NICU Presentation

MS4 Hugo Rivas September 23, 2010

About Me
‡ El Paso Native ‡ Undergraduate Texas Tech ‡ Interested in Pediatrics

Objectives
‡ Discuss some common problems in the ICN ‡ Case Examples ‡ Discuss and explain assisted ventilation as a concept

Pulmonary Problems in the Newborn

Respiratory Distress Syndrome
‡ Respiratory Distress Syndrome Type I/HMD ‡ Incidence ‡ Signs and Symptoms ‡ Pathology ‡ Diagnosis

Respiratory Distress Syndrome
‡ Treatment ‡ Risk Factors ‡ Protective Factors

Case 1
‡ Infant is born to a 32 yr old mom. Minutes after birth the baby has pink arms and cyanotic legs. VS BP: 60/40, RR: 85, P: 190, O2% 82. Physical exam shows a systolic murmur and soft S1. Blood gas shows high pCO2 and low pO2. Platelets 80,000. What is the most likely diagnosis?

Persistent Pulmonary Hypertension of the Newborn
‡ ‡ ‡ ‡ Stats What¶s wrong? Can we treat it? Who¶s at risk?

‡ interactions?

Persistent Pulmonary Hypertension of the Newborn
‡ Clinical Presentation ‡ Are you sure it¶s PPHN?

‡ Echocardiogram of PPHN

Persistent Pulmonary Hypertension of the Newborn
‡ Management ‡ Complications

Case Example 2
‡ 41 week baby girl was born to a 35 yr old mom. The pregnancy was complicated by hypertension and gestational DM. During delivery a meconium stained amniotic fluid is noted. PE reveals nasal flaring, cyanosis, desaturations, coarse rhonchi, green umbilical cord and mouth. CXR shows. What are the chances this baby will die?

Meconium Aspiration

Meconium Aspiration
‡ ‡ ‡ ‡ ‡ Prognosis Treatment Signs and Symptoms Diagnosis Chemical Pneumonitis

Case Example 4
29 year old mother gives birth to a boy at 30 weeks gestation. During labor the mother was reported to have a fever and tender uterus. Baby¶s VS: T37.2, P155, BP 60/40, wt 973g, R 30. Breathing is labored with subcostal retractions are noted and the pt is put on assisted ventilation. Attempts to wean the newborn over 2wks are unsuccessful. F/u echocardiogram shows a closed PDA.

Case Example 4

Case Example 4
Blood gases show pH 7.23, pCO2 65. BMP shows CO2 24. By 39 weeks cGA the patient gradually improves and is discharged home to mom. What kind of prophylaxis does this patient need upon discharge from the hospital?

Bronchopulmonary Dysplasia
‡ Synagis/Palivizumab ‡ Clinical Course of BPD ‡ Have increased risk of developing pulmonary hypertension

Bronchopulmonary Dysplasia
‡ ‡ ‡ ‡ Definition Pathology Risk factors Treatment

Ventilator Management Concepts

Ventilation vs Oxygenation
Ventilation Respiratory Rate Tidal Volume PEEP PIP Patient status Oxygenation Mean Airway Pressure FiO2 PEEP PIP V/Q Mismatch

MAP = K(PIP ± PEEP) x (Ti/Ti+Te) + PEEP

Mechanical Ventilation
‡ Concepts and Definitions ‡ Minute Ventilation VE
± VT; VA, VD, ± VE=VT x RR
‡ VT=

‡ PEEP similar to MAP in HFOV ‡ Mean Airway Pressure
± MAP = K(PIP ± PEEP) x (Ti/Ti+Te) + PEEP

Types of Assisted Ventilation
‡ Supplemental Oxygen without mechanical ventilation ‡ High Frequency ‡ CPAP ‡ Mechanical Ventilation

Supplemental Oxygen
‡ Hypoxic infants able to maintain an adequate minute ventilation are assisted with free-flow oxygen or air-oxygen mixtures. ‡ Nasal Cannula ‡ Hoods ‡ Mask

Supplemental Oxygen
‡ ‡ ‡ ‡ Flow 1-8 L/min FiO2 Nebulization/Vaporization Temperature

CPAP
‡ ‡ ‡ ‡ Nasal Prongs Nasal Pharyngeal Nasal Ventilation Mask

CPAP
‡ Pressure ‡ Flow ‡ Humidified

High Frequency
‡ High Frequency Oscillatory Ventilators (HFOV) ‡ High Frequency Jet Ventilators ‡ High Frequency Flow Interruptors

HFOV
‡ ‡ ‡ ‡ ‡ Mean Airway Pressure Amplitude analogous to PIP Flow Frequency Inspiratory time

Mechanical Ventilation
‡ ‡ ‡ ‡ ‡ Pressure Controlled Volume Controlled Patient Initiated Patient Triggered Synchronized Intermittent Mandatory Ventilation ‡ Proportional Assist

Increase in: FiO2 Rate PIP/TV PEEP

pCO2 no change decrease decrease usually no change

pO2 increase usually no change increase increase increase

MAP no change increase increase increase increase

Inspiratory time usually no change

The question becomes: In what kind of mechanical ventilation are these constant or set by the operator?

Volume controlled

Pressure Cycled (Pressure Control v Pressure Support) y Operator Set

Volume Cycled (SIMV v A/C) y Operator Set A/C

IMV

HFOV

CPAP

PEEP PIP

y

Operator set

y

FiO2 MAP Varies c resistance/ elasticity

Usually <40% Operator Set

AMP Hz I:E Flow Tidal Volume Varies c elasticity/risistance Operator Set A/C Fixed (PC) Operator set SIMV

Operator Set Usually 13Hz Usually .33 Usually 15L/min Varies with other set variables y

Mechanical Ventilation
‡ Variables

Websites
‡ http://www.uihealthcare.com/depts/med/pediatric s/iowaneonatologyhandbook/pulmonary/index.ht ml ‡ http://forums.studentdoctor.net/archive/index.ph p/t-498040.html ‡ http://www.hawaii.edu/medicine/pediatrics/pedte xt/s14c05.html ‡ http://www.merck.com/mmpe/sec06/ch065/ch06 5b.html#sec06-ch065-ch065b-339 ‡ Stat!Ref

Books
‡ Klaus

Questions

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