Essentials of Neonatal Ventilation, 1st edition

Cover
Title
Copyright
Contributors
Foreword
Preface
Acknowledgments
Contents
Section I - Introduction and History of Ventilation
	Chapter 1 - Introduction
	Chapter 2 - Evolution of Neonatal Ventilation a Retrospective View
		Introduction
		The development of neonatology
		The birth of modern neonatal intensive care unit (NICU)
		The birth of a new specialty: neonatology—the newborn medicine
		The evolution of ventilator care of the newborn
		Oxygen therapy
		Usher regime
		History of neonatal ventilation
		Ross symposium on neonatal intensive care
		Introduction of surfactant therapy in HMD/RDS
		The modern neonatal ventilators
		Summary
		References
Section II - Lung Development and Interventionsin the Prenatal and Perinatal Period
	Chapter 3 - Pathophysiology of Fetal Lung Development
		Chapter points
		Introduction
		Embryology
			Embryonic stage
			Pseudoglandular stage
			Canalicular stage
			Saccular stage
			Alveolar stage
		Pulmonary vascular development
		Transcription factors and growth factors in lung development
		Maturation of pulmonary surfactant system
		Intrauterine exposures and its effect on lung development
			Smoking
			Intrauterine growth restriction (IUGR)/maternal undernutrition
			Chorioamnionitis
		Physical factors: lung liquid and fetal breathing movements
			Glucocorticoids
			Premature birth and oxygen exposure
			Conclusions
		References
	Chapter 4 - Transition in the Delivery Room: Current NRP Recommendations
		Chapter points
		Introduction
		Physiologic changes in the fetal-to-neonatal transition
			Fetal circulation
			Fetal gas exchange
			Antioxidant defenses and surfactant production during fetal life
		Transition in the delivery room
			Cardiorespiratory changes in the first minutes after birth in the term infant
			Consequences of preterm birth on postnatal adaptation
			Oxidative stress during the fetal-to-neonatal transition
		Current NRP recommendations
			Anticipation
			Initial steps in stabilization: assessment and intervention
			Delayed cord clamping or umbilical cord milking
			Heart rate monitoring
			Temperature control
			Clearing the airway
			Normal oxygen saturation ranges in the delivery room
			Oxygen supplementation in term and preterm infants
			Ventilation: continuous positive airway pressure and intermittent positive pressure ventilation
			Endotracheal intubation and/or laryngeal mask
			Circulatory support
			Drugs: epinephrine
			Volume expansion
			Ethical considerations
				When should resuscitation not be initiated?
				When should resuscitation be withdrawn?
		References
	Chapter 5 - Sustained Lung Inflation
		Chapter points
		Physiology of the respiratory transition after birth
		Definition and rationale for sustained inflations
		What literature says
			Experimental animal studies
			Human studies
			Randomized clinical trials
		Current recommendations
		Unresolved issues about SI
		References
Section III - Applied Physiology, and Ventilator Support:General Considerations
	Chapter 6 - Introduction to Lung Mechanics
		Chapter points
		Introduction
		Overview of respiratory mechanics
		Physical principles of respiratory mechanics
		Mechanics of the respiratory pump
			Muscles of inspiration
			Muscles of expiration
			Chest wall
		Elastic properties of the respiratory system
		Resistive properties of the respiratory system
		Respiratory mechanics in disease states
			Transient tachypnea of the newborn
			Meconium aspiration syndrome
			Respiratory distress syndrome
			Bronchopulmonary dysplasia
		References
	Chapter 7 - Genesis of Lung Injury
		Chapter points
		Introduction
		Old versus new BPD
		Factors involved in pathogenesis of lung injury
			Prenatal factors
				Pregnancy-induced hypertension
				Hypoxia
				Infection
				Maternal smoking
				Antenatal steroids
				Genetic susceptibility
				Congenital anomalies
			Postnatal factors
				Lung immaturity
				Hyperoxia/Oxygen-related injury
				Mechanical ventilation-related lung injury
				Infection/Sepsis
				Corticosteroids
				Nutrition
				How to minimize lung injury?
		Conclusions
		References
	Chapter 8 - Hypoxic Respiratory Failure
		Chapter points
		Introduction
		Pathophysiology of HRF
		Etiology of HRF
		Clinical features and assessment
			Noninvasive monitoring
				Pulse oximetry
				Noninvasive PO2 and PCO2 monitoring
		Assessment of severity
			Alveolar–arterial gradient and (A–aDO2)
			Arterial to alveolar (a–A) oxygen ratio
			Oxygenation index
			Oxygen saturation index
			Respiratory severity score
			PaO2/FiO2 ratio
			SpO2/FiO2 ratio
		Management
			Respiratory support
			Permissive hypercapnia
			Permissive hypoxia
			Surfactant replacement therapy
			Extracorporeal membrane oxygenation (ECMO)
		References
	Chapter 9A - Comparison of Ventilators
		Chapter points
		Introduction
		Discrepancy between values set on the ventilators and the measured ones
			Bias in the compliance measurements
			Bias in the resistance measurements
			Assessment of accuracy and precision of measurements
		Ventilator mode classification
		Commonly used ventilators and ventilator performance comparison
		Summary of various factors in neonatal ventilators
			Inspiratory flow
			Sensors
			Pressure triggering
			Differences in setting pressure support
			Leak compensation
		High-frequency ventilators
		Discussion and final comments
		Further reading
	Chapter 9B - The Importance of Heating and Humidifying the Inspired Gases During Mechanical Ventilation: Identifying the Ideal S...
