Care of neonate on

respiratory support
Dr.Mohsin Raza
Specialist NICU
Sheikh Khalifa hospital Ajman
(women &children )
Respiratory Care for the Ventilated Neonate

Care of babies on nasal CPAP

Respiratory Care for the Ventilated Neonate
 There is an increasing trend in the neonatal intensive care units
(NICUs) to use non invasive ventilation modes; however,
invasive ventilation is still often necessary for treating preterm
and term infants with respiratory insufficiency
 Nowadays, preterm babies are extubated relatively quickly, and
prolonged invasive ventilation is considered an important risk
factor for bronchopulmonary dysplasia (BPD).
 Many different ventilation modes and strategies are available to
optimize mechanical ventilation and to prevent ventilator-
induced lung injury, and volume-targeted ventilation modes had
reported better outcomes when compared to pressure-limited
ventilation modes .
Important aspects to be considered in ventilated babies
include
- the use of correct sized endotracheal tube
- positioning of the patient, the nursing care
- sedation and analgesia
- infection prevention ( the ventilator-associated .
pneumonia and nosocomial infection)
- the treatment of complications such as air leaks and
. pulmonary haemorrhage

Individualized nursing care and respiratory therapy are

crucial and have become increasingly widespread in NICUs.
The Endotracheal Tube
 ETT is a cornerstone for successful ventilation. The appropriate sized
tube could be defined providing a sufficient seal for effective
ventilation.

 the resistance is inversely proportional to the tube ID, Resistance is

particularly marked for tubes with ≤2.5 mm ID

 Tube length also increases resistance, and long tubes should be cut to
decrease the dead space
 To clinically confirm endotracheal intubation, a combination of
clinical signs (breath sounds under the axillae, thoracic
expansion, increased heart rate, and condensation visible on the
tube) and exhaled CO2 monitoring.
 After successful intubation, placing the tube at a correct depth is
vital. Excessively deep insertion could lead to selective right
main bronchus intubation, pneumothorax, and/or atelectasis. A
shallow insertion puts the patient at greater risk for accidental
extubation.
 The ideal safe position for the ETT tip is the mid tracheal
position, usually at T1-T2 level . In ELBW neonates, however, the
level of the carina can be as high as T3- T4
Chest radiograph remains the gold standard for
adequate tube placement confirmation .
The tube has to be fixated ensuring minimal possible
movement with the patient’s head kept at a neutral
position .
Several methods for tube fixation have been reported,
but there is currently insufficient evidence to indicate
a particular method over another .
Positioning

the Patient
In neonates undergoing mechanical ventilation, it has been
observed that positions other than the standard supine position,
such as the prone position, may improve respiratory
performance However, no evidence was found to suggest that
particular body positions during mechanical ventilation of the
neonate are effective in producing sustained and clinically
relevant improvement
 There may be additional benefit in raising head of bed slightly
to allow expansion of the lungs. This position should be changed
periodically to avoid pooling of secretions at base of the lungs .
 For preterm infants, because of the risk of germinal matrix-
intraventricular hemorrhage and the effect of head position on
jugular venous drainage, should lie with the head in midline
position, during the first three days of life
Nursing Care
 Nurses caring for newborns receiving mechanical ventilation face several challenges.
Observing the monitor, ventilation devices, oxygen delivery systems, and patient’s
oxygenation along with the patient himself are essential components of nursing care.

Highly sensitive equipments are helpful for the monitoring of the patient. Alarm limits
(upper and lower) for heart rate, respiration, blood pressure, and oxygen saturation

Expertise and extreme care are important aspects in providing safe and effective nursing
care. Cardinal aspects of care include thermoregulation, optimal positioning, airway
clearance, stable hemodynamic status, and adequate nutrition for maintenance of
growth and development

Open, honest communication with the family is necessary for reducing their anxiety .
Nurses must provide a safe environment for the infants in the unit and regulate the
infection control policies .

