Newborn and Infant Nursing Reviews
Volume 6, Issue 2 , Pages 43-51, June 2006

Editorial

Article Outline

 

Although many practices in pulmonary care of the neonate remain controversial, much of our care can be evidence based. Knowledge of the evidence is one component of creating a culture change in the Neonatal Intensive Care Unit (NICU). Leaders need to create an environment to link practices and standards to quality improvement and research-based evidence. This facilitates a culture change from one of routine care to one where the spirit of inquiry is fostered. In order for change to be effective, leaders who teach it must “believe it and live it themselves”.1

To create a true change in our traditional practices, an administrative infrastructure must be provided to support the implementation, as well as compliance, of new practices. Resources must be accessible to staff to make evidence-based practice user-friendly. One way to accomplish this is to reference all policies and procedures and have them easily accessible by computer. A policy and procedure ICON that links directly to unit policies as well as educational resources facilitates this practice. In addition, all disciplines must be held accountable to the determined standards and performance indicators. Standards and expectations must be clearly defined and should be the product of a multidisciplinary approach, making implementation and compliance more uniform. To evaluate the effect of practice, particularly those practices supported by minimal evidence, it must be consistently applied. The following Neonatal Respiratory Management Policy is an example of a policy developed by a multidisciplinary team encompassing care related to the neonatal respiratory system and supported by the available evidence.

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Neonatal Respiratory Management 

Oxygen Administration 

A registered nurse (RN) may administer oxygen by face mask/oxyhood/ambubag to any infant in respiratory distress, while attempts are being made to notify physician/nurse practitioner (NP).

A.Place pulse oximeter on infant to better evaluate oxygen saturations. Advise physician/NP of your actions.

B.All oxygen must be administered via a heated humidifier system.

C.Document the concentration of oxygen from the analyzer and not blender. Refer to Table 1 for frequency of oxygen concentration and pulse oximeter documentation.
Table 1.
Support ModeFrequency of documentation (oxygen concentration and pulse oximetry)
Mechanical ventilationEvery 2 h
All other infantsEvery 2, 3, or 4 h with vital signs

D.The oxygen analyzer must be correctly calibrated before use. The procedure requires a two-point calibration: first to 21% and again to 100%.

Oxygen equipment 

A. Pulse oximeter
1. The site should be changed and documented every shift.
2. When using pulse oximeter, be careful not to impede circulation to an extremity, especially on small babies. Check distal extremity and area for discoloration and skin breakdown.
3. Oximeter alarm limits are set according to oxygen therapy guidelines (see Section III). High alarm limits may only be 101 if infant is on room air with no ventilator support or with physician/NP order.
4. If the infant has been stable on room air for at least 48 hours, ask for a discontinue order from physician/NP.
5. Discontinuation of pulse oximetry requires physician/NP order.
B. Head hood for environmental oxygen administration.
1. Head hood oxygen must be heated and humidified.
2. Thermometer in hood should read between 30°C and 31°C. Temperature can be adjusted as needed.
C. Incubator oxygen administration
1. Oxygen may be administered through an inlet on incubator if <30% oxygen is needed. A specific order for incubator oxygen is required.
2. Analyzer will be used. Addition of “sleeves” to port hole openings is necessary to maintain a consistent oxygen level.
D. Nasal cannula
1. Cannula oxygen delivery at less than 2 L per minute (lpm) is humidified and not heated.
2. Order must contain liter flow and concentration.
3. Check patency, placement, and liter flow every 2 hours. Document liter flow every 2 to 4 hours with vital signs and feedings.
4. Change cannula as needed.
5. Change water bottle as indicated by water mark on bottle.
E. High flow nasal cannula
High flow nasal cannula is humidified and heated oxygen at flow rates higher than 2 L per minute. The oxygen is delivered via a nasal cannula. The humidity and heat allow the infant to tolerate the higher flows.
1. Obtain a written order from physician/NP for the high flow nasal cannula and liter flow.
2. High flow nasal cannula oxygen must be heated and humidified. Consult neonatologist for settings above 4 LPM.
3. Document liter flow and oxygen concentration every 2 to 4 hours with vital signs and/or cares.
4. Change water for humidity as needed.
5. Change circuit and nasal cannula as needed.

