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1
Respiratory Management of the
Neonate:
Methods & Strategies
Loy Maslen, RN, MSN, NNP-BC, CPHM
Perinatal Clinical Nurse Specialist
UW/Valley Medical Center
1
Objectives:
• Define mechanisms of lung injury
• Review strategies to prevent or minimize lung injury
• Discuss respiratory interventions & methods of ventilation
• List nursing care for infants receiving respiratory support
2
Goals of treatment:
• Ultimate Goal is Normal Survival
• Decrease morbidity: Minimize CLD, PVL, IVH,
ROP, and Sepsis
• Decrease ventilator days: Decrease hospital
stay and cost
3
●Respiratory strategies and management has improved to the point
that few die because of acute respiratory failure.
● Mortality is now predominantly from complications of extreme
prematurity. Such as infection, necrotizing entercolitis (NEC), &
intracranial hemorrhage.
● Our focus has changed from reducing mortality to reducing the
incidence of chronic lung disease (CLD), which has improved the
survival of ELBW infants.
4
Causes of CLD or BPD
• Prematurity and Surfactant deficiency
• Volutrauma and/or Atelectrauma
• Oxygen free radicals via high inspired O2
concentrations
• Pre-existing lung damage and/or inflammation by
sepsis and chemical pneumonitis with resulting
inflammation
5
Acute Lung Injury
6
2
Acute Lung Injury
7
Chronic Lung Injury
8
CLD/BPD
9
Airway obstruction,
atelectasis and
over distention, air-
trapping, thickening
of alveolar wall,
edema, interstitial
infiltrates, PIE and
hyperinflation with
dropping of the
diaphragm
• Also known as bronchopulmonary
dysplasia (BPD)
• Defined as…
• Infants born less than 32 weeks gestation
require O2 at 36 weeks gestation or at
discharge
• Infants born greater than 32 weeks and
require O2 at 28 days or discharge
What is Chronic Lung Disease?
10
Identify Infants at Risk for Lung Injury
• ELBW infants (< 28 weeks gestation). This group is at the greatest risk due to lack of alveolar structure and surfactant deficiency
• Meconium Aspiration (MAS): injured and chemically inflamed lungs
• Infants with sepsis or pulmonary hypertension (PPHN). They require high support to maintain oxygenation
• Infants with lung hypoplasia due to Congenital diaphragmatic hernia (CHD), abdominal defects, & oligohydramnios.
11
Signs and Symptoms of CLD
• Babies with RDS generally begin to show signs of improvement at days 3-4 of life, however infants with CLD do not improve
• The infant's oxygen demands do not decrease as they should – they can even increase
• Tachypnea Tachycardia
• Continued grunting, flaring and retracting
• Poor weight gain or stunted growth – this is due to the increased demand for energy for breathing. Energy is used to breathe rather than for growth
• Coarse crackles may be heard in the chest
• PIE-Pulmonary Interstitial Emphysema on CXR
12
3
Surfactant
13
• Volutrauma: the over distention of alveoli and
airways
• Atelectrauma: the repeated alveolar collapse
and reopening
Volutrauma and Atelectrauma
14
Oxygen: Is O2 toxic?
• Too much O2 results in the over production of oxygen free radicals • Pulmonary inflammation • ROP
• Oxygen toxicity is the most severe side effect of oxygen therapy in newborns. The lungs take the brunt of the damage, which can result in inflammation, hemorrhaging and swelling
• O2 free radicals initiate lung injury sequence that can cause alveolar damage, and progressive pulmonary dysfunction
• However, PaO2 too low • PVL • Decreased growth • CP • Cor Pulmonale • Increased mortality
15
Strategies to Prevent or Minimize Lung
Injury
• Surfactant administration
• Minimize the use of inspired O2
• Minimize the use of mechanical ventilation
• Minimize inflation pressures
• Ensure optimal heat/humidity to inspired gases
• Reduce sepsis risk and airway injury
• Use optimal PEEP or Continuous Positive Airway Pressure (CPAP)
16
Surfactant
17
Surfactant Therapy: Prophylactic
Treatment of the ELBW
• Egberts (Peds 1993:92;768) Showed prophylactic surfactant especially beneficial in male neonates < 28 weeks or < 1000grams.