Hand washing, isolation, surveillance, and screening of visitors are relevant aspects to
nurses in the NICUs .
Kangaroo care offers benefits to stable
ventilated infants, as long as the procedure
is safely practiced according to nursing
protocols of transfer from and back to the
incubator
Heating and Humidification of the Inspired Air

 Intubation eliminates the natural mechanisms of filtration, humidification,

and warming of inspired air
Air inspired to the nose is warmed and nearly 90% humidified by the time it
passes through the pharynx ,The administration of dry oxygen lowers the
water content of the inspired air, and the use of artificial airway bypasses the
nasopharynx and oropharynx where the humidification of gases primarily
takes place .
If humidification of inspired gases is not appropriately addressed, ciliary
dysfunction, inflammation and necrosis of the ciliated pulmonary
epithelium, retention of dried secretions, atelectasis, bacterial infiltration of
the pulmonary mucosa, and pneumonia may occur. A humidifier warms and
humidifies the gases delivered to the infant during mechanical ventilation via
the inspiratory line of the ventilator circuit .
Humidifiers , The bypass humidifiers are the most widely used today in the
NICUs. The gas that goes to the infant passes over the surface of the heated
water .
Aerosolization and Nebulization
Equipment for aerosolization in neonates include
inhalers (metered dose inhalers (MDI)), holding
chambers, and nebulizers . Examples of drugs used in
critically ill neonates are surfactants, corticosteroids,
bronchodilators, diuretics, and antiviral and vasoactive
agents .
Effectiveness of inhalational therapies is influenced by
numerous other factors, including the device itself, type
and location of the nebulizer, aerosol characteristics
(particle size, shape, and density), ventilation gas
conditions (flow and humidity), patient interface, and
mode of breathing support .
. Sedation and Analgesia
It is now known that preterm infants are more sensitive to pain
than older children and that intubation and invasive mechanical
ventilation have physiologic changes determining stress and pain,
which can be reduced with sedatives and analgesics .
Nowadays, the prevention and treatment of pain and distress
represents an essential component of clinical practice
After the correct pain assessment, the treatment of pain and stress
should be done. Non pharmacological interventions such as non
nutritive sucking and sucrose must be tried .
Routine administration of sedation or analgesia in preterm
neonates is not recommended due to the safety concerns
regarding the pharmacotherapy. Nevertheless, preterm newborns
who remain ventilated can be under morphine or fentanyl .
Prevention of Infection
Infection, and its prevention, is an important concern in
neonatal ventilated patients, particularly those of very low
birth weight. Ventilator-associated pneumonia (VAP),
defined as a lung infection diagnosed in a mechanically
ventilated patient for >48 h , is the second most common
form of nosocomial infection and a common device
associated complication .
There are no universally accepted criteria to diagnose VAP
in the neonatal period .
Less than 12-month-old infant Centre of Disease
Control VAP diagnostic guidelines have been used in
neonates, according to which, in order to be diagnosed with
VAP, the ventilated patient has to fulfil clinical
at least one of the following:
1. presence of tachypnea, apnea, and/or retractions; increased need of
supplemental oxygen, respiratory settings to achieve targeted
respiratory values, amount of respiratory secretions, incidence of
desaturation events),
2. radiological (persistent infiltrates or consolidation in two sequential
radiographs after the initiation of mechanical ventilation)
3. - microbiological criteria (isolation of a microorganism obtained by
bronchoalveolar lavage or isolation of a microorganism in blood
culture without any other focus or histopathological examination) .
 Microbiological study of tracheal aspirates is not reliable for the
diagnosis of VAP since airway colonization cannot be dismissed by this
technique.
ventilator associated pneumonia
Several risk factors have been associated with the occurrence of VAP.
 duration of mechanical ventilation
ELBW infants seem to be the most significant in multivariate
analysis .
although others like length of hospital stay, reintubation, enteral
feeding, mechanical ventilation, transfusion, low birth weight,
prematurity, bronchopulmonary dysplasia, and parenteral
nutrition have been identified in a recent meta-analysis of
observational studies
 On the contrary, decreasing the frequency of ventilator circuit
changes from every seven to 14 days does not seem to influence the
VAP rate .
VAP
The most common agents involved in VAP are Gram-negative
bacteria (particularly Pseudomonas aeruginosa,
Enterobacter species, and Klebsiella species) although Gram-
positive bacteria, namely, coagulase negative staphylococci
and Staphylococcus aureus, also play a role .
 There is no consensus for the initial treatment of VAP. Initial
empirical treatment should include broad spectrum
antibiotics with coverage for Gram-positive and Gram-negative
bacteria, based on likely causative agents and local
antimicrobial resistance patterns .
VAP is associated with increased length of hospital stay and
mortality
Neonatal VAP prevention bundles
implementation has been shown to decrease the rate of VAP in NICUs . Such
bundles, which apply several evidence-based practices at the same time, have
proved to result in greater practice improvements than the sum of the
benefits of each practice on its own .
1. practices relative to head position in the ventilated neonate.
2. the use of closed multiuse suction catheters, frequency at which suctioning
systems should be changed, routine changing of breathing circuits.
3. assessment of readiness for extubation and cautious evaluation of the need
for reintubation.
4. use of medications that interfere with gastric acidity, use of antibiotic
bowel decontamination and oral hygiene, and use of separate oral and
tracheal suctioning equipment . As with other healthcare-related
infections,
 improvement of caregiver education and hand hygiene remains a very
important measure to control VAP incidence
Complications: Air Leaks and Pulmonary Hemorrhage
Air leak syndrome refers to the extravasation of air from the
tracheobronchial tree into the lung parenchyma and pleural
spaces where it is not normally present, and includes:
pneumothorax, pulmonary interstitial emphysema,
. pneumomediastinum, pneumopericardium,
. pneumoperitoneum, subcutaneous emphysema, and .
systemic air embolism.
Air leak is a common complication of mechanical ventilation
. Risk factors include prematurity, very low birth weight, low
Apgar score, high peak inspiratory pressure, high tidal volume,
high inspiratory time, respiratory distress syndrome,
meconium aspiration syndrome, amniotic fluid aspiration,
pneumonia, and pulmonary hypoplasia .
The most frequent air leak in mechanical ventilated
newborns is pneumothorax.
Different ventilatory strategies affect the risk of
pneumothorax with evidence that high-frequency
ventilation , volume-targeted ventilation
The clinical presentation ranges from asymptomatic to
severe progressive respiratory distress and, in case of
tension pneumothorax, hemodynamic compromise .
Physical examination may reveal tracheal deviation,
asymmetrical chest rise, diminished breath sounds
over the affected side, and muffled or shifted heart
sounds .
Diagnosis is usually made by radiography . However,
in neonates, the classic appearance may be more
difficult to recognize.
Therefore, these signs should be looked for in
ventilated newborns in order to perform an early
diagnosis of pneumothorax.
A tension pneumothorax requires immediate
diagnosis and intervention even before imaging is
obtained, and chest transillumination plays a role in
these cases .
Treatment options include conservative management,
needle aspiration, intercostal tube drainage.

