Research and Audit Nurse/Paediatric Clinical Educator Paediatric Critical Care Service/Paediatric Clinical Nurse Educator
Sept 2009
CONTENTS
Page
Swine Flu (H1N1) Information…………………………………………………….
3
Oseltamivir Drug Doses……………………………………………………………
4
Paediatric Respiratory System……………………………………………………
5-6
Assessment of the High Dependency Patient…………………………………
7-10
Fluids in Paediatrics…………………………………………………………………
11-13
Crib Sheet……………………………………………………………………………….
14
Emergency Equipment/Drug Calculator……………………………………………
15
Paediatric High Dependency Observation Chart……………………………….....
16-17
Non-Invasive Ventilation……………………………………………………………….
18 (open file)
Infant Flow Nasal CPAP…………………………………………………………………
18 (open file)
NIPPY Junior Ventilator………………………………………………………………….
19-24
MR850 Respiratory Humidifier…………………………………………………………. 25-29
Non-Invasive Ventilation Standard of Care………………………………………….
30-31
2
SWINE FLU (H1N1) INFORMATION
POSSIBLE GENERAL SYMPTOMS IN CHILDREN
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Pyrexia> 38 degrees Celsius or 100.4 degrees Fahrenheit
Tiredness
Headache
Runny nose and sneezing
Sore throat
Shortness of breath
Loss of appetite
Diarrhoea
Aching muscles, limb and joint pain
POSSIBLE SERIOUS SYMPTOMS IN CHILDREN
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Sepsis
Respiratory compromise requiring ventilatory support
Single or multi organ failure
Dehydration and electrolyte imbalances
TAMIFLU (OSELTAMIVIR PHOSPHATE)
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Anti viral medication
Use liquid in under one year olds then capsules over this age
Generally well tolerated
Side effects in children and adolescents include nausea and vomiting and possible change in
usual behaviour
SOURCES OF FURTHER INFORMATION
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www.nhs.uk/Conditions/Pandemic-flu/Pages/Sypmtoms-aspx
www.tamiflu.com
“The Source”- this includes links to website pages for Health Protection Agency (HPA), NHS
Direct, National Pandemic Flu Service, DoH, WHO and local Trust flu plans
Ward managers, paediatric clinical nurse educators and senior nursing staff
Paediatric Clinical Nurse Educator
August 2009
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4
The Paediatric Respiratory System
Paediatric Anatomy
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The paediatric respiratory system is different from adults because they have
A large head
Short neck which causes flexion
A large tongue
A small face
A small mandible
They might have loose teeth or orthodontic appliances which may be loose or impede opening
the airway
A compressible mouth.
The airway
 The epiglottis is horse shoe shaped and projects posteriorly
 The larynx is high and anterior at the level C2/3
 The cricoid ring is the narrowest part of the airway
 The trachea is short and soft
< 6 months
 Nasal breathers
 Narrow nasal passages
3- 5 year old
 Adenotonsillar hypertrophy
Breathing
The infant has;
 Immature lungs
 The air tissue interface has a small total surface area
 Less small airways
 Small upper and lower airways
*The infant is a diaphragmatic breather*
 Lower type 1 fibres (slow twitch, highly oxidative and fatigue resistant fibres)
 Horizontally lying ribs – less contribution to chest expansion
 A more compliant chest
Clinical Nurse Educator Paediatric Critical Care Service Sept 2009
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Respiratory Physiology
Infants and children have:
 High metabolic rate
 Higher respiratory rate
Both of these mean they have greater oxygen requirement.
 Prominent sternal recession
 Rib space in-drawing with obstruction
 Lower intrathoraxic pressure which reduces small airway patency
Recession:
 Intercostal
 Subcostal
 Sternal
The degree of recession gives an indication of respiratory difficulty.
In older children the above suggests severe respiratory distress.
Inspiratory and Expiratory noises
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Inspiratory noise (stridor) is a sign of tracheal or laryngeal obstruction
Expiratory noises such as wheezing indicates lower airway obstruction/ narrowing
Longer expiratory phase indicates lower airway narrowing
Grunting
This is a sign of severe respiratory distress
 This is produced on exhalation when the glottis is partially closed
 It is an attempt by the infant to increase end- expiratory pressure to prevent airway collapse
A silent chest is an extremely worrying sign!!!
Accessory muscles
 Head bobbing :
This is when the infant uses the sternomastoid muscle and breathing becomes ineffectual.

Flaring of the Alae Nasi
Flaring of the nostrils is seen in infants and children who are in respiratory distress.
Clinical Nurse Educator Paediatric Critical Care Service
Sept 2009
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ASSESSMENT OF THE PHDU
PATIENT
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BEDSPACE
Is the bed area safe?
Could you reach the child in an emergency?
Are lines and tubing out of harms way, unlikely to be pulled out, trodden on etc?
Is the oxygen and suction working?
Is there a bagging circuit and does it work?
