Neonatal Medicine: CPAP and Ventilation in Neonatal Respiratory Distress

You ar reviewing Nathan, a 12 hour old neonate with respiratory straiten. He is 37 weeks maternal quality and was born by caes atomic number 18an section following failure to progress. The oxygen saturation is 94% in 50% FiO2, the respiratory rate is 80. There is keep intercostal recession and an occasional grunt. Your hospital participated in the bubbles for babies trial and you have just started to use CPAP in your unit now the trial is finished. Your registrar suggests victimisation CPAP on this neonate, but the nursing staff have called you to arrange transfer.QuestionsWould you use CPAP or ventilate and transfer this neonate?Please give reasons for your choice with fiber to the current literature.In your answer you should also consider the following main points the benefits of CPAP over ventilation, particularly with reference to your current practice environment the potential complications of CPAP reasons why ventilation may be required even though CPAP is in situ.The bab y Nathan is suffering from Neonatal respiratory distress syndrome, which is a tally virtually lots seen in newborn babies and is characterized by a difficulty in subsisting. The condition more frequently develops in prematurely born babies as their lungs atomic number 18 not fully create. The lubricant that lines the inner membranes of the lungs (known as wetting agent) is deficient, thus causing difficulty in inflating the lungs and resulting in the song sacs collapsing.Surfactant helps to lower the dig up tension of water that is present on the alveoli, thus helping to prevent the lung sacs from collapsing. Usually, the condition develops in infants born before the 38 week. The baby is cyanosed and has difficulty in breathing. The accessory muscles of respiration are active and a frequent grunting sound is heard. The other symptoms that may be observed include nasal flaring, shallow breathing, futile legs, unusual movement of the chest wall, etc.The infant may be hypoxic and the CO2 levels in the melodic line rise. The symptoms usually develop at birth, or a little while after birth. The symptoms tend to worsen and may progress to respiratory failure and death. As the prematurity increases, so does the chance of developing this condition. This is because surfactant is produced only during the later stages of gestation in the infant. The diagnosis of RDS in babies is made based on the history, presence of certain risk factors, Chest X-ray, Blood tests, CSF studies, lung tests, blood gas analysis, etc (Greene, 2007 & Merck, 2005).When a neonatal is born, certain signs are observed which include-a heart rate between 110 to 150 beats per split seconda respiratory rate between 40 to 70 breathes per minuteabsence of cyanosis, nasal flaring, grunting sounds, forceful use of accessory muscles during respiration, etcOxygen saturation which is roughly 95 %the P ao2 is higher than 50 %the FiO2 is about 40 to 50 % (CCM, 2007, NGC, 2008, & Millar et al, 2004 )Previously, for the treatment of RDS, ventilatory support was utilized. This may be utilized if the blood hundred dioxide levels are high, the blood oxygen levels are low, and if acidosis sets in. To some extent ventilation helps to reduce the infant mortality rate arising from RDS, but the morbidity to develop Bronchopulmonary dysplasia (a condition characterized by oedema of the air sacs and of the connective tissues due to persistent inflammation) is high as the young neonatal lungs are damaged from ventilation.One of the treatments that have been developed in order to overcome the limitations of ventilation is Continuous Positive Airway Pressure (CPAP). This is an advanced form of therapy in which the upper and the lower airways receive a continuous distending pressure through the infants pharynx and/or nose throughout the respiratory cycle. An endotracheal tube can also be utilized. The artifice is connected to a gas source that provides humidified warm air continuously (NGC , 2008, Millar et al, 2004, Tidy, 2007).CPAP has several benefits including-helps to maintain a common breathing pattern helps to arrive at normal functional residual capacity helps to lower any airway resistance in the upper respiratory tract helps to