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Guide to Neonatal Ventilation Case Study 1

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Introduction
Introductory text here

Objectives

Upon the completion of this module the learner will be able to:

  • Discuss the pathophysiology and management of neonatal respiratory distress syndrome.
  • Describe the modes of ventilation used to support a neonate with respiratory distress syndrome.
  • Outline the presentation and management of pulmonary interstitial emphysema.
  • Discuss the pathophysiology and management of chronic lung disease in the neonate.

Case Study 1: Ventilation Management of RDS, PIE, and CLD  

  • Prenatal History (click to expand)
    • Baby girl C, Twin A, one of dichorionic/diamniotic twins was born to a 26-year-old G 1, P 0 mother. The pregnancy was complicated by preterm labor at 23 weeks gestation, with rupture of membranes at that time. There were no other complications of pregnancy and prenatal ultrasounds had shown that both twins were growing adequately. Mrs. C received betamethasone x 2 and magnesium sulfate.
      At 24 4/7 weeks, she was found to have complete cervical dilation and a ceserean section was performed because Twin B was a transverse lie. Baby A weighed 610 grams and had Apgar scores of 5 and 7 at one and five minutes respectively.

    • Guiding Questions
      1. What are the risk factors with regard to respiratory pathology/outcomes for this infant based on the prenatal history?
      2. What are the benefits of expectant management in regard to the use of antenatal steroids (betamethasone) as it relates to respiratory outcomes for this infant?

    • Learning Resources
  • Delivery Room to Day of Life (DOL) 4-13 (click to expand)
    • In the delivery room, the infant was placed under a preheated radiant warmer, in a plastic bag with a plastic cap over her head. A pulse-oximetry probe was placed on her right hand. She received positive pressure ventilation (PPV) via NeoPuff with a mask and was then intubated with a 2.5 mm endotracheal tube (ETT). After confirmation of ETT placement, she received surfactant at two minutes of age. PPV was continued after the infant was placed in a preheated transporter and taken to the NICU for further care.
      Baby C was placed on SIMV volume-targeted ventilation with the following settings: Targeted volume = 5 mL/kg, PEEP +5 cm H2Oand a rate of 50 breaths/minute. Her FiO2 requirements ranged from .24–.30. Her initial chest x-ray (Figure 1) showed the ETT just above the carina. Heart size was normal and the lung fields were hazy bilaterally; expanded to eight ribs. No air leaks were noted.
      On DOL 2 Baby C received a second dose of surfactant for increased requirement with some improvement noted. On DOL 4 she again required an increase in O2 and higher positive inspiratory pressure (PIP) and PEEP to maintain O2 saturations within normal levels. Her x-ray showed very hazy lung fields with low lung volumes. She was placed on high frequency oscillatory ventilation (HFOV) with initial settings of FiO2 0.50, MAP 12 cmH2O, Hz 10, Amplitude 20. In total, she required 10 days of HFOV corresponding to the acute phase of severe RDS/hypoxemic respiratory failure (HRF).

    • Guiding Questions
      1. What are the common radiologic findings associated with acute RDS in an infant of this gestational age?
      2. What are the benefits of prophylactic surfactant replacement for an infant of this gestational age?
      3. What are the basic principles and benefits of synchronized intermittent mandatory ventilation (SIMV)?
      4. What are the basic principles and benefits of volume-targeted ventilation?
      5. What are the basic principles and benefits of high frequency oscillatory ventilation (HFOV) in managing acute, progressive RDS?

    • Learning Resources
  • DOL 14-21 (click to expand) 
    • On DOL 14 Baby C had improved; however, an attempt to wean her to NIPPV from HFOV failed. She was placed back on SIMV and volume-targeted ventilation.
      By DOL 18 the infant developed radiographic evidence of PIE along with CO2 retention (Figure 2). Her blood gas at that time was as follows: pH 7.22, PCO2 74 mmHg, PO2 (capillary) 56 mmHg, and HCO3 24 mEq/L.
      She was placed on high frequency jet ventilation (HFJV) for 4 days for management of PIE. Her initial jet settings were: JET PIP 18 cmH2O, JET I-Time 0.02 seconds, JET Rate 420 bpm, CMV PEEP 7 cmH2O, CMV Rate 5 bpm, CMV PIP 15 cmH2O, CMV I-Time 0.4 seconds.

    • Guiding Questions
      1. What are the basic principles of noninvasive positive pressure ventilation (NIPPV)?
      2. What are the benefits and risks of NIPPV in managing RDS?
      3. What are the basic principles of high frequency jet ventilation (HFJV)?
      4. What is the mechanism by which HFJV improves PIE?

    • Learning Resources
  • DOL 22-60  (click to expand) 
    • On DOL 21 Baby C was placed back on SIMV with volume-targeted ventilation after resolution of PIE. An x-ray on DOL 25 showed chronic changes to lung fields (Figure 3). During the next 10 days, Baby C remained on SIMV pressure-limited ventilation and failed several extubation attempts. Baby C was extubated successfully to NIPPV on DOL 35 after a 7-day course of hydrocortisone. She was weaned to NCPAP on DOL 40 and switched to a high flow nasal cannula (HFNC) on DOL 50. On DOL 60 Baby C was placed on a standard nasal cannula.

    • Guiding Questions
      1. What are the common radiologic findings associated with evolving CLD? 
      2. What are the challenges of managing CLD/BPD?
      3. What are the basic principles of pressure-limited ventilation.
      4. What are the benefits of non-invasive modalities in managing CLD.

    • Learning Resources
  • Available CEU's (processing fees required)


About the Contributor

AnnMarie Barber, MS, MSN, CRNP, is an NNP with over 19 years of experience practicing in the Philadelphia area. She received her BSN and Masters in Human Organization Science degrees from Villanova University and her MSN degree from the University of Pennsylvania. Since 2013 she has been a Clinical Nurse Educator for Mallinckrodt Pharmaceuticals providing expert consultation and education to neonatal clinicians regarding the diagnosis and treatment of PPHN and the utilization of inhaled nitric oxide. She has also been a speaker at several conferences and clinical meetings including the Virginia Society of Respiratory Care Conference, the Robert Wood Johnson University Respiratory Conference, and ANN's 16th National Neonatal Nurses Conference. She served on ANN's Executive Committee until 2016.

 

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