Respiratory monitoring of premature and newborn neonate patients in the NICU or similarly tiered intensive care units presents a number of unique challenges. From preventing ventilator-induced lung injury to managing risks surrounding ventilator-associated pneumonia, ensuring patient safety aligns with various ventilation strategies is imperative.1
Anatomically speaking, infants do not breathe through their mouths as their adult counterparts would during continuous capnography monitoring, which presents additional challenges when attempting to capture appropriate ventilation and circulation.1 Although clinician care is approached differently from neonates to adults or even toddlers, studies find that non-invasive ventilation is an increasing trend and that type of ventilation may result in better outcomes.2
Whether hospitals have an on-site NICU or an emergency department (ED) whose protocol includes transportation of a neonatal patient to a level of care facility that supports resuscitative or supportive care, then respiratory monitoring precautions and use of the right tools must be taken to ensure care is not compromised for the tiniest of patients.
The American Heart Association (AHA) reports that approximately 10 percent of infants require delivery room respiratory intervention with 1 percent requiring extensive resuscitative measures.3 Neonates can be born with under-developed lungs, which may increase their need for mechanical ventilation.4 But oxygen delivery to pre-term infants must be strategic in order to avoid chronic lung disease issues such as bronchopulmonary dysplasia (BPD) or retinopathy of prematurity (ROP).2,5
Drawing arterial blood samples from a neonate presents its own set of risks. Due to the amount of blood needed and a neonate’s size, this could prevent an adequate sample from being drawn. Additionally, the longer the umbilical arterial line remains in, the higher risk of infection may also occur.6 An experienced clinician must ensure adequate management of the arterial line. As with adults, however, capnography can serve as a surrogate of arterial blood gases (ABGs).7
Reviewing the waveform during the respiratory cycle can indicate endotracheal tube (ETT) tubes are minimally taped, but millimeters can be crucial.4 The use of capnography may help make the difference between a catastrophic outcome or even death. Having ideal intubations to ensure a secure airway is important as well because neonates can de-saturate quickly and clinicians have less time to intervene without proper warning.
Previous capnography tools haven’t always provided accurate readings of neonate ventilation as they were not engineered for a neonate’s smaller size. However, clinicians’ care delivery is furthered with continuous capnography monitoring, which has been found to support improvements around control of neonate CO2 levels.8 This improvement is possible thanks to advancements in technology tailored toward neonates.8
Improved Microstream™ technology serves as a capnography solution — especially for neonate patients — and is offered in both intubated and non-intubated lines. The intubated lines are customized, catering to the petite size of a premature neonate. This allows for the appropriate air and space due to the small breath volume and the decreased size of a neonate’s lung capacity. This helps to minimize the dead space — the inhalation and exhalation space on the baby and where measurement readings occur for improved accuracy.
Infants that require transport to a more appropriate care facility benefit from the Microstream™ capnography monitoring to provide continuous assessment of ventilation and circulation. Pulse oximetry supports this as well, but capnography helps clinicians determine ETT placement or positioning during a transport that may present environmental interferences.9
Monitoring the continuous range of where the neonate should be supports early intervention. While Microstream™ capnography solution is not a diagnostic tool; it does support early monitoring of the at-risk neonate.
Additional benefits of the Microstream™ capnography monitoring lines for neonates includes:10
The Nellcor™ pulse oximetry monitoring system should not be used as the sole basis for diagnosis or therapy and is intended only as an adjunct in patient assessment.
1. Gnagi, Sharon H., Schraff, Scott A. Nasal Obstruction in Newborns. Pediatric Clinics of North America. August 2013. 60; 4: 903-922. https://www.sciencedirect.com/sdfe/pdf/download/eid/1-s2.0-S0031395513000667/first-page-pdf.
2. Rocha, G. Soares, P., Goncalves, A., Silva, AI. Almeida, D., Figueriedo, S., Pissarra, S., Costa, S., Henrique, S., Flor-de-Lima, F., Guimaraes,. H. Respiratory Care for the Ventilated Neonate. Canadian Respirator Journal. March 2018. https://doi.org/10.1155/2018/7472964.
3. American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC). Highlights of the 2010 American Heart Association Guidelines for CPR and ECC.
4. Lissauer, T. Avery, Neonatology at a Glance. 2006. https://download.e-bookshelf.de/download/0000/5951/26/L-G-0000595126-0003167438.pdf.
5. Fouzas, S., Volumetric Capnography in Infants with Bronchopulmonary Dysplasia et all Journal of Peddiatrics:2014. https://www.sciencedirect.com/science/article/abs/pii/S0022347613012055.
6. Cho HJ, Cho HK. Central line-associated bloodstream infections in neonates. Korean J Pediatr. 2019;62(3):79-84. doi:10.3345/kjp.2018.07003.
7. Hagerty, J., Kleinman, M., Zurakowski, D. et al. Accuracy of a New Low-flow Sidestream Capnography Technology in Newborns: A Pilot Study. J Perinatol 22, 219–225 (2002). https://doi.org/10.1038/sj.jp.7210672.
8. Kugelman, A., Golan, A., Riskin, A., Qumquam, N., Bader, D., Bromiker, R. Ronen, M., Shoris, I. Impact of Continuous Capnography in Ventilated Neonates: A Randomized, Multicenter Study. The Journal of Pediatrics. January 2016. https://doi.org/10.1016/j.jpeds.2015.09.051.
9. Kodali, B.S. Capnography in Pediatrics. A Comprehensive Educational Website. Edition 10, March 2019. https://www.capnography.com/pediatrics.
10. Medtronic. Quick Reference Guide. 2019:1-12. https://www.medtronic.com/content/dam/covidien/library/us/en/product/capnography-monitoring/microstream-capnography-sampling-lines-portfolio-reference-brochure.pdf.
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