Oxygen therapy 

A. Rationale: Oxygen is a drug, with potential toxicities. There is no evidence that oxygen saturations levels >94% offer benefit. Repeated episodes of alternating hypoxia/hyperoxia may pose risk to an immature vascular system.
B. Target oxygen saturations apply to all infants, regardless of oxygen delivery device. Target oxygen saturations and alarm limits are to begin at the time of birth and continue through to discharge.
1. Target oxygen saturation levels
a. Infants <34 weeks gestation at birth: 88% to 92%.
▪ Includes: Infants on nasal cannula, head hood, continuous positive airway pressure (CPAP), or mechanical ventilation.
▪ Excludes: Infants with evidence of clinically significant pulmonary hypertension.
b. Individual clinical scenarios may require modifications of these guidelines (ie, pulmonary hypertension).
2. Target oxygen saturations for infants >34 weeks will remain 90% to 98%
C. Alarm limits
1. Infants <34 weeks gestation at birth
a. Lower limit: 80% to 85%2
b. Upper limit: 95%
c. Upper alarm limit may be set to 100% when the infant is in room air.
d. Changes in these limits require a specific order.
2. Infants >34 weeks gestation at birth—alarm limits 85 to 98
D. Responses to low oxygen saturation alarms
Rapidity and sequence of responses should always be determined by the clinical status of the infant.2
1. Before Increasing oxygen
a. Determine whether an alarm is real, artifact of saturation monitor, or movement.
b. Assess equipment—is it functioning and positioned appropriately?
c. Assess infant: are secretions causing obstruction, head positioning, and irritation.
2. General guidelines for response to desaturations
a. When the pulse oximeter shows an alarm for low oxygen saturation, both the infant and the monitor will be evaluated before any changes are made in Fio2.
(i) Is the pulse wave appropriate?
(ii) Is there motion artifact?
(iii) How is the heart rate and respiratory effort?
(iv) How low is the saturation and for what period of time has it been below acceptable values?
b. Be cognizant of each baby's history of desaturations. Some infants are slower to recover than others. The primary nurse, resident, and NP can help identify the norm.
c. In most cases transient drops in saturations to 80% to 88% are acceptable, whether spontaneously, after weaning, or with care. Allow some time for recovery. Evidence of worsening distress or progressive desaturations would require more rapid intervention.
d. Consider developmentally appropriate interventions rather than increasing oxygen, if clinically appropriate.
e. Infants, who have wide swings in saturation values, even with small changes in oxygen, may benefit from resetting the target oxygen at a higher set point in an effort to avoid repetitive hyperoxic/hypoxic cycles. This requires discussion jointly between nursing, respiratory therapy and medicine. If different from that described in this policy, specific orders are to be written identifying target oxygen and alarm limits.
E. Increasing oxygen for infants on CPAP or mechanical ventilation
1. Before increasing oxygen
a. Oxygen may be increased in increments of 2% to 5% if the oxygen saturation remains lower than the acceptable/target range. If clinically appropriate, wait at least 10 minutes to allow recovery time before additional increase2.
b. A physician/NP must always be notified when it is necessary to increase the oxygen >10% from baseline. This does not include the need to increase oxygen back to baseline after weaning.2
c. In some circumstances increasing ventilator parameters other than oxygen (eg, rate—either manually or on the ventilator) may be appropriate.
d. Avoid the use of “100% oxygen breaths” from the ventilator unless desaturation is persistent and/or severe (<70%).
2. For infants on nasal cannula
a. Clinical judgment is required regarding rapidity with which flow and/or oxygen is increased.
b. What constitutes a significant increase will vary depending on flow rates, baseline oxygen needs and clinical status of the infant.
F. Weaning oxygen for infants on CPAP or mechanical ventilation
1. The objective in weaning is to keep saturations in target oxygen, but avoid cycles of hyperoxia/hypoxia
a. Oxygen may be decreased in increments of 2% to 5%.
b. Wean for oxygen saturations >92% to 93%.
c. Weaning may be done rapidly but with enough time to stabilize and prevent hyperoxic/hypoxic cycles.

