Essentials of Neonatal Ventilation

Cover
Title page
Table of Contents
Copyright
Contributors
Foreword
Preface
Acknowledgments

Section I: Introduction and History of Ventilation

Chapter 1: Introduction
Chapter 2: Evolution of Neonatal Ventilation a Retrospective View
Introduction
The development of neonatology
The birth of modern neonatal intensive care unit (NICU)
The birth of a new specialty: neonatology—the newborn medicine
The evolution of ventilator care of the newborn
Oxygen therapy
Usher regime
History of neonatal ventilation
Ross symposium on neonatal intensive care
Introduction of surfactant therapy in HMD/RDS
The modern neonatal ventilators
Summary

Section II: Lung Development and Interventions in the Prenatal and Perinatal Period

Chapter 3: Pathophysiology of Fetal Lung Development
Introduction
Embryology
Pulmonary vascular development
Transcription factors and growth factors in lung development
Maturation of pulmonary surfactant system
Intrauterine exposures and its effect on lung development
Physical factors: lung liquid and fetal breathing movements
Chapter 4: Transition in the Delivery Room: Current NRP Recommendations
Introduction
Physiologic changes in the fetal-to-neonatal transition
Transition in the delivery room
Current NRP recommendations
Chapter 5: Sustained Lung Inflation
Physiology of the respiratory transition after birth
Definition and rationale for sustained inflations
What literature says
Current recommendations
Unresolved issues about SI
Online Supplementary Material

Section III: Applied Physiology, and Ventilator Support: General Considerations

Chapter 6: Introduction to Lung Mechanics
Introduction
Overview of respiratory mechanics
Physical principles of respiratory mechanics
Mechanics of the respiratory pump
Elastic properties of the respiratory system
Resistive properties of the respiratory system
Respiratory mechanics in disease states
Chapter 7: Genesis of Lung Injury
Introduction
Old versus new BPD
Factors involved in pathogenesis of lung injury
Conclusions
Chapter 8: Hypoxic Respiratory Failure
Introduction
Pathophysiology of HRF
Etiology of HRF
Clinical features and assessment
Assessment of severity
Management
Chapter 9A: Comparison of Ventilators
Introduction
Discrepancy between values set on the ventilators and the measured ones
Ventilator mode classification
Commonly used ventilators and ventilator performance comparison
Summary of various factors in neonatal ventilators
High-frequency ventilators
Discussion and final comments
Chapter 9B: The Importance of Heating and Humidifying the Inspired Gases During Mechanical Ventilation:
Identifying the Ideal Settings and Circuit Configuration During Ventilation
Normal gas conditioning in the respiratory tract
Suboptimal conditioning of inspired gases to the AW
Structure and function of the AW lining
Achieving the optimum heat and humidity
Ventilators/ventilation: types, modes, and circuitry
Types of heat and humidifiers
Achieving optimum humidity
Dos and Don'ts
Chapter 10: Ventilator Graphics
Introduction
Historical timeline
Role of ventilator waveforms
Ventilator graphic classification
Basic waveforms
Pressure waveform
Flow waveform
Volume waveform
Pulmonary mechanics and loops
Pressure–volume loop
Flow–volume loop
Patient ventilator dyssynchrony
Pulmonary mechanics and graphics
Role of pulmonary graphics in bedside ventilator management
Troubleshooting for ventilator graphics
Ventilator graphics in special situations
Limitations of ventilator graphics
Summary
Chapter 11A: Initiation of Mechanical Ventilation
Introduction
Indications for mechanical ventilation
Equipment
Goals of mechanical ventilation
Initiation of mechanical ventilation
Ventilation strategies and choosing the right mode
Chapter 11B: Deterioration on the Ventilator
Approach to deterioration on a ventilator
Chapter 12: Extubation
Introduction
Extubation strategy
Optimizing an extubation attempt
Patient groups
Complications of Ventilation
Chapter 13A: Complications of Mechanical Ventilation
Barotrauma
Volutrauma
Oxytrauma
Atelectotrauma
Biotrauma
Injury related to endotracheal tube
Asynchrony
Inappropriate warmidification
Ventilator-associated pneumonia
Complications of mechanical ventilation in special situations
Chapter 13B: Pulmonary Air Leaks
Thoracic air leaks (Figs. 13B.1 and 13B.2)
Practice points
Acknowledgments
Chapter 13C: Pulmonary Edema and Pulmonary Hemorrhage
Clinical features and diagnosis
Remedial measures
Pulmonary hemorrhage
Clinical features and diagnosis
Remedial measures
Chapter 13D: Neonatal Necrotizing Tracheobronchitis
Pathogenesis
Clinical diagnosis
Investigations
Prevention
Treatment
Prognosis

