c hapter 48 neonatal and pediatric respiratory care

CChapter 48hapter 48

Neonatal and Pediatric Neonatal and Pediatric Respiratory CareRespiratory Care

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 2

ObjectivesObjectives

Describe the correct approach to assessment of the fetus Describe the correct approach to assessment of the fetus and newborn infant. and newborn infant.

Discuss the use of oxygen therapy, bronchial hygiene Discuss the use of oxygen therapy, bronchial hygiene therapy, aerosol drug therapy, airway management, and therapy, aerosol drug therapy, airway management, and resuscitation approaches during the care of infants and resuscitation approaches during the care of infants and children.children.


Objectives (cont.)Objectives (cont.)

Discuss the use of continuous positive airway pressure Discuss the use of continuous positive airway pressure and the basics of mechanical ventilation, including high-and the basics of mechanical ventilation, including high-frequency ventilation for the care of infants and children. frequency ventilation for the care of infants and children.

List clinical situations where nitric oxide and List clinical situations where nitric oxide and extracorporeal life support are used, and discuss the basic extracorporeal life support are used, and discuss the basic application of each. application of each.


Newborn Assessment:Newborn Assessment:Maternal FactorsMaternal Factors

Assessment begins with motherAssessment begins with mother Conditions that affect mother’s health or placental blood flow can Conditions that affect mother’s health or placental blood flow can

affect fetal development.affect fetal development.• Diabetes mellitusDiabetes mellitus

• Previous pregnancy complicationsPrevious pregnancy complications

• Age of mother (<17 or >35 years)Age of mother (<17 or >35 years)

• Smoking or drug useSmoking or drug use

• See Table 48-1. See Table 48-1.

The above could cause issues that require resuscitation at birth.The above could cause issues that require resuscitation at birth.


Fetal AssessmentFetal Assessment

This can be performed by various means.This can be performed by various means. Ultrasonography Ultrasonography

• Provides view of fetusProvides view of fetus Amniocentesis (next slide)Amniocentesis (next slide) Fetal heart rate monitoringFetal heart rate monitoring

• During labor, monitors level infant distressDuring labor, monitors level infant distress Fetal blood gas analysis during deliveryFetal blood gas analysis during delivery

• If fetus is in distress, may obtain sample from presenting body partIf fetus is in distress, may obtain sample from presenting body part

• Acidosis may indicate asphyxia.Acidosis may indicate asphyxia.


AmniocentesisAmniocentesis

Amniocentesis Amniocentesis Allows analysis of amniotic fluid to determine genetics or Allows analysis of amniotic fluid to determine genetics or

presence of meconium, presence of meconium, Lung maturation by assessing L/S ratio Lung maturation by assessing L/S ratio

• >2:1 mature lungs>2:1 mature lungs

• Occurs Occurs ~35 weeks~35 weeks


Amniocentesis (cont.)Amniocentesis (cont.)


Evaluation of NewbornEvaluation of Newborn

Standard steps at birthStandard steps at birth WarmingWarming Positioning of headPositioning of head DryingDrying SuctioningSuctioning

For low-risk deliveries, further resuscitation is seldom For low-risk deliveries, further resuscitation is seldom required.required.

Further physical stimulation required if infant fails to initiate Further physical stimulation required if infant fails to initiate breathing.breathing.


Apgar ScoreApgar Score

Assessment is made at 1 and 5 minutes.Assessment is made at 1 and 5 minutes.

Each parameter is scored 0, 1, or 2 (See Table 48-2)Each parameter is scored 0, 1, or 2 (See Table 48-2) Heart rateHeart rate RespirationsRespirations Muscle toneMuscle tone Reflex irritabilityReflex irritability ColorColor

One-minute Apgar score <7 usually indicates the need for One-minute Apgar score <7 usually indicates the need for more aggressive resuscitation. more aggressive resuscitation.


