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Flashcards in Neonatal Manual Ventilation Deck (70)
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1
Q

What is the expected preductal SpO2 after 2 minutes of age?

65-70%

70-75%

75-80%

80-85%

A

65-70%

At the zero to one minute it is 60-65% preductal SpO2after that it will keep increasing by 5% up to 10 minutes.

2
Q

see-saw breathing pattern

A

Normally the stomach and upper chest will be synchronized and move together.

Grade one on a Silverman score will show a lag of chest movement on inspiration.

Grade two Silverman score will show full see saw breathing where the chest and tummy are moving asynchronously.

This see-saw is a paradoxical inward movement of the chest wall and outward movement of the abdominal wall and is a sign of severe respiratory distress.

3
Q

A normal term infant at 5 hours of age would have a base excess of:

-5

0

+4

A

-5

Babies when born will always be acidotic.

4
Q

Which of the following is not associated with respiratory distress

Tachypnea

Grunting

Accessory Muscle Use

Cyanosis

A

Accessory Muscle Use

Babies will typically show respiratory distress through apnea, tachypnea, retractions, grunting, nasal flaring, stridor, and cyanosis

5
Q

What flow rate should be used to provided PPV

10 lpm

15 lpm

20 lpm

Adequate to get pressure to the patient

A

10 lpm

Flow rates should be between 8-12

6
Q

What rate should be used when providing PPV

A

Rate should be 20-25

7
Q

What FiO2should be used when initially resuscitating a neonatal patient

  1. 21
  2. 40
  3. 60
  4. 0
A

0.21

You begin at 0.21 for PPV and then if increasing the pressure is not working you can increase FiO2 to 0.40. If that is still not working you can suggest intubation because the baby seem to be unable to oxygenate themselves. You will only increase FiO2 to 1.0 if the HR is less than 60 and you begin chest compressions.

8
Q

What level of CPAP is recommended through the AHS algorithms for a neonate (type in number)

A

5

You being CPAP at 5 and if the baby is spontaneously breathing and has a HR greater than 100, but has a high WOB or SpO2 not within range you can increase CPAP by 1 but you cannot increase it any more than 1 as CPAP should not exceed a CPAP of 6

9
Q

According to the AHS CPAP algorithms at what FiO2would you consider increasing the CPAP level

>0.5

>0.4

>0.3

>0.25

A

>0.3

10
Q

At what HR would you consider moving from CPAP to PPV

90

110

170

210

A

90

If the baby has a HR of less than 100 or the baby is not spontaneously breathing on their own you can begin PPV.

11
Q

When using a T-Piece what should the Ti be limited to?

A

0.5

12
Q

Can free flow oxygen be delivered with a self inflated bag

A

Yes

13
Q

What level of CPAP does the European Consensus Guidelines recommend for babies with moderate distress

4 cmH2O

5 cmH2O

6 cmH2O

8 cmH2O

A

6 cmH2O

Initial CPAP levels should be at 5 cmH2O and then if the baby is in distress than move the CPAP up to 6 (but not above 6)

14
Q

What is the recommended SpO2 for newborns from the European Consensus Guidelines?

80-84%

85-89%

90-94%

95-99%

A

90-94%

15
Q

What pressure should be used to begin PPV

A

You should being PPV with 20/5

16
Q

What are NCPAP and SiPAP

A

Non-invasive support modes used to assit spontaneously breathing infants requiring respiratory assistance

Will be used to wither attempt to avoid mechanical ventilation or factiliate transition from mechanical ventilation to extubation

NCPAP and SiPAP decrease respiratory effort, facilitate the maintenance of Functional Residual Capacity (FRC), thereby facilitating oxygenation and ventilation, and the treatment of apneas and bradycardias.

17
Q

How is positive pressure maintained with NCPAP and SiPAP

A

Positive pressure is maintained in the lungs due to the anatomic seal formed between the infant’s tongue and soft palate.

