Management during neonatal ventilation

Mohamed KhashabaMohamed KhashabaProfessor of Pediatrics, Professor of Pediatrics,

NeonatologyNeonatologyHead of NICUHead of NICU

Mansoura Faculty of MedicineMansoura Faculty of Medicine

Care of Ventilated BabyCare of Ventilated Baby

Prof. M Khashaba,MDProf. M Khashaba,MD 11

Management Management considerationsconsiderations

1.1. Accept suboptimal ABG and pH.Accept suboptimal ABG and pH.

2.2. Raise HcT.Raise HcT.

3.3. Reposition the baby.Reposition the baby.

4.4. Change ETT to a larger size.Change ETT to a larger size.

5.5. Suctioning.Suctioning.

6.6. Infection control.Infection control.

7.7. Consider diuretics.Consider diuretics.

8.8. Drugs. Drugs.

9.9. Nutrition.Nutrition.

10.10. Consider EchocardiographyConsider Echocardiography..Prof. M Khashaba,MDProf. M Khashaba,MD 22









8.8. Drugs.Drugs.



Clinical applicationsClinical applications

Accept modest hypercarpia (50 -55 Accept modest hypercarpia (50 -55

mmHg) if modest changes are mmHg) if modest changes are

unsuccessful.unsuccessful.

Avoid high PiP > 30 unless Avoid high PiP > 30 unless

manipulation of other variables fail.manipulation of other variables fail.



1.1. Accept suboptimal ABG and pH.Accept suboptimal ABG and pH.2.2. Raise HcT.Raise HcT.3.3. Reposition the baby.Reposition the baby.4.4. Change ETT to a larger size.Change ETT to a larger size.5.5. Suctioning.Suctioning.6.6. Infection control.Infection control.7.7. Consider diuretics.Consider diuretics.8.8. Drugs.Drugs. 9.9. Nutrition.Nutrition.10.10. Consider EchocardiographyConsider Echocardiography..


OO22 Transport to Transport to TissuesTissues

Depends uponDepends upon

1.1. OO22 carrying capacity of blood. carrying capacity of blood.

2.2. Rate of blood flow.Rate of blood flow.


CaOCaO22 = = HB x 1.34 xSaO HB x 1.34 xSaO22 + 0.003x PaO + 0.003x PaO22..

Optimal HcT is 45 % or Hb 13 -16 Optimal HcT is 45 % or Hb 13 -16

gm/dl.gm/dl.


Clinical applicationsClinical applications

Rise of Hb by packed cell Rise of Hb by packed cell

transfusion is more effective in transfusion is more effective in

improving tissue oxygen than raising improving tissue oxygen than raising

FiO2.FiO2.


Oxygen is more readily released to the tissues with Oxygen is more readily released to the tissues with acidosis, increased body temperature, increased acidosis, increased body temperature, increased PaCOPaCO22, and increased 2,3-DPG levels, and increased 2,3-DPG levels..

Oxygen is less available to the tissues in alkalosis, Oxygen is less available to the tissues in alkalosis, hypothermia, decreased PaCOhypothermia, decreased PaCO22, and decreased , and decreased

2,3-DPG2,3-DPG. .


1.1. Accept suboptimal ABG and pH.Accept suboptimal ABG and pH.2.2. Raise HcT.Raise HcT.3.3. Reposition the baby. Reposition the baby. 4.4. Change ETT to a larger size.Change ETT to a larger size.5.5. Suctioning.Suctioning.6.6. Infection control.Infection control.7.7. Consider diuretics.Consider diuretics.8.8. Drugs.Drugs. 9.9. Nutrition.Nutrition.10.10.Consider Echocardiography.Consider Echocardiography.


PositioningPositioning

1.1. Prone position alters physiologyProne position alters physiology

improves compliance , oxygenation, improves compliance , oxygenation,

Wagaman et al 1979Wagaman et al 1979..

