How We Deal With Bad Baby's In A Small Town Hospital

It was 1997. A senior RT introduced me to OB for the first time. She showed me the Sechrist ventilator. It seemed stressful enough. But, then she introduced me to an older ventilator. I think it was called a Baby Bird. Now, that was a stressful baby ventilator.

The Sechrist was a great ventilator for its time. You plugged it in. And then you dialed in some settings. My preceptor taught me that all you have to do is remember numbers, such as 5 and 20. You set the PEEP at 5 and Pressure Control at 20. You set the rate at 30 or whatever the value was back then. And there were a few others to remember. Then you adjusted to meet the needs of the newborn.

But, they were all simple to remember. And then you set it up on the baby and didn't have to do much more.

This was nice, because it's stressful enough when you have a bad baby. When you work in a small hospital like I do, you might get only one bad baby in a five year period who requires a ventilator. So, it's good that you have something that is easy to set up if you do need it. But when I was introduced to that Baby Bird or whatever it was, that was stress. It was so confusing that you even had to take out a calculator to determine what your ventilator settings would be. It was stress just thinking about it.

Then we advanced to the Servo 300. It just sat back in the closet collecting dust. Well, not really, because we took it out monthly to play with it. We had fake scenarios that we would do. We needed to practice because we use this machine so seldom. And the few times we did have to set it up we were applauded by the nursing staff. They were so often impressed at how we therapists set it up with such aplomb. It was, as a nurse once said, as though you guys set these things up every day."

Then we advanced to the Servo i. By this time we also had another new machine. It was called the Neopuff. When this machine was first bought by the OB supervisor we RTs were annoyed. We weren't even checked off on it. We had no idea what it was. And we refused to use it. Instead, we resorted to the old method of bagging babies. Carefully squeeze, but not enough to pop a hole in the baby's lungs. Not easy to do, especially when you had to bag for 4 hours until the baby buggy arrived from larger hospital down south.

Then we started taking Neonatal Resuscitation. And here we learned of the value of the Neopuff. We learned how dangerous bagging was. That even minute changes in the pressures when we squeezed the bag could damage those baby lungs. And the Neopuff guarantees that each breath will be the same depth. Using it greatly reduced the incidence of conditions like hyaline membrane disease and bronchopulmonary dysplasia. Yep! Remember learning about those diseases?

Today we are told intubations can cause trauma to newborns too. Well, that makes sense. But, when a baby can't breathe, a tube is still needed. But, our protocol no longer calls for intubation on infants that are breathing. Even if they are retracting. And Lord knows infants born too early to make their own surfactant do need assistance. But, today the Neopuff can provide CPAP. So, we are encouraged to use it rather than intubate.

It's to the point now that we no longer even have a neonatal ventilator. Well, we have one, but it's no longer stored in OB. Basically, modern evidence shows CPAP and ship to larger children's hospital. Today I applied that CPAP to infants faces for four straight hours. Silly that we can't use our ventilator to apply that CPAP to the infant. But, this is how it is when you work at a small hospital. The experts at the children's hospital where we transfer infants to said it's best that we just use the Neopuff and leave everything else to the experts.

The baby buggy arrives eventually. Usually, it's 3-4 hours. And then we ship the baby. And our stress is gone. But, still, with the Neopuff and no ventilator, there's really not much to remember anymore other than the basic Neonatal Resuscitation stuff. A far cry from just 2 years ago.

Cord blood gases made easy

Cord Blood Gases Made Easy 

Why draw Cord Blood Gases?

Basically, the reason we draw cord blood gases (CBG) is in case there is a lawsuit years down the road accusing the delivering doctor of causing an anoxic brain injury that resulted in disorders such as cerebral palsy. 

The cord blood can prove that neurological deficits that develop in infants were caused by an anoxic brain injury that occurred after delivery or before delivery and was not the result of an anoxic episode at birth. The cord blood gas has been shown to be proof positive in about 80% of the cases (According to PubMed.com), and has in many cases cleared physicians from litigation.

When should a Cord Blood Gas be drawn?

A cord blood gas does not need to be drawn unless a baby is born and has a low APGAR score within 5 minutes of delivery, such as a 3 or less. When the APGAR score is low a cord blood gas should automatically be drawn.

What is a Cord Blood Gas?

When we refer to cord blood we are referring to blood drawn from the placenta after delivery. If you look at a placental cord (see picture below) you will see one large vein surrounded by two arteries that wrap around the vein.

According to PubMed.com, the Umbilical Vein delivers freshly oxygenated blood from the mom to the baby. Since an anoxic brain injury in the baby in not likely to change the pH of the Umbilical Vein, this is not where you will want to draw a cord gas from.

The Umbilical Artery is where the baby's venous circulation dumps unoxygenated blood. This is blood that was on its way back to the mom's heart and lungs to pick up oxygen. Thus, when you draw a cord gas for litigation purposes you will want to draw from one of the two Umbilical Arteries.

Blood from the Umbilical Artery is called a Cord Arterial Blood Gas (CABG), and basically shows how the baby was doing prior to birth.

