Respiratory Care: Going to New Heights

Suzanne Iniguez BSN, RN, RRT-NPS-ACCS, AE-C, C-NPT, CHSE

Respiratory Care

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Oxygen

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Thanks for Playing

Bubble CPAP

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Ventilation

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Scenarios

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Que

stion

Premature infants who exhibit good respiratory effort at birth should be placed on what immediately?

Que

stion

CPAP (Continuous Positive Airway Pressure)

Que

stion

Why do we use BCPAP?

Ans

wer CPAP increases FRC (Functional

Residual Capacity) and decreases WOB (Work of Breathing)

Que

stion

What is the time frame in which to receive early surfactant?

Que

stion

Within the first 2 hours of life?

Que

stion

How do we deliver surfactant?

Que

stion § 5F MAC needed to administer Curosurf.

§ Pt. can be given Curosurf while on ventilator or while manually bagging.

§ MAC can be saved for repeat dosing if needed.

Que

stion

What is the dose for surfactant?

Ans

wer Depends on the brand that you use –

Curosurf Dosing

Initial Dose 2.5ml/kg

Second dose in 12 hours1.25ml/kg

Third dose 12 hours later 1.25ml/kg

Que

stion

When intubated what is the preferred mode of ventilation?

Ans

wer

Volume Guarantee (VG) VentilationAssist Control – Volume Guarantee (AC-VG)SIMV – Volume Guarantee (SIMV-VG)

Que

stion

How many mls do we target for Vt ?

Que

stion

Vt Target 4.5 – 6.0 mls/Kg

Que

stion

What is the volume of an infant manual resuscitator?

Ans

wer

250mls

Que

stion

If a patient fails conventional ventilation what ventilator do they go to next?

Que

stion - High Frequency Oscillator Ventilation

(HFOV)

Que

stion What is different about the

oscillator when compared to other ventilators?

Que

stion

The oscillator has active inspiration and exhalation.

Conventional ventilation has passive exhalation.

Que

stion

If you want to increase oxygenation on the oscillator what are 2 parameters that you can change?

Que

stion

1. FiO22. MAP (Mean Airway Pressure)

Que

stion

If you want to decrease CO2 on the oscillator what are 2 parameters that you can change?

Que

stion

1. Amplitude (Delta pressure)2. Hz (the rate)

Que

stion

To decrease the CO2 do I turn the Hz up or down?

Ans

wer You turn the Hz down to blow off more

CO2

Que

stion

What is the Targeted Oxygen Saturation Range in your NICU?

Ans

wer

Your NICU?

My NICU is 90 to 95%With alarms set at 88 – 96%

Que

stion

What is the easiest way to provide low flow supplemental oxygen?

Ans

wer A simple Nasal Cannula

Que

stion

Where do you measure a Pre-Ductal Oxygen saturation?

Que

stion

On the right wrist/hand

Que

stion

A difference between the pre-ductal and the post-ductal saturation may be indicative of?

Ans

wer

Pulmonary Hypertension

Que

stion

What gas can we deliver to the patient to treat pulmonary hypertension?

Ans

wer

Inhaled Nitric Oxide (iNO)

Que

stion

What are the 3 components of BCPAP?

Ans

wer What are the 3 components of BCPAP

- Circuit

- Interface

- Pressure Generator

Que

stion

When checking BCPAP what do you look at?

Que

stion When checking BCPAP

- Look for appropriate sized prongs/mask- Ensure a cushion of air with prongs/barrier with

mask- Assess the skin- Is a chin strap needed- Is there bubbling (Suzanne’s 5 Types of Bubbling)- Check flowrate- Check FiO2- Check CPAP pressure- Does the infant need suctioning

Ans

wer What, What!!

Suzanne’s 5 Rules of Bubbling!

Que

stion

What do you use to suction an infant on BCPAP; and how far do you go?

Ans

wer 8Fr suction catheter

Measure from the nose to the ear X 1.5

Que

stion

What can you tell me about this CPAP set up?

