Manual of Neonatal Respiratory Care 3rd Edition

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Foreword

A successful transition from fetal to neonatal life is dependent upon the profound
cardiorespiratory adaptations occurring at this time. Unfortunately, these events
frequently require medical intervention, especially in preterm infants. The conse-
quences of the resultant pathophysiologic changes and therapeutic interventions in
such neonates may have long lasting effects on the developing respiratory system
and even the neurodevelopmental outcome of this high-risk population.
Recognition of the importance of neonatal respiratory management was an early
milestone in the history of neonatology. The role of surfactant deficiency in the
etiology of neonatal respiratory distress syndrome was sealed over 50 years ago,
and this paved the way for the introduction of assisted ventilation for this population
in the 1960s. I was privileged to be introduced to neonatal pediatrics in the early
1970s at a time when the advent of continuous positive airway pressure demon-
strated how physiologic insight can be translated into effective therapy. The decade
of the 1970s offered so many other innovations in neonatal respiratory care. These
included noninvasive blood gas monitoring, xanthine therapy for apnea, and our
first real understanding of the pathogenesis and management of meconium aspira-
tion syndrome, group B streptococcal pneumonia, and persistent fetal circulation or
primary pulmonary hypertension of the newborn, three frequently interrelated con-
ditions. The decade ended in remarkable fashion with the introduction of exogenous
surfactant therapy and recognition that the novel new technique of high-frequency
ventilation allows effective gas exchange in sick neonates.
The last 30 years have enabled us to build drastically on the foundation of this
earlier period in neonatal respiratory management. The improved survival of
extremely low birth weight infants has been nothing short of spectacular. For pre-
term infants, the focus is now clearly to reduce the unacceptably high incidence of
bronchopulmonary dysplasia. However, many key questions in neonatal respiratory
care still need to be addressed. What constitutes optimal ventilatory strategy and
optimal targets for gas exchange as reflected in levels of PaO2 and PaCO2? What is
the risk/benefit ratio of current and future pharmacologic adjuncts to ventilatory

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viii Foreword

support, such as inhaled nitric oxide, xanthine, or antioxidant therapy, to name a

few? How can we safely support ventilation and provide pharmacotherapy in the
most noninvasive manner?
For preterm or term infants with malformations of the respiratory system,
advances in pre- and postnatal imaging and surgical techniques hold promise for
improved outcome. Great strides are being made simultaneously in our understand-
ing of the molecular basis for normal and abnormal lung development. Furthermore,
it is being increasingly recognized that genotypic characteristics may greatly influ-
ence the consequences of subsequent environmental exposures on lung develop-
ment. These scientific advances need to be translated into improving adverse
neonatal outcomes, such as the unacceptably high rate of wheezing disorders and
asthma in the survivors of neonatal intensive care. As care providers to neonates, it
is our responsibility to encourage clinical trials and other patient-based investiga-
tion that will allow us to optimize the outcome of neonatal respiratory care.
The third edition of the Manual of Neonatal Respiratory Care is comprehensive
and provides an important educational tool to address many of these challenges.
It is, again, thoroughly edited by the accomplished trans-Atlantic team of Steven
Donn and Sunil Sinha. Once again, they have assembled physician/scientist leaders
in the field of Developmental Pulmonology who provide a true international
perspective to neonatal respiratory care. Both prior and new contributors provide a
concise overview that spans neonatal physiology, pathogenesis of disease, and
unique approaches to management of both simple and complex neonatal respiratory
disorders. The result is a comprehensive text that provides a strongly international
insight into neonatal respiratory care in a user-friendly, practical format.

