Nicu Pocket Guide

N.I.C.U.

Pocket Guide For Respiratory Therapists   1

Contributors   Charles Williams RRT Sonia Goede RRT Carissa Yackus RRT

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Contents 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

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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

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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

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Normal Vital Signs Birth weight (g)

Blood Blood Pressure Pressure Systolic Diastolic (mmHg)

(mmHg)

500-700 700-1000 1000-1500

50-60 48-58 47-58

26-36 24-36 25-35

1500-2000

47-60

25-35

2000-3000

51-72

27-46

Heart Rate

120-170

Respirato ry Rate

30-60

SpO2

88-94%

Normal Newborn Blood Gases

Term

64-72

50-55

pH Capillary 7.37-7.44

PCO2 31-45

PO2 60-100

HCO3 22-26

Arterial 7.37-7.44

31-45

80-110

22-26

Venous 7.35-7.45

34-50

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24-28

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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

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APGAR Scoring • •

Provides a quick assessment for depression upon delivery Perform at 1 minute and 5 minutes after birth

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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!

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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)

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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. 10

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

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Nasal CPAP (con’t) •

Utilize the prong size guide to select the appropriate sized nasal prongs.

•

3 sizes available: small, medium, large.

  •

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 

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.   •

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.

  •

Adjust flowmeter to achieve desired amount of CPAP (indicated on the Pressure bar graph display)  (Approx. flow of 8.5 = 5cm H2O pressure)

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Intubation 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

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Intubation (cont.) Intubation and Suctioning Guidelines

Birth Weight < 1000 g

Laryngoscope Blade Size 0

Endotracheal Suction Catheter Tube Size Size 2.5 mm 5 Fr.

1000-2000 g

0

3.0 mm

6 Fr.

2000-3000 g

0-1

3.5 mm

8 Fr.

>3000 g

1

3.5-4.0 mm

8 Fr.

Weight in kg.

cm mark @ lip

<1

6.5

1

7

2

8

3

9

4

10

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Mechanical Ventilation 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)

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Mechanical Ventilation (cont.) Suggested Initial Settings for Specific Disease States:

PIP

PEEP

Rate

Ti

Normal Infant

10-12

2-4

Minimal    (15-20)

0.3-0.5

RDS

20-30

4-8

20-40

0.3-0.5

Preemie (< 1000 gm)

Minimum   as poss.

2-4

20-30

0.3-0.5

Pulm Air Leak (PIE, Pneumothorax) PPHN

< 20

< 2

60 – 150

0.25-0.4

< 20

< 2

30-60  *

0.25-0.4

Meconium Aspiration (w/ atelectasis) Meconium Aspiration (w/ hyperaeration)) Diaphragmatic Hernia

30-60

4-6

25-50

0.3-0.5

< 20

< 2

20-25

0.25-0.4

< 20

< 2

25-100

0.3-0.5

Be sure to confirm Total PIP ordered.  (Total PIP – PEEP = Set PIP)

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High Frequency Ventilation

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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

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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.

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Survanta Delivery Supplies needed: • • • •

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 21

Survanta Dosing Chart WEIGHT (grams)

TOTAL DOSE (mL)

WEIGHT (grams)

TOTAL DOSE (mL)

600- 650

2.6

1301- 1350

5.4

651- 700

2.8

1351- 1400

5.6

701- 750

3.0

1401- 1450

5.8

751- 800

3.2

1451- 1500

6.0

801- 850

3.4

1501- 1550

6.2

851- 900

3.6

1551- 1600

6.4

901- 950

3.8

1601- 1650

6.6

951- 1000

4.0

1651- 1700

6.8

1001- 1050

4.2

1701- 1750

7.0

1051- 1100

4.4

1751- 1800

7.2

1101- 1150

4.6

1801- 1850

7.4

1151- 1200

4.8

1851- 1900

7.6

1201- 1250

5.0

1901- 1950

7.8

1251- 1300

5.2

1951- 2000

8.0

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Pneumothorax 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 23

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.

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Special Situations 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

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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.

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Resuscitation Flowchart

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Sources: Neonatal Resuscitation Handbook; American Heart Association Respiratory Care: Principles & Practice; Hess, MacIntyre Neonatal Mechanical Ventilation

Websites http://www.fphcare.com/neonatal/resuscitation.asp http://www.aap.org/nrp/nrpmain.html

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