Guideline for Use of Neopuff® Infant Resuscitator 

The Neopuff® may be used to provide positive pressure breathing to infants. It may also be used to provide CPAP and oxygen as a continuous flow system. The entire system is to be assessed and documented every shift and prior to use (Fig. 1).

A.Obtain infant resuscitator, patient and gas supply line, and appropriate size facemask.

B.Check equipment by occluding patient valve and verifying positive inspiratory pressure is 20 and positive end expiratory pressure is 5.

C.Gently inflate chest with Neopuff® to assure good chest movement and observe manometer pressure readings. Use minimum pressure necessary to inflate chest. In general, infants require rates of 40 to 60 to maintain ventilation if no spontaneous breathing is present3.

D.Listen for breath sounds and assess chest wall movement, assure adequate heart rate, color. Increasing heart rate is the first sign of successful ventilation3.

E.Infants should be ventilated with a minimal amount of oxygen necessary to maintain pink color and/or adequate saturations (according to gestational age as outlined above) or until good spontaneous respirations are established.

F.Report to physician/NP and document any use of Neopuff®.

Guidelines for Use of Anesthesia Bag 

The anesthesia bag system may be used to provide positive pressure breathing to infants. It may also be used to provide CPAP and oxygen as a continuous flow system. The entire system is to be assessed and documented every shift and prior to use (Fig. 2).

A. Use as an intermittent positive pressure breathing system:
1. Obtain reservoir bag, pressure valve, green oxygen tubing, manometer and manometer tubing, appropriate face mask.
2. Assemble as in Fig. 2.
3. Inflate bag by occluding opening and check pressure valve. A few rapid pumps on the reservoir bag will allow a manometer reading of inflation pressure prior to attaching to the baby. Use minimum pressure necessary to inflate chest. In general, infants require rates of 40 to 60 to maintain ventilation if no spontaneous breathing is present.3
4. Listen for breath sounds and assess chest wall movement, assure adequate heart rate, color. Increasing heart rate is the first sign of successful ventilation.3
5. Infants should be ventilated with a minimal amount of oxygen necessary to maintain pink color and/or adequate saturations (according to gestational age as outlined above) or until adequate spontaneous respirations are established.
6. Report to physician/NP and document any use of anesthesia bag.

Assisted Ventilation and Intubation 

Intubation may be performed by physician/resident/NP, certified respiratory therapist or certified RN. Notify the RCP or resuscitation team when intubation is anticipated or initiated.