Section IV: Bedside Application Principles of Assisted Ventilation Devices

Chapter 14: Various Modes of Mechanical Ventilation
Introduction
Conventional mechanical ventilation
Principal ventilation techniques
High-frequency ventilation
Importance of the “open lung strategy” (Fig. 14.5)
Clinical tips
Chapter 15A: Patient-Triggered Ventilation: Synchronized Intermittent Mandatory Ventilation (SIMV), Assist–
Control, Pressure-Support Ventilation (PSV), Neurally Adjusted Ventilatory Assist (NAVA)
Introduction
Applied physiology of synchronized mechanical ventilation in the newborn
Effects of the different types of ventilation
Indications and contraindications
Protocol of use
Bedside application of the technology
Failure of technology
Weaning from technology
Complications from technology
Strategies in specific diseases and effects of its use
One case scenario
New directions including neurally adjusted ventilatory assist (NAVA)
Chapter 15B: Neurally Adjusted Ventilatory Assist (NAVA) in Neonates
Neurally adjusted ventilatory assist basics
How NAVA works
Outcomes of neonates on NAVA
Set up of NAVA
Management of neonates on NAVA
Contraindications for NAVA
Conclusion
Disclosure statement
Chapter 16: Volume-Targeted and Volume-Controlled Ventilation
Rationale for volume-targeted ventilation
Volume-controlled versus volume-targeted ventilation
How does VTV work?
Importance of the open lung strategy
Practical guidelines for VTV
Chapter 17: Noninvasive Ventilation and High-Flow Nasal Cannula
Noninvasive ventilation
NCPAP
NCPAP in the NICU
Biphasic CPAP in NICU: Si-PAP/ Bi-PAP/DuoPAP
Suggested guidelines for use of CPAP and Si-PAP
NIPPV
NIPPV in the NICU
NIV in the delivery room
Suggested guidelines for using NIPPV in the delivery room
Suggested guidelines for use of NIPPV
Noninvasive high-frequency ventilation (NIHFV)
Suggested settings during NHFV
NHFJV
NIV during transport
High-flow nasal cannula
HFNC versus CPAP
HFNC versus LFNC
Guidelines for using HFNC
Summary and future of NIV
Major limitations with NIPPV use in low and middle income countries
Case reports
Online supplementary material
Chapter 18A: Continuous Positive Airway Pressure for Respiratory Failure in Newborn Infants
Introduction
Historical overview
Physiological effects of CPAP
Indications for nasal CPAP therapy
Desirable features and major components of CPAP devices
Randomized trials comparing continuous positive airway pressure devices
Practical aspects of nasal CPAP application and strategies for success
Randomized clinical trials of nasal CPAP versus intubation and surfactant
CPAP in meconium aspiration syndrome
Experience with nasal CPAP at Columbia University
Summary
Appendix: video of nasal CPAP application at birth in a 480 g preterm infant with RDS
Chapter 18B: Continuous Positive Airway Pressure in the Treatment of Meconium Aspiration Syndrome
Introduction
Diagnosing meconium aspiration syndrome
Pathophysiology of meconium aspiration syndrome
Pulmonary mechanics of meconium aspiration syndrome
Role of CPAP in meconium aspiration syndrome
Summary
Chapter 19: Nasal Intermittent Positive Pressure Ventilation
Introduction
History
Mechanism(s) of action (Fig. 19.1)
Types of NIPPV—primary mode versus secondary mode
NIPPV versus BiPAP
NIPPV versus SNIPPV
Clinical use of NIPPV
NIPPV failures
Flow synchronization
Practical guidelines for the use of NIPPV
Real-life case scenarios
Online supplementary material
Chapter 20A: High Frequency Ventilation
Introduction
Brief history on HFOV
Physiology of HFOV
Clinical application of HFOV
High-frequency jet ventilation
Clinical cases
Chapter 20B: High-Frequency Oscillatory Ventilation Management Strategy
Introduction
Patient groups and indications
Initiation of HFOV
Adjusting settings during HFOV
Weaning from HFOV and extubation
Chapter 20C: High-Frequency Jet Ventilation: Guide to Patient Management
Chapter 21: Pulmonary Vasodilators in the Treatment of Persistent Pulmonary Hypertension of the Newborn
Introduction
Regulation of vascular tone in pulmonary circulation
General management of PPHN
Use of surfactant therapy for PPHN
High frequency ventilation
Inhaled nitric oxide therapy
Phosphodiesterase-5 inhibitors
Prostaglandins in PPHN
Phosphodiesterase-3 inhibitors
Endothelin receptor antagonist
Other vasodilators tested in PPHN
Conclusions
Chapter 22: Extracorporeal Membrane Oxygenation for Refractory Respiratory Failure
Introduction
Indications
Contraindications
ECMO cannulation: venovenous or venoarterial? (Fig. 22.1)
Congenital diaphragmatic hernia
ECMO circuit and components
Neurologic system
Neuromonitoring on ECMO
Sedation and analgesia
Respiratory support
Cardiovascular supports
Fluids, electrolytes, and nutrition
Infection
Anticoagulation
Hematologic issues
Weaning ECMO
Neonatal ECMO survival
Long-term neurodevelopmental outcomes
CDH
Recommendations for long-term follow-up
Summary

