Neonatal Respiratory Support on Transport

Gillian Brennan, MB BCh BAO,* Jill Colontuono, APN,* Christine Carlos, MD*
*The University of Chicago Comer Children’s Hospital, Chicago, IL

Education Gaps
Evaluation for and use of respiratory support remains a common occurrence
in neonatal interfacility transport. Clinicians should be aware of the available
types of respiratory support and their appropriate uses, as well as how to
respond to respiratory emergencies to decrease the risk of complications
during transport and improve health outcomes.

Abstract
Respiratory support is frequently required during neonatal transport. This
review identifies the various modalities of respiratory support available
during neonatal transport and their appropriate clinical uses. The respiratory
equipment required during neonatal transport and appropriate safety checks
are also reviewed. In addition, we discuss potential respiratory emergencies
and how to respond to them to decrease the risk of complications during
transport and improve health outcomes.

Objectives After completing this article, readers should be able to:

AUTHOR DISCLOSURE Drs Brennan and
1. Describe the different modalities of respiratory support available for Carlos and Ms Colontuono have disclosed no
financial relationships relevant to this article.
neonatal transport and their appropriate clinical use. This commentary does not contain a
discussion of an unapproved/investigative
2. Review respiratory equipment and safety checks before transporting a
use of a commercial product/device.
patient receiving respiratory support.
ABBREVIATIONS
3. Describe the potential effects of transport on respiratory support. CPAP continuous positive airway
4. Identify respiratory emergencies during transport and how to manage pressure
ECMO extracorporeal membrane
them.
oxygenation
ETT endotracheal tube
FiO2 fraction of inspired oxygen
HFV high-frequency ventilation
INTRODUCTION iNO inhaled nitric oxide
IV intravenous
The need for respiratory support remains a frequent occurrence for neonatal LMA laryngeal mask airway
interfacility transport teams. The primary reason for transfer may be respira- MAS meconium aspiration syndrome
NCPAP nasal continuous positive airway
tory-based, such as premature infants with respiratory distress syndrome
pressure
(RDS), infants with meconium aspiration syndrome (MAS), infants with PPHN persistent pulmonary hypertension
persistent pulmonary hypertension (PPHN), or infants with airway obstruction. RDS respiratory distress syndrome
However, the need for respiratory support may also stem from other underlying RT respiratory therapist

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diagnoses such as congenital diaphragmatic hernia, ab- need positive pressure support, with either noninvasive
dominal mass, genetic syndrome, congenital cardiac de- ventilation or intubation and mechanical ventilation. In
fect, or metabolic disorder. Several types of respiratory the past, many infants with RDS required automatic intu-
support can be used during neonatal transport; these bation for transport. However, with the improvement in use
options are summarized in Table 1. (1) Members of the of antenatal steroids, availability of continuous positive
transport team should have a comprehensive understand- airway pressure (CPAP) in the delivery room, the adminis-
ing of these possible interventions. This review details the tration of intratracheal surfactant, and recent availability of
different types of respiratory support, their indications for noninvasive ventilation during transport, the use of non-
use, and how to address respiratory emergencies during invasive respiratory support for this patient population has
transport. increased.
After arrival at the outside hospital, the transport team
will need to decide what level of support the patient will
CLINICAL CONSIDERATIONS: WHEN TO USE
need. Should the patient be intubated? Should surfactant be
EACH MODALITY
given before transport? Surfactant therapy has had a pro-
After receiving a call for neonatal transport, it is vital to have found impact on patients in the NICU by reducing oxygen
a detailed discussion about the patient’s potential respira- and ventilation requirements. Many studies have investi-
tory support requirements. The content of this discussion gated the impact of administering surfactant before trans-
will frequently influence many steps in the transport pro- port and found it to be safe, with the caveat being that those
cess, most importantly, whether additional equipment is administering surfactant should have the “technical and
required and potentially the makeup of the transport team clinical expertise to administer surfactant safely.” (2) There-
itself. The transport team should also account for possible fore, pediatric clinicians who are without expertise, or who
changes in the patient’s status en route to the referring are inexperienced or uncomfortable with surfactant admin-
hospital. The patient’s gestational age, weight, and under- istration or managing an infant who has received surfactant
lying condition will frequently guide the mode and degree of should wait for the transport team to arrive. (3) In addition,
support required. the potential side effects of sudden hypoxemia, displace-
ment or plugging of the endotracheal tube (ETT), develop-
Respiratory Distress Syndrome ment of an air leak because of a sudden change in
The incidence of RDS is inversely proportional to birth compliance, development of a pulmonary hemorrhage,
gestational age. Other risk factors for RDS include maternal and hyperventilation should also be considered. (3) A ret-
diabetes and lack of antenatal steroids. Affected infants will rospective review published in 2010 concluded that, in a

