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Neonatal Ventilation

Made Easy

Published by Jitendar P Vij Jaypee Brothers Medical Publishers (P) Ltd B-3 EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi 110 002, India Phones: +91-11-23272143, +91-11-23272703, +91-11- +91-11-23245672, Rel: +91-11-32558559 Fax: +91-11-23276490, +91-11- 23245683 e-mail: [email protected], Visit our website: www.jaypeebrothers.com Branches  2/B, Akruti Society, Jodhpur Gam Road Satellite Ahmedabad 380 015 Phones: +91-79-26926233, Rel: +91-79- Fax: +91-79-26927094 e-mail: [email protected]  202 Batavia Chambers, 8 Kumara Krupa Road, Kumara Park East Bengaluru 560 001 Phones: +91-80-22285971, +91-80-22382956, +91-080-22372664, Rel: +91-80-32714073 Fax: +91-80- e-mail: [email protected]  282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza, Pantheon Road Chennai 600 008, Phones: +91-44-28193265, +91-44- Rel: +91-44-32972089 Fax: +91-44- e-mail:[email protected]  4-2-1067/1-3, 1st Floor, Balaji Building, Ramkote, Cross Road Hyderabad 500 095 Phones: +91-40-66610020, +91-40- Rel: +91-40-32940929 Fax:+91-40-24758499, e-mail: [email protected]  Kuruvi Building, 1st Floor, Plot/Door No. 41/3098, B & B1, St. Vincent Road Kochi 682 018 Kerala Phones: +91-484-4036109, +91-484- +91-484-2395740 e-mail: [email protected]  1-A Indian Mirror Street, Wellington Square Kolkata 700 013 Phones: +91-33-22651926, +91-33-22276404, +91-33-22276415, Rel: +91-33-32901926 Fax: +91-33- e-mail: [email protected]  106 Amit Industrial Estate, 61 Dr SS Rao Road, Near MGM Hospital, Parel Mumbai 400 012 Phones: +91-22-24124863, +91-22- Rel: +91-22-32926896 Fax: +91-22- e-mail: [email protected]  “KAMALPUSHPA” 38, Reshimbag, Opp. Mohota Science College, Umred Road Nagpur 440 009 Phone: Rel: +91-712-3245220, Fax: +91-712- e-mail: [email protected] Neonatal Ventilation Made Easy © 2007, Sujoy Chakravarty All rights reserved. No part of this publication and interactive DVD Rom should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.

This book has been published in good faith that the material provided by author is original. Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.

First Edition: 2007 ISBN 81-8448-165- Typeset at JPBMP typesetting unit Printed at Gopsons Papers Ltd, Sector 60, Noida

dedicated to

Soumil and

Swapnil

Foreword

It is a pride and pleasure for me to introduce Dr Sujoy Chakravarty, my ex-student for his outstanding and challenging contribution in writing this book on neonatal ventilation. This book is intended for postgraduate trainees, junior doctors and medical personnel involved in level I, II, and III care of children in neonatal resuscitation unit. Respiratory distress and/or failure is the common cause of pulmonary arrest in neonates which may be due to hypoventilation, diffusion mismatch, intrapulmonary shunting. All these disturbances may finally lead to respiratory arrest calling for ventilatory support. The two forms of ventilation practiced in NICU are—pressure controlled and volume controlled types—both discussed in this book. The author has also discussed some common pulmonary and extra pulmonary conditions frequently encountered in daily neonatal practice. I again congratulate this young doctor for his sound knowledge and expertise with a bold attempt in discussing neonatal ventilation in a concise and yet such user friendly form. I sincerely wish this book will be of true help to all concerned and hope he will go a long way in Pediatric Academy.

Prof (Dr) Manas Mukherjee Ex-President Indian Academy of Pediatrics Ex-Head of the Department of Pediatrics, NRS Medical College, Kolkata

Acknowledgements

I would like to thank my parents, my family for their constant inspiration and support. Also I would like to thank all my teachers and colleagues in neonatal units from whom I have learnt the ABC of Neonatology. My special thanks to Dr Rashmi Gandhi without whose help this book would not have seen the light of the day. I would like to extend my sincere thanks to the publishers, and in particular to Mr Sabyasachi Hazra and Mr Sandip Gupta for their tireless work and tenacity in getting this book published.

Contents

• 1. Newborn Life Support
• 2. Formulas Commonly Used in NICU
  • 3. Acid-Base Balance
  • 4. Continuous Positive Airway Pressure (CPAP)
    • Introduction and Terminologies 5. Positive Pressure Ventilation—
    • Ventilation 6. Different Modes of Positive Pressure
    • Blood Gas Changes 7. Ventilatory Adjustments According to
  • 8. Volume Controlled Ventilation
  • 9. High Frequency Ventilation
• 10. Nitric Oxide
      • (ECMO) 11. Extra Corporeal Membrane Oxygenation
• 12. Respiratory Distress Syndrome
• 13. Chronic Lung Disease
• 14. Meconium Aspiration Syndrome
• 15. Transient Tachypnoea of Newborn
• 16. Collapse of a Baby on Ventilator
• 17. Necrotising Enterocolitis

