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Pocket Guide For Respiratory Therapists
Contributors Charles Williams RRT Sonia Goede RRT Carissa Yackus RRT
Assessment of the Newborn Common Newborn Cardiopulmonary Disorders Normal Vital signs 5 Normal ABGs 5 Signs of Respiratory Distress 6 APGAR Scoring 7 Primary Apnea vs. Secondary Apnea 4
Airway Management and Mechanical Ventilation Positive Pressure Breaths 9 Neopuff™ Infant Resuscitator 10 Nasal CPAP 12 Intubation 14 Mechanical Ventilation 16 High Frequency Ventilation 18 Miscellaneous and Special Considerations Survanta Delivery 21 Pneumothorax 23 Free Flow Oxygen 24 Special Situations 25 Resuscitation Flowchart 27
Common Newborn Cardiopulmonary Disorders
TTNB – Transient Tachypnea of the Newborn Delayed clearance or absorption of fetal lung fluid RDS – Respiratory Distress Syndrome Immature lungs/surfactant deficiency causing alveolar instability and collapse BPD – Bronchopulmonary Dysplasia Chronic lung disease due to administration of high levels of oxygen MAS – Meconium Aspiration Syndrome Aspiration of fetal bowel contents causing airway obstruction and chemical pneumonitis PPHN – Persistent Pulmonary Hypertension of the Newborn Elevated pulmonary vascular resistance causes a right-to-left shunt, bypassing the lungs, resulting in arterial hypoxemia. P.I.E. – Pulmonary Interstitial Emphysema; Pulmonary Air Leaks • Pulmonary Interstitial Emphysema – air within the pulmonary interstitial tissue • Pneumothorax – air within the pleural space • Pneumomediastinum – air within the anterior mediastinum • Pneumopericardium – air within the pericardial sac surrounding the heart
Normal Vital Signs
Birth weight (g) Blood Blood Pressure Pressure Systolic Diastolic (mmHg)
500-700 700-1000 1000-1500 1500-2000 2000-3000 Term 50-60 48-58 47-58 47-60 51-72 64-72
Respirato ry Rate
26-36 24-36 25-35 25-35 27-46
Normal Newborn Blood Gases
pH Capillary 7.37-7.44 Arterial 7.37-7.44 Venous 7.35-7.45
PCO2 31-45 31-45 34-50
PO2 60-100 80-110 ---
HCO3 22-26 22-26 24-28 5
Newborn Signs of Respiratory Distress
Tachypnea - (RR > 60 breaths/min) Cyanosis - (Peripheral cyanosis is common, Central cyanosis usually indicates an arterial pO2 < 40 mm Hg) Nasal Flaring - (Sign of air hunger) Expiratory Grunting - (Neonate attempting to maintain positive pressure on expiration and prevent alveolar collapse) Retractions - • Intercostal - between the ribs, • Supraclavicular - above the clavicles, • Subcostal - below the rib margins
• • Provides a quick assessment for depression upon delivery Perform at 1 minute and 5 minutes after birth
Primary vs. Secondary Apnea
Primary Apnea • Initial response to hypoxemia • Initial tachypnea, then apnea, bradycardia, decreased neuromuscular tone • Responds to stimulation & blow-by O2 Secondary Apnea • Follows primary apnea • Deep, gasping respirations followed by apnea, bradycardia, decreased neuromuscular tone, and hypotension • Will only respond to assisted ventilation w/supplemental O2; if not done, death/brain damage rapidly ensues
If a baby does not begin breathing immediately after being stimulated, he or she is likely in secondary apnea and will require positive-pressure ventilation. Continued stimulation Will NOT help!
Positive Pressure Breaths
Recommended Pressures: Initial breath (After delivery) - >30 cm H20 Normal lungs (later breaths) - 15 to 20 cm H20 Diseased or immature lungs – 20 to 40 cm H20
Try to maintain a rate of 40 to 60 breaths per minute By saying aloud……….. Breath……two…...three……breath……two…...three...….breath…… (squeeze) (squeeze) (squeeze)
Neopuff™ Infant Resuscitator
The Neopuff™ Infant Resuscitator is an easy to use, manually operated, gas-powered resuscitator that provides optimal resuscitation. • • • Delivers controlled and precise Peak Inspiratory Pressure (PIP) and Positive End Expiratory Pressure (PEEP). Avoids the risks associated with uncontrolled pressures. Can also be used to deliver free-flow oxygen.
Neopuff™ Infant Resuscitator (cont.)
The desired PIP is set by turning the inspiratory pressure control.
The desired PEEP is set by adjusting the Tpiece aperture
The patient T-piece allows breath by breath resuscitation by simply occluding 11 the T-piece aperture with the thumb or finger.
Nasal CPAP (con’t)
• • • Choose the appropriate sized bonnet by measuring the baby’s head circumference.
