“Demonstration of Bubble CPAP for the Low Resource Environment” by Traci Wolbrink for OPENPediatrics
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“Demonstration of Bubble CPAP for the Low Resource Environment” by Traci Wolbrink for OPENPediatrics


Demonstration of Bubble CPAP for the Low Resource
Environment, by Dr. Traci Wolbrink. Hi. My name is Traci Wolbrink, and I’m a clinical
fellow in Pediatric Critical Care at Children’s Hospital Boston. Today I’ll be demonstrating how to set up
a bubble CPAP system. CPAP stands for Continuous Positive Airway
Pressure. It can be delivered in several different modalities,
including via an endotracheal tube with a mechanical ventilator, through nasal or mask
interface in a CPAP machine, or via a bubble CPAP system, which I’ll be showing you. I’ll be using equipment to set this system
up that should be readily available. However, you may need to modify the equipment
and resources based on what you have available in your institution. Indications. Continuous Positive Airway Pressure can be
helpful for patients in respiratory distress. It helps to keep the airways open, and helps
to alleviate the work of breathing, thus improving gas exchange and making it easier for the
patient to breathe. At each institution, you’ll need to decide
what your indications for using bubble CPAP will be. It will depend on the amount of oxygen supplies
that you have available and the amount of supplies to create the circuit. Additionally, it will depend on your ability
to use a mechanical ventilator or other CPAP systems, and your ability to have a fresh
oxygen supply for all the patients that are necessary. In some hospitals, they find it helpful to
use this on patients that are hypoxemic, which is refractory to oxygen therapy, or patients
with mild to moderate work of breathing. In those patients, it may be helpful to step
up from oxygen therapy and try a bubble CPAP interface to improve the work of breathing
and gas exchange. Contraindications. There are several patients that you may not
want to put on bubble CPAP. Those would be patients that have nasal or
facial fractures, because you risk causing pneumocephalus with using the positive airway
pressure. You would also want to caution the use of
bubble CPAP in patients that have air leak, such as pneumothorax or pneumomediastinum. And you would want to consider other modalities
if you have a patient that’s in severe respiratory distress or severely hypoxic, as bubble CPAP
may not be enough to help this patient. Equipment. I’m now going to go over the equipment that’s
necessary to set up the bubble CPAP system. The first thing that you’ll need is an oxygen
source. And I have a source here, that’s connected
to my in-wall oxygen. I have also attached a humidifier that will
allow humidification to the baby, which will make the system more comfortable for the baby
to breathe. You’ll need some sort of tubing to connect
this to the system. You can also use whatever type of oxygen source
you have at your hospital, such as an oxygen cylinder or an oxygen concentrator, as long
as you have enough flow to make the system bubble, which I’ll explain in a few minutes. What you will also need is, you’ll need a
suction catheter connected to a suction device. And you’ll need a sterile water bottle, which
here I have attached a 7 centimeter ruler to the bottom of this via tape. I filled the water bottle with sterile water. And as you can see, the meniscus of the water
reaches the top of the ruler. You should make sure that you change your
water at least once a day to help prevent the spread of infection. The other pieces of equipment that you’ll
need– you’ll need a low-resistance tubing, such as the corrugated tubing that I have
here. You’ll need two pieces; one for each limb. You’ll also need a nasal cannula set-up. This one here is a prepackaged bubble CPAP
nasal cannula set-up that you can purchase. You can also look around your hospital for
other pieces of equipment that you can make such a set-up. And I’ve made one here using a regular nasal
cannula for which I have cut on either side of the nasal prongs. And as you see here, I’ve cut each side, and
then I’ve attached it to two separate 3-way stopcocks. And I have a nasal cannula set-up that looks
very similar to what I have here. You’ll notice that the distance between the
nasal prongs is different for both of these interfaces, so you’ll need to adapt that to
which size patient you’re using. You’ll also need to have a 10 mL syringe,
which will be used to secure the tubing in place in your bottle. And you’ll need some way to secure this interface
to your patient. There are many commercially available products,
such as a baby bonnet that will go over the head– and I’ll show you this– which will
allow the system to be secured with either Velcro, or you can make a securing system
with rubber bands and safety pins. You could also choose to not use a bonnet
and instead use some gauze to wrap the system in place. Set-up. Now I’ll demonstrate how to set up your bubble
CPAP system. First of all, you’ll need to take your oxygen
tubing that’s connected to your oxygen source, and you’ll need to connect it to one piece
of your corrugated tubing, ensuring that you have a tight fit, and the two tubings are
not going to come apart. You’ll then take the other end and insert
your nasal cannula end into here, again, making sure that it fits tightly. You’ll then take your other piece of corrugated
