Canberra Hospital and Health Services Clinical



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Evaluation



Outcome Measures

  • The outcome measures for the Ventilation Management: Invasive and Non-Invasive Clinical Procedure and Guideline are to be considered in terms of improved performance in the domains of safe practice and prevention/reduction of potential complications.

  • This may include:

  • >95% Compliance against Clinical Procedural guidelines

  • Reduced incidence of accidental extubation

  • Improved Benchmarking performance against similarly delineated facilities

  • Where possible Parents/Primary caregivers should be encouraged to be engaged in their babies care while being kept informed of their condition and progress


Method

  • Clinical Audits of compliance against Clinical procedural guidelines as conducted by Clinical Development Nurses (CDNs) and reported on at Staff Unit Meetings

  • Accidental Extubation is reported via Riskman

  • The Neonatal Intensive Care and Special Care Nursery participate in collaborative audits and research, contributing data to the Australian and New Zealand Neonatal Network (ANZNN). The data is analysed and compared with data collected from Hospitals both in Australia and New Zealand providing a core data set. The ANZNN publish a report with the intention of improving clinical practice while maintaining national standards of evidence-based care.

  • Parents/Primary caregivers are involved with their babies care and are kept informed of their treatment


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Related Policies, Procedures, Guidelines and Legislation



Policies

  • Neopuff use of CHHS 10/006

  • X-rays in the Centre for Newborn Care CHHS12/135

  • Nasogastric and Orogastric tube insertion CHHS13/625

  • Observation and monitoring CHHS12/121

  • Developmental Care CHHS12/096

  • Sucrose for pain relief CHHS12/070

  • Nursing and Midwifery Continuing Competence Policy

  • Resuscitation of the Neonate CHHS10/005


Standards

  • IL


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References

De Paoli, A.G., Morley, C. & Davis, P.G. (2003) “Nasal CPAP for neonates: what do we know in 2003.” Archives of Diseases in Childhood 88 F168


Westwell, T.E. & Courtney, S.E. (2011) Noninvasive Respiratory Support. In Goldsmith, J.P. & Karotokin, E.H. Assisted Ventilation of the Newborn 5th Ed. St Louis, Elsevier.
Todd D.A., Shadbolt B., Wright A., Chauhan M., Cameron C., Broom M. (2010) CPAP weaning: Impact on time of CPAP and oxygen duration. J Paediatric Child Health; 46 (supp 1) A143
Broom M., Shadbolt B., Wright A., Chauhan M., Cameron C., Todd D.A. (2010) CPAP weaning: Impact on length of stay. J Paediatric Child Health; 46 (supp 1) A144
Wis ell, T.E. and Srinivasan, P. (2011) Continuous Positive Airway Pressure in Goldsmith, J.P. and Karotkin, E.H. (eds) Assisted Ventilation of the Neonate (5th Edition) Philadelphia: Saunders Elsevier. Inc
National Women's Newborn Services Clinical Guideline (2006) Nasopharyngeal CPAP http:www.adhb.govt.nz/newborn/Guidelines/Respiratory/CPAP/CPAPNasopharyng…
Niermeyer, S. and Clarke,S.B. (2006) Delivery Room Care in Merenstein, G.B. and Gardner, S.L. (eds) Handbook of Neonatal Intensive Care (6th Edition). Missouri: Mosby.
Berends, S.k. (2001) Nasopharyngeal CPAP: A Nursing Art. Neonatal Network 20(6):7-16

Davis, P., Davies, M., Faber, B. (2001) A randomised controlled trial of two methods of delivering nasal continuous positive airway pressure after extubation of infants weighing less than 1000g: binasal (Hudson) versus single nasal prong. Archives of Disease in Childhood - Fetal and Neonatal Edition 85: F82-F85.


