N.I.C.U.

Pocket Guide
For
Respiratory Therapists

Contributors

CharlesWilliamsRRT
SoniaGoedeRRT
CarissaYackusRRT

Contents
Assessment of the Newborn
CommonNewbornCardiopulmonaryDisorders
NormalVitalsigns
5
NormalABGs 5
SignsofRespiratoryDistress 6
APGARScoring
7
PrimaryApneavs.SecondaryApnea

Airway Management and Mechanical Ventilation

PositivePressureBreaths
9
NeopuffInfantResuscitator
10
NasalCPAP 12
Intubation
14
MechanicalVentilation
16
HighFrequencyVentilation 18

Miscellaneous and Special Considerations

SurvantaDelivery
21
Pneumothorax 23
FreeFlowOxygen
24
SpecialSituations
25
ResuscitationFlowchart
27

Common Newborn Cardiopulmonary Disorders

TTNB Transient Tachypnea of the Newborn
Delayedclearanceorabsorptionoffetallungfluid

RDS Respiratory Distress Syndrome

Immaturelungs/surfactantdeficiencycausingalveolarinstabilityandcollapse

BPD Bronchopulmonary Dysplasia

Chroniclungdiseaseduetoadministrationofhighlevelsofoxygen

MAS Meconium Aspiration Syndrome

Aspirationoffetalbowelcontentscausingairwayobstructionandchemicalpneumonitis

PPHN Persistent Pulmonary Hypertension of the Newborn

Elevatedpulmonaryvascularresistancecausesaright-to-leftshunt,bypassingthelungs,resultinginarterialhypoxemia.

P.I.E. Pulmonary Interstitial Emphysema; Pulmonary Air Leaks

PulmonaryInterstitialEmphysemaairwithinthepulmonaryinterstitialtissue

Pneumothoraxairwithinthepleuralspace

Pneumomediastinumairwithintheanteriormediastinum

Pneumopericardiumairwithinthepericardialsacsurroundingtheheart

Normal Vital Signs

Birth
weight
(g)

500-700
700-1000
10001500
15002000
20003000
Term

Blood
Pressur
e
Systolic

Blood
Pressur
e
Diastolic

(mmHg)

(mmHg)

50-60
48-58
47-58

26-36
24-36
25-35

47-60

25-35

51-72

27-46

64-72

50-55

Heart
Rate

Respirat
ory Rate

120-170

30-60

SpO2

88-94%

Normal Newborn Blood Gases

Capillar
y
Arterial
Venous

pH
7.377.44
7.377.44
7.357.45

PCO2
31-45

PO2
60-100

HCO3
22-26

31-45

80-110

22-26

34-50

---

24-28

Newborn Signs of Respiratory Distress

Tachypnea-(RR>60breaths/min)

Cyanosis-(Peripheralcyanosisiscommon,Centralcyanosisusuallyindicatesanarterial
pO2<40mmHg)

Nasal Flaring-(Signofairhunger)

Expiratory Grunting-(Neonateattemptingtomaintainpositivepressureonexpirationand
preventalveolarcollapse)

Retractions-
Intercostal-betweentheribs,
Supraclavicular-abovetheclavicles,
Subcostal-belowtheribmargins

APGAR Scoring

Provides a quick assessment for depression upon delivery

Perform at 1 minute and 5 minutes after birth

Primary vs. Secondary Apnea

Primary Apnea

Initialresponsetohypoxemia

Initialtachypnea,thenapnea,bradycardia,decreasedneuromusculartone

Respondstostimulation&blow-byO2

Secondary Apnea

Followsprimaryapnea

Deep,gaspingrespirationsfollowedbyapnea,bradycardia,decreasedneuromusculartone,and
hypotension

Willonlyrespondtoassistedventilationw/supplementalO2;ifnotdone,death/braindamagerapidly
ensues

Ifababydoesnotbeginbreathingimmediatelyafterbeingstimulated,heorsheislikelyin
secondaryapneaandwillrequirepositive-pressureventilation.ContinuedstimulationWill NOT
help!

