Test 2 Flashcards
Signs of Hypoxia
Grunting, Nasal Flaring, and Cyanosis
Oxygenation in the neonate/ pediatric
Neonate, PaO2= 60mmHg, SaO2= 90% (100 or higher PaO2 risk of blindness)
Pediatrics, PaO2= 80-100mmHg, SaO2= 95%-99%
When Hypoxia present SpO2 and PaO2 acceptable range
SpO2 88-95%, PaO2 50-80mmHg
Hazards of O2 Therapy (neonate)
+Retinopathy of prematurity (ROP) from high PaO2
+Atelectasis-absorption atelectasis-frigh high FiO2-Nitrogen washout
+Pulmonary vasodilation : V/Q mismatch
+O2 toxicity (pulm fibrosis) from high FiO2: stiffens lungs
best choice for long term low flow O2 Delivery
Cannula- be careful of necrosis
Usually tolerated well (tape to face, ears cant hold)
Cannula Flow
Flowmeters (0.1 to 3lpm) Max 5
Blenders to adjust FiO2-NICU precise FiO2
Disadvantages of Cannula
Inadvertent CPAP (can be advantage) Dries nasal mucosal Inaccurate FiO2 varies with patients : Resp pattern (RR, Flow rate), Size, age.
High flow nasal cannula
Heated and humidified, Reduces upper airway drying out, Equipment: blender, Heated Humidifier, Special Cannula
Face Masks
Usually tolerated poorly by conscious infants and children,
For moderate FiO2s
More control of FiO2
All Varieties available: Non-rebreathing, simple, Venturi (air entrainment)
Air Entrainment Nebulizer
Need high moisture, Need precise FiO2
Heat and humidity for application to artificial airway
Heat when applying to infants
Devices: Aerosol mask, trach collar, face tent, hood, tpiece
Best choice for controlled FiO2
Hood
- Oxygen must be heated and humidified
- Mixed gases may be supplied by a blender and either a heated humidifier or heated aerosol
Hood -Mixed gases may be supplied by a blender and either a heated humidifier or heated aerosol
- blender is quiet and accurate
- Heated neb on 100% with blender to adjust FiO2, cuts down on noise
- Heated humidifier most efficient
- Must have enough flow to flush through the system
Analyze O2 in hood where
as near to pt mouth as possible, dont keep analyzer in all the time due to moisture
Isolatte
Oxygen must be warmed and humidified. Oxygen analyzer near patients head.
FiO2 of 25-30% or less
Resuscitation bags
+Self inflating, use reservoir-mostly neo
+Flow-inflating- no valves
+Always have a manometer in line, dont want too much pressure-> barotrauma
Aerosolized drug therapy
Small volume neb (SVN)
Metered dose inhaler (MDI)- via Mask CHAMBER
Dry Powder Inhaler (DPI) - Older kids
Small Particle Aerosol Generator (SPAG)- Riboviran
Types of nebs
Jet nebulizer (most common) Ultra Sonic - break up particles Mesh nebulizer- Electronic, vent or home use
Neb inline with vent
Adds Vt if run off different source (electronic preferred)
Increases Peak pressure on volume vent. !!
