NICU clinicians reveal greatest practices and discover the newest developments in delivering resuscitation, oxygen remedy and aerosol remedy to newborns.
By Alyx Arnett
Practically all newborns run the danger of respiratory difficulties at delivery. Untimely infants usually grapple with respiratory issues resulting from underdeveloped lungs, whereas even full-term infants can encounter respiratory points from numerous components, similar to difficult labor, congenital issues, or infections.
Within the neonatal intensive care unit (NICU), respiratory therapists (RTs) are tasked with administering crucial respiratory help interventions—together with resuscitation, oxygen remedy, and aerosol supply—to those infants.
“All of those interventions maximize the possibilities of survival and contribute to a lower in hospital stays for our sufferers,” mentioned Daenna Burrs, BS, RRT, scientific supervisor for neonatal/pediatric respiratory care and ECMO companies on the Johns Hopkins Kids’s Heart.
Respiratory care clinicians weigh in on these various but interconnected elements of respiratory care within the NICU, specializing in greatest practices, challenges, and the newest developments in care.
Neonates within the NICU usually current with intricate well being points. Because of the severity of their circumstances, these infants are prone to cardiopulmonary incidents that will require resuscitation.1 Cardiopulmonary resuscitation (CPR) with chest compressions is required for about 0.25% to 1% of NICU sufferers.2
Two applications information resuscitation procedures: the Neonatal Resuscitation Program (NRP)—specializing in supply room resuscitation and efficient air flow of the new child lung—and the Pediatric Superior Life Help Program (PALS), specializing in treating the reason for the arrest and offering efficient cardiac compressions.2
These pointers diverge not solely of their focal factors but additionally within the sequence for CPR, how breaths are synchronized with compressions, and the ratio of chest compressions to ventilations.2 As an illustration, PALS pointers advocate initiating CPR with a compressions-airway-breathing method, deviating from the prior advice of airway-breathing-compressions. This transformation goals to enhance blood movement to the guts by means of extra fast chest compressions.
Whereas each applications are universally accepted, there aren’t any revealed suggestions on when to modify from NRP to PALS. “There’s a little bit of an issue of when to go from neonatal resuscitation to pediatric resuscitation,” mentioned Anne Hansen, MD, MPH, medical director of the NICU at Boston Kids’s Hospital. “What we consider is NRP is for the supply room, and when the newborn’s been delivered, we swap to PALS.”
Within the NICU the place Burrs works, the staff begins with NRP pointers however calls a fast response staff that transitions to PALS. “That’s one thing that’s been newly applied in our NICU for the final 12 months,” mentioned Burrs. “Quite a lot of our nurses/RTs and physicians aren’t PALS skilled in our NICU, and that’s why we name a fast response. We might then get an RT and a doctor from the PICU (pediatric intensive care unit) who would then observe the PALS algorithm.”
In accordance with Esther Taylor, BS, RRT-NPS, assistant supervisor of respiratory care NICU at Kids’s Healthcare of Atlanta, widespread challenges throughout neonatal resuscitation are having inexperienced employees and a scarcity of communication. “It’s crucial to affected person outcomes that everybody is correctly skilled on NRP and/or PALS,” mentioned Taylor. “Moreover, resuscitation debrief can guarantee greatest practices proceed to be adopted.”
One other problem, in keeping with Hansen, is offering efficient face masks air flow, which is usually ineffective resulting from airway obstruction and face masks leak—which can subsequently fail to extend a new child’s coronary heart charge. Hansen mentioned clinicians usually wrestle with securing a correct masks seal, which incorporates masking the newborn’s face from nostril to chin.
“Folks usually aren’t offering ample bag-mask air flow, and so they’re not getting good oxygenation,” mentioned Hansen, additionally an affiliate professor of pediatrics at Harvard Medical College. “So the guts charge’s not developing, after which they bail on the bag-mask air flow and transfer to chest compressions when the etiology of the bradycardia is hypoxia-based. It’s actually essential for the resuscitation staff to have very strong bag-mask air flow expertise,” she mentioned.
Whereas expert software stays key, technological developments additionally assist enhance affected person outcomes. Taylor highlighted the introduction of video laryngoscopes, which help clinicians in inspecting the affected person’s throat or airway. Furthermore, the supply of ECPR with ECMO for sufferers in cardiac arrest has markedly improved outcomes. “[This] has been a game-changer,” Taylor mentioned.
Morgan Hill, MD, a neonatologist specializing in neonatal resuscitation at Cincinnati Kids’s, credited enhancements in expertise to serving to overcome air flow challenges. For instance, respiratory operate displays present a steady show of the tidal quantity and face masks leak and a possibility to right method and supply applicable tidal quantity, “though randomized trials haven’t but demonstrated enchancment in clinically related outcomes,” she mentioned.
