THE PROCESS OF EDUCATION PROJECT
The process of this education project will have to focus amicably on the Neonatal Intensive Care Unit dealing towards such respiratory support in such brochure form as the education brochure in itself will then focus on different types of ventilators as well as the different modes of ventilations like for instance, the endo-tracheal tube, continuous positive airway pressure (CPAP) which involves high-flow nasal prong, low-flow nasal prong. There will also appropriate discussions for certain potential complications of artificial ventilation along with such basic terms in order for the parents mostly, the families as well as the care support group such as health care providers, physicians and nurses to understand fully how respiratory support usually occur in NICU and in turn, have the possibility to be aware of such issues and challenges regarding such matters when it comes to quality life and utmost care services and support that must be given to the new born babies mostly, those premature ones.
TOPIC CHOICE, RESEARCH DONE AND IMPLEMENTATION
The above topic has been chosen due to such cases of neonate mortality and sometimes not and immediate concern of the families involved and the parents may lack proper knowledge of how to make good choices when it comes to NICU support processes and the objective to bring in fully knowledgeable health and family community groups respectively. Thus, in order to allow professionalism in such medical practices to communicate as well as intervene properly of such situations arising from the NICU as it is a case to case basis. The topic was researched through collaboration of research knowledge and evidences in a well presented literature studies as found in related books, peer reviewed journals and articles from reliable resources and libraries such as as well as other supporting research materials and resources. Thus, explanation, analysis and evaluation of such collated data and information is very much evident in this brochure. Then, the execution of the education project integrates such plan of distribution through such awareness programs and campaigns for the parents and the society involved therein. The realization of such symposiums, panel discussions and related support seminars is imperative and an essential factor for inculcating the right knowledge to parents and families and the community involved and it is just appropriate to provide them copies of the brochures and whatsoever campaigns related to the core and essence of the topic as truly needed. True, physicians and nurses take better interest in ensuring that every neonate is receiving the proper medications, with the focal point that is, to care of medically delicate infants. Another is to help families make transition from illness to wellness and help them overcome fear of baby's condition when they are preparing for discharge as support group of parents is available to provide families with advice and support throughout baby's health condition.
BACKGROUND
Neonatal intensive care has become leader in provision of family-centered care, which recognize unique and individual needs of each infant and family. Family-centered care, philosophy of care which the pivotal role of family is acknowledged and respected the lives of children. Within the philosophy, parents and professionals are equal in partnership committed to the child and development of optimal quality in delivery of health care levels. Then, the nurse is responsible for monitoring the alarms and baby’s respiratory status and responsible for notifying the respiratory therapist when mechanical problems occur with the ventilator and when there physician orders requiring changes in the setting parameters. Meanwhile, the physician is responsible for keeping track of patient's status on ventilator settings and changing it if deemed necessary (2005 ; 2005).
The ability to better support vulnerable infants and families has changed because of substantial increase in knowledge and understanding of physiologic, psychosocial and neurobehavioral capabilities of high risk infants. In addition to growth in knowledge, there were advancements in technology, such as development of surfactants and the refinement of mechanical ventilation, that have influenced the ability of medical personnel to physiologically support infants. For example, although there is mystery to the underlying patho-physiology of retinopathy of prematurity, refined management of progression of disease often minimizes long-term problems for infants. The expert nursing care requires artful use of technology and integration of developmentally supportive and family-centered concepts into routine medical practices (2001 ; 2004 ; 2004).
TYPES OF VENTILATORS AND ITS MODES
Generally, there are kinds of technology including different types of infant ventilators and supportive devices, such as infusion pumps, oxygen hoods and incubators. Although equipment has become more responsive to the needs of the infants, there is still much the scientific and medical communities can learn about the use of technology to support neonates. The benefits of machines are often coupled with iatrogenic hazards that may lead to long-term complications and increased numbers of chronic patients. Although equipment is intended to support infants, many times all it does is increase the time infants spend in the NICU with little improvement in long-term outcomes. Technology must be used sensibly with outcomes and cost-benefit as part of decision-making process. Even with the technological advances and interventions available to the premature infant, nothing can substitute for normal environment of mother’s womb ( 2003;2005).
Amicably, ventilator is device used to provide assisted respiration and positive-pressure breathing and provide mechanical ventilation for neonate with respiratory problems, cannot breathe effectively on their own. These ventilators are then used to decrease myocardial gas consumption and or intracranial pressure, in providing stability of the chest wall when being sedated or paralyzed. Different types of ventilators were programmed to provide modes of ventilation as follows: Thus, positive pressure ventilators require artificial airway like, endo-tracheal tube and use positive pressure to force gas into infant’s lungs as inspiration can be triggered either by the baby or the machine as mode refers how the machine will ventilate the neonate in relation to baby’s own respiratory efforts ( 2005; 2004 ).
