Goldsmith’s Assisted Ventilation of the Neonate: An Evidence-Based Approach to Newborn Respiratory Care

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Front matter
Goldsmith’s assisted ventilation of the neonate: An evidence-based approach to newborn respiratory care
Copyright
Contributors
Foreword
Preface
Table of Contents
Section 1 History, Pulmonary Physiology, and General Considerations
1 Introduction and historical aspects
History of neonatal ventilation: Earliest reports
Sixteenth and seventeenth centuries
Eighteenth and nineteenth century
Twentieth century
Breakthroughs in ventilation
Recent advances and outcomes
Key references
2 Physiologic principles
Basic biochemistry of respiration: Oxygen and energy
Ontogeny recapitulates phylogeny: A brief overview of developmental anatomy
Lung development
Phases of lung development
Embryonic phase (weeks 3 to 6): Development of proximal airways
Pseudoglandular phase (weeks 6 to 16): Development of lower conducting airways
Canalicular phase (weeks 16 to 26): Formation of gas-exchanging units or acini
Terminal sac phase (weeks 26 to 36): Refinement of acini
Alveolar phase (week 36 to 3 years): Alveolar proliferation and development
Mechanics
Compliance
Static compliance
Dynamic compliance
Resistance
Flow rate
Airway or tube length
Airway or tube diameter
Viscosity and density
Work of breathing
Time constant
Gas transport
Mechanisms of gas transport
Oxygenation
Effects of altering ventilator settings on oxygenation
Ventilation
Perfusion
Control of ventilation
Conclusion
Acknowledgments
Selected readings
3 Control of ventilation
Introduction
Pathogenesis of apnea of prematurity
Central carbon dioxide chemosensitivity
Peripheral (hypoxic) chemosensitivity
Role of mechanoreceptor (laryngeal) afferents
Genesis of central, mixed, and obstructive apnea
Relationship between apnea, bradycardia, and desaturation
Cardiorespiratory events in intubated infants
Therapeutic approaches
Optimization of mechanosensory inputs
Optimization of blood gas status
Role of gastroesophageal reflux
Xanthine therapy
Continuous positive airway pressure
Long-term consequences of neonatal apnea
Key references
4 Ethical issues in assisted ventilation of the neonate
Introduction
An ethical basis for decision making
Withdrawing and withholding assisted ventilation
Nonescalation and “heroic measures”
Moral distress
Who makes the call? Shared decision making in the neonatal intensive care unit
Quality of life considerations
Coming to a consensus: When is withholding or withdrawal of assisted ventilation ethically permissible?
Chronic ventilation and tracheostomy
Conclusion
Key references
5 Evidence-based respiratory care
Background
The technical steps of evidence-based medicine
Formulating the question
Searching for the evidence
Evaluating evidence about therapy
Evaluating the quality (certainty) of evidence
Determining the quantitative effects of a therapy
Noninferiority trials
Systematic reviews of therapeutic interventions and meta-analyses
Weighing risks, benefits, and costs
Evaluating evidence about diagnostic tests
Evaluating the certainty of evidence for diagnostic tests
Determining diagnostic test accuracy
Bayesian reasoning in diagnostic testing
Special considerations in applying evidence to respiratory interventions
Cognitive skills for evidence-based practice
Critical thinking
Clinical reasoning and decision making
Translating evidence into practice
Summary
Suggested readings
6 Quality and safety in respiratory care
Quality and safety: Background
Donabedian’s triad
The institute of medicine’s domains of quality
Assessing and monitoring the quality of care
Quality indicators for comparative performance measures
Quality indicators for improvement
Improving the quality of care
The improvement team
Collaboration
Aim: What are we trying to accomplish?
Measurement: How will we know that a change is an improvement?
What changes can we make that will result in an improvement?
Plan–do–study–act cycles
Ensuring the success of quality improvement projects
Leadership and unit culture
Why is quality improvement important in neonatal respiratory care?
Examples of quality and safety improvement in neonatal respiratory care
Quality improvement projects in individual units
Collaborative quality improvement projects
Conclusion
Key references
7 Medical and legal aspects of respiratory care
Disclaimer
General legal principles
Supervision of others
Malpractice
Duty
Breach
The expert witness
Causation
Damages
Burden of proof
Malpractice issues specific to neonatology and neonatal respiratory care
Resuscitation
Prematurity/periventricular leukomalacia
Respiratory failure/mechanical ventilation
Patient safety/culture of safety
Decreasing the risk of a malpractice lawsuit
Competency
Communication
Documentation
The future of malpractice litigation
Conclusion
Key references
Section 2 Patient Evaluation and Monitoring
8 Physical examination
Historical aspects
Importance of the physical examination
Technique of the physical examination
Overview
Performing the neonatal respiratory physical examination
Interpretation of the findings of physical examination
General physical examination findings
Special technique of examination: Transillumination
Physical examination findings in specific clinical situations
Examination at birth
Examination of an infant receiving face mask or laryngeal mask ventilation
Examination of the ventilated infant
Conventional ventilation
High-frequency ventilation: Oscillation
High-frequency ventilation: Jet ventilation
Examination of an infant on constant positive airway pressure
Conclusion
Key references
9 Imaging: Radiography, lung ultrasound, and other imaging modalities
Introduction
Radiation exposure
Imaging modalities
Chest radiograph
Ultrasound
Computed tomography
Fluoroscopy
Magnetic resonance imaging
Invasive support devices
Endotracheal tube
Vascular catheters
Common etiologies of respiratory distress in infants
Respiratory distress syndrome
Transient tachypnea of the newborn
Meconium aspiration syndrome
Pneumonia
Air leak syndromes
Pneumothorax
Pneumomediastinum
Pneumopericardium
Pulmonary interstitial emphysema
Pulmonary hemorrhage
Pleural effusion
Bronchopulmonary dysplasia
