Page 1 of 5 PURPOSE: Provide guidelines for the management of mechanical ventilation in infants <34 weeks gestation. INTRODUCTION: Respiratory failure secondary to surfactant deficiency is a major cause of morbidity and mortality in preterm infants. The development of surfactant therapy has substantially reduced mortality and respiratory morbidity for this population. Rapid changes in pulmonary compliance may occur with surfactant administration making it necessary for weaning of mechanical ventilation based on blood gas sampling. PROCEDURE: Upon admission to the NICU, all infants <34 weeks will be given a loading dose of caffeine. In addition, infant s 32 weeks may receive their initial dose of surfactant prior to be transported from Labor and Delivery. Any infant that has not received a dose of surfactant prior to admission to the NICU will be evaluated immediately upon arrival to determine if the infant meets criteria for dosing. Infants should receive the initial dose of surfactant within 15-30 minutes of arrival to the NICU if criteria are met. Inclusion criteria: Infants <34 weeks with a diagnosis of RDS and patient is <2 weeks of life. Exclusion criteria: Meconium Aspiration Syndrome, PPHN, Congenital Heart Disease, Congenital Diaphragmatic Hernia. Initial Ventilator Settings: Mode: SIMV PRVC/ PS Rate: 30 to 40 (choose higher rate for very low birth weight infants) Tidal Volume: Set tidal volume at 4-5 ml/kg* PEEP: 4 to 6 cmh2o Inspiratory time: 0.35 to 0.4 seconds Pressure Support: 5 to 10 cmh2o (adjust to 30-50% of IMV breaths) FiO2: Titrate to minimal amount of oxygen needed to achieve target SpO2 (90-94% or 94-98% as determined by gestational age)**
Page 2 of 5 *If peak inspiratory pressures exceed 25 cmh20 or if excessive volume loss from airway leak, may consider Pressure Control ventilation. Blood Gases: A POC ABG/ CBG should be obtained 30 minutes to 1 hour after initiation of mechanical ventilation. Titrate to minimal amount of oxygen needed to achieve target SpO2 of 90-94% or 94-98%** ABG parameters: ph 7.25-7.45 PCO2 40-55 PO2 50-70 SpO2 90-94% or 94-98%** Point of care (POC) Blood Gas Frequency: First 24 hours of life: Q6 48 hours: Q8 72 hours: Q12 After 72 hours: Q12-24 Blood gases should be obtained 30 minutes to 1 hour after every ventilator change. Each frequency above is the minimum frequency to obtain blood gases. More frequent blood gases may be obtained to facilitate weaning from mechanical ventilation. Less frequent blood gases may be required on patient s that require less support. The NNP and/or physician may adjust frequency of blood gases based on the level of support that the infant is requiring. Surfactant Administration: Surfactant administration should occur at the order of the physician or NNP. This can be done in the delivery room for infant s 32 weeks or in the NICU for all other qualifying infants. The initial dose of Curosurf is 2.5 ml/kg via direct instillation into the OET. Consider subsequent dose of surfactant if FiO2 consistently exceeds > 30%. Subsequent doses of Curosurf are at a dose of 1.25 ml/kg and may be given up to a total of 3 doses (as needed per physician order). An ABG/ CBG should be obtained 30 minutes to 1 hour after surfactant administration.
Page 3 of 5 Blood Gas Values that fall outside of parameters: If PCO2 is > 55, increase setting back to previous value where PCO2 was within parameters o Wait 4 hours before attempting to wean settings again. If PCO2 is <30, notify physician or NNP of critical value and obtain order for multiple changes. Maintain SpO2/ PaO2 according to the Oxygen Management in the Neonatal ICU procedure. Notify MD/NNP physician or NNP if the base deficit is > -10. If set rate on the ventilator is 40, delivered tidal volume is >6 ml/kg and there is persistent hypercarbia, consider HFOV (see appendix 1 for settings). Minimal Settings: Tidal volume set at minimum of 4 ml/kg Rate set at minimum of 12 to 15 breaths per minute PEEP set at minimum of 4 cmh2o FiO2 30% Extubation criteria: Minimal settings obtained with blood gases within desired parameters Spontaneous respiratory rate < 80 Patient has been loaded with caffeine Patient is vigorous and minimal (or no) sedation being administered
Page 4 of 5 30% oxygen requirement Other laboratory data that may affect respiratory drive for patient is within normal ranges (i.e. magnesium level) Notify physician or NNP when extubation criteria are met and then the RT may proceed with extubation. The RT may enter orders for extubation, CPAP or SiPAP and discontinuation of ventilator orders per protocol. Extubation: Infants <28 weeks: Place patient on SiPAP (+5 with a rate of 30) OR Neotech RAM cannula (Non Invasive Ventilation: Pressure Control 15, PEEP 5, Rate 30 or as ordered by supervising physician) and minimum FiO2 to maintain target SpO2 Notify physician or NNP if >40% FiO2 is required to maintain target SpO2 Rate on SiPAP should be weaned only by physician or NNP order. Infants <34 weeks: Place patient on CPAP +5 and minimum FiO2 to maintain target SpO2 Notify physician or NNP if >40% FiO2 is required to maintain target SpO2 Notify physician or NNP if patient is having episodes of apnea and/or bradycardia, patient may require Sipap with rate. An ABG/ CBG should be obtained 30 minutes to 1 hour after extubation to assess oxygenation and ventilation. Reintubation: Notify physician or NNP immediately if any conditions exist that may warrant the patient requiring reintubation: Prolonged apnea that requires BVM ventilation Significant hypercarbia Inability to oxygenate patient References: Surfactant-Replacement Therapy for Respiratory Distress in the Preterm and Term Neonate William A. Engle, MD, and the Committee on Fetus and Newborn; AARC Neonatal ALI Guideline
Page 5 of 5 Approved by: C. Bunyapen MD, Medical Director, Children s Hospital of Neonatal Intensive Care Unit Mary Lynn Sheram, MD, Medical Director,