From this blood we want to watch for acidosis. Since anaerobic metabolism occurs during the absence of oxygen, the acid base balance (pH) of the baby's body increases due to an increase in the amount of lactic acid produced. Therefore pH is the most important indicator in the CABG.

What are acceptable CABG values?

If the pH of the CABG is above 7.10, then we know that the baby was not hypoxic during the delivery, and if there was a hypoxic episode it occurred prior to the delivery process.  You know this because the pH had time to normalize.

The anoxic episode may have occurred weeks or months prior to birth, or it may have occurred hours before birth. Either way, this proves the episode did not occur as a result of the delivery and should clear the physician of litigation.

What are critical CABG values?

If the pH is less than 7.10 the episode was more likely acute and the episode may have occurred during the delivery. You know this because the pH did not have time to normalize.

According to obgyn.org, some experts believe a pH of 7.0 with a significant metabolic component is a more significant sign of asphyxia at birth, and may lead to significant neurological dysfunction during life, or possibly even death.

Also according to obgyn.org, "Even when this low pH threshold is used to define significant acidemia, most newborns in this category will be neurologically normal, with no apparent morbidity."

What baby’s are at greatest risk for anoxic brain injuries?

The baby's at greatest risk of anoxic brain injury are premature infants, according to obgyn.org. They are at higher risk of "intracranial hemorrhage and subsequent neurological dysfunction, such as cerebral palsy.

Without umbilical cord blood gas analysis, these neurological complications could be incorrectly attributed to intrapartum or birth asphyxia, especially if the latter is solely based on APGAR scores.

Normal umbilical cord blood values in the premature infant virtually eliminate the diagnosis of significant intrapartum hypoxia or birth asphyxia."

Can you just draw an arterial cord blood gas?

Most experts recommend drawing both arterial and venous gas for the purpose of comparison.  One physician suggested “that the cost of approximately $2 per delivery should be absorbed by the hospital as a risk-management measure.

How do draw Cord Blood Gases?

Immediately following the delivery of the infant and before placental separation, obtain cord blood gases as follows (refer to pictures below):

·        A 6 inch segment of the cord should be isolated between 2 clamps (See figure 2 Below)

·        Select two 1cc heparinized blood gas syringes

·        Label the two syringes with the patient name and date of birth

·        Write on one syringe umbilical vein and the other umbilical artery

·        Identify the umbilical vein and umbilical artery

·        Grasp one end of the umbilical cord to prevent it from moving

·        With your other hand hold the syringe marked umbilical artery as you would hold a pencil

·        Prepare to insert the syringe parallel to the artery to avoid passing through the narrow vessel (this is demonstrated in figure 3 below).

·        Insert syringe into umbilical artery at a 45 degree angle (Be careful not to go all the way through the artery)

·        Pull back slowly on the syringe to allow it to fill with blood

·        Ideally we would like at least 1cc, however we need at least 0.3cc of blood

·        Remove the needle from the umbilical artery

·        Carefully discard the needle

·        Remove any air bubbles from the syringe

·        Follow the same above steps for drawing blood from the umbilical vein

·        Call respiratory therapy to run the samples as soon as possible

What do you do with a cord gas once it is drawn?

Once a CABG and a CAVG has been drawn, hospital policy requires that they be placed on ice, and respiratory therapy should be paged as soon as possible.  The samples should ideally be run through the ABG machine within 30 minutes of the draw

What are normal CABG values?                  What are normal CAVG results?

·     pH:        7.27 (range 7.22–7.32)           ph:        7.34  (range 7.28–7.40

·     pCO2:    50 (range 42–58)                   PCO2:  40.7  (range 32.8–38.6)

·     pO2       18 (range 12–24)                   pO2:     30  (range 28-32)

·     HCO3:   22 (range 24-26)                    HCO3:  21.4  (range 19-24)

·     BE:       -2.7  (range –5.5– 0.1)            BE:      -2.4  (range –4.4-0.4) 

The following are conditions that would warrant a CABG:

·     Any abnormality during delivery process (prolonged pushing, difficult delivery)

·     Low 5 minutes APGAR score (less than 3)

·     Any abnormality in patient condition that occurs within 1st 5 minutes after birth

·     Premature birth

·     Post term birth

·     Meconium in amniotic fluid

·     Intubation

·     Positive pressure ventilation (Neo-puff or bag mask ventilation)

·     Suctioning

·     Cesarean-section

·     Severe growth retardation

·     Abnormal fetal heart rate tracing

·     Maternal thyroid disease

·     Intrapartum fever

·     multifetal gestation

Conclusion:  Essentially, a CABG with a pH of 7.1 or greater can prove the infant was well oxygenated at time of birth, and can clear the delivering physician from litigation.  

Umbilical cord blood gases: routine measurement may exonerate ob.gyns

(From OB/GYN News) Dr. Hankins said that following the birth of a baby with Cerebral Palsy (CP), there are many factors that are beyond obstetricians' control in the cascade of events that spiral toward litigation--but doing cord blood studies is not one of them.