Congenital and surgical causes of respiratory distress
Congenital lung lesions
Pulmonary agenesis, aplasia, and hypoplasia
Bronchial atresia or stenosis
Congenital pulmonary airway malformation
Bronchopulmonary sequestration
Congenital lobar emphysema
Congenital diaphragmatic hernia
Key references
10 Blood gases: Technical aspects and interpretation
Introduction
Blood gas physiology
Oxygen transport
Understanding the oxyhemoglobin dissociation curve
Considerations regarding fetal hemoglobin
Hypoxemia and hypoxia
Carbon dioxide transport
Metabolic acidosis
Metabolic alkalosis
Techniques for obtaining blood samples
Umbilical artery catheters
Subumbilical cutdown
Complications of umbilical artery catheterization
Other indwelling catheter sites
Infusion of fluids through arterial catheters
Arterial puncture
Arterialized capillary blood
Continuous invasive monitoring
Noninvasive estimation of blood gases
Pulse oximetry
Near-infrared spectroscopy
Choice of monitoring methods
Transcutaneous monitoring
Capnography
Blood gas analyzers
Measuring principle of a blood gas analyzer
Blood gas analyzer quality assurance
Clinical interpretation of blood gases
Components of blood gas testing that are measured directly
pH
Carbon dioxide
Partial pressure of oxygen
Components of blood gas testing that are not measured directly
Bicarbonate
Base excess
Oxygen saturation
Lactate
Errors in blood gas measurements
Assessing the accuracy of a blood gas result
Final thoughts
Acknowledgment
Key references
11 Noninvasive monitoring of gas exchange
Noninvasive monitoring of oxygenation
Pulse oximetry
Indications for pulse oximetry
Delivery room resuscitation
Limitations of pulse oximetry
Functional versus fractional saturation
Additional considerations
Transcutaneous oxygen monitoring
Noninvasive assessment of partial pressure of carbon dioxide
Capnography and end-tidal carbon dioxide monitoring
Mainstream and sidestream capnography
Carbon dioxide monitoring in the neonatal intensive care unit
Capnography during neonatal anesthesia
Colorimetric carbon dioxide detectors
Optimizing ventilation settings with capnography
Limitations of capnography
Transcutaneous carbon dioxide monitoring
Tissue oxygen saturation monitoring using near-infrared spectroscopy
Normal values
Application of near-infrared spectroscopy in newborns
Management of hypotension
Resuscitation and stabilization in the delivery room
Patent ductus arteriosus
Cerebral perfusion with changes in mean airway pressure and ventilation
Mesenteric ischemia and risk of necrotizing enterocolitis
Limitations of near-infrared spectroscopy
Conclusion
Key references
12 Pulmonary function and graphics
Introduction
Technical aspects
Airflow measurement
Pressure measurement
End tidal CO₂ measurement
Volume measurement
Respiratory physiology and pathophysiology of respiratory diseases
Display of respiratory signals
Airway pressure
Peak inflation pressure, positive end expiratory pressure, continuous positive airway pressure
Mean airway pressure: five different ways to change map during conventional ventilation: Change in peak inflation pressure, positive end expiratory pressure, inspiratory time, inspiratory slope, and rate
Positive End Expiratory Pressure,Inspiratory Time, Inspiratory Slope, and Rate
Effect of inspiratory and expiratory time on tidal volume: Effect of the time constant on flow and volume
Measurement of airflow
Recognizing spontaneous respiratory efforts
Checking for synchronization
Cycling off the mechanical inflation (flow cycling)
Measurement of volume
Tidal volume—minute ventilation
Tidal volume—effect of endotracheal tube leaks
Effect of mechanical characteristics of the respiratory system on tidal volume
Display of pulmonary graphics using loops
Pressure-volume loops
Flow-volume loops
Pulmonary mechanics
Lung compliance
Clinical implications
Resistive properties
Clinical implications
End tidal CO₂ curve
Role of pulmonary graphics in daily ventilator management—optimizing ventilator settings
Optimizing peak inflation pressure
Optimizing positive end expiratory pressure
Optimizing inspiratory and expiratory flow by adjusting inspiratory and expiratory time
Optimizing tidal volume
Optimizing synchrony
Optimizing oxygen exposure
Optimizing gas exchange—permissive hypercapnia
Determining the relative contribution of spontaneous breaths versus mechanical inflations to minute ventilation
Special circumstances
Pitfalls of graphics monitoring—troubleshooting
Evidence for the use of respiratory function monitoring to improve neonatal outcome
Acknowledgments
Key references
13 Airway evaluation: Bronchoscopy, laryngoscopy, and tracheal aspirates
Introduction
Flexible nasopharyngolaryngoscopy in the neonate
Indications
Risks, contraindications, and limitations
Equipment
Direct microlaryngoscopy and rigid bronchoscopy in the neonate
Indications
Risks, contraindications, and limitations
Equipment
Fiberoptic flexible bronchoscopy
Indications
Risks, contraindications, and limitations
Equipment
Bronchoalveolar lavage and tracheal aspirates
Summary
Suggested readings
Section 3 Delivery Room Stabilization, Oxygen Therapy, and Respiratory Support
14 Delivery room stabilization and respiratory support
Introduction
Physiology of transition, asphyxia, and resuscitation
Physiology of normal transition
Physiology of asphyxia
Physiology of resuscitation
Anticipation and preparation for resuscitation
Training
Teamwork
Anticipation
Preparation
Clinical assessment, apgar score, saturation, and heart rate monitoring
Clinical evaluation
Pulse oximetry and electrocardiograph
Intervention basics: Cord clamping, warmth, position, suction, stimulation
Management of the umbilical cord
Warmth
Position
Suction
Meconium-stained amniotic fluid
Stimulation
Oxygen
Ventilation
Pressure sources
Interfaces
Endotracheal intubation
Intubation equipment and procedure
Laryngeal mask airway
Monitoring
Chest compressions
Epinephrine
Volume expansion
Special cases
Preterm neonates
Congenital diaphragmatic hernia
Fetal hydrops
Ethics
Deciding whether to commence resuscitation
Deciding whether to stop resuscitation
Postresuscitation care
Examination/monitoring
Therapeutic hypothermia for hypoxic ischemic encephalopathy