Have you got a full Oxygen cylinder at the bed space?
Is there an ambu bag appropriate size for the child?
Is there a facemask, airway appropriate to size of child?
Have you got appropriate size suction catheters?
Are your alarm limits set for that individual child?
OBSERVATIONS
 Consider the trends in observations over the last 24 hours and since admission. If there have
been deviations check previous observation charts. Has this happened before, if so when, why
and what treatment was given?
RESPIRATIONS AND SAO2
 Check the settings of the respiratory support machine over the last 24 hours. Is it being
weaned?
 Look at the most recent gas- is it arterial, venous or capillary. Is it normal? What is the trend?
(improvement or deterioration)
 What does the respiratory pattern of the patient look like? Are there signs of respiratory
distress?
 What is the oxygen saturation now? What has the trend been in the last 24 hours?
 How much oxygen is required to keep the SaO2 within requested parameters?
 What are the set limits
 Has the oxygen requirement increased or decreased over the last 24 hours?
Clinical Nurse Educator Paediatric Critical Care Service Sept 2009
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 Has the patient been assessed by a physio? What position do they recommend? Is one side
better than another?
 Is there any reason why high levels of oxygen shouldn't be given? (neonate/ cardiac defect)
 How does the patient respond to handling i.e. desaturations?
`VENTILATION SETTINGS
 Note the mode and settings of the BIPAP/ CPAP/ CNEP. Check these against what has been
prescribed
 Note Oxygen concentration
 Note concentration of Heliox / Oxygen if applicable
 Check alarms are set correctly
 Ensure ventilation tubing is fixed securely and free from water
 Does the ventilator tubing need changing? (every 7 days)
 Check the humidifier is set correctly and chamber is filled to black line with water. Is the water
bag about to run out?
 Check the position and tightness of face masks, nasal prongs and CNEP jacket. Are they
correctly fitted and are you achieving the correct pressures?
 What condition is the skin around the mask, prongs and jacket?
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HEART RATE/ BLOOD PRESSURE
Is the heart rate within normal limits?
If the patient is tachycardic reassess analgesia, temperature, pain etc
If the patient is bradycardic..WHY?
Is the bradycardia self correcting?
Is the patient in sinus rhythm?
What is the capillary refill time?
What are the pulses like? Bounding, normal, thready and weak?
Is the blood pressure within normal limits for age?
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TEMPERATURE
Is the patient pyrexial?
How long have they been pyrexial?
Are they prescribed anti-pyretics and if so have they been given?
Have bloods and swabs and other samples been taken?
Remember an increase in temperature can increase insensible loses, oxygen requirements
and sedation/ analgesia requirements.
Clinical Nurse Educator Paediatric Critical Care Service Sept 2009
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NEUROLOGY
 Are the pupils equal and reacting to light? Is the action brisk or sluggish?
 What is the GCS/ AVPU score?
 Are they settled or restless?
INTRAVENOUS INFUSIONS AND DRUGS
 What IV access has the patient got?
 Is it secure and is it working? How long has it been in?
 What is the patient’s total daily fluid allowance? (check on each ward round what the doctors
require)
 Check the fluid and infusions being given are prescribed correctly according to St Mary’s NHS
Trust policy and what is being given is actually what has been prescribed.
 Have the infusions been signed for? (Drs and Nurses)
 Are drugs included in total daily fluid allowance?
 Check IV infusion pressures on the pumps and set appropriate limits.
 Are the infusions and lines in date or do they need changing? (plan this into your shift)
 Are all fluid and syringes labelled correctly?
 Is each individual line labelled with the drug which is infusing through it?
 Are all the taps on the infusion lines turned on or off if not being used to prevent backflow?
 Are any infusions about to run out? Check how long is left.
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ENTERAL FEEDS
What type of feed are they having?
Have they been seen by the dietician and has a diet prescription been filled in?
Are they on full feeds or being worked up?
What route are the feeds running by i.e. NGT or NJ?
Is the feed continuous or bolus and when is their rest period due?
Is the patient tolerating the feed?
When does the feeding set need changing (see St Mary’s feeding policy)
Clinical Nurse Educator Paediatric Critical Care Service Sept 2009
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URINE OUTPUT
Is the urine output recorded?
What is the current input and output balance? What is the cumulative balance of the patient?
Is the patient catheterised or in nappies (male or female catheter)?
How many mls/kg/hr or urine is being passed
What are the limits set by the Drs?
Is the urine clear, cloudy, smelly, concentrated
Has the daily urinalysis been carried out and recorded? Was it normal?
When was the catheter inserted and does it need changing?
SEDATION AND ANALGESIA
 Is the patient on any sedation or analgesia infusions, if so what rate are they running at? Is it
correct to the prescription?
 Is the patient on a weaning regime? How often and by how much are they being weaned?
(consider how long the patient was receiving the drugs for and ensure date weaning started is
documented)
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OTHER DRUGS
Check the prescription chart. Does the child have any allergies? If so are they recorded on the
drug chart?