Positive Pressure Breaths

Recommended Pressures:
Initial breath (After delivery) - >30 cm H20
Normal lungs (later breaths) - 15 to 20 cm H20
Diseased or immature lungs 20 to 40 cm H20

Try to maintain a rate of 40 to 60 breaths per minute

By saying aloud..
Breathtwo...threebreathtwo...three....breath
(squeeze)
(squeeze)
(squeeze)

Neopuff Infant Resuscitator

TheNeopuffInfantResuscitatorisaneasytouse,manuallyoperated,gas-powered
resuscitatorthatprovidesoptimalresuscitation.

DeliverscontrolledandprecisePeakInspiratoryPressure(PIP)andPositiveEnd
ExpiratoryPressure(PEEP).
Avoidstherisksassociatedwithuncontrolledpressures.
Canalsobeusedtodeliverfree-flowoxygen.
10

Neopuff Infant Resuscitator (cont.)

ThedesiredPIPissetbyturningthe
inspiratorypressurecontrol.

ThedesiredPEEPissetbyadjustingtheTpieceaperture

ThepatientT-pieceallowsbreathbybreathresuscitationbysimplyoccluding
theT-pieceaperturewiththethumborfinger.

11

Nasal CPAP

12

Nasal CPAP (cont)

Utilizetheprongsizeguidetoselecttheappropriatesizednasalprongs.

3sizesavailable:small,medium,large.

Choosetheappropriatesizedbonnetbymeasuringthebabysheadcircumference.
-Toosmallofahatmaycauseittorideupthehead,puttingtensionontheprongsandcausing

nasalirritation.
-Toolargeofahatmayallowittoslidedownoverthepatient'seyesandreleaseCPAPprongsfrom
thenose.

Thefrontedgeofthebonnetshouldbeattheeyebrowlineandthebackcovertheentireskull.The
sidesshouldcovertheearsbutbecertainthattheearsarenotfoldedunderthebonnet.

PreparebabyforapplicationofnasalCPAPbysuctioningandclearingthenoseofanyobstructive
secretions.

AdjustflowmetertoachievedesiredamountofCPAP(indicatedonthePressurebargraphdisplay)
(Approx.flowof8.5=5cmH2Opressure)

13

Intubation
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Ventilateneonatewith100%oxygenusingbag/mask
InsertstyletintotheETtubejustshortofthetubestip
Ensureneonateissupineandairwayishyperextended(opened)butnotoverextended
Insertlaryngoscopebladeintomouth,openingtheairwayandvisualizingthevocalcords
InserttheETtubestoppingwhenthetipofthetubehaspassedthevocalcords
ResumepositivepressureventilationviaETtube
Confirmthetubesposition
End-tidalCO2detection
Chestx-ray
Auscultation
Observationofcondensationduringexhalation
SecuretheETtube

14

Intubation (cont.)
Intubation and Suctioning Guidelines

Birth Weight
< 1000 g

Laryngoscope
Blade Size
0

Endotracheal
Tube Size
2.5 mm

Suction
Catheter Size
5 Fr.

1000-2000 g

3.0 mm

6 Fr.

2000-3000 g

0-1

3.5 mm

8 Fr.

>3000 g

3.5-4.0 mm

8 Fr.

Weight in kg.

cm mark @ lip

<1

6.5

10

15

Mechanical Ventilation
Indications for Mechanical Ventilation in Neonates
Respiratory Failure

Paco2>55mmHg

Pao2<50mmHg

Neurologic compromise

Apneaofprematurity

Intracranialhemorrhage

Drugdepression

Impaired pulmonary function

RespiratoryDistressSyndrome(RDS)

Meconiumaspiration

Pneumonia

Prophylactic use

Persistentpulmonaryhypertensionofnewborn(PPHN)
16

Mechanical Ventilation (cont.)

Suggested Initial Settings for Specific Disease States:
PIP

PEEP

Rate

Ti

Normal
Infant

10-12

2-4

Minimal
(15-20)

0.3-0.5

RDS

20-30

4-8

20-40

0.3-0.5

Preemie
(<1000gm)

Minimum
asposs.

