Oxygenation (newborns)

PO2 (on room air)

arterial/50-80

Base Excess

arterial/capillary -4-+4

Bicarbonate (HCO3-)

arterial/capillary 19 - 26 mEq/L

PH

arterial/capillary7.3-7.45

Normal air that we breathe is

21%

Pneumothorax

A pneumothorax occurs when air escapes from air sacs in the lung and into the pleural space. The air can compress the lung, restrict ventilation, and in severe cases impair cardiac output. A pneumothorax can occur spontaneously in non-intubated infants with no history of assisted ventilation, or as a complication of mechanical ventilation.

Post-resuscitation stabilization

Administer O2 Maintain O2 saturation > 90% Avoid high saturation, especially if premature Record Amount of O2 provided Route of delivery O2 saturation Location of saturation probe

Pulmonary hemorrhage

Affects term or premature infants Onset of cardiorespiratory distress is sudden and is accompanied by blood in the trachea

Aspiration of meconium, amniotic fluid, blood, or gastric contents

Affects term or premature infants Onset of respiratory distress is at birth or at the time of aspiration The history should be evaluated for clues that help differentiate aspiration from sepsis, pneumonia, or TTN

gold standard for assessing oxygenation, ventilation and pH

Arterial samples

Evidence of central cyanosis?

Bluish discoloration of tongue and mucous membranes Desaturation of arterial blood secondary to cardiac/respiratory dysfunction If infant cyanotic on room air and respiratory distress present evaluate O2 saturation and provide oxygen

Causes of respiratory acidosis

CO2 retention can result from inadequate ventilation due to: Lung disease (pneumonia, aspiration, surfactant deficiency) Pneumothorax Airway obstruction Poor respiratory effort which occurs most often in preterm or very sick infants Neurologic injury and respiratory depression Severe apnea Mechanical interference with ventilation as occurs with hyperexpansion of the lungs in ventilated infants and with abdominal distention

Labs and Tests to Obtain

Chest x-ray if respiratory distress Abdominal x-ray if abdominal concerns Blood glucose Blood gas arterial or capillary Blood culture CBC with differential White blood cell count, hemoglobin, hematocrit and platelet count

what does Oxygen requirement mean?

How much O2 is required to keep O2 saturation greater than 90%? Rapidly increasing oxygen requirement may be a sign of respiratory failure

Treatment of Metabolic Acidosis

Hypoxia is treated by improving oxygenation, ventilation, and perfusion It is not recommended that metabolic acidosis be treated with hyperventilation as this would be a temporary maneuver that does not effectively treat the underlying problem. Hypotension and shock are treated aggressively with volume infusions, blood pressure medications, and correction of anemia as necessary. Heart failure is treated by identifying the primary cause, such as infection, structural heart disease, arrhythmias, hypoglycemia, and electrolyte disturbances, and treating appropriately. Inborn errors of metabolism require extensive workup and treatment to reverse the effects of acids that accumulate in the bloodstream

Hypoxia

Hypoxia-hypoxemia or cardiac failure that results in inadequate tissue oxygenation - below physiologic requirements

Causes of Metabolic Acidosis

Increased lactic acid production can be secondary to: Shock Poor perfusion Inadequate tissue oxygenation Anaerobic glycolysis Sepsis Hypothermia Hypoglycemia Severe forms of congenital heart disease that cause hypoxemia or left outflow tract obstruction Renal tubular acidosis Inborn errors of metabolism

Pneumothorax Respiratory and cardiovascular deterioration

Increased respiratory distress (tachypnea, grunting, nasal flaring, and retractions) Cyanosis Onset of bradycardia or tachycardia (attributed to displacement of the heart with tension pneumothorax) Irritability and restlessness Blood gas may reveal a respiratory and/or metabolic acidosis, and hypoxemia

Retractions

Intercostal - between ribs Intercostal alone signals mild respiratory distress Substernal - under sternum Subcostal - below rib cage Suprasternal - above sternum

Causes of tissue hypoxia

Interference with oxygenation of blood and O2 delivery to tissues secondary to: Lung disease - ventilation/perfusion mismatch or intrapulmonary shunting - pulmonary capillary blood poorly oxygenated Intracardiac shunt - lowers arterial PO2 Cardiac failure - inadequate tissue perfusion and development of pulmonary edema Increased utilization of O2 at cellular level Hemoglobin - anemia, altered binding - low O2 content