Cleveland, OH, USA Richard J. Martin, MBBS, FRACP

Preface

It is indeed a privilege for us to edit the third edition of the Manual of Neonatal
Respiratory Care, and we were honored when Springer Science+Business Media
approached us to do this.
In the years that have passed since the second edition, much has transpired, some
technological and some philosophical. Microprocessor-based technology continues
to refine the equipment at our disposal and to offer us almost limitless ways to man-
age neonatal respiratory failure. At the same time, there has been a resurgence in the
philosophy of minimal intervention, giving rise to the new popularity of continuous
positive airway pressure and noninvasive ventilation. We have entered the age of
evidence-based medicine, emphasizing the importance of the randomized, con-
trolled trial. We have seen enormous growth in information technology and world-
wide access to it. Therapeutic options also continue to expand, but greater care must
be taken as survival of even more premature babies accentuates their toxicities and
complications.
We have maintained the same outline format for the third edition, appreciating
the positive feedback we have received from many that this is conducive to bedside
use. We have not only updated previous chapters, we have added newer ones to
reflect changes in practice, equipment, and science. Some of these include an
expanded focus on oxygen toxicity, control of oxygen delivery, use of nasal cannula
therapy, noninvasive ventilation, newer ventilators, management of hemodynamics,
home ventilation, interpreting medical literature, medico-legal issues, and an expan-
sive contemporary bibliography on neonatal respiratory care.
Our list of contributors represents a world-class group of scientists, clinicians, and
experts in their respective fields. We are indebted to them for taking the time and
effort to provide their insights and knowledge. The Manual of Neonatal Respiratory
Care would also not have been possible without the efforts of many “behind the
scenes” individuals, including our development editor, Mike Griffin, and our acquisi-
tions editor, Shelley Reinhardt, both of Springer; Vicky Hall in Middlesbrough; and
Susan Peterson in Ann Arbor, who coordinated the efforts of more than 50 contributors,

ix
x Preface

and somehow managed to get all 85 chapters formatted the same way (an incredible
feat!). Lastly, we acknowledge our wives, Paula Donn, and Lalita Dean, for their
patience and sacrifices while we put the Manual together.
Change will continue to occur at a rapid pace. What we hope this edition accom-
plishes is the establishment of fundamentals that will enable the clinician to develop
the ability to assimilate change in a physiologically sound way while providing the
best possible care to his or her patients.

Ann Arbor, MI, USA Steven M. Donn

Middlesbrough, UK Sunil K. Sinha
Contents

List of Abbreviations ..................................................................................... xxv

Part I Lung Development and Maldevelopment

1 Development of the Respiratory System .............................................. 3

Vinod K. Bhutani
2 Developmental Lung Anomalies ........................................................... 17
Mohammad A. Attar and Subrata Sarkar

Part II Principles of Mechanical Ventilation

3 Spontaneous Breathing .......................................................................... 27

Emidio M. Sivieri and Vinod K. Bhutani
4 Pulmonary Gas Exchange ..................................................................... 39
Vinod K. Bhutani
5 Oxygen Therapy ..................................................................................... 49
Win Tin
6 Oxygen Toxicity ...................................................................................... 55
Ola Didrik Saugstad
7 Pulmonary Mechanics ........................................................................... 61
Emidio M. Sivieri and Vinod K. Bhutani
8 Basic Principles of Mechanical Ventilation ......................................... 73
Waldemar A. Carlo, Namasivayam Ambalavanan,
and Robert L. Chatburn
9 Classification of Mechanical Ventilation Devices ................................ 87
Waldemar A. Carlo, Namasivayam Ambalavanan,
and Robert L. Chatburn

xi
xii Contents

10 Ventilator Parameters............................................................................ 93
Waldemar A. Carlo, Namasivayam Ambalavanan,
and Robert L. Chatburn
11 Respiratory Gas Conditioning and Humidification ............................ 99
Andreas Schulze

Part III Procedures and Techniques

12 Clinical Examination ............................................................................. 109

Avroy A. Fanaroff and Jonathan M. Fanaroff
13 Neonatal Resuscitation .......................................................................... 121
Janet M. Rennie
14 Laryngoscopy and Endotracheal Intubation....................................... 129
Karen Wiseman and Steven M. Donn
15 Vascular Access ...................................................................................... 137
Steven M. Donn
16 Tracheostomy ......................................................................................... 143
Steven M. Donn