What other drugs is the patient on?
Are the drugs prescribed appropriate to the patient’s weight and body surface area?
Which drugs can centrally or peripherally, as boluses or infusions?
Is there a spare port to give drugs?
Have all the prescribed drugs been given from the last shift and signed for.
SKIN AND PRESSURE AREAS
 What is the condition of the skin?
 Are there any pressure sores?
 Have the probe sites been changed 2- 4 hourly?
Clinical Nurse Educator Paediatric Critical Care Service Sept 2009
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Fluids in Paediatrics
Fluid types
• Isotonic
• Hypertonic
• Hypotonic
• Colloid
Hypotonic Solution
• O.18% NaCl & 4% Dextrose
• This is a solution that pulls water from the blood vessels to the cells and will therefore cause
interstitial swelling (swelling of cells and tissue) other wise known as Oedema
Hypertonic Solutions
• Mannitol
• 3% Saline
• Any fluid with a salt concentration above 0.9%
• This pulls the fluid from the cells into the blood plasma reducing oedema
Isotonic solutions
• 0.9% Saline
• This is a solution that has the same salt concentration as the bodies cells and therefore does
not pull fluid from either the cells or blood plasma
Colloids
• Human Albumin 5%
• Gelofusin
• Hetastarch
These are all different types of volume expanders.
Clinical Nurse Educator Paediatric Critical Care Service Sept 2009
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Fluid Resuscitation
FLUID NEEDS TO BE GIVEN IMMEDIATELY AND QUICKLY
Sepsis:
•
Initial fluid resuscitation as per APLS guidelines:
20mls/kg 0.9% saline as boluses
(if worried about neurological status then give 10mls/kg per bolus)
Trauma:
10mls/kg 0.9% saline
NB: In Sepsis or Trauma if you need to give than 40mls/kg you must intubate to
protect the airways as pulmonary oedema can occur.
Daily Fluid Management
• Is it mls/kg/day?
Or
• % of a total volume?
Calculations
MLS/KG/ Day
Weight x mls prescribed = mls/kg/day
i.e.
5kg x 120mls = 600mls/ day total fluids
Hourly rate
600mls / 24 hours = 25mls/hr
100 % Fluids;
1st
10kgs =
2nd 10kgs =
3rd 10kgs > =
100mls x 10kgs
50mls x 10kgs
20mls x rest of weight
Clinical Nurse Educator Paediatric Critical Care Service Sept 2009
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For example:
35 kg child
Weight
mls
10 x
100 = 1000mls
10 x
50
= 500mls
15 x
20
= 300mls
100% Fluid allowance = 1800mls/day
The doctor wants 80% fluids only for the Patient –
100% volume/ 100/ % prescribed
1800mls / 100/ 80% = 1440mls per day
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Observations to do!
Heart Rate
Blood pressure
Capillary refill time
Strict Hourly urine output –
> 1ml/kg/hr paeds
>0.5mls/kg/hr adults
Clinical Nurse Educator Paediatric Critical Care Service Sept 2009
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CRIB SHEET
WEIGHT:
Estimated weight (kg) of infant < 1 year of age Birth weight, 6 months = 6 -7 kg,
1 year =10kg
Estimated weight (kg) of child > 1 year of age 2 (age in years + 4)
ETT SIZES:
Internal diameter (mm)
Length (cm) oral ETT
Length (cm) nasal ETT
Age / 4 + 4
Age / 2 + 12
Age /2 + 15
Age (years)
Heart rate
(Beats/min)
<1
1–2
2-5
5 - 12
>12
110 - 160
100 - 150
95 - 140
80 - 120
60 - 100
Systolic Blood
Pressure
(mmHg)
70 - 90
80 - 95
80 - 100
90 - 110
100 - 120
Respiratory
Rates
30
25
25
20
15
- 40
- 35
- 30
- 25
- 20
Emergency Fluid Resuscitation
Sepsis and Hypovolaemia
20 mls/kg of 0.9% Sodium Chloride
Trauma
10mls/kg of 0.9% Sodium Chloride
Urine
< 1year
1-2 mls/kg/hr
1 – 12 year 1 ml/kg/hr
>12 year
0.5 ml/kg/hr
Clinical Nurse Educator Paediatric Critical Care Service
Sept 2009
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Emergency Drugs/Equipment Calculator
To be calculated on the initial assessment
of a child needing high dependency care.
Name: ………………………………………..............
Estimated Weight:
Hospital Number: …………………………………..
Newborn = 3.5 kg
6 months = 7.0 kg
1 year to 12 years = [Age in years + 4] x 2
Date of Birth: ……………………………….............