"This is something that is within our hands, but once it escapes you, it is gone. The only opportunity the obstetrician has to obtain this information is going to be right at the moment of birth," said Dr. Hankins, professor of ob.gyn.at the University of Texas, Galveston.

He recommended that immediately following delivery a segment of the umbilical cord be doubly clamped and placed aside to remain stable for 30 minutes for pH and blood gas assessment.

"[Neither] ACOG nor anyone else has suggested that every baby that's delivered should have cord blood studies, but I say it would be a tremendously positive thing to do and it should get rid of some of this frivolous litigation."

He recommended drawing both arterial and venous gas for the purpose of comparison, and he suggested that the cost of approximately $2 per delivery should be absorbed by the hospital as a risk-management measure.

"It's not subjective; it's pure objective data. If you have a pair of blood gases--arterial and venous--by that alone, and with no other data, I can tell you much of what was happening in that delivery room," he said.

The task force document set the following criteria for the precise definition of an acute intrapartum event sufficient to cause cerebral palsy:

·         Evidence of metabolic acidosis in fetal umbilical cord arterial blood obtained at delivery (pH less than 7 and a base deficit of 12 mmol/L).

·         Early onset of severe or moderate neonatal encephalopathy in infants born at 34 or more weeks' gestation.

·         Cerebral palsy of the spastic quadriplegic or dyskinetic type.

·         Exclusion of other identifiable etiologies, such as trauma, coagulation disorders, infectious conditions, or genetic disorders.

By Kate Johnson, OB/GYN News Contributing Writer, July 1, 2004
http://findarticles.com/p/articles/mi_m0CYD/is_13_39/ai_n6114078/
COPYRIGHT 2004 International Medical News Group

COPYRIGHT 2008 Gale, Cengage Learning

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Everything you need to know about the Neopuff

Introduction to the NeoPuff:

The need to perform positive pressure ventilation (PPV) on neonates is rare.  In fact, statistics show that about 90% of infants make the transition to extra-uterine life with no problem.  The other 10% will need resuscitation, with 1% requiring an extensive work-up.

In the past PPV has been performed with an AMBU-bag, and rate and depth of breaths determined by a steady hand.  New evidence shows that using AMBU-bags on neonates is too risky, and many hospitals, including ours, are making the transition to using a NeoPuff instead of AMBU-bag.

What can a NeoPuff be used for?

• Blowby oxygen
• PPV
• CPAP

How to get NeoPuff ready for use? (Must be completed when birth expected)

1. Check manometer reads zero with no gas flow. (If not, call RT)
2. Make sure patient supply line is connected to outlet port
3. Make sure a T-piece is connected to the patient supply line
4. Turn on air & oxygen tanks (not needed if air & oxygen connected to wall source)
5. Connect test lung to T-piece
6. Turn flowmeter on NeoPuff to 8lpm (or 5-10lpm)
7. Check for desired oxygen (recommended setting is 40% FiO2)
8. Place finger over PEEP valve.  Pressure manometer should read 20cwp. 
9. While still occluding PEEP valve, turn PIP valve clockwise as far as it can go.  It should not go higher than 40.  If it does go to step 10.  If not, go to step 11
10. Continue occluding PEEP valve.  Remove cap from Maximum Pressure control knob.  Turn knob until Maximum Pressure set at 40 (or as desired)*
11. Close cap that so Maximum Pressure knob is covered
12. Turn PIP** knob to set desired PIP (We like to use 20cwp)
13. Adjust PEEP cap to desired PEEP level.  We like to use 5 CWP.  The PEEP cap is located on the T-Piece
14. Turn off gas supply from flowmeter on NeoPuff
15. If used, make sure you turn off the air and oxygen tanks (otherwise you’ll have to replace them when they go empty)
16. Make sure neonatal resuscitation mask is in the basket
17. Remove test lung from patient circuit
18. If used, check oxygen and air tanks and replace as necessary
19. Failure to complete any of the above steps may cause unacceptable delays in resuscitating newborns.

*The factory setting of the Maximum Pressure Relief is 40 cwp. This is to prevent the PIP from being adjusted over 40 cwp.  Likewise, resuscitation above 40 cwp cannot be achieved unless the Maximum Pressure Relief valve is adjusted.  So long as no one does this, step 10 above can be skipped.

**PIP is Peak Inspiratory Pressure.  This is the pressure given for each breath. 

How to get NeoPuff ready when you need it NOW?

• Turn on oxygen and air tanks (not necessary if O2 & air plugged into wall outlet)
• Turn flowmeter on NeoPuff to 8lpm (or 5-10lpm)
• Make sure PIP is set at 20
• Make sure PEEP is set at 5
• Make sure FiO2 is set to 40%
• Fit neonatal resuscitation mask to the T-Piece
• Now it is ready for the impending delivery.  Hopefully you won’t need it.

Blowby oxygen:  If the infant is breathing yet continues to be blue or otherwise requires oxygen, the NeoPuff can be used to blow oxygen past the patient’s face (an AMBU-bag cannot be used to give blowby oxygen) 

• Place mask (or that end of the tubing) close to baby’s mouth and/nose (no not place the mask on the baby's face, just NEAR the face)
• Occlude PEEP valve with your finger and hold it there
• Oxygen should now be blowing by the patient’s face
• Adjust oxygen as required to maintain desired SpO2 (see below)

How to give PPV with NeoPuff? 