TABLE 1. Types of Respiratory Support During Neonatal Transport

Noninvasive 1. Oxygen hood or free-flowing oxygen delivered into the incubator
respiratory 2. Low-flow nasal cannula delivering <2 L/min
support (1) 3. Humidified, heated high-flow nasal cannula delivering ‡2 L/min
4. Continuous positive airway pressure
5. Noninvasive intermittent positive pressure ventilation
Invasive 1. Conventional mechanical ventilation (CMV) with settings of:
respiratory -Peak inspiratory pressure
support -Positive end-expiratory pressure
-Rate
-Inspiratory:expiratory ratio
-Fraction of inspired oxygen
Indications for CMV: respiratory distress worsening with increasing oxygen requirement, recurrent apnea, cyanotic heart
disease, congenital diaphragmatic hernia
2. High-frequency ventilation: High-frequency flow interrupter most widely available; settings include:
-Mean airway pressure
-Amplitude
-Hertz
Indications for HFV: reduce volutrauma, air leak syndrome, infants who fail CMV

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 cohort of over 200 infants who received surfactant before Significant neonatal risk factors for a pulmonary air leak
transport, the rate of pneumothorax was only 2.9% com- include MAS, preterm birth with RDS, and pulmonary
pared with the incidence of hyperventilation, which was hypoplasia. The use of a long inspiratory time, high peak
18.9%. They also noted that infants who were hyperventi- pressures, and large tidal volumes are also considered risk
lated also had longer transport times, lower birthweights, factors. An air leak occurs as a result of overdistention of
and lower PCO2 levels before transfer to the tertiary center. alveoli from uneven air distribution leading to alveolar rup-
(4) ture. (8) Air can dissect into the perivascular connective tissue
The use of nasal CPAP (NCPAP) is known to reduce the presenting in different forms: pneumothorax, pneumome-
need for intubation and the incidence of bronchopulmonary diastinum, pulmonary interstitial emphysema, and pneumo-
dysplasia in infants with RDS. A 2014 study by Jani et al pericardium. (9)
found that the use of NCPAP in preterm infants (28–31 Frequently, an infant with a pneumothorax may initially
weeks’ gestation) was both safe and effective when per- appear to be asymptomatic and only later present with a
formed by a dedicated transport team. (5) Based on their rapid clinical deterioration. An increase in FiO2 require-
retrospective study, the authors developed some practical ment, asymmetric breath sounds, chest asymmetry, and
recommendations for the use of NCPAP during transport: shifting of the apex beat may be clinical indicators of
• A blood gas measurement should be obtained either at a pneumothorax. Transillumination of the chest may be
the time of stabilization for transport or 30 minutes helpful to diagnose a pneumothorax, with confirmation ob-
after starting NCPAP tained on radiography, if available.
• Administration of caffeine to very premature infants Treatment of a pneumothorax before transport will
receiving NCPAP depend on the size of the air leak. A small pneumothorax
• Intubation should be considered if the infant develops in a clinically stable infant may be managed with mild
moderate to severe respiratory distress while receiving respiratory support, such as a nasal cannula. Nitrogen
NCPAP (CPAP >6 cm H2O) with a fraction of inspired washout with the use of oxygen supplementation with an
oxygen (Fio2) >0.3 and blood Pco2 >55 mm Hg (7.3 kPa). FiO2 of 1.0 has not been shown to hasten resolution of the
Frequent episodes of apnea while receiving NCPAP are pneumothorax. (10) A large pneumothorax will likely need a
also an indication for intubation. (5) definitive chest tube placed before transport. A moderate
The intubation, surfactant, extubation (INSURE) tech- pneumothorax may potentially be treated definitively with
nique of intubation—administration of surfactant followed needle thoracentesis; however, chest tube placement should
by extubation—has been found to preserve the benefits of be considered before transport.
surfactant treatment while avoiding the potential side effects There are special considerations for transporting a new-
of mechanical ventilation. The use of this technique in the born with a pneumothorax by air. Transport personnel
setting of transport was analyzed in a retrospective study should consider the potential impact of altitude on air leak
examining moderately preterm infants (>28 weeks’ gesta- and air collections. The Boyle law states that entrapped gas
tion) with RDS who underwent intubation and required expands by 3% for every increase in altitude of 1,000 ft.
transfer to a tertiary referral center. The authors examined Thus, a small pneumothorax may increase with increasing
whether there were clinical indicators associated with those altitude.
infants who underwent extubation shortly after transport, For infants with an air leak of any type who are receiving
and thus would potentially be candidates for INSURE and mechanical ventilation, minimizing the mean airway pres-
transport with NCPAP. Although infants who underwent sure will help offset the accumulation or reaccumulation of
early extubation had a significantly lower FiO2 after surfac- air. High-frequency ventilation (HFV) has been found to
tant administration and stabilization by the transport team, provide adequate gas exchange using very low tidal volumes
the authors concluded that FiO2 only had a weak positive and a supraphysiologic rate, and thus HFV may be a useful
predictive value for extubation to NCPAP before transport. option if there is concern for ongoing air leak. Although
(6) evidence that HFV prevents air leaks from occurring is
insufficient, its use in the management of air leaks is
Air Leak ubiquitous and has not been found to be harmful. (11)
Pulmonary air leak can occur in newborns with underly-
ing pulmonary disease and those receiving positive pressure. Persistent Pulmonary Hypertension
(7) Thus, the clinical team should obtain a chest radio- A number of disease processes can lead to pulmonary
graph before transporting infants with respiratory distress. hypertension in the neonatal period. These include acute