There is mode for such NICU situation such as: ( 2005 ;2004 )
- CONTROL VENTILATION as this delivers the preset pressure regardless of neonate’s own inspiratory efforts
- ASSIST-CONTROL VENTILATION this convey the preset volume in response to the inspiratory effort, but will initiate the breath if the patient does not do so within preset amount of time. This mode is used for patients who can initiate breath but who have weakened respiratory muscles. The patient may need to be sedated to limit the number of spontaneous breaths
- SYNCHRONOUS INTERMITTENT MANDATORY VENTILATION as the vent initiates each breath in synchrony with the patient's breaths and used as a primary mode of ventilation as well as a weaning mode
- POSITIVE-END EXPIRATORY PRESSURE involves positive pressure that is applied by the ventilator at end of expiration. This mode does not deliver breaths but is used as an adjunct to other modes in improving oxygenation. Thus, complications from increased pressure can be in decreased cardiac output and increased intracranial pressure
- CONSTANT POSITIVE AIRWAY PRESSURE (CPAP). CPAP works only for patients who are breathing spontaneously. The effect is compared to inflating balloon but not letting it completely deflate before inflating it again. The second inflation is easier to perform because resistance is decreased. CPAP can be administered using mask and CPAP machine for patients who do not require mechanical ventilation but who need respiratory support
- PRESSURE SUPPORT VENTILATION refers to preset pressure which augments the patient's spontaneous inspiration effort and decreases the work of breathing. The patient completely controls the respiratory rate and tidal volume.
UNDERSTANDING OF NASAL PRONGS
There has to be evaluation of amount of high flow nasal cannula (HFNC) gas flow required to generate an equivalent positive distending pressure as that provided by nasal continuous positive airway pressure (NCPAP), assess the relationships between positive distending pressure, gas flow, oxygen requirement, and patient weight and develop appropriate protocol to be used in the NICU for transitioning patients from NCPAP to an equivalent amount of HFNC. The infant will subsequently be placed on humidified HFNC at 6 liters per minute of gas flow. A standardized neonatal high flow nasal cannula will be used in all patients. The use of non-invasive ventilator strategies, such as nasal continuous positive airway pressure (NCPAP), in the treatment of RDS is thought to provide positive distending pressure while minimize lung inflammation and injury associated with mechanical ventilation (2001 ; 2001).
Avoidance of intubation and increased use of NCPAP to treat respiratory distress syndrome has been shown to decrease the incidence of chronic lung disease. However, NCPAP have clinical limitations. First, the administration of NCPAP has inherent mechanical difficulties in appropriately maintaining the nasal prong apparatus within the small neonatal nose. Secondly, the nasal prongs used to deliver NCPAP can cause nasal septal trauma. Lastly, some premature infants do not tolerate the NCPAP apparatus which must be tightly affixed to their nose and face. Although NCPAP continues to be used in most neonatal intensive care units, due to its aforementioned drawbacks, there will continue to look for effective, non-invasive modes of ventilation to provide support to premature infants with respiratory distress. Humidified high flow nasal cannula has been introduced into neonatal respiratory care as means of providing positive distending pressure to the neonate with respiratory distress. There aims to maximize patient tolerance by employing heated, humidified gas flow through the standard neonatal nasal cannula that is used routinely in neonatal intensive care units (2001 ; 2001 ). Until recently, NCPAP was mainstay of non-invasive ventilator support for premature babies but, HFNC is better tolerated and uses nasal cannula that is less prone to mechanical mishaps than NCPAP, it is clear that there is ample need for extra information to accurately treat babies with HFNC and will help guide the use of HFNC in preterm babies with respiratory insufficiency within knowledge of positive distending pressures derived from the HFNC system crucial in minimizing trauma to fragile, premature lung. ( 2001).
Furthermore, nasal supply systems provide an advantage in that they are generally more convenient and less intrusive than mouth based or mouth covering devices. Despite their convenience, nasal based devices are deemed uncomfortable in light of secure straps placed across the face and/or around the head and used to secure the device to an individuals breathing cavity. Moreover, conventional cannulas do not provide proper seal around the nares to inhibit apnea and to provide a high flow system to stimulate the patient's breathing. Henceforth, even with such secure straps, these nasal devices often dislodge from the breathing cavity. This is particular concern with children, infants, or the elderly who do not understand the importance of keeping the nasal breathing device in place, whether it is nasal CPAP ( 2001 ; 2001 ).
