Respiratory Compromise in the Neonate

Neonatal Touch & Massage Cer3fica3on By Crea3ve Therapy Consultants

Ann Davis, RRT-‐NPS Miami Valley Hospital

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Welcome to Phase II of the Neonatal Touch & Massage

Cer8fica8on

Respiratory Compromise in the Neonate

Ann L. Davis, RRT-‐ NPS

Webinar recording and all informa3on contained within and downloaded regarding webinar recording is the property of Crea3ve Therapy Consultants. This material may not be used

without the express wriOen consent by Crea3ve Therapy Consultants. NTMC 2012

Presented by: Ann L Davis RRT-NPS

RESPIRATORY COMPROMISE IN THE NEONATE

LEARNING OBJECTIVES

ü Describe two major causes of lung injury in the newborn

ü Identify risk factors associated with chronic lung disease

ü Recognize the impact infant positioning has on the artificial airway

ü Identify possible causes of a BPD “spell”





FINDING BALANCE

Infants with chronic lung disease

often experience more medical/procedural touch than nurturing touch!

RISK FACTORS

INFANT: •  LESS THAN 30 WEEKS GESTATION •  LESS THAN 1000 GRAMS BIRTH WEIGHT •  PREMATURE, WHITE MALE •  PDA MATERNAL: •  CHORIOAMNIONITIS •  FAMILY HISTORY OF ASTHMA





WHAT CAUSES LUNG INJURY IN THE PREMATURE INFANT ?

EFFECTS OF POSITIVE PRESSURE: EXCESSIVE LUNG RECRUITMENT DAMAGE TO EPITHELIAL CELLS LEAKAGE OF FLUIDS (proteins, blood) into airway, alveoli, and inters33al space

RESULTS IN EDEMA (which impairs lung and surfactant func3on and interferes with gas exchange

EFFECTS OF SUPPLEMENTAL OXYGEN: OXYGEN (and other) FREE RADICALS DAMAGE CELL MEMBRANES

VENTILATOR STRATEGIES:

MEDS:

•  Extubate ASAP •  Lower tidal volume •  Permissive hypercapnia •  High Frequency Ventilation •  Lower baseline oxygen

saturation parameters

•  antenatal corticosteroids •  surfactant •  early methyzanthines •  Indocin •  vitamin A •  fluid restriction

PREVENTION

Ventilator Induced Lung Injury

Mathay et al, NEJM, 2000





CLINICAL DEFINITION OF CHRONIC LUNG DISEASE

“THE USE OF

SUPPLEMENTAL OXYGEN AT 36 WEEKS POST MENSTRUAL AGE”

DEVELOPMENTAL CHARACTERISTICS

Prematurity, lung injury, treatment, positional limitations, etc. •  Limited energy reserve •  At greater risk for slow growth •  At greater risk for impaired neuro-

development •  At greater risk for impaired muscular

development





CARDIOPULMONARY CHARACTERISTICS

On Respiratory support longer •  Effects of Positive pressure: ü lung insult continues ü hinders venous return ü decreases cardiac output ü affects renal blood flow •  Injurious effects of oxygen free radicals

continue •  At risk for tracheal malacia- “floppy” airway •  Changes in pulmonary mechanics •  Altered Acid/Base balance

HEALTHY FUNCTIONAL ALVEOLUS- GAS EXCHANGE

ACID/BASE BALANCE- NORMAL VALUES

PCO2 35-45 mmhg HCO3¯ 22-26 mEq/L

pH 7.35 - 7.45

BASE ACID





ACUTE – PERMISSIVE HYPERCAPNIA (CO2 RETENTION)

PCO2 45-55 mmhg

HCO3¯ 22-26 mEq/L

pH less than 7.35

ACID

BASE

CHRONIC- CO2 RETENTION

for example:

HCO3¯ 32 mEq/L PCO2 60 mmhg

pH 7.35

ACID BASE

TREATING CHRONIC LUNG DISEASE

•  CORTICOSTEROIDS- accelerate resolution of pulmonary edema, suppress inflammatory process produced by mechanical ventilation and O2 toxicity.

