Neonatal Manual Ventilation Flashcards
What is the expected preductal SpO2 after 2 minutes of age?
65-70%
70-75%
75-80%
80-85%
65-70%
At the zero to one minute it is 60-65% preductal SpO2after that it will keep increasing by 5% up to 10 minutes.
see-saw breathing pattern
Normally the stomach and upper chest will be synchronized and move together.
Grade one on a Silverman score will show a lag of chest movement on inspiration.
Grade two Silverman score will show full see saw breathing where the chest and tummy are moving asynchronously.
This see-saw is a paradoxical inward movement of the chest wall and outward movement of the abdominal wall and is a sign of severe respiratory distress.
A normal term infant at 5 hours of age would have a base excess of:
-5
0
+4
-5
Babies when born will always be acidotic.
Which of the following is not associated with respiratory distress
Tachypnea
Grunting
Accessory Muscle Use
Cyanosis
Accessory Muscle Use
Babies will typically show respiratory distress through apnea, tachypnea, retractions, grunting, nasal flaring, stridor, and cyanosis
What flow rate should be used to provided PPV
10 lpm
15 lpm
20 lpm
Adequate to get pressure to the patient
10 lpm
Flow rates should be between 8-12
What rate should be used when providing PPV
Rate should be 20-25
What FiO2should be used when initially resuscitating a neonatal patient
- 21
- 40
- 60
- 0
0.21
You begin at 0.21 for PPV and then if increasing the pressure is not working you can increase FiO2 to 0.40. If that is still not working you can suggest intubation because the baby seem to be unable to oxygenate themselves. You will only increase FiO2 to 1.0 if the HR is less than 60 and you begin chest compressions.
What level of CPAP is recommended through the AHS algorithms for a neonate (type in number)
5
You being CPAP at 5 and if the baby is spontaneously breathing and has a HR greater than 100, but has a high WOB or SpO2 not within range you can increase CPAP by 1 but you cannot increase it any more than 1 as CPAP should not exceed a CPAP of 6
According to the AHS CPAP algorithms at what FiO2would you consider increasing the CPAP level
>0.5
>0.4
>0.3
>0.25
>0.3
At what HR would you consider moving from CPAP to PPV
90
110
170
210
90
If the baby has a HR of less than 100 or the baby is not spontaneously breathing on their own you can begin PPV.
When using a T-Piece what should the Ti be limited to?
0.5
Can free flow oxygen be delivered with a self inflated bag
Yes
What level of CPAP does the European Consensus Guidelines recommend for babies with moderate distress
4 cmH2O
5 cmH2O
6 cmH2O
8 cmH2O
6 cmH2O
Initial CPAP levels should be at 5 cmH2O and then if the baby is in distress than move the CPAP up to 6 (but not above 6)
What is the recommended SpO2 for newborns from the European Consensus Guidelines?
80-84%
85-89%
90-94%
95-99%
90-94%
What pressure should be used to begin PPV
You should being PPV with 20/5
What are NCPAP and SiPAP
Non-invasive support modes used to assit spontaneously breathing infants requiring respiratory assistance
Will be used to wither attempt to avoid mechanical ventilation or factiliate transition from mechanical ventilation to extubation
NCPAP and SiPAP decrease respiratory effort, facilitate the maintenance of Functional Residual Capacity (FRC), thereby facilitating oxygenation and ventilation, and the treatment of apneas and bradycardias.
How is positive pressure maintained with NCPAP and SiPAP
Positive pressure is maintained in the lungs due to the anatomic seal formed between the infant’s tongue and soft palate.
NCPAP and SiPAP Indications
- Moderate respiratory distress, with one or more of the following:• retractions
- Nasal flaring
- Grunting
- Increased oxygen requirements, by >5% from a stable clinical baseline
- Chest x-ray findings of decreased lung volumes and/or pulmonary infiltrates
- Post-extubation mode for all infants <33 weeks Corrected Gestational Age
- Apnea of prematurity
- Pulmonary Edema
- Patent Ductus Arteriosus with left to right shunting
- Congestive heart failure
NCPAP and SiPAP Relative Contraindications
- Upper airway abnormalities
- Severe cardiovascular instability
- Severe ventilatory impairment demonstrated on arterial blood gas results
- pH <7.25; PaCO2 >60mmHg; PaO2 <50mmHg with FiO2 > 60%
- Necrotizing enterocolitis
- Hyperinflation
- Pulmonary interstitial emphysema
- Congenital Cystic Adenomatoid Malformation
- Bronchial cysts
- Infants post bowel resection
NCPAP and SiPAP Absolute Contraindications
- Tension pneumothorax
- Congenital Diaphragmatic Hernia
- Tracheoesophageal fistual
- Gastroschisis
- Omphalocele
NCPAP and SiPAP Points of Emphasis
- De-recruitment of unstable alveoli occurs within a few breaths of the removal of positive airway pressure.