Weight __________kg
Drug Name
Adrenaline
Dose (Kg)
0.1 ml/kg 1:10,000
[>50kg: 1mg - 10mls of 1:10,000]
Fluid bolus
20 ml/kg [max 500 mls]
Glucose 10%
5 ml/kg [max 250mls]
Sodium Bicarbonate 8.4%
1 mmol/kg [max 50mls]
Neonate -(20 micrograms) [min dose 100 micrograms]
1 month - 12 years:
10-20 micrograms/kg [max dose 600 micrograms]
12-18 years: (0.6-1.2 mg)
Atropine Sulphate
Thiopentone Sodium
3 - 5 mg/Kg
Suxomethonium
2 mg/kg [max 100mg]
Defibrillation Shock
4 Joules/Kg
Amount (ml)
Endotracheal Tube (ETT) Size
9 – 10 cm (length at lips)
Newborn:
3.0 mm (internal diameter)
6 Months:
3.5 mm (internal diameter)
1 to 8 years:
Diameter: (Age in years / 4) + 4
=
___________ mm
Length: [Oral] (Age in years / 2) + 12
=
___________ cm
[Nasal] Oral length + 3
=
___________ cm
Adult:
7.0 mm (female)
Check (1) ………………………………………... …
Reference:
11 cm (length at lips)
8.0 mm (male)
Check (2) …………………………………………...
BNF (2009) BNF for children, BMJ Publishing Group, London.
Research and Audit Nurse Paediatric Critical Care Service
Aug 2009
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Paediatric High Dependency Observation Chart
Name ………………………………………………….
Date……………………………
08
09
Time
Respiratory Assessment
Airway Type
10
11
12
13
Hospital No. ………………………….
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15
16
17
18
19
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DOB ……/……/……
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01
02
03
04
05
06
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Respiratory Pattern
Severity
Air Entry / Sounds
O2 (L/min)
O2 (%)
O2 Delivery Method
Ventilation Observations
Infant Flow CPAP
CPAP
Flow (L/min)
NIPPY Junior
Mode
IPAP (Inspiratory Positive
Airway Pressure)
EPAP (Expiratory
Positive Airway Pressure)
Set Breathing Rate
Total Breathing Rate
Tidal Volume
Leak
CNEP
Mode
Insp. Pressure (-)
Exp. Pressure (+)
Mean
Back up
Sensitivity
Frequency
I:E Ratio
Inspiratory Cough
Pressure
Expiratory Cough
Pressure
Cough Time
Humidification/Suction/Physio
Humidifier Temp(°C)
Suction (No.)
Secretion Colour
Secretion Type
Chest
Physiotherapy
Cardiovascular Assessment
Heart Rhythm
Capillary Refill Time
Peripheral Temp (°C)
Neurological and Pain Assessment
Pupil Size(R/L)
Pupil Reaction(R/L)
Pain Score
Cares
Patient Cares
Probe Site Change
Position
16
Paediatric High Dependency Observation Chart Key
Respiratory Assessment and Ventilation
Respiratory Pattern:
Normal (N)
Subcostal Recession (SR)
Intercostal Recession (IR)
Tracheal Tug (TT)
Grunting (Gr)
Nasal Flaring (Nf)
Severity:
Mild (M)
Moderate (Mo)
Severe (S)
Air Entry / Sounds:
Normal (N)
Reduced Right (R)
Reduced Left (L)
Reduced Both (B)
Wheeze (W)
Crackle (C)
Transmitted (T)
Ventilation Mode:
Self-Ventilating (SV)
Continuous Positive Airway Pressure (CPAP)
Pressure Support (PS)
Pressure Control (PC)
Continuous Negative (CN)
Controlled (C)
Respiratory Synchronized (RS)
Respiratory Triggered (RT)
Secretion Clearance (SC)
Airway Type:
Normal (N)
Face Mask (FM)
Nasal Mask (NM)
Nasal Prong (NP)
Tracheostomy (T)
Secretions:
Physio:
Tick and Initial
Colour
Clear (CL)
Creamy (CR)
White (W)
Yellow (Y)
Green (G)
Blood Stained (BL)
O2 Delivery Method:
Air (A)
Nasal Cannula (NC)
Nasal Prong (NP)
Face Mask (FM)
Flow-by/wafting (FB)
Tracheostomy (T)
Type
Thick (Tk)
Thin (Tn)
Loose (L)
Cardiovascular Assessment
Heart Rhythm:
Sinus Rhythm (SR)
Sinus Tachycardia (ST)
Supraventricular Tachycardia (SVT)
Sinus Bradycardia (SB)
Aystole (A)
Pulseless Electrical Activity (PEA)
Ventricular Fibrillation (VF)
Ventricular Tachycardia (VT)
Capillary Refill Time:
<2 seconds, or time in seconds if longer
Peripheral Temperature:
Warm (W)
Cool (C)
Unequal (U)
Neurological and Pain Assessment
Pupil Reaction:
Brisk (Br)
Sluggish (Sl)
Fixed (F)
Dilated (D)
Fixed and Dilated (FD)
Pinpoint (P)
Pupil Size:
Pain Score:
0 No Pain
1 Mild Pain/Discomfort
2 Moderate Pain
3 Severe Pain
Cares
Patient Cares:
Wash (W)
Mouthcare (M)
Teeth Brush (TB)
Eye Care (E)
Nappy Care (N)
Tracheostomy Tape Change (TT)
Urine Catheter Care (C)
Probe Site Change:
SpO2 (S)
BP Cuff (B)
ECG Electrodes (E)
Position:
Back (B)
Left Side (L)
Right Side (R)
Prone (P)
Paediatric Clinical Nurse Educator/Research and Audit Nurse and Clinical Nurse Educator Paediatric Critical Care Service Aug 2009
17
(double left click to open file)
___________________________
[Information from Viasys Healthcare (2004) Infant Flow Sales Support CD]
(double left click to open file)
18
NIPPY JUNIOR PAEDIATRIC VENTILATOR
Instructions (How-To-Guide)
Research and Audit Nurse Paediatric Critical Care Service
Aug 2009
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EXPLANATION OF CONTROLS
Rate 15 BPM
Est.Uol. 0.34L
i.
