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  a. Increased secretions (1) Necessitating more frequent suctioning (2) Loosening of tape b. Infant activity c. Procedures requiring repositioning infant d. Tube slippage E. Technique (See also Endotracheal Intubation on the Procedures Website, and Appendix D for Techniques of Intubation Specific to Unique Patient Needs) Orotracheal Intubation (Table 36.2) 1. Position infant with the head in midline and the neck slightly extended, pulling chin into a “sniff” position (Fig. 36.4). The head of the infant should be at operator’s eye level. It may be helpful to place a roll under the baby’s shoulders to maintain slight extension of the neck. 2. Put on gloves. 3. Clear oropharynx with gentle suctioning. 4. Empty stomach. 5. Bag-and-mask ventilate and preoxygenate infant as indicated by clinical condition. Follow heart rate and oxygenation. 6. Turn on the laryngoscope light, and hold the laryngoscope in left hand with thumb and first three fingers, with the blade directed toward patient. a.

  A B Fig. 36.1. A: Vallecula cyst, causing stridor and proximal airway obstruction. B: Endotracheal tube passes beneath cyst. C: Same patient after laser surgical treatment. Table 36.1 Endotracheal Tube Diameter for Patient Weight and Gestational Age Tube Size (ID mm) Weight (g) Gestational Age (wk) 2.5 <1,000 <28 3.0 1,000–2,000 28–34 3.5 2,000–3,000 34–38 4.0 >3,000 >38 238 Section VI ■ Respiratory Care b. Secure tube carefully in position to avoid dislodgement, kinking, or movement. (1) Vary contact point from side to side to prevent damage to developing palate and palatal ridges (7,8). (2) Note relationship of head position to intratracheal depth of tube on radiograph (9). 9. Do not leave endotracheal tube unattached from continuous positive airway pressure; the natural expiratory resistance is lost by bypassing the upper airway. 10. Recognize that in neonates, endotracheal tubes are often pushed in too far because of the short distance from the glottis to the carina.

  a. Miller blade size 1 for full-term infant b. Miller blade size 0 for preterm infant (size 00 for extremely low birth weight infant) Straight rather than curved blades are preferred for optimal visualization. c. Modified blade to allow continuous flow of oxygen at 1 to 2 L/min for better maintenance of oxygenation during procedure. The use of a Viewmax (Rusch, Duluth, Georgia) laryngoscope improves viewing of the larynx but requires a longer time for tracheal intubation (6). 6. Scissors 7. Oxygen tubing 8. Magill forceps (optional) Nonsterile 9. Humidified oxygen/air source, blender, and analyzer 10. Resuscitation bag and mask 11. Suctioning device 12. Cardiorespiratory monitor 13. Pulse oximetry oxygen saturation monitor 14. Stethoscope 15. Adhesive tape: Two 8- to 10-cm lengths of 0.5-inch-wide tape, with half the length split and one 10- to 15-cm length unsplit Chapter 36 ■ Endotracheal Intubation 237 D. Precautions (Table 36.2) 1. Select orotracheal route for all emergency intub

  Chapter 35 ■ Bubble Nasal Continuous Positive Airway Pressure 235 References 1. Gregory GA, Kitterman JA, Phibbs RH, et al. Treatment of the idiopathic respiratory distress syndrome with continuous positive airway pressure. N Engl J Med.1971;384:133. 2. Gregory GA. Devices for applying continuous positive pressure. In: Thibeault DW, Gregory GA, eds. Neonatal Pulmonary Care. Menlo Park, CA: Addison-Wesley; 1979. 3. Katwinkel J, Fleming D, Cha CC, et al. A device for administration of continuous positive pressure by the nasal route. Pediatrics. 1973;52:130. 4. Wung JT. Continuous positive airway pressure. In: Wung JT. (ed) Respiratory care of the newborn: A practical approach. New York: Columbia University Medical Center; 2009. 5. Aly H. Nasal prongs continuous positive airway pressure: a simple yet powerful tool. Pediatrics. 2001;108:759. 6. Aly H, Massaro AN, Patel K, et al. Is it safer to intubate premature infants in the delivery room? Pediatrics. 2005;115:1660. 7. Nowadzky T, Pant

  Fig. 35.3. An infant with CPAP properly attached to the head. (1) Head cap (cap fit well on head covering down to eye brows, almost entire ears and back of head); (2) breathing circuit tubes attached to side of hat while avoiding both eyes; (3) three-way elbow on expiratory limb allows the attachment of pressure manometer or could be capped to preserve pressure within circuit; (4) orogastric tube attached to lower lip and chin with Tegaderm; (5) neck roll allowing slight neck extension (sniff position); (6) nasal prongs applied to baby—prongs inserted into nares allowing a space between the transverse arm of the nasal prongs and nose to avoid damage to nasal columella; (7) supporting chin strip. Infant should be assessed during the trial for any tachypnea, retractions, oxygen desaturation, or apnea. If any of these signs are observed, the trial is considered failed. Infant should be restarted immediately on CPAP, for at least 24 hours, before another trial is undertaken. b. There is

