Algorithms Flashcards
Primary CPAP Management in the Delivery Room
GA 26-28 Weeks
What are your first steps
Clear airway
Initiate CPAP +5, FiO2 0.30
Stimulate
Attach pulse ox
Primary CPAP Management in the Delivery Room
GA 26-28 Weeks
What second steps
Assess for spontaneous breathing
Yes-Move on to HR assessment
No-Initiate Neopuff and NRP
Primary CPAP Management in the Delivery Room
GA 26-28 Weeks
You just assessed that the patient is spontaneously breathing
Assess that heart rate
If above 100-Move on to next assessment
If below 100-Begin neopuff and NRP
Primary CPAP Management in the Delivery Room
GA 26-28 Weeks
You just assessed that the patient’s heart rate, what do you assess next
Assess WOB and SpO2
Mild WOB and SpO2 within range- Maintain CPAP at +5 and FiO2 at 0.30 and prepare to move to NICU
Moderate or Severe WOB and/or SpO2 not within range- Increase CPAP by 1 (Max 6) and increase FiO2 by 0.10-0.20 to achieve targeted SpO2. Then reass WOB and SpO2 if now mild WOB and SpO2 then mainatin level and move to NICU.
If after you make your changes and then FiO2 is >0.60 or there is severe WOB then consider intubation
Primary CPAP Management in the Delivery Room
GA 26-28 Weeks
Principals
Maintain optimum lung volume and FRC in order to avoid derecruitment and over distention
In L&D and acute phase avoid CPAP >6 in infants 26-28 weeks
Infants 28 weeks or less will need ot be intubated by a senior practictioner
Early surfactant does not mean immediate surfactant rather surfactant should be administers in NICU when possible
Primary CPAP Management in the Delivery Room
GA 26-28 Weeks
Important Aspects
For preterm infants (>29 weeks) follow NRP algorithm
When using Neopuff or flow inflating bag pay attention to INSPIRTORY TIME
When providing PPV count out loud breath, two, three and occulde PEEP only when you say breath in order to avoid prolonged Ti
Avoid doing other tasks when prviding PPV
If HR is < 60 ensure adequate ventilatioation and start chest compression according to NRP
Intubation could be performed at any point at te discertion of the team leader
Primary CPAP Management in the NICU
GA 26-28 Weeks
First Steps
Upon admission to NICU start nCPAP at the same level needed in L&D
Load with caffine ASAP
Do a CXR and blood gas
Primary CPAP Management in the NICU
GA 26-28 Weeks
CXR and Blood Gas
Pneumothorax-Discontinued CPAP, intubate, early surfactant, drain pneumothorax as indicated
Hypoinflation: Consider increasing CPAP or consider intubation, and early surfactant
Hypercarbia (arterial): Consider incresing CPAP
Primary CPAP Management in the NICU
GA 26-28 Weeks
Second Steps
Assess WOB and SpO2
Severe WOB
Moderate WOB or FiO2>0.30
Moderate WOB AND FiO2>0.30
Primary CPAP Management in the NICU
GA 26-28 Weeks
Severe WOB
Assess interface fit and seal, assess the need for suction if all of those do not work consider intubation, CXR, early surfactant
Primary CPAP Management in the NICU
GA 26-28 Weeks
Moderate WOB OR FiO2 >0.3
Assess interface fit and seal
Assess need for suctioning
Review with dr consider CXR and blood gas
Increase CPAP by 1 with a max CPAP of 6
Primary CPAP Management in the NICU
GA 26-28 Weeks
Consider intubation with
Severe WOB: After you have assessed for interface seal and suction needs
FiO2 >= 0.30 OR
pH <7.20
PaCO2 >55mmHg
Primary CPAP Management in the NICU
GA 26-28 Weeks
Mild WOB and FiO2 <0.30
Leave CPAP at same level until able to maintain target SpO2 with FiO2 <0.25
SpO2 >92% for 6.24 hours AND FiO2 <0.25 (if no review with dr and increase CPAP). If yes then review histogram
Primary CPAP Management in the NICU
GA 26-28 Weeks
Review histogram
SpO2 >85% for 80% of the time and no significant apneas
No-Optimize CPAP for 2-5 days and optimize caffeine
Yes-Wean CPAP by 1
Primary CPAP Management in the NICU
