Respiratory Problems and Management

WOMEN AND NEWBORN HEALTH SERVICE King Edward Memorial Hospital
NCCU CLINICAL GUIDELINES SECTION: 2
RESPIRATORY PROBLEMS AND MANAGEMENT
Section: 2 Respiratory problems and management Modes of ventilation Date Revised: Dec 2008
Neonatology Clinical Guidelines King Edward Memorial/Princess Margaret Hospitals Perth Western Australia
MODES OF VENTILATION
Continuous positive airway pressure bubbleflow nasal CPAP Humidified High Flow Nasal Cannula Therapy Conventional ventilation Pressure Support ventilation (PSV) Volume Guarantee ventilation (VG) VIVE High-Frequency Oscillatory Ventilation (HFOV) Nursing an infant on HFOV Nitric Oxide therapy (iNO) Appendix: Information for parents on Nitric Oxide usage.
Page 1 of 24 This document should be read in conjunction with the NCCU Disclaimer.
MODES OF VENTILATION
PERMISSIVE HYPERCAPNIA - A strategy for the management of patients requiring mechanical ventilation in which hypocapnia is prevented and relatively high levels of PaCO2 are tolerated in order to avoid high tidal volumes, pulmonary hyperinflation and lung injury.CDH NORMOCAPNIA is a PaCO2 between 35-45 mm Hg and hypercapnia is defined as a PaCO2 between 45-60 mm Hg. Retrospective studies looking at risk factors for CLD have concluded that hypocapnia during the early neonatal course results in an increased risk of CLD. Severe lung injury can be induced by mechanical overventilation and a compensated respiratory acidosis has few adverse effects and may reduce lung injury. We try to avoid PaCO2s below 35 mm Hg. If the CO2 is this low on a blood gas reduce the ventilation immediately to achieve CO2 at the upper end of the normocapnic range.
CONTINUOUS POSITIVE AIRWAY PRESSURE BUBBLEFLOW NASAL CPAP

To maintain or increase functional residual capacity of the lungs, help prevent alveolar collapse, reduce the work of breathing and improve gas exchange in infants with: - Clinical signs of respiratory distress - At high risk of respiratory distress - In the weaning process from ventilatory support
KEY POINTS
Avoid too much space between prongs and nares as this will allow movement and cause trauma. Avoid too little space between prongs and nares as this causes blanching around the nostrils indicating too much pressure. CPAP pressure should not be altered / increased without discussion with medical staff. It is preferable that all infants use the CPAP Cap System. The CPAP Cap must be released for several minutes every few hours to minimise deformities of the head and pressure areas occurring. Strictly 3 - 4 hrly for infants <30weeks and 3 6 hrly for all others. CPAP delivery must be maintained at all times whenever the infant is handled e.g. cares, weighing and releasing of CPAP cap. Ear pads, which can be positioned around the pinna, may be applied if infants ears appear to be excessively flattened. Reassess in 72 hours. If any redness or trauma to septum or philtrum is noted when using nasal prongs a T- piece of comfeel may be applied to the infants nose as added protection. This should be regularly replaced when soiled. Reassess in 72 hrs Refer to a more experienced staff member if any concerns.
EQUIPMENT
Bubble flow circuit and appropriate size Hudson CPAP prongs to achieve a snug fit. size 0 < 700 grams size 1 700 1250 grams size 2 1250 2000 grams size 3 2000 3000 grams size 4 5 > 3000 grams
Section: 2 Respiratory problems and management Modes of ventilation Date Revised: Dec 2008 This document should be read in conjunction with the NCCU Disclaimer
Neonatology Clinical Guidelines King Edward Memorial/Princess Margaret Hospitals Perth Western Australia Page 2 of 24
Oxygen-Air blender Oxygen high flow meter IV pole/stand Clear combi-stop for outlet port on prongs Humidifier base and temperature probe Sterile water for irrigation
CPAP CIRCUIT SET-UP PROCEDURE

1. Adjust the CPAP gauge to the pressure setting of 5 cmH2O or as ordered. 2. Adjust the oxygen flow to 5-8 L/min, occlude the prongs and observe the bubble chamber for bubbles (make sure combi-stop in place). 3. Gently insert prongs into infants nares, with prongs facing downwards but not in contact with the nasal septum. Secure the prongs in a downward arch position to prevent distortion of the nares and compression of the septum. 4. Observe the bubble chamber for bubbling, this ensures the prongs are correctly positioned and positive pressure is being delivered. Bubbling assists recruitment of alveoli and gas exchange. 5. Insert and secure an orogastric tube (FG5 for infants 1500g, FG6 for infants 1501g) for gastric decompression. Decompression of the stomach and the removal of air must be performed 3 4 hourly. 6. Position the infant either prone, turn prone, side lying or supine depending on medical condition. A prone position is preferred for the preterm infant as it encourages optimal expansion of lungs whilst preventing positional deformities. Use appropriate positioning aids to ensure alignment of head and neck (to ensure a patent airway) and shoulder support to prevent pressure on the face from the circuit tubings.
METHODS OF SECURING CPAP DEVICE 1. BONNET / BILIBAND

A biliband is used in conjunction with a bonnet for first 4 hours after admission to facilitate prompt application of CPAP and to use resources effectively as the infant may not need CPAP for an extended period. Secure the tubings in position by wrapping the biliband around head. Do not stretch the biliband. A tightly wrapped Biliband will cause pressure areas to develop and may deform the shape of the infants head. Use a larger size Biliband if necessary. On WANTS retrievals it will also be necessary to use Comfeel and Velcro to maintain correct positioning during transit.
2. CPAP CAP SYSTEM

NEVER place woollen hats underneath CPAP Cap System. CPAP Cap system comprises of: CPAP Cap x1 (size appropriate) Long Velcro strip x2 Short Velcro strip x2 Chin strap x1 Self adhesive Velcro wrap x2 Securing device / toggle x 1 After initial stabilising period of 4 hours, if infant is to remain on CPAP select the appropriate CPAP Cap size. To determine the correct size, measure the circumference from the nape of the neck, across the ears to the middle of the forehead (like a turban) ie. not the same as a head circumference measurement. Place cap around the nape of the neck, over ears and across the middle of the forehead. Align the stitched marking on the cap to the tip of the left ear. Position overlap (at least 2 cm) of the cap in the middle of the forehead. No overlap means the cap is too small use the next size up. Gather the top of cap together with a twist and use toggle creating a snug fitting cap. Place self adhesive velcro lengthwise around each corrugated CPAP tubing as close as possible to the nasal prongs connection. Position nasal prongs in nares, ensuring a downward arch. Secure the CPAP tubings in place with the CPAP Cap long velcro strips.
3. BONNETS WITH TIES