		Chapter points
		Normal gas conditioning in the respiratory tract
			Essential terminologies and definitions
		Suboptimal conditioning of inspired gases to the AW
		Structure and function of the AW lining
		Achieving the optimum heat and humidity
			Circuit configuration
			Temperature and humidity (offset) settings
			Clinical situations with suboptimum conditions
		Ventilators/ventilation: types, modes, and circuitry
		Types of heat and humidifiers
			External heat and humidifiers
			Internal or inbuilt heat and humidifiers with ventilator such as Stephanie/Sophie
		Achieving optimum humidity
		Dos and Don’ts
		References
	Chapter 10 - Ventilator Graphics
		Chapter points
		Introduction
		Historical timeline
		Role of ventilator waveforms
		Ventilator graphic classification
		Basic waveforms
		Pressure waveform
		Flow waveform
		Volume waveform
		Pulmonary mechanics and loops
		Pressure–volume loop
			Patient-triggered pressure–volume loop
			Increased resistance
			Compliance changes
			Alveolar overdistension
			Volutrauma and atelectotrauma
			Circuit leak
			Air hunger
		Flow–volume loop
			Variable extrathoracic obstruction
			Variable intrathoracic obstruction
			Fixed airway obstruction
			Turbulence
			Airway leak
			Extubation
		Patient ventilator dyssynchrony
		Trigger asynchrony
		Flow asynchrony
		Termination asynchrony
		Expiratory asynchrony
			Pulmonary mechanics and graphics
			Compliance
			Resistance
		Role of pulmonary graphics in bedside ventilator management
			Optimizing PIP
			Optimizing PEEP
			Optimizing airflow
			Optimizing inspiratory time
			Optimizing synchrony
			Optimizing tidal volume
		Troubleshooting for ventilator graphics
			Air trapping (auto-PEEP)
				Causes
				How to identify it on the graphics
				How to fix
			Increased resistance
				Causes
				How to identify
				How to fix
		Decreased compliance
			Causes
			How to identify it
			How to fix
		Increased compliance
			Causes
			How to identify it
			How to fix
		Active exhalation
			Causes
			How to identify it
			How to fix
		Partial obstruction
			Causes
			How to identify
			How to fix it
		Overdistension
			Causes
			How to identify it
			How to fix it
		Leak
			Causes
			How to identify
			How to fix it
		Ventilator graphics in special situations
			Surfactant administration
			Bronchopulmonary dysplasia
			Pneumothorax
			Waveforms with high-frequency ventilators
			Limitations of ventilator graphics
		Summary
		References
	Chapter 11A - Initiation of Mechanical Ventilation
		Chapter points
		Introduction
		Indications for mechanical ventilation
		Equipment
		Goals of mechanical ventilation
		Initiation of mechanical ventilation
		Ventilation strategies and choosing the right mode
		References
	Chapter 11B - Deterioration on the Ventilator
		Chapter Points
		Approach to deterioration on a ventilator
			Deterioration awareness strategy
			Bad lung disease
			Obstructed, Long, or Displaced ETT
			Pneumothorax
			Equipment
			Equipment–Patient asynchrony
			Nonrespiratory causes of deterioration on the ventilator
			Approach to ventilator alarms
		References
	Chapter 12 - Extubation
		Chapter points
		Introduction
			Extubation strategy
			Optimizing an extubation attempt
			Patient groups
				26–31 weeks of gestation
				23–25 weeks of gestation
				Evolving severe BPD
				Recurrent air leaks
				Surgical
				Postextubation noninvasive respiratory support
				Recurrent failure of extubation
		References
	Chapter 13A - Complications of Mechanical Ventilation
		Chapter points
		Barotrauma
			How to recognize it
			Remedial measures
		Volutrauma
			How to identify
			Remedial measures
		Oxytrauma
			How to identify
			Remedial measures
		Atelectotrauma
			How to identify
			Remedial measures
		Biotrauma
		Injury related to endotracheal tube
			How to identify
			Remedial measures
		Asynchrony
			How to identify
			Remedial measure
		Inappropriate warmidification
			How to identify
			Remedial measures
		Ventilator-associated pneumonia
			How to identify
			How to treat
			Prevention
		Complications of mechanical ventilation in special situations
			Complications associated with high-frequency ventilation
			Complications associated with interface in NIMV
			How to prevent interface-related nasal injuries
				Nasal care
			Extrapulmonary complications
		References
	Chapter 13B - Pulmonary Air Leaks
		Chapter points
		Thoracic air leaks
			Pneumothorax
			Etiology
				Risk factors for pneumothorax
			Preventive strategies
				Diagnosis
			Clinical presentations
			Transillumination
			Chest X-ray
			Lungs ultrasound
			Management
			Bronchopulmonary fistula
			Pulmonary interstitial emphysema
			Prognosis
			Pneumopericardium
			Pneumomediastinum
			Pneumoperitonium
		Practice points
		Acknowledgments
		References
	Chapter 13C - Pulmonary Edema and Pulmonary Hemorrhage
		Chapter points
		Clinical features and diagnosis
		Remedial measures
		Pulmonary hemorrhage
		Clinical features and diagnosis
		Remedial measures
		References
	Chapter 13D - Neonatal Necrotizing Tracheobronchitis
		Chapter points
		Pathogenesis
		Clinical diagnosis
		Investigations
		Prevention
		Treatment
		Prognosis
		References
Section IV - Bedside Application Principles of Assisted Ventilation Devices
	Chapter 14 - Various Modes of Mechanical Ventilation
		Chapter points
		Introduction
		Conventional mechanical ventilation
			Basic principles of ventilation modes
			Pressure control ventilation
			Volume-targeted ventilation
			Synchronization of ventilation
		Principal ventilation techniques
			Synchronized intermittent mandatory ventilation
			Assist control (SIPPV)
			Pressure support ventilation
		High-frequency ventilation
		Importance of the “open lung strategy”
		Clinical tips
		References
	Chapter 15A - Patient-Triggered Ventilation: Synchronized Intermittent Mandatory Ventilation (SIMV), Assist–Control, Pressure-Sup...
