N.I.C.U.

Pocket Guide
For
Respiratory Therapists
 

1
 Contributors

Charles Williams RRT
Sonia Goede RRT
Carissa Yackus RRT

2
 Contents
Assessment of the Newborn
Common Newborn Cardiopulmonary Disorders 4
Normal Vital signs 5
Normal ABGs        5
Signs of Respiratory Distress 6
APGAR Scoring 7
Primary Apnea vs. Secondary Apnea 8

Airway Management and Mechanical Ventilation

Positive Pressure Breaths  9
Neopuff™ Infant Resuscitator 10
Nasal CPAP  12
Intubation 14
Mechanical Ventilation 16
High Frequency Ventilation 18
 
Miscellaneous and Special Considerations
Survanta Delivery 21
Pneumothorax                          23
Free Flow Oxygen 24
Special Situations 25
Resuscitation Flowchart 27 3
 Common Newborn Cardiopulmonary Disorders
TTNB – Transient Tachypnea of the Newborn
Delayed clearance or absorption of fetal lung fluid
 
RDS – Respiratory Distress Syndrome
Immature lungs/surfactant deficiency causing alveolar instability and collapse
 
BPD – Bronchopulmonary Dysplasia
Chronic lung disease due to administration of high levels of oxygen
 
MAS – Meconium Aspiration Syndrome
Aspiration of fetal bowel contents causing airway obstruction and chemical pneumonitis
 
PPHN – Persistent Pulmonary Hypertension of the Newborn
Elevated pulmonary vascular resistance causes a right-to-left shunt, bypassing the lungs, resulting in arterial hypoxemia.
 
P.I.E. – Pulmonary Interstitial Emphysema; Pulmonary Air Leaks
• Pulmonary Interstitial Emphysema – air within the pulmonary interstitial tissue
• Pneumothorax – air within the pleural space
• Pneumomediastinum – air within the anterior mediastinum
• Pneumopericardium – air within the pericardial sac surrounding the heart

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 Normal Vital Signs

Birth Blood Blood Heart Respirato SpO2

weight Pressure Pressure Rate ry Rate
(g) Systolic Diastolic

(mmHg) (mmHg)

500-700 50-60 26-36

700-1000 48-58 24-36
1000-1500 47-58 25-35

120-170 30-60 88-94%

1500-2000 47-60 25-35

2000-3000 51-72 27-46

Normal Newborn Blood Gases

Term 64-72 50-55

pH PCO2 PO2 HCO3

Capillary 7.37-7.44 31-45 60-100 22-26

Arterial 7.37-7.44 31-45 80-110 22-26

Venous 7.35-7.45 34-50 --- 24-28

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 Newborn Signs of Respiratory Distress
Tachypnea  - (RR > 60 breaths/min)
 
Cyanosis - (Peripheral cyanosis is common, Central cyanosis usually indicates an arterial 
pO2 < 40 mm Hg)
 
Nasal Flaring - (Sign of air hunger)
 
Expiratory Grunting - (Neonate attempting to maintain positive pressure on expiration and 
prevent alveolar collapse)
 
Retractions - 
• Intercostal - between the ribs, 
• Supraclavicular - above the clavicles, 
• Subcostal - below the rib margins

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 APGAR Scoring
• Provides a quick assessment for depression upon delivery
• Perform at 1 minute and 5 minutes after birth

7
 Primary vs. Secondary Apnea
Primary Apnea
• Initial response to hypoxemia
• Initial tachypnea, then apnea, bradycardia, decreased neuromuscular tone
• Responds to stimulation & blow-by O2
 
Secondary Apnea
• Follows primary apnea
• Deep,  gasping respirations followed by apnea, bradycardia, decreased neuromuscular tone, and 
hypotension
• Will only respond to assisted ventilation w/supplemental O2; if not done, death/brain damage rapidly 
ensues

 If a baby does not begin breathing immediately after being stimulated, he or she is likely in secondary 
apnea and will require positive-pressure ventilation. Continued stimulation Will NOT help!

