N.I.C.U.

Pocket GuideFor

Respiratory Therapists 

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Charles Williams RRT

Sonia Goede RRT

Carissa Yackus RRT

Contributors

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ContentsAssessment of the Newborn

Common Newborn Cardiopulmonary Disorders 4

Normal Vital signs 5

Normal ABGs 5

Signs of Respiratory Distress 6

APGAR Scoring 7

Primary Apnea vs. Secondary Apnea 8

 

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 3

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

Normal Newborn Blood Gases

Birth weight (g)

Blood Pressure Systolic

(mmHg)

Blood Pressure Diastolic

(mmHg)

Heart Rate Respiratory Rate

SpO2

500-700 50-60 26-36

120-170 30-60 88-94%

700-1000 48-58 24-36

1000-1500 47-58 25-35

1500-2000 47-60 25-35

2000-3000 51-72 27-46

Term 64-72 50-55

pH PCO2 PO2 HCO3

Capillary 7.37-7.44 31-45 60-100 22-26

Arterial 7.37-7.44 31-45 80-110 22-26

Venous 7.35-7.45 34-50 --- 24-28 5

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

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)

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

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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.

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Neopuff™ Infant Resuscitator (cont.)

The desired PIP is set by turning the inspiratory pressure control.

The desired PEEP is set by adjusting the T-piece aperture

The patient T-piece allows breath by breath resuscitation by simply occluding the T-piece aperture with the thumb or finger. 11

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. Ventilate neonate with 100% oxygen using bag/mask

2. Insert stylet into the ET tube just short of the tube’s tip

3. Ensure neonate is supine and airway is hyperextended (opened) but not overextended

4. Insert laryngoscope blade into mouth, opening the airway and visualizing the vocal cords

5. Insert the ET tube stopping when the tip of the tube has passed the vocal cords

6. Resume positive pressure ventilation via ET tube

7. Confirm the tube’s position

8. End-tidal CO2 detection

9. Chest x-ray

10. Auscultation

11. Observation of condensation during exhalation

12. Secure the ET tube

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Intubation (cont.)

Intubation and Suctioning Guidelines

Birth Weight Laryngoscope Blade Size

Endotracheal Tube Size

Suction Catheter Size

< 1000 g 0 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 15

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

NormalInfant

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)

< 20 < 2 60 – 150 0.25-0.4

PPHN < 20 < 2 30-60 * 0.25-0.4

MeconiumAspiration

(w/ atelectasis)

30-60 4-6 25-50 0.3-0.5

MeconiumAspiration

(w/ hyperaeration))

< 20 < 2 20-25 0.25-0.4

DiaphragmaticHernia

< 20 < 2 25-100 0.3-0.5

Be sure to confirm Total PIP ordered. (Total PIP – PEEP = Set PIP) 17

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',

inflate-deflate' 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 MAPΔP--- (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 wtBias Flow --20 l/m

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High Frequency Ventilation (cont.)3100A Performance Checklist

1. Connect gas source and plug machine in. (Never turn machine on without plugging in gas source)

2. Connect circuit and humidifier

3. Connect color-coded patient circuit control lines and clear pressure sense lines

4. Block off the ET connection port w/ rubber stopper

5. Turn main power on. (Switch is located on base of the stand)

6. Set Bias Flow at 20

7. Set both Mean Pressure Adjust and Mean Pressure Limit controls to max

8. Push in and hold RESET, and observe Mean Pressure read out. (It should read 39-43)

9. If read out is not 39-43, adjust with adjustment screw located on right side of vent.

10. Set Frequency to 15, % I-Time to 33, and Power to 0.0

11. Set Max Paw thumbwheel switch to 30 and set Min Paw thumbwheel switch to 10.

12. With the Mean Pressure Adjust control, establish a Paw of 19 to 21 cmH2O.

13. Press Start/Stop button

14. Increase power to 6.0, and center the piston

15. Verify that the ΔP and Paw readings are within range are within range for corresponding altitude (0-2000).

16. Press Start/Stop to stop vent.

17. Verify thumbwheel alarms by adjusting them to trigger the alarms.

18. Alarms should be set at 2-5 cmH2O of desired Paw pressure

19. Using your fingers, squeeze closed the expiratory limb tubing on the patient circuit to verify the Paw pop-off at 50 cmH2O and alarm.

20. Push and hold RESET to power up machine.

21. Set Mean Pressure Limit control to mid-scale

22. Again squeeze expiratory circuit and observe Paw readout. Adjust to desired level

23. Position vent for connection to patient.

24. Obtain settings from MD and dial in. Set power first. (changing power will change Paw).

25. Place baby on vent and press RESET button and start vent. Center piston. 20

Survanta DeliverySupplies 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. Warm Survanta for 20 min. at room temp. DO NOT SHAKE vial

2. Determine “safe suction” depth. (Length of ETT +5)

3. Exchange standard ETT connector with MAC catheter ETT connector

4. Draw up Survanta (4ml per kg)

5. 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

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Survanta Dosing ChartWEIGHT(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. Insert needle into 4th intercostal space (located at the level of the nipples)2. Connect butterfly needle to stopcock and syringe3. Open stopcock between needle and syringe and then aspirate air or fluid.4. Stopcock may be closed to empty syringe

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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 25

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. 26

Resuscitation Flowchart

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Sources:

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Neonatal Resuscitation Handbook; American Heart AssociationRespiratory Care: Principles & Practice; Hess, MacIntyreNeonatal Mechanical Ventilation

Websites

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