		Chapter points
		Introduction
		Applied physiology of synchronized mechanical ventilation in the newborn
		Effects of the different types of ventilation
			Modes of synchronized ventilation
				Synchronized intermittent positive pressure ventilation; SIMV
				Assist–control
				Pressure-support ventilation
				Proportional assist ventilation
			Cycling (trigger) techniques for synchronized ventilation
			Detection of autocycling and trigger failure
		Indications and contraindications
			SIMV
			A/C
			PSV
		Protocol of use
			SIMV
			A/C
			PSV
		Bedside application of the technology
			Adjustment of trigger threshold
			Adjustment of backup rate during A/C
			PSV
		Failure of technology
		Weaning from technology
			SIMV
			A/C
			PSV
		Complications from technology
			Autocycling
			Trigger failure
			PSV
		Strategies in specific diseases and effects of its use
		One case scenario
		New directions including neurally adjusted ventilatory assist (NAVA)
			NAVA
		References
	Chapter 15B - Neurally Adjusted Ventilatory Assist (NAVA) in Neonates
		Chapter points
		Neurally adjusted ventilatory assist basics
			What is neurally adjusted ventilatory assist
			Normal range for the Edi signal
		How NAVA works
			NAVA improves patient–ventilator interaction
			NAVA allows neonates to control peak pressure and tidal volume
		Outcomes of neonates on NAVA
			NAVA and specific neonatal diseases
		Set up of NAVA
			How to place the Edi catheter
			How to set the NAVA level
			How to set the Edi trigger
			How to set apnea time
			How to set the peak pressure limit
			Initial setting for invasive and NIV NAVA
		Management of neonates on NAVA
			How to escalate NAVA
			How to wean NAVA
			Troubleshooting on NAVA
			NAVA and BPD
			NAVA and apnea
		Contraindications for NAVA
		Conclusion
		Disclosure statement
		References
	Chapter 16 - Volume-Targeted and Volume-Controlled Ventilation
		Chapter points
		Rationale for volume-targeted ventilation
		Volume-controlled versus volume-targeted ventilation
		How does VTV work?
		Importance of the open lung strategy
		Practical guidelines for VTV
			When should VTV be used?
			Initiation of VTV
			Subsequent adjustment
			When to increase Vt?
			When to lower Vt?
			Weaning from VTV
			Caveats, pitfalls, and troubleshooting
		References
	Chapter 17 - Noninvasive Ventilation and High-Flow Nasal Cannula
		Chapter points
		Noninvasive ventilation
			History and timeline
			Indications of NIV
			Contraindications of NIV
		NCPAP
			Bubble CPAP
			SiPAP/Bi-PAP/DuoPAP
		NCPAP in the NICU
		Biphasic CPAP in NICU: Si-PAP/Bi-PAP/DuoPAP
		Suggested guidelines for use of CPAP and Si-PAP
		NIPPV
		NIPPV in the NICU
			Patient nasal interfaces
		Nasal injuries
		NIV in the delivery room
		Suggested guidelines for using NIPPV in the delivery room
		Suggested guidelines for use of NIPPV
			Recruitment phase
			Stable phase of NIPPV
		Weaning from NIPPV
		Noninvasive high-frequency ventilation (NIHFV)
			Clinical studies with NIHFV
			Recommendations
		Suggested settings during NHFV
			Initiation of NIHFOV
			Weaning of NHFV
		NHFJV
			Guidelines for NHFJV
			Initiation of NHFJV
			Suggested settings for NHFJV
			Weaning from NHFJV
			Transitioning from invasive HFV
			NIV during transport
		High-flow nasal cannula
			Physiologic principles
				Advantages of using HFNC
				Disadvantages and safety concerns
		HFNC versus CPAP
			HFNC for weaning from NCPAP
		HFNC versus LFNC
			Recommendations
		Guidelines for using HFNC
			Indications in NICU
			Initiation of high and low-flow cannula
		Stable phase for HFNC
		Stable phase for LFNC
			Weaning phase for HFNC
			Weaning phase for LFNC
			Precautions when using NIV
		Summary and future of NIV
		Major limitations with NIPPV use in low and middle income countries
		Case reports
		Online supplementary material
		References
	Chapter 18A - Continuous Positive Airway Pressure for Respiratory Failure in Newborn Infants
		Chapter points
		Introduction
		Historical overview
		Physiological effects of CPAP
		Indications for nasal CPAP therapy
		Desirable features and major components of CPAP devices
		Randomized trials comparing continuous positive airway pressure devices
			Randomized controlled trials performed at birth
			Randomized trials of continuous positive airway pressure after extubation
		Practical aspects of nasal CPAP application and strategies for success
			Choose the appropriate size of nasal prongs
			Proper fixation of the nasal interface
			Optimizing nasal CPAP delivery by using chin straps and pacifiers
			Infant care and positioning while on nasal CPAP
			Frequent systematic check of delivery system and nasal prong position
			Avoiding gastric distension
			Nipple feeding and skin-to-skin care during nasal CPAP
			Weaning nasal CPAP
			Identifying and managing nasal CPAP failure
			Avoiding potential complications with nasal CPAP
		Randomized clinical trials of nasal CPAP versus intubation and surfactant
		CPAP in meconium aspiration syndrome
		Experience with nasal CPAP at Columbia University
		Summary
		Appendix: video of nasal CPAP application at birth in a 480 g preterm infant with RDS
		References
	Chapter 18B - Continuous Positive Airway Pressure in the Treatment of Meconium Aspiration Syndrome
		Chapter points
		Introduction
		Diagnosing meconium aspiration syndrome
		Pathophysiology of meconium aspiration syndrome
		Pulmonary mechanics of meconium aspiration syndrome
		Role of CPAP in meconium aspiration syndrome
		Summary
		References
	Chapter 19 - Nasal Intermittent Positive Pressure Ventilation
		Chapter points
		Introduction
		History
		Mechanism(s) of action
		Types of NIPPV—primary mode versus secondary mode
		NIPPV versus BiPAP
		NIPPV versus SNIPPV
		Clinical use of NIPPV
			Respiratory distress syndrome (RDS)
			Prevention of postextubation failure
			Apnea of prematurity
			BPD
		NIPPV failures