Assessment of NewbornAssessment of Newborn

Respiratory rate: normal 40–60 beats/minRespiratory rate: normal 40–60 beats/min Tachypnea: hypoxemia, acidosis, anxietyTachypnea: hypoxemia, acidosis, anxiety Bradypnea: follow trend, may be fine or indicate compromiseBradypnea: follow trend, may be fine or indicate compromise

Heart rate: normal 100–160 beats/minHeart rate: normal 100–160 beats/min Weak pulse: think shock, hypotensionWeak pulse: think shock, hypotension Bounding pulse: think PDABounding pulse: think PDA

Blood pressure: normals vary with sizeBlood pressure: normals vary with size See Table 48-3. See Table 48-3.


Physical AssessmentPhysical Assessment

Chest assessment is complicated by small size and ease of Chest assessment is complicated by small size and ease of sound transmission.sound transmission.

Thorough observation greatly enhances effort to determine Thorough observation greatly enhances effort to determine infant distress. Key findingsinfant distress. Key findings Nasal flaring Nasal flaring Cyanosis, masked by hyperbilirubinemiaCyanosis, masked by hyperbilirubinemia Expiratory gruntingExpiratory grunting TachypneaTachypnea Paradoxical breathing with/without retractionsParadoxical breathing with/without retractions


Silverman Score to Determine Silverman Score to Determine Severity of Underlying Lung DiseaseSeverity of Underlying Lung Disease


Blood Gas AnalysisBlood Gas Analysis

Best for assessing infant’s oxygenation and ventilation statusBest for assessing infant’s oxygenation and ventilation status

Arterial sample preferredArterial sample preferred Capillary for acid/base and ventilation onlyCapillary for acid/base and ventilation only Normal values (see Table 48-4)Normal values (see Table 48-4)

Noninvasive methods are useful for trending Noninvasive methods are useful for trending Transcutaneous (PTranscutaneous (PTCOTCO22,, PPTCCOTCCO22)) Pulse oximetryPulse oximetry CapnographyCapnography


Oxygen Therapy:Oxygen Therapy:Goals and IndicationsGoals and Indications

Goal is to provide adequate tissue oxygenation at lowest Goal is to provide adequate tissue oxygenation at lowest possible Fpossible FIOIO22

Primary indication: documented hypoxemiaPrimary indication: documented hypoxemia Varies with ageVaries with age >28 days same as adult>28 days same as adult

• hypoxemia Pahypoxemia PaOO22 < 60 mm Hg, Sp < 60 mm Hg, SpOO22 < 90% < 90%


Oxygen Therapy: HazardsOxygen Therapy: Hazards

HyperoxiaHyperoxia Infant is more susceptible to oxygen toxicity.Infant is more susceptible to oxygen toxicity. May result in bronchopulmonary dysplasia (BPD)May result in bronchopulmonary dysplasia (BPD) Retinopathy of prematurity (ROP) can result.Retinopathy of prematurity (ROP) can result.

• In severest cases, can result in blindnessIn severest cases, can result in blindness

• Many causes (see Box 48-1)Many causes (see Box 48-1) Promotes PDA closure. If patient has PDA-dependent heart Promotes PDA closure. If patient has PDA-dependent heart

defect, this could be fatal.defect, this could be fatal.


Oxygen Therapy and “Flip Flop”Oxygen Therapy and “Flip Flop”

Neonatal pulmonary capillaries sensitive to changes in PaNeonatal pulmonary capillaries sensitive to changes in PaOO22

Decreasing FDecreasing FIOIO22 results in larger than expected drops in Pa results in larger than expected drops in PaOO22. .

Reestablishing FReestablishing FIOIO22 fails to improve the Pa fails to improve the PaOO22..

Probably due to reactive vasoconstriction and increased right-Probably due to reactive vasoconstriction and increased right-left shuntingleft shunting

Decreasing FDecreasing FIOIO22 in small increments of 1–2% usually avoids in small increments of 1–2% usually avoids “flip flop.”“flip flop.”