If the infant is not breathing adequately, or the heart rate dips below 100, you should do the following:

• Place mask over the baby’s mouth and/nose (or fit patient T-piece to ETT).
• Resuscitate by placing and removing thumb over the PEEP cap to allow inspiration and expiration. 
• Inhalaiton occurs when you place thumb over the PEEP cap
• Exhalation occurs when you remove thumb from PEEP cap
• Give 40-60 breaths per minute (recommended by NRP)
• Do this until HR > 100 and patient breathing adequately

How do you know PPV is working?

• Heart rate increases
• Improved Color
• Spontaneous respirations
• Increased muscle tone

If the NeoPuff appears to not be working:

• Check equipment
• Make sure have good seal
• Make sure PIP is adequate
• Check respirations
• Reposition infant

How to give CPAP with NeoPuff?

If infant heart rate is above 100 and breathing remains labored, CPAP may be trialed:

• Place mask over the baby’s mouth and/nose (or fit patient T-piece to ETT)
• Do not place finger over hte PEEP valve and hold
• This will allow patient to breath spontaneously while providing CPAP (PEEP)
• Verify it is working by observing the pressure manometer: during exhalation the hand should point to your dialed in PEEP setting.  

Why use the NeoPuff to give PPV rather than an AMBU-bagBag?

• Evidence shows the NeoPuff is the best way to ventilate neonates
• Less pressure (prevents pneumo)
• Consistent Pressure (prevents Hyaline Membrane Disease*)
• Bags should be available for backup only
• I-Time and Rate controlled by finger instead of whole hand
• Less stress on caregiver (don’t have to worry about giving too much or too little pressure)

*Evidence shows that inconsistent pressures from AMBU-bags actually cause bruising in the neonate airway and can result in further complications for newborns making them extremely difficult to treat.  The Neopuff gives constant, equal breaths that are much easier for the infant.

Fallacies about using Neo-Puff to give PPV: 

Many medical care practitioners are afraid to use the Neo-Puff because they are used to “feeling” each breath go into the baby with their hands by squeezing the bag. When using the Neo-Puff you will not “feel” the breath go in. 

However, every study so far completed comparing the Neo-Puff to PPV overwhelmingly supports using the Neo-Puff to the Ambu-Bag.  The Neonatal Resuscitation program (NRP) highly recommends we get over our fear of the Neo-Puff and use them. 

Oxygenating Neonates:

When using our AMBU-bags you have to give 100% oxygen.  The NeoPuff allows you to adjust the FiO2 from 21% to 100%.

A growing number of literatures have proven you shouldn’t use 100% oxygen for newborn infants.  New studies show that high levels of oxygen -- even for term babies -- can be detrimental to the short term and possibly even long term health of newborns.

Several studies have linked 100% oxygen (even for as little as ONE minute) to:

• Leukemia
• Cancer
• Cellular death
• Infection
• Delayed development of oxygen sensing tissues
• Oxygen radical disease of neonate

It is for this reason that 40% is the recommended starting point for FiO2.  If needed, this can be titrated as appropriate for the patient, or as recommended by physician.

Pay attention to oxygen sats, don’t just leave baby at 100% SpO2.  With Baby less than 30 weeks, Spo2 should be kept <90, the concern is early eye development.  Plus scientists are not sure if primie organs should be rapidly exposed to too much oxygen too fast; when in utero they were developing in a SpO2 of 60% or less. 

Some hospitals are currently doing a study of using 21% on all newborns.  It is now believed that it’s not oxygen that stimulates a baby to take its first breath, but heat, stimulation, and PPV.  So some hospitals have gone to 21% FiO2 already.  

Benefits of lowering oxygen Sats:

• Increased neurological function
• Decreased Retinopathy of Prematurity
• Decreased Chronic lung disease
• Increased weight gain
• Decreased Infection 
• Decreased Ventilator days
• Decreased Oxygen days
• Decreased Length of stay
• Decreased neonate mortality rate by 30-40%

However, if a baby is not responding to 40% FiO2 after 90 seconds, you should increase to 100%

The recommended goals of oxygenation:

Weeks Gestation	SpO2	Alarms High  Low
<30	85%	93	80
30-34	88%	93	83
35-39	91%	96	86
40 or >	94%	99	89

1. Achieve Sat gradually (increasing PO2 too fast has potential to cause harm)
2. Decrease FiO2 as Sats rise > 95%
3. If HR not rising, check for correct ventilation
4. Increase to 100% FiO2 if no improvement after 90 seconds
5. Do not chase saturations, fluctuations in sats is normal (better to bounce low than to bounce high
6. SPO2 should not exceed 95% unless suspect Persistent Pulmonary Hypertension

Benefits of CPAP for neonates: (PEEP and CPAP is the same thing)

• Always keeps little air in lungs to make next breath easier.
• If HR >100 and breathing remains labored, then you can try CPAP. 