Supplemental oxygen stays probably the most generally used medicine within the NICU.3 Oxygen remedy is usually important in treating respiratory sickness, from delicate hypoxemia to respiratory misery and respiratory failure.
Whereas widespread, Hansen mentioned it’s solely been extra just lately that oxygen has been widely known as medication—and thus as having negative effects. There’s now an understanding each within the supply room and past to provide much less oxygen. Immediately, oxygen pointers are generally posted on radiant heaters in supply rooms, acknowledging the gradual enhance in oxygen saturation throughout the first 10 minutes of life. “There’s additionally plenty of literature now wanting on the aim oxygen saturation rages, in keeping with gestational age and never giving an excessive amount of oxygen,” mentioned Hansen.
To reduce the potential antagonistic results of not solely an excessive amount of oxygen but additionally too little oxygen, cautious monitoring is required. Publicity to greater oxygen saturation ranges for extended durations in neonates is related to dangers of retinopathy of prematurity and bronchopulmonary dysplasia, whereas low oxygen ranges have been linked to necrotizing enterocolitis.4
Johns Hopkins All Kids’s Hospital steering states that randomized managed trials counsel a focused oxygen saturation vary of 90% to 95%.4 Equally, pointers from The Royal Kids’s Hospital advocate oxygen saturations needs to be focused inside the vary of 91-95%, with alarm limits set with a decrease restrict of 89% and an higher restrict of 96%.5
Nonetheless, adhering to this slim goal vary proves difficult.4 Pulse oximetry, the commonest methodology used to measure oxygen ranges and information oxygen titration, will be inaccurate and inadequate, in keeping with a research that decided pulse oximetry readings “didn’t fulfill the efficiency necessities for titrating oxygen in neonatal sufferers.”6 Johns Hopkins All Kids’s Hospital recommends setting alarm limits and utilizing histogram evaluation to enhance an toddler’s time within the goal vary.
There are a number of methods to manage oxygen, and the supply machine chosen relies on how a lot help is required, in keeping with Taylor. Strategies embrace oxygen hoods and low-flow or high-flow nasal cannulas for infants who can breathe independently. Nasal CPAP could also be used for infants who can breathe on their very own however want extra help than oxygen hoods and nasal cannulas present.
For infants requiring much more help, oxygen will be administered through invasive air flow (typical or high-frequency air flow), airway strain launch air flow, and neurally adjusted ventilatory help, mentioned Taylor.
Having labored within the NICU since 1976, Taylor mentioned developments in oxygen supply have improved affected person care. The introduction of heated cannulas, for example, has resulted in much less rainout and higher temperature management. “We even have new interfaces with noninvasive air flow to attenuate strain harm,” Taylor mentioned.
In accordance with Burrs, different enhancements might contain implementing an oxygen-weaning protocol tailor-made particularly for the NICU. “It might be good for RTs to observe for when to wean as a result of typically sufferers find yourself on supplemental oxygen longer than possibly they need to.”
Aerosol remedy is usually used within the NICU to deal with persistent lung illness or bronchopulmonary dysplasia sufferers, in addition to facilitate airway clearance, enhance pulmonary blood movement, and forestall or deal with an infection.7
In accordance with Hansen, a number of the mostly used aerosolized drugs within the NICU embrace albuterol and steroids, together with nebulized regular saline and hypertonic saline. “Epinephrine is one other nebulized medication that we give infants if we predict they’ve some airway edema after they’ve been extubated, and so they’re having some stridor,” she mentioned.
Aerosol is primarily delivered by means of the nostril in newborns, who’re preferential nostril breathers.8 Burrs usually makes use of an aerosol face masks to ship remedy to sufferers who aren’t on a ventilator or machine, similar to a high-flow nasal cannula, CPAP, or BiPAP. “We have now small neonatal masks to keep away from eye irritation,” she mentioned. A safe face masks seal is important to forestall aerosol from getting into the eyes and guaranteeing optimum drug deposition, in keeping with the American Academy of Respiratory Care, which notes that even masks leaks as small as 0.5 cm can considerably lower the quantity of drug inhaled.9
Nebulizers are generally used to ship aerosolized drugs to sufferers on ventilators who’re unable to obtain them by means of pressurized metered-dose inhalers.10 Three principal varieties of nebulizers exist: jet, ultrasonic, and mesh. For sufferers on ventilators or gadgets like CPAP, Burrs makes use of an ultrasonic nebulizer that matches into the circuit for in-line aerosol drug supply. Taylor makes use of a vibrating mesh nebulizer according to ventilators or high-flow gadgets and switches to a metered-dose inhaler as soon as a affected person is on low-flow oxygen or room air.