Upadhayay, A. and Deorari. A.K. (2004) Continuous positive airway pressure – a gentler approach to ventilation. Indian Pediatrics 41(4): 456-69.
http://www.indianpediatrics.net/may2004/may-459-469.htm
Kalyn, A., Blatz, S., Feuerstake, S., Paes, B. & Bautista, C. (2003) Closed Suctioning of Intubated Neonates Maintains Better Physiologic Stability: A Randomized Trial. Journal of Perinatology 23, 218–222. doi:10.1038/sj.jp.7210883
Hoellering, A. B., Copnell, B., Dargaville, P.A., Mills, J. F. (2008) Lung volume and cardiorespiratory changes during open and closed endotracheal suction in ventilated newborn infants Arch Dis Child Fetal Neonatal Ed;93:F436-F441
Gardner, D., Shirland, L. (2009)Evidence-Based Guideline for Suctioning the Intubated Neonate and Infant. Neonatal Network. 2 8( 5) 281-3

Cools, F. & Offringa, M. (2009) Neuromuscular paralysis for newborn infants receiving mechanical ventilation (Cochrane Review), The Cochrane Collaboration.


Goldsmith, J. P., & Karotkin, E. H. (2010). Assisted ventilation of the neonate (4th ed.) Philadelphia: Saunders.
Burton, S., Alexander, E. (2006). Avoiding the pitfalls and ensuring the safety of sustained neuromuscular blockade. AACN Advanced Critical Care, 17 (3), 239-245.
Bullock, S., Manias, E, & Galbraith, A. (2007). Funamentals of Pharmocology (5th ed.). Frenchs Forest, NSW: Pearson Education Australia.
Corso, L. (2008) Train-of-four results and observed muscle movement in children during continuous neuromuscular blockade. Critical Care Nurse, 28 (3), 30-39.
Merenstein, G. B., & Gardiner, S. L. (2011). Handbook of Neonatal Intensive Care (6th ed.). St. Louis: Mosby Elsevier.
Sorce, L. R., Hamilton, S. M., Gauvreau, K., Mets, M. B., Hunter, D. G., Rahmani, B., Wu, C., & Curley, M. A. (2009). Preventing corneal abrasions in critically ill children receiving neuromuscular blockade: A randomized, controlled trial. Pediatric Critical Care Medicine, 10 (2), 171-175.
Martin, L. D., Bratton, S., & O’Rourke, P. P. (1999). Clinical uses and controversies of neuromuscular blocking agents in infants and children. Critical Care Medicine. Official Journal of the Society of Critical Care Medicine, 27 (70) 1358-1368.
Verklan M. T. (2004) Adaptation to Extrauterine Life. In Verklan, M.T. & Walden, M. Core Curriculum for Neonatal Intensive Care Nursing. St Louis, Elsevier.
Cunningham, M GomellaT (2004) Neonatology: Management, Procedures, On-call Problems, Diseases, and Drugs, St Louis McGraw-Hill
Neotech products, inc. http://www.bamsalute.com/neotech/neobar_inst.pdf
Quinn, W., Sandifer, L., Goldsmith, J. (2005) Pulmonary Care In Goldsmith, J., Karotkin, J. Assisted Ventilation of the Infant. W.B. Saunders. Philadelphia.
Wratney, A.T. & Cheifetz, I.M. American Association for Respiratory Care (2007). AARC Clinical Practice Guidelines: Removal of the Endotracheal Tube in the Neonate. Respiratory Care, 52(1): 89‐93.
Szymankiew, M., Vidyasagar, D. & Gadinowski, J (2005). Predictors of successful extubation of preterm low‐birth‐weight infants with respiratory distress syndrome Pediatric Critical Care Medicine, 6(1):44‐49.
Shoemaker, M.T., Pierce, M.R., Yoder, B.A. DiGeronimo, R.J. (2007) High flow nasal cannula versus nasal CPAP for neonatal respiratory disease: a retrospective study. Journal of Perinatology.: 27 85-91.
Wilkinson, D., Andersen, C., Smith, K. & Holberton, J (2008) Pharyngeal pressure with high-flow nasal cannulae in premature infants. Journal of Perinatology.: 28(1), 42-47.