2-4

20-30

0.3-0.5

Pulm Air Leak

(PIE,
Pneumothorax)
PPHN

<20

<2

60150

0.25-0.4

<20

<2

30-60*

0.25-0.4

Meconium
Aspiration
(w/atelectasis)
Meconium
Aspiration
(w/hyperaeration))
Diaphragmatic
Hernia

30-60

4-6

25-50

0.3-0.5

<20

<2

20-25

0.25-0.4

<20

<2

25-100

0.3-0.5

BesuretoconfirmTotalPIPordered.
(TotalPIPPEEP=SetPIP)

17

High Frequency Ventilation

18

High Frequency Ventilation (cont.)

HFOVkeepsthelungs/alveoliopenataconstant,lessvariable,airwaypressure.Thispreventsthelunginflate-deflate',inflatedeflate'cycle,whichhasbeenshowntodamagealveoliwhenthereisdecreasedlungcompliance(i.e.RDS)andlungsarestiff.
HFOVcanbethoughtofasvibratingCPAP.
Musthaveadequatechestwigglefactor(CWF).
Besurelungsareinflatedto8 thor9thrib,donotover-inflate.

Bias Flow Itistherateatwhichtheflowofgas,throughtheoscillator,isdeliveredtothepatient.

AdjustingBiasFlowwillaffectMeanAirwayPressure.

MAP Adjust AffectedbychangesinBiasFlow

Increaseslungvolume,andcontrolsoxygenation,alongwithFIO2.

Frequency (Hz) - Hzx60=rate

Adecreaseinfrequency=increasedtidalvolume
Anincreaseinfrequency=decreasedtidalvolume
DiseaseVariableDiseaseVariableDiseaseVariable
PretermRDS<1000g-15HzPretermAirleak-15HzMAS-10to6Hz
TermorNearTermRDS-10HzTermorNearTerm-10HzCDH-10Hz

Power (P) - Amplitude

ControlsCO2removal
ControlsChestWiggleFactor(CWF)

Inspiratory Time %
Cankeepat33%formostapplications
AffectsAmplitude

Initial Settings:
MAP---2-4cmH20>conventionalMAP
P---(adequateCWF)
IT---33%
Hz---15Hz<1kgwt
12Hz1-2kgwt
10Hz2-3kgwt
8Hz>3kgwt
BiasFlow--20l/m

19

High Frequency Ventilation (cont.)

3100A Performance Checklist
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.

Connect gas source and plug machine in. (Never turn machine on without plugging in gas source)
Connect circuit and humidifier
Connect color-coded patient circuit control lines and clear pressure sense lines
Block off the ET connection port w/ rubber stopper
Turn main power on. (Switch is located on base of the stand)
Set Bias Flow at 20
Set both Mean Pressure Adjust and Mean Pressure Limit controls to max
Push in and hold RESET, and observe Mean Pressure read out. (It should read 39-43)
If read out is not 39-43, adjust with adjustment screw located on right side of vent.
Set Frequency to 15, % I-Time to 33, and Power to 0.0
Set Max Paw thumbwheel switch to 30 and set Min Paw thumbwheel switch to 10.
With the Mean Pressure Adjust control, establish a Paw of 19 to 21 cmH2O.
Press Start/Stop button
Increase power to 6.0, and center the piston
Verify that the P and Paw readings are within range are within range for corresponding altitude (0-2000).
Press Start/Stop to stop vent.
Verify thumbwheel alarms by adjusting them to trigger the alarms.
Alarms should be set at 2-5 cmH2O of desired Paw pressure
Using your fingers, squeeze closed the expiratory limb tubing on the patient circuit to verify the Paw pop-off at 50 cmH2O and
alarm.
Push and hold RESET to power up machine.
Set Mean Pressure Limit control to mid-scale
Again squeeze expiratory circuit and observe Paw readout. Adjust to desired level
Position vent for connection to patient.
Obtain settings from MD and dial in. Set power first. (changing power will change Paw).
Place baby on vent and press RESET button and start vent. Center piston.

20

Survanta Delivery
Supplies needed:

MACcatheter(orfeedingtubecuttolengthofETT)
Ballardin-linesuctionandETTadapters
12mlsyringeandneedle
Survanta;4mlor8mlvial

1.
2.
3.
4.
5.