A. Prepare the infant in radiant warmer or incubator, by positioning and monitoring heart rate before, during and after procedure.
B. Have available at least two oxygen outlets, one air outlet and wall suction, with one sterile suction tubing and one regular suction tubing.
C. Obtain the following equipment: laryngoscope with adequate light, 2 appropriately sized sterile endotracheal tubes and one of the next smaller and next larger sizes, prepared tape, and a stylet for endotracheal tube. Have mask of appropriate size and a Neopuff® or anesthesia bag. Test system as described above.
D. Have available sterile suction equipment, consisting of sterile suction tubing, one sterile bottle of water, one whistle tip suction catheter and glove set. Also have available regular oral suction.
E. Connect the Neopuff® or anesthesia bag to first oxygen line. Be present at all times to assist. Monitor oxygen saturation and heart rate during procedure.
F. After three unsuccessful attempts to intubate, a second qualified individual should attempt to intubate. Attempts should be limited to 20 seconds each.3
G. Once intubation is accomplished, auscultate the chest to determine equality of breath sounds, auscultate the epigastrium to rule out esophageal intubation. Monitor heart rate. Confirm intubation by placing carbon dioxide detector on endotracheal tube. Watch for color change.3
H. Secure the endotracheal tube.
I. These procedures are carried out while a second person ventilates the infant with the Neopuff®/Anesthesia bag.
a. Trim off tube about 4 cm from infant's lip using sterile scissors.
b. Connect the endotracheal tube to the ventilator.
c. Suction the infant as soon as needed.
d. Endotracheal tube placement is determined by chest x-ray ordered STAT to confirm placement.
J. Note measurement of tube on Nursing Flow Sheet along with size of endotracheal tube, date, time. Also record this information on suctioning card and place on the side of ventilator.
K. Bedside emergency equipment is to include an appropriate-sized mask, anesthesia bag and mechanical suction.
L. Avoid opening the ventilator circuit with repositioning; use the swivel device instead. Remove any condensation in the ventilator circuit prior to repositioning.
M. Avoid placing any positioning aids on ventilator tubing to prevent condensation in the tubing.
N. Humidification at 100% and heating at 32° to 34° of the oxygen should be maintained to prevent drying of secretions or damage to airway.4

Changing Nasopharyngeal CPAP Tubes 

A. Responsibility: RN, RCP, physician/NP
B. CPAP is a treatment used for several disease processes that compromise the respiratory status of the neonate. The application of CPAP improves oxygenation by increasing the functional residual capacity. Previously collapsed alveoli are opened producing an increased surface area for gas exchange and a decrease in intrapulmonic shunting.
C. Indications:
1. Nasopharyngeal CPAP tubes should be changed every 24 hours and whenever it is suspected that the tube is plugged.
2. A plugged tube should be suspected and the tube changed when any of the below occur:
a. Deterioration of the infant's clinical status (tachypnea, tachycardia, cyanosis, deep retractions).
b. Deterioration of the infant's blood gases, especially increasing partial pressure of carbon dioxide (Pco2).
c. Decreased or absent chest movement.
d. Decreased or absent breath sounds.
e. Passage of a suction catheter is difficult or impossible.
f. There is no fluctuation of the pressure manometer during respiration. (Watching the manometer in this case is the best indicator as small pressure fluctuations may not be detected otherwise).
3. The initial setup of nasopharyngeal CPAP is done only with a physician/NP order.
D. Equipment:
1. Appropriate size endotracheal tube (soft tube preferred)
2. Sterile lubricant
3. 1/2 in adhesive tape
4. Scissors
5. Appropriate size suction catheter kit
6. Laryngoscope with appropriate size blade
7. Gloves
E. Procedure
1. Assure that ventilator is set up.
2. Collect necessary equipment and place at bedside.
3. Two persons should be available at the bedside for assistance.
4. Wash hands. Wear gloves during the procedure.
5. If initial placement of nasopharyngeal tube, measure and document position. Feel along posterior palate just to feel the end of the endotracheal tube in the back of the throat. If this is a subsequent tube change, check nursing notes or Infant Vent and Oxygen Record Sheet for previous tube placement.
6. Place infant in the supine position. A second person may be needed to position infant.
7. If changing tube, gently remove old tape and pull tube. CPAP should be maintained by using Neopuff®/Anesthesia bag during the interim. A pulse oximeter should be used during tube changes to ensure adequate oxygenation.
8. Suction both mouth and nares.
9. Lubricate the last centimeter of the outside of the tube. Insert the tube 2 to 3 cm into selected nare at a 90° angle to infant's face. When inserting the tube, point the open end of the bevel toward top of the patient's head. This will aid the tube in making the bend in the nasopharynx. The tube should pass with little resistance.
10. Check placement of tube by placing your gloved index finger into infant's mouth to palpate tip of the tube. Tube should terminate in the pharynx, above the epiglottis, below the palate uvula. When taping in place, be sure blue line on nasopharyngeal tube is toward left shoulder. This will ensure that the bevel is up at the tip of the tube. If the tube bevel is directed toward the posterior hypopharynx, it may abut the hypopharyngeal wall thus occluding the tube.
11. Placement of the tube may also be confirmed with laryngoscope if palpation is not conclusive.
12. The laryngoscope handle is held in the left hand and the blade is inserted into the mouth, following the natural contour of the pharynx along the right side of the tongue. Visualization of the tip of the tube should occur, confirming placement.
13. Hold the tube in place, noting the centimeter marking at the nasal opening and secure tube with tape.
a. Assessment and/or changing of the orogastric tube should follow the placement of the CPAP tube to ensure proper placement.
b. Document the procedure to include:
• Time of change
• Purpose of change
• Infant's tolerance of procedure
• Marking of tube placement
• Assessment following tube change
• Method of verifying tube placement (chest x-ray is not required)
c. Nasopharyngeal tubes should be suctioned as needed to prevent plugging and assess tube patency.