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 Positive Pressure Breaths

Recommended Pressures:

Initial breath (After delivery) - >30 cm H20

Normal lungs (later breaths) - 15 to 20 cm H20

Diseased or immature lungs – 20 to 40 cm H20

Try to maintain a rate of 40 to 60 breaths per minute

By saying aloud………..

Breath……two…...three……breath……two…...three...….breath……
(squeeze) (squeeze) (squeeze)
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 Neopuff™ Infant Resuscitator

The Neopuff™ Infant Resuscitator is an easy to use, manually operated, gas-powered 
resuscitator that provides optimal resuscitation.

• Delivers controlled and precise Peak Inspiratory Pressure (PIP) and Positive End Expiratory 
Pressure (PEEP).
• Avoids the risks associated with uncontrolled pressures.
• Can also be used to deliver free-flow oxygen.

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 Neopuff™ Infant Resuscitator (cont.)

The desired PIP is set by turning the  The desired PEEP is set by adjusting the T-
inspiratory pressure control. piece aperture

The patient T-piece allows breath by breath resuscitation by simply occluding 
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the T-piece aperture with the thumb or finger.
Nasal CPAP

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 Nasal CPAP (con’t)

• Utilize the prong size guide to select the appropriate sized nasal prongs.
• 3 sizes available: small, medium, large.
 
• Choose the appropriate sized bonnet by measuring the baby’s head circumference. 
- Too small of a hat may cause it to ride up the head, putting tension on the prongs and causing 
nasal irritation. 
-Too large of a hat may allow it to slide down over the patient's eyes and release CPAP prongs 
from the nose.
 
• The front edge of the bonnet should be at the eyebrow line and the back cover the entire skull. The 
sides should cover the ears but be certain that the ears are not folded under the bonnet.
• Prepare baby for application of nasal CPAP by suctioning and clearing the nose of any obstructive 
secretions.
 
• Adjust flowmeter to achieve desired amount of CPAP (indicated on the Pressure bar graph display) 
(Approx. flow of 8.5 = 5cm H2O pressure)

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 Intubation

1. Ventilate neonate with 100% oxygen using bag/mask
2. Insert stylet into the ET tube just short of the tube’s tip
3. Ensure neonate is supine and airway is hyperextended (opened) but not overextended
4. Insert laryngoscope blade into mouth, opening the airway and visualizing the vocal cords
5. Insert the ET tube stopping when the tip of the tube has passed the vocal cords
6. Resume positive pressure ventilation via ET tube
7. Confirm the tube’s position
8. End-tidal CO2 detection
9. Chest x-ray
10. Auscultation
11. Observation of condensation during exhalation
12. Secure the ET tube

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 Intubation (cont.)
Intubation and Suctioning Guidelines

Birth Weight Laryngoscope Endotracheal Suction Catheter

Blade Size Tube Size Size
< 1000 g 0 2.5 mm 5 Fr.
1000-2000 g 0 3.0 mm 6 Fr.
2000-3000 g 0-1 3.5 mm 8 Fr.
>3000 g 1 3.5-4.0 mm 8 Fr.

Weight in kg. cm mark @ lip

<1 6.5
1 7
2 8
3 9
4 10 15
 Mechanical Ventilation
Indications for Mechanical Ventilation in Neonates

Respiratory Failure
• Paco2 > 55 mm Hg
• Pao2 < 50 mm Hg
 
Neurologic compromise
• Apnea of prematurity
• Intracranial hemorrhage
• Drug depression
 
Impaired pulmonary function
• Respiratory Distress Syndrome (RDS)
• Meconium aspiration
• Pneumonia
 
Prophylactic use
• Persistent pulmonary hypertension of newborn (PPHN)

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 Mechanical Ventilation (cont.)
Suggested Initial Settings for Specific Disease States:

PIP PEEP Rate Ti

Normal 10-12 2-4 Minimal 0.3-0.5

Infant    (15-20)
RDS 20-30 4-8 20-40 0.3-0.5

Preemie Minimum 2-4 20-30 0.3-0.5

(< 1000 gm)   as poss.
Pulm Air Leak < 20 < 2 60 – 150 0.25-0.4
(PIE,
Pneumothorax)
PPHN < 20 < 2 30-60  * 0.25-0.4