tubing inserting that on the other side of your nasal cannula, again, making sure that’s
tight. And this will be your patient interface. Your next step is going to be to put the end
of the corrugated tubing, which is not connected to your oxygen source, into your sterile water
bottle. So the first thing I’m going to do is unscrew
the top of my water bottle, and I’m going to place the end of the tubing into the bottle,
and into the water, to a depth of five centimeters. You can see the tip of the tubing is at five
centimeters. And I’ll take my 10mL syringe, insert it into
the top of the bottle. This will help to secure it in place, and
allow the tubing to stay at five centimeters. You also want to make sure that there’s space
for air to flow out of the water bottle, and that you haven’t occluded the opening completely. Now before attaching this to your baby, you’re
going to want to make sure that you test the system. You’ll make sure that there are no leaks in
the system. So you’ll want to occlude your nasal prongs,
and you’ll want to look at your water bottle to make sure that it’s bubbling. This will make sure that there are no leaks
in the system, and that everything seems to be connected properly. Point of clarification. It is important to consider the delivered
FiO2 to with this set-up. If the flow meter is connected to a pure oxygen
source, then the delivered FiO2 is likely to be near 100%. Ideally, the flow meter should be connected
to an air-oxygen blender that enables the clinician to select the desired oxygen concentration
from 21 to 100% oxygen. This is crucial in populations where oxygen
toxicity is a risk for the development of retinopathy of prematurity, especially those
born less than 31 weeks gestational age, and/or in subjects at risk for the development of
chronic lung disease. The next step, and most challenging step,
is to connect this to the baby. So what you’ll do is you’ll take your nasal
prongs and you’ll insert them into the nares of the baby. Most likely the baby will be crying, and kicking,
and squirming around. So it’s helpful to have a parent who can soothe
the child, or an assistant to help you connect that. And in order to secure the system to the baby’s
face there are multiple ways we can do this. I’m just going to show you a simple way using
some gauze. You can take the gauze and wrap it around
the system and around the baby’s head ensuring that it’s a tight fit. You want to make sure to avoid the eyes or
the mouth. And you can cut that when it’s finished. This should ensure that the system will stay
in place and will not move too far from the baby. So I’ve showed you how to secure the nasal
cannula with some gauze, but I’ll also show you how to do it with a baby bonnet. It’s helpful if you put the bonnet on before
you begin placing the nasal cannula, as it can sometimes be a challenge to put on a baby
who is moving their head all around. You can do one of two things to secure this. You can either use something like Velcro,
which you can see I have two pieces of Velcro here that are sticky on one side and Velcro
on the other. And I will just stick this Velcro on one side
of the baby bonnet. Alternatively, you can use two safety pins
and a rubber band to secure each side of the corrugated tubing. You’ll want to place the safety pins first
on the side of the baby’s head, and you’ll want to make sure that the tubing will run
between the safety pins. You’ll want to be careful when you place these
that you’re not going through the bonnet all the way and injuring the baby’s skin. Then you’ll take a rubber band, tie a knot
in the middle, and you’ll have this available for when you put the nasal cannula set-up
on the baby’s face. So I’ll set that right there for this moment. Next, I’m going to place the nasal cannula
in the baby’s nares as I did previously. And you can see here that the tubing runs
between both sides of the safety pins. I’ll take my rubber band, connect it around
the safety pin on one side, and again, I’ll take this, wrap it around the safety pin on
the other side, and this will create a resistance for the tube to move. Additionally, I’ll show you for the sake of
demonstration purposes on the other side. I’ll remove the top piece of Velcro, I’ll
place the nasal cannula set up through the Velcro, and again attach that. So there are many ways that you can use to
secure the nasal cannula in place to the baby, but it’s just very helpful to secure it. If this comes dislodged the cannula will come
out, and you won’t be delivering any of the positive airway pressure. Troubleshooting. So now I’ll go over some troubleshooting tips
for your bubble CPAP system. As you look at this system, we can see that
the baby is connected to the bubble CPAP system; however, the bottle is not bubbling. This is indicating that we have a leak somewhere
in our system. First of all, you may have complications with
the circuit itself where some of the parts may become disconnected. We did check the system prior to placing it
on the baby, and we know that our system is completely connected, and that there is no
leaks in the plastic, and that all of our connections were tight. Therefore, we must assume that the leak is
with the patient itself, and there are a couple areas that the patient can leak from. One is through the nares and the nasal cannula