Saslow, J., Aghai, Z., Nakhla, T., Hart, J., Lawrysh, R., Stahl, G. & Pyon, K. (2006) Work of breathing using high-flow nasal cannula in preterm infants. Journal of Perinatology. 26, 476-480


Rennie, J.M., Roberton N.R.C. (2002) A Manual of Neonatal Intensive Care 4th Ed Hodder Headline Group, Great Britain
Askie, L., Henderson-Smart, D., Inwig, L., Simpson, J.M. (2003) Oxygen Saturation Targets in Extremely Preterm Infants. New England Journal of Medicine 349 959-967
Neonatology Clinical Guidelines, King Edward Memorial/Princess Margaret Hospitals

Williams, L., Shaffer, T. & Greenspan, J. (2004) Inhaled Nitric Oxide Therapy in the Near-Term or Term Neonate with Hypoxic Respiratory failure. Neonatal Network. 23(1):5-13.

Barrington, K. & Finer, N. (2007) Inhaled Nitric Oxide for Preterm Infants: A Systematic Review. Pediatrics. 120(5):1088-1099.
Stephens, C & Fawcett, T. (2007) Nitric Oxide and Nursing: A Review. Journal of Clinical Nursing.
Clark, R.H. Auten R.L. & Peabody, J. (2001). A comparison of the outcomes of neonates treated with two different natural surfactants. Pediatrix Medical Group, Inc, Florida. Mosby Inc.
Hudak, L. Martin, D.J. Egan, E.A. & Matherson. E.J. (1997). Comparison of surfactants for Prevention of RDS. PEDIATRICS (ISSN 0031 4005).
Lal, M. & Kotecha, S. (2000). Surfactant Therapy. Journal of Neonatal Nursing, Vol 6 Issue 2, 2000.
Morley, C.J. & Soll, R.F. (2001). Prophylactic versus selective use of surfactant in preventing morbidity and mortality in preterm infants (Cochrane Review). The Cochrane library, Issue 1, 2002.
Suresh, G.K. & Soll, R.F. (2001). Current Surfactant use in Premature Infants. Clinics in Perinatology, Vol 28, Number 3. Pages 671-698. W.B. Saunders Company, Philadelphia.
Weaver, T.E. (2000). Surfactant Proteins and Chronic Lung Disease. Biol Neonate 2000; pages 247-248.
Walker, L. (1993). Synthetic Surfactant. Seminars in Perinatology, Vol 17 No 4, pages 275-284. W.B. Saunders Company. Philadelphia.
Rowley, S. & Cooper, D. S (1998). Surfactant Administration. Newborn Services Drug Protocol.
Yost,C.C. & Soll, R.F. (1999). Early versus delayed selective surfactant treatment for neonatal respiratory distress syndrome. The Cochrane Library, Issue 1, 2002. Oxford.
Soll, R.F. (1999). Multiple versus single dose natural surfactant extract for severe neonatal respiratory distress syndrome. The Cochrane Library, Issue 1, 2002. Oxford.
Rojas-Reyes MX, Morley CJ, Soll R. Prophylactic versus selective use of surfactant in preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev. 2012 Mar 14;3:CD000510. doi: 10.1002/14651858.CD000510.pub2. Review.
Pfister RH1, Soll RF. Initial respiratory support of preterm infants: the role of CPAP, the INSURE method, and noninvasive ventilation. Clin Perinatol. 2012 Sep;39(3):459-81..

John Hunter Children’s Hospital Surfactant Guideline



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Definition of Terms



Edi: It is the electrical activity of the diaphragm and can be thought of as a respiratory vital sign. The electrical nerve signal from the crural part of diaphragm are summated, filtered and processed to give the Edi signal. The Servo-n ventilator displays Edi as a waveform as well as numerically on a breath-by-breath basis. It is measured in microvolts (µV). When using the Edi to control all aspects of the ventilator breath, the patient determines inspiratory pressure (or volume), inspiratory and expiratory time and respiratory rate for each breath.