To be used if excessive moulding is observed in an infant 30 weeks gestation. Reassess in 72 hours and recommence CPAP Cap System if moulding resolved. Snug fitting woollen bonnet Blue ties (for securing CPAP tubings) Velcro (hook and fastener) Comfeel Apply skin prep to cheeks. Cut 2 pieces of comfeel to fit infants cheeks.
Apply hook velcro cut into an oblong to each piece of comfeel. Apply fastener velcro to prongs, ensuring it is wrapped all the way around the prongs TWICE to increase the distance between the nasal septum and prongs and reduce risk of trauma to nasal septum. Apply a well fitting bonnet with ties. The ties are to be placed appropriately, (ie, when the bonnet is in-situ, they are at the level of the tip of the ears) to facilitate securing of tubings with ties in the correct position.
EME MASK
CPAP pressure delivery via mask may be alternated with nasal prongs 4 hourly when there is evidence of septal redness / trauma. Select the appropriate size mask for the infant. The mask is to be used in conjunction with a size 2 nasal prong to provide a tight seal with the mask. Adjust the gas flow between 7 10 L/min to achieve bubbling (use lowest flow possible).
DOCUMENTATION
In addition to routine observations, document the following in the progress notes and bubbleflow CPAP chart: - Condition of infants nasal septum and nares, evidence of head moulding, infants position, hours on/off CPAP and comments on CPAP delivery/effectiveness. - Date of weekly CPAP Cap change.
HUMIDIFIED HIGH FLOW NASAL CANNULA THERAPY

THE FISHER & PAYKEL RT329 IS A HUMIDIFIED HIGH FLOW SYSTEM WHICH CAN BE USED TO DELIVER HIGH FLOW AIR OR OXYGEN VIA A NASAL CANNULA. *THE HUMIDIFIER REQUIRES A MINIMUM FLOW OF 300 ML/MIN TO FUNCTION.
INCLUSION CRITERIA: Infants who are ready to wean from CPAP and still require some support Infants with Chronic Lung Disease on PBF > 100 mL/min oxygen who would benefit from flow/humidity EXCLUSION CRITERIA: Not to be used for infants with Acute Respiratory Disease as initial mode of support Infants requiring short term CPAP support Infants on PBF < = 100 mL/min KEYPOINTS: Optimal humidification/gas exchange Allows normal cilia action Decreases mucous viscosity Reduced tracheal inflammation Minimizes risk of excoriation May reduce nasal deadspace More comfortable for infant than CPAP/and easier to position as per developmental care Easier for skin to skin contact
Section: 2 Respiratory problems and management Modes of ventilation Date Revised: Dec 2008 This document should be read in conjunction with the NCCU Disclaimer Neonatology Clinical Guidelines King Edward Memorial/Princess Margaret Hospitals Perth Western Australia Page 5 of 24
Assists in developmental care by allowing infant unrestricted head and hand to mouth movement May assist in weaning off CPAP earlier
EQUIPMENT Fisher & Paykel Circuit RT329 includes: Humidifier chamber Pressure manifold Blue Circuit from humidifier base to nasal cannula Connection piece to connect blue inspiratory circuit to cannula Short blue extension to be used only when infant is nursed in an incubator. Air/oxygen blender and low flow Oxygen flow meter (0.5 2.5 L/min) Appropriate sized RT329 cannula (maintain 2 mm gap between prongs and septum) Temperature probe Heater wire adaptor Water for irrigation (1 litre bag) Humidifier base MR 850 only Green oxygen tubing
SETUP: Connect one end of oxygen tubing to blender low flow meter and the other to the pressure manifold Connect the pressure manifold to the chamber Connect the elbow of the blue inspiratory circuit to the chamber Connect the blue temperature probe plug into the blue socket on the side of the humidifier Securely insert the blue twin probe into the blue circuit elbow above the chamber Insert the temperature probe into the port at the patient end of the circuit Connect one end of the yellow heater wire adaptor plug into the yellow socket on the side of the humidifier and the other into the blue circuit elbow Set the Blender to administer oxygen as per previous CPAP setting (see below) Connect the end of the blue circuit tubing to the end of the cannula MANAGEMENT: This system does not monitor pressure therefore it is not to be used with a flow > 2 L/min or as a substitute for CPAP therapy. 1. Infants on CPAP in air/oxygen who are ready to commence cycling: Flow to commence at 1-2 L/min as ordered.
Commence oxygen as per previous CPAP setting making blender adjustments as required to maintain oxygen saturations within normal limits. NB. The amount of oxygen required will depend on the flow used and the free space around the prongs at the entrance to the nares and may not equate exactly to that used on CPAP. Ensure comfeel has been removed prior to inserting prongs. Cannula must be loose fitting and must not occlude nares. Support weight of circuit to prevent drag on the nasal tubing.
2. Infants on PBF only who need > 100 mL/min of oxygen to change over to the Fisher and Paykel RT329 circuit set up as above. WEANING/ADJUSTMENTS: NB. Alteration of oxygen and/or flow is a medical decision and therefore must be discussed accordingly. a) Oxygenation: Decrease blender oxygen percentage to maintain peripheral hemoxyglobin saturations (O2 saturations) within normal limits. b) Flow: For infants with Chronic Lung Disease weaning from CPAP, maintain flow at 1-2 L/min until fully weaned from CPAP. After the infant is weaned from CPAP, flow may be decreased as ordered unless increased frequency of apnoea and bradycardia. In the absence of other precipitating factors (sepsis, anaemia etc), the recurrence of apnoea and bradycardia and/or increasing oxygen requirements are indications that the infant may require increasing the flow up to 2 L/min. DOCUMENTATION Document Oxygen setting, Delivery Mode, Flow and Humidity temperature on chart hourly Observe correct positioning of cannula and document hourly COMPLICATIONS Flow > 2 L/min may cause unpredictable CPAP pressures and overdistended airways. For this reason flows > 2 L/min will not be used in this unit. REFERENCES: 1. Product literature. Fisher & Paykel Healthcare; 2008. 2. Campbell D, Shah P, Shah V, Kelly E. Nasal continuous positive airway pressure from high flow cannula versus Infant Flow for preterm infants. Journal of Perinatology. 2006;26:5463. de Klerk A. Humidified High-Flow Nasal Cannula: Is it the New and Improved CPAP? Advances in Neonatal Care. 2008;8(2):98-106. 4. Finer N. Nasal Cannula Use in the Preterm Infant:Oxygen or Pressure. Pediatrics. 2005;116(5):1216-7. 5. Kubicka Z, Limauro J. Heated, Humidified High-Flow Nasal Cannula Therapy: Yet Another Way to Deliver Continuous Positive Airway Pressure:. Pediatrics. 2008;121(1):82-8. 6. Wilkinson D, Andersen C, Smith K, Holberton J. Pharyngeal pressure with high-flow nasal cannulae in premature infants. Journal of Perinatology. 2008;28(1):42-7.
CONVENTIONAL VENTILATION IPPV/IMV