Safe Levels of Oxygen TherapySafe Levels of Oxygen Therapy

Little agreement on safe upper limits for:Little agreement on safe upper limits for: PaPaOO22, Sa, SaOO22,, and Fand FIOIO22

Generally clinicians aim for the following:Generally clinicians aim for the following: PaPaOO22: 60–80 mm Hg: 60–80 mm Hg

SaSaOO22: 88–94%: 88–94%

FFIOIO22: <50% if possible: <50% if possible


Secretion Clearance Secretion Clearance

Considered whenConsidered when Secretion accumulation impairs functionSecretion accumulation impairs function New infiltrate seen on chest radiographNew infiltrate seen on chest radiograph

Secretion retention common withSecretion retention common with PneumoniaPneumonia Bronchopulmonary dysplasiaBronchopulmonary dysplasia Cystic fibrosisCystic fibrosis BronchiectasisBronchiectasis


Secretion Clearance (cont.)Secretion Clearance (cont.)

MethodsMethods Chest percussion and postural drainageChest percussion and postural drainage

See positioning and technique (see Figure 48-7).See positioning and technique (see Figure 48-7). Careful to avoid abdominal damageCareful to avoid abdominal damage

Other methods for larger childrenOther methods for larger children Directed coughingDirected coughing PEPPEP FlutterFlutter Intermittent percussive ventilation (IPV)Intermittent percussive ventilation (IPV) The last three are particularly useful for CF patients.The last three are particularly useful for CF patients.


Secretion Clearance (cont.)Secretion Clearance (cont.)

Complications and monitoringComplications and monitoring Complications includeComplications include

Vomiting and aspiration, especially after feedingVomiting and aspiration, especially after feeding• Use NG tube and wait 1–2 hours post feedUse NG tube and wait 1–2 hours post feed

Rib fractures, intraventricular hemorrhageRib fractures, intraventricular hemorrhage• Head down contraindicated with prematurityHead down contraindicated with prematurity

Monitoring crucial: instability of patient groupMonitoring crucial: instability of patient group Includes vital signs, color, ICPs, and breath sounds, pre, during, Includes vital signs, color, ICPs, and breath sounds, pre, during,

and post treatmentand post treatment Increased FIncreased FIOIO22 during treatment often required. during treatment often required.


Aerosol Drug TherapyAerosol Drug Therapy

Aerosol route is safer than oral or parenteral approaches.Aerosol route is safer than oral or parenteral approaches.

SVNs, MDIs, and DPIs can all be used.SVNs, MDIs, and DPIs can all be used.


Aerosol Drug Therapy (cont.)Aerosol Drug Therapy (cont.)


Airway Management: IntubationAirway Management: Intubation

Infant’s age or weight is used to estimate tube size and depth Infant’s age or weight is used to estimate tube size and depth of insertion.of insertion. Too small an ETT results in significant airway leak and Too small an ETT results in significant airway leak and

increased resistance (Raw).increased resistance (Raw). Too large an ETT may cause mucosal and laryngeal damage.Too large an ETT may cause mucosal and laryngeal damage.

Most ETTs for neonates and infants are uncuffed.Most ETTs for neonates and infants are uncuffed.

See Box 48-3, Complications of Intubation.See Box 48-3, Complications of Intubation.


Intubation Intubation

Miller blade: large tongue and high epiglottis make the Miller blade: large tongue and high epiglottis make the straight blade most usefulstraight blade most useful

Small changes in position can result in bronchial or Small changes in position can result in bronchial or esophageal placement of ETT.esophageal placement of ETT. In neonates, ETT placement is difficult to determine by In neonates, ETT placement is difficult to determine by

auscultation auscultation Capnographs are most useful to determine proper Capnographs are most useful to determine proper

placement in trachea or esophagus.placement in trachea or esophagus.


SuctioningSuctioning

Minimizes aspiration, ETT occlusion, and lowers RMinimizes aspiration, ETT occlusion, and lowers Rawaw

Be careful, many complications (see Box 48-4)Be careful, many complications (see Box 48-4)

Suction level Suction level ––60 to 60 to ––80 for neonates and 80 for neonates and ––80 to 80 to ––100 for 100 for larger infants and childrenlarger infants and children

1-minute preoxygenation generally required1-minute preoxygenation generally required Pediatrics at 100% oxygenPediatrics at 100% oxygen Neonates increase FNeonates increase FIOIO22 by 10–15% by 10–15%


CPAPCPAP

The constant positive pressure increases the FRC and The constant positive pressure increases the FRC and lung compliance.lung compliance.

