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For technical assistance: email expertconsult.help@elsevier.com call 1-800-401-9962 (inside the US) call +1-314-447-8200 (outside the US) Use of the current edition of the electronic version of this book (eBook) is subject to the terms of the nontransferable, limited license granted on expertconsult.inkling.com Access to the eBook is limited to the first individual who redeems the PIN, located on the inside cover of this book, at expertconsult.inkling.com and may not be transferred to another party by resale, lending, or other means Assisted Ventilation of the NEONATE AN EVIDENCE-BASED APPROACH TO NEWBORN RESPIRATORY CARE This page intentionally left blank Assisted Ventilation of the NEONATE AN EVIDENCE-BASED APPROACH TO NEWBORN RESPIRATORY CARE SIXTH EDITION JAY P GOLDSMITH, MD, FAAP Clinical Professor Department of Pediatrics Tulane University School of Medicine New Orleans, Louisiana EDWARD H KAROTKIN, MD, FAAP Professor of Pediatrics Neonatal/Perinatal Medicine Eastern Virginia Medical School Norfolk, Virginia MARTIN KESZLER, MD, FAAP Professor of Pediatrics Warren Alpert Medical School Brown University Director of Respiratory Services Department of Pediatrics Women and Infants Hospital Providence, Rhode Island GAUTHAM K SURESH, MD, DM, MS, FAAP Section Head and Service Chief of Neonatology Baylor College of Medicine Texas Children’s Hospital Houston, Texas 1600 John F Kennedy Blvd Ste 1800 Philadelphia, PA 19103-2899 ASSISTED VENTILATION OF THE NEONATE: AN EVIDENCE-BASED APPROACH TO NEWBORN RESPIRATORY CARE, SIXTH EDITION ISBN: 978-0-323-39006-4 Copyright © 2017 by Elsevier, Inc All rights reserved No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein) Notices Knowledge and best practice in this field are constantly changing As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein Previous editions copyrighted 2011, 2003, 1996, 1988, and 1981 Library of Congress Cataloging-in-Publication Data Names: Goldsmith, Jay P., editor | Karotkin, Edward H., editor | Keszler, Martin, editor | Suresh, Gautham, editor Title: Assisted ventilation of the neonate : an evidence-based approach to newborn respiratory care / [edited by] Jay P Goldsmith, MD, FAAP, Clinical Professor, Department of Pediatrics, Tulane University School of M edicine, New Orleans, Louisiana, Edward H Karotkin, MD, FAAP, Professor of Pediatrics, Neonatal/ Perinatal Medicine, Eastern Virginia Medical School, Norfolk, Virginia, Martin Keszler, MD, FAAP, Professor of Pediatrics, Warren Alpert Medical School, Brown University, Director of Respiratory Services, Department of Pediatrics, Women and Infants Hospital, Providence, Rhode Island, Gautham K Suresh, MD, DM, MS, FAAP, Section Head and Service Chief of Neonatology, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas Description: Sixth edition | Philadelphia, PA : Elsevier, [2017] Identifiers: LCCN 2016029284 | ISBN 9780323390064 (hardback : alk paper) Subjects: LCSH: Respiratory therapy for newborn infants | Artificial respiration Classification: LCC RJ312 A87 2017 | DDC 618.92/2004636 dc23 LC record available at https://lccn.loc.gov/2016029284 Executive Content Strategist: Kate Dimock Publishing Services Manager: Hemamalini Rajendrababu Senior Project Manager: Beula Christopher Designer: Renee Duenow Marketing Manager: Kristin McNally Printed in United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 This book is dedicated to my wife, Terri, who has supported me through six editions of this text and my many nights away from home while caring for sick neonates JPG I would like to dedicate this sixth edition of Assisted Ventilation of the Neonate to the numerous bedside NICU nurses, neonatal nurse practitioners, and respiratory therapists, and all of the other ancillary health care providers I have had the honor of working with over the past nearly 40 years at the Children’s Hospital of The King’s Daughters Without your commitment to providing the best of care to our patients I could not have done my job EHK I dedicate this book to my wife, Mary Lenore Keszler, MD, who has been my lifelong companion, inspiration, and best friend Without her incredible patience and unwavering support, none of this work would have been possible The book is also dedicated to the many tiny patients and their families who taught me many valuable lessons, and to the students, residents, and Fellows whose probing questions inspired me to seek a deeper understanding of the problems that face us every day MK I dedicate this book to my teachers and mentors over the years, who taught me and guided me I also thank my wife, Viju Padmanabhan, and my daughters, Diksha and Ila, for their support and patience with me over the years GKS CONTRIBUTORS Kabir Abubakar, MD Professor of Clinical Pediatrics Neonatology/Pediatrics Medstar Georgetown University Hospital Washington, DC Laura D Brown, MD Associate Professor Pediatrics University of Colorado School of Medicine Aurora, CO Namasivayam Ambalavanan, MBBS, MD Professor, Pediatrics University of Alabama at Birmingham Birmingham, AL Jessica Brunkhorst, MD Assistant Professor of Pediatrics Children’s Mercy Hospital University of Missouri - Kansas City Kansas City, Missouri Robert M Arensman, BS, MD Head, Division of Pediatric Surgery Department of Surgery University of Illinois at Chicago Chicago, IL Eduardo Bancalari, MD Professor of Pediatrics, Obstetrics, and Gynecology, Director, Division of Neonatology, Chief, Newborn Service Department of Pediatrics, Division of Neonatology University of Miami School of Medicine Miami, FL Keith J Barrington, MB, ChB Neonatologist and Clinical Researcher Sainte Justine University Health Center, Professor of Paediatrics University of Montréal Montréal, Canada Jonathan F Bean, MD Chief Resident Department of General Surgery University of Illinois Hospital and Health Sciences Center Chicago, IL Edward F Bell, MD Professor of Pediatrics Department of Pediatrics University of Iowa Iowa City, IA David M Biko, MD Assistant Professor The Children’s Hospital of Philadelphia, Pediatric Radiologist Pennsylvania Hospital The University of Pennsylvania Health System Philadelphia, PA Waldemar A Carlo, MD Edwin M Dixon Professor of Pediatrics University of Alabama at Birmingham, Director, Division of Neonatology University of Alabama at Birmingham Birmingham, AL Robert L Chatburn, MHHS, RRT-NPS, FAARC Clinical Research Manager Respiratory Institute, Cleveland Clinic, Director, Simulation Fellowship Education Institute, Cleveland Clinic, Adjunct Professor of Medicine Lerner College of Medicine of Case Western Reserve University Cleveland, OH Nelson Claure, MSc, PhD Research Associate Professor of Pediatrics, Director, Neonatal Pulmonary Research Laboratory Department of Pediatrics, Division of Neonatology University of Miami School of Medicine Miami, FL Clarice Clemmens, MD Assistant Professor of Pediatric Otolaryngology Medical University of South Carolina Charleston, SC Christopher E Colby, MD Associate Professor of Pediatrics Mayo Clinic Rochester, MN Sherry E Courtney, MD, MS Professor of Pediatrics Department of Pediatrics University of Arkansas for Medical Sciences Little Rock, AR Peter G Davis, MBBS, MD, FRACP Professor/Director of Neonatal Medicine The University of Melbourne and The Royal Women’s Hospital Melbourne, Victoria, Australia vi CONTRIBUTORS Eugene M Dempsey, MBBCH BAO, FRCPI, MD, MSc Clinical Professor Paediatrics and Child Health University College Cork, Department of Neonatology Cork University Maternity Hospital Wilton, Cork, Ireland Robert Diblasi, RRT-NPS, FAARC Seattle Children’s Research Institute - Respiratory Care Center for Developmental Therapeutics Seattle, WA Jennifer Duchon, MDCM, MPH Clinical Fellow Pediatric Infectious Disease Columbia-Presbyterian Medical Center New York, NY Jonathan M Fanaroff, MD, JD Associate Professor of Pediatrics Case Western Reserve University School of Medicine, Co-Director, Neonatal Intensive Care Unit, Director, Rainbow Center for Pediatric Ethics Rainbow Babies and Children’s Hospital Cleveland, OH William W Fox, MD Attending Neonatologist Division of Neonatology Medical Director Infant Breathing Disorder Center Children’s Hospital of Philadelphia, Professor of Pediatrics University of Pennsylvania Perelman School of Medicine Philadelphia, PA Debbie Fraser, MN, RNC-NIC Associate Professor Faculty of Health Disciplines Athabasca University Athabasca, Alberta, Canada, Advanced