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DeliveryRoomBubbleCPAPOptimizingRespiratorySupportinthe

VeryLowBirthweightInfant

DorothyHutchinson,MSN,CNSMichelleThomas,SNIV,ALSRNPaulaDaugherty,MPH,RRT-NPS

ObjectivesAttheendofthisinteractivelecturesession,participantswillbeableto:• DiscussrecommendationsforoptimizingrespiratorysupportforVLBWinfantsinthedeliveryroom• Discussteammembercompositionanddynamicsinthedeliveryroom• Describeusefultechniquesandprocedurestoconsiderwhenimplementingpracticechangesinthedeliveryroom

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“Stabilizationinthedeliveryroomwithpromptrespiratoryandthermalmanagementiscrucialtotheimmediateandlong-termoutcomeofprematureinfants,particularly

extremelyprematureinfants.”

Whatdoesthislooklike??InJanuary2014theAAPreleasedapolicystatementonrespiratorysupportfornewbornpreterminfants.Therecommendationsinclude:• Usinganindividualizedapproachtotheprovisionofcare• EarlyuseofCPAPwithselectiveuseofsurfactant• Ifmechanicalventilationisnecessary–earlyadministrationofsurfactantwithrapidextubation ifpossible

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Rationale

• InfantswithRDSmayvarymarkedlywithregardstotheseverityofillness,maturity,andthepresenceofothercomplications• CPAPstartedsoonafterbirthisastrategythatappearstoreduceBPD/deathandisanalternativetotheprophylacticorearlysurfactantapproach(withmechanicalventilation)•WhiledeliveryroomCPAPisnotexpectedtopreventallintubationevents,thereisnotevidenceofharmassociatedwithstartingCPAPinthedeliveryroom

WhatdoSTABLE&NRPsay

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STABLEAirway

• CandidatesforCPAPnotspecifictodeliveryroombutinclude• AdequateRespiratoryrate• Increasedrespiratorysupportneeded• IncreasedWorkofBreathing• IncreasedO2requirements• SomeApnea,mildacidosis• Co2<55-60• Supplementaloxygen40-70%tomaintainO2Sats 90-95%• AtelectasisonX-ray

STABLEAirway• InfantswhoarenotcandidatesforCPAP• Rapidprogressiverespiratoryfailure• Increasedfrequencyandseverityofapneawithcyanosisandorbradycardia• Gasping• Diaphragmatichernia• TracheoesophagealfistulaorEsophagealatresia• Choanal atresia• Cleftpalate• Poorrespiratoryorcardiovascularfunction

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NRPDeliveryRoomrecommendationsforCPAP

BreathingHeartrate>/=100LaboredbreathingOxygensaturations<targetsaturationrangeUseT-PieceresuscitatorIfprolongedCPAPconsidernasalprongsornasalmaskandafterinitialstabilization,CPAPcanbeadministeredwitha….Bubblewatersystem,adedicatedCPAPdeviceoramechanicalventilator

HowtoimplementBubbleCPAPintheDeliveryroom

IdentifyteamPre-BriefEquipment&Suppliessetupandchecked

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DeliveryPersonnel/TeamComposition

• Shouldbebasedonindividualpatientneeds• Atleasttwoproviderscommittedsolelytotheevaluationandcareofthenewborn• MostTeamshavealead(MD,NNP,oradvancedpracticeRN)aswellasanadditionalRNorRCP

BubbleCPAPforVLBWInfantsintheDeliveryRoom

•WorkwithteamtoidentifypatientsthatwilllikelyneedCPAPsupport(i.e.

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FlowtoinspiratorylineforBubbleCPAP

O2Tubingconnection(8-10L/min)

VLBWRTDeliveryItems:• BC190-05(FlexiTrunkInterface50mm)

• BC800-10(smallmask)• BC801-10(mediummask)• BC3020-10(3.0mmnareprongs)

• BC3520-10(3.5mmnareprongs)

• 22-25cmBonnet• 25-29cmBonnet• Oxygenconnectortubing• 500mLbottleofwater

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KeeptotakebacktoNICUfor

bedsideset-up

ConnectO2

tubingfor

shuttletransporttoNICU

MD Resource

RNRT The Baby

Let’sPractice

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DeliveryRoomBestPracticeDiscussion

WhoisdoingBubbleCPAPindeliveryroom?Howdoyoucoordinatecare?

WhoisgivingSurfactantindeliveryroom?Howareinfantstransportedfromthedeliveryroom?

Additionalbestpracticesharing?