Key references
15 Exogenous surfactant therapy
History
Surfactant function, composition, and metabolism
Function
Composition
Secretion and metabolism
Types of surfactant
Animal-derived surfactants
Synthetic surfactants without protein components
Protein-containing synthetic surfactants
Acute pulmonary and cardiac effects of surfactant therapy
Immediate pulmonary effects of surfactant therapy
Immediate effects on pulmonary circulation
Radiographic changes
Clinical trials of surfactant therapy
Surfactant therapy compared with placebo or no therapy
Prophylactic surfactant administration compared with post-birth stabilization on continuous positive airway pressure and selective surfactant administration
Early surfactant administration followed immediately by extubation to nasal continuous positive airway pressure
Targeted surfactant therapy
Single versus multiple surfactant doses
Criteria for repeat doses of surfactant
Methods of administration of surfactant
Administration through catheter, side port, or suction valve
Administration through dual-lumen endotracheal tube
Administration through a laryngeal mask airway
Nasopharyngeal administration of surfactant
Thin catheter endotracheal administration (less invasive surfactant administration)
Other methods
Chest position during administration of surfactant
Summary of administration methods
Choice of surfactant product
Comparison of animal-derived surfactant extract versus protein-free synthetic surfactant for the prevention and treatment of respiratory distress syndrome
Comparison of protein-containing synthetic surfactant versus animal-derived surfactant extract for the prevention and treatment of respiratory distress syndrome
Comparison of protein-containing synthetic surfactant versus protein-free synthetic surfactant for the prevention and treatment of respiratory distress syndrome
Comparison of different types of bovine surfactants
Comparison of porcine and bovine surfactants
Adverse effects of surfactant therapy
Economic aspects of surfactant therapy
Factors affecting the response to surfactant therapy
Long-term outcomes after surfactant therapy
Neurodevelopmental outcomes
Long-term respiratory outcomes
Physical growth
Outcomes of prophylactic versus rescue treatment strategies
Exogenous surfactant therapy for conditions other than respiratory distress syndrome
Meconium aspiration syndrome
Acute respiratory distress syndrome
Other conditions
Conclusion
Key references
16 Oxygen therapy
History of the use of oxygen in clinical medicine
Basic principles of oxygen physiology
Aerobic metabolism
Reactive oxygen species, redox regulation, and antioxidant enzymes
Redox regulation
Antioxidant defenses
Biomarkers of oxidative stress
Oxygen-sensing mechanisms and physiologic response
Oxygen in the fetal-to-neonatal transition and postnatal adaptation
Fetal-to-neonatal transition
Arterial oxygen saturation nomogram
Oxygen saturation in preterm infants with positive pressure ventilation and air
Oxygen administration in the delivery room
Oxygen during neonatal care in the neonatal intensive care unit
Evolving oxygen needs in the first weeks of life and new metabolic indices
Going home on oxygen
Oxygen saturation recommendations
Key references
17 Respiratory gas conditioning
Physiology and pathophysiology
Basics of the physical relationships among temperature, water vapor, and energy content of gases
Standards on humidification of medical gases for use with artificial respiratory support modalities
Procedures and devices for respiratory gas conditioning
Cold passover, bubble-through, and heated water humidifiers for use with nasal cannula therapy
Heated humidifiers with heated wire tubing circuitry
Heat and moisture exchangers (“artificial noses”)
Aerosol application
Irrigation of the airway
Estimation and measurement of the efficiency of respiratory gas conditioning device brands
Key references
18 Noninvasive respiratory support
Introduction
History of noninvasive respiratory support
What are the clinical indications and how does noninvasive respiratory support help?
Respiratory distress syndrome
Apnea of prematurity
Postextubation care
An overview of equipment used to provide noninvasive respiratory support
Interfaces
Pressure generators
Continuous positive airway pressure
Indications for continuous positive airway pressure support
Continuous positive airway pressure support for preterm infants from birth
Continuous positive airway pressure support for preterm infants postextubation
Continuous positive airway pressure support for apnea of prematurity
Continuous positive airway pressure support for other conditions
Contraindications to continuous positive airway pressure support
Continuous positive airway pressure devices and interfaces
Ventilator-generated continuous positive airway pressure
Bubble continuous positive airway pressure
Variable-flow continuous positive airway pressure
Benveniste gas-jet valve continuous positive airway pressure
Comparison of continuous positive airway pressure devices
Ventilator continuous positive airway pressure versus variable-flow (infant flow) continuous positive airway pressure
Ventilator continuous positive airway pressure versus bubble continuous positive airway pressure
Variable-flow continuous positive airway pressure versus bubble continuous positive airway pressure
Continuous positive airway pressure interfaces
Mononasal prongs, cut-down endotracheal tubes, and binasal nasopharyngeal prongs
Short binasal prongs
Future nasal prong development
Nasal masks
Nasal cannulae
Comparison between nasal interfaces
Comparison between nasal prong types
Comparison between nasal masks and nasal prongs
Comparison between standard interfaces and nasal cannulae
Optimal continuous positive airway pressure
Supportive care during continuous positive airway pressure
Administration of surfactant to infants on continuous positive airway pressure
Oropharyngeal, nebulized, and laryngeal mask airway surfactant administration
Less invasive surfactant administration and minimally invasive surfactant treatment: Surfactant administration via thin catheter
When has treatment with continuous positive airway pressure “failed?”