			Additional modes of synchronization to provide noninvasive support: NIV-NAVA
		Flow synchronization
		Practical guidelines for the use of NIPPV
			Indications
			Contraindications
			Potential hazards/complications
				Equipment and supplies
			Procedure
			Monitoring on NIPPV
			NIPPV—maintenance
			NIPPV: consideration for reintubation despite maximal support settings
		Real-life case scenarios
		Online supplementary material
		References
	Chapter 20A - High Frequency Ventilation
		Chapter points
		Introduction
		Brief history on HFOV
		Physiology of HFOV
			Mechanisms of HFOV
			Oxygenation in HFOV
			Ventilation in HFOV
				Amplitude
				Frequency
		Clinical application of HFOV
			The evidence behind HFOV
		High-frequency jet ventilation
			Mechanism of HFJV and ventilator adjustments
		Clinical cases
			Case of severe pneumomediastinum and pneumoperitoneum
			Case of severe BPD
		References
	Chapter 20B - High-Frequency Oscillatory Ventilation Management Strategy
		Chapter points
		Introduction
		Patient groups and indications
		Initiation of HFOV
			Patient preparation
			Initial settings
				Rescue therapy with optimal lung volume strategy
				Rescue therapy with “low” lung volume strategy (e.g., air leak, nonhomogeneous lung disease)
		Adjusting settings during HFOV
			Oxygenation
			Ventilation
			I:E ratio
			Volume targeting
			Radiology
			Monitoring
			Disconnection and suction
			Surfactant therapy during HFOV
			Potential complications of HFOV
			Assessing failure on HFOV
		Weaning from HFOV and extubation
			Weaning of HFOV
			Extubation
			Troubleshooting and alarms
			Supporting parents and careers
		References
	Chapter 20C - High-Frequency Jet Ventilation: Guide to Patient Management
		Chapter points
		References
	Chapter 21 - Pulmonary Vasodilators in the Treatment of Persistent Pulmonary Hypertension of the Newborn
		Chapter points
		Introduction
		Regulation of vascular tone in pulmonary circulation
		General management of PPHN
		Use of surfactant therapy for PPHN
		High frequency ventilation
		Inhaled nitric oxide therapy
			Use of iNO therapy in premature infants for hypoxic respiratory failure and prevention of BPD
			Use of vasodilators in BPD pulmonary hypertension
		Phosphodiesterase-5 inhibitors
		Prostaglandins in PPHN
			Epoprostenol (Flolan, Veletri)
			Iloprost (Ventavis)
			Treprostinil (Tyvaso, Remodulin and Orenitram)
			Prostaglandin E1 (Alprostadil)
		Phosphodiesterase-3 inhibitors
			Milrinone (Primacor)
		Endothelin receptor antagonist
		Other vasodilators tested in PPHN
			Magnesium sulfate
			Adenosine
			Steroids
		Conclusions
		References
		Further Reading
	Chapter 22 - Extracorporeal Membrane Oxygenation for Refractory Respiratory Failure
		Chapter points
		Introduction
		Indications
			Indications for ECMO enrollment
		Contraindications
			Weight less than 2 kg
			Gestational age less than 34 weeks
			Intracranial hemorrhage
		ECMO cannulation: venovenous or venoarterial?
		Congenital diaphragmatic hernia
			Efficacy of ECMO for CDH
			CDH surgery on ECMO
		ECMO circuit and components
		Neurologic system
		Neuromonitoring on ECMO
		Sedation and analgesia
		Respiratory support
		Cardiovascular supports
		Fluids, electrolytes, and nutrition
		Infection
		Anticoagulation
		Hematologic issues
		Weaning ECMO
		Neonatal ECMO survival
		Long-term neurodevelopmental outcomes
		CDH
		Recommendations for long-term follow-up
		Summary
		References
Section V - Clinical Management
	Chapter 23 - Principles of Mechanical Ventilation and Strategies of Ventilatory Support in Neonatal Lung Disease
		Chapter points
		Introduction
		Basics of conventional positive pressure ventilation
			Peak inspiratory pressure
			Positive end-expiratory pressure
			Ventilator rate
			Inspiratory–expiratory ratio
			Inspiratory fractional oxygen concentration
			Flow rate
			Effect of dead space
		Ventilator management of common respiratory conditions in the neonate
			Ventilator management of respiratory distress syndrome
				Clinical criteria
				Blood gas criteria
			Management of refractory apnea of prematurity
			Management of established bronchopulmonary dysplasia
			Term infants requiring mechanical ventilation
		Conclusion
		References
	Chapter 24 - Respiratory Distress Syndrome and Surfactant Therapy
		Chapter points
		Introduction
			Surfactant metabolism
			Surfactant functions
			Pathophysiology of RDS
			Epidemiology of RDS
			Prenatal diagnosis of RDS
			Clinical features
				Presenting features
			Clinical course
			Laboratory findings and diagnosis
			Differential diagnosis
		Management of RDS
		Prenatal management
			Antenatal corticosteroid therapy
				Mechanisms of action
				Recommendations
		Delivery room management
			Blended air and oxygen
			CPAP and NIV
			Sustained inflation
		Surfactant therapy: type, timing, technique for surfactant treatment
			Types of surfactant
				Synthetic surfactants
					First-generation synthetic surfactants
					Second-generation synthetic surfactants
			Studies with synthetic- versus animal-derived surfactants
			Animal-derived surfactants
				Preclinical studies
				Clinical studies with animal-derived surfactants
				Bovine surfactants
				Porcine surfactant
				Bovine versus porcine surfactant
			Third-generation synthetic surfactant
		Indications of surfactant administration
		European Consensus Guidelines for RDS management (2016 update) [89]
		Timing of surfactant administration: prophylaxis versus rescue
		Timing of surfactant administration: early versus delayed rescue/selective surfactant Rx
		Timing of surfactant administration: beyond the first week of age
		Techniques of surfactant administration: INSURE versus modified INSURE
			Modified insure technique
			Collaborative Paired Trial Investigating MIST (OPTIMIST)
			Noninvasive surfactant treatment (NIST)
				Aerosolized surfactant
		Combination therapies with surfactant
		Surfactant as vehicle
