The 23 Weeks < 500g infant

You are counseling a 23 4/7 week pregnant mother who was admitted this morning with PROM

• During fetal ultrasonography this am, the expected fetal weight (EFW) was 470g
• Mother has strong contractions every 5 minutes.

How would you plan to manage this newborn infant if delivered today?

The Spectrum of Respiratory Distress Syndrome

If you are a bCPAP starter: “Do Not” consider bCPAP in the “Initial” management of this infant. There are several factors that increase the chance for this infant to fail initial management with bCPAP:

• Severe lung immaturity
• Lung development is in the respiratory bronchiole phase
• Low number of developing alveoli
• Narrow collapsible airways
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• Reduced muscle mass
• Excessively compliant chest wall
• Severe apnea of prematurity

You may consider INSURE strategy for this infant or non-invasive instillation of surfactant

Insure StrategyWhat is Bubble Cpap

• INtubate-SURfactant-Extubate (intubate, give surfactant and extubate)
  Infants who are likely to need mechanical ventilation should be intubated and given surfactant as early as possible
• Infants who are not likely to need mechanical ventilation should not be exposed to the risk of intubation

Another alternative is to give surfactant non-invasively though MIST, LISA or LMA (see chapter: Contemporary Methods for Surfactant Administration in Neonates)

• Your 23-week infant was delivered the day after
• In the delivery room, infant didn’t breath and was limp and cyanotic
• After initial bag & mask ventilation, HR was 80 bpm but apnea continued
• Baby was intubated and bag ventilated
• HR, tone and color improved

The newborn infant was transferred to the NICU:

• Infant was placed on mechanical ventilation with PIP 20/ PEEP 5/ IMV 40/ FiO2 60%
• Central lines were placed and surfactant was administered
• Infant gradually stabilized and vent settings were gradually weaned…

Scenario for early extubation after surfactant administration

After 36 hours of life, infant is on

• SIMV PIP 17/PEEP 5/ IMV 25/FiO2 27%
• Trophic feeds of BM at 1ml q4 via orogastric tube

Do we have room for bCPAP?

• This infant is relatively ready for extubation
• You may extubate directly to bCPAP and if apnea develops you may switch to NIPPV
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OR

• You may extubate to NIPPV and if stable in 24–48h you can wean to bCPAP

On DOL#7 the infant has been on bCPAP over the last 2 days, after 2 days of intubation and mechanical ventilation and 3 days on NIPPV. This morning bloody gastric aspirates were noted! What should you do?

• Before starting your ‘NEC’ work up, check nasal septum
• Anterior and lateral nasal septum irritation, erosion, and bleeding may be induced by the continuous pressure and/or friction from inappropriately placed nasal prongs. The bridge between nasal prongs is resting or pressing on the nasal septum or the prongs are too large in size causing lateral compression on the septum.

Prevention is a key strategy:

• Use the correct size prongs
• Secure prongs with fitted hat and correctly position the corrugated tubes
• Do not allow the bridge of prongs to touch the nasal septum
• Avoid twisting prongs. This can cause lateral pressure against the septum

Case (5): Unexplained Failure

A 31 Week who is 24 hour old but failing bCPAP

This is a 31 week female with BW 1080 gram SGA who has been on bCPAP +5/ FiO2 21% for 12h. Now she is distressed with intercostal and subcostal retractions and her FiO2 is up to 38%. What is going on?

Think “Mechanical Failure”

• If bCPAP water bottle is not bubbling, then there is an air leak somewhere in the circuit. Remove prongs from nose and occlude them by hand to check for leak in the circuit
• Inspiratory or expiratory limbs are disconnected or have excessive water condensation will interfere with gas delivery
• There is a leak in the humidifier or leak in gas supply
• Inappropriate gas flow (< 5–7 L/m)

Check nasal interface placement

• Prongs may be outside the nose
• Prongs are too small (inappropriate size)
• Prongs are malpositioned
• Is the hat fitting snugly?
• Are the corrugated tubes fixed correctly to the hat on both sides and at the
• Correct angle to the prongs?
• Does the Velcro moustache need replacement?
• Infant’s mouth may be wide open leaking air out and needs a “chin strip”

If everything is Ok do chest x-ray

• Pneumothorax may occur on CPAP
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• It commonly occurs within first 12–24 hours
• Could be managed conservatively with expectant management (no needle aspiration)
• If a tension pneumothorax occurs, needle aspiration with no chest tube placement may be considered.
• If recurred, chest tube should be placed.
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Any of the above steps could be successfully achieved while on bCPAP (no routine intubation), intubation and mechanical ventilation should be considered only in unstable infants with severe hypercarbia, respiratory acidosis or bradycardia