Introducing Infant Introducing Infant Flow Advance SIPAPFlow Advance SIPAP

By By Joanne Joanne CooksonCookson

March 2008March 2008

AimAim

To introduce To introduce clinical clinical practionerspractionersto the new to the new SiPAPSiPAPmachinemachine

ObjectivesObjectives

To define what is To define what is SiPAPSiPAPTo look at different modes able to be delivered To look at different modes able to be delivered by the by the SiPAPSiPAP and relate to when appropriate to and relate to when appropriate to use in clinical practiceuse in clinical practiceTo To demonstatedemonstate how to initially set up the how to initially set up the SiPAPSiPAPmachine and alter accordinglymachine and alter accordinglyNursing careNursing care

IntroductionIntroduction

Infant flow sipap offers a comprehensive Infant flow sipap offers a comprehensive selection of modalities to provide non invasive selection of modalities to provide non invasive ventilatory support to the neonatal patient.ventilatory support to the neonatal patient.

Certain patients may benefit from a nonCertain patients may benefit from a non--invasive invasive approach incorporating biapproach incorporating bi--level nasal CPAP and level nasal CPAP and avoid the need for intubation. Still others may avoid the need for intubation. Still others may be effectively weaned from invasive ventilation be effectively weaned from invasive ventilation earlier with a biearlier with a bi--level approach.level approach.

What is SIPAP?What is SIPAP?

Infant flow SIPAP provides biInfant flow SIPAP provides bi--level nasal level nasal CPAP for the spontaneously breathing CPAP for the spontaneously breathing neonate through the delivery of sighs neonate through the delivery of sighs above a baseline CPAP pressure. These above a baseline CPAP pressure. These sighs may be timed, at a rate specified by sighs may be timed, at a rate specified by clinicians, or ‘triggered’ by patients own clinicians, or ‘triggered’ by patients own inspiratory efforts.inspiratory efforts.

Modes of OperationModes of Operation

CPAPCPAPCPAP and Apnoea CPAP and Apnoea Trigger BiPhasicTrigger BiPhasicBiPhasicBiPhasicBiPhasic + apnoeaBiPhasic + apnoea

NCPAPNCPAP

NCPAP NCPAP –– nasal continuous positive airway nasal continuous positive airway pressure using the Infant Flow Generator.pressure using the Infant Flow Generator.

NCPAP + apnoea NCPAP + apnoea –– NCPAP with apnoea NCPAP with apnoea monitoring and alarm added. Apnoea monitoring and alarm added. Apnoea interval is operator selectable.interval is operator selectable.

Trigger BiPhasicTrigger BiPhasic

BiPhasic tr BiPhasic tr –– BiPhasic mode which relies on BiPhasic mode which relies on patient triggering. Each time the patient initiates patient triggering. Each time the patient initiates a breathe the SIPAP machine will deliver a fully a breathe the SIPAP machine will deliver a fully supported breathe.supported breathe.The level of support will have been set by the The level of support will have been set by the clinician, as will the apnoea interval. There is clinician, as will the apnoea interval. There is also a need to set up a back up rate to ensure also a need to set up a back up rate to ensure some respiratory support in case of apnoeic some respiratory support in case of apnoeic episodes. episodes. As there is a need for the patient to actively As there is a need for the patient to actively trigger a breathe this mode is better suited to trigger a breathe this mode is better suited to patients who have an adequate respiratory drivepatients who have an adequate respiratory drive

BiPhasicBiPhasicBiPhasic BiPhasic –– This mode is time triggered as opposed to This mode is time triggered as opposed to patient triggered.patient triggered.The SIPAP machine will ensure a set amount of The SIPAP machine will ensure a set amount of pressure supported breathes are delivered within a pressure supported breathes are delivered within a minute.minute.The number of pressure supported breaths are set by The number of pressure supported breaths are set by the clinician as is the amount of support provided with the clinician as is the amount of support provided with each breathe and the inspiratory time. each breathe and the inspiratory time. This mode is better suited to patients with a poor This mode is better suited to patients with a poor respiratory drive as can provide adequate support or to respiratory drive as can provide adequate support or to term babies who will need to synchronise with support term babies who will need to synchronise with support provided. Rate needs to commence at same level as provided. Rate needs to commence at same level as babies own respiratory drive, and be altered accordingly.babies own respiratory drive, and be altered accordingly.BiPhasic + apnoea BiPhasic + apnoea –– BiPhasic mode with apnoea BiPhasic mode with apnoea monitoring and alarm added. Apnoea interval is operator monitoring and alarm added. Apnoea interval is operator selectable.selectable.