Practice Nurse NICU St Boniface Hospital Winnipeg, Manitoba, Canada John T Gallagher, MPH, RRT-NPS, FAARC Critical Care Coordinator Pediatric Respiratory Care University Hospitals, Rainbow Babies and Children’s Hospital Cleveland, OH Jay P Goldsmith, MD, FAAP Clinical Professor Pediatrics Tulane University New Orleans, LA Malinda N Harris, MD Assistant Professor of Pediatrics Mayo Clinic Rochester, MN William W Hay, Jr., MD Professor Pediatrics University of Colorado School of Medicine Aurora, CO Robert M Insoft, MD Chief Medical Officer and Attending Neonatologist Women and Infants Hospital Alpert Medical School of Brown University Providence, RI Erik A Jensen, MD Instructor of Pediatrics The University of Pennsylvania, Attending Neonatologist The Children’s Hospital of Philadelphia Philadelphia, PA Jegen Kandasamy, MBBS, MD Assistant Professor Pediatrics University of Alabama at Birmingham Birmingham, AL Edward H Karotkin, MD, FAAP Professor of Pediatrics Neonatal/Perinatal Medicine The Eastern Virginia Medical School Norfolk, VA Martin Keszler, MD, FAAP Professor of Pediatrics Alpert Medical School of Brown University, Director of Respiratory Services, Pediatrics Women and Infants Hospital Providence, RI John P Kinsella, MD Professor of Pediatrics Department of Pediatrics Section of Neonatology University of Colorado School of Medicine and Children’s Hospital Colorado Aurora, CO Haresh Kirpalani, BM, MRCP, FRCP, MSc Professor The University of Pennsylvania, Attending Neonatologist and Director Newborn and Infant Chronic Lung Disease Program The Children’s Hospital of Philadelphia Philadelphia, PA; Emeritus Professor Clinical Epidemiology McMaster University Hamilton, Ontario, Canada Derek Kowal, RRT Supervisor NICU, Respiratory Services Foothills Medical Centre Alberta Health Services Calgary, Alberta, Canada vii viii CONTRIBUTORS Satyan Lakshminrusimha, MBBS, MD Professor of Pediatrics Director, Center for Developmental Biology of the Lung University at Buffalo, Chief of Neonatology Women and Children’s Hospital of Buffalo Buffalo, NY John D Lantos, MD Director of Bioethics Children’s Mercy Hospital Professor Pediatrics University of Missouri - Kansas City Kansas City, MO Krithika Lingappan, MD, MS, FAAP Assistant Professor Section of Neonatology Department of Pediatrics Texas Children’s Hospital Baylor College of Medicine Houston, TX Bobby Mathew, MD Associate Program Director Assistant Professor of Pediatrics University at Buffalo Women and Children’s Hospital of Buffalo Buffalo, NY Patrick Joseph McNamara, MD, MRCPCH, MSc Associate Professor Pediatrics and Physiology University of Toronto, Staff Neonatologist Pediatrics Hospital for Sick Children Toronto, Ontario, Canada D Andrew Mong, MD Assistant Professor The University of Pennsylvania, Pediatric Radiologist The Children’s Hospital of Philadelphia Philadelphia, PA Akhil Maheshwari, MD Professor of Pediatrics and Molecular Medicine Pamela and Leslie Muma Endowed Chair in Neonatology, Chief, Division of Neonatology, Assistant Dean, Graduate Medical Education Pediatrics University of South Florida Tampa, FL Colin J Morley, DCH, MD, FRCPCH Professor Neonatal Research Royal Women’s Hospital Melbourne, Cambridge, Great Britain Mark C Mammel, MD Professor of Pediatrics Department of Pediatrics University of Minnesota Minneapolis, MN Leif D Nelin, MD Dean W Jeffers Chair in Neonatology Nationwide Children’s Hospital, Professor and Chief, Division of Neonatology The Ohio State University and Nationwide Children’s Hospital Columbus, OH George T Mandy, MD Associate Professor of Pediatrics Baylor College of Medicine Houston, TX Richard J Martin, MBBS Professor Pediatrics, Reproductive Biology, and Physiology and Biophysics Case Western Reserve University School of Medicine, Drusinsky/Fanaroff Professor Pediatrics Rainbow Babies and Children’s Hospital Cleveland, OH Kathryn L Maschhoff, MD, PhD Assistant Professor of Clinical Pediatrics The University of Pennsylvania, Attending Neonatologist The Children’s Hospital of Philadelphia Philadelphia, PA Donald Morley Null Jr., MD Professor of Pediatrics Department of Pediatrics University of California Davis Sacramento, CA Louise S Owen, MBChB, MRCPCH, FRACP, MD Neonatologist Newborn Research Royal Women’s Hospital, Honorary Fellow Murdoch Childrens Research Institute Melbourne, Victoria, Australia Allison H Payne, MD, MSCR Assistant Professor Pediatrics Division of Neonatology UH Rainbow Babies and Children’s Hospital Case Western Reserve University Cleveland, OH INDEX Intrapulmonary shunt, in meconium aspiration syndrome, 233 Intrathoracic masses, intraoperative management of, 409–410 Intrathoracic pressure, in mechanical ventilation, 139 Intravenous access, parenteral nutrition and, 327 Intravenous anesthetic drugs, for neonate, 415t Intraventricular hemorrhage (IVH), 1, 220, 227, 455 grade 4, 453 hypercarbia and, 455 Intrinsic tracheal compression, 399–400 Intubated infants, cardiorespiratory events in, 32–33 Intubation see also Endotracheal tube and continuous positive airway pressure, 170 evaluation of, 403 premedication for, 410–411, 412t skills, acquisition and maintenance of, 296–298 Invasive support devices, 70–71, 70f–71f Iodine, povidone, 85 IPPV see Intermittent positive-pressure ventilation Ipratropium bromide, 374t, 375 Iron intake, 325–326 Isofurans (IsoFs), as oxidative biomarkers, 156t Isoproterenol, 477 IVH see Intraventricular hemorrhage IWL see Insensible water loss J Jet nebulizers, 376 Jet ventilation, 213 high-frequency, 387, 417 for congenital diaphragmatic hernia, 238 for meconium aspiration syndrome, 234–235 physical examination and, 65 K Kasabach-Merritt syndrome, 398–399 Kennedy, Jacqueline, Kennedy, John F., Kennedy, Patrick Bouvier, Kilopascal to torr conversion table, 470 KL4 peptide, 340 L β-lactam/β-lactamase combination, for ventilatorassociated pneumonia, 337 Lactate, 95 Laennec, René, 61 Laplace relationship, 12 Large aggregate (LA) surfactants, 189 Large airway obstruction, mechanical ventilation in, 146t–148t Laryngeal anomalies, neonatal, 397–399 Laryngeal atresia, 397 Laryngeal clefts, 119, 398 Laryngeal mask airway (LMA), 283, 283f, 298, 430 for surfactant administration, 344 Laryngeal web, 119, 397, 397f Laryngeal-mask ventilation, infant receiving, examination of, 64 Laryngoceles, 119 Laryngomalacia, 118–119, 120f, 397–398, 398f Laryngoscope, proper placement of, 282, 283f Laryngoscopy, flexible, 118 Late-onset pneumonia, 73 Latin America, 419 Leadership, 54 Leakage flow, 181–182, 182f Left to right shunts, mechanical ventilation in, 146t–148t Left ventricle, impaired growth and function of, in congenital diaphragmatic hernia, 237 Left-ventricular function, in mechanical ventilation, 139 Leoni Plus high-frequency oscillator, 214, 217f Less-invasive surfactant administration, 344 Leukomalacia, prematurity/periventricular, neonatal respiratory care and, 58–59 Lidocaine, 87–88, 477 Light-emitting diode, Likelihood ratio, 46 Lingual thyroid, oropharyngeal obstruction and, 395 Lipid emulsions, 324 Lipid requirement, 324 Liquid oxygen, 449 LMA see Laryngeal mask airway Long-chain polyunsaturated fatty acids (LC-PUFAs), 324 Loop diuretics, 377 Loops, in operator-ventilator interface, 254, 255f Lorazepam, 369t, 372, 477 Lower conducting airways, development of, Lower esophageal sphincter (LES), 389–390 Lucinactant, 340, 345 Lung development of, phases of, and ventilator-induced lung injury, 190 developmental abnormalities of, 400–402 Lung biology, developmental, in respiratory distress syndrome, 229–230 Lung compliance and gas transport, 212 pulmonary function and graphics in, 112 Lung disease, mechanical ventilation in, 146t–148t Lung expansion curve, 11f Lung function, normal data, for term newborns during neonatal period, 467 Lung hypoplasia disorders, 236–239 key pathophysiologic features of, 236–237 high-frequency ventilation for, 194 Lung inflation, adequacy of, 164 Lung injury, pulmonary development and, 408–409 Lung liquid, in respiratory distress syndrome, 229 Lung mechanics in extubation readiness, 248 and function, in bronchopulmonary dysplasia, 240, 240t in mechanical ventilation, 140 Lung parenchyma disease, in severe bronchopulmonary dysplasia, 382, 382f Lung pathology, in bronchopulmonary dysplasia, 239–240 Lung protective ventilation, 220–221 Lung ultrasound, 67–79.e4 Lung volumes, 139 of infant, 466 pulmonary vascular resistance and, 128, 128f Lung-protective ventilation, 188–194.e3 basic