Meconium 30-60 4-6 25-50 0.3-0.5

Aspiration
(w/ atelectasis)
Meconium < 20 < 2 20-25 0.25-0.4
Aspiration
(w/ hyperaeration))
Diaphragmatic < 20 < 2 25-100 0.3-0.5
Hernia

Be sure to confirm Total PIP ordered. 
(Total PIP – PEEP = Set PIP) 17
High Frequency Ventilation

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 High Frequency Ventilation (cont.)
• HFOV keeps the lungs/alveoli open at a constant, less variable, airway pressure. This prevents the lung ‘inflate-deflate', inflate-
deflate' cycle, which has been shown to damage alveoli when there is decreased lung compliance (i.e. RDS) and lungs are “stiff”.
• HFOV can be thought of as “vibrating CPAP”. 
• Must have adequate chest wiggle factor (CWF).
• Be sure lungs are inflated to 8th  or 9th  rib, do not over-inflate.
 
Bias Flow -
It is the rate at which the flow of gas, through the oscillator, is delivered to the patient.
Adjusting Bias Flow will affect Mean Airway Pressure. Initial Settings:
 
MAP Adjust -
Affected by changes in Bias Flow
MAP --- 2-4 cmH20 > conventional MAP
Increases lung volume, and controls oxygenation, along with FIO2. ΔP--- (adequate CWF)
  IT --- 33%
Frequency (Hz) - Hz x 60 = “rate” Hz ---    15 Hz< 1kg wt
A decrease in frequency = increased tidal volume
              12 Hz 1-2 kg wt
An increase in frequency = decreased tidal volume
Disease Variable                                Disease Variable                               Disease Variable
              10 Hz 2-3 kg wt
 Preterm RDS <1000g-15 Hz             Preterm Air leak- 15 Hz                    MAS- 10 to 6 Hz                8 Hz > 3 kg wt
 Term or Near Term RDS- 10 Hz      Term or Near Term-10 Hz                CDH-  10 Hz Bias Flow --20 l/m
 
Power (ΔP) - Amplitude
Controls CO2 removal
Controls Chest Wiggle Factor (CWF)
 
Inspiratory Time %
Can keep at 33% for most applications
Affects Amplitude
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 High Frequency Ventilation (cont.)
3100A Performance Checklist
1. Connect gas source and plug machine in. (Never turn machine on without plugging in gas source)
2. Connect circuit and humidifier
3. Connect color-coded patient circuit control lines and clear pressure sense lines
4. Block off the ET connection port w/ rubber stopper
5. Turn main power on. (Switch is located on base of the stand)
6. Set Bias Flow at 20
7. Set both Mean Pressure Adjust and Mean Pressure Limit controls to max
8. Push in and hold RESET, and observe Mean Pressure read out. (It should read 39-43)
9. If read out is not 39-43, adjust with adjustment screw located on right side of vent.
10. Set Frequency to 15, % I-Time to 33, and Power to 0.0
11. Set Max Paw thumbwheel switch to 30 and set Min Paw thumbwheel switch to 10.
12. With the Mean Pressure Adjust control, establish a Paw of 19 to 21 cmH2O.
13. Press Start/Stop button
14. Increase power to 6.0, and center the piston
15. Verify that the ΔP and Paw readings are within range are within range for corresponding altitude (0-2000).
16. Press Start/Stop to stop vent.
17. Verify thumbwheel alarms by adjusting them to trigger the alarms.
18. Alarms should be set at 2-5 cmH2O of desired Paw pressure
19. Using your fingers, squeeze closed the expiratory limb tubing on the patient circuit to verify the Paw pop-off at 50 cmH2O and alarm.
20. Push and hold RESET to power up machine.
21. Set Mean Pressure Limit control to mid-scale
22. Again squeeze expiratory circuit and observe Paw readout. Adjust to desired level
23. Position vent for connection to patient.
24. Obtain settings from MD and dial in. Set power first. (changing power will change Paw).
25. Place baby on vent and press RESET button and start vent. Center piston.

