Download neonatal and pediatric respiratory care

Chapter 48
Neonatal and Pediatric
Respiratory Care
Objectives

Describe the correct approach to assessment of the fetus
and newborn infant.

Discuss the use of oxygen therapy, bronchial hygiene
therapy, aerosol drug therapy, airway management, and
resuscitation approaches during the care of infants and
children.
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Objectives (cont.)

Discuss the use of continuous positive airway pressure
and the basics of mechanical ventilation, including highfrequency ventilation for the care of infants and children.

List clinical situations where nitric oxide and
extracorporeal life support are used, and discuss the basic
application of each.
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Newborn Assessment:
Maternal Factors

Assessment begins with mother

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Conditions that affect mother’s health or placental blood flow can
affect fetal development.
• Diabetes mellitus
• Previous pregnancy complications
• Age of mother (<17 or >35 years)
• Smoking or drug use
• See Table 48-1.
The above could cause issues that require resuscitation at birth.
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Fetal Assessment

This can be performed by various means.
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Ultrasonography
• Provides view of fetus
Amniocentesis (next slide)
Fetal heart rate monitoring
• During labor, monitors level infant distress
Fetal blood gas analysis during delivery
• If fetus is in distress, may obtain sample from presenting body part
• Acidosis may indicate asphyxia.
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Amniocentesis
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Amniocentesis
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Allows analysis of amniotic fluid to determine genetics or
presence of meconium,
Lung maturation by assessing L/S ratio
• >2:1 mature lungs
• Occurs ~35 weeks
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Amniocentesis (cont.)
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Evaluation of Newborn
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Standard steps at birth
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Warming
Positioning of head
Drying
Suctioning
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For low-risk deliveries, further resuscitation is seldom
required.
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Further physical stimulation required if infant fails to initiate
breathing.
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Apgar Score
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Assessment is made at 1 and 5 minutes.
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Each parameter is scored 0, 1, or 2 (See Table 48-2)
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Heart rate
Respirations
Muscle tone
Reflex irritability
Color
One-minute Apgar score <7 usually indicates the need for
more aggressive resuscitation.
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Assessment of Newborn
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Respiratory rate: normal 40–60 beats/min
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Heart rate: normal 100–160 beats/min
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Tachypnea: hypoxemia, acidosis, anxiety
Bradypnea: follow trend, may be fine or indicate compromise
Weak pulse: think shock, hypotension
Bounding pulse: think PDA
Blood pressure: normals vary with size

See Table 48-3.
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Physical Assessment
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Chest assessment is complicated by small size and ease of
sound transmission.
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Thorough observation greatly enhances effort to determine
infant distress. Key findings
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Nasal flaring
Cyanosis, masked by hyperbilirubinemia
Expiratory grunting
Tachypnea
Paradoxical breathing with/without retractions
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Silverman Score to Determine
Severity of Underlying Lung Disease
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Blood Gas Analysis
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Best for assessing infant’s oxygenation and ventilation status
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Arterial sample preferred
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Capillary for acid/base and ventilation only
Normal values (see Table 48-4)
Noninvasive methods are useful for trending
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Transcutaneous (PTCO2, PTCCO2)
Pulse oximetry
Capnography
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Oxygen Therapy:
Goals and Indications
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Goal is to provide adequate tissue oxygenation at lowest
possible FIO2
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Primary indication: documented hypoxemia
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Varies with age
>28 days same as adult
• hypoxemia PaO2 < 60 mm Hg, SpO2 < 90%
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Oxygen Therapy: Hazards
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Hyperoxia
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Infant is more susceptible to oxygen toxicity.
May result in bronchopulmonary dysplasia (BPD)
Retinopathy of prematurity (ROP) can result.
• In severest cases, can result in blindness
• Many causes (see Box 48-1)
Promotes PDA closure. If patient has PDA-dependent heart
defect, this could be fatal.
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Oxygen Therapy and “Flip Flop”
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Neonatal pulmonary capillaries sensitive to changes in PaO2
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Decreasing FIO2 results in larger than expected drops in
PaO2.
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Reestablishing FIO2 fails to improve the PaO2.
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Probably due to reactive vasoconstriction and increased rightleft shunting
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Decreasing FIO2 in small increments of 1–2% usually avoids
“flip flop.”
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Safe Levels of Oxygen Therapy
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Little agreement on safe upper limits for:
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PaO2, SaO2, and FIO2
Generally clinicians aim for the following:
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PaO2: 60–80 mm Hg
SaO2: 88–94%
FIO2: <50% if possible
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Secretion Clearance
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Considered when
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Secretion accumulation impairs function
New infiltrate seen on chest radiograph
Secretion retention common with
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Pneumonia
Bronchopulmonary dysplasia
Cystic fibrosis
Bronchiectasis
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Secretion Clearance (cont.)
Methods
 Chest percussion and postural drainage
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See positioning and technique (see Figure 48-7).
Careful to avoid abdominal damage
Other methods for larger children
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Directed coughing
PEP
Flutter
Intermittent percussive ventilation (IPV)
The last three are particularly useful for CF patients.
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Secretion Clearance (cont.)
Complications and monitoring
 Complications include
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Vomiting and aspiration, especially after feeding
• Use NG tube and wait 1–2 hours post feed
Rib fractures, intraventricular hemorrhage
• Head down contraindicated with prematurity
Monitoring crucial: instability of patient group
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Includes vital signs, color, ICPs, and breath sounds, pre, during,
and post treatment
Increased FIO2 during treatment often required.
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Aerosol Drug Therapy
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Aerosol route is safer than oral or parenteral approaches.
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SVNs, MDIs, and DPIs can all be used.
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Aerosol Drug Therapy (cont.)
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Airway Management: Intubation
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Infant’s age or weight is used to estimate tube size and depth
of insertion.
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Too small an ETT results in significant airway leak and increased
resistance (Raw).
Too large an ETT may cause mucosal and laryngeal damage.
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Most ETTs for neonates and infants are uncuffed.
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See Box 48-3, Complications of Intubation.
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Intubation
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Miller blade: large tongue and high epiglottis make the
straight blade most useful
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Small changes in position can result in bronchial or
esophageal placement of ETT.
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In neonates, ETT placement is difficult to determine by
auscultation
Capnographs are most useful to determine proper
placement in trachea or esophagus.
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Suctioning
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Minimizes aspiration, ETT occlusion, and lowers Raw
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Be careful, many complications (see Box 48-4)
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Suction level –60 to –80 for neonates and –80 to –100 for
larger infants and children
1-minute preoxygenation generally required
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Pediatrics at 100% oxygen
Neonates increase FIO2 by 10–15%
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CPAP
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The constant positive pressure increases the FRC and
lung compliance.
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Improves oxygenation and decreases WOB.
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Initiated for respiratory distress with refractory hypoxemia
without ventilatory failure.
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Methods of application
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Neonates: nasal pharyngeal or nasal prongs
Pediatrics: nasal or full face mask
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Indications for CPAP
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High-Flow Nasal Cannula
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Simplest and most comfortable oxygen delivery device
2–8 L/min as effective as NCPAP in premature and
neonatal patients
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Heated humidification is available for systems.
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High flow results in CPAP but unknown level
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Stabilize hypoxemic patients, reducing the need for
noninvasive and invasive ventilation.
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Mechanical Ventilation