Improves oxygenation and decreases WOB.Improves oxygenation and decreases WOB.

Initiated for respiratory distress with refractory hypoxemia Initiated for respiratory distress with refractory hypoxemia without ventilatory failure.without ventilatory failure.

Methods of applicationMethods of application Neonates: nasal pharyngeal or nasal prongs Neonates: nasal pharyngeal or nasal prongs Pediatrics: nasal or full face maskPediatrics: nasal or full face mask


Indications for CPAPIndications for CPAP


High-Flow Nasal CannulaHigh-Flow Nasal Cannula

Simplest and most comfortable oxygen delivery device Simplest and most comfortable oxygen delivery device

22––8 L/min as effective as NCPAP in premature and 8 L/min as effective as NCPAP in premature and neonatal patientsneonatal patients

Heated humidification is available for systems.Heated humidification is available for systems.

High flow results in CPAP but unknown levelHigh flow results in CPAP but unknown level

Stabilize hypoxemic patients, reducing the need for Stabilize hypoxemic patients, reducing the need for noninvasive and invasive ventilation.noninvasive and invasive ventilation.


Mechanical VentilationMechanical Ventilation

Goals and indications are similar to those for adults (see Goals and indications are similar to those for adults (see Box 48-6).Box 48-6).

Most commonly used mode in infants is PCV-SIMV with Most commonly used mode in infants is PCV-SIMV with PSVPSV

Older pediatric patients may be ventilated with VCV-SIMV Older pediatric patients may be ventilated with VCV-SIMV or PCV-SIMV, both with PSV.or PCV-SIMV, both with PSV. Patients with low CPatients with low CLL usually on PCV-SIMV usually on PCV-SIMV

Advances in ventilation have allowed volume guaranteed Advances in ventilation have allowed volume guaranteed PVC-SIMV to also be used.PVC-SIMV to also be used.


Mechanical Ventilation (cont.)Mechanical Ventilation (cont.)

PIP and VPIP and VTT In PCV-SIMV, the difference between PIP and PEEP determines In PCV-SIMV, the difference between PIP and PEEP determines

the Vthe VTT.. PIP >25 cm HPIP >25 cm H22O may increase risk of barotrauma.O may increase risk of barotrauma.

Infant VInfant VTT targeted at 5–7 ml/kg targeted at 5–7 ml/kg

Children VChildren VTT targeted at 6–8 ml/kg targeted at 6–8 ml/kg

On older ventilators, effective VOn older ventilators, effective VTT may need to be calculated and may need to be calculated and

adjusted to achieve adequate volumes.adjusted to achieve adequate volumes.



f and If and ITT

Respiratory rateRespiratory rate Fast rates mimic neonatal ventilationFast rates mimic neonatal ventilation Permissive hypercapnia common strategyPermissive hypercapnia common strategy

• PaPaCOCO22 45–55 mm Hg 45–55 mm Hg

With fast rates, must ensure adequacy of EWith fast rates, must ensure adequacy of ETT

IITT

Infants: >0.3 secondInfants: >0.3 second Older children: up to 1 secondOlder children: up to 1 second



FFIOIO22, MAP (P, MAP (Pawaw), and PEEP), and PEEP FFIOIO22 low as possible to avoid O low as possible to avoid O22 toxicity toxicity

Toxicity in preterm infant leads to BPD and ROPToxicity in preterm infant leads to BPD and ROP Preterm: FPreterm: FIOIO22 to keep Sp to keep SpOO22 88–94% 88–94%

PEEP used to increase FRC and treat refractory hypoxemiaPEEP used to increase FRC and treat refractory hypoxemia Pediatrics commonly set 5–8 cm HPediatrics commonly set 5–8 cm H22OO

PPawaw: average of all airway pressures: average of all airway pressures Improves oxygenationImproves oxygenation >15 cm H>15 cm H22O thought deleterious, consider HFOO thought deleterious, consider HFO


Noninvasive Positive-Pressure Noninvasive Positive-Pressure Ventilation (NPPV)Ventilation (NPPV)

Connected to mask or nasal apparatus Connected to mask or nasal apparatus

Conventional ventilator provides source gasConventional ventilator provides source gas Some provide special modes for NPPVSome provide special modes for NPPV Problems with issue of leaks, sensing, alarmsProblems with issue of leaks, sensing, alarms

BiPAP devices have some advantages BiPAP devices have some advantages Cost, ease of use, designed for leaksCost, ease of use, designed for leaks

Treat children with NMD and postextubation respiratory Treat children with NMD and postextubation respiratory failure.failure.