17
16
Fascia Buttons
1. IPAP-
Selects the Inspiratory Positive Airway Pressure adjustment (scaled
in cmH2O). Value is displayed on screen adjacent to the switch.
2. EPAP-
Selects the Expiratory Positive Airway Pressure adjustment (scaled
in cmH2O). Value is displayed on screen adjacent to the switch.
3. Ti -
Selects the inspiratory time adjustment (scaled in Seconds). Value
is displayed on screen adjacent to the switch.
4. Back Up - Selects the Back-up Rate adjustment (scaled in Breaths Per
Minute). Value is displayed on screen adjacent to the switch.
5. Mode -
Displays the mode selection screen.
6. On/Off -
Starts and Stops the ventilator.
7. -
Decrements the selected parameter or moves the selection bar
down the menu.
8. Set -
Selects the current menu function displayed by the selection bar.
9. +
Increments the selected parameter or moves the selection bar up
the menu.
10. Mute -
Silences the alarm for 2 minutes. Press and hold for 2 seconds to
cancel alarm mute.
20
11. Menu -
Displays the menu screen.
12. Help -
Displays context sensitive help messages.
13. Lo Alarm-Selects the lo flow alarm adjustment (scaled in litres/minute). Value
is displayed on screen adjacent to the switch. Changes colour to
red in alarm condition.
14. Hi Alarm-Selects the high flow alarm adjustment (scaled in litres/minute).
Value is displayed on screen adjacent to the switch. Changes
colour to red in alarm condition.
15. Ext. Batt -Indicates that ventilator is running from an external battery.
16. Power - Indicates that mains power is connected.
17. Start -
Indicates that the ventilator is running.
Research and Audit Nurse Paediatric Critical Care Service
Aug 2009
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22
Estimated Tidal Volume
The estimated tidal volume is a calculated value, based on time and calibrated flow values. The
constant leak through the breathing circuit exhalation port is subtracted from this calculation to
give a reasonably accurate estimation of tidal volume. The estimated tidal volume is displayed
above the bar graph display.
Inspiratory Trigger
The Nippy junior employs flow triggering, detecting the start of the patient’s inspiratory effort when
the flow rate exceeds the level set by the Inspiratory Trigger sensitivity.
Expiratory Trigger
The expiratory trigger is used in Pressure Support mode only. Towards the end of inspiration,
when the inspiratory flow rate drops to the baseline (standing flow caused by exhale port leak)
minus the expiratory trigger sensitivity the ventilator will cycle into the expiratory phase.
The inspiratory and expiratory effort required to cycle the ventilator can be adjusted via the
Trigger option in the Menu.
For simplicity the trigger sensitivity is scaled 1 –10, with 10 being the most difficult.
How to adjust the Nippy Junior
Select the desired parameter with the relevant button.
The reading adjacent to the button will be highlighted by a purple flashing box.
Alter it with the _- or +_ buttons.
When you have finished, move on to the next adjustment or wait a couple of seconds for the
flashing box to disappear.
E.g. Press IPAP.
IPAP setting will be surrounded by a purple flashing box.
Press +_ to increase the pressure setting.
Locking the settings
The settings can be locked to prevent unauthorised adjustment. Hold the – and + keys for 3
seconds to lock and again to unlock. The padlock picture will be open or closed accordingly.
WARNING - Do not attempt to pass oxygen into the panel mounted air inlet.
Research and Audit Nurse Paediatric Critical Care Service
Aug 2009
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Alarms
Power Fail - If the electrical power to the ventilator is interrupted, an audible alarm will sound.
This alarm will run for 5 minutes unless cancelled with the mute button. Once cancelled the power
fail alarm will not re-activate.
Low External Battery - When running on an external battery, the alarm will operate when there
is approximately 10 minutes running time left. The alarm will also operate when the external
battery self discharges to approximately 75% of its capacity during standby.