Relating to vibrating mesh nebulizer expertise, Taylor mentioned, “The flexibility to place medicine on the dry facet of the humidifier and ship aerosolized medicine with out breaking the double-limb ventilator circuit with every remedy is an enchancment that helps scale back ventilator-associated pneumonia and avoids the interruption of constructive strain air flow.”
There are professionals and cons to every sort of nebulizer, in keeping with a research evaluating the three. Jet nebulizers are low-cost, straightforward to make use of, and efficient in delivering remedies that may’t be delivered by means of pressurized metered-dose inhalers or dry energy however will be inefficient, tough to wash, and require compressed fuel.9 Ultrasonic nebulizers are straightforward to make use of and extra environment friendly than jet nebulizers however have massive residual quantity and may’t aerosolize viscous options.9 Mesh nebulizers are mentioned to be extra environment friendly than different sorts and have a self-contained energy supply however are dearer, tough to wash, and incompatible with viscous liquids.9
When offering aerosol remedy to neonates, Taylor mentioned monitoring the affected person’s coronary heart charge and potassium ranges is essential if frequent remedies are wanted. If the affected person is on a ventilator, Taylor displays ventilator graphics for indicators of enchancment.
Burrs famous that infants requiring aerosol remedy will be irritable and distressed, complicating the drug supply course of. Face masks will be poorly tolerated, resulting in crying and discomfort, which can impression the effectiveness of the medicine. One research discovered that drug deposition is sort of 5 occasions greater in sleeping infants in comparison with those that are crying.6 It additionally discovered that sleeping infants obtain higher medicine distribution into the distal airways, whereas crying infants are likely to have extra deposition within the central airways.
Moreover, particular affected person circumstances warrant cautious consideration when selecting and administering remedies. As an illustration, in circumstances of tracheomalacia the place sufferers have smaller airways, the usage of bronchodilators is usually averted, in keeping with Burrs. As a substitute, remedy methods usually favor steroids. “These are issues we’re conscious of when administering aerosolized therapies,” she mentioned.
In mild of the continual developments in resuscitation, oxygen supply, and aerosol remedy, the clinicians underscore the significance of ongoing training and teamwork. With evolving greatest practices and bettering applied sciences driving higher outcomes, Taylor emphasizes the necessity for fixed studying. She mentioned, “Irrespective of how lengthy you’ve been working towards respiratory remedy within the NICU, there may be at all times one thing to be taught.”
Complementing this, Hill advocates for collaboration within the NICU, encouraging RTs to confidently contribute: “Keep in mind your significance, and don’t be afraid to talk up and share your distinctive information.”
Alyx Arnett is affiliate editor of RT. For extra data, contact [email protected].
- Harer MW, Konkol LJ, Limjoco JJ. Transitioning from NRP to a mixed PALS-NRP resuscitation mannequin at a degree IV NICU. J Perinatol. 2022;42(11):1533-4.
- Sawyer T, McBride ME, Ades A, et al. Issues on the usage of neonatal and pediatric resuscitation pointers for hospitalized neonates and infants: on behalf of the American Coronary heart Affiliation Emergency Cardiovascular Care Committee and the American Academy of Pediatrics. Pediatrics. 2024;153(1):e2023064681.
- Mathias M, Chang J, Perez M, et al. Supplemental oxygen within the new child: historic perspective and present developments. Antioxidants (Basel). 2021;10(12):1879.
- Yuhas D. Oxygen saturation targets for preterm infants scientific pathway. Johns Hopkins All Kids’s Hospital. Up to date 2023 March 9.
- Coordinated by Miller N. Oxygen saturation SpO2 degree focusing on in neonates. The Royal Kids’s Hospital Melbourne. Permitted by the Nursing Scientific Effectiveness Committee. Up to date 2023 June.
- Wackernagel D, Blennow M, Hellström A. Accuracy of pulse oximetry in preterm and time period infants is inadequate to find out arterial oxygen saturation and stress. Acta Paediatr. 2020;109(11):2251-7.
- DiBlasi RM. Scientific controversies in aerosol remedy for infants and kids. Respir Care. 2015;60(6):894-916.
- Chen IL, Chen HL. New developments in neonatal respiratory administration. Pediatr Neonatol. 2022;63(4):341-7.
- Gardenhire DS, Nozart L, Hinski ST. A information to aerosol supply gadgets for respiratory therapists. fifth ed. The American Affiliation for Respiratory Care.
- Arı A. Jet, ultrasonic, and mesh nebulizers: an analysis of nebulizers for higher scientific outcomes. Eurasian J Pulmonol. 2014;16:1-7.