WarmSurvantafor20min.atroomtemp.DONOTSHAKEvial
Determinesafesuctiondepth.(LengthofETT+5)
ExchangestandardETTconnectorwithMACcatheterETTconnector
DrawupSurvanta(4mlperkg)
Positioninfanthead-down/turnedtoRIGHT.Advancesuctioncathetertosafesuction
depth;Administerdoseandthenwithdrawthecatheter.Infantshouldremaininthis
positionfor30seconds.
6. Repeataboveprocedureinthefollowingorderhead-down/LEFT,head-up/RIGHT,and
finallyhead-up/LEFT
7. Donotsuctioninfantfor2hours
21

Survanta Dosing Chart

WEIGHT
(grams)

TOTAL DOSE
(mL)

WEIGHT
(grams)

TOTAL DOSE
(mL)

600- 650

2.6

1301- 1350

5.4

651- 700

2.8

1351- 1400

5.6

701- 750

3.0

1401- 1450

5.8

751- 800

3.2

1451- 1500

6.0

801- 850

3.4

1501- 1550

6.2

851- 900

3.6

1551- 1600

6.4

901- 950

3.8

1601- 1650

6.6

951- 1000

4.0

1651- 1700

6.8

1001- 1050

4.2

1701- 1750

7.0

1051- 1100

4.4

1751- 1800

7.2

1101- 1150

4.6

1801- 1850

7.4

1151- 1200

4.8

1851- 1900

7.6

1201- 1250

5.0

1901- 1950

7.8

1251- 1300

5.2

1951- 2000

8.0

22

Pneumothorax
Supplies needed:
21 or 23 gauge butterfly
needle
Three-way stopcock
20 ml syringe

1.
2.
3.
4.

Insertneedleinto4thintercostalspace(locatedatthelevelofthenipples)
Connectbutterflyneedletostopcockandsyringe
Openstopcockbetweenneedleandsyringeandthenaspirateairorfluid.
Stopcockmaybeclosedtoemptysyringe
23

Free Flow Oxygen

FreeFlowoxygencanbegivenwithaflow-inflatingbag,anoxygenmask,orbyusing
oxygentubingwithacuppedhand.

24

Special Situations
1. Meconium Present at delivery

Ifmeconiumispresent,andthenewbornisnotvigorous,suctionthe
babystracheabeforeproceedingwithanyothersteps.
Ifthebabyisvigorous,suctionthemouthandnoseonly,andproceed
withresuscitationasrequired.
Vigorousisdefinedasanewbornwhohasstrongrespiratoryefforts,
goodmuscletone,andaheartrategreaterthan100beatsperminute.

2. Diaphragmatic Hernia:

Ababywithadiaphragmaticherniawillpresentwithpersistent
respiratorydistressandwilloftenhaveanunusuallyflatabdomenwith
diminishedbreathsoundsonthesideofthehernia.
Donotbagmaskventilate,intubateassoonaspossible.
Insertanoralgastrictubetoevacuatethestomachcontents

25

Special Situations (cont.)

3. Choanal Atresia

Blockageoftheairwaycausedbyanimproperlyformednasalpassage.
Testbyattemptingtopassasmall-calibersuctioncatheter
Ifchoanalatresiaispresent,youmustinsertaplasticoralairwaytoallow
airtoenterthroughthemouth.

4. Robin Syndrome

Thebabyisbornwithaverysmallmandible.Thetonguefallsfarther
backintothepharynxandobstructstheairway.
Placethebabyonhisstomach(prone).Thiswillallowthetonguetofall
forward,thusopeningtheairway.
Ifunsuccessful,placealargecatheter(12F)orasmallendotrachealtube
(2.5)throughthenose.

26

Resuscitation Flowchart

27

Sources:
NeonatalResuscitationHandbook;AmericanHeartAssociation
RespiratoryCare:Principles&Practice;Hess,MacIntyre
NeonatalMechanicalVentilation

Websites
http://www.fphcare.com/neonatal/resuscitation.asp
http://www.aap.org/nrp/nrpmain.html

28