Airway Care. Jen-Tien Wung, M.D., FCCM. Neonatal Intensivist Children s Hospital of New York Columbia University Medical Center New York
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1 Airway Care Jen-Tien Wung, M.D., FCCM Neonatal Intensivist Children s Hospital of New York Columbia University Medical Center New York
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9 Practice insertion of UAC & UVC with umbilical cord Resuscitation with mask Resuscitation with nasopharyngeal tube
10 Endotracheal Intubation Head Position Laryngoscopy Nasotracheal vs Orotracheal Intubation
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13 Endotracheal Intubation Head Position
14 Endotracheal Intubation Head Position
15 Endotracheal Intubation Head Position
16 Endotracheal Intubation Head Position
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25 Endotracheal Intubation Laryngoscopy Oxygen Supplement Oxyscope
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31 Sedation for Intubation Sodium pentothal (6mg/kg) Propofol (bradyarrythmia) Etomidate (suppress adrenal gland) Versed (0.1mg/kg) Fentanyl (2-5 mcg/kg) Morphine (0.1mg/kg) None
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36 Laryngeal Mask Airway (LMA) Developed by British anesthesiologist Dr. Archie Brain Introduced into clinical practice in 1988 as an alternative to the facemask LMAs have been used in virtually all subspecialties of anesthesia ASA s difficult airway algorithm Used for resuscitation
37 Laryngeal Mask Airway (LMA) Insertion Technique: The LMA is completely deflated to form a smooth, flat wedge shape (Some are preferred partial inflation) A water-soluble lubricant is placed on the back of the mask The patient is placed in sniffing position A finger is placed on the anterior surface where the tube joins the mask, the posterior aspect of the LMA is pushed along the hard palate, following the natural curvature of the oropharynx, until seated The flattened mask allows the LMA to pass behind the epiglottis/arytenoids and for the tip to lodge in the area of the upper esophageal sphincter
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46 EXIT Procedure: Ex Utero Intrapartum Treatment Maintenance of intact feto-placental circulation to maintain oxygen delivery to the fetus until a patent airway is established. Must pose minimal additional maternal risk. Should optimize survival/benefits for fetus.
47 EXIT Procedure: Main goal is to maintain uteroplacental bypass after delivery of head and neck. Placental separation follows delivery within 4-10 minutes. Maintenance of uteroplacental bypass is achieved by: Pharmacologic uterine relaxation. Hemostatic hysterotomy. Maintenance of uterine temperature and amniotic fluid volume. Prevention of cord compression. Intrapartum fetal monitoring and treatment.?
48 EXIT Procedure: Intraoperative management at CHOP General endotracheal anesthesia with 2 MAC volatile agent.? Hemostatic hysterotomy with uterine stapler device. Amnioinfusion using Level 1 rapid infusor and amnioinfusion catheter. Fetal anesthesia and monitoring: pulse oximetry, fetal echocardiography.
49 EXIT Procedure: Variations for anesthetic management TIVA with intravenous nitroglycerine infusion (MH susceptible mother) [UCSF]. Epidural anesthesia with intravenous magnesium sulfate and nitroglycerine [BCCH].
50 EXIT (Ex uterus Intrapartum Treatment) Baby N, 3750 gm, Large neck mass (left & posterior, 11.6 X 7.6 X 8.0 cm)?cystic hygroma C-section via the EXIT Procedure 2/13/ ml straw colored fluid aspirated before able to deliver the face for orotracheal intubation with styleted 3.0 I.D. tube
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56 NO in Prematures Hypothesis Martin:NEJM :82 Lung parenchymal growth Surfactant function Bronchodilation Vasorelaxation Angiogenesis Elastin production Inflammation Airway smooth muscle proliferation
57 NO in Prematures In preterm infants, NO increases oxygenation but not survival Lancet 1999;354:1061,1066 Use of INO in premature infants with RDS decreases the incidence of chronic lung disease and death. Schreiber. NEJM 2003;349:2099 Use of INO in critically ill premature infants does not decrease the rates of death and BPD Van Meurs.. NEJM 2005;353:13
58 Post hoc analysis Schreiber (NO = Good) NO worked in patients with OI < 6.94 but not in others. Van Meurs (NO = No Good) NO worked in infants > 1000g. Infants < 1000g had mortality, severe IVH. NO + Conventional Vent = mortality