Edi peak (µV): It is the highest Edi waveform. It represents the work diaphragm has to perform for each breath and is responsible for the size and duration of the breath. Edi peak is higher while awake than during sleep and lower in the post-prandial state than pre-prandial and feeding states. The reference range for Edi peak is 10.8±3.7 µV (Stein 2013).

Edi min (µV): It is the lowest Edi waveform. It represents the spontaneous tonic activity of the diaphragm which prevents de-recruitment of alveoli during expiration. Edi minimum is higher while awake than during sleep but similar among feeding states. The reference range for Edi min is 2.8±1.1 µV (Stein 2013).

Edi trigger (µV): It is the minimum increase in electrical activity from the previous trough that triggers the ventilator to recognize the increase in electrical activity as a breath, not just baseline noise. It is generally set at 0.5.

NAVA Level: NAVA level is a conversion factor that converts the Edi signal into a proportional pressure. The units of the NAVA level are cmH20/ µV. The Edi is multiplied by this NAVA level to determine airway pressure delivered by the ventilator for each breath. The peak pressure is determined on an ongoing basis every 60 msec, and continues to increase as long as the instantaneous Edi increases, as determined by the formula:

Peak pressure = NAVA level x Edi (peak-min) + PEEP

Apnoea time: This represents the maximum amount of time the neonate can be apnoeic before going into backup ventilation. This provides a minimum guaranteed rate which is different from the backup rate. For e.g. setting apnoea time at 2 seconds guarantees minimum rate of 30 breaths/min.
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Search Terms

Intubation, Colormetric, Co2 Detector, ETT Strapping, Neobar, Nasal ETT, Ventilation, Ventilated Infant, Surfactant, Curosurf, Survanta, ETT Suction, Suction, HFOV, High Frequency, Muscle relaxed Infant, Nitric Oxide, ETT Aspirate, Extubation, CPAP, Continuous Positive Airway Pressure, Highflow, Lowflow, Nasal Prong Oxygen, NAVA, Neurally Adjusted Ventilatory Assist NI-NAVA



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Consultation

A/Prof Z. Kecskes, Director, Department of Neonatology

Prof A. Kent, Senior Staff Specialist, Department of Neonatology

Dr H. Carlisle Staff Specialist, Department of Neonatology

A/Prof Abdel-Latif Mohamed Staff Specialist, Department of Neonatology

Dr T. Chaudhari, Staff Specialist, Department of Neonatology

Dr. D. Todd, CMO, Neonatology, Department of Neonatology

Dr. R Maheshwari, Staff Specialist, Department of Neonatology

K. Thomas, A/g ADON, Department of Neonatology

D Colwill, A/g Clinical Nurse Consultant, Department of Neonatology

V. Gore, Clinical Nurse Consultant, Department of Neonatology

B. Dromgool, Neonatal Educator, ACT Health

L. Ehrlich, Clinical Support Nurse, Department of Neonatology

K Terrell, Senior Physiotherapist, Department of Neonatology



Attachments


Attachment 1: Edi Catheter positioning

Attachment 2: Guide to initial setting of NIV-NAVA in various scenarios


Attachment 3: NIV-NAVA quick Guide
Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.
Policy Team ONLY to complete the following:

Date Amended

Section Amended

Divisional Approval

Final Approval

03/11/2014

Complete Review

ED, WY&C

CHHS Policy Committee

19/03/2018

Information pertaining to NAVA included in section 10

ED, WY&C

CHHS-PC Chair


This document supersedes the following:

Document Number

Document Name















Attachment 1: Edi Catheter positioning


Insert the Edi catheter after measuring length from nose/mouth to ear to xiphisternum. When the Edi catheter is in a good position the following ECG landmarks will be seen (refer to picture below). When the Edi catheter is in good position the Purple circles to the left of ECG signals should be seen on Leads 2 &3 as well as superimposed on waveforms on Lead 2&3.