1. Keeps small amount of air in lungs
2. Keeps alveoli open, and prevents alveoli from collapsing
3. Improves oxygenation
4. Makes next breath easier

Conclusion:  So you can see the NeoPuff is proven to be a safe and effective method of providing blowby oxygen, PPV and CPAP for neonates.  It’s also easy to set up, requires only one finger to use, and takes away the stress of squeezing the bag too hard.  In this regard, a well educated caregiver will realize it’s actually easier to use than an AMBU-bag.

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Treatments cause cancer later in life????

I know that there have been studies that show that giving oxygen, even for a short period of time, can increase a neonates chances of getting cancers.

So, does that mean that giving a breathing treatment with oxygen, even for the short 4 minute duration, is also increasing the child's chances of getting cancer? One would imagine so.

So, one would think this is something that would be investigated further. Breathing treatments, when given to small children, should probably be given with air.

Most hospitals probably don't have to worry about this, but some -- like ours -- don't have piped in air, and give all their treatments with oxygen.

So, by giving breathing treatments with 100% oxygen to a neonate, are we increasing that kids risk of getting cancer down the road?

Another thing to consider is this: If the hypoxic drive theory is true, and as many COPD patients are hypoxic drive breathers as some doctors would have us believe, then why have no patients ever dropped dead during a breathing treatment?

Just a thought.

Neonates should be kept warm

We had 6 day old neonate present to the emergency room in respiratory distress. When I arrived on the scene I saw a baby lying limp on the ER bed. The first thing I said was, "We need to warm that baby up."

One of the nurses proceeded to get a warm blanket, while another went up to OB to get an incubator. Within moments of being warmed the baby's respiratory rate improved, and muscle tone was much improved.

The moral of this story is one of the first things to think of when you have a neonate is to make sure it is warm. Ideally you will want a core temperature between 36.5 and 37.5 degrees celcius.

You may not think of this, but you have heat and cold receptors in your skin deep in the tissue, which send signals to the hypothalamus in the brain to release norepinepherine, which start a cascade of events.

According to S.T.A.B.L.E Program, "In response to cold stress, a series of reactions are activated for the purpose of decreasing heat loss and increasing heat production These include constriction of blood vessels in the arms and legs, increased muscle flexion activity, and metabolism of brown fat. To mount these responses, the metabolic rate must increase which, in turn, increases utilization of both oxygen and glucose."

Vasoconstriction: This prevents blood from reaching the skin to keep vital organs warm. If prolonged, oxygen delivery to the skin is prevented.

Increased muscle activity and flexion: Infants do not shiver. Instead they cry and move around to keep warm. This also reduces surface area for heat loss. If a child is flaccid, heat loss is increased due to increased surface area.

Brown fat metabolism: 6-8% of infants body weight consists of brown fat, which can be burned to create heat. Brown fat exists around vital organs such as the kidneys, adrenal glands, mediastinum, subscapular and axillary regions and the nape of the neck. When signaled to burn, brown fat creates more energy than any other tissue in the body to produce heat. This is actually called "non-shivering thermogenesis."

If cold stress gets bad enough, this can lead to pulmonary vasoconstriction, which can lead to a right to left shunt of blood through the foraman ovale and the ductus arteriosis, which can actually lead to persistent pulmonary hypertenstion and hypoxemia. The child will ultimately decrease it's respiratory rate and become flacid.

Mechanism of heat loss:

1. Conductive: This is heat loss that involves the transfer of heat between two solid surfaces, such as a metal surface the baby is set on, or cold stethoscopes, x-ray plates, blankets, your hands. These things should all be pre-warmed.

2. Convection: This is heat loss that occurs as a result of air currents, such as air conditioners, windows, drafts from air vents, or lab coats. This is why it's important to make sure the air is warm before baby is born, and limit anything that might cause a cold breeze, such as lab coats. It's also important to warm and humidify oxygen to an infant.

3. Evaporative: Occurs when moisture on the skin surface or respiratory tract mucosa is converted into vapor. The process of evaporation is always accompanies by a cooling effect. This is why it's important to dry infants with a warm towel and immediately remove wet linens.

4. Radient Heat Loss: This is heat loss by transfer of heat between solid surfaces that are not in contact with each other. The infant's skin temp is usually warmer than surrounding surfaces, so the direction of heat transfer will be from the exposed parts of the infant's body to the adjacent solid surfaces. The cooler those surfaces, the greater the heat loss. Examples include cold windows.

5. Radient Heat Gain: Just for the sake of it, a child can also pick up heat from distant objects, such as the sun poking through the window, or an incubator that's set too high.

Preterm infants actually become hypothermic faster than term babies due to larger surface area, thinner and immature skin, decreased amounts of brown fat, poor muscle tone, and poor ability to vasoconstrict. Premature infants should be placed in an incubator and wrapped in polyethylene (plastic) from neck to feet to reduce evaporative and convective heat loss.

Temperature of neonates, particularly premature neonates, should be monitored closely.

