-up menu screen

Alarm set/confirm screen

1. Adjust the pressure low flowmeter until the desired

Press the nCPAP button or alarm bar for three seconds

nCPAP pressure displays on the screen. Press the flashing

to set the alarm limits and move to the next screen. If no

question mark icon, which changes to a static checkmark

button is pressed within two minutes, the alarm limits

to confirm the setting.

automatically set and the screen changes to the mode

2. Adjust the oxygen control dial to set the desire FiO2%.

select screen.

Press the flashing question mark icon. A checkmark appears to confirm the setting. 3. Adjust the pressure high flowmeter until the pressure displays 2 to 3 cmH2O above the set nCPAP pressure. Press the flashing question mark icon. A static checkmark appears to confirm the setting. 4. To use the low breathing rate/apnea monitor, connect Set-up menu screen

the transducer interface to the Infant Flow SiPAP driver. Press the flashing question mark under the infant respiratory sensor icon. This will change to a static checkmark to confirm the setting. This does not confirm that you want to use the respiratory monitoring option but ensures that all modes are available for later use. 5. After completing the above steps, the screen changes and displays the nCPAP mode. The infant can now be

Alarm set/confirm screen

connected to the Infant Flow SiPAP system.

Mode select screen All available modes display at the bottom of the screen.

3. Make the desired setting changes, and press the

1. For low breath rate/apnea modes, attach the abdominal

selected mode to confirm the settings and activate the new mode.

respiratory sensor to the transducer and properly place

4. If no selection is made within two minutes and no

it on the infant’s abdomen. 2. Select the desired mode of operation by pressing the corresponding button (mode select screen). The parameter adjust screen displays, and the new mode displays in the upper-left corner (parameter adjust screen).

Mode select screen

Parameter adjust screen

alarms sound, the screen locks to prevent entries. The mode buttons go blank, except for the last button on the right (locked screen). To unlock the screen, press the lock icon.

Locked screen 13

Infant Flow SiPAP set-up guide (continued) Parameter adjust screen 1. To change the settings during set-up and normal operation, touch the desired parameter button. 2. Press the up or down arrows to adjust the parameter to the desired setting. 3. Confirm the change by re-pressing the parameter button. The main screen displays.

Parameter adjust screen

Note: nCPAP and BiPhasic pressure levels are set by adjusting the flow.

Main screen and monitored parameter screen 1. To monitor therapy, use the main screen or monitored parameter screen. The main screen graphically displays the delivered pressure. The monitored parameter screen displays numerical values for the delivered pressure. 2. Press the Change Screen button to switch the screen display.

Main screen

Monitor parameter screen

Alarm reset/silence 1. Press the alarm bar to silence the active alarms for 30 seconds. 2. Press the alarm bar for three seconds to clear resolved and low-priority alarms and to reset alarm limits. Smart alarm technology automatically sets high pressure, low pressure and % oxygen thresholds. Main screen with active alarm

16.0

Flow pressure nomogram

Pressure (cmH2O)

14.0

The Infant Flow SiPAP LP system is subject to a direct

12.0

relationship between the controlled gas flow and airway

10.0

pressure. For example, 9 LPM of gas flow provides

8.0

approximately 5 cmH2O CPAP.

6.0

Tip: Manual breath: The high pressure flowmeter must be

4.0

set to deliver a manual sigh/breath during CPAP. The boost

2.0

4.0

14

in pressure delivers for the time high that was entered during 6.0

8.0

10.0

12.0

Flow (LPM)

14.0

16.0

18.0

the set-up process.

Respiratory abdominal sensor Respiratory abdominal sensor (optional) For use only with the Infant Flow SiPAP Plus and

breathes, the most movement is between the lowest

Comprehensive nCPAP drivers. The respiratory abdominal

rib and the abdomen.

sensor enables the clinician to monitor for apnea/low breath rate in both nCPAP and BiPhasic modes. The accessories include the reusable transducer and single-patient-use abdominal sensor. In the BiPhasic trigger mode, the respiratory abdominal sensor and transducer allow patient-triggered pressure assists with breath rate monitoring (not available in the U.S.). Respiratory transducer connection 1. Connect the transducer cable to the transducer port on the front panel.

2. If the infant is supine, place the capsule midway between the umbilicus and xiphisternum, which is the notch at the center of the two lower ribs. On larger infants, an alternative site is the upper chest to detect intercostal movement. 3. If the infant is prone, place the sensor laterally over the lower rib and abdomen. The sensor tubing should be directed over the back. 4. Tape the sensor firmly into position using a nonallergenic microprobe tape. Position the sensor line

2. Connect the abdominal sensor pressure line to the transducer interface.

perpendicular to the tape. Only use tape that is approved by your facility’s protocol.

3. Compress the sensor pad gently, repeating this several times while observing the transducer LED.

5. Verify correct placement. The transducer LED should illuminate on expiration, and the SiPAP front panel LED on inspiration.

Infant set-up To apply the sensor to the infant using suitable tape

6. If the LED does not illuminate, try repositioning the sensor and adding a second piece of tape making an

(figure 1): 1. Visually identify the optimum outward movement of

“X” over the sensor.

the abdomen during inspiration. When the infant

Figure 1: Abdominal sensor placement 15

Self assessment

1. Where should the circuit airway temperature probe be placed if the infant is in an isolette/incubator?

7. While in nCPAP, you press the manual breath button, but nothing happens. What would prevent a manual breath from being delivered?

