Final Review Flashcards
Composition of Pulmonary Surfactant
Mainly composed of depomitoylphosphatidlycholine (Lecithin) and shinogomyelinand
Surfactant Treatment
Most surfactant will be reprocessed and recycled in alveolar type 2 cells
This is why babies only need 1-2 treatment
Common Surfactant
Bovine Lipid Extract Surfactant (BLES)
Beractant (Survata)
Surfactant Production in the Body
Surfactant is produced in type two alveolar cells at 24 weeks gestation
Surfactant is then stored in the lambellar bodies
When is Surfactant Contraindicated
Pulmonary Hemorrhage
BLES Dosing
5 ml/kg
Neonatal Aspiration Risk
The airway is more anterior and superior putting neonates at a higher aspiration risk
Compliance in Neonates
Increased compliance
Cartilage is under developed creating high airway reistance and more collapse in the lower airway
Accessory muscle are under developed so they are more susceptible to failure
Neonate Respiratory Anatomy Compared to Adult
Laryngeal Shape
Neonate: Funnel Shape
Adult: Rectangular
Laryngeal soft tissue and lymph nodes which meakes them more susceptible to swelling and injury.
Neonate Respiratory Anatomy Compared to Adult
Shape and Location of Epiglottis
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).
Neonate Respiratory Anatomy Compared to Adult
Resting Poistion of Diaphragm
Higher in neonates
Carina Position in Neonates
Carina is higher (3rdvertebrae), T4/5 by age 10
Infants Neck Flexion
Infants have poor neck flexion = higher obstruction risk
Infants Airway
Infant airway is more funnel shaped, narrowest point is cricoid
Neonatal Epiglottis
Infant epiglottis is OMEGA Ω shaped, less flexible, more horizontal
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).
Infants Tongue Position
Infants have large tongue with posterior placements
Adults have a porportional tongue size
Larger amounts of lymph tissue = higher obstruction risk
Neonate Respiratory Anatomy Compared to Adult
Thoracic Shape
Neonate: Bullet shaped
Adult: Conical shaped
Neonate Respiratory Anatomy Compared to Adult
Laryngeal Shape
Neonate: Funnel Shape
Adult: Rectangular
Laryngeal soft tissue and lymph nodes which meakes them more susceptible to swelling and injury.
Neonate Respiratory Anatomy Compared to Adult
Anteroposterior transverse diameter ratio
Neonate: 1:1
Adult: 1:2
Neonate Respiratory Anatomy Compared to Adult
Body Surface Area/Body Size Ratio
Neonate: 9 x adult
Large heart and belly- increase impedance for tidal volume as the heart is taking up more room
Adult: Normal
Identifing the Patient is Hypoxic
Low SO2 and PaO2
PvO2 <35 mmHg
O2 Delivery <8 ml/kg/min
High lactate >2.8
Criteria to Consider SBT
Resolution of the disease
Adequate oxygenation
HR ≤ 140 bpm, stable blood pressure, stable cardiac rhythm, no ongoing myocardial ischemia, and no uncompensated shock.
No significant uncompensated respiratory acidosis (i.e. pH < 7.30).
Adequate mentation (GCS >= 13) or tracheostomy in place.
Before you Begin a SBT you need to check oxygenation what measure are you looking at
PaO2 ≥ 60mmHg
PaO2/ FiO2 > 150-200 or SpO2 >= 90%, with PEEP ≤ 5-8 cmH2O and FiO2 ≤ 0.4 (or as otherwise described in the regional O2 Protocol).
Initiation of spontaneous breathing trial
To perform the SBT, the RRT will place the patient on PSV of 7cmH2O and PEEP of 5 cmH2O.
If Automatic Tube Compensation (ATC) is used, then set PSV to 0.
First 5 min of SBT
Terminate the test is any of the below occurs
RR > 38
Rapid shallow breathing index (Tobin ratio) > 105
Sweating, anxiety or change in mental status SpO2 < 90% for > 5 minutes
Signs of distress or paradoxical breathing
HR > 140 bpm or a 20% change
Systolic BP < 90 or > 180 mmHg
New dysrhythmia or myocardial ischemia
After first 5 min of SBT
For patients ventilated < 72 hours, continue for 30 minutes.