Controlled ventilation according to a predetermined pattern (pressure and flow) and frequency - Time-controlled/pressure limited ventilation. - Mandatory ventilation, ignores patients spontaneous RR. - Tidal volume is determined by the pressure pattern (pressures set). Advantages of IPPV/IMV - Can control ventilation when the patient is muscle relaxed. - Can use with HFV and VIVE. - Inspiratory pressure is limited to PIP (prevent barotrauma). - Can use with and without pressure plateau. -
SYNCHRONISED INTERMITTENT MANDATORY VENTILATION (SIMV)

Combines spontaneous breathing with synchronised ventilation. Support is provided for the rate set by the operator, not for the breaths the infant takes in between the ventilator strokes. No pressure support for the patients breath. Useful for weaning bigger infants from the ventilator. If the patient is apnoeic, the ventilator cuts in at the set rate. Can be combined with VG and VIVE.
SYNCHRONISED INTERMITTENT POSITIVE PRESSURE VENTILATION (SIPPV)

Ventilation strokes are synchronised with spontaneous breathing: a stroke begins when a spontaneous inspiration is detected and ends after the IT (giving pressure support). The patient determines the respiratory rate. If the patient becomes apnoeic the ventilator cuts in at the rate determined by the IT & ET, the same as IPPV. Patient has time to breathe out. Can be combined with VG and VIVE. Use a low back up rate to promote triggering. Wean on pressure, not rate, and then switch to SIMV (larger infants only). Small infants should remain on a mode that supports all breaths taken until they are extubated. It is possible to maintain MV with lower VT than during low rate SIMV on SIPPV, potentially limiting volutrauma.
PEAK INSPIRATORY PRESSURE (PIP)

Changes in PIP alter the following: - MAP resulting in changes in arterial oxygen levels - PaCO2: Increase in PIP, increases tidal volume and minute ventilation thus decrease PaCO2 - Use of a high PIP may increase the risk of barotraumas and volutrauma with resultant air leaks and bronchopulmonary dysplasia or chronic lung disease (CLD). - The level of PIP needed is determined by lung compliance and airway resistance and can be assessed by blood gas analysis, chest rise and breath sounds. - Larger infants do not necessarily need a higher PIP as their lungs may be more compliant than the preterm lung.
Required PIP is determined by the tidal volume required (aim for 4-6 mL/kg) Initial clinical settings, breath sounds and visible (but not excessive) chest excursions are good indicators for tidal volume.
POSITIVE END-EXPIRATORY PRESSURE (PEEP)

Application of PEEP prevents alveolar collapse, maintains lung volume at end-expiration and improves V/Q matching. Increases in PEEP raise mean airway pressure and thus improve oxygenation. Levels of 3-6 cmH2O improve oxygenation in infants with HMD without compromising lung mechanics, CO2 elimination or haemodynamic stability. Older infants with chronic lung disease may tolerate higher levels of PEEP with improvement in oxygenation. Higher levels of PEEP may be beneficial for short periods in the presence of severe atelectasis.
RATE
Changes in frequency alter minute ventilation and thus PaCO2. An individualised approach should be taken, considering that the goal of infant minute ventilation is to provide adequate minute ventilation using minimal mechanical force. At very fast rates the short expiratory time used may result in incomplete expiration Gas trapped in the lung may increase the functional residual capacity and place the infant on the flat part of the pressure-volume curve, thus decreasing lung compliance. Rate changes alone (with no change in I:E ratio) usually do not alter the airway pressure (MAP) nor substantially affect PaO2.
FIO2
As FiO2 and MAP both determine oxygenation, they can be balanced as follows: - Initially FiO2 is first increased until about 0.6-0.7, then increases in MAP are warranted. - During weaning, FiO2 is first decreased to about 0.5-0.6 before MAP is reduced because maintenance of an appropriate MAP may allow a substantial reduction in FiO2. - It is essential that the tidal volume be monitored during this weaning phase to minimise volutrauma and barotrauma to the lung.
FLOW
Flows of 5 to 8 L/min are sufficient in most neonates. Lower flows allow more gradual inflation of the lung and may result in less shear stress injury.
PRESSURE SUPPORT VENTILATION (PSV)

Time cycled-pressure limited synchronised mode in which each spontaneous breath is supported like SIPPV and a back-up rate is set to maintain adequate support in case of apnoea. The patient determines the IT and ventilation rate. Check the flow vs time graph to ensure that the set inspiratory time is approximately 1.3 1.5 times the duration of the spontaneous inspiratory time (judged from when the inspiratory flow returns to zero).
Advantages - Major difference: The ventilation stroke is terminated when the inspiratory flow drops to about 15% of the peak flow or after IT. - This means that inspiratory hold is eliminated and the chance of active expiration against positive pressure is minimised. - Allows the infant control over the end of inspiration, not just the beginning. - Allows the infant to sigh, with pressure support given throughout the sigh, preventing atelectasis. - Maintains optimal inspiratory time for a given patient and automatically adjusts to changes in time constants. - Should reduce the risk of barotrauma and BP fluctuations (decrease IVH?). - Can use with VG. Other ventilators also provide mixed PSV + SIMV/SIPPV modes. - Need to set the maximum inspiratory time. Disadvantages In the presence of severe atelectasis and insufficient respiratory drive, spontaneous inspiratory time may be insufficient to achieve adequate lung volume recruitment.
VOLUME GUARANTEE VENTILATION

Despite improvements in respiratory care, ventilator induced lung injury remains an important cause of morbidity and mortality in neonatal patients who require assisted ventilation. Mechanisms of ventilator induced lung injury include barotrauma, volutrauma, atelectotrauma (alveolar collapse and re expansion) and biotrauma (increased inflammation). Animal studies have shown that it is mainly changes in cyclic and distending lung volume and not pressure that cause lung injury. Excessive tidal volumes can worsen clinical and pathological evolution of respiratory distress syndrome. Health care practices chosen during the first week of life may influence the incidence of bronchopulmonary dysplasia.
OPTIMAL TIDAL VOLUME

The primary goal of VG ventilation is to minimise volutrauma, but it also incorporates a feature to minimise the barotrauma because the operator sets the upper pressure limits. Volume guaranteed ventilation allows the ventilator to provide a set VT responsive to changes in the patient compliance, resistance or respiratory drive. The ventilator will automatically adjust the inspiratory pressure to achieve the desired VT. VG ventilation targets a specific volume of gas to be delivered by the ventilator, and inspiration ends when it has been delivered, within the limits of the existing ventilator settings. The pressure used to deliver the preset volume may increase to the preset maximum or decrease with improving lung compliance. In the Drager Babylog 8000+, it is based on an eight to ten breath average and is referenced to exhaled VT. Advantages Of VG Ventilation Include - Prevention of overdistension and volutrauma after surfactant treatment. - Response to sudden changes in compliance and resistance. - Automatic decrease of inspiratory pressure during weaning. - Stabilization of tidal volume and minute ventilation.
PROTOCOL FOR VOLUME GUARANTEE VENTILATION