18
Q

NCPAP and SiPAP Indications

A
  1. Moderate respiratory distress, with one or more of the following:• retractions
    • Nasal flaring
    • Grunting
    • Increased oxygen requirements, by >5% from a stable clinical baseline
  2. Chest x-ray findings of decreased lung volumes and/or pulmonary infiltrates
  3. Post-extubation mode for all infants <33 weeks Corrected Gestational Age
  4. Apnea of prematurity
  5. Pulmonary Edema
    • Patent Ductus Arteriosus with left to right shunting
    • Congestive heart failure
19
Q

NCPAP and SiPAP Relative Contraindications

A
  1. Upper airway abnormalities
  2. Severe cardiovascular instability
  3. Severe ventilatory impairment demonstrated on arterial blood gas results
    • pH <7.25; PaCO2 >60mmHg; PaO2 <50mmHg with FiO2 > 60%
  4. Necrotizing enterocolitis
  5. Hyperinflation
  6. Pulmonary interstitial emphysema
  7. Congenital Cystic Adenomatoid Malformation
  8. Bronchial cysts
  9. Infants post bowel resection
20
Q

NCPAP and SiPAP Absolute Contraindications

A
  1. Tension pneumothorax
  2. Congenital Diaphragmatic Hernia
  3. Tracheoesophageal fistual
  4. Gastroschisis
  5. Omphalocele
21
Q

NCPAP and SiPAP Points of Emphasis

A
  • De-recruitment of unstable alveoli occurs within a few breaths of the removal of positive airway pressure.
  • Repetitive opening and closing of marginally recruited alveoli may produce damage by amplifying local stresses and inducing the release of inflammatory mediators, resulting in atelectotrauma.
  • When non-invasive positive airway pressure is clinically indicated, all attempts ought to be made to ensure continuous delivery of NCPAP/SiPAP.
  • Removal of the NCPAP/SiPAP interface ought to be considered equivalent to the disconnection of an intubated patient from the ventilator circuit.
  • NCPAP/SiPAP apparatus should not be routinely removed for weighing infants.
  • Iatrogenic injuries to the face and nose may occur with NCPAP/SiPAP administration, and may result in irreparable damage to nasal structures.
  • When correctly applied these devices should provide a good seal without causing skin excoriation, pressure necrosis of the nasal tissue or pain.
  • Careful placement and assessment are vital.
22
Q

NCPAP and SiPAP

Clinical Practice Guidelines

A
  • The decision to initiate NCPAP/SiPAP is made with input from the physician/Neonatal Nurse Practitioner (NNP), Registered Respiratory Therapist (RRT), bedside nurse and Nurse Clinician.
    • All relevant clinical information available will be considered during the decision-making process, including a chest x-ray if appropriate.
  • NCPAP/SiPAP requires an order by a physician/NNP prior to therapy initiation.
  • NCPAP/SiPAP initiation will be performed by an RRT or supervised student RT.
23
Q

NCPAP/SiPAP Marameter monitoring

A
  • NCPAP/SiPAP parameter monitoring will be performed no less frequently than q6hrs by an RRT including:
    • A visual inspection to verify appropriate placement of the patient interface
    • Verification of appropriate delivery machine, settings, function and bedside placement.
    • Confirmation of appropriate circuit functional status.
24
Q

NCPAP SiPAP

Full Assessment

A
  • Infants receiving NCPAP/SiPAP will undergo a full coordinated RN and RRT assessment a minimum of q8-12hrs or more frequently as appropriate based on the infant’s clinical status comprised of:
    • Hat, straps, and nasal interfaces should be changed regularly, as stretching, infant edema and/or growth will impact proper fit and function.
    • The interface is to be alternated between mask and prongs, or different mask sizes, with 8 hours being the maximum time without an interface change.
    • Some infants (often less than 28 weeks) will require q2-4 changes to avoid skin breakdown.
25
Q

Skin Integrity with NCPAP and SiPAP

A

Skin/tissue integrity will be evaluated at all points of contact with the delivery interface, hat, and straps. Excessive pressure is the primary cause of skin breakdown. Assessment findings that may indicate excessive pressure include:

  • Nasal blanching at the side on nares– prongs may be too large for the size of nares
  • Blanching on the bridge of the nose as the straps may be too tight
  • Crease present on dorsum of the nose while on device and may persist when device removed – device is causing nose to deviate upward
  • Redness of skin in contact with device or visible skin breakdown – straps may be too tight
  • Periorbital edema – straps may be too tight.
26
Q

What is Appropriate Skin Care for NCPAP and SiPAP

A
  • Massaging of skin at points of contact with the delivery interface, hat, and straps.
  • If signs of excessive pressure are present, straps should be loosened, correct hat placement should be reviewed, and size of nasal prongs assessed.
  • If skin reddened, consider a skin barrier such as Duoderm.
  • If skin breakdown is present, consult physician/NNP for care management.
27
Q

NCPAP and SiPAP

Installation and Suctioning

A
  • Routine instillation and suctioning of nares is not recommended; nasal suctioning will be performed as indicated using a nasal aspirator if possible.
  • Infants on NCPAP/SiPAP must be frequently assessed to ensure a clear airway is maintained.
  • Gentle nasal or oral suctioning should be considered with each assessment.
28
Q