Needle thoracentesis with aspiration is the preferred

treatment in emergencies such as a tension
pneumothorax, but may not completely correct the
situation . The most traditional method of treatment
of a pneumothorax is a chest tube placed by
thoracostomy
Pulmonary hemorrhage
is a rare but severe condition,
which is characterized by massive bleeding within the lung
parenchyma and airways, with a mortality above 50% during the
neonatal period .
The most consistent risk factors for its occurrence are
prematurity, respiratory distress syndrome (RDS), the use of
exogenous surfactant, and a patent ductus arteriosus (PDA),
especially in premature infants less than 28 weeks gestational age
and/or birth weight less than 1000 grams.
Other risk factors include pulmonary interstitial emphysema
(PIE), pneumothorax, pulmonary infection, metabolic acidosis,
shock, hypothermia, hypoglycemia, disseminated intravascular
coagulation (DIC), ECMO therapy, hereditary coagulation
disorders, and airway trauma (especially following endotracheal
intubation) .
Pulmonary hemorrhage clinically presents with a rapidly
worsening pulmonary function (the speed of the setting
depends obviously on the magnitude of the
hemorrhage), with hypoxia, hypercarbia, and the need
for increased ventilatory parameters. Blood can be seen
in oropharyngeal or tracheal aspirates.
A systemic deterioration is established with metabolic
acidosis and shock. Investigations should include a chest
X-ray, an echocardiogram (to exclude a PDA), work-up
for sepsis, and eventual screening for hereditary diseases
of coagulation (if no other risk factors are detected) .
Treatment should include general supportive measures:
transfusions of blood, plasma or platelets, as indicated;
correction of metabolic acidosis; inotropic drugs to improve
systemic blood pressure; PDA treatment (except severe
thrombocytopenia); broad spectrum antibiotic treatment .
The ventilatory strategy : observational studies suggest that
the support with high-frequency oscillatory ventilation
(HFOV) allows to control more cases of pulmonary
hemorrhage when comparing to conventional support .
Other specific therapeutic measures include treatment with
recombinant factor VIIa , nebulized epinephrine, and
repeated instillations of epinephrine (0.5 mL of 1 : 10,000
dilution) by the endotracheal tube.
Monitoring of the Ventilated Neonate

