Nasal continuous positive airway pressure (NCPAP) has become a first line treatment for infants with respiratory distress in the Neonatal Intensive Care Unit (NICU) (Gupta & Donn, 2016). Nasal continuous positive airway pressure (NCPAP) was first introduced as a modality to improve oxygenation in neonates in 1971 (Gregory, 1971). Since its development, different NCPAP systems have become available with Bubble NCPAP reported to be the most widely used system (Mann, Sweet, Knupp, Buck, & Chipps, 2013). NCPAP has gained support as an alternative method of respiratory support in selected neonates and has been demonstrated to reduce the need for intubation and the incidence of bronchopulmonary dysplasia. However, the successful use of NCPAP is not without risks including nasal injury, and nasal breakdown. Similar risks to endotracheal suctioning are evident as well, including increased risk of infection, bradycardia, laryngospasms, cardiac dysthymias and even cardiac arrest. Registered Nurses (RNs) and Respiratory Therapists (RTs) who care for these neonates require extensive knowledge about the equipment set-up, maintenance and operation of the system.
Guidelines for endotracheal suctioning in neonates requiring mechanical ventilation (MV) are published in the literature but lack strong empirical support. No evidence-based guidelines for safe suctioning in neonates while on NCPAP have been published. Preliminary research shows that nurses’ decision-making regarding the frequency of and techniques for suctioning of neonates is quite variable (Mann et al., 2013), and is concerning because practice variation is often associated with less favorable outcomes.
Suctioning while on NCPAP is a very frequent nursing practice in NICUs across the world. This study represents the next steps toward the development of an evidence-based practice guideline for this nursing practice.
Purpose:
To describe the clinical/behavioral responses of neonates on Bubble NCPAP in a Level III NICU following routine suctioning.
To characterize variability in suctioning response among neonates by gestational age and birth age.
Methods: This pilot study has a one sample within-subject repeated measures design in which neonates served as their own control. This study took place at a level III-49 bed NICU in a large academic medical center in the Midwestern USA.
A convenience sample (n=16) neonates who met the inclusion criteria was recruited from the NICU. We included neonates who were (1) on Bubble NCPAP (Respiroinics Bubble NCPAP™) (2) 27-32 weeks gestation, (3) older than 3 days of life but less than 7 days of life; (4.) have a legally authorized representative; and (5) are clinically stable as defined by the NICU healthcare team. Exclusion criteria included: (1) any facial/cranial deformities, (2) chromosomal/genetic abnormalities, (3) congenital heart disease, (4) chest tube placement, (5) persistent pulmonary hypertension, (6) receipt of any medications that alter responses to pain such as paralytics, narcotics or other sedatives.
The suctioning procedure tested was based on the expert opinion from a focus group of our clinical experts of our NICU since no empirically based guidelines exist. Two experienced RNs served as the study RNs and they established interrater reliability on the suctioning procedure prior to data collection. Data on an infant’s physiological and behavior measures (heart rate, respiratory rate, O2 saturation, and Premature Infant Pain Profile (PIPP score)) were collected repeatedly: 5 minutes prior to suctioning (baseline), during suctioning (right nare, left nare, mouth), immediately upon completion of suctioning sequence and 10 minutes after suctioning OR the return to within 10% of baseline physiological parameters.
Results: A total of 16 neonates were enrolled with mean gestation age of 29.76 weeks (SD=1.49) and an average day of life of 3.4 (SD=1.15). Overall, the infants’ heart rates did not differ significantly (p=.51) across the suctioning sequence. Eight neonates required a second pass of either the nares or mouth and 2 neonates required a third pass of pass of the mouth. The average heart rate across the suctioning sequence ranged from 155 to 167 on the first pass. The largest change in heart rate occurred between after the second and third suctioning passes of the mouth. Respiratory rate dropped but only slightly during the suctioning sequence (p=.79). Oxygen saturation demonstrated a noted drop between baseline and the first pass of suctioning in the right nares as well a considerable drop from the first pass to second pass of the right nares in one infant (p=.0001). PIPP scores clearly demonstrated a precipitous increase in pain during the first suctioning pass and remained high throughout the procedure. (p=.0001). When controlling for gestational age and days of life, oxygen saturation had significant reduction of 3.0-4.4% (≤.01) and pain (PIPP) scores had significant increase of 3.0-3.7 points (≤ .001) across the first passes of the entire suctioning sequence.
Conclusion: Our results suggest that the procedure tested is tolerated by infants and no adverse events were observed; however the neonates did experience a mild to moderate amount of pain. Oxygen saturation remained within acceptable ranges and no clinically significant concerns were raised with respiration, and heart rate. Neonatal response to suctioning while on NCPAP was not highly sensitive to days of life or gestational age. Repeating this study and evaluating the use of “oral suckers” during suctioning and other pain management strategies will further support an evidence-based guideline for this frequent procedure.