Read from the top of the screen downwards where it reads mV

Lead 1-Tall P wave (the first peak before QRS wave)

Lead 2-Smalller P wave

Lead 3- No or very small P wave

Lead 4- No P wave &small QRS wave
When Edi catheter is in incorrect position:

If Purple circles are on Lead 1- Pull catheter out (1cm at a time) until purple circles are seen on lead 2 & 3

If Purple circles are on Lead 4- Push catheter in (1cm at a time) until purple circles are seen on lead 2 & 3

If ECG amplitudes are in reverse order (small P waves and QRS complexes in lead 1 and then tall P and QRS waves in lead 4): Push catheter in (often by 3 cm or so).

If tall P wave and QRS waves are seen in Lead 1 and Lead 4- Catheter is curled back forming a loop therefore reposition catheter.

Attachment 2: Guide to initial setting of NIV-NAVA in various scenarios








Post-extubation

Escalation mode from CPAP

Backup mode to treat apnoea

NAVA Level

1.0-1.5

1.5-2.0

0

PEEP

6-8

6-8

6-8




PC above PEEP

10

10

10

IT

0.40

0.40

0.40

Apnoea Time

2-3 sec

2-3 sec

2 sec

Back up rate

40-50

50

40-50

Comments

(All settings to be tailored according to individual patient requirements)



Usually NAVA level that generates PIP of 16-18 cmH20 provides adequate support

Usually NAVA level that generates PIP of 16-18 cmH20 provides adequate support

For nasal CPAP therapy, choose NIV-NAVA mode and set NAVA to zero. Do not choose nCPAP mode.


Attachment 3: NIV-NAVA Quick Guide
Initiation of NIV-NAVA

  1. Catheter selection, placement& positioning as per guidelines and appendix 1

  • 6FR-49 cm, weight 0.5-1kg, length<55cm

  • 6FR-50cm, weight 1-2kg, length<55cm

  • 8FR-50cm, weight 1-2kg, length<55cm

  • 8FR-100cm, weight >2kg, length 45-85cm

  1. Initiate NAVA as per settings mentioned in appendix 2 and titrate in 0.2 increments to babies’ comfort, targeting an Edi peak of <15 µV


Weaning

Consider weaning if the is baby is comfortable with regular respiratory rate and Edi is regular and peak is < 15 µV

Options for weaning


  • Decrease NAVA level 0.1-0.2 at a time (NAVA level of O is CPAP)

  • Increase apnoea time to 3-5 sec

  • Decrease Back-up respiratory rate to 40/min

  • Decrease PC above PEEP




Optimisation and monitoring

Optimise NAVA level to maintain Edi peak <15 µV



  • If Edi peak <5 µV consistently- consider decreasing NAVA level

  • If Edi peak >15 µV consistently- consider increasing NAVA level

  • If Edi min > 3 µV consistently- consider increasing PEEP

  • If frequent desaturations and bradycardias- consider decreasing apnoea time

  • Set respiratory rate (Back up PC) according to needs (desaturations, Pco2 & ABG)

Monitoring baby on NAVA

  • Review baby’s effort on NIV-NAVA and on trends/logs screen look at Edi waveform with Edi peak &min, respiratory rate (spontaneous and total), frequency of back up and % time in back up. Correct positioning of catheter must be ensured

  • Ensure adequate oxygenation

  • Ensure that Pressure above PEEP is achieving adequate chest movement

  • Check blood gas once settled on NIV-NAVA

Potential signs of deterioration

  • Increased Edi variability

  • Increasing Fio2 requirement

  • Bradycardias & haemodynamic variations

  • Increasing Back-up ventilation and % time in back up





Doc Number

Version

Issued

Review Date

Area Responsible

Page

CHHS14/032

1.2

03/11/2014

01/10/2018

WY&C - NICU

of

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register



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