CPAP Applied Via Nasal Prongs or Mask 


A.Responsibility: RN, RCP, physician/NP

B.Select prong or mask size appropriate for infant. Ensure the fit is snug but not tight or creating pressure on the bridge of the nose or nasal septum. Be aware that the larger sized masks are flatter and the tips of noses may become a pressure area.

C.Hydrocolloid protectant can be cut and placed to prevent breakdown on the bridge of the nose and/or septum.

D.Avoid the use of developmental positioning aids that may pull on the CPAP tubing.

E.Assess at least every 4 hours with particular focus on the septum and bridge of the nose for discoloration or skin breakdown, including whitening at the bridge of the nose (mask) or nasal septum (prongs) due to pressure and tightening. Coordinate assessment with other disciplines.

F.Change from prongs to mask or mask to prongs as needed to promote skin integrity.

G.Communicate between RCP and RN any changes in assessment or method of delivery.

H.Document the method of CPAP delivery on the flow sheet.

Endotracheal Suctioning 

Purpose: To maintain airway patency in an intubated patient by removing secretions, while maintaining optimal ventilation/oxygenation status.

There are two methods of suctioning intubated infants—open and closed suctioning. Suctioning should always be a two-person procedure. If open suctioning, the second person provides ventilation while the first suctions. If closed suctioning is used, a second person should be readily available in case the infant needs additional support. Closed suctioning is preferred as opening the ventilator circuit may result in increased risk of contamination and when on HFV, alveolar recruitment is lost when the circuit is opened.5

