Important Reminder: 

These are hypothetical situations and are not meant to be taken literally. Always follow your hospital's policies, procedures, and guidelines. Your hospital will have specific guidelines that you must follow in each department. These scenarios are purely educational. Always consult with your hospital providers before doing any medical procedure on patients. 

Medical Scenario #2 

Scenario: 

You are a respiratory therapist working in the Neonatal Intensive Care Unit (NICU) when you receive an call from the delivery room. They are expecting 39 week twins. You head over to the delivery room and the RN says they will be right behind you. As you are preparing you notice the RN has not arrived and the babies are almost ready to present. Do you need a second person for the delivery of twins? 

& DISCUSS:  Do you need a second person for the delivery of twins? 

ANSWER:  

Yes. There should be at least 1 person trained in neonatal resuscitation for each patient. 

ACTION:  

You make a phone call to the unit to get more help. An RN arrives just in time for the delivery. 

SITUATION:  

Baby A and Baby B have now been born. Baby A has good tone and breathes spontaneously. Baby B is noticed to have some grunting and retracting and has a very wet sounding cough. 

& DISCUSS:  What might you consider doing to improve the respiratory status of baby B at this time? 

ANSWER:  

Suctioning the oropharynx and possibly the nares.  Gently use a bulb syringe to relieve any secretion in the airway. Passing a suction catheter through the nares needs to be used with caution as this may cause additional damage and make it even more difficult for the baby to breathe. CPAP is also indicated for nasal flaring and retractions. There may be retained fluid in the lung. CPAP helps the baby overcome the higher resistance in the lung and can even help to push some of the retained fluid out of the alveoli. The goal is to decrease breathing and decrease resistance. 

ACTION:  

You suction the nares and oropharynx and obtain a large amount of thick clear fluid. You also start CPAP via flow inflating bag at 5 cm H20. 

SITUATION:  

You notice the baby still has a high WOB after 10 minutes in the delivery room and transfer the baby back to the NICU for further evaluation.  

& DISCUSS:  What are some items that you may want to consider recommending to the physician as a care plan for this

patient? 

ANSWER:  

 You would first want to address the respiratory component. Since there is still a high WOB, you would want to at least consider continuing CPAP in some way. This may be through high flow nasal cannula or a bubble CPAP system. If WOB is very high, you may want to consider NIV through a cannula/ventilator with a respiratory rate. Set Fio2 as low as possible to keep SPO2 in the appropriate range for the patient. Next you may consider obtaining a CXR and obtaining a blood gas for a baseline. Of course, this will need to be discussed with the physician before it is completed.  

ACTION:  

You start the patient on a bubble CPAP at 6 cm H20. A CXR is performed that reveals diffuse bilateral infiltrates. This looks like the beginning of RDS. A blood gas reveals: 

Ph          7.06 

CO2      82 

PO2       67 

HCO3   18 

BE          -6 

SITUATION: There are now severe substernal and intercostal retractions. 

& DISCUSS:  What interventions may you want to consider at this time? 

ANSWER:  

The blood gas indicated respiratory failure. There is also a metabolic acidosis component as well. Intubation should be considered now since the blood gas is so poor and WOB has increased despite BCPAP. We need to get Ph into a normal range to minimize cellular damage. The physicians may consider giving medications that can help bring the metabolic portion into the normal range. 

ACTION:

You decide the patient will be intubated. The patient weighs 3.5 kg. 

& DISCUSS: What size laryngoscope blade and ET tube will be used. What measurement marking will we secure the ET tube at

the lip? 

ANSWER:

The patient is intubated using a size 1 laryngoscope. A size 0 blade is also ready in case it is needed. A size 3.5mm ET tube is used since the patient is over 3kg. 

The tube is initially placed at 9.5 cm at the lip. We added 6 to the weight in kg. This is a good starting point to place the ET tube. 

& DISCUSS: What will you do to assess proper placement of ET tube? 

ANSWER: We will look at chest rise, condensation in the ET tube, listen for bilateral breath sounds, use capnometry, and monitor patient vital signs.  

SITUATION: You hear bilateral breath sounds and there is positive color change on the capnometer. You can visualize bilateral chest rise. You secure the ET tube at 9.5 cm at the lip and connect the patient to a conventional ventilator. 

Important Reminder: 

These are hypothetical situations and are not meant to be taken literally. Always follow your hospital's policies, procedures, and guidelines. Your hospital will have specific guidelines that you must follow in each department. These scenarios are purely educational. Always consult with your hospital providers before doing any medical procedure on patients.