Complications of continuous positive airway pressure
Gaseous intestinal distension
Pneumothorax or other air leak
Nasal skin trauma
Continuous positive airway pressure weaning
Nasal ventilation
Physiologic mechanisms
Clinical trials
Nasal intermittent positive pressure ventilation
Synchronized nasal intermittent positive pressure ventilation
High-frequency nasal ventilation
Mechanisms of gas exchange
Clinical trials
Future directions
Nasal high flow
Clinical trials in preterm infants
Primary (early) respiratory support
Postextubation/surfactant respiratory support
Future directions
Conclusion
Acknowledgments
Key references
19 Overview of assisted ventilation
Introduction
Unique challenges in mechanical ventilation of newborn infants
Lung mechanics
Uncuffed endotracheal tubes
Measurement of tidal volume
Basic ventilator mode classification
Initiation of mechanical ventilation
Indications for mechanical ventilation
Choosing the ventilator mode
Initial settings for pressure controlled ventilation
Assessment after starting ventilation
Subsequent ventilator adjustments
Oxygenation
Ventilation/carbon dioxide elimination
Monitoring and documentation during mechanical ventilation
Ventilation protocols
Key references
20 Basic modes of synchronized ventilation
Introduction
Trigger technology
Patient-ventilator interactions with synchronized ventilation
Synchronized intermittent mandatory ventilation
Assist control
Pressure support ventilation
Choice of assisted ventilation modes
Guidelines for clinical application
Synchronized intermittent mandatory ventilation
Assist control
Pressure support ventilation
Conclusion
Key references
21 Principles of lung-protective ventilation
Introduction
Neonatal respiratory failure
Ventilator-induced lung injury
Risk factors for ventilator-induced lung injury
Volutrauma
Atelectrauma
Oxygen toxicity
Pulmonary and systemic consequences of ventilator-induced lung injury
Structural injury
Biotrauma
Surfactant dysfunction
Lung development
Susceptibility of newborn lungs to ventilator-induced lung injury
Lung-protective ventilation: Basic principles
Minimizing volutrauma
Minimizing atelectrauma
Lung-protective ventilation: Conventional mechanical ventilation
Low tidal volume ventilation
Tidal volume stabilization
Permissive hypercarbia
Open lung ventilation
Lung-protective ventilation: High-frequency ventilation
Lung-protective ventilation: Weaning and extubation
Implications for practice and research
Key references
22 Volume-targeted ventilation
Rationale for tidal volume-targeted ventilation
Volume-controlled versus volume-targeted ventilation
Neonatal tidal volume-targeted ventilation
Volume guarantee
Suggested clinical guidelines (see also table 22.3)
Pressure-regulated volume control
Volume ventilation plus
Volume targeted ventilation/adaptive pressure ventilation
Targeted tidal volume
Importance of open lung strategy
Alarms/troubleshooting
Conclusion
Key references
23 Special techniques of respiratory support
Introduction
Automated control of inspired oxygen
Ventilation techniques that provide support proportional to patient effort
Proportional assist ventilation
Neurally adjusted ventilatory assist
Airway pressure release ventilation
Ventilation techniques designed to maintain minute ventilation
Targeted minute ventilation
Mandatory minute ventilation
Apnea backup ventilation
Adaptive backup ventilation
Adaptive support ventilation
Conclusion
Key references
24 High-frequency ventilation
Types of high-frequency ventilators
High-frequency jet ventilators
High-frequency oscillators
High-frequency flow interrupters/percussive ventilators
Evidence base for clinical applications of high-frequency ventilation
Elective versus rescue high-frequency ventilation
Lung protective strategies with HFV: Limiting pressure while optimizing volume
Clinical applications of high-frequency ventilation in specific diseases
Respiratory distress syndrome
High-frequency oscillatory ventilation strategy in respiratory distress syndrome
High-frequency jet ventilation strategy in respiratory distress syndrome
Air-leak syndromes
High-frequency jet ventilation strategy in air-leak syndromes
High-frequency oscillatory ventilation strategy in air leak
Pulmonary hypoplasia and congenital diaphragmatic hernia
High-frequency oscillatory ventilation strategy in congenital diaphragmatic hernia and other lung hypoplasia conditions
High-frequency jet ventilation strategy congenital diaphragmatic hernia and other lung hypoplasia conditions
Hypoxemic respiratory failure in term infants
Knowledge gaps and research directions
Summary
Key references
25 Mechanical ventilation: Disease-specific strategies
Introduction
Respiratory distress syndrome
Key pathophysiologic features
Lung surfactant
Lung liquid
Developmental lung biology
Relevant principles of ventilation
High-frequency ventilation
Conventional ventilation
Extubation
Evidenced-based recommendations
Gaps in knowledge
Meconium aspiration syndrome
Key pathophysiologic features
Surfactant dysfunction
Airway resistance
Pulmonary hypertension
Relevant principles of ventilation
High-frequency ventilation
Conventional ventilation
Evidenced-based recommendations
Gaps in knowledge
Lung hypoplasia disorders
Key pathophysiologic features
Lung hypoplasia
Pulmonary vascular bed
Relevant principles of ventilation
Pulmonary hypertension
Evidenced-based recommendations
Gaps in knowledge
Bronchopulmonary dysplasia
Key pathophysiologic features
Lung pathology
Lung mechanics and function
Relevant general principles of mechanical ventilation
Tracheostomy
Pulmonary hypertension
Evidenced-based recommendations
Gaps in knowledge
Conclusion
Key references
26 Weaning and extubation from mechanical ventilation
Background
Weaning from ventilatory support
Weaning from pressure-controlled ventilation
Weaning from high-frequency ventilation
General strategies to facilitate weaning
Permissive hypercarbia
Permissive hypoxemia
Weaning protocols
Adjunctive therapies
Caffeine
Diuretics
Closure of patent ductus arteriosus
Avoidance of routine sedation
Nutritional support
Chest physiotherapy
Systemic corticosteroids
Inhaled and intratracheal corticosteroids
Assessment of extubation readiness
Clinical predictors
Extubation readiness tests
Physiological assessments
Clinical assessments
Analysis of the dynamics of physiologic signals before extubation
Postextubation management
Adjunctive therapies
Caffeine
Nebulized racemic epinephrine and dexamethasone
Postnatal corticosteroids for the prevention and treatment of postextubation stridor
Chest physiotherapy
Extubation failure
Summary
Suggested readings
27 Common devices used for mechanical ventilation
Introduction to ventilators
Power inputs
Power conversion and control
Flow control valves
Control subsystems
Power outputs
Idealized pressure, volume, and flow waveforms
Ventilator alarm systems
Operator–ventilator interface: Displays
Alphanumeric values
Trends
Waveforms and loops
Patient–ventilator interface: Circuits
Understanding modes of ventilation
Defining a breath/inflation
Defining assisted breath
Assistance with volume or pressure control
Trigger and cycle events
Machine versus patient trigger and cycle events
Spontaneous versus mandatory breaths/inflations
Breath sequences
Ventilatory patterns
Targeting schemes
Full mode taxonomy
How to classify a mode of ventilation
Universal intensive care ventilators used for neonatal ventilation
AVEA CVS
Modes
Airway pressure release ventilation/biphasic.
Continuous positive airway pressure/pressure support.
Continuous positive airway pressure/pressure support with volume limit.
Infant nasal continuous positive airway pressure.