		Surfactant with nitric oxide
		Recombinant club cell protein (rhCC-10)
			Surfactant treatment for acute RDS (ARDS)
			Oxygen supplementation beyond stabilization during RDS management
		Caffeine therapy
		Permissive hypercapnia
		Postnatal steroids
		Inhaled nitric oxide
		Supportive management
		Temperature control
		Fluid management
		Nutrition
		Use of antibiotics
		Cardiovascular management
		Complications of RDS
			Endotracheal tube complications
			Pulmonary air leak
		Ventilator management of RDS
			Noninvasive respiratory support
		Mechanical ventilation strategies
		Ventilatory management of complications of RDS
		Summary and recommendations
		Cases
		References
	Chapter 25A - Meconium Aspiration Syndrome—Part 1: Epidemiology, Pathophysiology, Signs and Symptoms, and Diagnosis
		Chapter points
		Introduction
		Significance of MSAF
		Epidemiology of MSAF
		Pathophysiology of MSAF
		Meconium aspiration
			Definitions of MAS
			Incidence
			Pathophysiology of MAS
				Airway obstruction
				Noninflammatory
				Inflammatory response
				Pulmonary hypertension
			Clinical features
			Differential diagnosis
			Initial diagnostic tests
				Chest X-ray
				Lung ultrasonography
				Pre- and postductal oxygen saturation
				Arterial blood gas
				Complete blood count
				C-reactive protein and procalcitonin
				Blood culture
				Hyperoxia test
				Echocardiography
		References
	Chapter 25B - Meconium Aspiration Syndrome—Part 2: Clinical Management
		Chapter points
		Delivery room management
		Respiratory support—recruitment phase
		Respiratory support—stable phase
		Respiratory support—weaning phase
		Cardiovascular support
		Bicarbonate infusion
		Antibiotics
		Chest physiotherapy
		Pulmonary vasodilators
		Extracorporeal membrane oxygenation
		Air leak syndromes
		Cases
		References
	Chapter 26 - Persistent Pulmonary Hypertension of the Newborn (PPHN)
		Chapter points
		Introduction
		Definition
		Pathophysiology
			Pulmonary vasculature
			Lungs
			Cardiac changes
		Hemodynamic changes
		Mechanism of PPHN
		Etiology of PPHN
		Clinical features
		Severity of PPHN and HRF
		Management
		Inhaled nitric oxide
		Other pulmonary vasodilators
		Extracorporeal membrane oxygenation
		Asphyxia, hypothermia, and management of PPHN
		Long-term outcome of PPHN
		Conclusion
		References
	Chapter 27 - Bronchopulmonary Dysplasia
		Chapter points
		Definition
		Incidence
		Etiopathogenesis
		Clinical course
			Early phase (up to 1 postnatal week)
			Evolving phase (>1 PN week to 36 weeks’ PMA)
			Established phase (>36 weeks’ PMA)
		Acute episodes of respiratory deterioration
		Radiologic characteristics
		Management
			Antenatal interventions
			Golden hour practices in infants younger than 33 weeks’ gestation
			Postnatal interventions
				Oxygen therapy
				Ventilator strategy
					Noninvasive ventilation: NCPAP
					Nasal intermittent positive pressure ventilation
					Invasive ventilation: IPPV or IMV
					Patient-triggered ventilation
					Volume-targeted ventilation versus pressure-limited ventilation
					Mandatory minute ventilation
					High-frequency oscillatory ventilation
					“Gentle ventilation”: summary of approach
					Suggested ventilator settings and targets for infants with early, evolving, and established phases of BPD [10]
						Ventilatory parameters in phases of disease
						Monitoring of BPD patients
					Early phase (up to 1 PN week) [10]
					Evolving phase (>1 PN week to 36 weeks’ PMA) [10]
					Established phase (>36 weeks’ PMA) [10]
					Management of severe BPD
					Additional practical guidelines
				Surfactant replacement therapy
				Nutrition
				Patent ductus arteriosus [63]
					Clinically significant PDA
					Hemodynamically significant PDA
					Medical management of PDA
				Inhaled nitric oxide (iNO) therapy
				Caffeine administration
				Diuretics [79–86]
				Corticosteroids [87]
		Summary of the pharmacological management of BPD
		Complications
			Bronchoscopy indications in an infant with established BPD
			Tracheostomy indications
		Pulmonary outcomes
			Morbidity
			Radiologic findings
			Pulmonary function
			Neurodevelopmental outcomes
		Summary of treatment
		Home therapy/follow-up management [142]
		Mild BPD
		Severe BPD
		References
	Chapter 28 - Congenital Diaphragmatic Hernia
		Chapter points
		Pathophysiology
			Effects on lung and heart
			Genetic basis
			Antenatal diagnosis and monitoring
				Antenatal prediction of outcome
				Liver position
				Predicting severity of PH in CDH
					Monitoring
					Timing and mode of delivery
					Fetal surgery
					Summary for antenatal management once a CDH is diagnosed
			Postnatal presentation of CDH
				Hemodynamics in CDH and cardiac dysfunction
				Natural course of CDH–PH
			Management
				Respiratory management and mechanical ventilation
					Mode of ventilation
					Oxygenation
					Ventilator weaning
					Appropriate oxygen exposure in CDH–PH
			Summary of ventilator support based on OI and clinical course of disease
				OI of 15–25
					Initial stage
					Maintenance phase
					Weaning phase
				OI 25–40
					Initial phase
					Maintenance phase
					Weaning phase
				OI >40
				Complications of mechanical ventilation in CDH
				Hemodynamic support
					Diagnosis and management of CDH–PH
			Pulmonary vasodilators
				Inhaled nitric oxide (iNO)
				Other pulmonary vasodilators
			Milrinone
			Vasopressin
			Role of hydrocortisone supplementation/adrenal insufficiency in CDH
			Extracorporeal membrane oxygenation
			Surgical management of CDH
			Late PH in CDH
			Follow-up of infants with CDH complications and morbidities
				General follow-up guidelines
				Respiratory complications
				Chronic PH
				Gastrointestinal outcomes
				Surgical issues
				Neurodevelopmental morbidities and outcomes
		Future directions and therapies
			Antenatal
			Postnatal
		References
	Chapter 29 - Care of Extremely Low Birth Weight Infants