For patients ventilated > 72 hours, continue the trial for 60-120 minutes.
Monitoring should be done after the first 5 minutes and Q15 there after.
Initiating Mechanical Ventilation Goals
FiO2 at 0.60 and then adjust to maintain SpO2 > 90%.
The physician must order a target SpO2
Note: Default values will be SpO2 ≥ 88% and ≤ 92% for patients with obstructive lungs and chronic CO2 retention, and SpO2 ≥ 90% for all other patients.
When does the physician need to be notified of changes to FiO2
a. The FiO2 has to be set at > 0.60.
b. The FiO2 has to be increased by > 0.30.
This excludes changes for treatment such as suctioning
Arterial Blood Gas Protocol
PA Catheter
Mixed Venous samples will be drawn Q12h in a patient having a PA catheter
It is not mandatory to draw an arterial sample in conjunction with each mixed venous draw.
Weaning Parameters
POINTS OF EMPHASIS
Patient should be on PEEP < 8 cm H2 O and F1O2< 0.60.
Patient’s own minute ventilation should not be greater than 12Lpm.
Try to place the pt in sitting position or elevate their head in order to optimize pulmonary mechanics
Rapid Shallow Breathing Index (Tobin Ratio)
Rapid Shallow Breathing Index (Tobin Ratio) = f (bpm) / VT (L)).
This ratio is determined after the patient had been breathing spontaneously for one minute.
Infants = 32 Weeks 1st Week of Life
Target blood gas
Blood Gas >/= 7.20
PCO2 = 45-55 (40-50 in 1st 48 hours of life)
SpO2= 88-92%
Do not treat metabolic acidosis with hyperventilaion
Criteria for Possible HFV
You only need one of these but will probably have more than one
RR > 80 bpm
Vt >5ml/kg
PIP >25 cmH2O
MAP >12 cmH2O AND FiO2 >0.40
Infants = 32 Weeks 1st Week of Life
Order of Weaning
Volume (4 ml/kg) or PIP (<18 cmH2O) depending on mode
PEEP and Ti
Rate (5-10 increments until you reach 20)
VAP
Ventilator associated pneumonia (VAP) is a nosocomial infection occurring in patients receiving mechanical ventilatory support that is not present at the time of intubation and that develops more than 48 hours after the initiation of that support.
VAP can derive from endogenous bacteria (the baby’s own oropharyngeal flora) or exogenous bacteria (eg: Pseudomonas aeruginosa).
VAP is associated with prolonged hospitalization and increased mortality, especially in the very low birth weight infant.
T-Piece Resusictator
During Resucictation
To deliver inspiration - place finger over the PEEP cap.
To deliver expiration - remove finger from PEEP cap.
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 target respiratory rate of 40-60 breaths/minute repeat
Consider Extubation in Neonates When
RR > 40 with a set RR= 20 bpm AND
Vt= 4ml/kg with PIP <18 cmH2O AND
MAP 7-8 cmH2O AND
FiO2 <0.30 AND
Patient breathign comfortably, hemodynamically stable, no significant increase in TcPCO2, EtCO2 for 1 hour prior to extubation
Where does the MAC Catheter Attach
Attaches to the proximal end of ETT using wye connector, same as inline suctioning
Does not need the diconnection of teh closed system
Surfactant will be dleivered at distal end of ETT reducign the risk for obstruction
Closed Suctioning in Neonates
Suction level- 100-120 mmHg
Preoxygenate by setting FiO2 5-10% above current FiO2 for ~20 sec
Insertion catheter and apply suction for 1-3 sec before withdrawal
Pull out the catheter in a straight motion (without twirling) to prevent kinking. Time from insertion to complete withdrawal should not exceed 5 seconds.