Low Pressure - A pre-set low pressure alarm is provided. If the control pressure falls to below
50% of the set IPAP level for 10 seconds an audible and visual alarm will operate.
High Pressure - A pre-set high-pressure alarm is provided. If the pressure rises above 120% of
the working pressure, an audible and visual alarm will operate after a 2 second delay.
Breathing Circuit Disconnect - A disconnect alarm is provided. This is activated by analysis of
the inspiratory and expiratory flow waveform. An audible and visual alarm will operate. This alarm
may be set to a more sensitive level. Press and hold the Hi and Low Alarm buttons
simultaneously for 3 seconds. Select either normal or sensitive disconnect and press Set button.
High Flow - An adjustable alarm is provided to warn of excess inspiratory flow. This is activated
when the inspiratory flow exceeds the set high flow alarm level for 5 seconds. An audible and
visual alarm will operate.
Low Flow - An adjustable alarm is provided to warn of insufficient inspiratory flow. This is
activated when the inspiratory flow fails to achieve the set low flow alarm level for 10 seconds. An
audible and visual alarm will operate.
Fault - The alarm may also be operated by an internal fault. In this case the fault will be displayed
on screen. These alarms may be muted for approximately 2 minutes to allow for setting up of the
ventilator.
Low Internal Battery - An intermittent alarm (short beep) with no onscreen message indicates a
depleted mains fail alarm battery. If the ventilator has been stored for more than a few weeks the
internal battery will self discharge. In this case the alarm will stop after the battery has recharged.
The user cannot replace this battery. Refer to qualified technical personnel if the alarm operates
when the ventilator is in daily use.
(copied and adapted from B&D Electromedical NIPPY Junior Instruction Manual)
Research and Audit Nurse Paediatric Critical Care Service Aug 2009
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Fisher &Paykel
HEALTHCARE
MR850 RESPIRATORY HUMIDIFIER
Humidifier Operation
The MR850 humidifier is designed to add heat and moisture to respiratory gases. The gas is passed
through a humidification chamber where it is warmed and humidified.
The MR850 has two heating systems. The first is a heater plate, which heats the water contained in
the humidification chamber, humidifying the air passing through it. The humidifier monitors the
temperature of the gas at the chamber outlet with the chamber probe, and controls the amount of
power delivered to the heater plate, in order to maintain the chamber set point. Under normal
conditions the gas is heated to 37 °C in the invasive mode, 31 °C for the non-invasive mode.
Heater Wire Setup and Operation
RT100
Breathing
Circuit
r
MR850 Humidifier
Humidified gas from the chamber travels through the inspiratory limb, where its temperature must be
maintained in order to prevent the generated humidity from condensing. This is achieved with a
heater wire encapsulated within the inspiratory limb. The humidifier maintains the temperature along
the inspiratory limb by monitoring the temperature at the airway probe and controlling the power
delivered to the heater wire. Under normal conditions the gas is heated to 40 °C in the invasive mode,
34 °C for the non-invasive mode.
An optional, second heater wire, located in the expiratory limb, minimizes condensate in this limb.
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Humidifier Controls
Power Button
The humidifier will power on if this button is held down briefly, but must be held for one
second to turn the humidifier off.
CAUTION: Although the display is not illuminated, the unit may still be energized.
After power-on the humidifier starts an internal diagnostic routine which checks for
possible problems in the humidifier setup. If everything is working correctly, normal control
is initiated.
Mode Button
When held down for one second, the mode button toggles the humidifier between NonInvasive and Invasive mode. The Mode indicator LED shows the user which mode is
selected.
Invasive mode is for use with patients whose upper airways have been bypassed by
either a tracheostomy or endotracheal tube. In this mode of operation the humidifier
attempts to deliver optimal humidity to the patient (37 °C, 100 % RH). This mode is the
default mode on power up of the humidifier.
The humidifier normally controls the chamber outlet temperature to 37 °C, and the airway
temperature to 40 °C, maintaining a +3 °C temperature gradient along the inspiratory limb.
If however this temperature gradient is not maintained, the chamber set point is reduced in
0.5 °C steps (minimum setting of 35.5 °C), in order to reduce condensate buildup in the
breathing circuit. If the chamber set point is less than 37 °C and sufficient temperature
gradient has been maintained along the inspiratory limb, then the chamber set point is
increased back up to 37 °C in 0.5 °C steps.
Non-Invasive mode is suitable only for patients whose natural humidification system
(i.e. upper airways) has not been bypassed, but are receiving gas via a facemask or
similar.
The humidifier normally controls the chamber outlet temperature to 31 °C, and the airway
temperature to 34 °C, maintaining a +3 °C temperature gradient along the inspiratory limb.
If automatic or manual humidity compensation has been activated then the displayed
temperature may be higher than 37 °C (Invasive mode) or 31 °C (Non-Invasive mode).