Endotracheal Intubation Supplies and Equipment

Laryngoscope with an extra set of batteries and extra bulb No.1 (term infant) No. 0 (preterm infant) No. 00 (very low birthweight infant) ET tubes with an inside diameter of 2.5, 3.0, 3.5, and 4.0 mm Oxygen tubing Resuscitation bag and mask capable of providing a high concentration of oxygen CO2 detector Stylet Suctioning device, or suction setup with 8 and 10 F suction catheters Shoulder roll Roll of adhesive tape, ½ or ¾ inch, or endotracheal tube stabilizer if that is what your institution uses for securing the ET tube Scissors

Degrees of Respiratory Distress

Mild-consisting only of a rapid respiratory rate without the need for supplemental oxygen and with no, or minimal signs of distress, such as retractions, grunting, or nasal flaring Moderate-the infant is cyanotic on room air, and has other signs of respiratory distress, including an abnormal blood gas Severe-the infant has central cyanosis, is struggling to breathe, and has an abnormal blood gas Infants may progress from mild to moderate to severe respiratory distress very rapidly.

Pneumothorax - Treatment

NEEDLE ASPIRATION 18, 20, or 22 g IV catheter (preferred) or 21 or 23 g butterfly needle 30 ml syringe 3-way stopcock T-connector if using catheter Antiseptic solution to cleanse skin Following needle aspiration of the chest Attach T-connector/stopcock/syringe Open stopcock to patient Aspirate on plunger until resistance is met or syringe is full of air Turn stopcock off to patient Rapidly push air out of syringe CHEST TUBE - 10 or 12 French Heimlich one-way flutter valve or chest tube drainage system

Airway obstruction

Obstruction may occur at the nose, mouth and jaw, larynx or trachea, bronchi If there is airway obstruction in the upper respiratory tract, then stridor will be heard

Oxygen saturation

Percentage of hemoglobin that is saturated or bound with oxygen

Side Effects and Risks of prolonged O2 therapy

Prolonged oxygen therapy can be related to retinopathy of prematurity (ROP). This is why oxygen is weaned (decreased) as soon as possible. Sometimes, infants under hoods or tents can get chilled if the temperature of the humidified oxygen is not warm enough. Infants on nasal cannula oxygen can get dry or irritated noses from the cannula prongs.

Treatment of Respiratory Acidosis

Renal compensation (retention of bicarbonate) for an elevated PCO2 is a slow process. In most cases, providing continuous positive airway pressure (CPAP) or positive pressure ventilation by bag and mask or intubation will rapidly correct a respiratory acidosis

Process of Gas Exchange

Respiration > Breath taken > PO2 in the aveoli rises > O2 diffuses through the interstitium of the lung to the plasma in pulmonary capillary blood > O2 moves from the plasma into the red blood cells > O2 binds with hemoglobin molecules contained in the red blood cells > hemoglobin becomes saturated with O2 > blood is returned to the where it is pumped via the arterial system to the body hemoglobin releases O2 to the tissues > O2 diffuses into the tissues, through cell membranes, and into the cells > O2 is supplied to the cells for normal cellular function > CO2 diffuses from the cells into the capillaries to veins > to lungs > CO2 removed from the lung by ventilation > process is repeated

Evaluate Respiratory Distress

Respiratory rate < 30 per minute If labored, may be sign of exhaustion May be secondary to a decrease in central respiratory drive because of brain injury (for example, hypoxic ischemia, encephalopathy, edema, or intracranial hemorrhage), medications (for example opioids), or severe shock Assess severity of apnea and quality of air entry Gasping Gasping respirations are a sign of impending cardio-respiratory arrest. When an infant is gasping, ventilation and air exchange is ineffective. If not already intubated, the infant should be given bag and mask positive pressure ventilation, followed by endotracheal intubation and assisted ventilation

Tachypnea

Respiratory rate > 60 breaths per minute, tachypnea Evaluate ventilation and oxygenation Work of breathing May be tachypneic for many reasons Shock May hyperventilate to breathe off CO2 to correct metabolic acidosis Blood gas