Medical wisdom continues to make life better

One of my favorite topics to write about is how much medical wisdom has improved just in my lifetime. Many of the ailments you and I suffer from today may not even be ailments in the future.

In fact, while I suffered from uncontrolled asthma as a child as well as did many other asthmatics, new wisdom has it so that it's very rare for anyone to have uncontrolled asthma in 2010. In fact, as I will write about in an upcoming article, asthma deaths and hospitalizations have significantly dropped since 1996 alone.

I recently dropped over at a fellow asthmatic's blog, Kerry, over at Hold Your Breath to Breathe, and she posted (see here) her medical records from when she was born a premature baby. I hope she doesn't swat me for linking to them here, yet I think having access to such records is a great reminder of how well we have it today, or at least how much better our children will have it than we do.

If nothing else, it's neat to look back and know why things are the way they are. I have the discharge papers from my stay in a hospital in 1981 for asthma (somewhere on this page), and the doctor wrote about how important it was for me to quit using my inhaled corticosteroid as soon as I was feeling better. Of course that was good wisdom back then. Today we know that you should never stop using your inhaled corticosteroid, especially when you are feeling well.

I see from Kerry's first ABG that her PO2 was 370, which by 1991 standards was acceptable. By 2010 standards, we know that's way to much oxygen, especially for a premature baby, and can lead to more harm than good -- such as ROP (I write about this here). In a class I attended just a few days ago, it is now common wisdom to allow a PO2 to remain as low as 40, which is the PO2 that a neonate's organs were developing inside the uterus before birth. That to shock those organs with a higher PO2 can lead to other problems right away and later in life, such as retinopathy of prematurity, which is a disease of the eyes.

Another neat thing to note is that new wisdom actually greatly diminished the risk for diseases such as hyline membrane disease and neonatal sepsis. So while in 1980 most sick premature babies died, by 1990 most survived. And, while many of those kids in 1990 may have been forced to live with certain illnesses such as ROP, new wisdom has greatly improved even those risks.

I imagine that 10 years down the road new wisdom will make things even better. As asthma experts have learned that prematurity can lead to asthma, perhaps there will be something that can be done to limit this risk. And, while experts have learned that lack of exposure to certain germs can lead to asthma in term kids with the asthma gene, perhaps there will be a germ vaccine some day to prevent asthma altogether.

Ironically, through the suffering of our fathers things are better for us today. Because kids suffered from asthma years ago, beta adrenergic medicine was invented, and ultimately lead to the rescue inhaler that I got to use as a kid. And while asthmatics like me had to use the rescue inhaler often as a kid, most kids today with asthma barely know they have the disease.

The same can be said of other diseases. Modern wisdom is making life better for us all. This is why we must never forget the past, for what we learn by the past will only make the future a better place.

Setting up vent on pediatric

Guidelines for Set-up of Servo for Pediatrics:

1. Pt Range: Pediatric (if ideal VT greater than 40cc or less than 400cc)
2. Mode: PC if less than 10kg, otherwise PRVC
3. VT: 5-7 cc/kg post-term to 14 YO
4. PIP: Not greater than 30
5. PEEP: Start 4 – 5 CWP
6. FiO2: 5 – 10% above pre-intubation adjust to maintain desired SpO2.
7. Rate: Normal for age
8. I-time: a. Maintain I:E of 1:2
9. I-Rise time: As appropriate for patient to create pseudo sign wave.
10. PIP limit: 2-3 greater than PIP (other alarms as appropriate)

For a printable cheat sheet with this information and more, click here.

For a cheatsheet on setting up ventilator for neonates, click here.

The basics of neonatal CPAP

If you work for a smaller hospital and rarely see bad baby's and yet are asked to set up CPAP on one, you ought to know what you're doing. We usually stabilize the baby and then ship the baby to a regional neonatal intensive care unit.

To help us stabilize the patient, we often use CPAP.

That in mind, here's the advice I received from our regional intensive care unit on setting up CPAP on neonates:

Setting up CPAP for a neonate:

1. 5–6 CWP good place to start
2. 2. 7 – 8 CWP if FiO2 needs greater than60%, or signs increased SOB
3. If SpO2 greater than target range, down FiO2 by 5–20, then allow 4 minutes for stabilization between each change.
4. If SpO2 less than target range, up FiO2 by 5–20, then wait 4 min for stabilizing between changes
5. Continue assuring AW patent, HR greater than 100, & infant not apneic.

(For a printable cheat sheet with this information and more, click here. )

It's also important to know when to use CPAP and when not to.

Indications for setting up CPAP on neonate:

1. PaO2 less than 50-60 and FiO2 greater than 60
2. Infant needs increased level of respiratory support but does not yet need intubation and positive pressure breaths
3. Infant experiencing increased frequency or severity of apnea, yet episodes not severe enough to warrent intubation
4. Infant has increased work of breathing and/or increasing oxygen requirements (Retractions, grunting, etc.)
5. Infant has mild CO2 retention and mild acidosis
6. Infant has atelectasis on x-ray
7. Infant has trancheobronchomalacia
8. Respiratory Distress Syndrome
9. Meconium Aspiration
10. Apnea of Prematurity
11. Patent Ductus Arteriosis

(Information obtained from STABLE program.