Goals and indications are similar to those for adults (see
Box 48-6).
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Most commonly used mode in infants is PCV-SIMV with
PSV
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Older pediatric patients may be ventilated with VCV-SIMV
or PCV-SIMV, both with PSV.
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Patients with low CL usually on PCV-SIMV
Advances in ventilation have allowed volume guaranteed
PVC-SIMV to also be used.
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Mechanical Ventilation (cont.)
PIP and VT
 In PCV-SIMV, the difference between PIP and PEEP determines
the VT.
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PIP >25 cm H2O may increase risk of barotrauma.
Infant VT targeted at 5–7 ml/kg
Children VT targeted at 6–8 ml/kg
On older ventilators, effective VT may need to be calculated and
adjusted to achieve adequate volumes.
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Mechanical Ventilation (cont.)
f and IT
 Respiratory rate
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Fast rates mimic neonatal ventilation
Permissive hypercapnia common strategy
• PaCO2 45–55 mm Hg
With fast rates, must ensure adequacy of ET
IT
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Infants: >0.3 second
Older children: up to 1 second
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Mechanical Ventilation (cont.)
FIO2, MAP (Paw), and PEEP
 FIO2 low as possible to avoid O2 toxicity
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PEEP used to increase FRC and treat refractory hypoxemia
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Toxicity in preterm infant leads to BPD and ROP
Preterm: FIO2 to keep SpO2 88–94%
Pediatrics commonly set 5–8 cm H2O
Paw: average of all airway pressures
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Improves oxygenation
>15 cm H2O thought deleterious, consider HFO
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Noninvasive Positive-Pressure
Ventilation (NPPV)
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Connected to mask or nasal apparatus
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Conventional ventilator provides source gas
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BiPAP devices have some advantages
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Some provide special modes for NPPV
Problems with issue of leaks, sensing, alarms
Cost, ease of use, designed for leaks
Treat children with NMD and postextubation respiratory
failure.
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Monitoring Patients on
Mechanical Ventilation
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Systematic approach required to include:
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Evaluation of artificial airway
Physical examination
Patient–ventilator interaction
Analysis of lab and radiographic data
Assess humidification
Check alarm settings
Documentation guides process and records assessed data
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High-Frequency Ventilation
(HFV)
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Ventilation at 1–3 ml/kg and rates >150 beats/min
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Two forms: jet and oscillation
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High-frequency jet ventilation (HFJV)
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Pulses high velocity gas via ETT side port
PEEP and sigh breaths from ventilator
Rates 100–600 beats/min
Inspiratory times 20–40 milliseconds
Exhalation passive
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High-Frequency Oscillatory
Ventilation (HFOV)
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Frequencies of 3–15 Hz (180–900 beats/min)
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I and E are active oscillating around Paw
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Bias flow fresh gas intersects oscillatory path to eliminate
CO2 and replenish O2
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Oxygenation determined by FIO2 and PEEP
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CO2 elimination determined by amplitude (VT) and rate.
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Lower rate results in better CO2 elimination opposite
conventional ventilation.
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Inhaled Nitric Oxide
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Selective pulmonary vasodilator
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Used with mechanical ventilation
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Not currently used with extreme premature neonates
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Initial INO dose of 20 ppm
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While maximal lung inflation is maintained INO gradually
reduced
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50% increments to
1 ppm attained with stable patient, D/C drug
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Inhaled Nitric Oxide (cont.)
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Inhaled Nitric Oxide (cont.)
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Monitoring is crucial as NO and O2 form NO2 which is
potentially toxic
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MetHB is also formed, so monitor carefully.
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Extracorporeal Membrane
Oxygenation (ECMO)
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Modified cardiopulmonary bypass
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Pulmonary or cardiopulmonary life support when maximum
medical support has failed
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Two types of support
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Venoarterial: heart and lung supported
• Blood taken from RA
• CO2 removed, O2 added
• Heated returned right common carotid artery
Venovenous: only lungs supported
• Same process but returned to right heart
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