S.T.A.B.L.E. Blood Gas Rules 5

Rule 1: Think of carbon dioxide (CO2) as an acid. The only way to remove CO2 is through the lung. CO2 reflects the respiratory component of acid-base balance. Rule 2: Think of bicarbonate (HCO3-) as a base (a hydrogen ion acceptor) Changes in HCO3- reflect the metabolic component of acid-base balance. To regulate acid-base balance bicarbonate is retained or excreted by the kidney. Rule 3: That which happens on the acid side (loss of, or accumulation of, acid or CO2) will be balanced by the base side (HCO3-), and vice versa. If the base side goes down, the acid side will try to go up to balance out or "compensate" for the change on the base side. The overall purpose of this balancing act is to maintain a normal pH value. Rule 4: If the pH is normal the blood gas is normal or the blood gas is compensated. Rule 5: If the pH is low, then the blood gas is uncompensated secondary to metabolic and/or respiratory acidosis or alkalosis.

Ways to administer O2

The first is an oxygen hood (halo). This is used for babies who can breathe on their own but still need extra oxygen. A hood is a plastic dome or box with warmed and humidified oxygen inside. The baby's head is placed under the hood. Oxygen tents are the same set up as hoods, except that they are made of a soft, flexible plastic. Another way to give oxygen is via nasal cannula (NC). This is made of soft, thin, plastic tubing through which oxygen flows. There are soft prongs that fit into the baby's nose so they can breathe the oxygen. This type of oxygen therapy is usually reserved for babies who are going to need oxygen for some period of time. Some infants will even go home on oxygen with a nasal cannula.

Transient Tachypnea

Transient tachypnea of the newborn (TTN) Affects term or near term infants Onset of respiratory distress is usually within 6 hours of birth The infant may have mild to moderate respiratory distress, but usually the oxygen requirement remains less than 40%

Respiratory Failure-Warning Signs

Unable to maintain acceptable saturation for infant suspected disease process Rapidly increasing O2 concentration to maintain O2 saturation greater than 90% Increased PCO2 and respiratory acidosis Labored respiratory effort Moderate to severe retractions + grunting + nasal flaring *consider intubation

Bag/Mask Positive Pressure Ventilation

Use cushioned, anatomically shaped mask Mask must cover nose and mouth completely Bottom rim should cover edge of chin Avoid pressure over the eyes A well-fitting mask will help ensure a good seal Place thumb over nose position of mask Use light downward pressure Do not press head into bed Avoid pressure on trachea Squeeze bag Watch for chest rise If bradycardic, watch for increase in heart rate Avoid excessive chest rise If chest does not rise or heart rate not increasing: Recheck seal Reposition head Ensure mouth is open Suction mouth and throat Increase inflating pressure

Evaluate/Assess and record

Vital signs Temperature Heart rate and rhythm Respiratory rate and effort, how much oxygen is being provided and the oxygen saturation Blood pressure Other signs of well-being Skin perfusion Strength of the pulses Neurologic status Urine output

Assessment of Respiratory Distress

When determining degree of respiratory distress, it is important to evaluate the respiratory rate, work of breathing, oxygen requirement, oxygen saturation, chest x-ray and blood gas. Respiratory rate Respiratory effort Quality of air entry on auscultation Retractions-location, severity Grunting, nasal flaring Apnea frequency, duration, heart rate and O2 saturation during apnea, self-resolved versus required stimulation O2 requirement O2 saturation Blood gas if requiring oxygen or concerned about shock

PCO2

arterial/35 - 45 mmHg capillary/35-50

Hypoxemia

below normal O2 content in arterial blood

Grunting

infant's attempt to increase intrathoracic pressure when there is collapse of alveoli Helps retain small volume of air in alveoli The louder the grunting, the more severe the respiratory distress

Respiratory rate > 60 per minute and LOW PCO2 consider what?

non-pulmonary causes such as: Congenital heart disease Metabolic acidosis and shock Brain disorders Hemorrhage Meningitis Edema

When oxygen is given to babies, it is measured in

percentages, from 21% up to 100

Respiratory rate > 60 per minute and HIGH PCO2 consider what?

pulmonary causes: Respiratory distress syndrome Pneumonia Aspiration Airway obstruction Other Chest masses Diaphragmatic hernia Pneumothorax

most common reason for referral to intensive care nursery

respiratory distress

Nasal flaring

sign of air hunger as infant attempts to decrease airway resistance and increase airway diameter

Endotracheal tube sizes and insertion depth for orally intubated infants according to

weight and gestational age