2.2. Avoid abdominal distensionAvoid abdominal distension

3.3. Reduces energy requirements.Reduces energy requirements.

4.4. Allow ventilation of dependant areas.Allow ventilation of dependant areas.Prof. M Khashaba,MDProf. M Khashaba,MD 1111


1.1. Accept suboptimal ABG and pH.Accept suboptimal ABG and pH.2.2. Raise HcT.Raise HcT.3.3. Reposition the baby.Reposition the baby.4.4. Change ETT to a larger size.Change ETT to a larger size.5.5. Suctioning.Suctioning.6.6. Infection control.Infection control.7.7. Consider diuretics.Consider diuretics.8.8. Vasopressors.Vasopressors.9.9. Nutrition.Nutrition.10.10. Consider EchocardiographyConsider Echocardiography..Prof. M Khashaba,MDProf. M Khashaba,MD 1212

Air Way CareAir Way Care

Suctioning every 2-3 hours.Suctioning every 2-3 hours. Suctioning not frequently needed in the first Suctioning not frequently needed in the first

48 hrs.48 hrs. Copious secretions may necessitate more Copious secretions may necessitate more

frequent care.frequent care. Sudden deterioration may indicate need for Sudden deterioration may indicate need for

suctioning.suctioning. No suctioning after surfactant administration.No suctioning after surfactant administration.










8.8. Drugs. Drugs.



Infection ControlInfection Control Sources of infectionSources of infection

1.1. Contaminated circuits.Contaminated circuits.

2.2. Humidification systems.Humidification systems.

3.3. Medical gas source.Medical gas source.

4.4. Others e.g suctioning, sampling Others e.g suctioning, sampling and infused fluidsand infused fluids


Clinical interventions and Clinical interventions and applicationsapplications

1.1. Bacterial filters in both inspiratory and expiratory limbs.Bacterial filters in both inspiratory and expiratory limbs.

2.2. Use only sterile water for humidification.Use only sterile water for humidification.

3.3. Change circuits weekly.Change circuits weekly.

4.4. Periodic draining of condensed fluid in circuits.Periodic draining of condensed fluid in circuits.

5.5. Single use suction cath. and sterile technique.Single use suction cath. and sterile technique.

6.6. Orotracheal rather than Nasotracheal tubeOrotracheal rather than Nasotracheal tube

7.7. Sterile punctures.Sterile punctures.

8.8. Disinfect probes.Disinfect probes.

9.9. Barrier precautions.Barrier precautions. Prof. M Khashaba,MDProf. M Khashaba,MD 1616









8.8. Drugs. Drugs.



DrugsDrugs

Respiratory stimulants may prevent Respiratory stimulants may prevent post extubation apneas in preterm.post extubation apneas in preterm.

Dopamine for hypotensive baby, rate Dopamine for hypotensive baby, rate is individualized.is individualized.

Dobutamine is more effective in Dobutamine is more effective in increasing LV output.increasing LV output.

Combination appears promising Combination appears promising (dobut.+ low dose dobam.).(dobut.+ low dose dobam.).Prof. M Khashaba,MDProf. M Khashaba,MD 1919

DopamineDopamine

Avoid use in hypovolemic babyAvoid use in hypovolemic baby..Dose tapered to response Dose tapered to response

(1-20ug/kg/min)(1-20ug/kg/min)..

Extravasation may cause tissue Extravasation may cause tissue necrosisnecrosis..


StabilityStability

— — Protect from light; solutions that Protect from light; solutions that are darker than slightly yellow should are darker than slightly yellow should not be usednot be used ; ;

incompatible with alkaline solutions or incompatible with alkaline solutions or iron salts; compatible when iron salts; compatible when coadministered with dobutaminecoadministered with dobutamine


DobutamineDobutamine

2-152-15 mcg/kg/minute, titrate to desiredmcg/kg/minute, titrate to desired ResponseResponse

Stimulates beta1-adrenergic receptors, Stimulates beta1-adrenergic receptors, causing increased contractility and causing increased contractility and heart rate, with little effect on beta2heart rate, with little effect on beta2 - -

