Neonatal and Pediatric Noninvasive and Invasive Ventilation



Neonatal and Pediatric Noninvasive and Invasive Ventilation


Brigham C. Willis







Equipment




The use of mechanical ventilation is one of the most significant advances in the history of medicine, enabling therapies, procedures, and interventions in an incredibly wide array of otherwise unrelated subspecialties. Nearly all of the critical care and surgical interventions we currently provide would be impossible or prohibitively difficult without the use of mechanical ventilation. Many thousands, even millions, of lives have likely been saved because of this technology. However, the use of mechanical ventilation also brings with it a host of associated problems and complications. Referencing the delicate nature of the appropriate use of mechanical ventilation, and obviously indulging in a bit of hyperbole, a respected mentor of the author of this chapter once referred to the mechanical ventilator as “the single deadliest instrument ever placed in the hands of physicians” (and respiratory therapists [RTs]). As such, the appropriate selection of patients for, management of, and ultimate timely liberation from mechanical ventilation can dramatically affect patient outcomes.



The history of pediatric mechanical ventilation is rich, originating, for the most part, in the early twentieth century. Alexander Graham Bell in 1889 described his design for a neonatal ventilator. Recognizing the need for assisted ventilation in neonates with surfactant deficiency, he said, “Many children, especially those prematurely born, die from inability to expand their lungs sufficiently when they take their first breath. I have no doubt that in many of those cases, lives could be saved by starting the respiration artificially by means of apparatus operating in the manner described above.” The history of mechanical ventilator use in the 1920s during the polio epidemic is generally well known. Subsequently, many advances in mechanical ventilation have come from pediatric and neonatal applications, including some of the first uses of continuous positive airway pressure (CPAP) and high-frequency ventilation (HFV).


The broad range of patient sizes, diagnoses, and unique anatomies leads to added levels of complexity when initiating or managing mechanical ventilation in a neonate, infant, or child. Pediatric respiratory care is truly a specialty in and of itself. This chapter intends to outline the basics of a number of neonatal and pediatric respiratory procedures and competencies. It is hoped that understanding of the procedures in this chapter will provide a fundamental knowledge for the RT caring for children needing mechanical ventilation. It is also expected that this understanding will result in safer, higher-quality care for children and will transform the ventilator from a ventilatory device to a safe, reliable tool in the hands of a skilled RT.



» Skill Check Lists


26-1 Initiation of Neonatal and Pediatric Noninvasive Positive Pressure Ventilation


Noninvasive positive pressure ventilation is a life-saving intervention in neonatal and pediatric care. The ability to noninvasively provide respiratory support, improve upper and lower airway patency, and improve lung recruitment has proven invaluable. Noninvasive support can be utilized simply as CPAP or as bilevel positive airway pressure (BiPAP), with additional inspiratory pressure added to spontaneous or controlled breaths. Widespread use of nasal CPAP has reduced intubation times, intubation rates, pulmonary morbidity, and bronchopulmonary dysplasia rates dramatically in neonates. Pediatric applications of both CPAP and BiPAP, including those in acute lung injury, asthma, and postoperative conditions, have also resulted in significant improvements in care. Indications for CPAP in children are listed in Box 26-1.



Noninvasive positive pressure ventilation is positive pressure applied to the upper oropharynx through a noninvasive interface, providing improved pulmonary mechanics and modest lung recruitment. Interfaces are varied but include nasal prongs, nasal masks, nasal–oral masks, full-face masks, and helmets. Images of these interfaces are given in Figure 26-1. The effort required to adequately set up a CPAP interface is well worth it, as avoiding intubation and its attendant complications is a worthy goal. A respiratory therapist skilled in the application of noninvasive ventilator interventions is invaluable in a pediatric or neonatal unit. The following is the step-by-step process for initiating neonatal and pediatric noninvasive positive pressure ventilation.






Implementation




1. Place the patient in a comfortable position.


2. Assess vital signs.


3. Assess the upper airway for abnormalities.


4. Obtain the interface and the securing devices.


5. Establish and implement the appropriate settings or execute the physician’s orders:



6. Apply and secure the device to the patient.


7. Ensure suitable fit and minimal leak.


8. Ensure patient comfort.


9. Reassess vital signs.


10. Set the alarms appropriately.


11. Set up the noninvasive monitors.


12. Remove the supplies from the patient’s room, and clean the area, as needed.


13. Remove PPE, and perform proper hand hygiene prior to leaving the patient’s room.





26-2 Assessing the Neonatal and Pediatric Noninvasive Positive Pressure Ventilation System


Appropriate monitoring of the adequacy of therapy is important for any respiratory intervention, but for noninvasive respiratory support, it is even more critical. The odds of a child of any age being continuously compliant with a therapy that involves blowing liters of air up the nose every minute are extremely slim. Added to this difficulty is the fact that most masks are not well designed for children, which creates extremely challenging problems with leak management. Considering all these factors together, the astute RT needs to pay frequent attention to the adequacy of therapy when a noninvasive positive pressure system is utilized on any pediatric patient. Constant communication between the RT, the bedside nurse, and the ordering physician is critical to the continued success of the management of noninvasive respiratory support in children. The following is the step-by-step process for assessing the neonatal and pediatric noninvasive positive pressure ventilation system.




Procedural Preparation




1. Review the patient’s chart for the patient’s current vital signs and NIV settings.


2. Review the patient’s most recent arterial blood gas (ABG) or SpO2 values.


3. Review the most recent chest radiograph.


4. Identify the current sedation medications.


5. Verify the physician’s order or the facility’s protocol for standard of care.


6. Obtain, clean, and inspect the appropriate equipment prior to entering the patient’s room.


7. Follow PPE requirements, and observe standard precautions for any transmission-based isolation procedure.


8. Identify the patient using two patient identifiers.


9. Introduce yourself to the patient and to the family.


10. Explain the procedure to the patient and to the family, and acknowledge the patient’s understanding.


11. Perform proper hand hygiene, and put on gloves, mask, and protective eyewear, as appropriate for the procedure.



Implementation




1. Approach the patient before you approach the CPAP generator.


2. Assess the patient:



3. Assess the NIV generator function and settings:



4. Ensure that the manual ventilation device and the suction equipment are available at the patient’s bedside.


5. Remove the supplies from the patient’s room, and clean the area, as needed.


6. Remove PPE, and perform proper hand hygiene prior to leaving the patient’s room.





26-3 Initiating Neonatal and Pediatric Mechanical Ventilation


The initiation of neonatal or pediatric mechanical ventilation begins with the decision to intubate or not intubate a patient. Clinical indications for mechanical ventilation and initial ventilator settings are given in Boxes 26-2 and 26-3. This decision is difficult and has many implications, as intubating too early or too late may both result in increased patient morbidity. Complications and hazards of endotracheal intubation in infants and children are listed in Box 26-4. In general, it is a well-tolerated and safe procedure when done with care and attention to detail. The RT plays a key role in the proper initiation of pediatric mechanical ventilation, and the establishment of age-appropriate and disease-appropriate therapeutic goals at the outset of therapy.


Jun 12, 2016 | Posted by in RESPIRATORY | Comments Off on Neonatal and Pediatric Noninvasive and Invasive Ventilation

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