Download - 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
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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”
Neonatal Touch & Massage Cer3fica3on By Crea3ve Therapy Consultants
Ann Davis, RRT-‐NPS Miami Valley Hospital
These Handouts are not intended to be used outside of NTMC On-‐Line Educa3on.
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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
Neonatal Touch & Massage Cer3fica3on By Crea3ve Therapy Consultants
Ann Davis, RRT-‐NPS Miami Valley Hospital
These Handouts are not intended to be used outside of NTMC On-‐Line Educa3on.
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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
Neonatal Touch & Massage Cer3fica3on By Crea3ve Therapy Consultants
Ann Davis, RRT-‐NPS Miami Valley Hospital
These Handouts are not intended to be used outside of NTMC On-‐Line Educa3on.
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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
Neonatal Touch & Massage Cer3fica3on By Crea3ve Therapy Consultants
Ann Davis, RRT-‐NPS Miami Valley Hospital
These Handouts are not intended to be used outside of NTMC On-‐Line Educa3on.
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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
Neonatal Touch & Massage Cer3fica3on By Crea3ve Therapy Consultants
Ann Davis, RRT-‐NPS Miami Valley Hospital
These Handouts are not intended to be used outside of NTMC On-‐Line Educa3on.
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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
Neonatal Touch & Massage Cer3fica3on By Crea3ve Therapy Consultants
Ann Davis, RRT-‐NPS Miami Valley Hospital
These Handouts are not intended to be used outside of NTMC On-‐Line Educa3on.
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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
Neonatal Touch & Massage Cer3fica3on By Crea3ve Therapy Consultants
Ann Davis, RRT-‐NPS Miami Valley Hospital
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NEUTRAL
FLEXION
EXTENSION
Neonatal Touch & Massage Cer3fica3on By Crea3ve Therapy Consultants
Ann Davis, RRT-‐NPS Miami Valley Hospital
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ETT POSITION OUTSIDE MOUTH INFLUENCES ETT WITHIN TRACHEA
ETT STRAIGHT OUT OF MOUTH, HEAD/BODY ALIGNED
Neonatal Touch & Massage Cer3fica3on By Crea3ve Therapy Consultants
Ann Davis, RRT-‐NPS Miami Valley Hospital
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ETT: INFANT SUPINE, HEAD TURNED TO SIDE
Cxr
ETT: INFANT PRONE, HEAD TO SIDE
Neonatal Touch & Massage Cer3fica3on By Crea3ve Therapy Consultants
Ann Davis, RRT-‐NPS Miami Valley Hospital
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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)
Neonatal Touch & Massage Cer3fica3on By Crea3ve Therapy Consultants
Ann Davis, RRT-‐NPS Miami Valley Hospital
These Handouts are not intended to be used outside of NTMC On-‐Line Educa3on.
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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
Neonatal Touch & Massage Cer3fica3on By Crea3ve Therapy Consultants
Ann Davis, RRT-‐NPS Miami Valley Hospital
These Handouts are not intended to be used outside of NTMC On-‐Line Educa3on.
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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
Neonatal Touch & Massage Cer3fica3on By Crea3ve Therapy Consultants
Ann Davis, RRT-‐NPS Miami Valley Hospital
These Handouts are not intended to be used outside of NTMC On-‐Line Educa3on.
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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
Neonatal Touch & Massage Cer3fica3on By Crea3ve Therapy Consultants
Ann Davis, RRT-‐NPS Miami Valley Hospital
These Handouts are not intended to be used outside of NTMC On-‐Line Educa3on.
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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)
Neonatal Touch & Massage Cer3fica3on By Crea3ve Therapy Consultants
Ann Davis, RRT-‐NPS Miami Valley Hospital
These Handouts are not intended to be used outside of NTMC On-‐Line Educa3on.
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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)
Neonatal Touch & Massage Cer3fica3on By Crea3ve Therapy Consultants
Ann Davis, RRT-‐NPS Miami Valley Hospital
These Handouts are not intended to be used outside of NTMC On-‐Line Educa3on.
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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
Neonatal Touch & Massage Cer3fica3on By Crea3ve Therapy Consultants
Ann Davis, RRT-‐NPS Miami Valley Hospital
These Handouts are not intended to be used outside of NTMC On-‐Line Educa3on.
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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