interface, and the other is through the mouth if the baby’s doing open mouth breathing. First of all, I’m just going to reposition
the nasal cannulas to see if we can get a better fit. And you can see here, just by making sure
that the nasal cannulas are indeed in place in the nares, you do get bubbling in the system. So that was the trouble that we had with this
baby. Now if, by placing the cannula in the nares
we still weren’t getting bubbling, we could try a couple of things. The first thing that you notice with this
baby is that the baby is open mouth breathing, and this could also be a loss of positive
airway pressure because the pressure is going in through the nose and coming out of the
mouth. So another thing that you can do to help this
baby is to place a chinstrap. I’m just going to use gauze. You can use whatever you have at your institution. I’m just going to wrap this gently around
the baby, making sure not to dislodge the nasal cannula in the process, and I’m going
to wrap it around here. And in a regular baby, this would help to
keep the mouth closed. I’m just going to readjust the nasal cannula
in place here, making sure that they’re in. There we go. And you’ll want to make sure that this chinstrap
is tight enough so that it closes the baby’s mouth, but not so tight so that the baby is
unable to cry, yawn, or vomit, because you wouldn’t want the baby to aspirate if the
baby did vomit. Some other troubleshooting tips: you want
to watch for abdominal distension. As you’re providing positive airway pressure
into the baby, there is a chance that some of this airway pressure is not going only
to the lungs, but is also going into the stomach. With that, you may get some gastric distension
and the baby may be very uncomfortable with that. So you could consider placing an orogastric
tube or even a nasogastric tube and use one nasal cannula side only. This will help to alleviate some of the abdominal
distension. Many babies will tolerate an orogastric tube. You may have some plugging of the nasal cannula
with secretions, and so it’s important that at least once per shift you take the baby
off and clean the nasal cannula, making sure that the secretions aren’t building up in
the nasal cannula system. And the last thing that you’ll want to do
when you’re troubleshooting is to look at the quantity and quality of your bubbling
in your circuit. As you see here, there’s quite a lot of bubbling
now that we have an occlusive nasal cannula in place and a chinstrap on our baby. So you can dial down your oxygen a bit, to
the point where you’re getting just a nice gentle bubbling like you see here. You’ll notice if you turn down the oxygen
too much, or even turn it completely off, you lose the bubbling. And in this way, you’re not delivering enough
oxygen to the baby, and the baby may actually be rebreathing CO2 because they’re not able
to push the carbon dioxide out the expiratory limb into the bottle. So you’ll want to make sure that your flow
is high enough that you’re getting enough bubbling so that you’re able to deliver oxygen
into the patient, and that when the baby exhales through the nasal cannula, they’ll exhale
in the exhalation loop and exhale carbon dioxide out into the bottle. So it’s very important that there’s adequate
amount of bubbling. The baby may also exhale some carbon dioxide
out their mouth, but if you have a chinstrap in place and you’re trying to keep their mouth
closed, you may not have enough carbon dioxide removal. Complications. The last thing that I’ll discuss is some of
the complications you may encounter while you have a patient on bubble CPAP. As we discussed previously with the troubleshooting
video, if you don’t have enough gas flow going through the patient, you may re-breathe carbon
dioxide, which would not be very helpful for these patients. You may also develop some nasal breakdown
by using the system, especially if your cannula is moving quite often. That’s why it’s very important to secure this
to the baby’s head. Also if you have a cannula that is not the
right size and is moving around inside the nares or is very stiff, you may develop more
nasal breakdown. And additionally, if you’re using non-humidified
oxygen, it may be more uncomfortable and more drying to the nares, which can promote more
nasal breakdown. So if you have the capabilities to use humidified
oxygen, it’s generally safer and more comfortable for the patient. You may also develop an air leak such as a
pneumothorax. You’ll want to watch for that and notice if
your baby develops increased work of breathing, hypoxia, or diminished breath sounds. You want to make sure that you think about
pneumothorax as a possible complication. Additionally, you may find when you put a
patient on nasal cannula CPAP for the first time that the baby develops a lot of excessive
oral secretions. That’s normal, and that’s as the positive
airway pressure is building in the oral cavity, some of the secretions are forced out of the
mouth. You can reassure the parents and the patient
that this is normal and should go away after four to six hours. Finally, you may notice gastric distension,
as we discussed in the previous segment, and you may need to place a nasogastric or an
orogastric tube in order to help alleviate that. So this concludes the video on bubble CPAP. I hope that you find it helpful. Please help us improve the content by providing
us with some feedback.

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