Infants of any gestation with birth weight more than 500 grams who are being ventilated for RDS Recurrent apneas not responding to CPAP and other measures. Asphyxiated infants. Ventilation for other indications: still possible to use VG ventilation, but needs to be discussed with attending consultant to decide mode of ventilation.
SETTINGS
These settings are for ventilating an infant with RDS. If ventilating for other indications, discuss the ventilator settings with the neonatal consultant. 1. Start with SIPPV with VG 2. Set the initial TV 4.5 5 ml/kg. The initial PIP should be increased by no more than 4 from the previous value during ventilation without VG, or on a new infant, should be initially limited to 22 cmH20). 3. The delivered PIP required to achieve this set TV is observed for 10 minutes. 4. Set the PIP limit at 20 percent above the observed pressure requirement. 5. Start with rates of 45 per minute and IT of 0.3 to 0.35 sec. 6. Review the flow graph and ensure that expiratory time is set at least long enough to allow flow to return to zero (at least 3 time constants are required to remove 95% of delivered volume from the lung) 7. Initial PEEP to be kept at 5 or 6 cmH2O. 8. FiO2 to maintain oxygen saturations target range between 88 % to 92 %. 9. Flow is set at 8 L/min but may need to be increased if high pressures are required or decreased if PSV is used. Adequacy of flow on SIPPV and SIMV can be checked by reviewing the pressure graph. A pressure plateau should be reached by the end of the first 1/2 of the inspiration. In PSV, The pressure plateau is reached at the end of inspiration. 10. Aim to alter PaCO2 by inducing changes in minute ventilation (MV). This may require a change in set VT or set RR or both, to achieve desired goal. Always aim for achievement of physiologically appropriate respiratory rates and tidal volumes. Remember that it is possible to achieve good gases but have inappropriate ventilator settings. 11. If PaCO2 is above 60 mmHg AND RR is > 60-70 br/min - Increase the tidal volume by 0.3-0.5 mL/kg increments. 12. After each increment in set tidal volume, increase the set pressure limit to stay no more than 45 cmH2O above the average delivered pressure ( approximately 2 cmH2O). 13. If the ventilator is unable to deliver the set tidal volume using the set pressure, then it will give alarm saying low tidal volume. In this situation, first check that flow is sufficient for the higher pressure (look at rise time on pressure slope) and increase flow by 1-2 l/min if necessary. If low tidal volume alarm continues, increase the set pressure by another 2 cmH2O. 14. If PaCO2 is above 60 mmHg AND RR is < 40-50 br/min - Increase the ventilation rates so as to give a higher minute volume with the same set tidal volume. 15. If PaCO2 is between 45-60 mmHg - Check RR and Vt to ensure that these are appropriate for the infant. An infant breathing very fast with a Vt that is too small will be consuming unnecessarily high amounts of oxygen and will be prone to developing atelectotrauma (and on
SIPPV also potentially developing airtrapping). Likewise, an infant breathing very slowly with high Vt may be incurring overdistension volutrauma. 16. If PaCO2 is less than 45 mmHg - Reduce the tidal volume by 0.2-0.5ml/kg decrements till you reach a tidal volume of 3.5 5.0 ml/kg. It is advisable to observe the actual pressure needed over next 10 minutes and reduce set pressure limit by 1-2 cmH2O every time the set VT is reduced. The following data is recorded: - Set tidal volume / Average delivered tidal volume. - Set / Actual respiratory rate - Set MIT - Actual minute volume - Set pressure limit / Average actual delivered pressure (use trend tables to review this). - % Spontaneous breaths.
WEANING FROM MECHANICAL VENTILATION ON VOLUME GUARANTEE

For larger infants: - Reduce the tidal volumes stepwise till target VT (4.5 mL/kg-5.0 mL/kg) is reached. - Change to SIMV+VG from SIPPV+VG. - Reduce the rates to maintain PaCO2 around 50 55 mm Hg. - Consider extubation when infants set tidal volume is 4.5 mL/kg 5.0mL/kg, set rates are 20-25/minute, and FiO2 is less than 30%. For smaller infants: - Reduce the tidal volumes stepwise till target VT (3.5ml/kg-4.5ml/kg) is reached. VT <4 mL should only be used in <26 w infants during acute initial phase (ie <2 w) of their illness. - If changing to SIMV, follow protocol for larger infants with appropriate adjustments to set VT - If remaining on SIPPV (preferable for very small/immature infants on 2.5 mm and 3.0 mmID ETT): - Stepwise (5-10 br/min per step) reduce the set backup rates to around 25- 30/min to encourage the infant to initiate and regulate its own breathing pattern. - Gradually reduce peak inspiratory pressure limit to encourage the infant to take over as much of the work of breathing from the ventilator as possible (muscle conditioning). - Consider extubation when infants set tidal volume is 3.5 mL/kg 4.5mL/kg, set rates are 25-30/minute, the baby is breathing regularly with a sustainable and physiologically appropriate breathing rate (40-60 min), maintaining PaCO2 around 50 55 mm Hg and FiO2 is less than 30 % (higher FiO2 if has chronic lung disease). - The rate volume ratio (RVR) is a useful monitoring tool for assessing how well an infant is coping with weaning procedures. If the RVR increases, this indicates decompensation. Do not use tidal volumes of <4 mL/kg unless infant is <26 w and <2 w old.
TROUBLESHOOTING WITH VOLUME GUARANTEE VENTILATION

The most common problems encountered are air leaks, flow sensor issues, alarms and limitations at very low volumes.
AIR LEAKS
Draeger Babylog 8000+ determines tidal volume by measuring the amount of air exhaled in each breath. Flow sensor for the Babylog 8000+ is located next to the infant in the ventilator circuit. The
sensor will measure the volume of air exhaled each breath, recording flow and volume. If there is air leak more than 60 percent, the volume cannot be guaranteed with each breath. If the exhaled volume is low, the ventilator will increase the pressure with each breath in an effort to deliver the guaranteed volume. Air leaks of more than 60% and unable to achieve acceptable gases - discuss with senior reg/consultant about ETT orientation, to consider taking the baby off volume guarantee or change of endotracheal tube to a bigger size.
FLOW SENSOR ISSUES