A. Equipment:
i. Suction catheter
1. size 5/6F for endotracheal tubes less than or equal to 3.0
2. size 8F for endotracheal tubes greater than or equal to 3.5
a. Appropriate sized suction catheters decreases the risk of hypoxemia and atelectasis caused by alveolar collapse related to negative airway pressure6
ii. Sterile gloves when open suction is used
iii. Sterile water
iv. Sterile normal saline
v. Wall suction set at a pressure of 806
vi. Suction container and tubing
vii. Neopuff® or anesthesia bag and oxygen source
viii. Nasal/oral suction device
B. Procedure
i. Individualize the frequency of suctioning based on the infant's need and diagnosis. Assessment of need for suctioning should occur with vital signs or at least every 4 hours. This assessment includes: breath sounds, color, activity level and vital signs. If hypoxia, sudden deterioration, decreased breath sounds or acute hypercarbia occurs, suctioning should be performed to rule out increased secretions and/or plug.
ii. Equipment check: All equipment to be used during procedure should be checked prior to proceeding. Sterile water is to be available to flush the catheter after suctioning or normal saline bullet to flush in-line suction catheter. Have a nasal suction device available for naso- and oropharynx suctioning.
iii. Oximeter should be in place and monitored to determine the infant's response to suctioning and the need for increased oxygen or ventilator support.
iv. Breath sounds are to be evaluated and documented before and after suctioning.
v. Suction catheters are not to be passed beyond the tip of the endotracheal tube (measured suctioning).6 This measurement should be the length of the endotracheal tube plus the length of the adapter (usually 3 to 4.5 cm). For in-line suction, follow manufacturer's recommendation for length to be added for adapter as this will vary with type of in-line suction.
vi. Open suction catheter, have sterile water available to rinse catheter. Apply gloves, maintaining sterility of glove handling catheter.
vii. DO NOT use irrigants for suctioning routinely. If clinical judgment indicates a need for normal saline, administer normal saline from bullet by direct instillation and just prior to passing suction catheter.
1. Saline used should be warmed to the temperature of the infant's environment before use.
2. 3 to 5 drops of saline only should be administered, as indicated by assessment
3. Care should be taken to prevent contamination of the saline solution.
4. When using saline with an inline system, instill into the side port.
viii Gently insert suction catheter into endotracheal tube to premeasured point to avoid deep suctioning. Protect the integrity of the carina and mucosal tissue.
ix. No suction is to be applied during insertion. Apply suction while withdrawing catheter from endotracheal tube.
1. Watch the infant's response including heart rate and pulse oximeter to determine tolerance of the procedure.
2. Repeat suction passes as necessary to clear the secretions
3. Allow infant to fully recover between catheter passes (oxygen saturation, color and heart rate).
4. There is no need to rotate the infant's head during suctioning as the catheter is not being advanced beyond the end of the endotracheal tube. Secretions are being removed from the tube itself, not from the lung.
x. Be certain the suction control is kept in the locked position (for closed suction) between uses to prevent inadvertent suction application.
xi. When suctioning is complete, discard suction catheter (used for open suctioning). Inline suction catheters are changed as needed. Containers for sterile water used for rinsing the suction catheter should be discarded after use.
xii. Use nasal/oral suction device to suction back of throat, mouth and nasopharynx.
xiii. Provide oral care using a 2 x 2 sterile gauze and sterile water every 3 to 4 hours. Wipe gums and tongue as well as lips.
xiv. Documentation: Document type, amount and color of secretions. Also note patient's tolerance to the procedure, and change in breath sounds as a result of this procedure.

Protocol for Surfactant Administration 

A. Background/Indication: Surfactant replacement with exogenous synthetic or animal surfactant has been extensively studied and proven to be effective for treating respiratory distress syndrome/surfactant deficiency. It clearly reduces the severity of disease and short-term need for ventilatory support in most infants. While surfactant replacement can definitely improve pulmonary function and reduce the need for both positive pressure and oxygen, there are side effects associated with this use. Therefore, selection of appropriate patients for surfactant administration is essential to minimize the risk benefit ratio.
B. A physician/NP order is required.
C. Dosing:
a. Surfactant will be dosed according to manufacturer's recommendation.
D. Administration
a. May be administered by physician, NP, RCP. RN to remain at bedside and assist/monitor during administration.
b. Suction endotracheal tube immediately before instillation of surfactant and not for at least 2 hours following administration. (Refer to manufacturer's recommendations for length of time before suctioning. Generally, the longer one can wait before suctioning, the better. This allows more time for distribution of the surfactant).
c. Ensure adequate oxygenation during administration with oxygen and rate as clinically indicated.
E. Post Administration Management: Monitor infant carefully for changing respiratory support needs. Position infant so chest expansion can be observed.
a. Wean oxygen as quickly as necessary to maintain saturation 88% to 92%
b. Wean positive inspiratory pressure as quickly as possible.
c. Document indications for administration, dose administered, how patient tolerated dosing, response, and any adverse effects.