principles of, 190–191 and conventional mechanical ventilation, 191–193 and high-frequency ventilation, 193–194 implications of, for practice and research, 194 weaning and extubation, 194 Lusupultide, 340 M MABP see Mean arterial blood pressure Macroglossia, 394 Magnesium sulfate, 477 Magnetic resonance imaging (MRI), 70 Maimonides, 1–2 Mainstream capnography, 103 Malawi, 419 Malondialdehyde (MDA), as oxidative biomarker, 156t Malpractice lawsuit, decreasing risk of, 59–60 Malpractice litigation, 60 Mandatory breath, 143 Mandatory minute ventilation (MMV), 209 Mandibulofacial dysostosis, 395 Mannose, 325 Manual ventilation, 291–292, 292t, 412 493 Maquet Servo ventilators, 180–181 Maquet SERVO-i, 267–269, 268f modes of, 267–269, 268t operator interface of, 267 Mask ventilation, 280 MBP see Mean blood pressure Mean airway pressure, in high-frequency jet ventilators, 224, 224f Mean arterial blood pressure (MABP), cerebral blood flow and, 451, 452f Mean blood pressure (MBP), 130 by birth weight and gestational age, 472–473 Mechanical ventilation, 229–242.e5, 384–387, 459 adverse events related to, 50t appropriate rate and inspiration time for, 385–386 common situations in, 146t–148t complications of, in newborns, 244b conventional, 384–387, 456 documentation during, 151 on hemodynamics, 138–139 indications for, 146, 146t initiation of, 146–151 and augmentation, 139 clinical evaluation after, 150t subsequent ventilator adjustments in, 151 ventilator mode in, choosing, 146–149 key goals in, 141 medical and legal aspects, 59 monitoring, 151 nitric oxide during, 357 in respiratory care, 313–316 sedation and analgesia in, 368 target tidal volume, setting, 385 targets and strategies for setting, 385, 385t unique challenges in, 140–141 lung mechanics as, 140 tidal volume in, 141 Mechanoreceptor (laryngeal) afferents, role of, 32 Mechanosensory inputs, optimization of, 33 Meconium aspiration syndrome (MAS), 72–73, 73f, 233–236, 348, 417–418 evidence-based recommendations for, 236 gaps in knowledge for, 236 key pathophysiologic features of, 233–234, 234f airway resistance, 234, 235f pulmonary hypertension, 234 surfactant dysfunction, 233 relevant principles of ventilation for, 234–236 conventional ventilation, 235–236, 235t high-frequency ventilation (HFV), 234–235, 235t Meconium-stained amniotic fluid, in newborn care, 279 Medical and surgical interventions, for airway management, 391–406.e2 Medical discharge coordinator, 447 Medical futility, 38–39 Medical malpractice stress syndrome, 59 Medical management of neonatal airway, 391 neonates with common respiratory disorders, 392–393 Medications, in pharmacologic therapies, 366–379.e5 bronchodilators, 374–376 diuretics, 376–377 mucolytic agents, 374–376 muscle relaxants, 372–374, 373t respiratory stimulants, 377–379 sedation and analgesia in, 367–372, 369t steroids, 366–367 MEDLINE, for evidence, 41 Membrane oxygenators development of, 434 principles of gas transfer in, 436f Mepilex, 175 Meta-analyses, systematic reviews of therapeutic interventions and, 45 Metabolic acidosis, 84 494 INDEX Metabolic alkalosis, 84 Metabolic disorders, oropharyngeal obstruction and, 394–395 Metered-dose inhalers (MDIs), 376 Methemoglobin, 89–90, 95 Methemoglobinemia, 357–358 Methyldopa, 477 Methylprednisolone, 477 Methylxanthines, 456–457 for neonatal apnea, 377, 378t Metoclopramide, 477 Microlaryngoscopy, direct, 119–121 “Micropreemies,” 18 Midazolam, 369t, 371–372, 477 premedication for intubation, 410–411 Milrinone, 129, 362–363 for systolic hypotension, 134 Mineral requirements, 325–326, 326t Minute ventilation, 18, 109t in extubation readiness, 248 pulmonary function and graphics in, 111 Mixed apnea, genesis of, 32 MMV see Mandatory minute ventilation Möbius syndrome, 395 Model for improvement, 51f Modern intensive care ventilator, simplified schematic of, 252f Modern neonatology, 56 Modified umbilical clamp, 297t Monsoon jet ventilator, 214 Morphine, 369–370, 369t premedication for intubation, 410–411 Morphine 3-glucuronide (M3G), 369 Morphine sulfate, 477 Motion-mode ultrasound, 69f Mouth-to-mouth resuscitation, 280 Movement artifact, in pulse oximetry, 101 MRI see Magnetic resonance imaging Mucolytic agents, 374–376 Murphy endotracheal tube, 294, 295f Muscle paralysis, 372 Muscle relaxants, 372–374, 373t Muscle relaxation, premedication for intubation, 411 Myelin, tubular, 338–339 N Nager syndrome, 396 Naloxone, 477 Narcotic abstinence syndrome (NAS), 319–320 Nasal cannulae, 168, 172f humidified high-flow, 162, 177–179, 178f effectivity of, 178 systems of, 178 infants on, FiO2 conversion tables for, 475, 475t–476t malpositioned, 174 Nasal continuous positive airway pressure (NCPAP), 162–164 bubble, 165–166 pressure monitoring in, 166 systems for, 166 clinical management of patients on, 164–165 continuous flow, 165 contraindications to, 176 loss of pressure during, 170, 172f optimal levels of, determination of, 176 or noninvasive ventilation, for apnea, 174 in respiratory care, 313, 314f variable-flow, 166, 166f–169f systems for, 166–167 and work of breathing, 166 Nasal high-frequency ventilation (NHFV), 174 Nasal masks, 168, 171f Nasal prong, 167–168, 169f–170f Nasopharyngeal administration, of surfactant, 344 Nasopharyngeal obstruction, 393–394 Nasopharyngeal prongs binasal, 172–173 single, 167 Nasopharyngeal synchronized mandatory ventilation (NPSIMV), 172–173 Nasopharyngolaryngoscopy (NPL), flexible, in neonate, 118 National Institute of Child Health and Human Development (NICHD), 459–460 National Neonatal-Perinatal Database, 423 National Neonatology Forum (NNF), 418 NCPAP see Nasal continuous positive airway pressure Near-infrared spectroscopy (NIRS), 89, 91 cerebral monitoring with, 106f tissue oxygen saturation monitoring using, 105–107 Nebulized racemic epinephrine, for postextubation management, 249 Necrotizing enterocolitis, Necrotizing tracheobronchitis (NTB), 227, 227f, 399–400 Negative predictive value, in test accuracy, 46 Negative-pressure gradient, 19f Negative-pressure ventilators, 3–4 Alexander Graham Bell’s, 3f Neocirc group, 365 Neonatal airway anatomical disadvantages of, 391–392 developmental abnormalities of, 393–400 medical management of, 391 surgical management of, 393, 393b Neonatal anesthesia, capnography during, 104 Neonatal apnea, longer term consequences of, 35 Neonatal history, elements of, 311t Neonatal Intensive Care Quality (NICQ) projects, 54–55 Neonatal intensive care unit (NICU), 5, 49, 56, 61, 80, 407 CO2 monitoring in, 103 neonatal airway and, 391 neonatal care in, oxygen during, 159–160 patients in, 408 perioperative period in, 407, 408t Neonatal intubation, 282 Neonatal manual resuscitators, 291, 292t Neonatal period, proposed morbidities attributable to intermittent hypoxia in, 35f Neonatal pneumonia, 73 Neonatal Research Network Generic Database, 381–382 Neonatal respiratory care malpractice issues specific to neonatology and, 58–59 quality and safety improvement in, 54–55 quality improvement in, 54 Neonatal respiratory physical examination, performing, 61–62 Neonatal resuscitation, 36 devices for, 281f emergency medications for, 287t risk factors for, 277t supplies and equipment for, 278t Neonatal Resuscitation Program (NRP), 58, 417, 427 guidelines, in pulse oximetry, 99–101 Neonatal resuscitation time line, 4b Neonatal ventilation Covidien PB 840 in, 263 Dräger Evita Infinity V500 in, 267 Dräger Evita XL in, 265 GE Healthcare Engström Carestation in, 271 growth in, 422–423 history of, 1–2 Maquet SERVO-i in, 269 outcomes of, 423 targeting schemes used for, 258t universal intensive care ventilators used for, 256–271 Neonates assessment of, 310, 311t assisted ventilation of, ethical issues in, 36–40.e2 historical background of, 37–40 Neonates (Continued) blood gas values in cord blood and in arterial blood of, 469–470 cardiorespiratory drugs in, administration of, 477–480 general care of, 317–320 healthy term, capillary blood gas values in, 469 hemodynamic problems in, 363–365 invasive and noninvasive assessment of gas exchange in, 98f lung function data in, 467 resuscitation record of, 474–475 Neonatology, common malpractice lawsuits in, 58b Neostigmine, 477 Neurally adjusted ventilatory assist (NAVA), 173–174, 207, 208f in Maquet SERVO-i, 268 Neurodevelopmental outcomes after surfactant therapy, 347 following ventilation, 462 Neurofurans (NeuFs), as oxidative biomarker, 156t Neurologic effects, of respiratory support, 451–458.e2 Neurologic Outcomes and Preemptive Analgesia in Neonates (NEOPAIN), 369 Neuromuscular blockade, 372 Neuromuscular disease, mechanical ventilation in, 146t–148t Neuroprostanes (NeuPs), as oxidative biomarkers, 156t Newborn care, basic steps of, 278 chest, examination of, 311t clinical assessment of, 278 clinical evaluation of, 278, 278t transient tachypnea of, 72, 73f Newborn and Infant Chronic Lung Disease Program, 382 Newport Breeze, 219f Newport Wave, 219f NHFV see Nasal high-frequency ventilation NICHD see National Institute of Child Health and Human Development NICU see Neonatal intensive care unit NIPPV see Noninvasive intermittent positive-pressure ventilation NIRS see Near-infrared spectroscopy Nitroprusside, 477 NNF see National Neonatology Forum Noise, transport physiology and, 427 Nondepolarizing agents, 372 Nondissipative forces, 10 “Nondistressed tachypnea,” 353 Noninvasive high-frequency ventilation, 162, 166f Noninvasive intermittent positive-pressure ventilation (NIPPV), 162, 172–174 neurally adjusted ventilatory assist in, 173–174 or nasal CPAP, for apnea, 174 synchronized and nonsynchronized, 172–173 Noninvasive neurally adjusted ventilatory assist (NIV-NAVA), 162 Noninvasive respiratory support, 162–179.e4 background and historical aspects of, 162–164 complications of, 174–176 monitoring during, 298–299 Noninvasive ventilation, 383–384, 384f in respiratory care of newborn, 298 Nonlinear flow resistive sensors, 108 Nonrandomized trial, 42t–43t Norepinephrine for diastolic hypotension, 134 for septic shock, 364 Normal transition, physiology of, 275 NRP see Neonatal Resuscitation Program NTB see Necrotizing tracheobronchitis Null value, 45 Number needed to treat (NNT), 44, 48t Nursing care, 310–321.e3 INDEX Nutrition enteral, 327–329 advantages of, 328 composition of, 328–329 in neonate, 318 Nutritional requirements, 322–326 carbohydrate, 324–325, 325t energy, 323, 323t lipid, 324 mineral, 325–326, 326t protein, 323–324, 323t vitamin, 326, 326t water, 322–323 Nutritional support, 322–329.e4 weaning and, 247 O Observational studies, 42t–43t Obstructive apnea, genesis of, 32 Obstructive disease, mechanical ventilation in, 146t–148t ODC see Oxyhemoglobin dissociation curve Odds ratio, 45, 48t Omeprazole, 477 Omphalocele, 15, 410 Open lung strategy, importance of, 202, 203f Open lung ventilation, 192–193 Operative management, 412–414 Operator-ventilator interface, 253–254 Opioids, 368–371 premedication for intubation, 410–411 Optimal lung volume, 220–221 Optimal nutritional support, 322 Optimal targeting scheme, for mechanical ventilation, 144t–145t Optimum PEEP, 14, 386–387, 387f Oral sucrose, in neonate, 319 Oropharyngeal obstruction, 394–396 Oscillation, physical examination and, 64–65 OSI see Oxygen saturation index Ototoxicity, furosemide and, 376 Overcirculation, 139 Overstimulation, strategies in minimizing, 319t Oxidative phosphorylation, Oxidative stress, biomarkers of, 155–156 Oxygen, 8–9 administration of, in delivery room, 158–159 brain injury and, 455–456 cerebral blood flow and, 454 in fetal-to-neonatal transition, 156–157 in first weeks of life, 160 hemorrhagic-ischemic injury and, 455–456 history of, 153 homeostasis, 156 inspiratory, optimizing, 116 in metabolic indices, 160 during neonatal care, 159–160 physiology, principles of, 153–156 aerobic metabolism in, 153–154, 154f antioxidant defenses in, 155 oxidative stress in, biomarkers of, 155–156, 156t reactive oxygen species in, 154, 155f redox regulation in, 154–155 PPHN and, 363 sensing mechanisms, 156, 157f supplemental, 354, 409 therapy, 153–161.e2 home, 160–161, 161b transfer, 435–436 transport, 80–82, 81f used in neonatology, 279 Oxygen concentrator, 449 Oxygen dissociation curve, 81, 81f Oxygen saturation, 95 monitoring of, 312, 312f nomogram, arterial, 157, 157f–158f Oxygen saturation (Continued) in preterm, with positive pressure ventilation and air, 158, 158f recommendations, 161 Oxygen saturation index (OSI), 101 Oxygen tension, in blood gas, of neonates, 469 Oxygen therapy, 449 Oxygen toxicity, in ventilator-induced lung injury, 189 Oxygenation, 21–23, 191, 192f compromised, cardiovascular assessment of, 125–129 extracorporeal membrane, 434–445.e1, 434f–435f acute deterioration in, 438 barotrauma in, 439 before cannulation, 439–440 carotid artery repair in, 443 chronic lung disease and, 444 complications in, 442f contraindications to, 439 daily management of, 441–443 disease states and, 437 distribution of, 444f echocardiography during, 442 evaluation before, 439 operative procedure in, 440–441 outcome of, 443–444 by patient category, 437f, 445f patient selection in, 437–439 pump, development of, 435 selection criteria in, 437–438, 438b sensorineural hearing loss and, 444 technique for beginning, 439–441 vascular access in, 435 venoarterial, 441t venovenous, 441t weaning of, 443 lung recruitment guided by, 193, 193f mean airway pressure and, 110 in mechanical ventilation, 151 noninvasive monitoring of, 97–102 pulse oximetry in, 97–102, 99f–100f transcutaneous oxygen monitoring in, 102 ventilator settings and, 23 Oxygenation index (OI), 356–357, 438 Oxyhemoglobin, 89, 95 Oxyhemoglobin curve, 21, 21f Oxyhemoglobin dissociation curve (ODC), 82 P p value, in determining quantitative effects of therapy, 43–44 PaCO2, noninvasive assessment of, 102–105 capnography in, 102–104 end-tidal CO2 monitoring in, 102–104, 103f transcutaneous CO2 monitoring in, 104–105, 105t Pain assessment of, 311 as “fifth vital sign,” 311 management of, in neonate, 319–320, 319t Pain perception, of neonate, 415 Pakistan, 418–419, 423 Palpation, of chest, 310 Pancuronium, 373, 373t, 477 PaO2, 94–95 Papyrus, Ebers, Paracelsus, Parenteral nutrition, 326–327 composition of, 327 intravenous access and, 327 Patent ductus arteriosus (PDA), 134–138 clinical importance of, 134 closure of, weaning and, 247 ductal closure strategies in, 137–138 ductal shunt in, 134 echocardiography in, 135–137, 135t 495 Patent ductus arteriosus (Continued) hemodynamic significance of, 135–137 inhaled nitric oxide therapy and, 360 left-heart volume loading in, assessment of, 136, 136f management of, 137–138, 389 conservative, 137 perioperative physiology and, 138 pulmonary overcirculation in, assessment of, 136 size of, assessment of, 135 surgical ligation of, 138 symptomatic, treatment of, 138 systemic steal, assessment of, 136–137 transductal flow pattern of, assessment of, 135, 136f Patient circuit, 254, 256f Patient cycling, 143 Patient safety, 50 in mechanical ventilation, 59 Patient triggering, 143 Patient-centered care, 49 Patient-ventilator interface, 254–255, 256f PAV see Proportional assist ventilation PDA see Patent ductus arteriosus Peak expiratory flow, 109t Peak inflation pressure (PIP) limit, 199–201 Peak inspiratory flow, 109t Peak inspiratory pressure (PIP), 23, 211–212 optimizing, 115 Pediatric surgeon/otolaryngologist as consultant, 403–406 as diagnostician and therapist, 393–403 PEEP see Positive end-expiratory pressure Pendelluft effect, 19 Pepsin, bronchopulmonary dysplasia and, 331–332, 332f–333f Peptic ulcer disease (PUD) prophylaxis, ventilatorassociated pneumonia and, 335 Percussion, in airway clearance techniques, 304–306 Perfusion, 26–29 Perfusion index (PI), 101, 102f Periodic breathing, 32 Peripheral chemoreceptors, 31 Peripheral (hypoxic) chemosensitivity, 31–32 Peripherally inserted central venous catheters (PICCs), 70–71 Periventricular hemorrhagic infarction, 453, 453f Periventricular leukomalacia (PVL), 220, 227, 453–454 coronal head ultrasound, 454f focal and diffuse, 454f inhaled nitric oxide therapy and, 360 Periventricular-intraventricular hemorrhage, 452–453 Permissive hypercarbia, 116, 245–246 Permissive hypoxemia, 246 Peroxynitrite, 154 Persistent fetal circulation, 125 Persistent pulmonary hypertension of the newborn (PPHN), 28, 125, 363 black lung, 354 cardiovascular support for, 363 cardiovascular therapy and, 362–365.e1 circulatory pathophysiology of, 127f clinical assessment of, 126–127 clinical evaluation in, 363 cyanotic congenital heart disease versus, 126–127 disorders associated with, 349, 351f echocardiographic evaluation of, 355, 355t intervention in, 363 management of, 127–129 mechanical ventilation in, 146t–148t pulmonary vasodilator therapies for, 128–129 research needs for, 363 resuscitation for, 128, 128f specific therapy for, 363 supplemental oxygen for, response to, 354 targeted neonatal echocardiography for, 128–129, 129t 496 INDEX pH in blood gas testing, 92–94 at various ages during the neonatal period, 