If the flow sensor is removed for surfactant administration or any other reason, then ventilator will automatically revert to the conventional pressure limited time cycled mode of ventilation and will utilise the preset pressure limit as the PIP. Thus when the sensor is removed, the PIP will potentially be set at 15-20 percent higher than the pressure that is actually needed to provide the required VT and the baby will receive an unnecessarily high VT and potential volutrauma. If the flow sensor becomes dirty, it may incorrectly read tidal volume, and provide widely variable pressures to reach target volumes. If flow vs. time waveform appears noisy, and secretions are cleared from tubing/circuitry, consider replacing flow sensor.
ALARMS
Low minute volume alarm: - Do a blood gas analysis. If there is respiratory acidosis, check for appropriate respiratory rate and VT and make adjustments if necessary. - Consider increasing the rates or set tidal volume. - If gases are good and ventilation settings are appropriate, then consider resetting the minute volume limits but do not exceed 50% of the desired range (eg minimum 0.1 L/kg/min and max 0.45 L/kg/min). High minute volume alarm - Set VT may be too low so that you are not providing adequate alveolar volume and the infant has to breathe very quickly. adjust VT up. - There may be water in the line causing the ventilator to trigger at times when the infant is not taking a breath. This situation can lead to gas trapping. Clear the water from the circuit and observe. - If excess triggering is not due to either of the above, discuss a small increase (0.3) in the trigger sensitivity with your consultant (do not exceed a trigger sensitivity of 1.3). Low tidal volume - Look for obstruction. - See if there is air leak more than 60 percent. If so, review tube position & orientation , discuss about changing the Tube to a bigger one or consider taking baby off volume guarantee. - Check that appropriate amount of flow is delivered to ensure that pressure achieves plateau within first 33-50% of inspiratory period. Increase flow if necessary to achieve this goal. - Check that inspiratory time is not set to an inappropriate low value (review duration of inspiration on flow vs. time graph). - Limitations at very low volumes - The ventilator cannot accurately deliver volumes of less than 2 mL.
VIVE
Inspiratory flow (VI) is effective during ventilation strokes, while the expiratory flow (VE) is effective during spontaneous breathing phases.
Continuous expiratory flow can be adjusted independently of the continuous inspiratory flow. Potential advantages of higher expiratory flow. Provides the patient with a higher flow for spontaneous breathing than that used for the ventilation strokes. Promotes flushing of the dead space volume in the Y-piece by means of increasing turbulence in the hose system. Permits adjustment of the pattern of manually initiated ventilation strokes in CPAP mode. Reduced expiratory flow reduces gas (oxygen and medical air) utilisation and may decrease expiratory work of breathing.
HIGH-FREQUENCY OSCILLATORY VENTILATION (HFOV)

High frequency oscillation ventilation uses tidal volumes that may be less than or equal to the anatomical deadspace volume. It produces adequate gaseous exchange at lower peak airway pressures, theoretically reducing the risk of barotrauma. Breaths are delivered by a vibrating diaphragm that provides for both a positive inspiration and active exhalation.
MODE OF ACTION
This utilises a piston diaphragm to produce oscillatory gas flows within the airway. A vibrator diaphragm moves a small volume of gas toward and away from the patient. A continuous gas flow eliminates C02 build up and delivers 02. It allows continuous gas flow to escape while maintaining vibration of gas in the airway. Bias flow is delivered to the proximal airway in order to provide a supply of oxygen and a means of CO2 removal. Lung volume is maintained above FRC by the use of a constant distending pressure determined by end-expiratory or mean airway pressure. Frequencies range from 3-20 Hz. Some oscillators have adjustable I:E ratios (Sensormedics); others are fixed (Draeger/Humming V). Proximal airway pressure, not alveolar pressure, is monitored by the ventilator.
INDICATIONS
1. Severe lung disease that is unresponsive to conventional ventilation - rescue therapy. 2. Pulmonary air leaks, pulmonary interstitial emphysema, pneumothorax, bronchopleural fistulas, and pneumopericardium. 3. Hypoplastic lung, diaphragmatic hernia. 4. Persistent Pulmonary Hypertension (PPHN) of the newborn, meconium aspiration.
Advantages Of HFOV HFOV effectively separates oxygenation from ventilation in that changes made to alter oxygenation have little effect on CO2 removal, and visa versa, therefore one has control of induced respiratory alkalosis, without oxygenation deteriorating, as in conventional ventilation.
During HFV, lung volume is held constant and the cycle of inflation and deflation is greatly reduced, therefore HFOV: - Avoids high lung volumes and prevents overinflation of the more compliant lung units. - Avoids low lung volumes and prevents collapse of the less compliant lung units. - Prevents the propagation of lung injury by supporting adequate gas exchange with small tidal volumes (0.8-2 ml/kg). - Improves ventilation/perfusion, decreases dead space volume, and maintains gas exchange with less lung injury. - Improves lung volume recruitment, therefore less barotrauma. - HFOV may also improve cardiac status. Disadvantages Of HFOV HFOV may impair cardiac function (increased PEEP in CMV, and increased MAP in HFOV) due to limited cardiac reserve in the very sick neonate (ECMO candidate) and inhibition of pulmonary blood flow. Impede venous return as the relatively constant pleural pressure and minimal lung volume changes result in nearly constant (and sometimes higher) intrathoracic pressure. Result in further gas-trapping and air-leak.
PARENT EDUCATION
Explain the purpose and function of the oscillator to the parents, stressing that the neonate may not exhibit spontaneous respirations. Promote parental involvement in care as much as possible.
CLINICAL MANAGEMENT OF HFOV

The goal is to maintain optimal lung inflation and the lowest level of FiO2 necessary to maintain adequate oxygen saturation. To switch to HFOV from CMV one must consider 3 aspects of the patients physiology: Current Mean Airway Pressure (MAP) -CMV settings are used as a reference point. Inflation of Lung fields Disease Pathology - will determine the strategy used with HFOV
COMMENCING HFOV FROM CONVENTIONAL VENTILATION

1. Read mean airway pressure. 2. Switch to HFOV. 3. Set PIP value (Humming V only) to 2-5 cmH2O below conventional PIP value (this becomes the Sigh pressure). 4. Set MAP as ordered (usually 2-3 cmH2Oabove conventional MAP). 5. Set oscillatory frequency as ordered according to patient age and disease pathology (usually between 10-15 Hz). 6. Commence amplitude at 100% and prepare to connect baby to HFO tubing. 7. Connect HFO tubing to ETT and commence HFO 8. Adjust amplitude up until the babys chest wall is visibly vibrating. 9. Assess lung inflation with a chest X-ray 30 to 60 minutes after commencing HFO. Optimal lung inflation correlates with obtaining an 8 to 9 posterior rib level expansion.
GUIDELINES TO VENTILATOR ADJUSTMENT USING HFOV