Pressure vent. will still only reach preset pressure
Add near humidifier and neb on exhalation, fills the inspiratory limb
Cool gas to run neb cools down gas and causes more rainout, losing meds to rainout
Intermittent vs Continuous neb
up to Q15 min treatments until relief
continuous neb, between 7.5mg to 15 mg per hour
-need special neb (Heart or hope)
-Must have continous heart monitoring
No Aerosols on
Asthmatics except neb
Undiluted Albuteral
Continuous neb.. Asthmatic in crisis, Nebulize 1-2ml (5-10mg Continuous monitoring (heart rate increases affects electrolyte K+, kids self regulate dose to size 10%)
DPI flow rate
Each DPI is different
Need flow rate of 30-60 lmp
Cough techniques (most effective)
Forced Expiration Technique (FET) “huff cough”
Autogenic Drainage: CF pt very focused and difficult-> partial breath repeat cough
Positive Expiratory Pressure (PEP) technique
EzPAP
Flutter Valve-certain angle
Acapella
Metaneb
Cough Assist Technique
Insufflator-exsufflator
Manual Rib cage compressions
Quad Cough-push on ab
Procedure before and after airway clearance techniques
Auscultation, Postural drainage, Percussion, vibration, removal of secretions (cough) (can increase ICP if head down), reapeat auscultation
Hyperinflation Therapy
IS-Cant hold up head, cant see, cant 10ml/kg IBW
IPPB- Cant cooperate
Mask CPAP-last resort, atelectasis
Indication for intubation
Pulmonary function (disease)-Lung not working Provide an airway (obstruction)- Epiglotitis Protect the airway (aspiration) Pulmonary hygiene (Secretion removal)
ETT
1cm markings, standard 15mm adaptor, 2.5-10size range (may have size 2) ID=(age / 4) + 4 Adult size at 12-14 years, F 7-8.5, M 8-10
Cuffed vs. Uncuffed
Up to practitioner, all sizes except 2.5 come with cuffs or without, all cuffed at 5.5
LMA
Used in surgery, covers throat opening, back up airway for difficult intubations, short term ventilation, low pressure ventilation (no High)
Suction
Yankauer (tonsil tip) Catheters etc Peds sx 80-100 infants 60-80 Adults 100-120
Intubation Procedures
\+Orotracheal -Sniffing Position, do not over extend -Preoxygenate -30sec max -Co2 detector(only work with BF) -Auscultate -Direct visualization(watch two cords) -CXR \+Nasotracheal -One size smaller than oral -Magill forceps \+blind (DONT DO)
withdrawal ETT tube when
during manual inspiration at peak if possible. Complications after extubation: Sore throat, Hoarseness, Edema: leading to stridor- treat with racemic epi, steroids, heliox
when to trach
Airway obstruction (congenital) long term vent Pulmonary hygiene
IRDS can develop
bronchopulmonarydysplasia
Complications of tracheostomy
Most common leading to death -Plugging of airway with mucous: keep air moist -Accidental decannulation Others -Bleeding -granulation -erosion -Tracheomalacia -Speech and phonation (passy muir) -Swallowing
catheter size for suctioning
1/2 the ID of tube
Preoxygenate
10-20% higher or 100 if needed, manually ventilate using same peak pressures and PEEP
Lavage Controversial
NaCL
Use small amounts, 0.5 to 1ml for neonates
Surfactant agents
Surface-active agents that lower surface tension
-Surface tension is the force caused by attraction between like molecules that occurs at liquid-gas interfaces and that hold the liquid surface intact (measure in dynes per centimeter)
Two types of surface tension in the lung
- Surface tension of pulmonary edema, you want to decrease the tension to break the bubble
- Pulmonating P.E : pink frothy secretions overload - Force in the alveoli that pulls them in, you want to decrease the tension of the alveoli to prevent collapse
Surfactant is produced by
Type II alveoli cells: 26weeks
90-95% is reabsorbed by the Type II cells and recycled
Surfactants does what
regulates the surface tension forces of the liquid alveolar lining.
Lowers surface tension as it is compressed during expiration, thus, reducing the amount of pressure and inspiratory effort needed to re-expand the alveoli during inspiration
Surfactant is composed of
lipids and proteins
- 90% lipids: 90% of lipids are phospholipids. About 50% of phospholipids are DPPC, aka lecithin, primary component component responsible for reducing tension
- 10% proteins: Serum proteins, surfactant specific protein (SP-A, SP-B, SP-C, SP-D)
Exogenous means
surfactant produced outside of the body
- places surfactant in the lungs of premature babies born before the type II alveoli cells are able to produce their own
- Once the surfactant is in the alveoli it will be reabsorbed by the type II alveoli cells and they will start producing their own
Types of Surfactant
- Natural/ modified: from natural sources (human or animal) with addition or removal of substances. Advantage of being natural and having the needed lipids, disadvantages risk of contamination (i.e. passing on a virus)
- Synthetic: Prepared by mixing in vitro synthesized substances which may or may not be in natural surfactant. Advantage of not causing contamination but does not have as many of the needed lipids.