59 NO in Prematures-controversy NO = Good Schreiber, Chicago, n =207 BW ~992g, 27.4 weeks OI = 7 Mortality 22.5% Prophylactic indomethacin, NO/O 2 NO = No Good Van Meurs,Multicenter, n = 420 BW ~ 839g, 26 weeks OI >20 Mortality 44%
60 NO in Prematures 2006 Inhaled NO therapy improves the pulmonary outcome for premature infants who are at risk for BPD Ballard et al. NEJM 2006;355:343 Among premature newborns with respiratory failure, low dose inhaled NO did not reduce the overall incidence of BPD Kinsella et al. NEJM 2006:355:354
61 NO for Premature Infants 2006 NO = Good Started dol 7-21 (best 7-14d) 7 20 ppm then reduced Minimum duration 21 days NO = Bad Started in the 1 st 48 hours 5 ppm Stopped with extubation or 21 days In the mean time, the use of inhaled NO in this setting should be limited to trials. A. Stark NEJM 2006;355:405
62 ..all who drink of this remedy will recover except except those whom it does not help, who will die. Therefore it is obvious that it fails only in incurable cases. Galen
63 NO and Development No long term neurodevelopmental sequelae J Peds 2000;136:611 Premature infants treated with NO have improved neurodevelopmental outcomes Mestan.NEJM 2005;353:23
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65 735 gm, 26 wks,prom x7 days, oligohydramions Stat c-section for preterm labor, variable deceleration, breech presentation, cord prolapse, Apgar score 7/1, 8/5 CPAP FiO 2 40%, Deteriorated during transport from TN to NICU, FiO 2 60% NTT FiO 2 100%, IMV rate 40, P 20/5, O 2 sat. 50 s Curosurf O 2 sat. transiently to 90 s for 5 min. and then to <20 s ECHO revealed PPHN INO 20ppm started with slowly O 2 sat. INO X 3days, IMV X 4days, CPAP X 85 days, Discharged at DOL#100
66 Endotracheal Tube
67 Endotracheal Tube Low dead Space Connector
68 Endotracheal Tube Low dead Space Connector
69 Endotracheal Tube Size <700 gm 2.5 mm I.D gm 3.0 mm I.D. >1500 gm 3.5mm I.D.
70 Endotracheal Tube Length Orotracheal Tube : 6 cm + BW (kg) Nasotracheal Tube: 8 cm for 1000 gm premie 10 cm for 2500 gm
71 Crown Heel Length(cm) Nasotracheal Tube Length (cm)
72 Endotracheal Tube Position of Tip Chest X-ray (head in neutral position) < 1000 gm premie 1 cm above carina >2000 gm 2 cm above carina
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75 Endotracheal Intubation Nasotracheal vs Orotracheal Better fixation Less inadvertant extubation Less tracheal irritation More comfortable Better oral hygiene
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82 Secure Nasotracheal Tube
83 Endotracheal Tube Suctioning
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87 Endotracheal Tube Suctioning Catheter size Suction length Frequency
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89 Endotracheal Tube Suctioning Catheter size: 6.5 Fr. for 2.5 mm I.D. ET tube 8.0 Fr. for 3.0 & 3.5 I.D. ET tube
90 Endotracheal Tube Suction length: ET tube length (inside + outside) +3 cm: for <1000 gm premie +4 cm: for gm +5 cm: for >2000 gm
91 Endotracheal Tube Suctioning
92 Endotracheal Tube Suctioning Time: As short as possible
93 Endotracheal Tube Suctioning Pressure: -100 to -200 cmh 2 O (-80 to -150 mmhg) 1mmHg = 1.36 cmh 2 O
94 Endotracheal Tube Suctioning Frequency: Q 2-4 hr & prn
95 Endotracheal Tube Suctioning Lubricate catheter with sterile water or saline if necessary
96 Endotracheal Tube Suctioning Head position: Turn to left side for suction of right main-stem bronchus Turn to right side for suction of left main-stem bronchus
97 Name: Length(C-H): Depth of suction: cm. = NTT length ( cm. Inside + cm. Outside) + 3 to 5cm. (3 cm for 1000 gm premie and 5 cm. for term infant) NTT size: Nurse signature: Date:
98 ET Tube Suction Before After
99 Chest Physical Therapy Percussion Vibration
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101 Changing Chest Position
102 Chest Positioning Alternate supine, side to side, or prone position Affected side up for atelectasis Affected side down for pulmonary interstitial emphysema (PIE)
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105 Ultra-thin endotracheal tube, I.D. 2.9 mm, O.D. 3.6mm (same as I.D.2.5mm ET- tube)
106 Ultra-thin endotracheal tube, I.D. 2.9 mm, O.D. 3.6mm ET- tube I.D.2.5mm, O.D. 3.6 mm
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108 Ultra-thin, low dead space endotracheal tube
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