2. If condensation occurs in the breathing circuit, what should you do?

8. When should you perform an oxygen sensor calibration on the Infant Flow SiPAP?

3. Explain how to disable the oxygen sensor: Notes:

4. Demonstrate how to reset the alarm limits when the device is in operation:

5. To deliver a CPAP of 5 cmH2O, what would the flow rate be?

6. Where is the best placement for the respiratory abdominal sensor?

16

Infant Flow SiPAP nCPAP driver

Modes of operation nCPAP mode nCPAP mode delivers constant, stable positive pressure

be set for a duration of 0.1 to 3 seconds to produce

to infant airways to help restore the FRC in assisting the

a “sigh.”

correction of hypoxemia. Adjust the flow rate setting to deliver CPAP up to 11 cmH2O.

Note: This is not the same as pressure support. In pressure support, the pre-set pressure supports the

CPAP parameters:

inspiratory effort and the patient’s breathing pattern

• CPAP pressure (set by low pressure flowmeter)

determines the inspiratory time. In the BiPhasic mode, the infant can breathe spontaneously at either pressure level.

• Oxygen percentage

The time high setting determines the cycle time between

Initial settings:

the two levels of CPAP.

• CPAP 4 to 6 cmH2O

BiPhasic parameters:

nCPAP + low breath rate (LBR)/Apnea

• Baseline CPAP (set by low pressure flowmeter)

The mode allows the delivery of CPAP pressures up to

• High CPAP (set by high pressure flowmeter)

11 cmH2O and breath rate monitoring via respiratory abdominal sensor and transducer interface. For the SiPAP

• Time high (T-high)

Plus system, the LBR setting is determined by LBR time (TLBR)

• Rate (cycle rate between pressures)

setting from 10 to 30 seconds. For the SiPAP Comprehensive

• Oxygen percentage

system, the Apnea setting is determined by the apnea time (T-apnea) setting from 10 to 30 seconds. If the apnea alarm

Initial settings based on respiratory conditions:9

is triggered, the device delivers one breath at the high

• Baseline CPAP 4 to 6 cmH2O

pressure setting. The high pressure flowmeter must be set.

• Pressure high (PHigh) 1 to 3 cmH2O above CPAP level

BiPhasic mode

• T-high 1.0 sec

This mode cycles between high/low CPAP levels on a timed

• Rate 6 cycles/minute

basis. Small incremental pressure increases of 2 to 3 cmH2O

Time (s)

16

Volume change (ml/kg)

cmH2O

Pressure (cmH2O)

Ti = 0.2 s

10 above CPAP creates a “sigh” breath, and augments FRC 9 and decreases WOB. The switch to the high CPAP level can 8 6 7 6 5 5 4 4 3 3 2 2 1 1 0 0 0 1 2 5 3 4 Seconds

In this study, a 3 cmH2O shift in pressure on an average increased FRC by 5.5 mL/kg.

12

8

5.5 ml/kg 4

Pandit, P. Pediatric, 2001, 108(3):682–685.

0 0

2

4

6

8

10

CPAP pressure 17

BiPhasic + LBR/apnea mode This mode is the application of BiPhasic therapy with low breath rate detection via the respiratory abdominal sensor

Timed BiPhasic breaths are given at the set backup rate, PHigh and T-high. If the infant triggers within the next time-out period, the alarm silences and triggered-BiPhasic resumes.

and transducer interface. For SiPAP Plus, the LBR setting is

If no breaths are detected after the next apnea timeout,

determined by the TLBR setting from 10 to 30 seconds. For

the audible alarm resumes until the operator intervenes.

SiPAP Comprehensive, the Apnea setting is determined by T-apnea setting from 10 to 30 seconds. SiPAP Comprehensive BiPhasic tr* mode This mode utilizes the respiratory abdominal sensor and transducer interface to synchronize pressure high breaths with the infant’s respiratory efforts. It allows patienttriggered pressure assists with breath rate monitoring enabled, adjustable apnea time interval, apnea alarm and adjustable apnea backup rate. The upper level pressure delivers based on operator set T-high and PHigh flow rate settings. The maximum pressure setting is 15 cmH2O. If the respiratory efforts are not detected, the infant receives the low CPAP setting and the apnea alarm initiates the delivery of the set backup rate. BiPhasic tr parameters:

• Peak inspiratory pressure (PIP) (set by high pressure flowmeter) • T-high • Backup respiratory rate • Apnea time • Oxygen percentage Initial settings: Initial settings should be tailored to the infant’s respiratory condition. • Baseline CPAP at clinical indicated level (4 to 6 cmH2O) • PIP: 2 to 3 cmH2O above set CPAP level. Set by the PHigh flowmeter. • T-high: ≤ 0.3 • Rate (Rb): Set rate is active only if Tapnea (sec) threshold is surpassed. Generally, set it close to the infant’s own respiratory rate. • Apnea time (tapnea): 10 to 30 seconds. The apnea alarm triggers when no breaths are detected within the selected apnea timeout.

18

Pressure (cmH2O)

• Baseline CPAP (set by low pressure flowmeter)

10 9 8 7 6 5 4 3 2 1 0

Ti = 0.2 s

0

1

2

3

4

5

Time (s) *BiPhasic tr mode available in comprehensive configurations only. Not available in the U.S.