Keep Bias Flow as low as possible to achieve MAP (ie: can be reduced from 20 L/min to ~12 L/min) MAP is increased during the initial volume recruitment phase until PaO2 improves by 2030mmHg, or until CXR shows normal inflation, or until CVP increases with signs of decreased systemic blood flow. During the initial optimisation phase, changes in MAP may need to occur every 10 min in order to avoid prolonged periods of atelectasis. During subsequent treatment, 30-60 min should be allowed between changes in MAP to assess effect. MAP is not reduced until FiO2 is at <0.6 (unless signs of over inflation). MAP should then be decreased in steps, until FiO2 requirements increase. (Volume Optimisation) PaCO2 is the best indicator of tidal volume. CXR are obtained frequently to assess lung volume, and assess tube position. In-line suctioning is preferred, to minimise the amount of lung collapse and the period before lung volume is re-established.
HYPOXIA
Increase MAP up to 25 cmH2O max (if CVP does not increase). Increase bias flow if necessary to achieve the higher MAPs. Alternatively, apply intermittent sustained inflation or sigh manoeuvre (10-20 s at PIP 5-10 cmH2O above MAP)
HYPEROXIA
Reduce Fi02 down to about 0.6-0.3. Decrease MAP in steps until FiO2 starts to increase, return to previous MAP. Low MAP (ie 6-7 cmH2O) can be achieved by using low bias flow.
HYPERCAPNIA
Decrease amplitude of oscillation. Decrease frequency (however this is accompanied by increased barotraumas, and should be reserved for high resistance diseases). Occasionally, hypercapnia is due to generalised atelectasis, or over distension. Changes in MAP at extremes of lung volume may also affect PaCO2.
HYPOCAPNIA
Decrease amplitude. Increase frequency.
OVERINFLATION
Reduce MAP. Discontinue HFO.
HYPOTENSION / INCREASE IN CVP

Volume expansion in hypotension. Dopamine/Dobutamine. Reduce MAP. Discontinue HFO.
MAP/OXYGENATION
Adjustment of lung volume allows manipulation of oxygenation.
Lung volume is established with MAP, which has the most profound effect on oxygenation. Optimum MAP corresponds to an A-P chest film of 8 to 9 posterior ribs. Manipulation of the amplitude (Delta-P), affects oxygenation when lungs are either over- or under-inflated.
AMPLITUDE/VENTILATION
TV during HFOV is influenced by the length and internal diameter of the tracheal tube, airway resistance, and lung compliance. CO2 elimination during HFOV is closely tied to the delivered volume (VT) and less to frequency (f). It is proportional to f x VT2. This differs from conventional ventilation where minute volume (f x VT) is the determinant of CO2 removal. Thus despite delivering small tidal volumes, HFOV is very efficient at removing CO2 and maintaining acid-base balance.
Three ventilator parameters that affect the tidal volume in HFOV: Amplitude (Delta-P). Frequency (Hz). % I-Time.
AMPLITUDE - Primary manipulations in PaCO2 are achieved by altering the oscillatory pressure amplitude (or power). Increasing the amplitude increases the displacement of the diaphragm, increasing the VT delivered to the patient, lowering the PaCO2. FREQUENCY - In contrast to CMV, lowering the frequency increases the tidal volume (when
there is a fixed I:E ratio- ie the IT is a fixed percentage of the total cycle time), thereby lowering the PaCO2. However, as frequency decreases, the percentage of the oscillatory amplitude transmitted to the proximal airways increases. The frequency at which this amplitude increases significantly, is influenced by the mechanical properties of the lung. The appropriate frequency is dependent on the disease being treated. As a general rule, higher frequencies (12-15 Hz) are used for low compliance (eg HMD), whilst lower frequencies (8-10 Hz) are used in the presence of high resistance (eg early phase meconium aspiration, CLD). Smaller babies with poorly compliant lungs require higher frequencies than more mature infants. Gas Trapping is not an issue during HFOV due to active expiratory phase, unless mean airway pressure is inappropriately low, when choke points can form in the airways preventing full expiration.
% INSPIRATORY TIME (IT) - In extreme cases (large patients with severely elevated physiologic dead space) % IT can be increased to improve CO2 elimination, by allowing a longer inspiratory phase thus maximising the delivered tidal volume from 33 % to 50 %.
The additional inspiratory time results in a greater VT being delivered to the patient by either allowing for more piston displacement or by allowing the piston to remain in the forward position longer (at the same amplitude), resulting in more volume transfer across the endotracheal tube.
WEANING FROM HFOV

Maintenance of lung volume during weaning is the key to success. It is important to consider disease pathology when setting/adjusting HFOV parameters.
Reduce Fi02 in increments down to 0.3 - 0.4. If MAP is maintained too long during weaning then over-distension will result which will impair oxygenation therefore a CXR may be needed to determine level of distension. Once Fi02 is reduced to appropriate levels then MAP should be reduced in 1-2 cmH20 increments every 2-4 hours (monitored by ABG and TCM). If MAP is weaned too rapidly then atelectasis can occur and blood gases will deteriorate. If this occurs, the MAP should be increased 2 cmH2O above the weaning value and decreased more slowly. Once MAP is 8-9 cmH2O, amplitude can then be decreased, until the infant is either extubated to CPAP or conventional ventilation is (re-)introduced. If further decrease in MAP is desired, this can be achieved by decreasing Bias Flow.
DIFFUSE ALVEOLAR DISEASE

(ie Hyaline Membrane Disease/Respiratory Distress haemorrhage, and Acute hypoxic respiratory failure). Syndrome, Pneumonia, Pulmonary
The goal is to recruit gas exchange surface area by opening alveoli and increasing lung volume, without compromising cardiac function and avoiding barotrauma. In the Preterm Infant: - MAP is started 2-3 cmH2O above that on CMV, but must be sufficient enough to inflate the lungs (ie with complete white-out and stiff lungs, may require a much higher MAP). - Aggressive weaning of MAP as lung volume and compliance improve. - Frequency ranges from 12-15 Hz (<1000 gm: Generally start at 12 Hz when the PaCO2 is low, and 15 Hz for infants < 750 gm). - The amplitude is set to achieve least chest wall movement and the desired PaCO2, which will usually be at a delta P of 20-25 cmH2O. - Fractional IT is left 0.33 sec. - If adequate PaCO2 is not achieved with the max amplitude, the frequency is decreased to increase the tidal volume (and visa versa for over ventilation). - May apply sustained inflations to improve lung volume (IMV breaths on the draeger), providing pulsatile periods of increased pressure during oscillation to re-expand atelectatic alveoli and to bring the lung onto the deflation limb of the pressure volume curve. Term and near term: - MAP commences 2-4 cmH2O greater than that on IMV. - Frequency of 10-12 Hz. - Amplitude is as above, although usually higher for term infants (rough rule of thumb amplitude = 3 x MAP).
PULMONARY INTERSTITIAL EMPHYSEMA (PIE)

With air-leak syndromes, the goal of optimising alveolar surface area is reduced to allow for resolution of the air leak syndrome, resulting in adequate by not optimal oxygenation and ventilation. - Allow elevated PaCO2 levels but with pH > 7.25. - MAP should be set equal to, or slightly less than that on CMV. - Frequency at 10-15 Hz. - Amplitude set to achieve minimal chest wall movement. - The use of low oscillatory pressure amplitudes (c/w PIP or CMV) often leads to resolution of the air-leak without requiring great reductions in MAP.
In those with severe air-leak/PIE, continuation of HFO for 24-48 hours after the resolution of the leak is sometimes recommended (to allow complete resorption of interstitial air). In cystic air-trapping, use a MAP than that on CMV and accept low arterial PaO2 and high PaCO2 and gradually increase in small increments. Weaning MAP is given priority over FiO2 in those with large cysts. In those whose PIE fails to improve, wean back to IMV after FiO2 is reduced to 50 % and PIP< 30 cmH2O (sometimes associated with mobilisation of pulmonary oedema and clearance of airway secretions).
GROSS AIR LEAK