•  METHYZANTHINES- CNS stimulant, decrease diaphragm fatigue (also weak bronchodilator and diuretic)

•  DIURETICS- decrease pulmonary fluids •  BETA AGONIST- bronchodilation (decrease airway

resistance) •  O2 MANAGEMENT- appropriate titration (lungs/eyes) •  OPTIMIZE NUTRITION- huge energy requirement





UNDERSTANDING DIFFERENT LEVELS OF RESPIRATORY SUPPORT

INTUBATED PATIENT: •  The artificial airway •  Conventional ventilation •  High frequency ventilation NON-INTUBATED PATIENT: •  Conventional CPAP SIPAP/NiPPV •  Bubble CPAP •  High flow nasal cannula

THE ENDOTRACHEAL TUBE (ETT)

•  Uncuffed •  Beveled tip •  Tube size determined

by weight/gestational age

•  Held in place by tape or other securing device

•  Can be shortened •  Rigidity affected by

heat

POSITIONING OF INFANT’S HEAD INFLUENCES ETT LEVEL IN TRACHEA





NEUTRAL

FLEXION

EXTENSION





ETT POSITION OUTSIDE MOUTH INFLUENCES ETT WITHIN TRACHEA

ETT STRAIGHT OUT OF MOUTH, HEAD/BODY ALIGNED





ETT: INFANT SUPINE, HEAD TURNED TO SIDE

Cxr

ETT: INFANT PRONE, HEAD TO SIDE





ETT: SIDELYING WITH HEAD/BODY ALIGNED

INTUBATED PATIENT: CONVENTIONAL VENTILATION MODES Assist Control-

•  All breaths are fully supported by vent, even those initiated by infant

•  PEEP •  Vent assumes the work of

breathing •  Very little diaphragm

exercise •  Pressure ventilation •  Volume ventilation (with

some ventilators)

CONVENTIONAL VENTILATION MODES

Simv- •  Synchronized Intermittent

Mandatory Ventilation •  Breaths above the ordered

RR are the infant’s own wob

•  PEEP •  Exercise of diaphragm •  May be considered a

weaning mode •  Pressure ventilation •  Volume ventilation (with

some ventilators)





HIGH FREQUENCY OSCILLATOR •  Useful for patient’s with

difficulty oxygenating •  Respiratory rates typically

5 to 10 Hertz 1 hz = 60 breaths

•  Very low tidal volumes •  Slow recovery of PEEP with

disconnect, loss of opening pressure

•  Chest “wiggling” indicator of ventilation

•  Positional limitations with rigid tubing

HIGH FREQUENCY JET VENTILATION •  Effective in treating air leaks •  Respiratory rate typically

420 breaths/minute •  Very low tidal volumes •  Works in tandem with

conventional vent providing PEEP/CPAP/matching O2

•  Slow recovery of CPAP or PEEP with disconnect

•  Jet box stationed within isolette, must be covered to shield infant from noise

NON-INTUBATED PATIENT Continuous Positive Airway Pressure

•  For spontaneously breathing infant

•  Splints airway open; especially helpful with tracheal malacia

•  Maintains FRC (lung volume at end exhalation)

•  Improves ventilation/perfusion ratio

•  Splinting of airway lost when CPAP disconnected or infant’s mouth open





CPAP PRONGS

•  Various sizes available •  There should be NO

blanching of nares •  Barriers may be used to

protect tissues •  Prongs should NEVER

be forced all the way into nares.

•  Feeding tubes OG •  Less cumbersome

devices show promise

CPAP PRONE POSITIONING

“BUBBLE” CPAP

COMPONENTS: •  Blender •  Flowmeter •  Bubble chamber •  Humidifier ü  level of tubing depth in bubble

chamber dictates CPAP level ü  bubble produces “oscillations”

-may be of physiologic benefit to the premature infant’s lungs

ü  no alarm for disconnect/loss of CPAP ü  no bubble in canister: prongs

dislodged, circuit disconnect, mouth open





SIPAP •  Adds a respiratory rate, peak

inspiratory pressure, and an inspiratory time to baseline CPAP

•  Useful for infants with apnea •  MAP= mean airway pressure •  May be used with prongs or

mask NiPPV- •  conventional vent in IMV

mode-RR, PiP, ITL •  Mask/prongs

SIPAP HEAD GEAR

SIPAP DURING SKIN TO SKIN





HIGH FLOW NASAL CANNULA

COMPONENTS: •  Blender allows for

titration of FiO2 •  Flow meter

typical ranges 1-5 LPM

•  Requires humidifier/vapotherm

•  CPAP possible with higher flows=airway “splinting” possible

HIGH FLOW NASAL CANNULA

SIGNS OF RESPIRATORY DISTRESS AKA “BPD SPELL”