469 Pharmacotherapy, for bronchopulmonary dysplasia, 387–388 Phentolamine, 477 Phlogiston, 153 Phosphodiesterase, 358 Phosphodiesterase-3 inhibitors, 362 Phylogeny, ontogeny and, Physical examination, 61–66.e1 at birth, 63–64 findings in specific clinical situations and, 63–65 general findings, 62–63 historical aspects of, 61 importance of, 61 of infant on CPAP, 65 receiving face-mask or laryngeal-mask ventilation, 64 interpretation of findings of, 62–65 respiratory, performing neonatal, 61–62 special technique of, 63 technique of, 61–62 of ventilated infant, 64–65 Physiologic principles, 8–30.e1 Physiological signals, analysis of dynamics of, prior to extubation, 248–249 PI see Perfusion index PICCs see Peripherally inserted central venous catheters PIE see Pulmonary interstitial emphysema Pierre Robin syndrome, 395 Piperacillin/tazobactam, for ventilator-associated pneumonia, 337 Plan-do-study-act cycles, 51–53 Plethysmographic variability index (PVI), 101–102 Pleural effusion, 75–76, 76f, 76.e1 Pneumomediastinum, 74, 74f–75f Pneumonia, 73, 73–74, 73f neonatal, exogenous surfactant therapy for, 348 ventilator-associated, 330 Pneumopericardium, 74 Pneumotachometers, 108, 255, 256f Pneumothorax, 26, 63, 74, 74f, 414, 456 Poiseuille’s law, 15 Polymorphonuclear (PMN) white blood cells, 189 Polyvinyl chloride tubing, 440 Poractant, 339 Poractant alfa, 477 Portable gas cylinders, 431t Positioning in airway clearance techniques, 304, 305f in newborn care, 279, 279f in respiratory care, 312–313 Positive end-expiratory pressure (PEEP), 5–6, 10, 211–212 during conventional mechanical ventilation, 220–221 functional residual capacity and, 410 inadvertent, 17, 174–175, 227, 386 intrinsic, 386 lung hyperinflation in, 386, 386f optimum, 14, 115, 386–387, 387f for respiratory distress syndrome, 231 settings, key considerations in, 149 Positive predictive value, in test accuracy, 46 Positive-pressure gradient, 19f Positive-pressure oxygen air lock, 3f Positive-pressure ventilation, 29, 281–282 aim of, 279–280 techniques providing, 291–298 acquisition and maintenance of intubation skills and, 296–298 depth of tube insertion and, 295 determination of placement and, 295 equipment and, 294, 294t, 294b Positive-pressure ventilation (Continued) laryngeal mask airway and, 298 through endotracheal intubation, 292–293, 293b through face masks, 292 through manual ventilation, 291–292, 292t through routes of intubation, 293–294, 294b tube fixation and, 295–296, 296f–297f, 297t types of tubes and, 294–295, 295f Positive-pressure-generating devices, comparison of attributes across range of, 281t Postextubation management, 249–250, 249b adjunctive therapies for, 249–250 Postextubation respiratory failure, 292–293 Postnatal corticosteroids, for prevention and treatment of postextubation stridor, 249 Postnatal steroids, 457 Postnatal viability, 229–230 Postoperative support, mechanical ventilation in, 146t–148t Postresuscitation care, 290 examination/monitoring in, 290 Potassium-sparing diuretics, 377 Povidone iodine, 85 Power, defined, 251 Power control, of ventilators, 251–252 Power conversion, of ventilators, 251–252 Power inputs, of ventilators, 251 Power outputs, of ventilators, 252–253 PPHN see Persistent pulmonary hypertension of the newborn Prednisone, 477 for subglottic hemangioma, 399 Premature infants continuous tracheal gas insufflation for, 210 normal, arterial blood gas values in, 468–469 Premature newborn, inhaled nitric oxide therapy and, 359–361 Prematurity, 459 apnea of, 34 from CPAP, 164 pathogenesis of, 31–32 Preresuscitation “time out,” 277, 277t Pressure A/C, in CareFusion AVEA, 261 Pressure A/C with flow cycle, in CareFusion AVEA, 261 Pressure A/C with machine volume, in CareFusion AVEA, 261 Pressure A/C with volume guarantee, in CareFusion AVEA, 261 Pressure control, 143f assistance with, in ventilators, 255–256, 257f, 258t in conventional ventilation, 142 in Maquet SERVO-i, 268 Pressure control airway pressure release ventilation in Dräger Babylog VN500, 272 in Dräger Evita Infinity V500, 267 Pressure control assist control in Dräger Babylog VN500, 271 in Dräger Evita Infinity V500, 267 with volume guarantee, in Dräger Babylog VN500, 272 Pressure control biphasic positive airway pressure, in Dräger Evita Infinity V500, 267 Pressure control continuous mandatory ventilation in Dräger Babylog VN500, 272 in Dräger Evita Infinity V500, 267 with volume guarantee, in Dräger Babylog VN500, 273 Pressure control mandatory minute volume ventilation with volume guarantee, in Dräger Babylog VN500, 273 Pressure control pressure support, in Dräger Evita Infinity V500, 267 Pressure control pressure support ventilation, in Dräger Babylog VN500, 273 Pressure control pressure support ventilation with volume guarantee, in Dräger Babylog VN500, 273 Pressure control synchronized intermittent mandatory ventilation in Dräger Babylog VN500, 273 in Dräger Evita Infinity V500, 267 with volume guarantee, in Dräger Babylog VN500, 273 Pressure controlled ventilation-volume guarantee, in GE Healthcare Engström Carestation, 270 Pressure measurement, 110 Pressure SIMV, in CareFusion AVEA, 261 Pressure SIMV with volume guarantee, in CareFusion AVEA, 261 Pressure sources, 280–281, 281f, 281t Pressure support, in Maquet SERVO-i, 269 Pressure support ventilation (PSV), 143–144 Pressure ulcers, in neonate, 319 Pressure-controlled ventilation, 195, 195f in GE Healthcare Engström Carestation, 270 initial settings for, 149 plus assist, in Dräger Evita XL, 264 plus/pressure support, in Dräger Evita XL, 264–265 Pressure-limited ventilation, 192 weaning from, 244 Pressure-passive circulation, 451 Pressure-regulated volume control (PRVC), 201 A/C, in CareFusion AVEA, 261 A/C with flow cycle, in CareFusion AVEA, 261 initiation of, 201 limitation of, 201 in Maquet SERVO-i, 268–269 Pressure-regulated volume control SIMV, in CareFusion AVEA, 261 Pressure-regulated volume control SIMV with flow cycle, in CareFusion AVEA, 261 Pressure-support ventilation (PSV), 184–186, 184f–185f clinical application of, guidelines for, 187 and synchronized intermittent mandatory ventilation, 185, 185f Pressure-volume curves, 190–191, 190f comparison of, 11f deflation limb of, 111f pulmonary function and graphics in, 111–112 Pressure-volume loop, 12f Pressure-volume relationships, 109f, 112–113, 190, 191f, 224, 225f Preterm neonates, resuscitation and, 288 Primary health centers, 416–417 Primary outpatient physician, 447 Procainamide, 477 Process, defined, 49 Propofol, 372 Proportional assist ventilation (PAV), 206–207, 207f Propranolol, 477 Prostacyclin, 27 Prostaglandin E1, alprostadil, 477 Prostaglandin synthesis inhibitor, 27–28 Prostaglandins for PDA, 137 for transport, 428 Protein requirement, 323–324, 323t Protein-containing synthetic surfactants, 340 animal-derived surfactants versus, 345 protein-free synthetic surfactant versus, 345–346 Protein-free synthetic surfactants animal-derived surfactants versus, 345 protein-containing synthetic surfactants versus, 345–346 Proximal airways, development of, PRVC see Pressure-regulated volume control Pseudoglandular phase, PSV see Pressure-support ventilation Pulmonary agenesis, 77–78, 78.e1 Pulmonary alveoli, 338 Pulmonary arterial hypertension, mechanical ventilation in, 146t–148t Pulmonary blood flow, factors affecting, 27t INDEX Pulmonary cystic lesions, 402 Pulmonary development, lung injury and, 408–409 Pulmonary function and graphics, 108–117.e1 accuracy of, 108, 109t alternative sensors in, 108 bedside, limitations of, 116 dynamic compliance in, 112 flow measurement in, 111, 111f–113f lung compliance in, 112 measurements displayed on, 110–114 minute ventilation in, 111 pathophysiology of, 109–110, 109f–110f pneumotachometers in, 108 pressure measurement in, 110 pressure-volume curve in, 111–112, 114f pulmonary mechanics and, 112–114 resistive properties in, 112–114 respiratory physiology of, 109–110, 109f–110f signal calibration in, 108–109 synchronous and asynchronous breathing in, 114 technical aspects of, 108–109 in tidal volume, 110–111 in ventilator management, 114–116 volume measurement in, 110–111 Pulmonary function testing and imaging, 461 Pulmonary hemorrhage, 75, 75.e1 exogenous surfactant therapy for, 348 Pulmonary hypertension, 81f, 139 in bronchopulmonary dysplasia, 241–242 cardiovascular assessment of, 125–126, 126f differential diagnosis of, 408t home oxygen therapy and, 449 late, 359 in lung hypoplasia disorders, 238, 238t management of, 388–389, 