The Low Pressure Approach Initial MAP is dependent on the volume of the non-air leak lung, which needs to be normalised to attain adequate gas exchange. If atelectasis occurs in the good lung, a minimal leak may have to be accepted while re-opening the lung. In the Preterm infant: MAP is set 1 cmH2O above that on CMV. Frequency 10-15 Hz depending on the patients size. Amplitude as before. Term and Near Term Infant (2 categories): a) Air-leak with adequate inflation MAP to equal that on CMV. Frequency of 10 Hz. Amplitude as above. b) Air-leak with poor inflation MAP set 1-2 cmH2O higher than that on CMV. Frequency of 8-10 Hz.
NON-HOMOGENOUS LUNG DISEASE

Most often Meconium Aspiration Syndrome (amniotic fluid aspiration, ARDS, pneumonia) Any strategy that is effective in opening damaged areas may result in over-inflation and trauma to more normal areas of the lung. Focal gas-trapping may be worsened by HFO and result in airway rupture and pneumothorax. Less responsive than in diffuse homogeneous lung disease especially if there is marked gastrapping). Allow MAP to equal that on IMV initially, and then volume recruit. Frequency 6-10 Hz is required to overcome some of the airway obstruction and associated high resistance present with this pathology, also allows for greater elimination of CO2. Amplitude as above. The most severely affected lung is placed in the dependent position to increase resistance to gas delivery to that lung. Avoid sustained inflations After the first 24 hours in meconium aspiration syndrome, chemical pneumonitis develops and poor compliance may become more important than increased resistance. In this instance, it is worth considering an increase in frequency after the 1st 24 hours.
PNEUMONIA
Set MAP initially at 1cmH2O above that on IMV.
Frequency at 10-15 Hz (use lower frequencies if a viral pneumonia with significant airway involvement). Amplitude as above.
HYDROPS
MAP initially same as that on CMV and then gradually increased to achieve maximum oxygen saturation (at risk of lung injury). If still poor oxygenation at 5-6 cmH2O greater than CMV, re-check X-Ray for lung volume, and position. Frequency at 10-15 Hz. Amplitude as above.
PULMONARY HYPOPLASIA/CONGENITAL DIAPHRAGMATIC HERNIA

MAP initially started at equal or greater than that on IMV, depending on the contra-lateral lung. Start in the 10-12 cmH2O range and increase in 1 cmH2O increments to optimise inflation of the unaffected lung. Try not to go above MAP 15-16 cmH2O as you are ventilating one lung. Be aware of cardiac function when increasing MAP, as the mediastinum may be shifted from its optimal position compromising cardiac output, as well as existing PPHN. Frequency 10 Hz. Amplitude as above. See Lung protective strategy.
NURSING A NEONATE ON HFOV

Ensure bullet port in situ on HFO tubing. Due to rigid tubing, more attention to TT position is needed to prevent accidental dislodgment and excess pressure on nasal tissues. Use of the plastic block on the side edge of the warmer enables more stability of the tubing. Every time the tubing is disconnected consider brief (max 5 min) increase in mean airway pressure of 1-2 cmH2O. Neonate is nursed on a warmer, with a sheepskin, in the supine position. Do not muscle relax unless requested to do so by a consultant. Babies can (and should) have spontaneous gentle breathing on HFOV. Continuous TCM is usually required with the site rotated every 3 hours, to continuously observe trends in Pa02 and PaC02 without need excessive blood gases. Pre and post ductal oxygen saturations may be required if PPHN is present. Monitor ABGs closely, especially 20-30 minutes after a ventilation parameter change.
PHYSICAL AND AIRWAY ASSESSMENT

Visual assessment includes activity, posture, behavioural state, chest wall vibration (indicates tidal volume) and symmetry. Chest wall vibration will be affected by the diameter of the ETT, mucous plugging and ETT displacement. A change in the magnitude of chest wall vibration in the absence of alteration in the oscillatory parameters should be investigated immediately. Respiratory rate cannot be measured. Auscultation of heart tones, breath sounds and bowel sounds can be achieved by briefly interrupting the oscillation (CPAP will be maintained). Breath sounds can be assessed during oscillation to note air entry and symmetry of oscillatory intensity. Changes in pitch or rhythm of delivered breaths, may indicate changes in ETT position or need for suctioning. Suction should only be performed when absolutely necessary and is not required routinely for HFOV. Frequent, even temporary disconnections are discouraged as this results in immediate
loss of alveolar recruitment, hence in-line suctioning should be used when possible. Periods of disconnection should be minimised. It may be necessary to temporarily increase MAP (20 % for 2 minutes) to re-recruit lung volume if indicated by deterioration in arterial oxygen saturations post-suctioning.
NITRIC OXIDE THERAPY (INHALED) INO INDICATIONS

Hypoxic respiratory failure despite maximal medical therapy ie. surfactant, sedation, conventional or HFOV, and maintenance of mean arterial blood pressure within the normal range. Presence of persistent pulmonary hypertension of the newborn (PPHN).
A cranial ultrasound should be performed if possible prior to commencing iNO therapy
CONTRAINDICATIONS
Evidence of severe hypoxic or haemorrhagic brain injury (eg. Grade III, IV IVH) Evidence of a coagulopathy.
A systematic review of the literature does not support the use of iNO in preterm (<34 weeks gestation) neonates with hypoxic respiratory failure as despite a transient improvement in oxygenation no significant benefits on mortality or chronic lung disease (CLD) are reported. Additionally data on long-term neurodevelopmental outcome is not available. Although an increased incidence of IVH has been a concern, this was not noted on systematic review. Lack of power makes it difficult to rule out the possibility of reduction in the severity of CLD due to the shortened duration of assisted ventilation. The use of iNO in preterm neonates should thus be considered as an experimental therapy at present.
DOSAGE OF INO
Ensure optimal inflation of lung (adequate MAP, surfactant) prior to iNO delivery. Changing over to HFOV may help in augmenting iNO delivery. A cranial ultrasound is necessary prior to commencing iNO therapy. Informed parental consent is required. >34 weeks: Start with 5 parts per million (ppm) and increase by 5 ppm every 10 minutes up to a maximum of 30 ppm if no improvement in oxygenation or partial improvement in oxygenation (rise in PaO2 by <20 mmHg) is seen. 28 to 34 weeks: Start at 5 ppm and increase by 5 ppm every 10 minutes to a maximum of 20 ppm if required. <28 weeks: Start at 5 ppm and increase by 2 ppm every 30 minutes to a maximum of 15 ppm if required.
PROCEDURE
1. Attach blender tubing to oxygen blender and nitric oxide cylinder. The longest length of tubing should be attached to Laerdel bag. 2. Dial up the infants oxygen requirement on the blender. 3. Calculate the flow of nitric oxide (in mL/min) using 4. Use the conversion below, to calculate the flow required from the nitric oxide cylinder. EXAMPLE: If an infant is receiving 8 parts per million of nitric oxide, round this up to the nearest figure available in this being 10 ppm. Knowing that the blender is set at 6 L per minute, using this calculates to 60 ml/min. Using the Conversion 60 mL/min is equivalent to 1/16, which is the figure dialled up on the nitric oxide cylinder.
TABLE 1: NITRIC OXIDE FLOW (ML/MIN)