Indications for Surfactant
- Prophylactic in infants less than 1250g birth weight (29 weeks)
- Prophylactic in infants more than 1250g birth weight but have signs of pulmonary immaturity or RDS (over 29weeks)
Rescue
in infants that have developed RDS less than 72 hour from onset
Surfactant Brands
Survanta (Beractant)
Infasurf (calfactant)
Curosurf (portactant)
Exosurf (colfosceril)
Surfanta
Beractant
-Modified natural, made from bovine (cow)lungs, has proteins and DPPC added
-Dose, 100mg/kg , repeat no sooner than 6 hours if needed
-Direct tracheal instillation via ETT tube
+administer via 5fr catheter placed in ETT
+split into 4 doses, bag pt after each dose for at least 30 sec (1/4 dose-bag- 1/4 dose)
Infasurf
Calfactant
-Modified natural, from bovine lungs, lipids and proteins
-Dose, 3ml/kg up to 3 doses 6-12 hours apart
-Direct instillation via ETT
+side port, slowly instill half dose with pt on right side, repeat on left side
+Catheter, give 4 doses one each -supine, prone, right, and left, pace on MV in between
Curosurf
Portactant
-Natural from porcine (pig) lungs, lipids and proteins
-Dose, 2.5 ml/kg , 1.25 ml/kg second and third dose 12 hours later if needed
-Direct instillation via ETT
+two doses through catheter one with pt on each side
+bag or MV in between
Exosurf
Colfosceril
-Synthetic surfactant
Hazards and complications of surfactant
-Airway occlusion from liquid reading to desaturation and bradycardia
-As drug works and lungs improve the infant may become over ventilated
+increased PaO2
+Increased Volumes and barotrauma
-Apnea
-pulmonary hemorrhage in infants less than 700mg (bleeding in lungs, not much you can do)
-Cerebral Hemmorage (brain bleed, nothing you can do)
Nitric Oxide (NO) (blue tank)
Laughing gas
- Normally produced by all cells
- Vasodilation of pulmonary vascular bed
- better perfusion
Inhaled iNO preferred because
Preferred because the NO only gets to the blood vessels that are connected to open alveoli therefore dilating only blood vessels that can pick up O2. Moves more air past ventilating alveoli
Nitric oxide used when
Hypoxic resp failure of newborn (pulonary hypertension of newborn) near or full term
ARDS, not shown to work in adults possible in children in combination with HFV: want to open up alveoli and better BF that are working
Nitric Oxide Titrate into vent circuit via a specialty machine
Starting dose anywhere from 1-80ppm
recommended start from .gov 18ppm
Complication NO
Nitrogen Dioxide (NO2)
- byproduct of NO and O2
-Toxic to pt and health care providers
-add NO gas right before the wye so less time to mix
-Scavenge the exhaled gas-sucks up gases
(can cause) Methemoglobin
-can combine with hemoglobin decreasing O2 carrying capacity
Helium-oxygen (heliox)
- Inert gas
- lighter gas gets around obstruction better
- Non rebreather (venti mask)
- vent circuit
- Deliver aerosol medications (asthmatics)
Flow meters
H:O2
80:20 multiply flow rate by 1.8
70:30 multiply flow rate by 1.6
or just keep bag inflated on NRB
To lower FiO2 less than 0.21
use CO2 or N2
Bronchodilators
Beta agonist
Anticholinergic
Beta Agonist
- Beta II agonist
- Beta Adrenergic
- Sympathomimetic
Sympathomimetic
- Albertal and levalbuterol
- Racemic Epi for croup and Epiglottitis
Albuterol and levalbuterol
Usually use regular unit dose unless child is less than one year old, even then many time use full dose
Racemic epi for croup and epiglottitis
Officially you are not suppose to give for epiglottitis, the child needs to go to surgery for intubation
Anticholinergic
Parasympatholytics
Atrovent- remember not to use Atrovent on an asthmatic with allergies to peanuts
Antiinflammatory
Corticosteroids
Cromolyn Sodium/ Nedocromyl Sodium
Corticosteroids
Inhaled steroids- still controversial, many practitioners do not like to use on kids. Will try intal, oral anti-inflammatory, and/ or theophylline
Cromolyn Sodium/ Nedocromyl Sodium
inhaled for asthma, maintenance drug, don not give in acute situation. Mast cell stabilizer stops the allergic reaction from getting started
Mucolytics
Mucomyst
Pulmozyme
Antibiotics/ Antiviral
Tobramycin
Pentamidine
Ribaviron
Systemic drugs
Steroids, Leukotrienes, Methylxanthines, Magnesium Sulfate VI
Steroids
Solumedrol, IV
Prednisone, Oral
Decadron, IV
Methylxanthines
Theophyline
Magnesium Sulfate, IV
Promotes bronchodilation in asthmatic children
RespiGam and Synagis
Prevent RSV
Omalizumab
Reduce inflammation in asthma
nose breathers wks
6-8 weeks obligated nose breathers
Nasotracheal watch for
Vagal stimulation (bradycardia)-not just carina: can happen b4