• Take surfactant to delivery room, administer before 15” of life if intubation is completed
18
4
Surfactant Therapy: Rescue
• Infants with HMD diagnosis should get surfactant within 1st hour of life.
• Not all premature infants need exogenous surfactant, particularly those who have received antenatal corticosteroids
• Repeated doses may be given for PaO2 < 80 with FIO2 > 30%
• Variety of surfactant types
19
FIO2: Titration to SpO2 in the DR
Time SpO2 (pre-ductal)
1 minute 60-65%
2 minutes 65-70%
3 minutes 70-75%
4 minutes 75-80%
5 minutes 80-85%
5-10 minutes 85-95%
Admissions maintain SpO2 88-97% (target 90-95%)
20
Strategies to Minimize Lung Injury:
Gentle Ventilation to Decrease VILI
• “Just a few cycles can trigger an inflammatory reaction” • Excessive tidal volume (VT), not pressure, is chiefly
responsible for lung injury. (Volutrauma)
• Gentle ventilation is of fundamental importance to reducing the incidence of these injuries
21
Minimizing VILI
• Use lung protective ventilation modes
• Conventional Ventilation vs. High Frequency
Ventilation
22
Minimize VILI: Conventional Ventilation
(CMV)
• Current ventilators have microprocessor controls that
allow ELBW infants to trigger the ventilator, allowing
for synchronization.
• Volumes are calculated or measured through
pneumotachometers
23
Minimize VILI: CMV
• Optimal choice of VT is 4-6 ml/kg
• Use minimal inflation pressures. Only
enough to achieve optimal VT
• PEEP 4-6 cm H20 to maintain FRC
• Inspiratory Time (Ti): 0.3-0.4 seconds
24
5
Minimize VILI: HFOV
• In theory, the benefit of HFOV is the
reduction of iatrogenic ventilator injury
while maintaining adequate gas exchange
using similar Mean Airway Pressures
(MAPs), but lower peak inspiratory
pressure associated with continuous
mechanical ventilation (CMV)
25
HFOV
• Cochrane Data Base did not find evidence of great advantages of HFOV over CMV in the ELBW infants. Thus, there are two theories to the use of HFOV. • Prophylactic treatment of the ELBW infant. It is recommended in
experienced centers.
• Rescue Treatment: Severe respiratory failure refractory to CMV or in newborns with significant CO2 retention. Standard of care for infants with PPHN, Congenital Diaphragmatic Hernia (CDH), active air leak, Meconium Aspiration
26
Strategy: Minimize use of
Mechanical Ventilation • Attempt early extubation with NCPAP support (Nasal
Continuous Positive Airway Pressure) • Studies show that employing NCPAP reduces the duration
and need for intubation, which reduces the risk of BPD
• Continuous pressure is applied during the entire respiratory cycle to prevent the alveoli from collapsing and thus permit a more normal breathing pattern
27
Strategy: Minimal Use of
Mechanical Ventilation: NCPAP
• Stabilizes the upper airway
• Improves lung function by restoring FRC
• Promotes normal breathing and reduces apnea
• Allows development of small airways
• Facilitates utilization of natural surfactant
• Non-invasive, thus no risk for sepsis from Ventilator Acquired Pneumonia (VAP)
28
Strategy:
Optimal Humidification
• Ensure optimal heating of gas to ~37°C. for all inspired gases to provide optimal humidification of airways. • Mechanical ventilation
• NCPAP
• SiPAP
• Hi flow NC
• Hood Therapy
29
Respiratory Interventions & Modes of
ventilation:
• NCPAP: Conventional vs. Variable Flow
• Vapotherm/Hi Flow NC
• CMV: Draeger Baby Log, Maquet Servo I &
300A
• HFOV: Sensormedic 3100A
30
6
NCPAP
• Disadvantages: • Fixation and application can be difficult to maintain
• It is a challenge to maintain a constant stable positive pressure
• Some systems have increased expiratory resistance leading to increased work of breathing (WOB) and respiratory fatigue
• Increased abdominal distention and increased production of secretions
31
NCPAP:
Conventional vs. Variable Flow
• Conventional: maintains CPAP via a mechanical ventilator or “Bubble CPAP” uses continuous flow and expiratory valve to produce ambient expiratory pressure (PEEP)
• During expiratory phase of respiratory cycle infant has to exhale against the oncoming gas flow which can lead to added WOB.
