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Respiratory Care: Going to New Heights
Suzanne Iniguez BSN, RN, RRT-NPS-ACCS, AE-C, C-NPT, CHSE
Respiratory Care
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Oxygen
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Thanks for Playing
Bubble CPAP
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Ventilation
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Scenarios
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Que
stion
Premature infants who exhibit good respiratory effort at birth should be placed on what immediately?
Que
stion
CPAP (Continuous Positive Airway Pressure)
Que
stion
Why do we use BCPAP?
Ans
wer CPAP increases FRC (Functional
Residual Capacity) and decreases WOB (Work of Breathing)
Que
stion
What is the time frame in which to receive early surfactant?
Que
stion
Within the first 2 hours of life?
Que
stion
How do we deliver surfactant?
Que
stion § 5F MAC needed to administer Curosurf.
§ Pt. can be given Curosurf while on ventilator or while manually bagging.
§ MAC can be saved for repeat dosing if needed.
Que
stion
What is the dose for surfactant?
Ans
wer Depends on the brand that you use –
Curosurf Dosing
Initial Dose 2.5ml/kg
Second dose in 12 hours1.25ml/kg
Third dose 12 hours later 1.25ml/kg
Que
stion
When intubated what is the preferred mode of ventilation?
Ans
wer
Volume Guarantee (VG) VentilationAssist Control – Volume Guarantee (AC-VG)SIMV – Volume Guarantee (SIMV-VG)
Que
stion
How many mls do we target for Vt ?
Que
stion
Vt Target 4.5 – 6.0 mls/Kg
Que
stion
What is the volume of an infant manual resuscitator?
Ans
wer
250mls
Que
stion
If a patient fails conventional ventilation what ventilator do they go to next?
Que
stion - High Frequency Oscillator Ventilation
(HFOV)
Que
stion What is different about the
oscillator when compared to other ventilators?
Que
stion
The oscillator has active inspiration and exhalation.
Conventional ventilation has passive exhalation.
Que
stion
If you want to increase oxygenation on the oscillator what are 2 parameters that you can change?
Que
stion
1. FiO22. MAP (Mean Airway Pressure)
Que
stion
If you want to decrease CO2 on the oscillator what are 2 parameters that you can change?
Que
stion
1. Amplitude (Delta pressure)2. Hz (the rate)
Que
stion
To decrease the CO2 do I turn the Hz up or down?
Ans
wer You turn the Hz down to blow off more
CO2
Que
stion
What is the Targeted Oxygen Saturation Range in your NICU?
Ans
wer
Your NICU?
My NICU is 90 to 95%With alarms set at 88 – 96%
Que
stion
What is the easiest way to provide low flow supplemental oxygen?
Ans
wer A simple Nasal Cannula
Que
stion
Where do you measure a Pre-Ductal Oxygen saturation?
Que
stion
On the right wrist/hand
Que
stion
A difference between the pre-ductal and the post-ductal saturation may be indicative of?
Ans
wer
Pulmonary Hypertension
Que
stion
What gas can we deliver to the patient to treat pulmonary hypertension?
Ans
wer
Inhaled Nitric Oxide (iNO)
Que
stion
What are the 3 components of BCPAP?
Ans
wer What are the 3 components of BCPAP
- Circuit
- Interface
- Pressure Generator
Que
stion
When checking BCPAP what do you look at?
Que
stion When checking BCPAP
- Look for appropriate sized prongs/mask- Ensure a cushion of air with prongs/barrier with
mask- Assess the skin- Is a chin strap needed- Is there bubbling (Suzanne’s 5 Types of Bubbling)- Check flowrate- Check FiO2- Check CPAP pressure- Does the infant need suctioning
Ans
wer What, What!!
Suzanne’s 5 Rules of Bubbling!
Que
stion
What do you use to suction an infant on BCPAP; and how far do you go?
Ans
wer 8Fr suction catheter
Measure from the nose to the ear X 1.5
Que
stion
What can you tell me about this CPAP set up?