Power LED

Alarm Mute / Reset

¼” LCD Display

NCPAP/ Pres Low Flow Meter

Blender Control

Pres’ High Flow Meter

Transducer LED

Proximal Pressure Line

Gas outlet to Patient

Transducer Interface Connection

CalibrationCalibration

Prior to connecting to the Prior to connecting to the patient, the operator needs to patient, the operator needs to access the O2 calibration access the O2 calibration screen by pressing the CAL screen by pressing the CAL button.button.Need to ensure that a Need to ensure that a minimum of 8 LPM is set on minimum of 8 LPM is set on NCPAPNCPAPAdjust oxygen to 21% Adjust oxygen to 21% -- allow allow to stabilise. Confirm by to stabilise. Confirm by touching the flashing buttontouching the flashing buttonAdjust oxygen to 100% Adjust oxygen to 100% -- allow allow to stabilise. Confirm by to stabilise. Confirm by touching flashing buttontouching flashing button

Successful CalibrationSuccessful Calibration

A calibration that has failed will display .

Set Up ScreenSet Up Screen

Screen will appear as aboveScreen will appear as aboveFirst need to set required CPAP level using left hand flow dial First need to set required CPAP level using left hand flow dial ––once digital display in right hand corner has stabilised press fonce digital display in right hand corner has stabilised press first irst question mark to confirm question mark to confirm –– tick will then appeartick will then appearSecondly need to set require oxygen using oxygen dial Secondly need to set require oxygen using oxygen dial –– once once stabilised press second question mark to confirm stabilised press second question mark to confirm –– tick will then tick will then appearappear

Thirdly need to set pressure high level to 3Thirdly need to set pressure high level to 3--4 cms h20 4 cms h20 above preset CPAP level above preset CPAP level -- once stabilised press third once stabilised press third question mark to confirm question mark to confirm –– tick will then appeartick will then appearLastly need to confirm if using apnoea transducer (not Lastly need to confirm if using apnoea transducer (not using may limit modes which can be accessed)using may limit modes which can be accessed)

Alarm set/confirm ScreenAlarm set/confirm Screen

To set alarms, touch the To set alarms, touch the Alarm Mute / Reset Alarm Mute / Reset button for 3 seconds. If button for 3 seconds. If this button is not touched this button is not touched within 2 minutes, the within 2 minutes, the alarm limits will be alarm limits will be automatically set. automatically set. There are 2 alarms There are 2 alarms incorporated within the incorporated within the machinemachine

-- Medium priority Medium priority –– flashes flashes yellowyellow

-- High priority High priority –– flashes redflashes red

Display Screen Organization Display Screen Organization –– Main ScreenMain Screen

Mode Indicator

Mode, control settings and function buttons

Pressure / Time Graphics

Alarm Priority Indicator

Control Indicators

Monitored parameters

Battery Charge Status

Operational Information

Mode Select ScreenMode Select Screen

From this screen the From this screen the operator can select a operator can select a different mode of different mode of operation or continue in operation or continue in the currently operating the currently operating mode by pressing one of mode by pressing one of the mode buttons on the the mode buttons on the bottom of the screen.bottom of the screen.

After selecting the mode After selecting the mode of operation, the screen of operation, the screen changes to the Set Up changes to the Set Up Screen for the new mode.Screen for the new mode.

Setting up a new modeSetting up a new mode

Controls associated with the Controls associated with the proposed mode appear and proposed mode appear and are available for adjustment are available for adjustment along the lower portion of the along the lower portion of the screen.screen.

The new mode and control The new mode and control settings are accepted and settings are accepted and applied when the proposed applied when the proposed mode button (highlighted) is mode button (highlighted) is pressed. pressed.

The mode in active operation The mode in active operation is displayed at all times in the is displayed at all times in the mode indicator window (top left mode indicator window (top left hand side) while a new mode hand side) while a new mode is being configured.is being configured.

Parameter Adjust ScreenParameter Adjust Screen

During routine operation During routine operation the operator can adjust the operator can adjust controls available in the controls available in the currently active mode. currently active mode. Only the controls active Only the controls active for the current operating for the current operating mode are visible. mode are visible. To adjust a control, touch To adjust a control, touch the button. The control the button. The control and its associated and its associated numeric display will numeric display will highlight. Press up or highlight. Press up or down arrows to adjust. down arrows to adjust. Confirm change by Confirm change by pressing control againpressing control again

MainMain screen displayscreen display

Shows adjustable Shows adjustable controls, current settings, controls, current settings, pressure time graphic pressure time graphic and monitored and monitored parameters.parameters.With no screen With no screen interaction for 2 minutes interaction for 2 minutes the screen will the screen will automatically lock to automatically lock to prevent inadvertent prevent inadvertent changeschangesScreens unlock with a Screens unlock with a touch of the unlock button touch of the unlock button