- Too small of a hat may cause it to ride up the head, putting tension on the prongs and causing
Utilize the prong size guide to select the appropriate sized nasal prongs. 3 sizes available: small, medium, large.
nasal irritation. -Too large of a hat may allow it to slide down over the patient's eyes and release CPAP prongs from the nose. • • • Adjust flowmeter to achieve desired amount of CPAP (indicated on the Pressure bar graph display)
(Approx. flow of 8.5 = 5cm H2O pressure)
The front edge of the bonnet should be at the eyebrow line and the back cover the entire skull. The sides should cover the ears but be certain that the ears are not folded under the bonnet. Prepare baby for application of nasal CPAP by suctioning and clearing the nose of any obstructive secretions.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Ventilate neonate with 100% oxygen using bag/mask Insert stylet into the ET tube just short of the tube’s tip Ensure neonate is supine and airway is hyperextended (opened) but not overextended Insert laryngoscope blade into mouth, opening the airway and visualizing the vocal cords Insert the ET tube stopping when the tip of the tube has passed the vocal cords Resume positive pressure ventilation via ET tube Confirm the tube’s position End-tidal CO2 detection Chest x-ray Auscultation Observation of condensation during exhalation Secure the ET tube
Intubation and Suctioning Guidelines
Birth Weight < 1000 g 1000-2000 g 2000-3000 g >3000 g
Laryngoscope Blade Size 0 0 0-1 1
Endotracheal Suction Catheter Tube Size Size 2.5 mm 5 Fr. 3.0 mm 3.5 mm 3.5-4.0 mm 6 Fr. 8 Fr. 8 Fr.
Weight in kg. <1 1 2 3 4
cm mark @ lip 6.5 7 8 9 10
Indications for Mechanical Ventilation in Neonates Respiratory Failure • Paco2 > 55 mm Hg • Pao2 < 50 mm Hg Neurologic compromise • Apnea of prematurity • Intracranial hemorrhage • Drug depression Impaired pulmonary function • Respiratory Distress Syndrome (RDS) • Meconium aspiration • Pneumonia Prophylactic use • Persistent pulmonary hypertension of newborn (PPHN)
Mechanical Ventilation (cont.)
Suggested Initial Settings for Specific Disease States:
PIP Normal Infant RDS Preemie (< 1000 gm) Pulm Air Leak (PIE, Pneumothorax) PPHN Meconium Aspiration (w/ atelectasis) Meconium Aspiration (w/ hyperaeration)) Diaphragmatic Hernia 10-12 20-30 Minimum as poss. < 20 < 20 30-60 < 20 < 20
PEEP 2-4 4-8 2-4 < 2 < 2 4-6 < 2 < 2
Rate Minimal (15-20) 20-40 20-30 60 – 150 30-60 * 25-50 20-25 25-100
Ti 0.3-0.5 0.3-0.5 0.3-0.5 0.25-0.4 0.25-0.4 0.3-0.5 0.25-0.4 0.3-0.5
Be sure to confirm Total PIP ordered. (Total PIP – PEEP = Set PIP)
High Frequency Ventilation
High Frequency Ventilation (cont.)
• • • • HFOV keeps the lungs/alveoli open at a constant, less variable, airway pressure. This prevents the lung ‘inflate-deflate', inflatedeflate' cycle, which has been shown to damage alveoli when there is decreased lung compliance (i.e. RDS) and lungs are “stiff”. HFOV can be thought of as “vibrating CPAP”. Must have adequate chest wiggle factor (CWF). Be sure lungs are inflated to 8th or 9th rib, do not over-inflate.
Bias Flow It is the rate at which the flow of gas, through the oscillator, is delivered to the patient. Adjusting Bias Flow will affect Mean Airway Pressure. MAP Adjust Affected by changes in Bias Flow Increases lung volume, and controls oxygenation, along with FIO2. Frequency (Hz) - Hz x 60 = “rate” A decrease in frequency = increased tidal volume An increase in frequency = decreased tidal volume Disease Variable Disease Variable Disease Variable Preterm RDS <1000g-15 Hz Preterm Air leak- 15 Hz MAS- 10 to 6 Hz Term or Near Term RDS- 10 Hz Term or Near Term-10 Hz CDH- 10 Hz Power (ΔP) - Amplitude Controls CO2 removal Controls Chest Wiggle Factor (CWF) Inspiratory Time % Can keep at 33% for most applications Affects Amplitude
Initial Settings: MAP --- 2-4 cmH20 > conventional MAP ΔP--- (adequate CWF) IT --- 33% Hz --- 15 Hz< 1kg wt 12 Hz 1-2 kg wt 10 Hz 2-3 kg wt 8 Hz > 3 kg wt Bias Flow --20 l/m
High Frequency Ventilation (cont.)