		Chapter points
		Introduction
		Prenatal management
			Prenatal consultation
			Prenatal steroids
			Magnesium for neuroprotection
			Delivery room care of the ELBW neonate
				Temperature maintenance
			Placental transfusion after birth
				Delayed umbilical cord clamping
				Umbilical cord milking
			Respiratory support in the DR
				CPAP
				PPV in the DR
				Sustained lung inflation
				Use of oxygen and pulse oximeter in the delivery room
				Surfactant administration
					Golden hour
			Management of RDS
				Early caffeine therapy
				Gentle ventilation strategies
				Permissive hypercapnia
			Synchronized mechanical ventilation
				SIMV
				A/C
				PSV
			Volume-targeted ventilation
			High-frequency ventilation
			Suggested ventilator management of RDS
				Initial (recruitment) phase
				Stable phase
				Respiratory support—weaning phase
				Management of pulmonary air leaks
				Postextubation respiratory support
					Neurally adjusted ventilatory assist
		Management/prevention of nonrespiratory complications in ELBW infants
			Hemodynamic instability and neonatal shock
				Defining hypotension
					Subsequent therapy
			Intraventricular hemorrhage
			Retinopathy of prematurity
			Patent ductus arteriosus
			Sepsis
			Necrotizing enterocolitis
			Fluids, electrolytes, and nutrition management
				Fluids
			Hypokalemia
			Hyperkalemia
			Neonatal hyperglycemia
		Outcomes of ELBW infants
		Clinical cases
		References
		Further reading
Section VI - Cardiac Issues in Neonatal Respiratory Care
	Chapter 30A - Echocardiography and Hemodynamics
		Chapter points
		Cardiopulmonary interdependence
			The transition
			Impaired transition
			The impact of ventilation on the cardiovascular system
				Impact on right heart filling
				Impact on PVR
				Impact on left ventricular performance
		Cardiovascular assessment
			Clinical assessment
			The utilization of echocardiography in the neonatal intensive care unit
				Assessment of pulmonary pressure
				Assessment of right ventricular systolic performance
				Assessment of LV systolic performance
				Novel modalities
		Hemodynamic assessment in specific situations
			Classic pulmonary hypertension in the term/preterm neonate
			Acute pulmonary hypertension and structural congenital heart disease
			Congenital diaphragmatic hernia
			Hypoxic ischemic encephalopathy
			The infant of a diabetic mother
			Patent ductus arteriosus
			Post-PDA ligation cardiorespiratory considerations
			Chronic pulmonary hypertension in the preterm infant
			Role of targeted neonatal echocardiography in guiding cardiorespiratory care
				Acute pulmonary hypertension in the term neonate
				Acute pulmonary hypertension in the preterm neonate
				Structural congenital heart disease
				Congenital diaphragmatic hernia
				Hypoxic ischemic encephalopathy
				Infant of a diabetic mother
				Patent ductus arteriosus
				PDA ligation postoperative management
				Chronic pulmonary hypertension
		References
	Chapter 30B - Patent Ductus Arteriosus
		Chapter points
		Introduction
		Ductus arteriosus in the fetus
		Pathophysiology of ductal closure after birth
		Etiology of patency of the ductus arteriosus
			Prematurity
			Genetic factors
			Environment factors
			Infectious
		Hemodynamic changes associated with PDA
			Term infant
			Preterm infant
				Impact of PDA on lung function
				Impact of PDA on systemic hemodynamics
		Influence of PDA on neonatal respiratory care and management
		Clinical features
		Diagnosis and work-up
			Radiology
			Electrocardiogram
			Echocardiography
				Left atrium
				Left ventricle
				Left ventricular function
					LV fractional shortening
					LV area shortening
				Pulmonary artery pressure
					Tricuspid insufficiency jet
					Pulmonary insufficiency jet
					Patent ductus arteriosus jet
				PDA diameter
				Descending aortic flow pattern
				Summary of echo-Doppler findings of the PDA
				Comments
				Ductal aneurysm
				Cardiac catheterization
			Biomarkers
		Classification of the PDA
		Severity of the PDA (hemodynamically significant)
		Management
			Conservative or expectant management
				Respiratory management of hsPDA
			Pharmacological management of the PDA
				Prophylactic use of Indomethacin
				Prophylactic use of ibuprofen
				Prophylactic use of indomethacin or ibuprofen
				Pharmacologic treatment of symptomatic PDA
				Other cyclooxygenase inhibitors
					Mefenamic acid
					Paracetamol
				Approach to pharmacological therapy
			Conventional surgical closure of the PDA
			Video-assisted thoracoscopic surgical closure of the PDA
			Percutaneous closure of the PDA
				Devices available for closure of PDAs in term infants
				Devices available for closure of PDAs in premature infants
				Indications and selection for percutaneous closure of PDA in premature infants
				Method of percutaneous closure of PDA in the premature infant
				Reported experience with percutaneous closure of the PDA
				Percutaneous PDA closure experience at our institution
			Which procedure
		Summary and conclusions
		References
		Further reading
	Chapter 30C - Cyanotic Heart Disease in a Neonate
		Chapter points
		Background information
			Disease categories
				Duct-dependent pulmonary circulation
				Admixture lesion causing cyanosis in newborn period
				Parallel circulation
				Obstructed pulmonary venous return
			Diagnostic evaluation
			Initial resuscitation and stabilization of a newborn with suspected heart disease
				Airway and respiratory support
				Access
				Oxygen
				Prostaglandin
			Transportation
				Communication checklist for transportation
				Personnel for neonatal transport
				Monitoring during transport
				Care of the newborn during transport
			Definitive management of congenital heart disease
			Mechanical ventilation in newborns with congenital heart disease
				Why does ventilation become necessary? How does it alter hemodynamics?
