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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. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 2 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. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 3 Newborn Assessment: Maternal Factors Assessment begins with mother 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. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 4 Fetal Assessment This can be performed by various means. 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. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 5 Amniocentesis Amniocentesis 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 Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 6 Amniocentesis (cont.) Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 7 Evaluation of Newborn Standard steps at birth Warming Positioning of head Drying Suctioning For low-risk deliveries, further resuscitation is seldom required. Further physical stimulation required if infant fails to initiate breathing. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 8 Apgar Score Assessment is made at 1 and 5 minutes. Each parameter is scored 0, 1, or 2 (See Table 48-2) Heart rate Respirations Muscle tone Reflex irritability Color One-minute Apgar score <7 usually indicates the need for more aggressive resuscitation. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 9 Assessment of Newborn Respiratory rate: normal 40–60 beats/min Heart rate: normal 100–160 beats/min 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. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 10 Physical Assessment Chest assessment is complicated by small size and ease of sound transmission. Thorough observation greatly enhances effort to determine infant distress. Key findings Nasal flaring Cyanosis, masked by hyperbilirubinemia Expiratory grunting Tachypnea Paradoxical breathing with/without retractions Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 11 Silverman Score to Determine Severity of Underlying Lung Disease Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 12 Blood Gas Analysis Best for assessing infant’s oxygenation and ventilation status Arterial sample preferred Capillary for acid/base and ventilation only Normal values (see Table 48-4) Noninvasive methods are useful for trending Transcutaneous (PTCO2, PTCCO2) Pulse oximetry Capnography Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 13 Oxygen Therapy: Goals and Indications Goal is to provide adequate tissue oxygenation at lowest possible FIO2 Primary indication: documented hypoxemia Varies with age >28 days same as adult • hypoxemia PaO2 < 60 mm Hg, SpO2 < 90% Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 14 Oxygen Therapy: Hazards Hyperoxia 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. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 15 Oxygen Therapy and “Flip Flop” Neonatal pulmonary capillaries sensitive to changes in PaO2 Decreasing FIO2 results in larger than expected drops in PaO2. Reestablishing FIO2 fails to improve the PaO2. Probably due to reactive vasoconstriction and increased rightleft shunting Decreasing FIO2 in small increments of 1–2% usually avoids “flip flop.” Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 16 Safe Levels of Oxygen Therapy Little agreement on safe upper limits for: PaO2, SaO2, and FIO2 Generally clinicians aim for the following: PaO2: 60–80 mm Hg SaO2: 88–94% FIO2: <50% if possible Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 17 Secretion Clearance Considered when Secretion accumulation impairs function New infiltrate seen on chest radiograph Secretion retention common with Pneumonia Bronchopulmonary dysplasia Cystic fibrosis Bronchiectasis Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 18 Secretion Clearance (cont.) Methods Chest percussion and postural drainage See positioning and technique (see Figure 48-7). Careful to avoid abdominal damage Other methods for larger children Directed coughing PEP Flutter Intermittent percussive ventilation (IPV) The last three are particularly useful for CF patients. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 19 Secretion Clearance (cont.) Complications and monitoring Complications include 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 Includes vital signs, color, ICPs, and breath sounds, pre, during, and post treatment Increased FIO2 during treatment often required. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 20 Aerosol Drug Therapy Aerosol route is safer than oral or parenteral approaches. SVNs, MDIs, and DPIs can all be used. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 21 Aerosol Drug Therapy (cont.) Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 22 Airway Management: Intubation Infant’s age or weight is used to estimate tube size and depth of insertion. Too small an ETT results in significant airway leak and increased resistance (Raw). Too large an ETT may cause mucosal and laryngeal damage. Most ETTs for neonates and infants are uncuffed. See Box 48-3, Complications of Intubation. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 23 Intubation Miller blade: large tongue and high epiglottis make the straight blade most useful Small changes in position can result in bronchial or esophageal placement of ETT. In neonates, ETT placement is difficult to determine by auscultation Capnographs are most useful to determine proper placement in trachea or esophagus. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 24 Suctioning Minimizes aspiration, ETT occlusion, and lowers Raw Be careful, many complications (see Box 48-4) Suction level –60 to –80 for neonates and –80 to –100 for larger infants and children 1-minute preoxygenation generally required Pediatrics at 100% oxygen Neonates increase FIO2 by 10–15% Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 25 CPAP The constant positive pressure increases the FRC and lung compliance. Improves oxygenation and decreases WOB. Initiated for respiratory distress with refractory hypoxemia without ventilatory failure. Methods of application Neonates: nasal pharyngeal or nasal prongs Pediatrics: nasal or full face mask Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 26 Indications for CPAP Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 27 High-Flow Nasal Cannula Simplest and most comfortable oxygen delivery device 2–8 L/min as effective as NCPAP in premature and neonatal patients Heated humidification is available for systems. High flow results in CPAP but unknown level Stabilize hypoxemic patients, reducing the need for noninvasive and invasive ventilation. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 28 Mechanical Ventilation Goals and indications are similar to those for adults (see Box 48-6). Most commonly used mode in infants is PCV-SIMV with PSV Older pediatric patients may be ventilated with VCV-SIMV or PCV-SIMV, both with PSV. Patients with low CL usually on PCV-SIMV Advances in ventilation have allowed volume guaranteed PVC-SIMV to also be used. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 29 Mechanical Ventilation (cont.) PIP and VT In PCV-SIMV, the difference between PIP and PEEP determines the VT. 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. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 30 Mechanical Ventilation (cont.) f and IT Respiratory rate Fast rates mimic neonatal ventilation Permissive hypercapnia common strategy • PaCO2 45–55 mm Hg With fast rates, must ensure adequacy of ET IT Infants: >0.3 second Older children: up to 1 second Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 31 Mechanical Ventilation (cont.) FIO2, MAP (Paw), and PEEP FIO2 low as possible to avoid O2 toxicity PEEP used to increase FRC and treat refractory hypoxemia 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 Improves oxygenation >15 cm H2O thought deleterious, consider HFO Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 32 Noninvasive Positive-Pressure Ventilation (NPPV) Connected to mask or nasal apparatus Conventional ventilator provides source gas BiPAP devices have some advantages 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. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 33 Monitoring Patients on Mechanical Ventilation Systematic approach required to include: 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 Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 34 High-Frequency Ventilation (HFV) Ventilation at 1–3 ml/kg and rates >150 beats/min Two forms: jet and oscillation High-frequency jet ventilation (HFJV) 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 Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 35 High-Frequency Oscillatory Ventilation (HFOV) Frequencies of 3–15 Hz (180–900 beats/min) I and E are active oscillating around Paw Bias flow fresh gas intersects oscillatory path to eliminate CO2 and replenish O2 Oxygenation determined by FIO2 and PEEP CO2 elimination determined by amplitude (VT) and rate. Lower rate results in better CO2 elimination opposite conventional ventilation. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 36 Inhaled Nitric Oxide Selective pulmonary vasodilator Used with mechanical ventilation Not currently used with extreme premature neonates Initial INO dose of 20 ppm While maximal lung inflation is maintained INO gradually reduced 50% increments to 1 ppm attained with stable patient, D/C drug Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 37 Inhaled Nitric Oxide (cont.) Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 38 Inhaled Nitric Oxide (cont.) Monitoring is crucial as NO and O2 form NO2 which is potentially toxic MetHB is also formed, so monitor carefully. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 39 Extracorporeal Membrane Oxygenation (ECMO) Modified cardiopulmonary bypass Pulmonary or cardiopulmonary life support when maximum medical support has failed Two types of support 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 Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 40