389f in meconium aspiration syndrome, 234 persistent, high-frequency ventilation in, 222 in severe bronchopulmonary dysplasia, 382–383 transitional physiology and, 407–408 ventilation strategies for, 408 Pulmonary hypoplasia, 400–401 high-frequency ventilation in, 222 mechanical ventilation in, 146t–148t Pulmonary insufficiency of prematurity, 12 Pulmonary interstitial emphysema (PIE), 75, 75f, 75.e1, 214 Pulmonary mechanics, 112–114 Pulmonary microaspiration, minimizing, 389–390 Pulmonary outcomes, following ventilation, 460–462 Pulmonary system, reduced end-organ function in, 132t Pulmonary vascular bed, in congenital diaphragmatic hernia, 237 Pulmonary vascular resistance (PVR), 139, 362 lung volume and, 27f, 128, 128f Pulmonary vasodilation, iNO therapy and, 349, 350f Pulmonary vasodilator therapies, for PPHN, 128–129 Pulse oximetry, 89–90, 89f, 97–102, 99f–100f, 278 considerations in, 101–102 in delivery room, 159 indications for, 99 interpretation of measurements, 354 limitations of, 101 principles of, 97, 100f Pulse oximetry sign, 312f Purolia Model, 420 PVI see Plethysmographic variability index PVL see Periventricular leukomalacia Q Quality improvement (QI), 51 changes for, 52 measurement of, 51 steps in, 53t Quality improvement projects in individual units, 54 success of, 53–54 Quality indicators for comparative performance measures, 50 for improvement, 50–51 Quality of care assessing and monitoring, 50 improvement of, 51 Quality of evidence evaluating, 42–43 for diagnostic tests, 45–46 weighing risks, benefits, and costs, 45 Quality of life, 37–38 Quinidine gluconate, 477 Quinlan, Karen Ann, 40 R Racemic epinephrine, 375 Radial diffusive mixing, 19–20 Radiation exposure, 67 Radiography, 67–79.e4 RAM Nasal Cannula, 168–170 Randomized controlled trials (RCTs), 42t–43t, 165 CPAP, 170–172 for HHFNC, 177–178 Rapid eye movement (REM) sleep, 10 Rapid morphine bolus infusions, 369 Rated flow, 435–436, 437f RCTs see Randomized controlled trials RDS see Respiratory distress syndrome Reactive oxygen species (ROS), 154, 155f Redox regulation, 154–155 Reduced end-organ function, clinical and biochemical parameters of, 132t Relative risk (RR), 44, 48t reduction, 44, 48t Remifentanil, premedication for intubation, 410–411 Renal system, reduced end-organ function in, 132t Renal water excretion, 322–323 Residual volume, 24 Resistance, 15–16 airway, 15 Resistive gain, 206 Resistive properties, 112–114 Resource-limited countries, 416–424.e2 clinical care pathways for, 421–422 clinical monitoring in, 422 current status in, 417–419 equipment for respiratory care programs in, 421 establishing respiratory care programs in, 419–422 ethical dilemmas in, 423, 424b infrastructure in, 417, 420 limiting factors in, 416–417 outcomes of neonatal ventilation in, 423 projected growth in, 422–423 resources of, 420 respiratory care program barrier in, 417 respiratory support for, 419f scope of need in, 416 skilled health care personnel in, 417 support equipment in, 417 ventilators for, 421 Respiration, basic biochemistry of, 8–9 Respiratory care, 311–317 evidence-based, 41–48.e1 high-frequency ventilation in, 316–317 inhaled nitric oxide in, 317 malpractice issues specific to neonatology and neonatal, 58–59 malpractice lawsuit, decreasing risk of, 59–60 malpractice litigation and, 60 mechanical ventilation in, 59, 313–316 medical and legal aspects of, 56–60.e1 disclaimer, 56 general legal principles, 56 malpractice, 57–58 supervision of others, 56–57 497 Respiratory care (Continued) nasal continuous positive-airway pressure in, 313, 314f neonatal, quality improvement in, 54 of newborn, 291–309.e4 oxygen saturation monitoring in, 312, 312f positioning and containment in, 312–313 quality and safety, 49–55.e2 sudden deterioration in, 317 Respiratory care clinicians, 447 Respiratory care programs clinical care pathways in, 421–422 clinical monitoring in, 422 components of, 420f education in, 422 equipment for, 421 establishing, 419–422 evaluation of, 422 guidelines for setting up, 420b implementation of, 419–422 infrastructure in, 420 leadership in, 419 partnership in, 419 resources in, 420 Respiratory control impaired, 33 preterm infant development, 31 term infant development, 31 Respiratory control center, in newborn infant, 30 Respiratory distress, medical and surgical interventions for, 391–406.e2 Respiratory distress syndrome (RDS), 62, 71–72, 72f, 72 e1f, 229–233, 417 clinical trials on, 340–341 congenital and surgical causes of, 76–79 CPAP for, 162 evidence-based recommendations for, 233 furosemide and, 376 gaps in knowledge for, 233 high-frequency ventilation in, 221 key pathophysiologic features of, 229–230, 230t developmental lung biology in, 229–230 lung liquid, 229 surfactant in, 229 physical examination in diagnosing, 63f prevention and treatment of, 345 relevant principles of ventilation for, 230–233, 230t–231t conventional ventilation, 231 extubation, 231–233, 233t for high-frequency ventilation, 231, 232t score system, 422t surfactant on, 342 Respiratory failure, 1, 59, 188 hypoxemia and, 349, 354t medical and legal aspects in, 59 neonatal, 188 preterm infants with, 193–194 Respiratory illnesses, 67, 461–462 Respiratory inductive plethysmography, 191 Respiratory interventions, special considerations in applying evidence to, 47 Respiratory parameters, 109t Respiratory physical examination, 61–62 Respiratory quotient (RQ), 22 Respiratory rhythm-generating circuitry, 33 Respiratory stimulants, 377–379 Respiratory support, 275–290.e4 complications of, 330–337.e2 humidification and warming during, 300–301, 301f monitoring during, 298–300 neonates needing, 310 neurologic effects of, 451–458.e2 brain injury in, mode of ventilation and, 456 cerebral blood flow, influence of oxygen and carbon dioxide on, 454–455 498 INDEX Respiratory support (Continued) hemorrhagic-ischemic injury, changes in carbon dioxide and oxygen concentration and, 455–456 medications in, 456–457 special techniques of, 205–210.e2 Respiratory system dimensions, changes in, 466 mechanics of, 9–10, 12f resting state of, 12 Respiratory tract, administration of medications into, 306–308 Resuscitation anticipation for, 276–277, 277t deciding whether to commence, 289 deciding whether to stop, 289–290 at delivery, 309 monitoring in, 284, 284f–286f neonatal respiratory care and, 58 physiology of, 276 for PPHN, 128 preparation for, 276–277, 277t–278t risk factors for, 277t special cases for, 288–289 training in, 276 Resuscitation record, of neonates, 474–475 Retrolental fibroplasia (RLF), 153 Reynolds number, 15 Rigid bronchoscopy, 119–121, 119f Rigid microlaryngoscopy, 119 Rocuronium, 373t, 374 Root cause analysis (RCA), 52 steps in, 52t Routine endotracheal suctioning, 302 Routine sedation, avoidance of, weaning and, 247 RQ see Respiratory quotient S Safety, culture of, in mechanical ventilation, 59 Salbutamol, 374–375, 374t Saturation, 278 Scalar monitoring, 110f SciMed Kolobow spiral silicone membrane lung, 436f Sechrist, 219f Sedation and analgesia, 367–372, 369t benzodiazepines in, 371–372 chloral hydrate in, 372 morphine and, 369 opioids in, 368–371 propofol in, 372 Selective decontamination of the digestive tract (SDD), 335–336 Self-inflating bags (SIBs), 280, 291 Sensitivity, in test accuracy, 46 Sensorineural hearing loss, ECMO and, 444 Septic shock, 363–364 Sequestration, 401–402, 402f Servo, in targeting schemes, for mechanical ventilation, 144, 144t–145t Setback jets, 214 Set-point, in targeting schemes, for mechanical ventilation, 144, 144t–145t “7-8-9 rule,” in endotracheal tube, 411 Sidestream capnography, 103 SIDS see Sudden infant death syndrome Siggaard-Andersen alignment nomogram, 471–472 Sigh intermittent positive airway pressure (SiPAP), 173 Signal calibration, in pulmonary function and graphics, 108–109 Silicone, 434 Silverman-Anderson respiratory severity score, 164 SIMV see Synchronized intermittent mandatory ventilation SIMV (volume control), in Maquet SERVO-i, 269 SIMV pressure control in Maquet SERVO-i, 269 with pressure support, in Covidien PB 840, 263 with tube compensation, in Covidien PB 840, 263 SIMV pressure regulated volume control, in Maquet SERVO-i, 269 SIMV volume control plus (with tube compensation), in Covidien PB 840, 263 SIMV volume control with pressure support, in Covidien PB 840, 263 SIMV volume ventilation plus (with pressure support), in Covidien PB 840, 263 Sinapultide, 340 Single limb circuit, 254, 256f Skeleton, developmental abnormalities of, 402–403 