Respiratory System Disorders Care Guide

Indications for Mechanical Ventilation in Neonates

• Severe respiratory dysfunction:
• Partial pressure of arterial oxygen (PaO₂) < 50 mmHg despite oxygen therapy at 80–100%.
• Partial pressure of arterial carbon dioxide (PaCO₂) > 60–65 mmHg.
• Arterial pH < 7.35 (acidosis).
• Severe respiratory distress:
• Chest retractions and signs of impending respiratory failure, as assessed by the physician.
• Apnea:
• Prolonged apnea or increasing frequency of apnea episodes.

Mechanical Ventilation Systems

Nurse’s Role in Mechanical Ventilation

1. Monitoring and Recording Ventilator Settings and Readings

2Assisting with Endotracheal Tube (ET Tube) Insertion – Nursing Role

The nurse plays a crucial role in assisting the physician during endotracheal intubation and monitoring the tube after placement. This includes knowing how to select the appropriate tube size, determining the insertion depth, and ensuring proper care.

Nurse’s Responsibilities Before ET Tube Insertion

1. Determining the Appropriate ET Tube Size:

• The tube size is selected based on the neonate’s birth weight and gestational age.

2Preparation of Equipment for Endotracheal Tube (ET Tube) Insertion

1. Required Equipment:

• Laryngoscope – fully functional, with extra battery available.
• Laryngoscope blades – straight and curved, sizes 0 and 1.
• Endotracheal tubes – sizes 2.5, 3.0, 3.5, and 4.0 mm.
• Suction device.
• Suction catheters – sizes 5, 6, 8, 10 Fr.
• Adhesive tape (plaster).
• Scissors.
• Stethoscope.
• Resuscitation bag (Ambu bag) with appropriate mask.
• Oxygen source.

2. Types of Resuscitation Bags (Ambu Bags) and Masks for Neonates:

General Characteristics:

• Bag volume: 200–750 mL.
• Oxygen delivery capability: 90%–100%.
• Equipped with a pressure relief mechanism to prevent overinflation.
• Mask: appropriately sized, cushioned, and suitable for the neonate’s birth weight and gestational age.

• Oral Intubation:

Appropriate Depth (cm)=6+Infant’s weight (kg)\text{Appropriate Depth (cm)} = 6 + \text{Infant's weight (kg)}Appropriate Depth (cm)=6+Infant’s weight (kg)

• Nasal Intubation:

Appropriate Depth (cm)=8+Infant’s weight (kg)\text{Appropriate Depth (cm)} = 8 + \text{Infant's weight (kg)}Appropriate Depth (cm)=8+Infant’s weight (kg)

Nurse’s Role During Endotracheal Tube Placement

1. Positioning the Infant:
• Place the infant on their back (sniffing position).
• Place a folded towel under the shoulders and slightly extend the neck to open the airway.
2. Suctioning:
• Suction the mouth and nose to remove accumulated mucus, ensuring clear visualization for tube insertion.
3. Monitoring Vital Signs:
• Observe and document:
• Skin color
• Respiratory rate
• Oxygen saturation (SpO₂)
• Heart rate
4. Preparing the Resuscitation Bag (Ambu Bag):
• Connect to an oxygen source.
• Place an appropriately sized mask over the infant’s chin, mouth, and nose.
• Secure the mask:
• Thumb and index finger on the mask
• Middle finger supporting the lower jaw
• Slightly extend the chin to maintain airway patency
5. Bag Ventilation:
• Hold the Ambu bag with the right hand.
• Squeeze using thumb, index, and middle fingers at a rate of 60 breaths per minute.
• Adjust the squeeze force according to the infant’s size and condition.
6. Chest Movement Observation:
• Ensure adequate chest rise with each ventilation and adjust squeeze force as needed.
7. Intubation Timing:
• Insert the endotracheal tube once the infant’s color improves and SpO₂ stabilizes.

• Bag Ventilation:
• Use the Ambu bag to provide approximately 60 breaths per minute.
• Adjust the squeeze strength to achieve adequate chest rise.

Steps for Endotracheal Tube Insertion

1. Open the laryngoscope and hand it to the physician.
2. Slightly extend the infant’s neck to open the airway.
3. Hand the endotracheal tube to the physician.
4. If needed, gently apply pressure on the larynx to facilitate tube passage.
5. Be prepared to suction if secretions obstruct the view.
6. Time the intubation attempt carefully to minimize apnea duration.