  Chapter 35 ■ Bubble Nasal Continuous Positive Airway Pressure 233 c. Fixing corrugated tubes in place (1) Use appropriate-sized hat and fold rim back 2 to 3 cm. (2) Place the hat on the infant’s head so that the rim is just over the top of the ears. (3) Hold the corrugated tubing to one side of the head. (4) Tape the tube to the hat at the side of the head. (5) Repeat the same procedure for the tubing on the other side of the head. d. Draining excess air from the stomach (1) Pass an orogastric tube and aspirate the stomach contents. (2) Fix tube at appropriate position. (3) Leave tube open to air to ventilate excess air from stomach. e. Maintaining a good seal for CPAP pressure (1) Gently apply a chin strip to minimize air leak from the mouth. 1 2 3 5b 6 4 5a Fig. 35.2. Components of the CPAP attachment device.(1)Infant’s nose before applying b-CPAP; (2) protective DuoDERM applied to upper lip and nose; (3) thin Velcro moustache piece: applied to upper lip on top of DuoDERM with shar

  232 Section VI ■ Respiratory Care a. Short binasal prongs b. Velcro (to make attachment circles and moustache for upper lip) c. DuoDERM (to make nasal septum protective layer) d. CPAP head cap e. Adhesive tape E. Technique (See Procedures Website for Video) 1. Starting b-CPAP Nonventilator-derived b-CPAP apparatus involves making a simple water seal device that can be put together in neonatal units. It consists of a container of water, through which the expiratory gas from the baby is bubbled at a measured level below the surface (e.g., 5 cm below the surface = 5cm H2O CPAP). The lower the level of the tip of the expiratory tubing below the surface of the water, the higher the CPAP (Fig. 35.1). It is important to fix the water bottle to an IV pole at or below the level of the baby’s chest to avoid any accidental displacement or water spills. The recent, commercially available, preassembled circuits rely on the same basic principle. a. Before attaching the device to an infant (1) P

  231 Hany Aly M.A. Mohamed Bubble Nasal Continuous Positive Airway Pressure 35 A. Definition Continuous positive airway pressure (CPAP) is a noninvasive, continuous flow respiratory system that maintains positive pressure in the infant’s airway during spontaneous breathing. CPAP was developed by George A. Gregory in the late 1960s (1). Positive pressure was originally applied by placing the neonate’s head into a semiairtight “box” (the Gregory box) and, subsequently, by a fitted face mask covering the mouth and nose (2). A major problem with both these methods of application was the fact that it was difficult to feed the baby without discontinuing the CPAP, thus the evolution to the current method of applying CPAP through bilateral nasal prongs (3). “Bubble CPAP” (b-CPAP) is a modern resurgence of the original method of supplying CPAP, wherein pressure is generated in the breathing circuit by immersing the distal end of the expiratory limb of the breathing circuit under a water seal (

  Chapter 34 ■ Management of Vascular Spasm and Thrombosis 229 5. Roy M, Turner- Gomes S, Gill G, et al. Accuracy of Doppler ultrasonography for the diagnosis of thrombosis associated with umbilical venous catheters. J Pediatr. 2002; 140: 131. 6. Manco- Johnson MJ, Grabowski EF, Hellgreen M, et al. Laboratory testing for thrombophilia in pediatric patients. On behalf of the Subcommittee for Perinatal and Pediatric Thrombosis of the Scientific and Standardization Committee of the International Society of Thrombosis and Haemostasis (ISTH). Thromb Haemost. 2002;88:155. 7. Raffini L. Thrombophilia in children: who to test, how, when and why? Hematology Am Soc Hematol Educ Program. 2008: 228. 8. Yang JYK, Chan AKC. Neonatal systemic venous thrombosis. Thrombosis Res. 2010;126:471. 9. Wong AF, McCulloch LM, Sola A. Treatment of peripheral tissue ischemia with topical nitroglycerine ointment in neonates. J Pediatr. 1992;121:980. 10. Vasquez P, Burd A, Mehta R, et al. Resolution of peripheral

  228 Section V ■ Vascular Access procedure such as lumbar puncture is required, skip two doses of LMWH, and measure anti-FXa level prior to the procedure. (g) If an immediate antidote is required, protamine may be administered. The dose is usually a 1:1 ratio with LMWH; administration of the dose may be done in 2 to 3 aliquots with monitoring of anti-FXa levels (18). (3) Thrombolytic agents (a) Thrombolytic agents should be considered in the presence of extensive or severe thrombosis when organ or limb viability is at risk. (b) The use of streptokinase and urokinase has been superseded by rTPA. (c) rTPA acts by converting fibrin-bound plasminogen to plasmin, which then proteolytically cleaves fibrin within the clot to fibrin degradation products. rTPA is nonantigenic and has a short half-life. Supplementation with plasminogen in the form of fresh frozen plasma enhances the thrombolytic effect. (d) Thrombolysis does not inhibit clot propagation, so anticoagulation may be necessary. The