Chapter 48 Neonatal and Pediatric Respiratory Care Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier.

Chapter 48

Neonatal and Pediatric Respiratory Care

Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 2

Learning Objectives


Learning Objectives (cont.)

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


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

Above could cause issues that require resuscitation at birth


Fetal Assessment

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

Fetal Heart Rate



All of the following are clinical tools for fetal assessment, except:

A.Maternal ABG during delivery

B.Fetal blood gas analysis during delivery

C.Amniocentesis

D.Ultrasonography


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


Amniocentesis (cont.)


Apgar Score

Assessment made at 1 and 5 minutes Each parameter is scored 0, 1, or 2

Heart rate Respirations Muscle tone Reflex irritability Color

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

Neonatal Resuscitation



Assessment of Pediatric Patient

Normal respiratory and heart rates are higher in younger children and decreases with age.

Respiratory rate: Heart Rate

Toddler (1-3) 24-40 80-100 Preschooler (4-5) 22-34 70-90 School age (6-12) 18-30 70-90 Adolescent (13-18) 12-16 60-80


Assessment of Newborn

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

compromise Heart rate: normal 100–160 beats/min

Weak pulse: think shock, hypotension Bounding pulse: think PDA

Blood pressure: normals vary with size


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


All of the following are manifestations of infant in respiratory distress, except:

A.Nasal flaring

B.Expiratory grunting

C.Paradoxical breathing

D.Gag reflex


Silverman Score to Determine Severity of Underlying Lung Disease


Blood Gas & Pulse Oximetry 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 useful for trending Transcutaneous (PTCO2, PTCCO2) Pulse oximetry Capnography


Oxygen Therapy:Goals & Indications

Goal is to provide adequate tissue oxygenation at lowest possible FIO2

Infants and children receiving oxygen therapy will have variable oxygen saturation target ranges depending on age and underlying condition

Emphasis for oxygen therapy for all newborns should be to provide only as much oxygen as indicated by the infant’s condition


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.


All of the following are hazards of oxygen therapy in newborns, except:

A.Bronchopulmonary dysplasia

B.Retinopathy of prematurity

C.Foramen ovale closure

D.Promotes PDA closure


Secretion Clearance

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

Secretion retention common with Pneumonia Bronchopulmonary dysplasia Cystic fibrosis Bronchiectasis


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)

• Last three particularly useful for CF patients.





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

pre, during, and post treatment Post treatment should be supplemented with pulse

oximetry monitoring if hypoxemia is suspected


Aerosol Drug Therapy

Aerosol route is safer than oral or parenteral approaches

SVNs, MDIs, and DPIs can all be used


Aerosol Drug Therapy (cont.)


Airway Management: Intubation

Infant’s age or weight 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


Which of the following factors is considered to determine the correct ET tube size used during intubation?

A.Patient weight

B.Patient hand size

C.Patient lung size

D.Available ET tube at the hospital


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


Suctioning

Minimizes aspiration, ETT occlusion, and lowers Raw

Be careful, many complications Suction level –60 to –80 for neonates and –80 to –100 for larger infants and children Catheter sizes are chosen according to the

age of the patient and the size of the tracheal airway


CPAP

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

CPAP (cont.)



Indications for CPAP


High-Flow Nasal Cannula

Simplest and most comfortable oxygen delivery device

2–8 L/min as effective as Nasal CPAP in premature and neonatal patients

Heated humidification available for systems High flow results in CPAP but unknown level Stabilize hypoxemic patients, reducing the

need for noninvasive and invasive ventilation


Mechanical Ventilation

Goals and indications 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.

Mechanical Ventilation



Which of the following is the most common ventilatory mode for infants?

A.PCV-SIMV

B.PCV-AC

C.VCV-SIMV

D.VCV-AC


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.



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



FIO2, MAP (Paw), and PEEP

FIO2 low as possible to avoid O2 toxicity• Toxicity in preterm infant leads to BPD and ROP• Preterm: FIO2 to keep SpO2 88–92%

PEEP used to increase FRC and treat refractory hypoxemia

• Pediatrics commonly set 5–8 cm H2O

Paw: average of all airway pressures• Improves oxygenation• >15 cm H2O thought deleterious, consider HFO


Noninvasive Positive-Pressure Ventilation (NPPV)

Connected to mask or nasal apparatus Conventional ventilator provides source gas

Some provide special modes for NPPV Problems with issue of leaks, sensing, alarms

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

Treat children with NMD and postextubation respiratory failure


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


All of the following are components of a systemic approach in monitoring patients on mechanical ventilation, except:

A.Evaluation of patient only as needed

B.Assess humidification

C.Checking alarm settings

D.Analyzing lab and radiographic data


High-Frequency Ventilation (HFV)

Two forms: jet and oscillation Oxygenation achieved by inflating patient’s

lungs to a high resting level, or FRC, by establishing a high mean airway pressure, similar to CPAP

This “recruitment” improves the ventilation perfusion ratio by opening previously collapsed alveoli


High-Frequency Oscillatory Ventilation (HFOV)

Frequencies of up to 15 Hz (sometimes >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.


Inhaled Nitric Oxide

Selective pulmonary vasodilator Used with mechanical ventilation Not currently used with extreme premature neonates Initial recommended 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

Nitric Oxide Delivery System



All of the following are characteristics of Inhaled Nitric Oxide, except:

A.It is approved by the FDA for PPHN

B.Initial recommended INO dose of 80 ppm

C.Used for pulmonary vasodilation

D.Not used with extreme premature neonates


Inhaled Nitric Oxide (cont.)

Monitoring is crucial as NO and O2 form NO2 which is potentially toxic

MetHB is also formed, monitor carefully


Extracorporeal Membrane Oxygenation (ECMO)

Modified cardiopulmonary bypass Pulmonary or cardiopulmonary life support when

maximum medical support has failed Two types of support

1. Venoarterial: heart and lung supported• Blood taken from RA

• CO2 removed, O2 added• Heated returned right common carotid artery

2. Venovenous: only lungs supported• Same process but returned to right heart

Venoarterial ECMO Circuit


Chapter 48 Neonatal and Pediatric Respiratory Care Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier.

Documents

imprint of elsevier

fetal assessmentcan

fetal heart ratecopyright

placental blood flow

analysis of amniotic

maternal abg

maternal factorsassessment

newborn assessment