Section V: Clinical Management

Chapter 23: Principles of Mechanical Ventilation and Strategies of Ventilatory Support in Neonatal Lung
Disease
Introduction
Basics of conventional positive pressure ventilation
Ventilator management of common respiratory conditions in the neonate
Conclusion
Chapter 24: Respiratory Distress Syndrome and Surfactant Therapy
Introduction
Surfactant metabolism
Pathophysiology of RDS
Epidemiology of RDS
Prenatal diagnosis of RDS
Clinical features
Laboratory findings and diagnosis
Differential diagnosis
Management of RDS
Prenatal management
Delivery room management
Surfactant therapy: type, timing, technique for surfactant treatment
Types of surfactant
Indications of surfactant administration
European Consensus Guidelines for RDS management (2016 update) [89]
Timing of surfactant administration: prophylaxis versus rescue
Timing of surfactant administration: early versus delayed rescue/selective surfactant Rx
Timing of surfactant administration: beyond the first week of age
Techniques of surfactant administration: INSURE versus modified INSURE
Noninvasive surfactant treatment (NIST)
Combination therapies with surfactant
Surfactant as vehicle
Surfactant with nitric oxide
Recombinant club cell protein (rhCC-10)
Surfactant treatment for acute RDS (ARDS)
Oxygen supplementation beyond stabilization during RDS management
Caffeine therapy
Permissive hypercapnia
Postnatal steroids
Inhaled nitric oxide
Supportive management
Temperature control
Fluid management
Nutrition
Use of antibiotics
Cardiovascular management
Complications of RDS
Ventilator management of RDS
Mechanical ventilation strategies
Ventilatory management of complications of RDS
Summary and recommendations
Cases
Chapter 25A: Meconium Aspiration Syndrome— Part 1: Epidemiology, Pathophysiology, Signs and Symptoms, and
Diagnosis
Introduction
Significance of MSAF
Epidemiology of MSAF
Pathophysiology of MSAF
Meconium aspiration
Pathophysiology of MAS
Clinical features
Differential diagnosis
Initial diagnostic tests
Chapter 25B: Meconium Aspiration Syndrome—Part 2: Clinical Management
Delivery room management
Respiratory support—recruitment phase
Respiratory support—stable phase
Respiratory support—weaning phase
Cardiovascular support
Bicarbonate infusion
Antibiotics
Chest physiotherapy
Pulmonary vasodilators
Extracorporeal membrane oxygenation
Air leak syndromes
Cases
Chapter 26: Persistent Pulmonary Hypertension of the Newborn (PPHN)
Introduction
Definition
Pathophysiology
Hemodynamic changes (Fig. 26.1)
Mechanism of PPHN
Etiology of PPHN
Clinical features
Severity of PPHN and HRF
Management
Inhaled nitric oxide
Other pulmonary vasodilators
Extracorporeal membrane oxygenation
Asphyxia, hypothermia, and management of PPHN
Long-term outcome of PPHN
Conclusion
Chapter 27: Bronchopulmonary Dysplasia
Definition
Incidence
Etiopathogenesis
Clinical course
Acute episodes of respiratory deterioration
Radiologic characteristics
Management
Summary of the pharmacological management of BPD
Complications
Pulmonary outcomes
Summary of treatment
Home therapy/follow-up management [142]
Mild BPD
Severe BPD
Chapter 28: Congenital Diaphragmatic Hernia
Pathophysiology
Antenatal diagnosis and monitoring
Postnatal presentation of CDH
Management
Follow-up of infants with CDH complications and morbidities
Future directions and therapies
Chapter 29: Care of Extremely Low Birth Weight Infants
Introduction
Prenatal management
Delivery room care of the ELBW neonate (Fig. 29.1)
Management of RDS
Management/prevention of nonrespiratory complications in ELBW infants
Outcomes of ELBW infants
Clinical cases