xiv NEONATAL VENTILATION MADE EASY

**18. Jaundice ...................................................................... 65

19. Neonatal Feeding—Difficulties ............................. 69
20. Neonatal Vomiting—Common Causes ................ 71
21. Anaemia in Neonates .............................................. 73
22. Hypoxic Ischaemic Encephalopathy (HIE) .......... 75
23. Intraventricular Haemorrhage and Periventricular** **Leucomalacia ............................................................ 77
24. Persistent Pulmonary Hypertension of the** **Newborn (Persistent Foetal Circulation) .............. 79
25. Sepsis in Neonates ................................................... 81
26. Tit-Bits ........................................................................ 85
27. Neonatal Formulary (Commonly used** Medications) .............................................................. 89

Index ............................................................................ 91

2 NEONATAL VENTILATION MADE EASY

The care of the newborn in the first few minutes after birth is extremely crucial with regards to the subsequent flow of events. The foetus was in a nice and warm atmosphere inside the womb requiring no effort to breathe and not having to worry about its nutrition as well. As soon as the cord is severed the newborn baby has to find ways of independent existence.

RESUSCITATION AT BIRTH

Preparation

It is always useful to reach for the delivery with a few minutes to spare (absolute necessity for preterm labours). A brief maternal history is to be taken and all equipments (the overhead heater, the laryngoscope, the suction apparatus, appropriate masks, proper size ET tube) to be checked. Few dry towels should always be available.

Collecting the Baby

After the baby is born and cord is clamped the baby should be collected in a dry and clean towel. In case of extreme prematurity, babies are put in a plastic bag immediately after birth to minimize further chances of heat loss.

In the Resuscitaire

1. Start the clock.
2. Dry the baby and transfer to a fresh and warm towel.
3. Keeping the baby covered feel or listen for the heart beat. (Heart rate can be felt by palpating the umbilical cord) Also assess the respiratory effort, colour and tone of the baby.
4. If the heart rate is > 100 and regular , all the baby might need is gentle stimulation and the doctor’s patience.

NEWBORN LIFE SUPPORT 3

5. If the heart rate is slow (< 80), the baby will need stimulation by inflation breaths with a mask. Before doing that it is important to check for the patency of the airway. Blind suction is strongly discouraged. Sometimes simple airway opening manoeuvres, e.g. head tilt and chin lift or jaw thrust might do the trick and the condition of the baby might improve.
6. If these doesn’t work and after airway is reassessed 5 inflation breaths are given and each breath should ideally last for about 2 seconds. These breaths are given with the aim to displace as much lung fluids as possible. The inflation breaths should measure about 30 cm H 2 O pressure. The important point to note here is the chest movement with the inflation breaths_. If the chest is not_ moving then airway needs to be reassessed again. If the chest rises with each breath, the baby is examined after the 5 breaths. If by this time the heart rate has improved and the baby is making spontaneous efforts to breathe, masterly inactivity is what might be needed at this stage. If heart rate has improved but the breathing is still not satisfactory, ventilation breaths might be needed till the baby establishes regular and spontaneous breathing. The ventilation breaths are of much shorter duration compared to the inflation breaths.
7. If above methods have failed and the baby is still bradycardiac with a very poor tone, the baby needs intubation for a definite and a secure airway. If intubation is difficult ( not possible within 30 seconds, i.e. one attempt) revert to bag and mask ventilation and ask for help. (According to Scandinavian studies 1 in 500 babies only need intubation). Once the ET tube is in place and secured continue ventilation and reassess the heart rate. If the heart rate is still low start cardiac compression ( 3:1 ) with one hand or two hand technique. If there is no improvement in heart rate

Chapter 2

Formulas

Commonly Used in NICU

6 NEONATAL VENTILATION MADE EASY

1. Size of ET tube —Gestation/10 (a baby of 25 weeks gestation needs a 2.5 mm size tube).
2. Length of ET tube—6 + weight of baby.
3. Umbilical artery catheter —Birth weight (in kg) × 3 + 9 cm. For term babies a length of 16-17 cm suffice. For preterms 10-12 cm should be sufficient.
4. Umbilical venous catheter —1.5 × Birth weight (in kg)
   • 5.5 cm. For term babies a length of 10 cm suffice. For preterms 5 cm should be sufficient.
5. Half correction of bicarbonate—0.3 × weight (in kg) × base deficit (over 2 hours).
6. Dilutional (Partial) exchange transfusion—(Desired HB-Current HB) × Blood volume/Current Haematocrit.
7. Blood transfusion (Packed cells) —15 ml/kg or (Desired Hb-Current Hb) × weight × 4.
8. Sodium requirement for neonates—3 mmol/kg (Add in 500 ml of 10% Dextrose).
9. Potassium requirement—2 mmol/kg (Add in 500 ml of 10% Dextrose).
10. Calcium requirement—1 mmol/kg (Add in 500 ml of 10% Dextrose). Accepted position of catheters:

• UVC—T-
• UAC—T6-T
• Long line tip (upper arms)—T
• Long line tip (lower limbs) —T9-T