NCPAP/SiPAP seal

A
  • “Treat the NCPAP/SiPAP seal like an endotracheal tube” and maintain uninterrupted NCPAP throughout the assessment.
  • NCPAP/SiPAP delivery should only be interrupted (for no more than three infant breaths) when direct access to nares is required (ie. during nasal suctioning).
29
Q

NCPAP and SiPAP Flows

A
  • Settings should be verified ensuring desired pressure levels are being achieved with appropriate flows by occluding:
  • The patient interface when not attached to the infant using a sterile glove. In the interim, NCPAP/SiPAP should be maintained via an alternate source
  • Flows should not routinely be adjusted in an attempt to achieve a desired NCPAP/SiPAP pressure while the patient interface is attached to the infant.
30
Q

When are NCPAP/SiPAP Circuits Changed

A
  • Between patients
  • In all cases when the circuit becomes visibly contaminated
  • Every 7 days while on the same patient

Prongs and mask interfaces will be discarded and replaced every 7 days/ prn

31
Q

NCPAP and SiPAP VAP Protocols

A

Ventilator Associated Pneumonia (VAP) protocols are to be followed at all times while infants are receiving NCPAP/SiPAP support.

Humidifiers will remain on, with a minimum flow of 1.5 lpm continuously going through the circuit. When the patient interface is removed the patient end must be secured in a sterile glove.

32
Q

Principal of T-Piece Resucitator

A

To provide a procedure for the use of the T-Piece Infant Resuscitator when delivering positive pressure ventilation, CPAP or free flow oxygen to neonates both in the delivery room and in the neonatal intensive care unit (NICU).

33
Q

What is a T-Piece Resuscitator

A

T-piece resuscitators are an easy to use resuscitator which provides consistent positive inspiratory pressure (PIP) and positive end-expiratory pressure (PEEP) during manual resuscitation.

The T-piece resuscitator is an acceptable method to initiate and continue ventilation in the newborn infant, particularly in the preterm infant where control of peak inspiratory pressure (PIP) and positive-end expiratory pressure (PEEP) is crucial.

34
Q

What benefits do T-Pieces have over Conventional Self-Inflating and flow inflating Resuscitation Bags

A
  • The device is able to provide safe, controlled PIP, consistent PEEP, and free flow oxygen.
  • The pressure is set by the user prior to and during resuscitation to deliver consistent distending pressures regardless of the skill level or experience of the operator.
    • Considering the potential complications of overdistension and under inflation of the alveoli during resuscitation, controlled PIP and PEEP is essential.
  • Given that several studies have demonstrated the inability of even skilled operators to provide accurate and effective PIP and PEEP with conventional resuscitation bags, a device that provides consistent inflation pressures is essential.
35
Q

T-Piece Points of Emphasis

A

The device may be used to deliver CPAP and free flow oxygen to spontaneously breathing infants.

The time of occlusion (inspiration) should be limited to approximately 0.5 seconds, regardless of the intended respiratory rate.

Alternate manual resuscitation devices (flow inflating and self- inflating bags) will continue to be available.

All resuscitation and ventilation will be performed according to the latest Neonatal Resuscitation Guidelines.

The T-piece resuscitator should be used when transferring non-intubated infants requiring CPAP or free flow oxygen from the resuscitation room to the NICU and, intubated infants when a transport ventilator is not available.

The T-piece resuscitator will be tested at the beginning of each shift, and prior to use.

The T-piece resuscitator will be re-circuited and a leak test performed after each use.

36
Q

T-Piece Potential Complications

A

Equipment failure: Backup resuscitation devices must always be present.

Under-inflation due to inadequate pressure can result in hypoxia.

Overdistention: Potential for barotrauma leading to pneumothorax, pulmonary interstitial emphysema, pneumoperitoneum, pneumomediastinum or pneumopericardium.

Note: The lowest possible PIP required to adequately oxygenate the neonate should be used. These complications are observed with all ventilation devices. However, the T-piece resuscitator allows the operator to accurately and consistently deliver safe and controlled PIP. Therefore, the incidence of complications is less than with conventional manual ventilation methods.

37
Q

T-Piece Prior to Use

Manometer

A

Ensure the manometer reads zero with no gas flow.

If not, the manometer should be sent to Biomedical Services for adjustment.

Connect gas supply. The gas supply line should be connected to an oxygen/air blender whenever available. Otherwise, connect the gas supply line to an oxygen source.