Section VI: Cardiac Issues in Neonatal Respiratory Care

Chapter 30A: Echocardiography and Hemodynamics
Cardiopulmonary interdependence
The impact of ventilation on the cardiovascular system
Cardiovascular assessment
Hemodynamic assessment in specific situations
Role of targeted neonatal echocardiography in guiding cardiorespiratory care
Online supplementary material
Chapter 30B: Patent Ductus Arteriosus
Introduction
Ductus arteriosus in the fetus
Pathophysiology of ductal closure after birth
Etiology of patency of the ductus arteriosus
Hemodynamic changes associated with PDA
Influence of PDA on neonatal respiratory care and management
Clinical features
Diagnosis and work-up
Classification of the PDA
Severity of the PDA (hemodynamically significant)
Management
Summary and conclusions
Chapter 30C: Cyanotic Heart Disease in a Neonate
Background information
Conclusions
Chapter 30D: Neonatal Arrhythmias
Abbreviations
Types of rhythm disturbances
Tachyarrhythmia: rhythm disturbances with fast heart rate
Important points for tachycardia
Premature beats and pauses
Important points about premature/ectopic beats
Bradyarrhythmia: rhythm disturbances with low heart rate
Others
Evaluation and management protocol
Management of arrhythmia in neonates
Management of Shock
Chapter 31A: Neonatal Shock Management
Introduction
Definition
Stages of shock
Types of shock
Shock pathophysiology
Enhanced hemodynamic assessments tools
Basic pharmacology
Summary and conclusion
Chapter 31B: Hypotension and Shock in Preterm Newborns
The unique characteristics of the neonatal cardiovascular system
Hemodynamic monitoring of preterm infants
Blood pressure and cerebral blood flow
Hypotension
Pathophysiology of hypotension
Shock
Shock without hypotension
Shock with hypotension
Key learning points
Chapter 31C: Hypotension and Poor Circulation in Neonates
Introduction
Hemodynamic assessment of the newborn
Clinical assessment
Blood pressure
Blood flow
Cardiovascular support therapies
Stepwise approach to cardiovascular support

Section VII: Ancillary Services

Chapter 32: Monitoring of Gas Exchange in the NICU
Physiology of gas exchange
Blood gas analysis
Common acid–base disturbances in the NICU
Sampling sites for blood gas analysis
Noninvasive monitoring of oxygenation—pulse oximetry
Noninvasive assessment of PaCO2
Near-infrared spectroscopy (Fig. 32.10)
Chapter 33: Nursing Care and Endotracheal Suction
Introduction
Neonatal history
Assessment of neonate
Selection and set up of equipment for respiratory support
Nursing care of the neonate and monitoring of equipment
Airway patency and suction
Chest physiotherapy
Monitoring for complications
General supportive care
Summary
Chapter 34: Neonatal Airway Management
Introduction
Airway pathology
Procedures
Online supplementary materials
Chapter 35: Ventilator-Associated Pneumonia and Infection Control
Introduction
Magnitude and significance of VAP
Definition and diagnosis of VAP
Pathogenesis of VAP (Fig. 35.1)
VAP treatment and prevention
Health care-associated infection and central line-associated bloodstream infection
Audit and surveillance of VAP, CLABSI and HAI
Cleaning, disinfection, and sterilization in NICU
Implications for practice
Chapter 36: Nutrition in the Preterm Neonate Requiring Respiratory Support
Introduction
Nutritional goals
Fluids
Human milk fortification
Probiotics
Chapter 37A: Neonatal Procedures Involving Catheters and Tubes
Abbreviations
Introduction
Umbilical arterial catheters
Umbilical venous catheters
Peripherally inserted central catheters
Peripheral artery catheterization
Thoracocentesis and intercostal chest drain placement
Endotracheal intubation
Laryngeal mask airway (Fig. 37A.10)
Conclusions
Chapter 37B: Neonatal Limb Ischemia Due to Arterial Catheters
Introduction
Umbilical arterial catheterization
Peripheral arterial catheterization
Clinical presentation of limb ischemia associated with arterial catheters
Prevention
Management

Section VIII: General Issues

Chapter 38: Neonatal Developmental Follow-Up Program
Introduction
Programs, criteria, its objectives, and benefits
Recommended follow-up schedule
Calculation of the corrected age
The tools used in newborn to 12 months
Speech and language evaluation
Emotional and social behavior and adaptation
Other evaluation tools recommended for research purposes
Chapter 39: Management of Ethical Challenges in Neonatal Intensive Care
Common ethically challenging questions in the NICU
A framework for ethical analysis
Preventive ethics and advance planning
Brain death
Palliative care
Care after LST has been withheld, withdrawn, or limited
Communication skills and language in ethically challenging situations
Care after death
Chapter 40: Normal Reference Values
Hematological parameters
Biochemistry values
Coagulation parameters
Blood gas
CSF values
Urine
Blood pressure
Growth charts (Fenton for girls and boys)
Index