ARDSnet Algorithm
ABG
Oxygenation: PaO2 55-90 and SpO2 88-95%
Ventilation: pH 7.30-7.45
SUCTIONING ENDOTRACHEAL TUBES: NEONATAL
Open Suction Procedure-What Should You Adjust Suction To
Adjust suction to 80-100mmHg and test by kinking tube and reading suction gauge
Primary CPAP Management in the Delivery Room
GA 26-28 Weeks
Principals
Maintain optimal lung volume and FRC
In L&D and acute phase avoid CPAP >6 in infants 26-28 weeks
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
What are your first steps
Clear airway
Initiate CPAP +5, FiO2 0.30
Dry and Stimulate
Attach pulse ox
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 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 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 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
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
Reviewing 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
Normal ICP
5-15 mmHg
Rapid Shallow Breathing Index
Calculation
Tobin Score
RR/Tidal Volume
Bradycardia is persisting even after CPR
Epinphrine
Atropine
Consider pacing
Atropine
Think bratropine
used for increase vagal tone and primary AV block
Epinephrine Dosing
0.01 mg/kg and 0.01 ml/mg
Repeat every 3-5 min
Suction Levels for Children
80-100 mmHg for both open and closed
What Happends When Secretions Build Up in the Suction Catheter
Increased Resistance
Decreased ability to efectivly remove secretions
Can be due to the fact that we are using too small of a catheter
Suction Level for Neonates
60-80 mmHg for both closed and open suctioning
High Suction Levels
Suction flow is proportional to suction level when flow is smooth and laminar
However flow in suction system will be turbulent and disorderly so if suction increases by 50% then flow may only increase by 20-25%
Sputum Induction Procedure
Do in AM and get 3 samples
If needed can rinse mouth and pretreat with bronchodilator
Incentive Spirometry
Increases transpulmonary pressure gradient by decreasing Pplat
Inspiration will cause a drop in Pplat due to expansion of the thorax allowing negtaive Palva and more gas to flow into alveoli and lung expansion
Medication Calculation
(What you want/what you have) x quantity is comes in
Lung Protective Strategy
Permissive Hypercapnia-PaCO2 of 45-55 mmHg
pH ≥ 7.25
VT~ 4 mL/kg
Peak pressures should be < 25 cmH2O
Neonatal ABG Goals
pH >7.25
PaCO2 45-55
PaO2 45-65
HCO3 15-18
SpO2 85-92
BPD and Mechanical Ventilation
Permissvie Hypercapnia
VT4-6 mL/kg
Goal pH ≥ 7.25
Peak pressures < 25 cmH2O
Target lower SpO2 85-94%
Volume-targeted modes tend to work best for BPD.
Congenital Diaphragmatic Hernia
ABG Goals
pH >7.25
Pre-ductal SpO2 85%, though ideal is 90-95%
PPHN
Ventilation Goals
Target low to normal PaCO2 (35-40) and pH 7.40-7.45
Hyperoxygenate PaO2 >100mmHg
Nitric Oxide Therapy
Cyanotic Defect and Target SpO2
Rule of 40s
pH 7.40
PaCO2 40s
PaO2 40s
SpO2 70-80%
These mimic in-utero conditions and maintain a PDA
Mechanical Ventilation and Harmful Effects on Respiratory Sys.
V/Q Mismatching
- Increase shunt and deadspace
- Decreased pulmonary perfusion
Ventilator Induced Lung Injury
- Barotrauma, volutrauma, shear stress, atelectatrauma, biotrauma
Oxygen toxicity
PC CMV Absolute Pressure
Decreased Ti sec
Ti tot Decreased
Te Increase
I:E Decrease
Pmean Decrease
PC CMV Absolute Pressures
Decreased in Compliance
Vt Decrease
Ve Decrease
Ti dyn Decrease
PC CMV Absolute Pressure
Increased in PEEP
PIP Decrease
Pplat Decrease
Pmean Increased
PC CMV Delta Pressure
Decreased Rate
Ve Decreased
Te Increases
I:E Decrease
Pmean Decrease
PC CMV Delta Pressure
Increased Ti sec
Ti tot Increased
Te Decrease
I:E Increased
Pmean Increased
PC CMV Absolute Pressure
Increased Rate
Ve Increase
Te Decrease
I:E Increase
Pmean Increase
VC-CMV
Vt Increased
PC CMV
Delta Pressures
Resistance Decreased
Ti dyn Decreased
PC CMV Pressure Control Delta
Increased PC
PIP Increased
Pplat Increased
Vt Increased
Ve Increased
Pmean Increased
Atelectrauma
Caused by the repeated opening and closing of alveoli due to inappropriate PEEP
Usually occurs in dependent area
PPV and Renal System
- Urinary output (UO) due to changes in CO
- Endocrinological Effects
- Increased ADH release
- Decreased ANP release
- Activation of the renin-angiotensin-aldosterone system
- Abnormal ABGs PaO2 results in decreased renal function and UO
- Function is dramatically decreased when < 40 mmHg
