Neonate and Pediatric Final

Indications to Mechanical Ventilation-
Hypoxemic Respiratory Failure

- Alkalosis from high RR
- PaO2 <50 on FI02 60%
-Spo2 <90 c supplemental 02 and/or NCPAP
*Babys will be Agitated kicking and Cyanotic
Use CPAP or MV

Indications to Mechanical Ventilation-
Hypercapnic Respiratory Failure

-PaCO2 > 50mmHg accompied c pH <7.25
*Babys will be Listless c no movement and Cyanotic
Use MV

Indications to Mechanical Ventilation-
Mixed Respiratory Failure

- Acidosis

CPAP is the Preferred Method

- Nasal Prongs (NCPAP) is the Preferred device

CPAP - Physical Exam Indication

1. Increased WOB (30% RR increase)
2. Suprasternal and substernal retractions
3. Grunting
4. Nasal Flaring
5. Pale or Cyanotic c Agitation

CPAP - Non Physical Indications

1. Decreased FRC
-PNA, Atelectasis, Pulm Edema, Thoracotomy, Meconium Aspiration, Severe Mucus block, RDS, RDS II (TTHN), L-R Shunt
2. Airway Collaspe
-Tracheobronchial Malacia, Apnea
3. Weaning from Mechanical Vent
4. Abnormal ABG

CPAP Contraindications

1. Upper airway abnormalities: Chonanal Atresia, Cleft Palate, Tracheoesophageal fistula
2. Untreated Airleaks: Pneumo
3. Cardiovascular unstability: BP up or down
4. Can not maintain adequate ventilation: Poor CO2
5. Untreated congenital diaphragmatic he

CPAP Settings

4 to 5 cmH20
Increase in increments of 2 cmH20
No higher than 10 to 12 cmH20
-Keep FIO2 <60% c PaO2 >50 , PaCo2 between 50 to 60mmHg or pH>7.25

Full Support vs. Partial Support

Backup rate > 30= Full Support
Backup rate < 30= Partial Support

Full Support

SIMV = Rate >30
PCV - Indication for PCV = Plat > 35cmH20, PIP >40cmH20
IRV- Paralyzed and sedated
*If below 10kg, preffered method is PCV

Inital Vent Settings for Neonates

PIP= 15-20 cmH20
PEEP= 3-5 cmH20
FIO2= Keep Pink, Spo2 >90%
Rate= 30 to 40bpm
Flow= 6 to 8 L/min
I time= LBW: 0.25-0.5 sec
Term: 0.5-0.6 sec
I:E= 1:1.5-1:2
Vt= Term: 8-10 ml/kg
6-8 ml/kg
4-6 ml/kg

Inital Vent Settings for Pediatrics

Pplat <35 cmH20
PEEP= 5 cmH20
FIO2= 1.0 or maintain, Spo2 >93%
Rate= Maintain PaCo2 40-48 mmHg
Flow= 25-30 L/min
I time= 1.0 to 1.5 seconds
I:E= 1:2- 1:4 to maintain pt comfort
Vt= Term: 8-10 ml/kg

Sensitivity Settings

1. Pressure Trigger= -1 to -2 cmH20
2. Flow Trigger= 0.15 L/m to 1 L/m
3. Volume Trigger= 3.0 mL

I:E (RR and I-Time)

1. Determine the TCT
- 60/RR
2. Determine the E Time
- I-Time - TCT
3. TE/TI
4. Convert to Ratio (Always gonna have 1 first)

Tuning Factor

Neonates 2ml/cmH20
Adults 3ml/cmH20

Corrected Tidal Volume

Set Vt - (PIP x 2)

Optimal Peep

Set Vt- (PIPx2) / (Plat-Peep)
*Subtract Pplat-PEEP and the smallest number will be optimal PEEP

Auscultation: Diminished

Complaince Change

Ausculation: Rales/Crackles


Ausculation: Coarse Rales/Crackles

Large Airway secretions
Needs secretion clearence.. Suction

Ausculation: Medium Rales.Crackles

Middle Airway Secretions
Need mobilization... CPT, PD&P

Ausculation: Fine Rales/Crackles

Lower Airway Secretions
Fuild in Aveoli
CHF, Pulmonary Edema
Need Lasix

Ausculation: Wheezing

Airway Narrowing
Need Bronchodilator

Ausculation: Uni-Laterial Wheezing

Foregin Body Aspiration

Ausculation: Ronchi

Low pitched continous sound

Ausculation: Vasicular


Ausculation: Adventitous


Percussion: Resonance

Normal Air Sound

Percussion: Flatness


Percussion: Dullness

Pleural Effusion, PNA

Percuussion: Hyperresonance

Increased Air (Pneumo, emphysema, air-trapping)

CXR Term: Infiltrate

Ill defined radiodensity"