•  Heartrate/respirations increased •  Sweating •  Breath sounds markedly diminished •  “Air Hungry”-Increase in FIO2 in

response to falling oxygen saturation levels •  Grunting, flaring, and retracting •  “Head bobbing”-use of the scaleni and

sternocleidomastoid muscles to assist ventilation (elimination of CO2)





Infant with lung injury at risk for:

Ac8on ?:

�  Tracheal Malacia

�  Impaired airway clearance �  Increased airway resistance �  Increased energy requirements

Is resp support device dislodged/disconnected? need suctioning? bronchospasm? overstimulated?

POSSIBLE CAUSES OF RESPIRATORY DISTRESS/”SPELL”

INFANT WITH BPD

KEY POINTS- CONVENTIONAL VENTILATION

•  Be aware of effect head position has on ETT •  Maintain ventilator connection to patient

ETT •  Consider the ventilator tubing to be an

extension of the ETT when positioning •  Postural drainage may occur with

positioning requiring suctioning of the ETT •  High levels of support can impair cardiac/renal

function

•  If infant recently changed from Assist Control to Simv, we are asking the infant to assume more of the work of breathing (weaning)





KEY POINTS: HIGH FREQUENCY VENTILATION

•  Note the character of chest movements before providing touch

•  Be aware of effect head position has on ETT •  Consider the ventilator tubing to be an extension of

the ETT when positioning •  Infant has limited mobility with HFOV •  Can be slower to re-recruit alveoli if disconnected •  FIO2 to patient from HFJV and “background”

ventilator must match •  High levels of support can impair cardiac/renal

function

KEY POINTS- NON-INTUBATED

•  Imperative to maintain CPAP at ALL times •  Appropriate prong placement crucial for

reliable CPAP levels and tissue integrity •  Must be accepting of higher PCO2 levels •  High CPAP levels can impair cardiac/renal

function •  Gas also enters the GI tract and can cause

distention •  Splinting of the airway is possible with high

flow nasal cannula

MAINTAINING BALANCE





REFERENCES: Jobe AH, Bancalari E. Bronchopulmonary dysplasia. Am J Respir Crit Care Med 2001; 163: 1723-‐1729. Clark RH, Gerstmann DR, Jobe AH. Lung injury in neonates: Causes, strategies for preven3on, and long-‐term consequences. J Pediatr 2001;139:478-‐486. Bhandari A. Bhandari V. Pathogenesis, pathology and, pathophysiology of pulmonary sequelae of bronchopulmonary dysplasia in premature infants. Front Biosci 2003;8:e370-‐380. Shenai JP. Vitamin A supplementa3on in very low birth weight neonates: Ra3onale and evidence. Pediatrics 1999; 104:1369-‐1374. Lewis-‐Huns3ger and Jay P. Goldsmith,Nathaniel R. Payne, Meena LaCorte, Shyan Sun, Padmani Karna, Martha Evalua3on and Development of Poten3ally BeOer Prac3ces to Reduce Bronchopulmonary Dysplasia in Very Low Birth Weight Infants Pediatrics 2006;118;S65 Donn, S. M.; Kuhns, L. R.; (1980). "Mechanism of endotracheal tube movement with change of head posi3on in the neonate." Pediatric Radiology 9 (1): 37-‐40. Pillow JJ et al. Bubble Con3nuous Posi3ve Airway Pressure Enhances Lung Volume and Gas Exchange in Preterm Lambs. Am J Respir Crit Care Med, 2007. Narendran V et al. Early bubble CPAP and outcomes in ELBW preterm infants. J Perinatol, 2003. 23(3): p. 195-‐199. Bhandari V. et al. Noninvasive Ven3la3on for Respiratory Distress Syndrome: A Randomized Controlled Trial. Pediatrics Vol. 127 No. 2 February 1, 2011 pp. 300 -‐307

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Webinar recording and all informa3on contained within and downloaded regarding webinar recording is the property of Crea3ve Therapy Consultants. This material may not be used

without the express wriOen consent by Crea3ve Therapy Consultants. NTMC 2012

Respiratory Compromise in the Neonate

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