- Repetitive opening and closing of marginally recruited alveoli may produce damage by amplifying local stresses and inducing the release of inflammatory mediators, resulting in atelectotrauma.
- When non-invasive positive airway pressure is clinically indicated, all attempts ought to be made to ensure continuous delivery of NCPAP/SiPAP.
- Removal of the NCPAP/SiPAP interface ought to be considered equivalent to the disconnection of an intubated patient from the ventilator circuit.
- NCPAP/SiPAP apparatus should not be routinely removed for weighing infants.
- Iatrogenic injuries to the face and nose may occur with NCPAP/SiPAP administration, and may result in irreparable damage to nasal structures.
- When correctly applied these devices should provide a good seal without causing skin excoriation, pressure necrosis of the nasal tissue or pain.
- Careful placement and assessment are vital.
NCPAP and SiPAP
Clinical Practice Guidelines
- The decision to initiate NCPAP/SiPAP is made with input from the physician/Neonatal Nurse Practitioner (NNP), Registered Respiratory Therapist (RRT), bedside nurse and Nurse Clinician.
- All relevant clinical information available will be considered during the decision-making process, including a chest x-ray if appropriate.
- NCPAP/SiPAP requires an order by a physician/NNP prior to therapy initiation.
- NCPAP/SiPAP initiation will be performed by an RRT or supervised student RT.
NCPAP/SiPAP Marameter monitoring
- NCPAP/SiPAP parameter monitoring will be performed no less frequently than q6hrs by an RRT including:
- A visual inspection to verify appropriate placement of the patient interface
- Verification of appropriate delivery machine, settings, function and bedside placement.
- Confirmation of appropriate circuit functional status.
NCPAP SiPAP
Full Assessment
- Infants receiving NCPAP/SiPAP will undergo a full coordinated RN and RRT assessment a minimum of q8-12hrs or more frequently as appropriate based on the infant’s clinical status comprised of:
- Hat, straps, and nasal interfaces should be changed regularly, as stretching, infant edema and/or growth will impact proper fit and function.
- The interface is to be alternated between mask and prongs, or different mask sizes, with 8 hours being the maximum time without an interface change.
- Some infants (often less than 28 weeks) will require q2-4 changes to avoid skin breakdown.
Skin Integrity with NCPAP and SiPAP
Skin/tissue integrity will be evaluated at all points of contact with the delivery interface, hat, and straps. Excessive pressure is the primary cause of skin breakdown. Assessment findings that may indicate excessive pressure include:
- Nasal blanching at the side on nares– prongs may be too large for the size of nares
- Blanching on the bridge of the nose as the straps may be too tight
- Crease present on dorsum of the nose while on device and may persist when device removed – device is causing nose to deviate upward
- Redness of skin in contact with device or visible skin breakdown – straps may be too tight
- Periorbital edema – straps may be too tight.
What is Appropriate Skin Care for NCPAP and SiPAP
- Massaging of skin at points of contact with the delivery interface, hat, and straps.
- If signs of excessive pressure are present, straps should be loosened, correct hat placement should be reviewed, and size of nasal prongs assessed.
- If skin reddened, consider a skin barrier such as Duoderm.
- If skin breakdown is present, consult physician/NNP for care management.
NCPAP and SiPAP
Installation and Suctioning
- Routine instillation and suctioning of nares is not recommended; nasal suctioning will be performed as indicated using a nasal aspirator if possible.
- Infants on NCPAP/SiPAP must be frequently assessed to ensure a clear airway is maintained.
- Gentle nasal or oral suctioning should be considered with each assessment.
NCPAP/SiPAP seal
- “Treat the NCPAP/SiPAP seal like an endotracheal tube” and maintain uninterrupted NCPAP throughout the assessment.
- NCPAP/SiPAP delivery should only be interrupted (for no more than three infant breaths) when direct access to nares is required (ie. during nasal suctioning).