Setting the Apnoeic IntervalSetting the Apnoeic Interval

The SIPAP machine is able to provide pressure The SIPAP machine is able to provide pressure supported breaths in the event of an apnoeic episode as supported breaths in the event of an apnoeic episode as long as all set up settings have been confirmed when long as all set up settings have been confirmed when initially switching on. If pressure high is not originally set initially switching on. If pressure high is not originally set this facility is not functionalthis facility is not functionalThe SIPAP will automatically deliver one pressure The SIPAP will automatically deliver one pressure supported breathe after detecting an apnoeic episode. supported breathe after detecting an apnoeic episode. Example if apnoea interval is set at 20 secs after this Example if apnoea interval is set at 20 secs after this time the low priority alarm will sound and one pressure time the low priority alarm will sound and one pressure supported breathe will be delivered. If the patient supported breathe will be delivered. If the patient remains apnoeic after a further 20 seconds the high remains apnoeic after a further 20 seconds the high priority alarm will soundpriority alarm will soundIt is possible for a manual breathe to be given in the It is possible for a manual breathe to be given in the event of apnoeic episodes by simply pressing the event of apnoeic episodes by simply pressing the manual breathe iconmanual breathe icon

Troubleshooting Troubleshooting

There are several reasons why the alarm There are several reasons why the alarm maybe activated please refer to operators maybe activated please refer to operators manual for further guidance or contact manual for further guidance or contact EBMEEBME

The Fixation TechniqueThe Fixation Technique

Select correct size of Select correct size of prongs or maskprongs or maskMeasure head Measure head –– centre of centre of forehead to nape of neck forehead to nape of neck and backand backSelect appropriate Select appropriate bonnetbonnet

Prongs or Mask?Prongs or Mask?

Prong fixation is generally the best choice as the Prong fixation is generally the best choice as the best seal is obtaining using the prongsbest seal is obtaining using the prongsMask fixation has been designed for infants who Mask fixation has been designed for infants who develop sore nasal develop sore nasal septumsseptums or for those infants or for those infants whose nostrils are too big or too small for the whose nostrils are too big or too small for the prong fixationsprong fixations

Fixation TechniqueFixation Technique

Weave generator straps through the buttonholesWeave generator straps through the buttonholesPlace bonnet onto infant’s head. Button holes Place bonnet onto infant’s head. Button holes should be positioned over infant’s earsshould be positioned over infant’s earsGently insert mask or prongs into placeGently insert mask or prongs into placeDo not over tighten strapsDo not over tighten strapsSplit Split inspiratoryinspiratory and pressure lines and secure and pressure lines and secure with secondary with secondary velcrovelcro tiesties

Final ChecksFinal Checks

Nose and ears in normal positionNose and ears in normal positionEyes clearly Eyes clearly visablevisableGenerator is stable and secureGenerator is stable and secureInfant is receiving required level of CPAPInfant is receiving required level of CPAPEnsure infant is kept warm, comfortable and Ensure infant is kept warm, comfortable and well oxygenatedwell oxygenatedObserve and monitor vital signsObserve and monitor vital signs

Nursing CareNursing Care

Hourly AssessmentHourly Assessment-- Infant’s nose in normal position and not pushed Infant’s nose in normal position and not pushed

upwardsupwards-- Eyes clearly Eyes clearly visablevisable-- Correct level of CPAP is being deliveredCorrect level of CPAP is being delivered

Nursing CareNursing Care

At care timesAt care times--Ensure skin around nasal area is kept clean and Ensure skin around nasal area is kept clean and

dry, document any changesdry, document any changes--Clean skin with water, do not apply creamsClean skin with water, do not apply creams--Check prongs are clean and free from obstruction Check prongs are clean and free from obstruction

or water dropletsor water droplets

NutritionNutrition

Infants receiving CPAP can still receive Infants receiving CPAP can still receive enteralenteralnutrition.nutrition.NasogastricNasogastric tubes should not be used due to tubes should not be used due to interuptioninteruption in the seal necessary to maintain in the seal necessary to maintain desired CPAP level desired CPAP level –– Increases WOBIncreases WOBOrogastricOrogastric tubes are recommended for tubes are recommended for evacuation of gas that accumulates in the evacuation of gas that accumulates in the stomachstomach

Holistic ApproachHolistic Approach

Humidification Humidification –– Gases delivered to infant need Gases delivered to infant need to be humidifiedto be humidifiedRoutine suctioning not required Routine suctioning not required –– only when only when indicatedindicatedPositioning of the infant Positioning of the infant –– need to ensure need to ensure maintaining a clear airwaymaintaining a clear airwayUse of NNS Use of NNS –– if mouth open, continuous leak if mouth open, continuous leak of gas from mouthof gas from mouthKeep the infant as comfortable as possibleKeep the infant as comfortable as possible

Any Questions?Any Questions?

SummarySummary

Reviewed the theory behind the Reviewed the theory behind the SiPAPSiPAP machinemachineLooked at the different modes of delivering Looked at the different modes of delivering assisted support using assisted support using SiPAPSiPAP and defined when and defined when appropriate to useappropriate to usePractised how to set up and alter accordingly the Practised how to set up and alter accordingly the SiPAPSiPAP systemsystemDiscussed nursing implications when caring for Discussed nursing implications when caring for an infant on an infant on SiPAPSiPAP