• Variable Flow CPAP: Infant Flow uses Fluidic Flip action/Airlift uses Vortex • No valves or moving parts are needed
• A flow driver is required
• CPAP is created in the generator to provide constant stable positive airway pressure
• This flow is converted by kinetic energy to a specified pressure level
• This allows a constant and stable CPAP that supports the infants efforts and ensures that FRC is maintained
• Decreased WOB
32
NCPAP:
Infant Flow vs. Airlife
33
Infant Flow NCPAP:
Generator/Application
34
Airlife NCPAP: Generator Application
35
NCPAP Equipment Fit
• Correct application of Silicone Prongs & masks • Prongs too small= leak
• Prongs too large = may misshape nares or pop out
• Masks too small=collapse of nasal structure & obstruction
• Mask too large= leak
• Correct cap size and placement
36
7
• Nursing Care: • √ prong position with hourly vitals
• Skin condition and color
• Chest wall stability & retractions (WOB)
• Blood Gases, SpO2, TcCO2
• Signs of irritability
• Suctioning: Gently with multi-purpose device, lower pressures. Watch for thick oral secretions that can occlude airway.
• Enteral feeds-via orogastric route only • NG tubes impede fixation and increase risk for nasal
erosion
NCPAP Care Considerations
37
• Nasal Care done with hands on at least
Q 3-4 hours
• Skin should be kept clean and dry
• Perform skin integrity assessment
• Any changes to skin condition needs to
be documented and evaluated
NCPAP Hands On
38
Skin Integrity Assessment Tool
Stage 0 No discoloration or indent. No intervention
Stage I Mild redness and indent noted. Color and indent improves with
brief rest period. No other interventions required
Stage II Redness or bruising that does not improve with brief rest.
Infant may require increased breaks off CPAP or change in
appliance (alteration of prong/mask). Check prong size to
ensure that the largest the nare can accommodate are used
(lessens amount of pressure required on appliance). Consider
barrier to halt progression to stage III.
Stage III Nares excoriated and weepy. May or may not have bleeding.
Prongs should not be used if septal damage noted. Mask
should not be used for upper lip damage. Consider frequent
breaks. Notify MD or ARNP of findings.
Stage IV Nares necrotic with severe tissue damage. Consider removal of
NCPAP, intubation may be required.
39
NCPAP
• Parameters for CPAP should be set according to the needs of each infant. • PEEP 4-6 cm H2O (many use aggressive levels of 6-8 cm
H2O)
• PaCO2 tolerated at 45-65 mmHg
• (Permissive Hypercapnia) with pH > 7.2
• O2 to maintain PaO2 50-70 mmHg
• Adequate heated & humidified gases
• Primary reason for failure is apnea
• Methylxanthines or Caffeine
40
SiPAP
• Delivers CPAP and inspiratory pressure (up to 10 cmH2O
• Infant Flow SiPAP is a device which enables the Biphasic
continuous positive end-expiratory pressure (Biphasic) by
addition of an intermittent “Sigh, SiPAP pressure” to the
nasal CPAP)
• Potential benefits
• Recruit lung volume
• Off-load respiratory work (VT-3-6 ml/kg)
• Stimulate respiratory center
41
SiPAP
42
8
SiPAP
43
Hi Flow Nasal Cannula
Vapotherm: Precision Flow F & P: Optiflow Jr.
