Noninvasive positive airway pressure (PAP) therapy uses mild air pressure to keep airways open delivered via a mask. This treatment can help the body to maintain better carbon dioxide and oxygen levels in the blood. PAP therapy may be used to treat many adult disorders, such as sleep apnea, obstructive sleep apnea, obesity hypoventilation syndrome, acute cardiogenic pulmonary edema, heart failure, COPD, and acute hypoxemic respiratory failure (Hess et al., 2021; Martin, 2020; Medline Plus, 2021). It also may be used to treat disorders in infants and children, such as respiratory distress syndrome in preterm infants (Stanford Children's Health, 2021), infants with bronchiolitis (Franklin et al., 2019), and obstructive sleep apnea in children (Al-lede et al., 2018).

Continuous positive airway pressure (CPAP) provides continuous mild air pressure to keep airways open. Bilevel positive airway pressure (BiPAP) changes the air pressure while the patient breathes in and out. Autotitrating (adjustable) positive airway pressure (APAP) changes pressure throughout the therapy, based on the patient's breathing patterns (Medline Plus, 2021). All therapies use a mask or other device that fits over the nose or nose and mouth. Straps keep the mask in place. A tube connects the mask to the machine, which blows air into the tube.

This skill addresses noninvasive CPAP, the use of continuous mild air pressure applied throughout the respiratory cycle in a spontaneously breathing patient to promote alveolar and airway stability and increase functional residual capacity (Hinkle et al., 2022). CPAP is an effective treatment of obstructive sleep apnea; the air pressure holds the upper airway and trachea open during sleep (Bauldoff et al., 2020). CPAP may also be used as an adjunct to mechanical ventilation with an endotracheal tube or tracheostomy tube (Hinkle et al., 2022). Use of CPAP is contraindicated for patients with poor inspiratory drive and those who are not spontaneously breathing (Pinto & Sharma, 2021). Additional contraindications are identified in the Special Considerations discussion at the end of the Skill.

Nurses also play an important role in assisting with adherence to the prescribed CPAP intervention; nurses can assist patients by reinforcing accurate information about treatment and providing support and encouragement (López-López et al., 2020). If the device is used in the hospital or other facility or in the community, nursing responsibilities also may include monitoring the settings, ensuring correct use by the patient, and assessment of respiratory status. Initial use of CPAP may be difficult while patients acclimate to the device (Pinto & Sharma, 2021). Box 14-1 presents tips to avoid/address common problems encountered with CPAP.

Careful assessment of the patient's skin on the face, in the areas where the mask or nosepiece sits, and on the head where the straps sit is an important part of care. Pressure and moisture from the mask or nosepiece can cause alterations in skin integrity (Alqahtani et al., 2018). There are many kinds of CPAP machines and masks/nosepieces. Refer to the manufacturer's information for details for the specific equipment in use.

Assessment

Assess respiratory status. Assess vital signs and oxygen saturation. Ask the patient about symptoms, including loud, ongoing snoring; daytime sleepiness; snorting/gasping during sleep; morning headaches; and waking up with a dry mouth or sore throat. Assess the patient's skin on the areas that come in contact with the CPAP headgear. Assess the patient's understanding of the use of CPAP.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

• Altered breathing pattern
• Fatigue
• Knowledge deficiency

Outcome Identification and Planning

The expected outcomes to achieve when implementing CPAP are that the headgear fits properly and is comfortable for the patient, there is no air leakage from the headgear during use, and the CPAP remains in place during sleep. Other outcomes that may be appropriate include that the patient experiences restful sleep and symptom improvement and verbalizes an understanding of and engages in the plan of care.