Henceforth, the application of such sufficient pressure, called continuous positive airway pressure has been found to be advantageous in maintaining minimum air volume or lung pressure when an individual is spontaneously breathing. CPAP can be supplied through nasal attachment devices such as nasal cannula or endo-tracheal devices. In care facility setting, it is not uncommon for an attendant to discover that the CPAP device has been disconnected from patient's nose, which can lead to hypoxia which is dangerously low oxygen levels in the blood. In practice, the tubing for CPAP's is draped around both sides of the patient's cheek which means that the most comfortable lying down position is on the patient's back. Pressure on patient's cheeks caused by the secure device can make other position comfortable ( 2001 ;2001). Accordingly, what is needed is security device having comfortable secure apparatus and method and which eliminates placement of supply tubes which wrap around the head to secure the CPAP device. The secure device should be easy to use and still provide steadfast attachment of nasal CPAP device in position directly under an individual's nose. The device provides port for assessment of the mean airway pressure in the device so that CPAP can be monitored or controlled. The combination of cone shaped prongs and adjustable secure tape will facilitate creation of a secure seal about the nares of the individual which enhances the effectiveness of the NCC device ( 2006 ; 2003 ).
Figure One: NC flow required to generate positive distending pressure in preterm neonates
POTENTIAL COMPLICATIONS OF VENTILATION
There describes unusual complication of nasal continuous positive airway pressure ventilation in preterm low birth weight neonate being weaned from respiratory support. The tube used to administer nasal CPAP became dislodged from its metal connector whilst in the nasopharynx and slipped into the stomach. After waiting eight days the tube showed no signs of passing spontaneously through the gastrointestinal tract and retrieval was then successfully achieved by means of a 3.5 mm pediatric fibreoptic bronchoscope without complication. The use of continuous positive airway pressure using nasal prongs and an underwater system for the management of premature babies with acute respiratory disease has gained popularity but remain controversial while the more common practice of surfactant replacement in the context of conventional approaches to intubation and ventilation with research-based evidence from clinical trials (2005; 2005). Nevertheless, the use of nasal prong bubble CPAP is used by neonatal intensive care units for acute management of respiratory disease to facilitate extubation and in non-NICU centers for early management of older gestational aged babies with respiratory distress. The decision as to whether baby had failed to respond to CPAP and required intubation was made by the attending neonatologist based on the consideration of respiratory or metabolic acidoses, rising oxygen requirement and the decision to wean off CPAP to low-flow oxygen was made by attending neonatologist (2005; 2005)
Mechanically ventilated patients are at high risk for nosocomial pneumonia along with the term infection such, early onset pneumonia as result of aspiration during the intubation process as these infections are often caused by antibiotic-sensitive organisms like, oxacillin-sensitive Staphylococcus aureus and Streptococcus pneumonia. Also, cultures obtained by suctioning secretions through the endo-tracheal tube do not reliably differentiate pneumonia and bacterial colonization of the trachea. The use of fiberoptic bronchoscope to obtain specimens with quantitative cultures of bronchial lavage fluid may be helpful in excluding a pulmonary source of infection in intubated patients who have new clinical signs that may be caused by noninfectious process. Thus, also atelectasis is common cause of severe hypoxemia that develops during mechanical ventilation, left lung atelectasis may result from intubation of the right main stem bronchus, problem that also may lead to over distention of the right lung signaled by increased inflation pressures. Massive pleural effusion should cause the trachea to deviate away from the involved lung (Walsh et al., 2005 p. 804; Weiss et al., 2004 p. 79). Moreover, worsening respiratory distress may develop as result of changes in the patient's cardiopulmonary status into mechanical malfunction. The first priority is to ensure patency and correct positioning of the patient's airway so that adequate oxygenation and ventilation can be administered during the ensuing evaluation. Briefly, note ventilator alarms, airway pressures and tidal volume. Low-pressure alarms with decreased exhaled tidal volumes may suggest a leak in the ventilator circuit. There implies understanding of complications of neonatal illnesses as well as of their treatments can enhance the effectiveness of early intervention services, devising creative approaches aimed at promoting the optimal development of medically vulnerable infants and supporting families during prolonged periods of intense stress. Community intervention professionals such as infant educators and physical, occupational, and speech therapists can improve these children's long-term outcomes by being knowledgeable about these health problems and devising creative family-centered early intervention strategies. The purpose is to provide early intervention professionals with a basic familiarity and understanding of newest technologies employed in NICU. The goal is to give early intervention professionals information about the types of medical problems facing infants to enhance the developmental care and the support for their families. Therefore, care should be taken to avoid exposing these babies to other people who are sick, and at the first sign of increased breathing effort visit to the infant's doctor should be considered. The particular importance is the emphasis on the behavior organization of infants. Some infants that leave NICU still lack a well-organized central nervous system, which result in less control of sleep, arousal, alerting, attention, fussing and feeding. Traditional hands on interventions may be contraindicated because many of the infants are not stabilized at neurophysiologic level that would allow them to effectively process the sensory input of therapies offered (2003 ; 2005 ).
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