Stable in various parenteral solutions Stable in various parenteral solutions for 24 hours; incompatible with for 24 hours; incompatible with

alkaline solutionsalkaline solutions , ,


Pharmacological Agents Pharmacological Agents CorticosteroidstsCorticosteroidsts

Pharmacological Agents Pharmacological Agents CorticosteroidstsCorticosteroidsts


Suggested Protocol for Suggested Protocol for Dexamethasone for WeaningDexamethasone for WeaningSuggested Protocol for Suggested Protocol for Dexamethasone for WeaningDexamethasone for Weaning


Pharmacological AgentsPharmacological AgentsCorticosteroidsCorticosteroids

Pharmacological AgentsPharmacological AgentsCorticosteroidsCorticosteroids

Peri-extubation corticosteroid treatmentPeri-extubation corticosteroid treatment

received repeated or restrict its use to infants at received repeated or restrict its use to infants at increased risk for airway edema and obstruction, increased risk for airway edema and obstruction,

such as those who have prolonged intubationsuch as those who have prolonged intubation


complex Fluid balancecomplex Fluid balance

11..immature kidneys have limited immature kidneys have limited concentrating abilitiesconcentrating abilities

22..insensible losses vary with insensible losses vary with gestational age, use of radiant heaters gestational age, use of radiant heaters and phototherapy, and the water and phototherapy, and the water content of inspired aircontent of inspired air . .

Fluids should be adjusted to maintain Fluids should be adjusted to maintain neutral or slightly negative water neutral or slightly negative water balancebalance..


excessive fluid increases the risk of excessive fluid increases the risk of patent ductus arteriosus, necrotizing patent ductus arteriosus, necrotizing enterocolitis (NEC), pulmonary edema, enterocolitis (NEC), pulmonary edema, and death. Excessive fluid may also and death. Excessive fluid may also increase the risk of BPDincrease the risk of BPD..


Pharmacological AgentsPharmacological Agents

DiureticsDiuretics

Pharmacological AgentsPharmacological Agents

DiureticsDiuretics

The use of diuretics for RDS has no effect on The use of diuretics for RDS has no effect on mortality, CLD, duration of mechanical mortality, CLD, duration of mechanical ventilation and oxygen supplementation, and ventilation and oxygen supplementation, and

length of hospitalizationlength of hospitalization


DIURETICSDIURETICS

no evidence to support the routine no evidence to support the routine use of diuretics in preterm infants with use of diuretics in preterm infants with

RDSRDS



1.1. Accept suboptimal ABG and pH.Accept suboptimal ABG and pH.2.2. Raise HcT.Raise HcT.3.3. Reposition the baby.Reposition the baby.4.4. Change ETT to a larger size.Change ETT to a larger size.5.5. Suctioning.Suctioning.6.6. Infection control.Infection control.7.7. Consider diuretics.Consider diuretics.8.8. Drugs.Drugs.9.9. Nutrition.Nutrition.10.10. Consider EchocardiographyConsider Echocardiography..Prof. M Khashaba,MDProf. M Khashaba,MD 3030

Nutritional ManagementNutritional Management

Nutritional compromise leads to muscle Nutritional compromise leads to muscle atrophy , pulmonary changes and atrophy , pulmonary changes and difficulty in weaning.difficulty in weaning.

Initiation of enteral feeds is based on the Initiation of enteral feeds is based on the degree of stress , perfusion and gut status.degree of stress , perfusion and gut status.


Successful weaning occur more Successful weaning occur more

frequently in those on adequate frequently in those on adequate

nutrition compared to malnourished nutrition compared to malnourished

babies.babies.


Contraindications to Contraindications to feedingfeeding

1.1. Unstable baby.Unstable baby.

2.2. 24 hours before extubation.24 hours before extubation.

3.3. Marked abdominal distensionMarked abdominal distension..










8.8. Drugs. Drugs.


10.10. Consider Echocardiography.Consider Echocardiography.Prof. M Khashaba,MDProf. M Khashaba,MD 3434

Role of Role of EchocardiographyEchocardiography

Essential in hypoxemic respiratory failure.Essential in hypoxemic respiratory failure.

Follow up suspected PDA, PPH and LV Follow up suspected PDA, PPH and LV

dysfunction.dysfunction.


Management during neonatal ventilation

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