- PaCO2 > 65 mmHg decreases kidney function
PC CMV Delta Pressure
Decreased Ti sec
Ti tot Decreased
Te Increase
I:E Decrease
Pmean Decrease
PC CMV Delta Pressures
Increased in Compliance
Vt Increase
Minute Ventilation Increase
Ti Dyn Increased
PC CMV Absolute Pressure
Decreased Rate
Ve Decreased
Te Increases
I:E Decrease
Pmean Decrease
PPV-Increase Intrapulmonary Shunt
Perfusion will go to gravity dependent areas and ventilation will go to gravity independent areas
The gravity dependent areas will be located on the posterior side when the patient is lying on their back
Oxygen Index
OI = (FiO2 * MAP *100) / PaO2
If you are using FiO2 as a decimal then times by 100 if you are using it was a whole number then you do not need to multiple by 100
Positively correlated with mortality risk
You want a low OI (the lower the better) with <5 being normal
When you are in the 20 you need to begin to look at things such as ECMO because you lungs can no longer properly oxygenate the blood
Biotrauma
Due to atelectrauma and volutrauma the lung releases inflammatory mediators
This can result in injury to other organs
Volume Support Mode
Spontaneous Mode
Pressure Limited
Flow Cycled
Volume Targeted
PAV
How to Manipulate Tidal Volume with E Senesitivity
A decrease in E sensitivity will increase tidal volume and Ti
Unless the patient is air hungry then they will be trying to breath at a high peak volume and it will cut them off faster= smaller breath
What will happen to tidal volume if you decrease the resistance in pressure control
Volume will stay the same and Tidy will get shorter
What will happen to tidal volume if you decrease the compliance in pressure control
Decrease TC and Ti dyn and volume will go down
Porportional Assist Ventilation
Used to assist spontanesou ventilation as the breath that will be delivered is similar to pressure support but the support level if variable and porportional to spontaneous effort
This means that the harder the patient works the more support the vent will deliver - POSITIVE FEEDBACK
Porportional Assist Ventilation and E Sensitivity
E Sensitivity set at 27% (27% of inspiratory peak flow)
Pressure support patient trigger pressure limited flow cycles (flow cycle=e sensitivity)
You will never get equilibrium on a pressure support breath
Mandatory Minute Ventilation
There is a set MV and if it is not reached the ventilator will kick and deliver mandory breaths until the set MV has been reached
AHS Initiation of SBT
PSV of 7 and PEEP of 5 unless there is automatic tube compensation then you put PSV to 0
In first 5 minute monitor tobin score (>105), sweating, anxiety, mental status, SpO2 >90%
If any negative changes occur increase PSV and inform physician
Tobin Score
Also known as rapid shallow breathing index
= (RR)/ (Vt)
An RSBI < 105 breaths/min/L has been widely accepted by healthcare professionals as a criteria for weaning to extubation.
Whereas patients with RSBI > 105 will have a high chance of failure and require re-intubation.
Length of SBT
If pt has been ventilated >72 hours continue SBT 60-120 min
If pt has been ventilated <72 hours continue SBT 30 min
Monitoring should be done first 5 min and the Q15 after
European Consensus and Delivery Room Oxygenation
Oxygen for resusucitation should be controlled via a blender
An initial concentration of 30% oxygen is appriopraite of babies <28 GA
For babies that are 28-10 week use an FiO2 of 21-30
European Consensus and Spontaneous Breathing Babies
In spontaneous breathing babies stabilize babies with CPAP at 6 cmH2O via mask or nasal prongs
European Consensus Saturation Goals
Saturation goals should be 90-94%
In Labor and Delivery and Acut ephase what should you keep CPAP under
<6
CPAP Waveforms
Variable flow is most desireable and is seen in CPAP system (ex. Arabella)
Sechrist systems will deliver a constant flow
SiPAP Machine
SiPAP is a brand name
Less expiratory resistance and lower flows due to the flip flop gate which will manage baseline pressure
Delivers stable baseline pressure
Uses the Graesby capsule
Arabella System
Most common method of NIV (CPAP) with infants
Can use nasal prongs or nasal mask
Do you set flow or pressure in CPAP
With CPAP set the flow to get the pressure you need (you don’t set pressure because of the leaks)
What will happen to the ABG if the baby is crying
Will be more acidotic
BiPhasic Mode Basic Settings
6/9 (FiO2 0.5-0.3)
7/10 (FiO2 >0.5)
Rate: 20
Ti: 1 sec.
