Quiz 2 (Mike, Ch. 6).txt

• - Retained secretions:
• Atelectasis
• RDS
• BPD
• Intubation
• Ineffective cough
• Pain
• Paralysis
• Neuromuscular disease
• - Excessive secretions:
• Cystic fibrosis
• Pneumonia
• Asthma
• Broncholitis
• Bronchiectasis
• - Aspiration:
• Meconium
• Foreign body
• - Prophylaxis:
• Post-extubation

• Pulmonary hemorrhage
• Hypoxemia during treatment
• Feedings within the previous 45-60 minutes
• History of reflux
• History of intraventricular hemorrhage
• Untreated pneumothorax
• Congestive heart failure

To facilitate the removal of respiratory tract secretions

• Bradycardia.
• - Vagal nerve stimulation.
• - Hypoxemia induced.
• Hypoxemia.
• Mucosal damage.
• Atelectasis.
• Airway contamination

• Suction catheter should be no larger than half the size of the inner diameter of the endotracheal tube.
• - Table 6-5 pg. 167
• Suction vacuum should be set at negative 60-80 for infants.
• - Negative 80-100 for pediatric patient
• Limit to less than 5 seconds of suction.
• Saline irrigation needs to be limited to 0.5 ml of normal saline.
• Pre-oxygenate at 10-15% higher FI02 unless patient has problems, then increase as needed.

Placing the patient in the correct gravity dependent position to let gravity pull the secretion up toward larger airways

• Rhythmic clapping on the chest to get the vibration to loosen secretions from the airways.
• Done while the patient is in gravity dependent position, this will facilitate secretion removal

A rapid movement of the chest wall to shake loose secretions

• A resistance device is used to create positive expiratory pressure as the patient breathes in and out through via mask or mouthpiece.
• May (or may not) be given in conjunction with aerosol therapy.
• The expiratory resistance is performed 10-20 times followed by forced exhalation technique to expel secretions.
• The expiratory resistance causes mechanical bronchodilation and increases the ventilation of areas distal to the mucous obstructions.
• Forced exhalations then propel mucous up and our of the airway.
• Use as many repeated attempts as needed to remove mucous.
• As the patient exhales resistance is adjustable to 15-30 or as high as 60-80 cm H2O

• After performing PEP therapy, the patient should perform a
• forced expiratory maneuver (Huff Cough).
• - Patient inhales slowly then does 2-3 "huff" exhalations against an open glottis followed by a strong cough.
• - The "huffs" help to stabilize and keep the airways open, allowing secretions to mobilize in the airways.

• Action: Loosens mucus through expiratory oscillation as positive expiratory pressure splints airways
• Used independently
• Technique dependent
• Portable
• May not be effective at low airflows
• Time required: 10 - 15 minutes

Generally, you will start with the pressure control dial at #1 and increase, as tolerated.

• Setting the frequency for CF patients.
• Low freq. 5-10 Hz for 10 min.
• Medium freq. 11-15 Hz for 10 min.
• High freq. 16-20 Hz for 10 min

• Used independently or with caregiver supervision
• Used with aerosolized meds
• Technique dependent
• May not be well tolerated by patient
• Action: "percussion" on both inspiration, but most benficial on expiration
• Rate 120-300 cycles/min (2 - 5 Hz).
• Pressures of 10-40 cm H2O
• Nebulizer produces dense, small particle aerosol
• Time required: 20 minutes

• 1. percussive oscillatory vibrations which loosen retained secretions.
• 2. high density aerosol delivery to hydrate viscous mucous plugs
• 3. positive expiratory pressure (PEP) to recruit alveolar lung units and assist in expiratory flow acceleration during a cough maneuver.

• Action: creates mechanical "cough" through the use of high flows at positive and negative pressures.
• Positive/negative pressures up to 60 cm of water.
• Used independently or with caregiver assistance.
• There are five primary settings on the typical automatic in-exsufflator:
• - The inhale time.
• - The inhale pressure.
• - The exhale time.
• - The exhale pressure.
• - The pause time between the inhale and exhale phases.
• These settings are adjusted so that they generate a good, productive cough without causing discomfort.

the need to deliver an aerosol medication to the lower airways

• Beta adrenergic agents
• Anticholinergic agents
• Anti-inflammatory agents (Corticosteroids)
• Mediator-modifying compounds (Mast Cell Wall Stabilizers)
• Mucokinetics (Mucolytics)

• Nosocomial infection
• Medication side effects
• Drug reconcentration
• Ventilator malfunction
• Excessive noise

• - Depends on the type of nebulizer.
• - Jets are used often but the amount varies considerably depending on the type and brand of nebulizer used.
• - In pediatrics, like adults, much of the medication is lost during expiration.
• More drug is delivered when the volume of diluents is increased.
• When administered to intubated infants, the dosages need to be increased due to the reduced deposition.