38
Q

T-Piece Prior to Use

What do you attach to the gas outlet port of resuscitators

A

Connect the patient supply line and patient T-piece to the gas outlet port of the resuscitator.

39
Q

T-Piece Prior to Use

Flow Rate

A

A flow rate of 10 litres per minute is typical for neonates.

40
Q

T-Piece Prior to Use

Maximum Pressure Relief Setting

A

Occlude the positive end expiratory pressure cap (PEEP) and turn the inspiratory pressure control knob fully clockwise.

Adjust maximum pressure relief knob to set desired maximum pressure relief (Note: this is not the inspiratory pressure used for ventilation). The value should be set to 45 cm H2O.

41
Q

T-Piece Prior to Use

Set PIP

A
  • While continuing to occlude the PEEP cap, turn the inspiratory pressure control knob clockwise or counter-clockwise until the desired inspiratory pressure is set.
    • The initial inspiratory pressure should be set at 20 cm H20, although, it may need to be individualized in certain situations.
  • Timely adjustments after initiation of resuscitation should be made to ensure immediate improvements in heart rate.
  • PIP as high as 35 cm H20 may occasionally be required in some infants. Weaning of PIP should be considered when possible, particularly post-surfactant administration.
42
Q

T-Piece Prior to Use

PEEP Adjustments

A

Remove finger from the PEEP cap. While observing the manometer, adjust PEEP to desired level:

  • initial PEEP should be set at 5 cmH2O.
  • Further PEEP and PIP adjustments may be necessary after initiation of resuscitation.
43
Q

T-Piece Set Up

Delivery Pending

A

If delivery is pending, leave gas supply on, remove test lung and apply appropriate sized face mask. Ensure the blender is set to room air.

44
Q

T-Piece During Resuscitation

A
  • Ensure the flow rate is set to the appropriate level.
  • FiO2 should be set and titrated as per NRP guidelines.
  • Attach open end of the T-Piece to a face mask or an artificial airway.
45
Q

T-Piece During Resuscitation

To Deliever Manual Ventilation

A

To deliver inspiration - place finger over the PEEP cap.

To deliver expiration - remove finger from PEEP cap.

NOTE: Inspiratory time is operator controlled. A longer expiratory time is optimal, therefore the PEEP cap occlusion should be limited to approximately 0.5 seconds, regardless of the intended respiratory rate.

To achieve the target respiratory rate of 40-60 breaths/minute repeat and

Observe manometer closely to ensure that appropriate PIP and PEEP levels are being achieved.

Make adjustments as described above.

Pressure adjustments should be made only after an adequate seal has been established by the operator.

46
Q

T-Piece During Resuscitation

To deliver CPAP in spontaneous breathing infants:

A

Ensure a tight seal has been created between the mask and the baby’s face.

Do not occlude the aperture on the PEEP cap.

Adjust PEEP cap until desired PEEP is displayed on the manometer.

47
Q

T-Piece During Resuscitation

To deliver free flow oxygen without CPAP

A

Release the seal between the mask and the infant’s face.

Hold the mask close to the face and allow the continuous gas flow to circulate around infant’s face.

Delivered FiO2 can be adjusted with the blender, if available.

48
Q

T-Piece During Resuscitation

Completion of Resuscitation

A

Turn off the gas supply,

Remove the patient circuit from the machine and discard.

Clean external device with the approved disinfectant wipe as per IP&C

Attach new circuit.

Ensure appropriate pressure settings are reset on the T-Piece.

Cover T-piece with a clean bag.

49
Q

What peak inspiratory pressure should be used with the T-piece resuscitator

A

Enough to move the chest adequately and maintain HR> 100

50
Q

Spontaneous Parameters of Neonate

A

RR: 40-60

Vt: 5-7

Vd/Vt: 0.3

FRC: 30

Resistance: 25-50

Compliance: 1-2

51
Q

Neonate Respiratory Anatomy Compared to Adult

Head/Body Ratio

A

Neonate: 1:4

Adult: 1:8

52
Q

Neonate Respiratory Anatomy Compared to Adult

Tongue Size

A

Neonate: Large

Adult: Porportional

Largetongue with small mouth which makes it easy to cause an obstruction and is more difficult to navigate around it with a laryngoscope.

53
Q

Neonate Respiratory Anatomy Compared to Adult

Laryngeal Shape

A

Neonate: Funnel Shape

Adult: Rectangular

Laryngeal soft tissue and lymph nodes which meakes them more susceptible to swelling and injury.