Infant nasal intermittent mandatory ventilation.
Pressure assist-control.
Pressure assist-control with flow cycle.
Pressure assist-control with machine volume.
Pressure assist-control with volume guarantee.
Pressure-regulated volume control assist-control (not available for neonatal ventilation).
Pressure-regulated volume control assist-control with flow cycle (not available for neonatal ventilation).
Pressure-regulated volume control synchronized intermittent mandatory ventilation with flow cycle (not available for neonatal ventilation).
Pressure-regulated volume control synchronized intermittent mandatory ventilation (not available for neonatal ventilation).
Pressure synchronized intermittent mandatory ventilation.
Pressure synchronized intermittent mandatory ventilation with volume guarantee (available for neonatal patient size setting only).
Time-cycled pressure-limited assist-control (available for neonatal patient size setting only).
Time-cycled pressure-limited assist-control with flow cycle.
Time-cycled pressure-limited assist-control with flow cycle and volume guarantee.
Time-cycled pressure-limited assist-control with volume guarantee (available for neonatal patient size setting only).
Time-cycled pressure-limited synchronized intermittent mandatory ventilation (available for neonatal patient size setting only).
Time-cycled pressure-limited synchronized intermittent mandatory ventilation with volume guarantee (available for neonatal patient size setting only).
Volume assist-control (with demand flow).
Volume assist-control with Vsync.
Volume assist-control with Vsync and flow cycle.
Volume synchronized intermittent mandatory ventilation.
Volume synchronized intermittent mandatory ventilation with Vsync.
PB 980
Modes
Assist-control pressure control.
Assist-control volume ventilation plus.
Assist-control volume control.
Bilevel + pressure support.
Bilevel + tube compensation.
Synchronized intermittent mandatory ventilation pressure control + pressure support.
Synchronized intermittent mandatory ventilation pressure control + tube compensation.
Synchronized intermittent mandatory ventilation volume control + pressure support.
Synchronized intermittent mandatory ventilation volume ventilation plus + pressure support.
Synchronized intermittent mandatory ventilation volume control plus + tube compensation.
Spont pressure support.
Spont volume support.
Neonatal ventilation.
Bellavista 1000
Modes
Adaptive ventilation mode.
Airway pressure release ventilation.
beLevel.
Continuous positive airway pressure.
Nasal continuous positive airway pressure.
Nasal intermittent positive pressure ventilation.
Pressure control-synchronized intermittent mandatory ventilation.
Pressure control-synchronized intermittent mandatory ventilation + targetvent.
Pressure assist-control ventilation.
Pressure assist-control + targetvent.
Pressure-controlled ventilation.
Pressure support ventilation.
Pressure support ventilation + targetvent.
Spontaneous.
Spontaneous + targetvent.
Spontaneous/timed.
Spontaneous/timed + targetvent.
Timed.
Volume assist-control.
Evita infinity V500, V600/800
Modes
Pressure control assist-control.
Pressure control airway pressure release ventilation.
Pressure control continuous mandatory ventilation.
Pressure control pressure support.
Pressure control synchronized intermittent mandatory ventilation.
Smartcare/pressure support.
Spontaneous continuous positive airway pressure.
Spontaneous continuous positive airway pressure/pressure support.
Spontaneous continuous positive airway pressure/variable support.
Spontaneous continuous positive airway pressure/volume support.
Spontaneous/proportional pressure support.
Volume control assist-control.
Volume control assist-control + autoflow/volume guarantee.
Volume control assist-control + pressure limitation.
Volume control continuous mandatory ventilation.
Volume control continuous mandatory ventilation + autoflow.
Volume control continuous mandatory ventilation + pressure limitation.
Volume control mandatory minute volume ventilation.
Volume control mandatory minute volume ventilation + autoflow/volume guarantee.
Volume control continuous positive airway pressure.
Volume control synchronized intermittent mandatory ventilation + autoflow/volume guarantee.
Volume control synchronized intermittent mandatory ventilation + pressure limitation.
Neonatal ventilation
Evita infinity V600/800
SERVO-I and SERVO-U
Modes
Automode (pressure control to pressure support).
Automode (pressure-regulated volume control to volume support).
Automode (volume control to volume support).
BiVent.
Neurally adjusted ventilatory assist.
Pressure control.
Pressure-regulated volume control.
Pressure support.
Synchronized intermittent mandatory ventilation (volume control).
Synchronized intermittent mandatory ventilation (pressure-regulated volume control).
Synchronized intermittent mandatory ventilation (pressure control).
Spontaneous/continuous positive airway pressure.
Volume control.
Volume support.
Neonatal ventilation with SERVO-I.
SERVO-n and SERVO-U
Carescape R860
Modes
Assist-control pressure control.
Assist-control pressure regulated volume control.
Assist-control volume control.
Assist-control volume control + pressure limit.
Airway pressure release ventilation.
Bilevel airway pressure ventilation.
Bilevel airway pressure ventilation + volume guaranteed.
Continuous positive airway pressure/pressure support.
Noninvasive ventilation.
Synchronized intermittent mandatory ventilation pressure controlled.
Synchronized intermittent mandatory ventilation pressure regulated volume control.
Synchronized intermittent mandatory ventilation volume control.
Synchronized intermittent mandatory ventilation volume control + pressure limit.
Spontaneous breathing trial.
Volume support.
Neonatal ventilation.
Hamilton G5
Modes
Adaptive support ventilation.
Airway pressure release ventilation.
Adaptive pressure ventilation continuous mandatory ventilation (APVCMV).
Adaptive pressure ventilation intermittent mandatory ventilation (APVIMV).
DuoPositive airway pressure.
INTELLiVENT adaptive support ventilation.
Nasal continuous positive airway pressure/pressure support.
Noninvasive ventilation.
Noninvasive ventilation-spontaneous/timed.
Positive-continuous mandatory ventilation.
Positive-synchronized intermittent mandatory ventilation.
Synchronized continuous mandatory ventilation.
Synchronized intermittent mandatory ventilation.
Spontaneous.
Volume support.
Specialized neonatal ventilators
Babylog VN500 and 600/800
Modes
Pressure control-assist-control.
Pressure control-assist-control + volume guarantee.