44
Hi Flow NC
Special cannula’s for each device.
Liter flow 1-8
Vapotherm Cannula Optiflow cannula
45
Modes of Ventilation: Drager
Baby Log
VN 500
46
Drager
• Volume Guarantee: (volume targeting
4-6ml/kg)
• Can be used with SIMV , AC and PSV
(Pressure support ventilation)
• Requires flow sensor-airleak sensitive
• Set Target VT, Max PIP, Rate, PEEP, Ti,
flow
47
Modes of Ventilation: Maquet Servo i
Versatile modes of ventilation:
PRVC (pressure regulated volume control)
PRVC SIMV
PC (pressure control)
Volume support & automode
NIV: NAVA
48
9
Maquet Servo i: PRVC
• Delivers targeted VT (4-6ml/kg) at the lowest pressure possible/responds to changes in compliance.
• Set Vt, peep, rate, iT
• Flow is variable
• Volumes are measured at ventilator, unless “Y sensor software and flow sensor are added.
• Y sensor allows volume and pressure measurement at ETT.
49
Management of CMV
• Volume Control or Volume Targeting:
*manipulation of the pH & pCO2 is by adjusting the minute ventilation.
Ve= rate x volume.
*Control of PO2 is adjustments of the FIO2, PEEP, & indirectly adjusting the PIP to increase VT or increasing the VT.
▪ Pressure Control Ventilation:
*manipulation of pH & pCO2 adjust Ve, by adjusting rate and ∆P (PIP-PEEP)
*Control pO2 by adjustments to the FIO2 & PEEP
50
Modes of Ventilation:
Sensormedics 3100A
Zone of de-
recruitment
Safe Window
Zone of over
distention
51
iNO
• NO is administered in gaseous form through the
inspiratory limb of the ventilator circuitry between the
ventilator and the humidifier
• Expiratory gas is scavenged from the expiratory block of
the ventilator to the wall suction
• Babies receiving iNO therapy have a bagging circuit
complete with scavenging device fitted, so that in the
event of ventilator failure or resuscitation, iNO may
continue to be administered
52
iNO What is It?
• Nitric oxide is an endogenous free radical, synthesized in
endothelial cells, that causes vascular smooth muscle
relaxation vasodilation.
• Inhaled nitric oxide (iNO) selectively targets pulmonary
vessels, causing a potent and sustained vasodilatation
increased pulmonary blood flow
• iNO is a treatment for pulmonary hypertension
• iNO efficacy is improved by prior optimization of an
infant's clinical condition (pulmonary disease and
ventilation, cardiac performance and systemic
hemodynamics and physiology) and should only be
considered as part of an overall clinical strategy
53
Who
• Term or near term infants with pulmonary hypertension
evidenced by poor oxygenation and, if possible, confirmed
by echocardiography
• Primary pulmonary hypertension
• Secondary pulmonary hypertension resulting from:
• Infection
• Parenchymal disease such as meconium aspiration syndrome,
pneumonia or RDS
• Pulmonary hypoplasia: idiopathic or secondary to congenital
diaphragmatic hernia or anhydramnios/oligihydramnios
• Severe peripartum hypoxia
• Congenital lung malformations such as alveolar capillary dysplasia
or congenital cystadenomatoid malformation (CCAM)
• Congenital heart disease
54
10
HFOV:
• Oxygenation=MAP (Mean Airway Pressure)
• Lung volume is maintained by a continuous pressure holding
the lung open at an optimal level
• Lung recruitment:
• Chest X-ray should show 8-9 ribs
• If air leak or CLD 7-8 ribs
55
HFOV: Optimal Inflation
Over
inflation
No inflation
Proper inflation
56
HFOV
• Ventilation is controlled by adjustments to the
Amplitude of each cycle “Power”
• The Frequency is the time allowed for each
cycle
• 1 Hertz=60 cycles“
• Recommended Hertz in neonates12-15
• Term infants=10 Hz.