Contraindications for setting up CPAP on neonate:

1. Infants with rapidly progressing respiratory failure
2. Infants with increasing CO2, decreasing pH, and progressive hypoxemia
3. Diaphragmatic hernia
4. Tracheosophageal fistula
5. Choanal atresia
6. Cleft palate
7. Cardiovascular instability and poor heart function
8. poor respiratory drive
9. no respiratory drive

(Information obtained from STABLE program)

Pulmonary effects of CPAP:

1. Decreases respiratory rate, tidal volume and minute ventilation
2. Increases FRC
3. Decreasees lung compliance and dynamic compliance
4. Decreases total aireway resistance
5. Protective effect on surfactant

(Information obtained from this slide presentation Thrathip Kolatat MD)

neonatal tidal volumes

If you deal with neonates on a regular basis you may have a pretty good idea of what tidal volumes to set up. Yet, if you work mainly with adults and still have to be responsible for the occasional neonate and peds patient, you better have a good idea of what you are doing.

Since no RT is a genious, what I find works best if I have a cheat sheet on hand. What you see here are the ideal tidal volumes for neonates. For a printable cheat sheet, click here.

Why are premature baby's at risk for complications

Why are premature baby's at risk for complications:

1. Large surface area, thin skin, less fat = easy to lose heat. When get hypothermic it stops breathing. So if you have a newborn it's important to make sure you have adequate warmth provided. This should be the #1 goal after you receive a sick baby.
2. Immature tissues sensitive to effects of oxygen
3. Weak muscles make it hard to breath
4. Immature nervous system makes it hard to breath
5. Surfactant deficiency (especially in premature infants)
6. Immature immune system = increased risk of infection
7. Fragile capillaries in brains may rupture
8. Small blood volume increases effects of hypovolemia
9. Oxygen can be toxic even to term babies. Do not overoxygenate.

Do not overoxygenate neonates

I work for a smaller hospital, so we usually stabilize newborn babies that are having trouble and then package them up to be sent to a neonatal specialty center like that of Motts Children's hospital at the University of Michigan or Devos Children's Hospital in Grand Rapids.

Recently we set up new ventilator guidelines based on the recommendations of the hospitals we send our kids to (see this post). One of the recommendations was not to over oxygenate neonates. That not only can too much oxygen cause morbidity in neonates, it can cause long term complications in term infants too.

The old wisdom we had to change was that any neonate who had a heart rate of less than 100 should receive positive pressure breaths with 100% FiO2 in order to stimulate breathing.

Why was it believed that 100% oxygen was needed? Well, allow me to walk you through the anatomy of an infant's circulation before and after birth:



1. Before birth, all oxygen to the baby comes from the placenta via the umbilical vein, and most oxygenated blood takes the path of least resistance across the ductus arteriosis. Resistance is high in the lungs due to constricted arterioles and fluid filled alveoli.

2. After birth there are several major changes that take place

• The cord is clamped, which causes constricting of cord vessels
• The baby's systemic blood pressure increases immediately
• The baby is forced to take a breath to get oxygen
• In a matter of seconds after oxygen enters the lungs the pulmonary vessels relax
• and the Ductus Arteriosis constricts
• This makes the lungs the route of least resistance for blood from the right side of the heart
• thus causing oxygenated blood to be sent to the system
• Fluid in lungs is absorbed by the body and gradually replaced by oxygen

Of course 90% of baby's take this initial breath on their own. However, for one reason or another, 10% need to be stimulated to breath. Usually drying, suctioning and stimulating the baby works great. Still 10% of that 10% do not start breathing even then, and more aggressive therapy is indicated.


Back in the 1970s there was a lot of litigation where the parents of children who either died or had complications due to anoxic brain injuries that occurred at birth, and that is why the Neonatal Resuscitation Program (NRP) was started. This was an opportunity for experts at larger institutions to share their wisdom with all hospital workers throughout the U.S.

The #1 sign of low oxygen to the tissues in newborn infants is a drop in heart rate. Thus, a heart rate of less than 100 is the first sign that action needs to be taken -- per the NRP guidelines. Most of these children respond well to positive pressure breaths. Some, however, continue to need additional support, such as intubation, epinephrine, glucose or fluid depending on the determined cause.

However, based on the fact that oxygen in the lungs results in a relaxation of the pulmonary vasculature, it was believed, inaccurately it now turns out, that 100% oxygen would help trigger that first breath. However, recent studies show us the following:



1. A growing # of literature show you don't need 100% oxygen when ventilating neonates



2. New studies show that high levels of oxygen, even in otherwise healthy term babies, can be detrimental to the health and long term health of newborns

3. Several studies have linked 100% oxygen even for as little as one minute to:

• Leukemia
• Cancer
• Cellular death
• Infection
• Delayed development of oxygen sensing tissue
• Oxygen radical disease of neonate
• Retnopathy of Prematurity
• Chronic lung disease

4. Studies show little difference in heart rate and APGAR. Some actually showed improved APGAR score on room air as opposed to oxygen. It appears more kids are not breathing when exposed to 100% FiO2.