Pressure control-airway pressure release ventilation.
Pressure control-continuous mandatory ventilation.
Pressure control-continuous mandatory ventilation + volume guarantee.
Pressure control-mandatory minute volume ventilation + volume guarantee.
Pressure control-pressure support ventilation.
Pressure control-pressure support ventilation + volume guarantee.
Pressure control-synchronized intermittent mandatory ventilation.
Pressure control-synchronized intermittent mandatory ventilation + volume guarantee.
Spontaneous continuous positive airway pressure/pressure support.
Spontaneous continuous positive airway pressure/volume support.
Spontaneous proportional pressure support.
Automatic tube compensation (ATC).
High-frequency oscillatory ventilation (with volume guarantee).
Babylog VN600/800
SERVO-n and SERVO-U
Fabian high-frequency oscillatory
Modes
Intermittent positive-pressure ventilation (continuous mandatory ventilation).
Intermittent positive-pressure ventilation (continuous mandatory ventilation) + volume guarantee.
Synchronized intermittent positive pressure ventilation (ASSIST).
Synchronized intermittent positive pressure ventilation (ASSIST) + volume guarantee.
Synchronized intermittent mandatory ventilation.
Synchronized intermittent mandatory ventilation + pressure support ventilation.
Pressure support ventilation.
Pressure support ventilation + volume guarantee.
High-frequency oscillatory ventilation.
Continuous positive airway pressure.
Nasal continuous positive airway pressure/duo positive airway pressure.
Leoni plus
Modes
Continuous positive airway pressure.
High-frequency oscillation.
Intermittent positive-pressure ventilation/intermittent mandatory ventilation.
Intermittent positive-pressure ventilation/intermittent mandatory ventilation + volume guarantee.
Nasal continuous positive airway pressure.
Nasal intermittent positive pressure ventilation.
Pressure support-intermittent mandatory ventilation.
Pressure support-intermittent mandatory ventilation + volume guarantee.
Pressure support-S intermittent positive pressure ventilation.
Pressure support-intermittent positive pressure ventilation + volume guarantee.
S-intermittent mandatory ventilation.
S-intermittent mandatory ventilation + volume guarantee.
S-intermittent positive pressure ventilation.
S-I intermittent positive pressure ventilation + volume guarantee.
Vyaire infant flow SiPAP
Modes
BiPhasic.
BiPhasic tr.
Continuous positive airway pressure.
Summary
Key references
28 Extracorporeal membrane oxygenation
Introduction
History of cardiopulmonary bypass
Development of membrane oxygenators
Development of a pump
Vascular access
Physiology of extracorporeal circulation
Membrane lung
Oxygen and carbon dioxide transfer
Patient selection
Disease states
Selection criteria
Alveolar-arterial oxygen gradient
Oxygenation index
Acute deterioration
Ventilator-associated lung injury
Contraindications
Evaluation before extracorporeal membrane oxygenation
Technique for beginning extracorporeal membrane oxygenation
Before cannulation
Venoarterial versus venovenous cannulation
Operative procedure
Daily management
Weaning
Decannulation
Outcome
Key references
Section 4 Bedside Care, Nutritional and Pharmacologic Support
29 Respiratory care of the newborn
Introduction
Techniques to provide positive-pressure ventilation
Manual ventilation
Face masks for ventilation
Endotracheal intubation
Routes of intubation
Equipment
Types of tubes
Depth of tube insertion
Determination of placement
Tube fixation
Acquisition and maintenance of intubation skills
Laryngeal mask airway
Noninvasive ventilation and continuous positive airway pressure
Heated humidified high-flow nasal cannula
Monitoring during respiratory support
Monitoring during noninvasive respiratory support
Monitoring during conventional and high-frequency ventilation
Humidification and warming during respiratory support
Airway clearance techniques
Chest physiotherapy
Positioning of the patient
Percussion and vibration
Administration of medications into the respiratory tract
Surfactant treatment
Surfactant administration
Optimization of aerosol drug delivery
Clinician-based ventilator and weaning protocols
Resuscitation and stabilization at delivery
Key readings
30 Nursing care
Introduction
Assessment of the neonate
Pain assessment
Respiratory care
Oxygen saturation monitoring
Positioning and containment
Noninvasive ventilation
Mechanical ventilation
Airway security
Endotracheal tube movement and malposition
Suctioning
Ventilator-associated pneumonia
High-frequency ventilation
Inhaled nitric oxide
Sudden deterioration
General care of the neonate
Thermal instability
Nutrition
Skin care
Adhesive application and removal
Pressure ulcers and skin injury
Managing pain
Developmental care
Skin-to-skin holding
Care of the family
Conclusion
Key references
31 Nutritional support
The importance of nutrition during critical stages of lung development
Nutritional requirements
Water requirement
Insensible water loss
Renal function and water excretion
Energy requirement
Protein requirement
Lipid requirement
Carbohydrate requirement
Mineral requirements
Vitamin requirements
Parenteral nutrition
Composition of total parenteral nutrition
Enteral nutrition
Advantages of enteral nutrition
Methods of gavage feeding
Minimal enteral feedings and enteral feeding advancement
Human milk
Donor human milk
Human milk fortification
Formulas
Special nutritional considerations for infants with established bronchopulmonary dysplasia
Key references
32 Pharmacologic therapies
Introduction
Steroids
Early postnatal (<8 days) steroid therapy for prevention of bronchopulmonary dysplasia
Late (≥8 days) postnatal steroid therapy for prevention or therapy of bronchopulmonary dysplasia in preterm infants
Sedation and analgesia
Opioids
Morphine
Fentanyl
Dexmedetomidine
Benzodiazepines
Midazolam
Lorazepam
Diazepam
Other sedative agents
Muscle relaxants
Pancuronium
Vecuronium
Rocuronium
Cisatracurium
Bronchodilators and mucolytic agents
Albuterol (salbutamol)
Cromoglycic acid
Ipratropium bromide
Racemic epinephrine
N-acetylcysteine
Combination therapies
Diuretics
Furosemide
Bumetanide
Thiazides and potassium-sparing diuretics
Respiratory stimulants
Theophylline
Caffeine
Doxapram
Summary
Key readings
33 Common hemodynamic problems in the neonate requiring respiratory support
Introduction
Normal transition
Hemodynamic problems in the neonate
Persistent pulmonary hypertension of the newborn
Clinical evaluation
Intervention
Specific therapy.