Part IV Monitoring the Ventilated Patient

17 Continuous Monitoring Techniques ..................................................... 149

Christian F. Poets
18 Pulse Oximetry ....................................................................................... 155
Win Tin and Samir Gupta
19 Interpretation of Blood Gases ............................................................... 159
David J. Durand
20 Neonatal Pulmonary Graphics ............................................................. 167
Joanne Nicks
21 Radiography ........................................................................................... 181
Ramon Sanchez and Peter J. Strouse
22 Transillumination ................................................................................... 211
Steven M. Donn
23 Echocardiography .................................................................................. 213
Jonathan Wyllie
24 Bronchoscopy ......................................................................................... 225
Neil N. Finer
Contents xiii

Part V Non-invasive Ventilatory Techniques

25 Nasal Cannula Therapy......................................................................... 231

Andrea L. Lampland and Mark C. Mammel
26 Continuous Positive Airway Pressure .................................................. 237
Colin J. Morley
27 Non-invasive Ventilation ........................................................................ 247
Brigitte Lemyre and Haresh Kirpalani

Part VI Ventilatory Modes and Modalities

28 Positive End-Expiratory Pressure ........................................................ 255

Sarvin Ghavam and Haresh Kirpalani
29 Intermittent Mandatory Ventilation .................................................... 261
Steven M. Donn and Sunil K. Sinha
30 Synchronized Intermittent Mandatory Ventilation ............................ 267
Steven M. Donn and Sunil K. Sinha
31 Assist/Control Ventilation ..................................................................... 271
Steven M. Donn and Sunil K. Sinha
32 Volume-Targeted Ventilation ................................................................ 275
Steven M. Donn and Sunil K. Sinha
33 Pressure Control Ventilation ................................................................. 281
Steven M. Donn
34 Pressure Support Ventilation ................................................................ 285
Sunil K. Sinha and Steven M. Donn
35 Proportional Assist Ventilation ............................................................. 291
Andreas Schulze

Part VII High-Frequency Ventilation

36 High-Frequency Ventilation: General Concepts ................................. 301

J. Bert Bunnell
37 High-Frequency Jet Ventilation ............................................................ 319
Martin Keszler
38 High-Frequency Oscillatory Ventilation .............................................. 327
Reese H. Clark
xiv Contents

Part VIII Commonly Used Neonatal Ventilators

39 VIP Bird Gold Ventilator ...................................................................... 341

Michael A. Becker and Steven M. Donn
40 AVEA Ventilator..................................................................................... 349
Michael A. Becker and Steven M. Donn
41 Bear Cub 750PSV...................................................................................... 357
Joanne Nicks
42 Newport Wave ........................................................................................ 363
Robert L. Chatburn and Teresa A. Volsko
43 Newport e360 .......................................................................................... 369
Cyndy Miller
44 Dräger Babylog VN500 Infant and Pediatric Ventilator .................... 379
Donald M. Null, Jr.
45 SERVO-i Ventilator and Neurally Adjusted
Ventilatory Assist (NAVA) ..................................................................... 387
Jennifer Beck and Louis Fuentes
46 SLE5000 and SLE4000 Infant Ventilators........................................... 397
Barbara Pilgrim and Sunil K. Sinha
47 Bunnell Life Pulse High-Frequency Jet Ventilator ............................. 403
Martin Keszler
48 Sensormedics 3100A High-Frequency Oscillatory Ventilator ........... 407
David J. Durand and Jeanette M. Asselin

Part IX Adjunctive Therapies

49 Hemodynamic Support.......................................................................... 417

Keith J. Barrington
50 Nutritional Support of the Ventilated Infant ....................................... 425
David Adamkin
51 Surfactant Replacement Therapy ........................................................ 443
Fernando Moya and Maria-Cristina Javier
52 Pharmacologic Agents ........................................................................... 455
Varsha Bhatt-Mehta and Steven M. Donn
53 Automatic Control of Oxygen Delivery ................................................ 469
Nelson Claure and Eduardo Bancalari
54 Sedation and Analgesia.......................................................................... 473
Elaine M. Boyle and Neil McIntosh
Contents xv