				Specific considerations in neonatal population with CHD
					Duct-dependent lesions
						Duct-dependent systemic circulation
						Duct-dependent pulmonary circulation
				Transposition of great arteries with intact ventricular septum
				Complex CHD with increased pulmonary blood flow
				Ventricular dysfunction
					Right ventricular dysfunction
					Left ventricular dysfunction
				Pulmonary hypertension
			Postoperative ventilation: general principles
		Conclusions
		References
		Further reading
	Chapter 30D - Neonatal Arrhythmias
		Chapter Points
		Abbreviations
		Types of rhythm disturbances
		Tachyarrhythmia: rhythm disturbances with fast heart rate
		Important points for tachycardia
		Premature beats and pauses
		Important points about premature/ectopic beats
		Bradyarrhythmia: rhythm disturbances with low heart rate
		Others
			Long QT syndrome
			Bundle branch block
		Evaluation and management protocol
		Management of arrhythmia in neonates
			General points
			Specific treatment
		Further reading
	Chapter 31A - Neonatal Shock Management
		Chapter Points
		Introduction
		Definition
		Stages of shock
		Types of shock
		Shock pathophysiology
			Pathophysiological correlates of neonatal disease states
			The autoregulation
		Enhanced hemodynamic assessments tools
			Targeted neonatal echocardiography assessment
			Whom to treat and when to treat hypotension
			Interventions in hypotension
		Basic pharmacology
			Volume replacement
			Dopamine
			Dobutamine
			Adrenaline/Epinephrine
			Noradrenaline
			Vasopressin
			Milrinone
			Levosimendan
			Pentoxifylline
				The dilemma of treatments
					In the NICU A
					In the NICU B
					In the NICU C
			Future directions, trials, and research
		Summary and conclusion
		References
		Further reading
	Chapter 31B - Hypotension and Shock in Preterm Newborns
		Chapter points
		The unique characteristics of the neonatal cardiovascular system
		Hemodynamic monitoring of preterm infants
		Blood pressure and cerebral blood flow
		Hypotension
		Pathophysiology of hypotension
		Shock
		Shock without hypotension
		Shock with hypotension
		Key learning points
		References
		Further reading
	Chapter 31C - Hypotension and Poor Circulation in Neonates
		Chapter points
		Introduction
		Hemodynamic assessment of the newborn
		Clinical assessment
		Blood pressure
		Blood flow
		Cardiovascular support therapies
		Stepwise approach to cardiovascular support
			Transitional hypotension in the very preterm infant
			Sepsis with cardiovascular compromise, or systemic inflammatory response syndrome after major surgery
			Cardiovascular support in infants with pulmonary hypertension
			Cardiovascular support after significant perinatal hypoxia
		References
Section VII - Ancillary Services
	Chapter 32 - Monitoring of Gas Exchange in the NICU
		Chapter points
		Physiology of gas exchange
			Oxygen transport
				Carbon dioxide transport
				Assessment of acid-base balance
		Blood gas analysis
			Measurement of pH
			Measurement of PaCO2
			Measurement of PaO2
			Measurement of bicarbonate
			Measurement of base excess
		Common acid–base disturbances in the NICU
			Respiratory acidosis
			Respiratory alkalosis
			Metabolic acidosis
			Metabolic alkalosis
		Sampling sites for blood gas analysis
			Arterial blood gas
			Venous blood gas
			Capillary blood gas
			Temperature correction
			Errors in blood gas monitoring
		Noninvasive monitoring of oxygenation—pulse oximetry
			Indications of pulse oximetry
			Delivery room
			CHD screening
				Limitations of pulse oximetry
			Hypoperfusion and hypothermia
			Movement artifact
			Signal averaging time
			Hemoglobin variants—functional versus fractional saturation
			Additional considerations
		Perfusion index and plethysmographic variability index
			Transcutaneous oxygen saturation monitoring
			Noninvasive assessment of PaCO2
			Capnography and end-tidal CO2 monitoring
				Measurement
				Mainstream and sidestream capnography
				CO2 monitoring in NICU
				Capnometry during neonatal anesthesia
			Colorimetric CO2 detectors
				Endotracheal intubation
			EtCO2 in nonintubated patients
				Pitfalls
			Transcutaneous CO2 monitoring
			TcCO2 versus capnography
			Near-infrared spectroscopy
				Limitations of NIRS
			Conclusions
		References
	Chapter 33 - Nursing Care and Endotracheal Suction
		Chapter points
		Introduction
		Neonatal history
			Maternal history
			Birth history
		Assessment of neonate
			Observation
			Palpation and percussion
			Auscultation
			Newborn respiratory distress score
		Selection and set up of equipment for respiratory support
			Essential equipment for each infant care area
			Supplemental oxygen
			Continuous positive airway pressure
			Bubble CPAP
			Infant Flow SiPAP
			Nasal high-flow therapy
			Noninvasive mechanical ventilation (NIMV/NIPPV)
			Positive-pressure ventilation
			High-frequency oscillatory ventilation
			Endotracheal intubation
			Ventilator-associated pneumonia
		Nursing care of the neonate and monitoring of equipment
			Hand hygiene
			Clinical evaluation and ongoing assessment
			Assessment of blood gases
			Noninvasive respiratory monitoring
			Ventilator settings
			Imaging
			Real-time pulmonary graphics [42]
		Airway patency and suction
			Noninvasive nasal and nasopharyngeal suction
			Endotracheal suction
		Chest physiotherapy
			Indications
			Contraindications
			Precautions
			Procedure
		Monitoring for complications
		General supportive care
			Minimal handling
			Positioning
			Oral care procedure for ventilated neonate
			Sedation and pain management
			Medications
			Nutrition
			Developmental care [65]
			Documentation
		Summary
		Online supplementary materials
		References
	Chapter 34 - Neonatal Airway Management
		Chapter points
		Introduction
		Airway pathology
			Nose
				Congenital nasal pyriform aperture stenosis (CNPAS)