Along with respiratory care for the ventilated neonate,

ventilation monitoring is of great importance for a
good oxygenation avoiding hypercapnia and
hypocapnia, not only on preterm but also on term
brain.
Pulse oximetry, pH and blood gases measurements,
transcutaneous carbon dioxide measurement, and
capnography are standard of care in most actual
NICUs .
Online pulmonary function and mechanics testing are
currently valuable tools to aid clinical decision making
in the management of ventilated infants. They are a tool
for assessment of patient status, therapeutic evaluation,
and management guidance of infants on ventilator.
The knowledge of pulmonary graphics also improves
understanding of pulmonary physiology and
pathophysiology and their responses to mechanical
ventilatory support .
 The new ventilators now provide such information and
the clinicians should be familiar with.
Weaning and Extubation
Weaning and extubation shifts the work of breathing from ventilator to patient, and
respiratory drive must be adequate to sustain alveolar ventilation with a tidal volume
of 4 ml/kg .
 Sedation should be reduced and stopped if possible before extubation . As patient’s
ventilation improves, FiO2 should be reduced to below 0.40 and ventilatory
parameters can be decreased along with normal blood gases, and one should decrease
the most harmful parameter first and each at a time .
 Methylxanthines( Caffiene citrate ) ) are helpful in the preterm neonate, and these
populations should be started on nasal CPAP or high flow nasal cannula after
extubation .
Systemic steroids and diuretics may be useful to extubate preterm still ventilated after
the first week of life .
Anemia may need to be corrected and a hemoglobin over 10 g/dl is indicated in
selected cases .
Prone positioning can be helpful in stabilizing the chest wall and improving
diaphragmatic excursion.
 A chest radiograph is not routinely necessary, unless there is clinical evidence of
respiratory distress .
Tracheostomy
Neonatal tracheostomy is a common need of newborns requiring prolonged
ventilation. Studies have shown that early tracheostomy reduces the incidence of
subglottic and tracheal stenosis in children who are intubated for long periods and
results in improved comfort, decreased need for sedation, systemic corticosteroid,
improved nutrition and growth, ability to attempt oral feeds, and, once established,
vocalization with a speaking valve.
Improved survival of extremely low and very low birth weight and medically complex
infants can result in prolonged mechanical ventilation and sometimes tracheostomy .
The indications for neonatal tracheostomy have changed over time. With the need
for long-term ventilation, it has become more common .
Common indications for neonatal and infant tracheostomy include congenital or
acquired airway obstruction and chronic medical conditions (cardiac disease,
neuromuscular disease, and bronchopulmonary dysplasia).
Decisions about tracheostomy in neonates involve careful consideration of a number
of factors. Mortality, potential short- and long-term outcomes, prospects for home
ventilation therapy, and alternatives to tracheostomy should be considered .
Care of babies on nasal CPAP
Indications
Increased work of breathing – tachypnoea, nasal flaring, grunting, retractions, cyanosis, increasing
oxygen requirements
Respiratory acidosis on blood gas
The following conditions when associated with the above signs may be responsive to CPAP
Respiratory Distress Syndrome (RDS)
Pulmonary oedema
Atelectasis
Recent extubation
Transient Tachypnoea of the newborn (TTN)
Tracheomalacia or similar disorder of the lower airway
Apnoea of prematurity

Contraindications
Upper airway abnormalities that make CPAP ineffective or dangerous, e.g. choanal atresia, cleft
palate, unrepaired trachea-oesophageal fistula
Congenital Diaphragmatic hernia pre surgical repair
Complications
Complications Related to Equipment:
Obstruction of prong due to kinking of prong and/or delivery circuit
Inefficient delivery due to malposition of bi-nasal prongs/mask
Skin irritation from securing tapes to the face (SNP)
Pressure necrosis around nostrils and distortion of the nasal septum due to incorrect strapping and
positioning
Pressure necrosis around head/ears and head molding due to failure to release hat and strapping
regularly (bi-nasal prongs)
High air leak around prongs due to mouth being open (SNP and bi-nasal prongs) or air escaping from
other nostril (SNP)
Complications related to infant's clinical condition:
Obstruction of SNP or bi-nasal prongs from secretions
Pneumothorax
Pneumomediastinum
Pulmonary interstitial emphysema
Decreased cardiac output (due to decreased venous return) with excessive CPAP levels
Gastric distension and feed intolerance
Increased work of breathing related to increased airway resistance (related to diameter of SNP or bi-
nasal prong)
Inadequate ventilation
Management
A medical order is required to initiate CPAP, to alter the amount of CPAP delivered, and to
discontinue CPAP. These should be documented by the medical officer. 