54
Q

Neonate Respiratory Anatomy Compared to Adult

Narrowest Portion of Upper airway

A

Neonate: Cricoid Cartilage

Adult: Rima Glottidis

Cricoid cartilage is the narrowest part of the airway and is shaped in a funnel shape.

55
Q

Neonate Respiratory Anatomy Compared to Adult

Shape and Location of Epiglottis

A

Neonate: Long/C1

Adult: Flat C4

large and floppy epiglottis (in infants we are using the miller blade to help move the large floppy epiglottis).

56
Q

Neonate Respiratory Anatomy Compared to Adult

Level of Trachea Bifurcation

A

Neonate: T3-4

Adult: T5

57
Q

Neonate Respiratory Anatomy Compared to Adult

Compliance of Trachea

A

Neonate: Compliant, fleixble

Adult: Noncompliant

58
Q

Neonate Respiratory Anatomy Compared to Adult

Angle of mainstream bronchi

A

Neonate: 10 degree to the right and 30 degrees to the left

Adult: 30 degrees to the right and 50 degrees to the left

Infant has a higher degree of curvature and are less prone to right lugnintubation also the trachea is shorter which is why they are so easy to extubate

59
Q

Neonate Respiratory Anatomy Compared to Adult

Anteroposterior transverse diameter ratio

A

Neonate: 1:1

Adult: 1:2

60
Q

Neonate Respiratory Anatomy Compared to Adult

Thoracic Shape

A

Neonate: Bullet shaped

Adult: Conical shaped

61
Q

Neonate Respiratory Anatomy Compared to Adult

Resting Poistion of Diaphragm

A

Neonate: Higher than adult

Adult: Normal

62
Q

Neonate Respiratory Anatomy Compared to Adult

Location of Heart

A

Neonate: Center of chest midline

Adult: Lower portion of chest left of midline

63
Q

Neonate Respiratory Anatomy Compared to Adult

Body Surface Area/Body Size Ratio

A

Neonate: 9 x adult

Large heart and belly- increase impedance for tidal volume as the heart is taking up more room

Adult: Normal

64
Q

Respiratory Anatomy and Sniffing Position

A

Large occipital which makes it harder to get the baby in sniffing position (best way is to put a small blanket under their shoulders or even just use your hand),

Sniffing position is very important becase the airway is easy to coallpse

65
Q

Neonates Aspiration Risk

A

Airway and trachea more anterior and superior which puts them on a greater risk for aspiration and difficult intubation

Smaller trachea making it easier for stuff to get stuck in there

Obligated nose breathers so when they get an infection with a stuffy nose their nose will occlude quicker and will have to be stimulated to breath

66
Q

Neonatal Compliance

A

Morecompliant chest wall because the cartilage under developed which will create high airway resistance in upper airway and more collapse in the lower airway (so when it comes out easier it will also collapse inwards easier

Accessory muscle are under developed so they are more susceptible to failure

67
Q

Infant Trachea and Carina

A

Infant trachea is 4 mm wide; adult trachea is 16 mm wide

Carina is higher (3rdvertebrae), T4/5 by age 10

Infant airway is more funnel shaped, narrowest point is cricoid

Infant epiglottis is OMEGA Ω shaped, less flexible, more horizontal

Infants have poor neck flexion = higher obstruction risk

Infants have large tongue with posterior placements and larger amounts of lymph tissue = higher obstruction risk

68
Q

Respiratory Failure

A
  • CO2 production is higher than adults and, so if baby/child is working harder to breathe than normal, they will tire out faster than an adult
    • Metabolic rate is twice as high as adults
  • O2 consumption is much higher than in adults, so hypoxemia effects will be more profound
    • Respiratory failure will occur much more quickly in an infant than in an adult
    • If infant goes hypoxemic it will be very profound and very quick
  • Infants tend to have smaller FRC’s than adults, so airway closure can occur more quickly creating shunting
69
Q

Respiratory distress in the neonate

A
  • Observed prior to birth via fetal monitoring strip, scalp pH, heart rate:
    • Distress = profound bradycardia, late decelerations, variable decelerations, loss of normal heart rate variability, scalp pH less than 7.15
  • Allows for preparation for resuscitation
  • Observedafter delivery via rapid assessment:
    • Assessment of the neonate commences as soon as baby presents…inspection!
70
Q

Signs & Symptoms of Respiratory Distress in the Neonate

A
  • Retractions
    • Intercostal, suprasternal, substernal (xiphoid)
  • Grunting
  • Nasal flaring
  • Increasing oxygen requirements
  • Cyanosis
  • Tachypnea
    • RR > 60 bpm