				Choanal atresia
				Nasal masses
			Oral cavity/oropharynx
				Micrognathia
			Larynx
				Laryngomalacia
				Laryngeal cyst
				Laryngeal cleft
				Laryngeal web
				Vocal cord paralysis
				Subglottic stenosis
			Trachea and bronchi
				Tracheobronchomalacia
				Tracheoesophageal fistula
				Tracheal stenosis
				Necrotizing tracheobronchitis
			Vascular abnormalities
				Hemangioma
				Vascular compression
		Procedures
			Flexible fiberoptic laryngoscopy
			Direct laryngoscopy and bronchoscopy
			Tracheostomy
			Supraglottoplasty
			EXIT procedure
		References
	Chapter 35 - Ventilator-Associated Pneumonia and Infection Control
		Chapter points
		Introduction
		Magnitude and significance of VAP
		Definition and diagnosis of VAP
			Procedures for obtaining tracheal aspirate
			Isolation of microorganism from tracheal aspirate: colonization versus true infection
		Pathogenesis of VAP
			Susceptible host with compromised defense system
			Microbial causes and sources
			Endogenous sources of microbes
				Role of Naso-oro-pharyngeal and stomach microbes in causing VAP
				Exogenous sources of microbes
			Biofilm formation and VAP
			Pathogenic sequential evolution of microbes in NICU and development of VAP
		VAP treatment and prevention
			VAP treatment
			VAP prevention
		Health care-associated infection and central line-associated bloodstream infection
			Background
			CLABSI definition
			CLABSI prevention
		Audit and surveillance of VAP, CLABSI and HAI
		Cleaning, disinfection, and sterilization in NICU
		Implications for practice
		References
	Chapter 36 - Nutrition in the Preterm Neonate Requiring Respiratory Support
		Chapter points
		Introduction
		Nutritional goals
		Fluids
			Total fluid requirements
			Term infants
			Preterm infants
			Monitoring and considerations
			Summary
			Enteral nutrition
			Energy intake
			Initial feedings
			Advancement of enteral feeds
			Feeding method
			Feeding intolerance
			Re-feeding aspirates
			Considerations
			Nutritional supplements
				Proteins
				Carbohydrates
				Lipids
				Calcium
				Vitamin D
				Iron
				Other supplements
		Human milk fortification
		Probiotics
			Definitions
			Summary
			Parenteral nutrition
			Indications
				Medical
				Surgical
			Routes
			Fluids and energy
			Nutrients and respiratory diseases
				Carbohydrates
				Lipids
				Protein
				Minerals
				Vitamins
			Composition of parenteral nutrition solutions
				Carbohydrates
				Proteins
				Cysteine hydrochloride and glutamine
				Lipids
				Carnitine
				Vitamins
				Trace elements
				Electrolytes
			Heparin
			Complications of parenteral nutrition
			Monitoring of parenteral nutrition
			Weaning parenteral nutrition
			Summary
		References
		Further reading
	Chapter 37A - Neonatal Procedures Involving Catheters and Tubes
		Chapter points
		Abbreviations
		Introduction
		Umbilical arterial catheters
			Procedure
			Complications
			Care and surveillance
			Recommendations
		Umbilical venous catheters
			Procedure
			Complications
			Care and surveillance
			Recommendations
		Peripherally inserted central catheters
			Procedure
			Complications
			Care and surveillance
			Recommendations
		Peripheral artery catheterization
			Procedure
				Allen’s test
			Technique
			Complications
			Care and surveillance
			Recommendations
		Thoracocentesis and intercostal chest drain placement
			Pneumothorax
			Pneumopericardium
			Procedure
			Complications
			Care and surveillance
			Recommendations
			Pericardiocentesis
				Complications
				Procedure
					Apical
					Parasternal
					Subxiphoid
				Care and surveillance
		Endotracheal intubation
			Premedication
			Procedure
			Complications
			Care and surveillance
			Recommendations
		Laryngeal mask airway
		Conclusions
		References
		Further reading
	Chapter 37B - Neonatal Limb Ischemia Due to Arterial Catheters
		Chapter points
		Introduction
		Umbilical arterial catheterization
		Peripheral arterial catheterization
		Clinical presentation of limb ischemia associated with arterial catheters
		Prevention
		Management
			Conservative management
			Medical management (drug therapy)
				Nitroglycerin patch
				Nitroglycerin patch and Papaverine
			Thrombolytic therapy
				Heparin
				Streptokinase (SK) and urokinase (UK)
				Tissue plasminogen activator
			Surgical management
		References
Section VIII - General Issues
	Chapter 38 - Neonatal Developmental Follow-Up Program
		Chapter points
		Introduction
		Programs, criteria, its objectives, and benefits
		Recommended follow-up schedule
		Calculation of the corrected age
		The tools used in newborn to 12 months
		Speech and language evaluation
		Emotional and social behavior and adaptation
		Other evaluation tools recommended for research purposes
		References
	Chapter 39 - Management of Ethical Challenges in Neonatal Intensive Care
		Chapter points
		Common ethically challenging questions in the NICU
			In which patients, should life-sustaining therapy not offered or considered optional?
			How should disagreement between the parents and the clinicians about initiation, continuation, or escalation of life-sustai...
			How should decisions about life-sustaining therapy be made when resources are limited?
		A framework for ethical analysis
		Preventive ethics and advance planning
		Brain death
		Palliative care
		Care after LST has been withheld, withdrawn, or limited
		Communication skills and language in ethically challenging situations
		Care after death
	Chapter 40 - Normal Reference Values
		Chapter points
		Hematological parameters
			Hemoglobin
			Hematocrit
			Nucleated red blood cell (nRBC)
			Total count and differential count
			Platelet counts
		Biochemistry values
		Coagulation parameters
		Blood gas
		CSF values
		Urine
		Blood pressure
		Growth charts (Fenton for girls and boys)
Index