Skilled health care personnel, 417 Skin antisepsis, use of products for, 318 Skin breakdown, in neonate, 319 Skin care, in neonate, 318–319 Skin trauma, 175–176, 175f–177f Skin-to-skin holding, 320, 320f Sleep developmental aspect of, 31 respiratory control of, 30 Slings, in vascular rings, 400 Slow infusion, of surfactants, 344 “Slow units,” 20 Small aggregate (SA) surfactants, 189 Small airway obstruction, mechanical ventilation in, 146t–148t “Sniffing” position, 279, 279f Sodium bicarbonate, 477 Sodium chloride, for diastolic hypotension, 134 Sodium polystyrene sulfonate, 477 Soranus of Ephesus, Specialized neonatal ventilators, 271–274 Specific lung compliance, 13 Specificity, in test accuracy, 46 Spirometry, 109, 109f Spironolactone, 377, 477 Split-flow ventilation, 210 Spont pressure support, in Covidien PB 840, 263 Spont volume support, in Covidien PB 840, 263 Spontaneous breathing, 143 passive expiratory flow during, 112f respiratory parameters in, 109t scalar monitoring during, 110f Spontaneous breathing trials (SBTs), in extubation readiness, 248 Spontaneous continuous positive airway pressure/pressure support in Dräger Babylog VN500, 273 in Dräger Evita Infinity V500, 267 Spontaneous continuous positive airway pressure/volume support in Dräger Babylog VN500, 273 in Dräger Evita Infinity V500, 267 Spontaneous proportional pressure support, in Dräger Babylog VN500, 273 Spontaneous/CPAP, in Maquet SERVO-i, 269 Stabilization, at delivery, 309 State and federal government court system hierarchies, 57f Static compliance, 13 Static pressure-volume curves, 11f Statistical process control chart, 52f Stenosis bronchial, 78 subglottic, 119, 120f Steroids, 366–367 Stimulation, in newborn care, 279 Stress, strategies in minimizing, 319t Stridor, neonatal, 393, 393b, 394f Study designs, 42t–43t Stylet, for endotracheal tube, 282 Subglottic hemangioma, 398–399 Subglottic stenosis, 119, 120f acquired, 398 congenital, 398 Subglottis, 375 Subumbilical cutdown, 86 Suction, for newborn care, 279 Suction catheter, selection of appropriate-sized, 294t Suctioning, in mechanical ventilation, 314–316, 316f Sudden deterioration, 317 Sudden infant death syndrome (SIDS), 35 Sulfhemoglobin, 95 Sulfonamides, 377 SUPPORT trial, 170–171, 312 Supraglottic devices, 283 Surfactant, 456 administration, 432 animal-derived, 339 bovine, 346 criteria for repeat doses of, 343 doses of, single versus multiple, 343 dysfunction of, 189–190 early administration of, 342–343 exogenous, 193 long-term respiratory outcomes of, 347 methods of administration of, 343–345 bolus administration as, 344 chest position in, 345 laryngeal mask airway, 344 nasopharyngeal, 344 slow infusion, 344 thin catheter endotracheal, 344 through catheter, side port, or suction valve, 343–344 through dual-lumen endotracheal tube, 344 vibrating membrane nebulizers in, 344 neurodevelopmental outcomes of, 347 physical growth and, 347 porcine and bovine, 346 products, choice of, 345–346 prophylactic versus rescue treatment strategies in, 347–348 protein-containing synthetic, 340 in respiratory distress syndrome, 229 secretion and metabolism of, 338–339, 339f synthetic, without protein components, 339–340 targeted, 343 therapy, 338–348.e6, 306 acute pulmonary and cardiac effects of, 340 adverse effects of, 346 clinical trials of, 340–343 compared to placebo or no therapy, 340–341 composition of, 338 economic aspects of, 346–347 exogenous, 348 history in, 338 immediate pulmonary effects of, 340, 340f–341f long-term outcomes after, 347–348 prophylactic administration of, 341–342 on pulmonary circulation, 340 radiographic changes in, 340 response to, factors affecting, 347 types of, 339–340 for ventilator-associated pneumonia, 337 Surfactant administration, 306–307, 306t Surfactant dysfunction, in meconium aspiration syndrome, 233 Surfactant replacement therapies, Surfactant TA, 339 Surfacten, 339 Surfaxin, 340 Surgical ligation, for PDA, 138 Survanta, 339, 477 Survival rates, neonatal, 418t Sustained inflation, 224 Swiss Cheese model, 52, 52f INDEX Synchronized intermittent mandatory ventilation (SIMV), 182–183, 183f clinical application of, guidelines for, 186–187 in Dräger Evita XL, 265 and pressure-support ventilation (PSV), 185, 185f Synchronized intermittent mandatory ventilation (SIMV) mode, for respiratory distress syndrome, 231 Synchronized intermittent mandatory ventilation (SIMV) rate, and targeted minute ventilation, 209 Synchronized intermittent mandatory ventilation with AutoFlow, in Dräger Evita XL, 265 Synchronized intermittent mandatory ventilationpressure controlled, in GE Healthcare Engström Carestation, 270 Synchronized intermittent mandatory ventilationpressure controlled volume guaranteed, in GE Healthcare Engström Carestation, 270–271 Synchronized intermittent mandatory ventilation-volume controlled, in GE Healthcare Engström Carestation, 271 Synchronized intermittent mandatory ventilation-volume controlled with pressure limit, in GE Healthcare Engström Carestation, 271 Synchronized ventilation, 180–187.e1 basic modes of, 182–186 benefits of, 181t clinical application of, guidelines for, 186–187 patient-ventilator interactions with, 182, 183f trigger technology in, 180–182, 181t Synchronous breathing, 114 Synchrony, optimizing, 116 Synthetic surfactants without protein components, 339–340 animal-derived surfactants versus, 345 protein-containing synthetic surfactants versus, 345–346 Systemic blood flow (SBF), low, 129–130 Systemic corticosteroids, weaning and, 247 Systemic vascular resistance (SVR), 363 Systolic blood pressure by birth weight and gestational age, 472–473 in the first days of life, 473–474 Systolic blood pressure (SBP), 130 Systolic hypotension management of, 133–134 in neonates, 131t T Tachypnea nondistressed, 353 transient, 15 Target saturation levels, in nursing care, 312 Targeted minute ventilation, 208–209 Targeted neonatal echocardiography (TNE) in compromised systemic hemodynamics, 132 for PPHN, 128–129, 129t Targeted tidal volume (TTV), 202 Tarnier, Étienne, Teamwork, in resuscitation, 276–277 Terminal sac phase, The New York Times, 4, 4f Theophylline, 34, 378, 378t, 477 Therapeutic hypothermia, for hypoxic-ischemic encephalopathy, 290 Therapy, quantitative effects of, determining, 43–45 Thermal instability, in neonate, 317–318 Thermoregulation, in transport physiology, 428 Thiazides, 377 Thin catheter endotracheal administration, 344 Thoracotomy, 25 Ti, Hwang, Tidal breathing flow-volume loop, 115f Tidal flow-volume loops, 112f–113f Tidal volume, 18, 109t choice of, 198 in HFOV, 231 Tidal volume (Continued) measurement of, in mechanical ventilation, 141 optimizing, 116 as primary control variable, 195–196 pulmonary graphic representation of, 110–111 stabilization, 192 target, setting, 385 uncorrected exhaled, 198–199 and ventilator-induced lung injury, 195 during weaning, 201 Tidal volume-targeted ventilation, 195–204.e1 alarms/troubleshooting in, 202, 203t–204t neonatal, 197 rationale for, 195–196, 196f Time constant, 17–18, 212 Time control (TC), 142 “Time-cycled, pressure limited,” 145 Time-cycled pressure-limited A/C, in CareFusion AVEA, 261 Time-cycled pressure-limited A/C with flow cycle, in CareFusion AVEA, 261 Time-cycled pressure-limited A/C with flow cycle and volume guarantee, in CareFusion AVEA, 261 Time-cycled pressure-limited A/C with volume guarantee, in CareFusion AVEA, 261 Time-cycled pressure-limited SIMV, in CareFusion AVEA, 261 Time-cycled pressure-limited SIMV with volume guarantee, in CareFusion AVEA, 261 Timeliness, defined, 49 Tobramycin, for ventilator-associated pneumonia, 337 TOHOP study, 365 Topical antiseptic products, 318 Torr to kilopascal conversion table, 470 Tort law, 57 Tort litigation, strategies to avoid, 59b Torts, 57 Total lung capacity, 24 Total parenteral nutrition (TPN), composition of, 327 T-piece, 3, 280–281 T-piece resuscitator, 292 TPN see Total parenteral nutrition Tracer gas washout techniques, 191 Trachea, intubation of, 296 Tracheal anomalies, 399–400 Tracheal aspirates, 123 Tracheal obstruction, 393–400 Tracheal stenosis, 399, 399f Tracheobronchitis, necrotizing, 399–400 Tracheoesophageal fistula, 26, 120–121 Tracheomalacia, 122, 399, 399f Tracheostomy, 403–406 anterior cricoid split procedure, 405, 405f for bronchopulmonary dysplasia, 241 care, 448 for long-term support, in bronchopulmonary dysplasia, 390 procedure in, 404–405, 404f–405f tube, 405–406 changing, 448–449 Training, in resuscitation, 276 Transcutaneous