5.. Benefits of lowering oxygen sats (SpO2):

• Increased neurological function
• Decreased retnopathy of prematurity
• Decreased chronic lung disease
• Increased weight gain
• Decreased infection
• Decreased ventilator days
• Decreased oxygen days
• Decreased length of stay

6. Room air decreased neonate mortality rate by 30-40%


7. These studies have scientists now thinking it is not oxygen that stimulates that first breath, but heat, positive pressure breaths, and stimulation by either suctioning, rubbing the baby with a warm blanket, tapping the soles of the feet, etc.

8. Some institutions are currently doing studies using 21% FiO2 during positive pressure breaths . I believe the Spectrum Health in Grand Rapids is currently undergoing one such study.

9. Some studies are being done to determine if there are ways to keep the SpO2 of a newborn baby at less than 60% to allow for the best growing environment for premature organs. These organs are not meant to be exposed to an over oxygenated environment, and should not be exposed to too much oxygen.

10. For term babies, the reason you don't want to over oxygenate is because new studies show that too much oxygen can cause an increase of free radicals which may not cause immediate problems, but may increase the risk of various cancers.

11. It may take up to 10 minutes for a newborn baby's sat to get up to 90%. In the first few minutes an SpO2 of 70-80% is normal and acceptable. Therefore it's not a good idea to shock a baby with 100% FiO2.

12. According to Roy Ramirez, "Oxygen Management of the Very Low Birth Weight Infant" (RT Magazine, Roy Ramirez, February, 2010), "Gladstone et al showed a correlation between oxygen use and an increase in protein-bound carbonyl in lung fluid, which is a marker for oxidative injury.

13. Likewise, According to Ramirez, "Munkeby et al demonstrated that oxygen at high concentrations, even for short periods of time, can produce a significant increase in inflammatory markers.

14. Also Accoridng to Ramirez, "Some infants could be predisposed to chronic lung disease as demonstrated in a study by Tsao et al, which showed a direct correlation in placenta growth factor (P1GF) levels in cord blood at birth and risk for pramature infants to develop chronic lung disease, also known as bronchopulmonary dysplasia).

15. Ramirez also notes an infant in utero lives in an SpO2 environment of about 60%, and this can drop to 30% during labor. So it is acceptable to allow the SpO2 to slowly increase to the recommended level (see below) over a 10 minute period. This is one of the main reasons why shocking the baby with 100% FiO2 can be detrimental to the infant, and can actually have the opposite effect as desired.

Based on studies, the following are now the new recommendations:

1. Many institutions, including the Neonatal Resuscitation Program, now recommend you no longer ventilate at 100% oxygen. While it used to be believed that every baby who needs positive pressure ventilation should get 100% FiO2, this is no longer deemed acceptable due to recent study results.

2. A new recommendation is that oxygen should be considered a drug, and each patient should get a different dose based on need.


3. The new recommended starting FiO2 is 40%, which is to be adjusted to maintain target sats (see below)


4. Since it is no longer believed oxygen stimulates that first breath, and considering the dangers of oxygen, some hospitals have gone to 21% FiO2 already. I imagine this will be the recommended FiO2 for the NRP program of the future.

5. It is essential that you pay attention so sats (see below) Do not leave any baby at 100%.



6. The only exception is for PPHN (Persistent Pulmonary Hypertention of the newborn). If you suspect PPHN, make sure you give 100% FiO2 or at least try to keep sats 95-99%.



7. With a baby less than 30 weeks the SpO2 should be kept at less than 90%. The concern is early eye development. Plus scientists are not sure if its organs should be rapidly exposed to too much oxygen, when in utero they were developing in an environment where the SpO2 was less than 60%.



8. It is okay to use room air. If you only have room air, use room air. This is acceptable per the Neonatal Resuscitation Program.


9. It is recommended that all OB departments have an oxygen blender.

10. It is recommended that all tails be taken off Ambu-bags so that 100% is never given just in case you have to use them (Ideally, however, you should use a T-piece resuscitator like a Neo-puff which has a blender built in).

11. If you see low sats try to fix the problem before reaching for oxygen. Don't treat the number or the symptom. Treat the patient.

12. If baby spontaneously breathing and continues to be labored, consider CPAP even if you don't have a doctor's order. According to Neonatal Resuscitation Program, CPAP is considered good practice. You may use Neo-puff to administer CPAP by holding the mask over the neonates mouth and nose.

According to Spectum Health in Grand Rapids, the following are the new target SpO2s you should reach for:

• Less than 30 weeks gestation: SpO2 of 85%
• 30-34 weeks gestation: SpO2 of 88%
• 35-39 weeks gestation: SpO2 of 91%
• 40 weeks gestation or greater: SpO2 of 94%

The following are the new rules for oxygenating neonates:

• Achieve sat gradually
• Decrease FiO2 as sats rise greater than 95%
• If heart rate not rising, check for correct ventilation
• Do not chase saturations, as fluctuations in sats are normal (better to bounce low than high)
• In other words: don't stare at the sat monitor