Ans

wer • The mask is gently

contouring to the infant’s face• Side attachments are

loosely secured• ‘Trunk’ is parallel to the

face• Velcro over the ‘trunk’

is not pulled tight

Que

stion

What is the most important thing to help prevent a HAPI (Hospital Acquired Pressure Injury) with CPAP?

Que

stion

YOU!!!!!

Ans

wer

Que

stion

What is the calculation that we use to determine approximate ETT depth?

Que

stion

Weight in Kg + 6 = approximate ETT depth

Que

stion

What landmark do we use to determine where the ETT is secured?

Que

stion

The LIP

Que

stion

What is a great position for the ETT?

Que

stion

T3 to T4

Que

stion

Ans

wer

Que

stion

What are some common modes of ventilation?

Ans

wer

AC VG – Assist Control Volume Guarantee Settings - Rate, Vt, Ti, PEEP, P Max

SIMV VG – Synchronized Intermittent Mandatory Ventilation Volume GuaranteeSettings – Rate, Vt, Ti, PEEP, P Max

AC PC – Assist Control Pressure ControlSettings – Rate, PIP/PEEP, Ti

SIMV PC - Synchronized Intermittent Mandatory Ventilation Pressure ControlSettings – Rate, PIP/PEEP, Ti

Que

stion

What is a benefit of using VG mode after dosing with surfactant?

Ans

wer Variation in PIP with VG

Que

stion

What are some of the benefits of Kangaroo Care?

Que

stion

- Physiologic stability (temperature and blood pressure regulation, heart rate and respiratory stability)- Brain, cognitive and motor development.- Improved immune system function.- Weight gain.- Better, deep sleep.- Greater bonding with decrease in stress and crying.

Que

stion

Can an intubated infant participate in Kangaroo Care?

Ans

wer

Yes!

Que

stion

What is the Gold Standard for confirmation of ETT position?

Que

stion

A Chest X-Ray

Que

stion

How does the head movement in these three positions effect the depth of the ETT?

Ans

wer

Reference: Donn, SM and Kuhns LR. Mechanism of Endotracheal Tube Movement with Change of Head Position in the Neonate. Pediatric Radiology 9, 37-40, 1980.

Que

stion

You have been called to a delivery of a term infant there is thick meconium.What do you need to consider for this infant’s delivery?

Que

stion

All meconium stained infants receive warm, dry and stimulate- Then reassess

Que

stion

Where do we set the suction pressure?

Ans

wer Where do we set the suction pressure?

Suction pressure is set at -80 to -100 mmHg

Que

stion You have been called to a delivery of a

term infant of a diabetic mom, the OB is anticipating a large infant.What do you need to consider for this infant’s delivery?

Que

stion A consideration for a large infant is shoulder dystocia

Que

stion Forceps delivery

Que

stion

Ans

wer

Que

stion You have been called to a delivery

of a 28 week gestation infant.What do you need to consider for this infant’s delivery?

Que

stion If the infant has good tone and

respiratory effort – consider providing CPAP

Ans

wer If the infant has poor tone and little

respiratory effort consider –- Intubation- Dosing with surfactant- Evaluate for extubation- Remaining intubated and positive

pressure ventilation

Que

stion You have been called to a delivery of a

term infant that is experiencing decels.What do you need to consider for this infant’s delivery?

Que

stion Possible nuchal cord, possibility of

an hypoxic event

Ans

wer

Hypoxic Ischemic Encephalopathy

Perinatal asphyxia, more appropriately known as hypoxic-ischemic encephalopathy (HIE), is characterized by clinical and laboratory evidence of acute or subacute brain injury due to asphyxia.

The primary causes of this condition are systemic hypoxemia and/or reduced cerebral blood flow (CBF).

Consider passive cooling and transfer to a center that can perform cooling.

Que

stion You have been called to a delivery of

an infant whose mother presented to triage with bright red bleeding.What do you need to consider for this infant’s delivery?

Ans

wer Anticipate a depressed infant that

may be in need of resuscitation

- Intubation- PPV- Lines placed- Fluid resuscitation