Ans
wer • The mask is gently
contouring to the infant’s face• Side attachments are
loosely secured• ‘Trunk’ is parallel to the
face• Velcro over the ‘trunk’
is not pulled tight
Que
stion
What is the most important thing to help prevent a HAPI (Hospital Acquired Pressure Injury) with CPAP?
Que
stion
YOU!!!!!
Ans
wer
Que
stion
What is the calculation that we use to determine approximate ETT depth?
Que
stion
Weight in Kg + 6 = approximate ETT depth
Que
stion
What landmark do we use to determine where the ETT is secured?
Que
stion
The LIP
Que
stion
What is a great position for the ETT?
Que
stion
T3 to T4
Que
stion
Ans
wer
Que
stion
What are some common modes of ventilation?
Ans
wer
AC VG – Assist Control Volume Guarantee Settings - Rate, Vt, Ti, PEEP, P Max
SIMV VG – Synchronized Intermittent Mandatory Ventilation Volume GuaranteeSettings – Rate, Vt, Ti, PEEP, P Max
AC PC – Assist Control Pressure ControlSettings – Rate, PIP/PEEP, Ti
SIMV PC - Synchronized Intermittent Mandatory Ventilation Pressure ControlSettings – Rate, PIP/PEEP, Ti
Que
stion
What is a benefit of using VG mode after dosing with surfactant?
Ans
wer Variation in PIP with VG
Que
stion
What are some of the benefits of Kangaroo Care?
Que
stion
- Physiologic stability (temperature and blood pressure regulation, heart rate and respiratory stability)- Brain, cognitive and motor development.- Improved immune system function.- Weight gain.- Better, deep sleep.- Greater bonding with decrease in stress and crying.
Que
stion
Can an intubated infant participate in Kangaroo Care?
Ans
wer
Yes!
Que
stion
What is the Gold Standard for confirmation of ETT position?
Que
stion
A Chest X-Ray
Que
stion
How does the head movement in these three positions effect the depth of the ETT?
Ans
wer
Reference: Donn, SM and Kuhns LR. Mechanism of Endotracheal Tube Movement with Change of Head Position in the Neonate. Pediatric Radiology 9, 37-40, 1980.
Que
stion
You have been called to a delivery of a term infant there is thick meconium.What do you need to consider for this infant’s delivery?
Que
stion
All meconium stained infants receive warm, dry and stimulate- Then reassess
Que
stion
Where do we set the suction pressure?
Ans
wer Where do we set the suction pressure?
Suction pressure is set at -80 to -100 mmHg
Que
stion You have been called to a delivery of a
term infant of a diabetic mom, the OB is anticipating a large infant.What do you need to consider for this infant’s delivery?
Que
stion A consideration for a large infant is shoulder dystocia
Que
stion Forceps delivery
Que
stion
Ans
wer
Que
stion You have been called to a delivery
of a 28 week gestation infant.What do you need to consider for this infant’s delivery?
Que
stion If the infant has good tone and
respiratory effort – consider providing CPAP
Ans
wer If the infant has poor tone and little
respiratory effort consider –- Intubation- Dosing with surfactant- Evaluate for extubation- Remaining intubated and positive
pressure ventilation
Que
stion You have been called to a delivery of a
term infant that is experiencing decels.What do you need to consider for this infant’s delivery?
Que
stion Possible nuchal cord, possibility of
an hypoxic event
Ans
wer
Hypoxic Ischemic Encephalopathy
Perinatal asphyxia, more appropriately known as hypoxic-ischemic encephalopathy (HIE), is characterized by clinical and laboratory evidence of acute or subacute brain injury due to asphyxia.
The primary causes of this condition are systemic hypoxemia and/or reduced cerebral blood flow (CBF).
Consider passive cooling and transfer to a center that can perform cooling.
Que
stion You have been called to a delivery of
an infant whose mother presented to triage with bright red bleeding.What do you need to consider for this infant’s delivery?
Ans
wer Anticipate a depressed infant that
may be in need of resuscitation
- Intubation- PPV- Lines placed- Fluid resuscitation
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