Implementation

Action	Rationale
1. Review the health care record for contraindications to the use of CPAP. Review the health record to verify the prescribed intervention, including the use of CPAP, pressure settings, and administration parameters. Gather equipment.	Verifying the prescribed intervention and the absence of contraindications ensures the patient appropriately receives the prescribed intervention. Assembling equipment provides for an organized approach to the task.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Assemble equipment on the overbed table or other surface within reach.	Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse.
5. Close the curtains around the bed and close the door to the room, if possible. Explain to the patient what you are going to do and why.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates engagement.
6. Assist the patient to a comfortable sleeping position in the bed.	Comfort supports relaxation and sleep.
7. If it is the first time the CPAP machine is being used, install the CPAP machine filter as directed by the manufacturer.	Room air is drawn into the machine through a filter to remove dust, lint, and other large airborne matter (Hess et al., 2021).
8. Place the CPAP machine on a flat, stable surface near the bed (Figure 2). Position the vents of the machine at least 12 inches away from the wall, curtains, and other objects. Plug the electric cord into the electric outlet.	Proper positioning is necessary for optimal functioning of the device and allows for clean, unobstructed airflow (ASA, 2021). Plugging the machine into the outlet provides power to the machine.
9. Attach the CPAP hose and mask/nosepiece (Figure 3). Add distilled or sterile water to the humidifier compartment of the machine; fill to the “MAX” fill line.	The hose and mask provide the means for delivery of the positive pressure. Some CPAP machines have a humidifier built into the device; water provides humidification to moisturize the air to reduce the risk of drying of the mouth, nose, and throat (Suni, 2020). Use of distilled or sterile water prevents mineral buildup (Suni, 2020). Overfilling of the humidifier can cause water to enter the hose (Suni, 2020).
10. Enter the prescribed pressure setting (5 to 10 cm H2O) into the CPAP machine, if not already programmed into the device.	Most CPAP machines have a pressure setting range from 4 to 25 cm H2O (Fountain, 2021a); the usual pressure range is between 5 and 10 cm H2O (Pacheco, 2021).
11. Assist the patient to put on the mask or nosepiece. Position the mask/nosepiece on the face and attach or pull the straps to secure it. The mask/nosepiece should form a seal against the face/nose but should not pinch or press deeply into the skin (Figure 4). Adjust the straps for a comfortable fit.	A proper fit is necessary to ensure optimal delivery of pressure but reduce the risk for pressure injury (Pinto & Sharma, 2021; Suni, 2020). A properly fitting mask should not be uncomfortable or cause pain (MFMER, 2018a).
12. Turn the machine on. The patient should experience pressurized air coming through the mask/nosepiece. Assess for air escaping/leaking from the mask/nosepiece. Adjust the straps as needed for a tighter seal.	A proper fit is necessary to ensure optimal delivery of pressure but reduce the risk for pressure injury (Pinto & Sharma, 2021; Suni, 2020).
13. Assist the patient to adjust their sleeping position, as necessary, to attain comfort without interfering with wearing of the mask/nosepiece or pinching or blocking the machine's hose (Suni, 2020).	This positioning supports optimal sleep and functioning of the device.
14. Remove PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
15. Monitor the patient's use of the CPAP during sleep. Assist the patient to remove the CPAP upon waking, as needed. Evaluate the patient's tolerance, respiratory status, and symptom management. Assess for possible complications from use, such as discomfort, feelings of claustrophobia or embarrassment, dry mouth, nosebleeds, nasal congestion, and skin irritation (MFMER, 2018a). Provide interventions as necessary to assist with transition to the use of CPAP. Refer to Box 14-1 for tips to avoid/address common problems with CPAP.	Monitoring and evaluation after use supports effective use and provides information to guide adjustments to use and maintain compliance. Initial use of CPAP maybe difficult while patients acclimate to the device (Pinto & Sharma, 2021).
16. Clean the CPAP tubing and mask/nosepiece regularly, at least weekly and preferably daily with warm water and a mild detergent, or according to the manufacturer's instructions (ASA, 2021; Fountain, 2021b). Refer to suggested cleaning guidelines in the Community-Based Care Considerations section below.	Cleaning the equipment removes contaminants, microorganisms, mold, dust, and debris (Fountain, 2021b; Pinto & Sharma, 2021). Rinsing removes soap. Components must be in good working order to support optimal functioning of the device.

Evaluation

The expected outcomes have been met when the headgear has fit properly and was comfortable for the patient, no air has leaked from the headgear during use, the CPAP has remained in place during sleep, the patient has experienced restful sleep and symptom improvement, and the patient has verbalized an understanding of and has engaged in the plan of care.