CXR Term: Consolidation

Soild White Area
Pnueumonia or Pleural Effusion

CXR Term: Hyperlucency

Extra Air
COPD, Asthma, Pneumo

CXR Term: Vascular Markings

Vessels "Absent vascular markings"
Increased = CHF
Absent= Pneumo

CXR Term: Fluffy Infiltrates

Scattered/Diffuse whiteness
Pulmonary Edema

CXR Term: Butterfly wings

White butterfly shape
Pulmonary Edema

CXR Term: Ground Glass

Reticulogranular ARDS/IRDS

CXR Term: Honeycomb Pattern

Reticulogranular ARDS/IRDS

Waveforms: Shift to Right

Decrease in Complaince

Waveforms: Shift to Left

Increase in Comlpaince

Waveforms: Duck Bill

Overdistension - to correct you must decrease Vt

Waveforms: Airleak

Loop never goes back to baseline

Waveforms: Sawtooth look

Exhalation side sawtooth apperance= secretions in tubing and AW

Flow time waveforms

Increased Ti/Flow = Increased Vt

Flow time Waveforms

Flow x time= Vt

Ventilator Management
Volume Ventilator

- 8 to 10 ml/kg
- Once reached - increase RR

Ventilator Management
Pressure Control= Ventilation(PaCO2)

PIP: Increasing PIP will increase Volume
-Direct Relationship
-Adjust until PIP = 15
RR: Will fix PaCO2 the quickest
-Adjust in 2-5bpm... no drastic changes
I-Time: More gas movement/more CO2 elimination
*VT= I-Time x Flow (Sec)
Flow: Increased Flow=Incre

High Frequency Ventilation

Classied in Hz Ranges
Delivers small Vt at High Rates

HFV = Hertz (Rate)

1 Hz= 60 cpm
Affects= Ventilation (PaCO2)

HFV= Amp/Power/Driving Pressure/DeltaP

Mimicks Vt
-#1 Parameter to change to affect PaCO2
- Bring down a High PaCO2 =
Decrease Hz to Increase Amp
- Strength/Depth of Asculation
Affects = Ventilation (PaCO2)

HFV = mPaw

Affects= Oxygenation (PaO2)

HFV= Indications

- Resp Failure that does not respond to Conv. MV
- Pulm Airleaks

HFV= Hazards

- Airway Obstruction
- CWF = Chest wiggle factor
- ETT = obstruction or malpositioned tube

HFV= Monitor Closely For

- Signs of Pallor
- Cyanosis
- Bradycardia
- Hypotension
-Increased WOB

HFPPV - High Frequency Postive Pressure Ventilation

-Passive Exhalation
- 1 to 2.5 Hz
- Vt may exceed deadspace

HFJV - High Frequency Jet Ventilation

-Passive Exhalation
- 4 to 11 Hz
- Used in conjunction c Conventional Vents
- Occasional Sigh helps stimulate production of surfactant & prevent microatelectasis
- Deliver PEEP
- Delivers continous flow of gas
- Need to re-intubate

HFOV- High frequency Osc. Ventilator

-Active Exhalation
- 8-30 Hz (Can go to 50)
Advantage= PIP dont fluctuate- alveoli constantly stay open

Surfactant Replacement

Phospholipids (80%)
Proteins (10%)
1. Prophylactic
2. Therapeutic (Rescue)

Surfactant - Prophylactic

High risk patients
- Infants born before 32 weeks
- Weighing less than 1300 gms
- L/S Ratio < 2:1
Absence of PG in the amnoitic fluid
* Infant recieves the surfant as quickly as possible right after delivery

Surfactant - Therapeutic (Rescue)

Given after signs of developing RDS
-WOB, Grunting, nasal flaring, retractions
-Increased Oxygen requirements
-CXR evidence of RDS
* Also effective in PNA and Meconium Aspiration

Surfactant - Exosurf

5 ml/kg

Surfactant - Survanta

4 ml/kg

Surfactant - Infasurf

3 ml/kg

Surfactant - Curosurf

2.5 ml/kg

Surfactant reduces the severity of:

Pulmonary air leaks
Development of BPD (Baby COPD)

Monitoring the Neonate

1. UAC
2. Arterial Sample
3. TCM
4. CBG
5. Transillumination

ABG "Safe Range" Neonate

PaO2 = 50 to 70 mmHg
PCO2 = 35 to 45 mmHg
pH = 7.35 to 7.45
*Acceptable pH range = 7.30 - 7.50

ABG "Safe Range" Pediatric

PaO2 = 85 to 100 mmHg (sea lvl)
55 to 80 mmHg
PCO2 = 35 to 45 mmHg
pH = 7.35 to 7.45
*Acceptable pH range = 7.30 - 7.50

CO2 Electrode


O2 Electrode


pH Electrode


Weaning of Neonate

PIP = wean to 15-18 cmH20 ( 1-2 cmH20 increm.)
PEEP = 3-5 cmH20 (1-2 cmH20 increm)
RR= < 10bpm (1-5bpm increm)
FIO2 = 0.3 to 0.4 (1-5% increm)

Weaning of Pediatric

FIO2 = < 40
PEEP= < 5 cmH20
RR= 3-5bpm to support spont breathing
PSV = 5cmH20 (May be discontinued if pt can maintain spont Vt