PPM 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 210 220 230 240 250 260 270 280 290 300 15 30 45 60 75 90 105 120 135 150 165 180 195 210 225 240 255 270 285 300 315 330 345 360 375 390 405 420 435 450 20 40 60 80 100 120 140 160 180 200 220 240 260 280 300 320 340 360 380 400 420 440 460 480 500 520 540 560 580 600 25 50 75 100 125 150 175 200 225 250 275 300 325 350 375 400 425 450 475 500 525 550 575 600 625 650 675 700 725 750 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 480 510 540 570 600 630 660 690 720 750 780 810 840 870 900 35 70 105 140 175 210 245 280 315 350 385 420 455 490 525 560 595 630 665 700 735 770 805 840 875 910 945 980 40 80 120 160 200 240 280 320 360 400 440 480 520 560 600 640 680 720 760 800 840 880 920 960 1L 45 90 135 180 225 270 315 360 405 450 495 540 585 630 675 720 765 810 855 900 945 990 50 100 150 200 250 300 350 400 450 500 550 600 650 700 750 800 850 900 950 1L
B I A S F L O W I N L P M
Table 2: NO Flow Conversion 30 mL/min NO 60 mL/min NO 125 mL/min NO 250 mL/min NO 375 mL/min NO 500 mL/min NO 1/32 1/16 1/8 1/4 3/8 1/2
APPENDIX A: INFORMATION FOR PARENTS FOR USE OF INHALED NITRIC OXIDE IN NEONATES BORN AT OR ABOVE 34 WEEKS GESTATION
Dear Parents We request your permission in using nitric oxide, a medical gas for inhalation, as part of treatment for your baby who has severe breathing difficulties. Despite significant support from the breathing machine, and/or the use of surfactant (a medication given down the breathing tube into the lungs to make them work better) and supplemental oxygen. Why do we need to use inhaled nitric oxide? We know/suspect that an element of spasm of the blood vessels in the lungs is not allowing the blood to flow properly to the lungs in your baby leading to worsening of the breathing difficulty. This condition is called as pulmonary hypertension. Inhalation of the medical gas called nitric oxide may help to relieve this spasm to restore proper blood flow to the lungs. This is expected to reduce the severity of breathing difficulties in most but not all babies. It is important to remember that nitric oxide does not appear to have any significant effect on the chances of survival of babies with significant breathing difficulties. Are there any side effects of nitric oxide that we need to worry? Use of nitric oxide is associated with two main issues in babies. The first is that in some circumstances formation of toxic compounds like methemoglobin and nitrogen dioxide may occur, especially when very high levels of nitric oxide are used, and the second is the theoretical possibility of increased risk of bleeding inside the brain. Toxic compounds: Formation of toxic compounds like methemoglobin and nitrogen dioxide higher than the recommended levels has not been shown to be a problem in the range of doses of nitric oxide that we currently use. We do carefully monitor the levels of these toxic compounds in all babies who receive inhaled nitric oxide and take appropriate actions if needed. Specific treatment for high levels of toxic compounds like methemoglobin is also available if needed. Risk of bleeding inside the brain: Very sick as well as very premature babies can be prone to develop haemorrhages in or around the brain. When they occur, they are often small and cause no long-term problems. Despite the anxieties a few years ago the possibility of inhaled nitric oxide either causing a new bleeding or aggravating a pre-existing bleed inside the brain has not shown to be a significant problem worldwide, particularly in babies at or above 34 weeks gestation. We will routinely be monitoring (by brain scans) for any such event. We always reduce the dose of nitric oxide or stop it as soon as the babys condition allows. We appreciate your involvement in the treatment for your baby. Please do not hesitate to contact us any time if you have any questions/anxieties regarding your babys treatment.

Respiratory Problems and Management

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WOMEN AND NEWBORN HEALTH SERVICE King Edward Memorial Hospital

NCCU CLINICAL GUIDELINES SECTION: 2

RESPIRATORY PROBLEMS AND MANAGEMENT

CONTINUOUS POSITIVE AIRWAY PRESSURE BUBBLEFLOW NASAL CPAP

CPAP CIRCUIT SET-UP PROCEDURE

METHODS OF SECURING CPAP DEVICE 1. BONNET / BILIBAND

2. CPAP CAP SYSTEM

3. BONNETS WITH TIES

HUMIDIFIED HIGH FLOW NASAL CANNULA THERAPY

CONVENTIONAL VENTILATION IPPV/IMV

SYNCHRONISED INTERMITTENT MANDATORY VENTILATION (SIMV)

SYNCHRONISED INTERMITTENT POSITIVE PRESSURE VENTILATION (SIPPV)

PEAK INSPIRATORY PRESSURE (PIP)

POSITIVE END-EXPIRATORY PRESSURE (PEEP)

PRESSURE SUPPORT VENTILATION (PSV)

VOLUME GUARANTEE VENTILATION

OPTIMAL TIDAL VOLUME

PROTOCOL FOR VOLUME GUARANTEE VENTILATION

WEANING FROM MECHANICAL VENTILATION ON VOLUME GUARANTEE

TROUBLESHOOTING WITH VOLUME GUARANTEE VENTILATION

FLOW SENSOR ISSUES

HIGH-FREQUENCY OSCILLATORY VENTILATION (HFOV)

CLINICAL MANAGEMENT OF HFOV

COMMENCING HFOV FROM CONVENTIONAL VENTILATION

GUIDELINES TO VENTILATOR ADJUSTMENT USING HFOV

HYPOTENSION / INCREASE IN CVP

WEANING FROM HFOV

DIFFUSE ALVEOLAR DISEASE

PULMONARY INTERSTITIAL EMPHYSEMA (PIE)

GROSS AIR LEAK

NON-HOMOGENOUS LUNG DISEASE

PULMONARY HYPOPLASIA/CONGENITAL DIAPHRAGMATIC HERNIA

NURSING A NEONATE ON HFOV

PHYSICAL AND AIRWAY ASSESSMENT

NITRIC OXIDE THERAPY (INHALED) INO INDICATIONS

A cranial ultrasound should be performed if possible prior to commencing iNO therapy

TABLE 1: NITRIC OXIDE FLOW (ML/MIN)

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