3100A Performance Checklist
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. Connect gas source and plug machine in. (Never turn machine on without plugging in gas source) Connect circuit and humidifier Connect color-coded patient circuit control lines and clear pressure sense lines Block off the ET connection port w/ rubber stopper Turn main power on. (Switch is located on base of the stand) Set Bias Flow at 20 Set both Mean Pressure Adjust and Mean Pressure Limit controls to max Push in and hold RESET, and observe Mean Pressure read out. (It should read 39-43) If read out is not 39-43, adjust with adjustment screw located on right side of vent. Set Frequency to 15, % I-Time to 33, and Power to 0.0 Set Max Paw thumbwheel switch to 30 and set Min Paw thumbwheel switch to 10. With the Mean Pressure Adjust control, establish a Paw of 19 to 21 cmH2O. Press Start/Stop button Increase power to 6.0, and center the piston Verify that the ΔP and Paw readings are within range are within range for corresponding altitude (0-2000). Press Start/Stop to stop vent. Verify thumbwheel alarms by adjusting them to trigger the alarms. Alarms should be set at 2-5 cmH2O of desired Paw pressure Using your fingers, squeeze closed the expiratory limb tubing on the patient circuit to verify the Paw pop-off at 50 cmH2O and alarm. Push and hold RESET to power up machine. Set Mean Pressure Limit control to mid-scale Again squeeze expiratory circuit and observe Paw readout. Adjust to desired level Position vent for connection to patient. Obtain settings from MD and dial in. Set power first. (changing power will change Paw). Place baby on vent and press RESET button and start vent. Center piston.
• • • • MAC catheter (or feeding tube cut to length of ETT) Ballard in-line suction and ETT adapters 12ml syringe and needle Survanta; 4ml or 8ml vial
1. 2. 3. 4. 5.
Warm Survanta for 20 min. at room temp. DO NOT SHAKE vial Determine “safe suction” depth. (Length of ETT +5) Exchange standard ETT connector with MAC catheter ETT connector Draw up Survanta (4ml per kg) Position infant head-down/turned to RIGHT. Advance suction catheter to “safe suction” depth; Administer ¼ dose and then withdraw the catheter. Infant should remain in this position for 30 seconds. 6. Repeat above procedure in the following order head-down/LEFT, head-up/RIGHT, and finally head-up/LEFT 7. Do not suction infant for 2 hours
Survanta Dosing Chart
WEIGHT (grams) TOTAL DOSE (mL) WEIGHT (grams) TOTAL DOSE (mL)
600- 650 651- 700 701- 750 751- 800 801- 850 851- 900 901- 950 951- 1000 1001- 1050 1051- 1100 1101- 1150 1151- 1200 1201- 1250 1251- 1300
2.6 2.8 3.0 3.2 3.4 3.6 3.8 4.0 4.2 4.4 4.6 4.8 5.0 5.2
1301- 1350 1351- 1400 1401- 1450 1451- 1500 1501- 1550 1551- 1600 1601- 1650 1651- 1700 1701- 1750 1751- 1800 1801- 1850 1851- 1900 1901- 1950 1951- 2000
5.4 5.6 5.8 6.0 6.2 6.4 6.6 6.8 7.0 7.2 7.4 7.6 7.8 8.0
Supplies needed: •21 or 23 gauge butterfly needle •Three-way stopcock •20 ml syringe
1. 2. 3. 4.
Insert needle into 4th intercostal space (located at the level of the nipples) Connect butterfly needle to stopcock and syringe Open stopcock between needle and syringe and then aspirate air or fluid. Stopcock may be closed to empty syringe
Free Flow Oxygen
Free Flow oxygen can be given with a flow-inflating bag, an oxygen mask, or by using oxygen tubing with a cupped hand.
1. Meconium Present at delivery
• • • If meconium is present, and the newborn is not vigorous, suction the baby’s trachea before proceeding with any other steps. If the baby is vigorous, suction the mouth and nose only, and proceed with resuscitation as required. “ Vigorous” is defined as a newborn who has strong respiratory efforts, good muscle tone, and a heart rate greater than 100 beats per minute.
2. Diaphragmatic Hernia:
• A baby with a diaphragmatic hernia will present with persistent respiratory distress and will often have an unusually flat abdomen with diminished breath sounds on the side of the hernia. Do not bag mask ventilate, intubate as soon as possible. Insert an oral gastric tube to evacuate the stomach contents
Special Situations (cont.)
3. Choanal Atresia
• • • Blockage of the airway caused by an improperly formed nasal passage. Test by attempting to pass a small-caliber suction catheter If choanal atresia is present, you must insert a plastic oral airway to allow air to enter through the mouth.
4. Robin Syndrome
• • • The baby is born with a very small mandible. The tongue falls farther back into the pharynx and obstructs the airway. Place the baby on his stomach (prone). This will allow the tongue to fall forward, thus opening the airway. If unsuccessful, place a large catheter (12F) or a small endotracheal tube (2.5) through the nose.
Neonatal Resuscitation Handbook; American Heart Association Respiratory Care: Principles & Practice; Hess, MacIntyre Neonatal Mechanical Ventilation
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