• MEC Aspiration=8Hz
• Recommended Amplitude titrate to“Chest
Wiggle”
57
HFOV Strategy for Diffuse Alveolar
Disease-RDS
• Set MAP 1-2 cm H2O > CV (this opens and
stabilizes the lung volume)
• Frequency 12-15 Hz (720-900 cycles)
• Amplitude set to give adequate chest wiggle or
shake
• Adjust with blood gases to keep PaCO2 in high
40’s
• Wean FIO2 to < ~40%, then wean MAP
58
Nursing Care with the ELBW
Infant on Respiratory Support
59
Nursing Care: Positioning
• Prone, supine or side lying
• Positioners & containment
• Chin ideally in the midline
• Watch Endotracheal Tube
60
11
Nursing Care: Positioning
61
Positioning:
62
Positioning: Supine with head
support
63
Positioning on NCPAP
64
Positioning on NCPAP
65
Kangaroo Care on Ventilator
66
12
Kangaroo Care with NCPAP
67
Kangaroo Care with Hi Flow NC
68
Nursing Care: Suctioning
• Goal: Minimize injury that could be caused by suctioning by ensuring proper suctioning catheter placement and using sterile technique
• The ETT is suctioned to prevent a build up of secretions and therefore blockage of the airway
• Indications for suctioning • Use of Saline
• Frequency of Suctioning
• Variable methods of technique: • Shallow vs. deep suctioning
• Closed vs. open suctioning
69
Closed Suction System
70
Oral Care
• To minimize tenacious secretion collection in the mouth
• To maintain mucosal integrity
• Minimize VAP
• Use of colostrum and breast milk to prevent VAP is a
feasible method
71
Special Considerations with HFOV
72
13
HFOV considerations
• Prevent inadvertent extubation: • Set brakes on Oscillator
• Use flexible tubing and secure
• Avoid pulling on ETT, keep in straight alignment
• Suctioning & Turns: DO NOT DISCONNECT. This will cause alveolar collapse and loss of lung volume • Stop oscillations with advancement of catheter, maintain MAP,
resume oscillations after removal of catheter from ETT
• Weighing: • Make sure infants are placed on a bed with in bed scales
• X-Rays • Keep on mechanical ventilation
• Hold head midline
73
HFOV Considerations-2 People
Positioning of HFOV in incubator “Pancake-flip” on HFOV
74
Nursing Care: Minimize Use of
Inflation/Ambu Bags
• If using inflation bags, ensure that excessive inflation pressures are avoided • Flow inflating bags with
manometer
• Self inflating bags with pop-off
• Neopuff (recommended)
75
Neopuff:
T-piece resuscitator
Adjustment of Peep Adjustment of PIP
76
Review
• Chronic lung disease is a chronic pulmonary
syndrome affecting infants after exposure to
mechanical ventilation and supplemental O2
and characterized by the need for
supplemental O2 beyond 36 weeks
postmenstrual age
77
Conclusion
• Prevention of lung injury in extremely premature infants requires that the multiple variables contributing to their development be minimized while factors that facilitate the normal development of the lungs are maximized • Avoid premature delivery
• Antenatal steroids/MgSO4 for neuroprotection/treat suspected chorio
• Early surfactant
• Gentle mechanical ventilation techniques
• Minimal stimulation protocol/Developmentally appropriate support
• Early extubation, with use of NCPAP
• Avoid hyperoxia & hypoxia, hypo & hyper carbia
• Other: Management of PDA, postnatal steroids (inhaled), antioxidants & nutritional support
78
14
Questions?
79
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21.Inhaled nitric oxide iNO therapy for the term or near term neonate
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