prevent development of apnea prevents the airways and the air sacs from collapsing helps stimulate release of surfactant helps to increase the lung volume and lung function After expiration, CPAP helps to keep the air sacs open The chances of developing lung trauma such as barotrauma and atelectotrauma are lesser (CCM, 2007, Sehgal, 2003, NGC, 2008, Millar et al, 2004). CPAP is required in several situations that arise from RDS including-When it is difficult to maintain the Pa02 above 50 %.When the respiratory rate is above 70 breathes per minute unwarranted use of the accessory muscles of respirationThe oxygen saturation falls to between 90 to 95 %The presence of apneaIt can be utilized along with system of surfactant that develops out of the need to treat RDS (CCM, 2007, Sehgal, 2003, NGC, 2008, Millar et al, 2004).As the patient is not suffering from a severe form of RDS and the oxygen saturation levels have not dropped to a serious extent, ventilatory support is not required, and the patient can be treated with CPAP. Besides, the findings do not suggest that the patient is suffering from a cardiovascular complication, an upper respiratory tract abnormality or intractable apneic episodes. Along with CPAP, several other measures are required such as using larger nasal prongs, ensuring that the baby is in a prone position and keeping a towel below the neck. This helps to ensure that the certain areas are aerated better (CCM, 2007, Sehgal, 2003, NGC, 2008, Millar et al, 2004).CPAP has several complications including-mucous from the upper respiratory tract may block the nasopharyngeal tube that delivers CPAP Sometimes blockages may result in the pressure rising to higher levels in the tube If the peak pressure is very high, then gastric complications can develop The nasopharyngeal tube has to be placed in exact position. Any deviation from the position can result in fluctuation of the air pressure The nasal devices may be swallowed or aspirated resulting in severe complications Sometimes harnesses may be utilized to place the head and the neck in position. This may cause serious dermatologic and musculoskeletal complications in the infant Air leakage problems in the lungs Abdominal distention Decrease in the cardiac output Higher working of breathing pneumothoraces and air embolism can also develop Cardiac monitoring needs to be performed more closely in the case of CPAP compared to ventilation often air leaks from the nose and the mouth it may be very difficult to control the air pressure in the lower airways If CPAP is applied to an infant with normal lungs, several problems can develop Several respiratory complications such as pneumothorax, pneumomediastinum, and pneumopericardium can develop (CCM, 2007, Sehgal, 2003, NGC, 2008, Millar et al, 2004, Halamek et al, 2006) ReferencesCalifornia College of Midwives (20080, Guidelines for Assessing the Neonate, Online, Available http//www.collegeofmidwives.org/Standards_2004/Standards_MBC_SB1950/Assess_HealthyNeonate_Oct2004_OOO.htm Retrieved on 2008, April 2.Greene, A. (2007), Neonatal respiratory distress syndrome, Online, Available http//www.nlm.nih.gov/medlineplus/ency/article/001563.htm Retrieved on 2008, April 2.Halamek, L. P. Et al (2006), Continuous Positive Airway Pressure During Neonatal Resuscitation, Clin Perinatol, 33, pp. 83-98. http//www.mdconsult.com/das/article/body/91421747-3/jorg=journal&source=MI&sp=16080552&sid=690389052/N/525142/s0095510805001235.pdf?issn=0095-5108Millar, D., & Kirpalani, H. (2004), Benefits of Non Invasive Ventilation, Indian Pediatrics, 41, pp. 1008-1017. http//www.indianpediatrics.net/oct2004/oct-1008-1017.htmNGC (2008), Complete Summary, Online, Available http//www.guideline.g ov/summary/summary.aspx?ss=15&doc_id=6516&nbr=4085, Retrieved on 2008, April 2.Sehgal A. Et al (2003), Improving Oxygenation in Preterm Neonates with Respiratory Distress, Online, Available http//www.indianpediatrics.net/dec2003/1210.pdf, Retrieved on 2008, April 2.The Merck manual (2005). Respiratory Distress Syndrome, Online, Available http//www.merck.com/mmpe/sec19/ch277/ch277h.html, Retrieved on 2008, April 2.Tidy, C. (2006), Infant Respiratory Distress Syndrome (RDS), Online, Available http//www.patient.co.uk/showdoc/40000462/, Retrieved on 2008, April 2.