Separation of 3 cmH2O
Indications of CPAP
PaO2 < 50 mmHg when FiO2 >0.60
Minute Ventilation is Adequate
PaCO2 is >50 and pH 7.25
Respiratory Distress
Neonatal Respiratory Failure
PaCO2 > 60 mmHg
pH < 7.25
Pediatric Positive Pressure Devices
Pressure Targeted
BiLevel/BiPAP (Pressure Support)
When there is a high WOB we will use pressure support rather than CPAP
Pediatric Positive Pressure Devices
Pressure Targeted Advantages
Leak compensation
Spontaneous and time modes
Pediatric Positive Pressure Devices
Volume Targeted
Portable home ventilators
Most devices do not have a pressure support feature
Do not trigger well or support spontaneous breathing
Set up so Vt is greater than physiologic Vt
Factors Unique to Pediatric Patients that Promote Complications of NPPV
Aspiration-Immaturity of airway protective reflexes
Reflux-Impaired gastroesophageal sphincter function during infancy
Upper Airway Obstruction-Anatomical factors, difficulty clearing secretions, large oral leak, mouth breathing
Agitation-Anxiety, incomplete understanding, developmental disorders
PRVC
Compliance Decreases
Vt will remain the same so there will be an increase in Pplat an PIP (overall increase in Pmean)
MV will not change because RR and Vt is set
Tidyn decreases and Tistatic will increase, but Titotal does not change
Flow will increase
PRVC
Resistance Decreases
Pressure will remain the same but flow will change due to the changing airway diameter
Tidyn decreases and Tistatic increases (Titotal does not change)
Peak flow will be directly proportional to resistance but overall flow will not change (and we can not measure)
PRESSURE CONTROL VOLUME REGULATED
AS TI DECREASES
Titotal will decrease and may decrease to the point where we are no longer meetign equilibrium before exhalation starts
Because Ti total is shorter it means that Te is longer, so I:E will decrease
As Ti decreases PIP will increase in order to deliver set Vt
Because the time that we are dleivering the pressure has decrease there will be a overall decreased in Pmean
Pressure Control
Compliance Increases
Vt will increase because we can increase the volume delivered at certain pressures, because Vt is changing MV will increase
Tidyn will increase and Tistatic will decrease, but Titotal will not change so I:E will not change
The change in Tidyn will increase flow and decrease Pmean
Pressure Control
Resistance Increases
The only thing that will change is that your Ti dyn will get longer
Remember as resistance increase your flow will decrease making a longer Ti dyn and a short Ti static
Mechanical Ventilation and BPD with a PDA
When there is a left to right shunt it can lead to chronic pulmonary edema (BPD) making the baby oxygen dependant
So when the baby cries it will create pressure in their lungs creating a right to left shunt which will decrease saturation, but as soon as the baby relaxes their saturations will improve
BPD AND OXYGENATION
Supplemental oxygen is the main therapy for infants with BPD but the appropriate target remains controversial
Oxygen saturations are accepted at 85-90% after preterm birth
Keep in mind though that patients with severe BPD usually are <36 weeks which is past the time when ROP is a major concern
For BPD, growth failure, respiratory exacerbations and PPHN however we accept saturations of 92-95%
Severe Refractory Hypoxemia in Neonates
PaO2 < 50mmHg despite CPAP and FiO2> 0.60
Silverman Index
The higher the silverman score the high the distress
Score 10=Severe respirtory distress
Score >/=7 Impending respirtroy failure
Score 0 No respirtory distress
Long Acting B2 Agonists (LABA)
Oxeze® (Formoterol)
Serevent® (Salmeterol)
Onbrez® (Indacaterol)
Streverdi® (Oladaterol)*Not on the market yet
LAMA/LABA
Ultibro® (Glycopyronnium/Indacaterol)
Anoro® (Umeclidinium/Vilanterol)