Guidelines for Using High-Frequency Ventilation (HFV) 

A. High Frequency ventilation is a rapid rate, low tidal volume ventilation. HFV can be used as a “rescue” or “primary” mode of ventilation. Reasons for using HFV include:
1. Reduce ventilator associated lung injury
2. To prevent/treat pneumothoraces and interstitial emphysema
3. To reduce the incidence of bronchopulmonary dysplasia
4. In infants when adequate pulmonary gas exchange cannot be achieved by conventional ventilation.
B. When initiating HFV
1. Establish a continuous measurement of the infant's oxygenation.
2. Establish continuous monitoring of the arterial blood pressure when possible; otherwise monitor noninvasive blood pressure at least every 2 hours.
C. Assessment
1. Chest auscultation for breath or heart sounds is virtually impossible in the HFV mode. The infant may need to be disconnected from the ventilator and ventilated for a short period using Neopuff®/anesthesia bag in order to assess breath/heart sounds. This will require 2 staff at bedside to accomplish and should be coordinated with Respiratory, Nursing and Medicine. Keep in mind that disconnection from HFV will allow alveoli to collapse, possibly requiring a prolonged recovery period once reconnected. Disconnection from HFV should be kept to a minimum.
2. Chest x-rays can be performed during HFV. Chest x-rays are obtained following the initiation of HFV to determine the degree of lung inflation and periodically as needed.
3. Check for good chest vibration. Inadequate vibration may be due to inappropriate ventilator settings, obstructed endotracheal tube, or change in pulmonary dynamics (eg, pneumothorax).
D. Blood gas interpretation
1. Pco2
a. Change amplitude (start a minimum setting and increase until the chest seems to be vibrating) watch transcutaneous carbon dioxide, if available, for trend and get blood gas, if possible, within 5 minutes to see if Pco2 warrants an increase or decrease in amplitude.
b. Hertz may also be decreased to less than 12 to 15 for improved ventilation.
2. Po2 (partial pressure of oxygen)
a. Adjust oxygen level
b. Change mean airway pressure (obtain blood gases with changes; be careful of air trapping, check chest x-ray and observe thorax for signs of hyperinflation).
E. Troubleshooting blood gas changes
1. Rapid increase in Pco2
a. Tension pneumothorax
b. Obstruction of endotracheal tube with change in distal amplitude and reduction in the amount of chest vibration
c. Endotracheal tube placement (too far down or leak with change in head positioning)
2. Gradual increase Pco2
a. Pulmonary interstitial edema development
b. Atelectasis
c. Patent ductus arteriosus
d. Amplitude drift, change in amplitude secondary to change in compliance
e. Change in patient sedation, agitation
3. Rapid decrease Po2
a. Tension pneumothorax
b. Precipitous drop in blood pressure, due to decreased cardiac output
c. Obstruction of endotracheal tube (can be seen with change in distal amplitude and reduction in chest vibration)
d. Endotracheal tube placement (too far down or leak with change in head positioning)
4. Gradual decrease Po2
a. Pulmonary interstitial edema development
b. Microatelectasis
c. Patent ductus arteriosus
d. Change metabolic rate, eg, hyperthermia
e. Subtle change in blood pressure, due to decreased pulmonary venous return; infant may require more fluids
f. Change in patient sedation, agitation