CPAP commencement and ongoing care is the responsibility of the infant's nurse, with the
assistance of a second nurse.

Initial CPAP settings:

The usual range of settings is  
5-8cmH2O, however in some clinical conditions (e.g. bronchiolitis, severe chronic lung disease and
tracheal issues) higher CPAP up to 12-14cmH2O may be ordered by the NICU consultant. An
increase in CPAP may be required from the initial setting if work of breathing, respiratory rate,
oxygen requirement, and underlying lung pathology deteriorate.

Delivered CPAP:
Commonly the measured CPAP pressure will be lower than the set pressure because of CPAP
attenuation within the interface and leak. In general, both should be documented in the EMR
Flowsheets and the delivered pressure should not be targeted beyond the usual care of the patient
(e.g. repositioning the patient or interface, and being aware of leak through the patient’s mouth). If
the clinical situation determines that a specific delivered CPAP pressure should be targeted.
Weaning CPAP settings:
CPAP is usually weaned in increments of 1cmH2O every 12-24 hours. . The
factors to consider when deciding to wean the CPAP include work of
breathing, respiratory rate, oxygen requirement, and underlying lung
pathology.
Ceasing CPAP:
When the infant has demonstrated a stable respiratory pattern on CPAP of
5cmH2O in <30% oxygen for 12-24 hours, the CPAP may be removed. In some
circumstances it may be appropriate to cease CPAP at a higher CPAP level
(e.g. older, larger infants). This decision should be discussed with the NICU
medical team before the CPAP is removed from the infant. At times, the
NICU medical staff, in discussion with the nurse, may decide to electively
change the infant from CPAP to High or Low Flow Nasal Cannulae Oxygen,
if deemed appropriate (this requires a medical order).
Ongoing care and considerations:
Respiratory assessment – 
Blood gases as required (determined by clinical condition and previous blood gases)
Respiratory rate
Heart rate
Chest rise and fall
Work of breathing 
Oxygen requirements
Pulse oximetry
Capillary refill
Enteral feeds can be administered via naso/oro gastric tube, however due to the
increased risk of abdominal distension, ensure increased venting/aspiration of
naso/oro gastric or other gastrostomy tubes, including when on continuous feeds
Ensure gastric decompression with naso/oro gastric tube in situ and open to vent
Maintain neutral thermal environment 
Ensure cardio-respiratory and pulse oximetry monitoring, correct alarm setting
parameters, and documentation
Referrence
 NICE guideline: Specialist neonatal care draft scope for consultation
F. Flor-de-Lima, G. Rocha, and H. Guimarães, “Impact of changes in perinatal care on
neonatal respiratory outcome and survival of preterm newborns: an overview of 15 years,” 
A. Azevedo, F. Flor-de-Lima, G. Rocha, C. Rodrigues, and H. Guimarães, “Impact of changes
in perinatal care on bronchopulmonary dysplasia: an overview of the last two
decades,” Journal of Pediatric and Neonatal Individualized Medicine,
C. Klingenberg, K. I. Wheeler, N. McCallion, C. J. Morley, and P. G. Davis, “Volume-targeted
versus pressure-limited ventilation in neonates,” Cochrane Database of Systematic Reviews,
vol. 17, no. 10, Article ID CD003666, 2017. View at Publisher
C. C. Almeida, S. M. S. Pissarra da Silva, F. S. D. Flor de Lima Caldas de Oliveira, and M. H. F.
Guimarães Pereira Areias, “Nosocomial sepsis: evaluation of the efficacy of preventive
measures in a level-III neonatal intensive care unit,” Journal of Maternal-Fetal & Neonatal
Medicine, vol. 30, pp. 2036–2041, 2017. 
K. Langhammer, S. Sülz, M. Becker-Peth, and B. Roth, “Observational study shows that
nurses spend more time caring for mechanically ventilated preterm infants than those
receiving noninvasive ventilation,” Acta Paediatrica, vol. 106, pp. 1787–1792, 2017.