Mute Button
The mute button silences the humidifier's audible alarm. The muted time depends on
the alarm condition. In general, alarms will be muted for 2 minutes.
A chamber or airway probe alarm is muted for a longer time, until the humidifier
determines whether the probe is in or out. The temperature alarm is treated differently.
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Temperature Display
The front panel shows the lower of the chamber or airway temperatures. This temperature gives
an indication of the dew point (in °C) of the gas that is being supplied to the patient. The dew point
of a gas is the best indication of both its humidity and energy content. Under normal operation, the
displayed temperature will be the chamber temperature, as its control set point is lower. If the
temperature is above 70 °C, "Hi" will be displayed. If the temperature is below 10 °C, "Lo" will be
displayed. If HC mode has been enabled the decimal point on the temperature display will flash.
Showing Chamber and Airway Temperature
Both the chamber and airway temperature can be displayed by pushing and holding the mute
button for 1 second. The temperatures are displayed in the following sequence:
1
Chamber temperature is displayed until two seconds after the mute button is released. The
chamber probe indicator will also light to show which temperature is being
displayed.
2
The display will blank, and then the airway temperature will be displayed until two seconds
after the mute button is released. The airway probe indicator will also light
to show which temperature is being displayed.
3
The temperature display will blank again, and revert to normal operation.
Setup Indicators
The MR850 setup indicators, placed on the lower left of the front panel, are intended to aid the
user in identifying problems with the incorrect setup of the device and its accessories.
Heater Wire Connector
These indicators light if the heater wire in the breathing circuit has not been
connected correctly, or if the heater wire or heater wire adaptor is faulty. An
intermittent connection or excessive current (total current in all limbs > 3.5 A) in the
heater wires will also produce this alarm. The humidifier will remove power from the
heating systems if this alarm is active.
Temperature Flow Probe Connector
This indicator will light if the temperature probe is not correctly plugged in, or the
probe used is faulty. The humidifier tests for the following probe fault conditions:

Temperature probe disconnected
•
Chamber thermistor open or short circuit
•
Airway thermistor open or short circuit
•
Flow thermistor open or short circuit (shorted probe test)
•
One thermistor shorted to another (shorted probe test)
•
Flow calibration resistor open or short circuit (shorted probe test)
An alarm will be generated if any of the above faults are found, and the
humidifier will remove power from all heating systems.
NOTE: the shorted probe tests and flow thermistor tests are only performed on
start-up, or when temperature probe or heater wire alarms are cancelled.
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Chamber Probe & Airway Probe
These indicators are used to show that either the chamber probe or airway probe is
not inserted into the breathing circuit correctly. On start-up, and during rapid changes
in temperature, the humidifier tests to see if a probe is in place by cooling and then
heating the probe. If the humidifier finds that either probe is not inserted into the
breathing circuit, an alarm will be generated and the humidifier will enter stand-by.
During this alarm the humidifier will initiate a probe out test periodically, or a test will
be initiated immediately after mute has been pressed.
During periods of low or zero gas flow, the airway probe out alarm is disabled. As
soon as flow is detected however, an airway probe test is initiated.
Chamber or Airway Probe Alarm with Probe connector alarm
The humidifier checks to see if the temperature probe is faulty by testing for the
following conditions:
•
•
•
•
Chamber temperature has been greater than 50 °C for 20 minutes
Chamber temperature is greater than 80 °C
Airway temperature has been greater than 50 °C for 5 minutes
Airway temperature is greater than 80 °C
If an apparent fault is found, the humidifier will give a temperature / flow probe
connector alarm, and also indicate either the chamber or airway probe. The
humidifier will stay in stand-by until the chamber or airway temperature drops
below 50 °C. Once this occurs, a probe test will also be initiated.
Water Out Indicator
This indicates that there is insufficient water in the humidification chamber.
The humidifier measures the amount of power used to obtain the chamber
temperature. If a lower than expected amount of power is used, a 'water out' alarm is
generated. It may take 15 minutes or longer to generate an alarm especially if there
is a disturbance (change in flow).
This alarm can be cancelled by pressing the mute button. If however the water out
condition remains, the humidifier will alarm again.
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Operational Alarms
These alarms are generated if problems occur with the operation of the humidifier.
Temperature Indicator
This alarm will occur if the displayed temperature is too high, or if the delivered
temperature (Invasive mode only) has been low for a period of time.
High temperature:
The humidifier will immediately alarm if at any time the displayed temperature
exceeds 41 °C, or if the airway temperature exceeds 43 °C. If either of these
high temperature alarms occur, the humidifier will immediately shut down the
heater wire and heater plate.
Low Temperature:
The low temperature warning (visual only) and alarm (visual and audible) are
active only when the humidifier is in Invasive mode. Both are disabled during
warm-up conditions. The warning alerts the user that low temperature is being
delivered to the patient. The alarm alerts the user that a low level has been
delivered to an Invasive patient for too long.