monitoring, 90–91 CO2, 104–105, 105f, 105t Transcutaneous oxygen (TcPo2), monitoring of, 102 Transient tachypnea of the newborn (TTN), 62, 63f, 72, 73f Transillumination, 87 Transition, to home care, 446–450.e1 Transitional cardiovascular physiology, 124 Transitional physiology, pulmonary hypertension and, 407–408 Transport, 425–433.e2 clinical issue in, 428–429 continuous positive airway pressure and, 432 education, 427 499 Transport (Continued) equipment in, 429–433 extracorporeal membrane oxygenation and, 433 future directions of, 433 inhaled nitric oxide and, 432–433 interhospital medications for, 429b supplies for, 430b regionalized care in, 425 stabilization in, 428 surfactant administration and, 432 ventilators, 430–431 Transport physiology, 427–428 Transport Risk Index of Physiologic Stability (TRIPS), 429 Transport team composition, 426 role of, 425 Transpulmonary pressure, 13, 24, 112–113 Trauma, from adhesives, prevention of, 319 Treacher Collins syndrome, 395, 396f Trends, in operator-ventilator interface, 254, 254f Tricuspid regurgitant jet velocity (TRJV), 388 Trigger technology, 180–182, 181t Triple-lumen endotracheal tube adapter, 213 Troubleshooting, 202, 203t–204t Truog, Robert, 38 TTN see Transient tachypnea of the newborn Tube diameter, 16, 16f Tube displacement, 414 Tube fixation, 295–296, 296f–297f, 297t Tube length, 15–16 Tube obstruction, 414 Tubular myelin, 338–339 3N2-Tyrosine, as oxidative biomarker, 156t m-Tyrosine, as oxidative biomarker, 156t o-Tyrosine, as oxidative biomarker, 156t U Ultrasound, 68, 69f–70f Umbilical artery catheters, 84–87, 85f complications of, 86–87 Umbilical cord blood gas values, normal, 467–468 Umbilical cord clamping (UCC), delayed, 124–125 Umbilical stump, 84f Uncuffed endotracheal tubes, in mechanical ventilation, 141 Unit culture, 54 Universal intensive care ventilators, used for neonatal ventilation, 256–271 V Vagolytic agents, premedication for intubation, 411 VAP see Ventilator-associated pneumonia Vascular rings, 400, 400f Vasculogenesis, 229–230 Vasoconstrictors, 362 Vasopressin, in HRF, 128–129 VDR-4®, 216 Vecuronium, 373–374, 373t, 477 Venoarterial bypass, 440 Venoarterial cannulation, 440 Venoarterial extracorporeal membrane oxygenation chest radiograph of, 441f comparison with venovenous extracorporeal membrane oxygenation, 441t vessel cannulation for, 440f Venovenous bypass, 440 Venovenous cannulation, 440 Venovenous extracorporeal membrane oxygenation, comparison with venoarterial extracorporeal membrane oxygenation, 441t Venticute, 340 Ventilated infant examination of, 64–65 transport of, 425–433.e2 500 INDEX Ventilated infant (Continued) clinical issue in, 428–429 continuous positive airway pressure and, 432 education in, 427 equipment in, 429–433 extracorporeal membrane oxygenation and, 433 future directions of, 433 inhaled nitric oxide and, 432–433 medications for interhospital, 429b regionalized care in, 425 stabilization in, 428 supplies for interhospital, 430b surfactant administration and, 432 ventilators in, 430–431 Ventilation, 24–26, 25f see also specific methods altering ventilator settings on, 26 assisted, 140–152.e1 chronic, 39 control of, 31–35.e1, 30 conventional, modes of, 142–145 effects of different time constants, 20f modes of, 141, 251–252, 255–256 for newborn infant, 279–280 pressure-controlled, 149 protocols in, 152 pulmonary and neurodevelopmental outcomes following, 459–464.e2 starting, assessment after, 149–150 Ventilator alarm systems, 253 Ventilator cycle, 143 definition of, 142, 142f Ventilator management, pulmonary graphics in, 114–116 Ventilator mode, 412–413 Ventilator triggering, 143 Ventilator-associated pneumonia (VAP), 316, 330 diagnosis of, 334–335 distribution of, 331f, 331t epidemiology of, 330–331 microbiology of, 334, 334t pathogenesis of, 331–332, 332f prevention of, 335–336 treatment of, 336–337 Ventilator-induced lung injury (VILI), 1, 188–190 avoidance of, 298 pulmonary and systemic consequences of, 189–190 biotrauma as, 189 in lung development, 190 structural injury as, 189 surfactant dysfunction as, 189–190 risk factors for, 188–189 susceptibility of newborn lungs to, 190 Ventilators, 251–255 defined, 251 infant stabilization using, 281 principles of, 141 Ventilators (Continued) simplified schematic of, 252f subsequent, adjustments in, 151 Ventilatory patterns, in conventional ventilation, 144 Ventilatory support initiating, 37 rate of, optimizing, 116 weaning from, 243, 244b withdrawal (nonescalation) of, 37 Venturi effect, 213, 391 Verapamil, 477 Vermont Oxford Network (VON), 50, 366 Very low birth-weight (VLBW) neonates, 51 Vesalius, Andreas, Vibrating membrane nebulizers, for surfactant administration, 344 Vibration in airway clearance techniques, 304–306 in transport physiology, 427 Vicious circle, 28f VILI see Ventilator-induced lung injury Viscosity, 16 Viscous resistance, 10 Visual bedside charts, 302, 302f Vital signs, operative management of, 413 Vitamin A, 326 Vitamin D, 326 Vitamin E, 326 Vitamin K, 326 Vitamin requirements, 326, 326t VLBW see Very low birth-weight (VLBW) neonates VN 500, volume guarantee in, 197–198 Vocal cord paralysis (VCP), 118 congenital, 397 Volume assistance with, in conventional ventilation, 142 of ventilators, 253, 253f Volume A/C, in CareFusion AVEA, 261 Volume control, 142, 143f assist control with AutoFlow, in Dräger Evita Infinity V500, 267 assistance with, in ventilators, 255–256, 257f, 258t continuous mandatory ventilation with AutoFlow, in Dräger Evita Infinity V500, 267 in Maquet SERVO-i, 269 synchronized intermittent mandatory ventilation with AutoFlow, in Dräger Evita Infinity V500, 267 Volume expansion, in newborns, 288 Volume guarantee, 197–199, 198f–199f Volume limit, 202 Volume measurement, 110–111 Volume SIMV, in CareFusion AVEA, 261 Volume support, in Maquet SERVO-i, 269 Volume ventilation plus, 201–202 Volume-controlled ventilation, 195, 195f in GE Healthcare Engström Carestation, 271 limitation of, 197, 197f Volume-controlled ventilation (Continued) with pressure limit, in GE Healthcare Engström Carestation, 271 versus volume-targeted ventilation, 196–197 Volume-cycled ventilators, 196 Volume-targeted ventilation, 195–196, 202 benefits of, 195–196, 196t clinical guidelines for, 199–201, 200t versus volume-controlled ventilation, 196–197 Volumetric capnography, 104 Volutrauma, 170, 220 minimizing, 190 in ventilator-induced lung injury, 188 VON see Vermont Oxford Network Vulnerable pulmonary circulation, mechanical ventilation in, 146t–148t W Warm shock, 363–364 Warming, during respiratory support, 300–301, 301f Warmth, in newborn care, 278–279 Washout of flow sensor, 210, 210f Wasted ventilation, 18–19 Water requirement, 322–323 Water-seal CPAP, 165–166 Waveforms, in operator-ventilator interface, 254, 255f Weaning adjunctive therapies during, 246–247 avoidance of routine sedation in, 247 caffeine in, 246 chest physiotherapy in, 247 closure of patent ductus arteriosus in, 247 diuretics in, 246–247 inhaled corticosteroids in, 247 nutritional support in, 247 systemic corticosteroids in, 247 general strategies to facilitate, 245–246 permissive hypercarbia and, 245–246 permissive hypoxemia and, 246 from high-frequency ventilation, 244–245 inhaled nitric oxide therapy and, 357 in lung protective ventilation, 194 from mechanical ventilation, 243–250.e3 from pressure-limited ventilation, 244 protocols, 246, 308–309 from ventilatory support, 243, 244b Wheezing, 461–462 White blood cells, polymorphonuclear, 189 White matter injury, 455 Withdrawal (nonescalation) of ventilator support, 37 appropriate care after, 39–40 Work of breathing (WOB), 10, 16–17 and NCPAP, 166 X Xanthine therapy, 34, 34f This page intentionally left blank This page intentionally left blank This page intentionally left blank This page intentionally left blank This page intentionally left blank This page intentionally left blank ... publication of the sixth edition of their classic text, Assisted Ventilation of the Neonate The first edition was published in 1981, when neonatal ventilation was in its infancy, and long before the. .. of the Neonate was born The preface to the first edition started with a quotation from Dr Sydney S Gellis, then considered the Dean of Pediatrics in the United States: As far as I am concerned,... of the chapters and they exceeded our expectations in producing a “how to” guide for successful ventilation of the distressed newborn The first edition, published in 1981, was modeled after the