55 Inhaled Nitric Oxide Therapy............................................................... 485

John P. Kinsella
56 Extracorporeal Membrane Oxygenation ............................................. 497
Robert E. Schumacher
57 Liquid Ventilation for Neonatal Respiratory Failure ......................... 505
Ronald B. Hirschl

Part X Management of Common Neonatal Respiratory Diseases

58 Mechanisms of Respiratory Failure ..................................................... 513

Anne Greenough and Anthony D. Milner
59 Tissue Hypoxia ....................................................................................... 517
Anne Greenough and Anthony D. Milner
60 Indications for Mechanical Ventilation ................................................ 521
Anne Greenough and Anthony D. Milner
61 Respiratory Distress Syndrome ............................................................ 523
Steven M. Donn and Sunil K. Sinha
(Case Study by Brooke D. Vergales and Jay P. Goldsmith)
62 Pneumonia .............................................................................................. 533
Elvira Parravicini and Richard A. Polin
63 Meconium Aspiration Syndrome.......................................................... 555
Thomas E. Wiswell
(Case Study by Brooke D. Vergales and Jay P. Goldsmith)
64 Persistent Pulmonary Hypertension of the Newborn ......................... 565
Robert E. Schumacher and Steven M. Donn
(Case Study by Brooke D. Vergales and Jay P. Goldsmith)
65 Congenital Diaphragmatic Hernia ....................................................... 577
Deepak Kalbigiri Vasudev and David Field
(Case Study by Brooke D. Vergales and Jay P. Goldsmith)
66 Pulmonary Hypoplasia/Agenesis .......................................................... 587
Deepak Kalbigiri Vasudev and David Field
67 Apnea Syndromes .................................................................................. 593
Alan R. Spitzer
68 Weaning and Extubation ....................................................................... 609
Steven M. Donn and Sunil K. Sinha
(Case Study by Brooke D. Vergales and Jay P. Goldsmith)
xvi Contents

Part XI Bronchopulmonary Dysplasia

69 Etiology and Pathogenesis ..................................................................... 625

Natasha Henner and Jonathan M. Davis
70 Management ........................................................................................... 633
Eduardo Bancalari
71 Long-Term Outcome of Newborns
with Bronchopulmonary Dysplasia ...................................................... 639
Sumesh Thomas, Prashanth Murthy, and Saroj Saigal

Part XII Complications Associated with Mechanical Ventilation

72 Thoracic Air Leaks ................................................................................ 647

Jennifer Dalton and Steven M. Donn
73 Patent Ductus Arteriosus ...................................................................... 659
Jonathan Wyllie
74 Neonatal Pulmonary Hemorrhage ....................................................... 665
Tonse N.K. Raju
75 Retinopathy of Prematurity .................................................................. 675
Alistair R. Fielder
76 Neurologic Complications of Mechanical Ventilation ........................ 685
Gillian Brennan and Jeffrey M. Perlman

Part XIII Other Considerations

77 Nursing Care of the Ventilated Infant .................................................. 693

Kimberly LaMar
78 Transport of Ventilated Babies ............................................................. 705
Steven M. Donn and Molly R. Gates
79 Home Ventilation.................................................................................... 717
Wan Chong Tsai
80 Discharge Planning and Follow-Up of the NICU Graduate .............. 723
Win Tin and Mithilesh Lal

Part XIV Ethical and Legal Considerations

81 Initiation of Life Support at the Border of Viability .......................... 733

Naomi Laventhal, Joanne Lagatta, and William Meadow
82 Withdrawal of Ventilatory Support ..................................................... 739
Malcolm L. Chiswick
Contents xvii

83 Medical Liability, Documentation, and Risk Management ............... 747

Steven M. Donn and Jonathan M. Fanaroff

Part XV Research and the Literature

84 Interpreting Medical Literature ........................................................... 753

Omar Kamlin and Peter Davis
85 Contemporary Classics in Neonatal Respiratory Care ...................... 759
Rachel L. Chapman and Lorelei Woody

Appendix ......................................................................................................... 767

Index ................................................................................................................ 769