Nurse’s Role After Tube Placement

1. Connect the Ambu bag to the endotracheal tube and provide manual ventilation.
2. Listen for bilateral breath sounds to confirm proper placement.
3. Insert a nasogastric (Ryle) tube and decompress the stomach.
4. Continuously monitor vital signs and SpO₂.
5. Secure the tube at the calculated insertion depth.
6. Prepare and connect the mechanical ventilator, verifying all settings with the physician.
7.  Airway Suctioning: Remove mucus secretions to prevent airway obstruction and ensure effective mechanical ventilation.
8. Chest X-ray:Perform radiographic imaging as per physician’s instructions to confirm tube placement and assess lung condition.
9. Documentation in the Infant’s Record:

• Time of endotracheal tube insertion and the size used.
• Method of insertion (oral or nasal).
• Depth of tube placement in centimeters.
• Observations during insertion, including any medications administered.
• Signs of the infant’s response to mechanical ventilation, such as skin color, respiratory rate, and chest movement.

Complications of Endotracheal Tube Insertion and Prevention Strategies

Routine Nursing Care for a Neonate on Mechanical Ventilation

1. Ventilator Monitoring:

• Verify that the ventilator settings match the orders recorded in the infant’s chart.
• Check that all connections are secure.
• Ensure tubing is free from condensed water; drain if necessary.
• Respond promptly to ventilator alarms and notify the physician immediately.

Types of Ventilator Alarms and Actions:

1. Arterial Blood Gas (ABG) Sampling

Neonates on mechanical ventilation require continuous monitoring of their overall condition and respiratory function. This is achieved by analyzing arterial blood gases (ABG), which provide information about:

• Oxygenation status (PaO₂)
• Carbon dioxide levels (PaCO₂)
• Acid-base balance (pH)

These results are compared with normal reference values to guide adjustments in ventilator settings according to the neonate’s needs.

Normal Blood Gas Values in Neonates

Blood Gas Sampling in Neonates on Mechanical Ventilation

• Timing of Sampling:
• A blood gas sample should be obtained and analyzed within 10–15 minutes of starting mechanical ventilation.
• Routine blood gas analysis is performed every 6 hours or as per physician instructions, unless there is a sudden change in the neonate’s condition.
• Blood gas should be analyzed every 10–15 minutes whenever ventilator settings or positions are adjusted.

Method for Obtaining a Blood Gas Sample from the Heel

Heel sampling can be used as an alternative to arterial blood gas. The following precautions must be observed to ensure accurate results:

1. Warm the Site: Wrap a cotton pad soaked in warm water (~42°C) around the heel for 5 minutes before sampling.
2. Avoid Over-Milking: Do not excessively squeeze the heel to prevent contamination of the sample.
3. Disinfect: Clean the sampling site with alcohol and allow it to dry completely.
4. Puncture Site: Prick one side of the heel, avoiding the center.
5. Discard First Drop: Remove the first drop of blood to avoid tissue fluid contamination.
6. Fill the Capillary Tube: Collect the sample without introducing air bubbles.
7. Send Immediately: Send the sample to the laboratory immediately after collection.
8. Apply Pressure: Press on the puncture site after sampling to prevent bleeding. 

Care for Neonates on Mechanical Ventilation and Nasal CPAP

1. Endotracheal Tube (ETT) Care

• Ensure the tube is securely fixed with minimal tape, without pulling or stretching the lips or nose.
• Inspect the skin around the lips and nose for irritation or wounds.
• Change the fixation site daily from right to left to prevent skin breakdown.
• Check that the tube is not blocked due to kinking or thick secretions.
• Suction the ETT every 3–4 hours or as needed.
• Auscultate breath sounds bilaterally every 2–4 hours.
• Watch for signs of accidental tube dislodgement: cyanosis, decreased oxygen saturation, sudden deterioration, abdominal distension, audible crying, reduced chest movement, or bradycardia.

2. Monitoring Vital Signs

• Connect the neonate to cardiorespiratory monitoring.
• Record vital signs every 3 hours, focusing on respiratory effort and blood pressure.
• Observe skin color and oxygen saturation.

3. Chest Physiotherapy and Suctioning

• Perform chest physiotherapy as indicated.
• Suction as needed to maintain airway patency.

4. Nutrition

• Neonates may receive nutrition via an orogastric or nasogastric tube as per physician instructions.

5. Repositioning

• Reposition the neonate every 2 hours (side, back, or prone) to prevent secretion accumulation while ensuring proper tube fixation.

Weaning from Mechanical Ventilation

• Gradually reduce ventilator settings (pressure, oxygen concentration, respiratory rate) to encourage spontaneous breathing before extubation.

Extubation Procedure

• Stop tube feeding 2 hours before extubation.
• Perform chest physiotherapy and suction immediately prior to tube removal.
• Remove the ETT during inhalation.
• Closely monitor breathing after extubation.
• Perform a blood gas analysis 30 minutes after extubation.
• Notify the physician of any complications.

Potential Complications of Mechanical Ventilation

• ETT obstruction due to secretions or kinking.
• Accidental extubation.
• Pneumothorax or emphysema from excessive pressure.
• Reduced cardiac output due to high intrathoracic pressure.