Inhaled Nitric Oxide (iNO) Administration 

A. Purpose:
Nitric oxide has been shown to relax and dilate constricted pulmonary blood vessels as the nitric oxide passes from the alveoli toward the blood stream. The improved dilation of these blood vessels allows more oxygen to pass into the blood stream to be carried through out the body.
B. Indications:
1. Mechanically ventilated term or near-term infants, >34 weeks, with hypoxic respiratory failure in spite of optimal medical management.
2. Mechanically ventilated preterm infants should only be treated with NO under research protocol.
C. Contraindications:
1. Infants with congenital heart disease as the reason for hypoxemia
2. Infants with congenital methemoglobinemia (level >5%)
D. Equipment:
1. iNOVent® with injector module and sample line
2. 800 ppm nitric oxide cylinder
3. Calibration gases for NO and nitrogen dioxide (NO2)
4. Oxygen flowmeter
E. Procedure:
Guidelines for Use of Inhaled Nitric Oxide (iNO) In the NICU (Term and Near Term—>34 Weeks Gestation):
1. iNO treatment should be instituted in conjunction with other treatments designed to first optimize cardiac and pulmonary function. These may include:
a. Surfactant administration
b. High frequency ventilation
c. Fluid resuscitation
d. Inotropic agents for cardiac support
e. Sedation
2. Term and near term infants without an immediate response to iNO should be promptly transferred to a center capable of providing extracorporeal membrane oxygenation support.
F. Medical management protocol:
1. The RCP will begin screening oxygenation indices when the following clinical scenario presents as a potential need for iNO:
a. Suspected persistent pulmonary hypertension. Verify with echocardiogram if possible.
b. Mechanical ventilation with an oxygen requirement >60% after surfactant administration and/or other optimized medical support.
2. Prior to initiating iNO:
a. Obtain a methemoglobin level
b. Establish an arterial line if possible.
3. Dosing (The responses identified below are meant to be guidelines and each dosing change is to be discussed with the physician or designee):
a. Term Infants
▪ Start iNO at 20 parts per million (ppm). Do not change ventilator settings until first arterial blood gas is drawn.
▪ Obtain arterial blood gas 30 minutes after initiation.
▪ If there is a greater than 10 mm Hg increase in Po2, keep at 20 ppm.
▪ Infants who do not have a significant Po2 increase at 20 ppm are unlikely to respond and transfer to a center capable of providing extracorporeal membrane oxygenation treatment or discontinuation of iNO should be considered.7
4. Weaning:
a. After a positive response to iNO with oxygenation stable at 94% to 95% or Po2 80 to 100 mm Hg, begin to wean oxygen slowly to 60%.
b. After oxygen is 60% begin weaning iNO by 5 ppm until 10 ppm plateau is reached.
c. Then wean oxygen to 45%
d. Next, wean iNO to 5 ppm
e. After the 5 ppm plateau has been reached and oxygen is less than 45%, wean iNO by 1 ppm slowly every 1 to 4 hours until the 1 ppm plateau is reached.
5. Discontinuation of iNO:
a. If the oxygen is at less than 45% and the Po2 is greater than 60 mm Hg, physician to consider discontinuing iNO.
b. Consider restarting iNO if a rebound effect occurs requiring a prolonged need for increased oxygen levels.
c. Investigate other causes of persistent pulmonary hypertension if iNO therapy is required for longer than 5 days.
6. Monitoring:
a. Obtain methemoglobin levels within 3 hours of reaching maximum initial dose, then every 12 hours for 48 hours, followed by every 24-hour levels.
▪ If the methemoglobin level is 5% to 10% and the dose of iNO is >5 ppm, wean iNO by 50% every hour and repeat methemoglobin levels until level is <5%.
▪ If the methemoglobin level is 5% to 10% and the dose of iNO is <5 ppm, wean iNO by 1 ppm ever hour and repeat methemoglobin levels until level is <5%.
▪ If the methemoglobin level >10%, discontinue iNO.
b. Monitor NO2 levels continuously.
▪ If the NO2 levels are 3 to 5 ppm and the dose of iNO is >5 ppm, wean iNO by 50% every 15 minutes until NO2 is <3 ppm.
▪ If the NO2 levels are 3 to 5 ppm and the dose of iNO is <5 ppm, wean iNO by 1 ppm every 15 minutes until NO2 is <3 ppm.
▪ If NO2 >5 ppm, discontinue iNO.

NOTE: Notify physician immediately of high levels of methemoglobin or NO2.

Areas Primarily Affected: NICU/SCN

Implemented:

Reviewed/Revised:

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References 

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PII: S1527-3369(06)00048-1

doi:10.1053/j.nainr.2006.04.001

Newborn and Infant Nursing Reviews
Volume 6, Issue 2 , Pages 43-51, June 2006

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