Cardiovascular support.
Research needs
Septic shock
Clinical evaluation
Research needs
Hypoxic ischemic encephalopathy
Cardiogenic shock
Hypotension in the extremely low gestational age newborn
Research needs
Conclusion
Key references
Section 5 Treatment of Specific Conditions, Surgical Interventions and Other Considerations
34 Diagnosis and management of persistent pulmonary hypertension of the newborn
Introduction
Etiology
Clinical features
Hypoxemia in persistent pulmonary hypertension of the newborn
Diagnosis
Echocardiography and hemodynamic assessment in persistent pulmonary hypertension of the newborn²⁰
Severity of persistent pulmonary hypertension of the newborn
Ventricular function
Shunt direction
Precapillary versus pulmonary venous hypertension
Supportive management
Asphyxia, hypothermia, and persistent pulmonary hypertension of the newborn
Oxygen
Carbon dioxide and pH targets
Noninvasive ventilation
Invasive ventilation
Surfactants in persistent pulmonary hypertension of the newborn
Inhaled nitric oxide
Initiation of inhaled nitric oxide
Weaning inhaled nitric oxide
Sildenafil
Milrinone
Prostaglandin E1
Endothelin receptor antagonists
Management of systemic hypotension in persistent pulmonary hypertension of the newborn
Fluid management
Sodium bicarbonate
Vasoactive infusions
Hydrocortisone
Preterm infants with early pulmonary hypertension (preterm persistent pulmonary hypertension of the newborn)
Conclusion
Key references
35 Care of the infant with congenital diaphragmatic hernia
Introduction
Antenatal assessment of severity and fetal management
Initial treatment and procedures in the delivery room
Transport from delivery room to neonatal intensive care unit
Initial ventilation in congenital diaphragmatic hernia
Gentle ventilation in congenital diaphragmatic hernia
Supportive measures
Echocardiogram
Pulmonary vasodilator therapy
Inhaled nitric oxide
Milrinone
Prostaglandin infusion
Sildenafil
Extracorporeal membrane oxygenation
Surgical repair
Pulmonary and nutritional outcome
Discharge and follow-up
Conclusion
Acknowledgment
Key references
36 Management of the infant with bronchopulmonary dysplasia
Introduction
Epidemiology, pathophysiology, and diagnosis of bronchopulmonary dysplasia
Prevention of bronchopulmonary dysplasia
Clinical presentation and evaluation of infants with established bronchopulmonary dysplasia
Clinical presentation of severe bronchopulmonary dysplasia
Severe lung parenchymal disease as the leading feature of severe bronchopulmonary dysplasia
Pulmonary hypertension as the leading feature of severe bronchopulmonary dysplasia
Airway disease as the leading feature of severe bronchopulmonary dysplasia
Evaluation of infants with severe bronchopulmonary dysplasia
Physiologic basis for respiratory support in infants with established bronchopulmonary dysplasia
Ventilatory control in infants with bronchopulmonary dysplasia
Pulmonary mechanics in infants with bronchopulmonary dysplasia
Management of infants with established bronchopulmonary dysplasia
Keys to successful bronchopulmonary dysplasia management
Respiratory management in infants with established bronchopulmonary dysplasia
Noninvasive ventilation
Mechanical ventilation
Conventional mechanical ventilation.
High-frequency ventilation.
Adjunctive respiratory support therapies in infants with established bronchopulmonary dysplasia
Heliox
Pharmacotherapies
Management of pulmonary hypertension
Management of persistent ductus arteriosus
Nutritional support
Minimizing pulmonary micro-aspiration
Role of tracheostomy in infants requiring long-term support
Pulmonary outcomes in infants with bronchopulmonary dysplasia
Conclusion
Selected readings
37 Medical and surgical interventions for respiratory distress and airway management
Introduction
Medical management of the neonatal airway
Anatomic disadvantages of the neonatal airway
Medical management of neonates with common respiratory disorders requiring surgical intervention
Congenital airway disorders
Acquired airway disorders
Surgical management of the neonatal airway
The pediatric surgeon/otolaryngologist as diagnostician and therapist
Developmental abnormalities of the airway
Nasopharyngeal obstruction
Choanal atresia
Oropharyngeal obstruction
Macroglossia.
Beckwith-Wiedemann syndrome.
Metabolic disorders.
Trisomy 21 (Down syndrome).
Severe bronchopulmonary dysplasia.
Lingual thyroid.
Craniofacial Dysmorphology syndromes.
Pierre Robin sequence.
Treacher Collins syndrome.
Hallermann-Streiff syndrome.
Möbius syndrome.
Freeman-Sheldon syndrome.
Nager syndrome.
Laryngeal anomalies
Laryngeal atresia.
Laryngeal web.
Congenital vocal cord paralysis.
Laryngomalacia.
Congenital subglottic stenosis.
Acquired subglottic stenosis.
Laryngeal cleft.
Subglottic hemangioma.
Tracheal anomalies
Intrinsic tracheal compression.
Tracheomalacia.
Tracheal stenosis.
Necrotizing tracheobronchitis.
Extrinsic tracheal compression.
Cystic hygroma.
Vascular rings.