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 Survanta Delivery
Supplies needed:

• MAC catheter (or feeding tube cut to length of ETT)
• Ballard in-line suction and ETT adapters
• 12ml syringe and needle
• Survanta; 4ml or 8ml vial

1. Warm Survanta for 20 min. at room temp. DO NOT SHAKE vial
2. Determine “safe suction” depth. (Length of ETT +5)
3. Exchange standard ETT connector with MAC catheter ETT connector
4. Draw up Survanta (4ml per kg)
5. Position infant head-down/turned to RIGHT. Advance suction catheter to “safe suction” 
depth; Administer ¼ dose and then withdraw the catheter. Infant should remain in this 
position for 30 seconds.
6. Repeat above procedure in the following order head-down/LEFT, head-up/RIGHT, and 
finally head-up/LEFT
7. Do not suction infant for 2 hours

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 Survanta Dosing Chart
WEIGHT TOTAL DOSE WEIGHT TOTAL DOSE
(grams) (mL) (grams) (mL)

600- 650 2.6 1301- 1350 5.4

651- 700 2.8 1351- 1400 5.6

701- 750 3.0 1401- 1450 5.8

751- 800 3.2 1451- 1500 6.0

801- 850 3.4 1501- 1550 6.2

851- 900 3.6 1551- 1600 6.4

901- 950 3.8 1601- 1650 6.6

951- 1000 4.0 1651- 1700 6.8

1001- 1050 4.2 1701- 1750 7.0

1051- 1100 4.4 1751- 1800 7.2

1101- 1150 4.6 1801- 1850 7.4

1151- 1200 4.8 1851- 1900 7.6

1201- 1250 5.0 1901- 1950 7.8

1251- 1300 5.2 1951- 2000 8.0

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 Pneumothorax
Supplies needed:
•21 or 23 gauge butterfly needle
•Three-way stopcock
•20 ml syringe

1. Insert needle into 4th  intercostal space (located at the level of the nipples)
2. Connect butterfly needle to stopcock and syringe
3. Open stopcock between needle and syringe and then aspirate air or fluid.
4. Stopcock may be closed to empty syringe
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 Free Flow Oxygen
Free Flow oxygen can be given with a flow-inflating bag, an oxygen mask, or by using 
oxygen tubing with a cupped hand.

24
 Special Situations

1. Meconium Present at delivery 

• If meconium is present, and the newborn is not vigorous, suction the 
baby’s trachea before proceeding with any other steps.
• If the baby is vigorous, suction the mouth and nose only, and proceed 
with resuscitation as required.
• “ Vigorous” is defined as a newborn who has strong respiratory efforts, 
good muscle tone, and a heart rate greater than 100 beats per minute.
 
 
2. Diaphragmatic Hernia:
• A baby with a diaphragmatic hernia will present with persistent 
respiratory distress and will often have an unusually flat abdomen with 
diminished breath sounds on the side of the hernia.
• Do not bag mask ventilate, intubate as soon as possible.
• 25
Insert an oral gastric tube to evacuate the stomach contents
 Special Situations (cont.)

3. Choanal Atresia
•  Blockage of the airway caused by an improperly formed nasal passage.
• Test by attempting to pass a small-caliber suction catheter
• If choanal atresia is present, you must insert a plastic oral airway to allow 
air to enter through the mouth.
 
 
4. Robin Syndrome
• The baby is born with a very small mandible. The tongue falls farther 
back into the pharynx and obstructs the airway.
• Place the baby on his stomach (prone). This will allow the tongue to fall 
forward, thus opening the airway.
• If unsuccessful, place a large catheter (12F) or a small endotracheal tube 
(2.5) through the nose. 26
Resuscitation Flowchart

27
 Sources:

Neonatal Resuscitation Handbook; American Heart Association
Respiratory Care: Principles & Practice; Hess, MacIntyre
Neonatal Mechanical Ventilation

Websites
http://www.fphcare.com/neonatal/resuscitation.asp
http://www.aap.org/nrp/nrpmain.html

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