Monitoring Patients on Monitoring Patients on Mechanical VentilationMechanical Ventilation

Systematic approach required to include:Systematic approach required to include: Evaluation of artificial airwayEvaluation of artificial airway Physical examinationPhysical examination Patient–ventilator interactionPatient–ventilator interaction Analysis of lab and radiographic dataAnalysis of lab and radiographic data Assess humidification Assess humidification Check alarm settingsCheck alarm settings Documentation guides process and records assessed dataDocumentation guides process and records assessed data


High-Frequency Ventilation High-Frequency Ventilation (HFV)(HFV)

Ventilation at 1Ventilation at 1––3 ml/kg and rates >150 beats/min3 ml/kg and rates >150 beats/min

Two forms: jet and oscillationTwo forms: jet and oscillation

High-frequency jet ventilation (HFJV)High-frequency jet ventilation (HFJV) Pulses high velocity gas via ETT side portPulses high velocity gas via ETT side port PEEP and sigh breaths from ventilatorPEEP and sigh breaths from ventilator Rates 100–600 beats/minRates 100–600 beats/min Inspiratory times 20–40 millisecondsInspiratory times 20–40 milliseconds Exhalation passiveExhalation passive


High-Frequency Oscillatory High-Frequency Oscillatory Ventilation (HFOV)Ventilation (HFOV)

Frequencies of 3Frequencies of 3––15 Hz (18015 Hz (180––900 beats/min)900 beats/min)

I and E are active oscillating around PI and E are active oscillating around Pawaw

Bias flow fresh gas intersects oscillatory path to eliminate Bias flow fresh gas intersects oscillatory path to eliminate COCO22 and replenish O and replenish O22

Oxygenation determined by FOxygenation determined by FIOIO22 and PEEP and PEEP

COCO22 elimination determined by amplitude (V elimination determined by amplitude (VTT) and rate. ) and rate. Lower rate results in better COLower rate results in better CO22 elimination opposite elimination opposite

conventional ventilation. conventional ventilation.


Inhaled Nitric OxideInhaled Nitric Oxide Selective pulmonary vasodilator Selective pulmonary vasodilator

Used with mechanical ventilationUsed with mechanical ventilation

Not currently used with extreme premature neonatesNot currently used with extreme premature neonates

Initial INO dose of 20 ppmInitial INO dose of 20 ppm

While maximal lung inflation is maintained INO gradually reducedWhile maximal lung inflation is maintained INO gradually reduced 50% increments to 50% increments to 1 ppm attained with stable patient, D/C drug1 ppm attained with stable patient, D/C drug


Inhaled Nitric Oxide (cont.)Inhaled Nitric Oxide (cont.)


Inhaled Nitric Oxide (cont.)Inhaled Nitric Oxide (cont.)

Monitoring is crucial as NO and OMonitoring is crucial as NO and O22 form NO form NO22 which is which is

potentially toxicpotentially toxic

MetHB is also formed, so monitor carefully.MetHB is also formed, so monitor carefully.


Extracorporeal Membrane Extracorporeal Membrane Oxygenation (ECMO)Oxygenation (ECMO)

Modified cardiopulmonary bypassModified cardiopulmonary bypass

Pulmonary or cardiopulmonary life support when maximum Pulmonary or cardiopulmonary life support when maximum medical support has failedmedical support has failed

Two types of supportTwo types of support Venoarterial: heart and lung supportedVenoarterial: heart and lung supported

• Blood taken from RA Blood taken from RA

• COCO22 removed, O removed, O22 added added• Heated returned right common carotid arteryHeated returned right common carotid artery

Venovenous: only lungs supportedVenovenous: only lungs supported• Same process but returned to right heartSame process but returned to right heart

c hapter 48 neonatal and pediatric respiratory care

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