GA 26-28 Weeks
Wean CPAP by 1
CPAP = 4 AND FiO2 < 0.25
YES-SpO2 >85% for 80% of the time and there is no significant apneas then you can discontinue CPAP (then you can discontinue CPAP and start NP at 0.5 lpm)
No: Review whether SpO2 >92% for 6-24 hr and FiO2 <0.25
Primary CPAP Management in the NICU
GA 26-28 Weeks
Discontinue CPAP
After you discontinue CPAP start with NP 0.5 lpm
If FiO2 increases by >0.05 OR increased WOB OR frequent desaturations the return to CPAP
Primary CPAP Management in the NICU
GA 26-28 Weeks
Principals
Maintain optimum lung volume and FRC
Avoid de recruitment and over distention
Use histogram data to optimize support
if necessary infants < = 28 weeks will be intubated by a senior practictioner
Primary CPAP Management in the NICU
GA 26-28 Weeks
Tips
Resurging FiO2 may indicate seal, nasal secretiosn, pneumothorax, PPHN, or worsening RDS
Careful clinical assessment by a senior practictioner is essential before esculating the management
Post Extubation CPAP Management
Infants 23-25 Weeks or Birth Weight <750 g
First step after extubation
Start SiPAP on 9/6
RR 20
Ti 1 second
Post Extubation CPAP Management
Infants 23-25 Weeks or Birth Weight <750 g
First step after SiPAP Set up
Assess whether FiO2 is >0.30
Yes: Increase settings with first increase Ti to 2 seoncds and then if needed increase Ti to 3 seconds and RR to 15 (in both cases keep pressure 9/6
No: Assess for significant apnea. If there is not a significant apena then after 24 hours review histogram if there is a significant apnea increase rate to 30 and optimize caffeine
Post Extubation CPAP Management
Infants 23-25 Weeks or Birth Weight <750 g
There is a significant apnea and first increases in SiPAP and caffeine have not helped
Consider CXR
Review with dr
Consider sraight CPAP
consider re intubation
Post Extubation CPAP Management
Infants 23-25 Weeks or Birth Weight <750 g
After initial changes based on FiO2 and FiO2 is still >0.30 in 1st week of life OR increased WOB OR apnea
YES: Assess for significant apnea or do more diagnostic tests
No: Review histogram specifically looking for SpO2 >85% for 80% of the time, mild WOB, AND no significant apnea. If yes then we can wean gradually wean until minimal SiPAP settings
Post Extubation CPAP Management
Infants 23-25 Weeks or Birth Weight <750 g
Review histogram Daily
Check for is SpO2 is >85% for 80% of the time, mild WOB, and NO significant apneas. If no then maintain or optimize SiPAP levels. If yes intitate CPAP at equivalent level to SiPAP MAP
Post Extubation CPAP Management
Infants 23-25 Weeks or Birth Weight <750 g
After you initiate CPAP at equivalent level to SiPAP MAP
FiO2 >/= 0.05 above SiPAP FiO2. Significant apnea
Yes: Return to previous SiPAP settings and re-enter algorithm
No: Leave CPAP at same level until able to maintain target SpO2 with FiO2 <0.25
Post Extubation CPAP Management
Infants 23-25 Weeks or Birth Weight <750 g
Review histogram and SpO2 is >85% for 80% of the time with no significant apnea
Yes: Wean CPAP by 1 and then if SpO2 is >85% for 80% of the time with no significant apnea, and the last attempt to discontinue was greater than a week you can discontinue CPAP and start NP at 0.5 lpm
No: Optimize CPAP for 2-5 days and Optimize caffine then review histogram again
Post Extubation CPAP Management
Infants 23-25 Weeks or Birth Weight <750 g
Discontinued CPAP
Start NP 0.5 lpm
If FiO2 increases by 0.05 OR increased WOB, OR frequent desaturations/brady return to a CPAP of 5
Post Extubation CPAP Management
Infants 23-25 Weeks or Birth Weight <750 g
Tips
Resurging FiO2 may indicate inadequate seal, nasal secretions, pneumothorax, PPHN, or worsening RDS. Careful clinical assessment by a senior house staff (+/- CXR) is essential before escalating the management
