Chapter 9: Respiratory Management

INTRODUCTION

The management of infants with respiratory distress has long been a basic function of neonatal intensive care. Today, death from acute respiratory failure is uncommon, even among the extremely premature, but significant morbidity from mechanical ventilation persists. Current trends in neonatal ventilation focus on reducing ventilator-induced lung injury, and noninvasive support is preferred. When mechanical ventilation is needed, new ventilators cede as much control as possible to the patient. Optimal treatment continues to be difficult to define, and considerable variability exists in assessing the risk–benefit ratio of various management strategies. This chapter provides an overview of current techniques used for neonatal respiratory support.

I. ASSESSING AND MONITORING RESPIRATORY STATUS

1. Physical examination. The presence of the following signs may be useful in recognizing respiratory distress and evaluating the response to treatment. The absence of signs may be secondary to neurologic depression rather than absence of pulmonary disease.

   1. Nasal flaring. One of the earliest signs of respiratory distress, nasal flaring may be present in intubated, ventilated patients as well.

   2. Grunting. Commonly seen early in respiratory distress syndrome (RDS) and transient tachypnea, grunting is a physiologic response (partial closure of the glottis during expiration) to prevent end-expiratory alveolar collapse. Grunting helps maintain functional residual capacity (FRC) and therefore oxygenation.

   3. Retractions. Intercostal, subcostal, and sternal retractions are present in conditions of decreased lung compliance or increased airway resistance and may persist during mechanical ventilation if support is inadequate.

   4. Tachypnea. A respiratory rate >60 breaths/min implies the inability to generate an adequate tidal volume and may persist during mechanical ventilation.

   5. Cyanosis. Central cyanosis indicates hypoxemia. Cyanosis is difficult to appreciate in the presence of anemia. Acrocyanosis is common shortly after birth and is not a reflection of hypoxemia.

   6. Abnormal breath sounds. Inspiratory stridor, expiratory wheezing, and rales should be appreciable. Unfortunately, unilateral pneumothorax may escape detection on auscultation.

2. Blood gases. Management of ventilation, oxygenation, and changes of acid-base status is most accurately determined by arterial blood gas studies.

   1. Arterial blood gas studies. The most standardized and accepted measure of respiratory status, especially for the oxygenation of low-birthweight infants. They are considered invasive monitoring and require arterial puncture or an indwelling arterial line. Access is now considered routine by the umbilical artery or peripherally in the radial or posterior tibial artery.

   2. Normal arterial blood gas values. May not be the same as target values for particular patients, nor acceptable values. Table 9–1 lists examples of normal values for infants.

   3. Calculated arterial blood gas indexes. For determining progression of respiratory distress and are as follows:

      1. Alveolar-to-arterial oxygen gradient (AaDO₂). Greater than 600 mm Hg for successive blood gases over 6 hours is associated with high mortality in most infants if treatment and ventilation do not become effective. The formula for AaDO₂ is

         

         where Pb = barometric pressure (760 mm Hg at sea level), 47 = water vapor pressure, PaCO₂ is assumed to be equal to alveolar ...