Developmental abnormalities of the lung
Pulmonary and lobar agenesis
Pulmonary hypoplasia
Congenital lobar emphysema
Congenital pulmonary airway malformation
Sequestration
Pulmonary cystic lesions
Developmental abnormalities of the diaphragm
Diaphragmatic hernia of bochdalek
Diaphragmatic paralysis/eventration
Developmental abnormalities of the skeleton
The pediatric surgeon/otolaryngologist as consultant
Neonatal bronchoscopy
Anatomic considerations
Pathophysiology
Evaluation of intubation
Endoscopes
Tracheostomy
Procedure
Anterior cricoid split procedure
Tracheostomy tubes
Key references
38 Intraoperative management of the neonate
Transitional physiology and pulmonary hypertension
Pulmonary development and lung injury
Anatomic considerations
Intrathoracic masses
Abdominal wall defects
Location of operation
Premedication for intubation
Selection and placement of the endotracheal tube
Operative management
Ventilator mode
Vital signs
Intraoperative fluid management and electrolyte management
Additional operative considerations
Troubleshooting
Temperature regulation
Neonate pain perception
Conclusion
Key references
39 Complications of respiratory support
Complications of respiratory support
Mechanical ventilation
Endotracheal intubation
Unplanned extubation
Ventilator-induced lung injury
Ventilator-associated pneumonia
Ventilator-associated events and ventilator-associated conditions
Noninvasive respiratory support
Continuous positive airway pressure
High-flow nasal cannula
Positive pressure ventilation
Nasal intermittent positive pressure ventilation
Less invasive surfactant administration
Suggested readings
40 Neonatal respiratory care in resource-limited countries
Introduction
Scope of the need
Limiting factors
Current status
Asia
India
Other countries
Africa
Latin America
Establishing respiratory care programs
Outcomes of neonatal ventilation
Projected growth in neonatal ventilation: A global perspective
Ethical dilemmas
Conclusion
Acknowledgment
Key references
41 Transport of the ventilated infant
Important role of the transport team
Regionalized care
Transport team composition
Transport education
Transport physiology
Hypoxia
Air expansion
Noise and vibration
Thermoregulation
Stabilization
Clinical issues
Equipment
Transport ventilators
High-frequency ventilation
Continuous positive airway pressure
Surfactant administration
Inhaled nitric oxide
Extracorporeal membrane oxygenation
Hypothermia for hypoxic ischemic encephalopathy
Future directions
Key references
42 Discharge and transition to home care
Factors to consider when determining readiness for discharge
Discharge team
Predischarge needs assessment
Home environment
Equipment and supplies
Personnel resources
Home nursing
Emergency planning
Postdischarge follow-up
Tracheostomy care
Changing tracheostomy tubes
Outpatient management of supplemental oxygen therapy
Indications for home oxygen therapy
Hypoxemia
Growth failure
Intermittent hypoxemia and pulmonary hypertension
Oxygen delivery systems for home oxygen therapy
Oxygen concentrator
Liquid oxygen
Compressed gas system
Strategies for discontinuation of home oxygen therapy
Key references
43 Neurologic effects of respiratory support in the neonatal intensive care unit
Introduction
Cerebral blood flow in the neonate
Cerebral autoregulation and pressure-passive circulation
Brain injury in the preterm infant
Periventricular-intraventricular hemorrhage
Physiologic factors contributing to intraventricular hemorrhage
Inflammation and intraventricular hemorrhage
Antenatal corticosteroids and indomethacin
Delayed cord clamping
Diagnosis of intraventricular hemorrhage
Periventricular hemorrhagic infarction (grade 4 intraventricular hemorrhage)
Periventricular leukomalacia and diffuse white matter injury
Pathogenesis of white matter injury
Influence of oxygen concentration and carbon dioxide on cerebral blood flow
Oxygen and hemoglobin
Carbon dioxide
Linking changes in carbon dioxide and oxygen concentration to hemorrhagic–ischemic injury
Hypocarbia and white matter injury
Hypercarbia and intraventricular hemorrhage
Oxygen and brain injury
Mode of ventilation and brain injury
Continuous positive airway pressure
Conventional mechanical ventilation
High-frequency oscillatory ventilation
Medications used to treat respiratory conditions
Surfactant
Methylxanthines
Inhaled nitric oxide
Postnatal steroids
Summary
Key references
44 Pulmonary and neurodevelopmental outcomes following ventilation
Introduction
Incidence and definitions of bronchopulmonary dysplasia
Pulmonary outcomes
Pulmonary function testing and imaging
Longer-term respiratory morbidity
Health care utilization
Neurodevelopmental outcomes of preterm infants with bronchopulmonary dysplasia
Outcomes after neonatal hypoxic respiratory failure
Inhaled nitric oxide
Extracorporeal membrane oxygenation
Conclusion
Key references
45 Gaps in knowledge and future directions for research
Introduction
Development and application of new methods of generating knowledge
Basic and clinical study designs
Respiratory care
Delivery room management
Mechanical ventilation
Noninvasive respiratory support
Exogenous surfactant administration
Management of specific respiratory and nonrespiratory conditions requiring assisted ventilation
Bronchopulmonary dysplasia
Other conditions requiring ventilatory support
Congenital diaphragmatic hernia
Pulmonary hypertension of the newborn
Ancillary support
Nutritional support
Development of devices
Current research
Ongoing clinical trials around the world
Concluding comments
Selected readings
Appendices
Appendix 1
Lung volumes in the infant
Appendix 2
Changes in respiratory system dimensions with growthª
Appendix 3
Effect of age on lung sizeª
Appendix 4
Normal lung function data for term newborns during the neonatal period
Appendix 5
Allen’s test
Appendix 6
Procedure for obtaining capillary blood gases
Appendix 7
Normal umbilical cord blood gas values
Appendix 7a
Arterial blood gas values in normal full-term infantsª
Appendix 7b
Arterial blood gas values in normal premature infantsª
Appendix 8
Capillary blood gas reference values in healthy term neonates
Appendix 9
Blood gas values in cord blood and in arterial blood at various ages during the neonatal period
A. Oxygen tension
B. Carbon dioxide tension
C. pH
D. Base excess
Appendix 10
Conversion tables
A. Torr to kilopascal
B. Kilopascal to torr
Appendix 11
Siggaard-Andersen alignment nomogram
Appendix 12
Systolic, diastolic, and mean blood pressure by birth weight and gestational age
Appendix 13
Systolic and diastolic blood pressure in the first 5 days of life
Appendix 14
Neonatal resuscitation record
Appendix 15
Effective FiO₂ conversion tables for infants on nasal cannula
Appendix 16
Neonatal indications and doses for administration of selected cardiorespiratory drugs
Cardiorespiratory pharmacopeia for the newborn period
Administration routes
Appendix 17 apps
Alveolar-arterial oxygen gradient
Respiratory quotient and barometric pressure
Information about alveolar–arterial oxygen gradient and PAO₂/FiO₂ ratio
Complete ABG
For metabolic alkalosis
ETCO₂ tutor
Index
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Inside back cover