The low temperature warning and alarm operate by monitoring the displayed
temperature. If the displayed temperature is below 35.5 °C for 25 seconds, the
temperature indicator will light, and act as a warning to the user. If the
temperature remains below this level for too long, then a Temperature Alarm is
activated. The time taken for the humidifier to alarm is dependent on how far
below the 35.5 °C threshold the displayed temperature is.
Pressing mute during a temperature alarm silences the alarm for half the normal
time period, if the same temperature is maintained.
The low temperature warning and alarm can be caused by cold or drafty ambient
conditions.
(copied and adapted from Fisher and Paykel Healthcare MR850 Respiratory Humidifier technical manual)
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Non-Invasive Ventilation Standard of Care
(Infant Flow System, NIPPY Junior and RTX Respirator)
Goal Objective
 To maintain a patent airway.
 To promote optimum respiratory function.
Management
1.
Ensure paediatric ambu-bag and appropriate sized face mask and oropharyngeal airway are at the
bedside.
2.
Ensure laminated ‘Emergency Equipment/Drug Calculator’ is correctly completed.
3.
Correctly set up the Infant Flow System and NIPPY Junior with Fisher & Paykel MR850 humidifier.
Correctly set up RTX.
4.
Ensure twin backbar with O2 flow meter and Schrader valve is inserted into wall O2 outlet.
5.
Set Fisher & Paykel MR850 Humidifier to ‘Invasive Mode’.
6.
Infant Flow System:

Follow the ‘Step by Step Fixation Technique’ (see HDU Resource Folder).

Record the prong size, bonnet size measurement and bonnet colour in the infants nursing
documentation.
7.
Set the ventilation mode and pressures to parameters prescribed by the HDU Paediatric
Consultant/Registrar.
8.
Ensure continuous nursing supervision and assessment.
9.
Ensure continuous ECG and O2 saturation monitoring.
10.
Record heart rate, respiratory rate and O2 saturation hourly at a minimum.
11.
Record blood pressure at a minimum of every 4 hours.
12.
Calculate a Paediatric Early Warning Score each time a set of observations are carried out and
record.
13.
Assess chest movement (i.e. symmetry and recession) at least hourly and air entry as clinically
required (at a minimum of every 4 hours). Report any changes to the HDU doctor.
14.
A blood gas should be taken 30 minutes to 1 hour after commencement of non-invasive ventilation
and as clinically required thereafter. This is normally every 4 - 6 hours if the child is stable. If the
child is not stable, a blood gas may need to be taken every 30 mins, or 1 to 2 hourly.
15.
A blood gas should be taken 1 hour after non-invasive ventilation has been discontinued and as
clinically required thereafter. If the infant is stable, this is normally every 4 - 6 hours.
16.
Each blood gas result must be reviewed by the HDU doctor.
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17.
Infant Flow System - Check and record the set CPAP pressure, gas flow, and O2 concentration
every hour on the HDU Observation Chart.
18.
NIPPY Junior - Check and record the mode, inspiratory and expiratory pressures, set rate, tidal
volume, and leak every hour on the HDU Observation Chart.
19.
RTX Respirator - Check and record the mode, inspiratory, expiratory and mean pressures, back up,
sensitivity, frequency, I : E ratio, cough pressures and time.
20.
Check the prongs / mask / currass jacket seal hourly for any air leaks and reposition / secure.
21.
Check and record the humidification temperature every hour.
22.
Check the water level in the humidification chamber every hour.
23.
To promote airway patency, assess the need for nasopharyngeal / oral suctioning hourly and
suction accordingly.
24.
Infant Flow System and NIPPY Junior - Insert an orogastric or nasogastric tube and leave on free
drainage if NBM or aspirate air 4 hourly if receiving milk feeds. Observe child for abdominal
distension.
25.
Following pain assessment administer regular analgesia as prescribed and monitor effect.
26.
Assess the need for sedation and administer if prescribed by the HDU doctor. Monitor effect.
27.
Remove nasal prongs / nasal or facial mask / currass jacket every 4 hours to provide pressure relief
and assess the area. Ensure the mask / prong area is kept clean and dry (no creams or ointments
to be applied).
28.
Apply pressure relief dressing if required.
29.
Infant Flow System - Check the prongs are clean and free from secretion obstruction every 4 hours.
30.
RTX Respirator – Vest or pillow case must be worn underneath currass jacket.
31.
Provide mouth care every 4 hours.
Any variation from the above care standards should be noted in the child’s shared care records.
Normal Blood Gas Values
Ph
PCO2
PO2
7.36 – 7.44
4.7 – 6 kPa
10 – 13 kPa
HCO3
BE
22 – 26 mmol/L
–2 to +2 mmol/L
[Advanced Life Support Group (2005) Advanced Paediatric Life Support (4th edition)]
References
Goggin M (2001) Developments in nCPAP Fixation Journal of Neonatal Nursing 7(2)
Viasys Healthcare (2004) Infant Flow Sales Support CD
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