• Hygroscopic nature of particles.
• Viscosity and concentration of the medication.
• Velocity the drug (due to the administration device).

• The narrower the airway, the greater the deposition.
• Neonatal airway is small to start with then add the ET tube, bronchoconstriction, and mucous.
• Whitaker believes that the amount that the amount of drug reaching the terminal airways is negligible.

• Best pattern is with laminar flow in a slow deep inspiration with inspiratory pause.
• This may be done on a ventilator but is near impossible with a breathing infant.

• Little patient coordination required
• Effective in acute respiratory distress, flow, or volume
• Ability to give either a large or small volume of aerosol
• Drug dosage and/or particle size can be modified

• Relatively expensive
• Less easily transported
• Cleaning and preparation required
• Amount of medication delivered is variable
• Provides a medium for bacterial growth.

• Very portable
• Efficient drug delivery
• Short preparation and delivery time
• Particles resist hygroscopic growth
• Can be used on newborns/infants

• Coordination difficulties.
• Limited choice of drugs and concentrations.
• Possible reaction to propellants.
• Oropharyngeal impaction.
• Foreign body aspiration.

• Similar to MDI
• Limited hand breath coordination needed
• No propellants
• Doses easily counted

• Limited number of drugs
• Possible airway irritation
• Possible reaction to the carrier powder
• Requires high inspiratory flow
• Requires loading before use
• Less useful in acute obstruction
• Can only be used on ages 4+

• Designed to deliver Ribavirin for RSV bronchiolitis
• Gas-powered jet nebulizer uses three jets
• Uses drying chamber to shrink particles
• Baffle is sides of container
• Aerosolized Ribavirin has generally fallen out of favor as a treatment for RSV.
• The exception being patients with chronic respiratory or cardiac anomalies who go on to develop RSV.
• New research is looking at Ribavirin as a possible treatment for SARS.

• Treat and relieve documented hypoxemia
• Decrease WOB
• Decrease workload on heart

NONE!

• Pao2 50 - 70 mmHg
• Spo2 88 - 95%

• Pao2 > 60 mmHg
• Spo2 > 95%

• Retractions
• Grunting
• Nasal flaring
• Apnea and/or bradycardia
• Cyanosis
• - Because fetal Hb has increased affinity for 02 the newborn's pa02 may drop to 30-40 torr before cyanosis appears

• ROP
• Oxygen toxicity
• Cerebral vasoconstriction
• Fire hazard

• Maintain pa02 of 50-80 torr based on the age of the newborn
• Pa02 of pa02 of 100 torr may be required for PPHN (persistent pulmonary hypertension in the newborn)

• Oxygen Hood
• Oxygen Cannula
• Mist Tent
• Oxygen Mask
• Resuscitation Bag

• delivery device of choice in the preemie for the first days of life.
• The oxygen is administered via a heated humidified hood via a blender.
• - Both the fi02 and the air temperature must be controlled.
• - An O2 analyzer should always be used.
• Increased CO2 build up if the flow is too low is a potential hazard

• Newborns, even preemies can be given 02 by nasal cannula.
• USED ON PATIENT with chronic oxygen needs or as weaning tool from other modes of delivery.
• Because the infant's Ve is so low, the FI02 at a given flow rate differs drastically from the FI02 of adult 02 cannula.
• Neonatal flow meters can be calibrated as low as 0.025 lpm.
• Estimated FIO2 on the nasal cannula at various flowrates for patients under two years of age:
• 1/4 Lpm 25%
• 1/2 Lpm 30%
• 1 lpm 35%

• RARELY USED ANYMORE
• Once the infant is old enough to roll over and sit up, he is too big for a O2 hood.
• The disadvantage of a mist tent is that the infant will no longer get an exact fi02 inside the croup tent.
• The fi02 of the mist tent runs between 21% and 50%, but there is little control because the enclosure is too large for fine-tuning.
• Mist tents are more tolerated by the infant, since mom can get in tent to hold them

• The 02 mask is a poor choice for an infant because it can obstruct his/her airway.
• It is a poor choice for the toddler because the child has an instinct to protect his/her face and nose and he/she will pull it off.
• At about 3 years of age the child might wear a mask, but the nasal cannula is generally preferred.
• Once a child is old enough to tolerate a mask, one has the same choices as with the adult.
• As with the adult patient the entrainment mask is the only sure method of exact fi02 delivery because these are high flow systems.

• Delivery of oxygen for short periods.
• Delivery of oxygen during initial resuscitation.
• FIO2 80-100% when used properly with reservoir.