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hypoxia because of perinatal depression, RDS, pneumonia, (19) Many physiologic stressors are associated with trans-
MAS, severe intrauterine growth restriction, and pulmonary port, particularly aeromedical transport, which is affected by
hypoplasia. (12) High pulmonary vascular resistance favors the Boyle law (the expansion of gas with rising altitude),
blood flow to the systemic circulation leading to a differen- Dalton law (the partial pressure of gas decreases with
tial cyanosis of more than 5% to 10% between the lower limb increasing altitude), and Henry law (the solubility of gas
and the right upper limb. (13) This disease process is alters with a changing altitude). (20) All of these issues may
managed by optimizing ventilatory support, either with be negated somewhat by the presence of cabin pressuriza-
the conventional ventilator or with HFV, surfactant admin- tion in a fixed wing aircraft. In contrast, helicopters are not
istration, inhaled nitric oxide (iNO), and if needed, extra- pressurized and therefore limited to less than 10,000 ft,
corporeal membrane oxygenation (ECMO). When these with typical flying altitudes of 1,000 to 3,000 ft. Lung
treatments are not available to an infant with a presumed volume can expand at altitudes as low as 1,000 ft, with
diagnosis of PPHN, the infant must be transferred to a volume expansion of up to 13.8% occurring in an artificial
tertiary referral center by an experienced transport team pneumothorax model at 5,000 ft. (21) During transport, it is
that is equipped with iNO. (14) important to be cognizant of these potential physiologic
Nitric oxide is a potent inhaled pulmonary vasodilator stressors and anticipate potential complications.
that has been shown to reduce the need for ECMO in
newborns with PPHN. (15) Lowe and Trautwein examined Hypoxemia
the benefits of starting iNO in the outlying hospital before Lollgen et al examined oxygen saturation levels during
transport to a tertiary center. They found that the initiation of aeromedical transport of infants younger than 6 months
iNO before transport did not alter infant mortality rate or and found that desaturations (<94%) occurred in about a
need for ECMO. (16) However, in patients who did not need third of infants, with a trend toward an increased incidence
ECMO, early administration of iNO significantly reduced in younger infants (44.4% at 6 weeks of age vs 18% at 3
the receiving hospital length of stay, in addition to the total months of age vs 16% at 3–6 months of age). (22) Factors
(combined referring and receiving hospital) length of stay. such as ventilation/perfusion mismatch, increased fetal he-
(16) moglobin, pulmonary vasoconstriction, and smaller airway
Up to 40% of infants with diseases such as parenchymal diameter are believed to contribute to altitude-associated
disease, pulmonary vascular disease, and cardiac dysfunc- hypoxemia in infants. (23)(24)(25) The British Thoracic
tion will not respond to iNO for a wide variety of reasons Society 2004 guidelines for commercial air travel recom-
such as parenchymal disease, pulmonary vascular disease, mend that infants with oxygen saturation less than 90%
and cardiac dysfunction. (17) Optimizing lung expansion receive supplemental oxygen during transport. (26)
by using HFV in addition to improving cardiac function
with inotropic support may be necessary considerations. (17) Gas Expansion
A retrospective study by Mainali et al found that high- Gas expansion may occur in a number of areas in a neonate,
frequency jet ventilation during transport was shown to most notably in the gastrointestinal tract. During transport,
significantly improve ventilation in neonates before receiv- this side effect can be proactively managed by placement of a
ing ECMO. (18) nasogastric or orogastric tube in infants receiving mechan-
Labile hypoxemia can be a characteristic of PPHN as a ical ventilation and those at risk for vomiting. Extra caution
result of the delicate balance between pulmonary vascular should be taken when transporting an infant with a pneu-
resistance and systemic vascular resistance. (13) The trans- mothorax because frequent reevaluation is necessary and
port team should monitor pre- and postductal oxygen sat- the transport team should be prepared for a possible needle
urations during transport in infants at risk for PPHN. thoracentesis if the air leak worsens. If more air accumu-
lates and the transport occurs via air travel, the transport
team could potentially request that the pilot fly at a lower
RESPIRATORY SIDE EFFECTS OF TRANSPORT
altitude to minimize additional air leaks.
Respiratory side effects of transporting a newborn can vary.
Before being transported, it is paramount that the infant Vibration
achieves respiratory stability, because transfer of an unstable Vibration is inherent in all types of transport. Vibration can
infant can potentially worsen the infant’s clinical condition. be a significant physiologic stressor, particularly during
During transport, patients can develop hypoxemia and hy- helicopter transports. This stress may worsen respiratory
percapnia but may also develop hyperoxia and hypocapnia. distress. In a study of rat pups, the authors found that the

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 forces transmitted to the animals during a simulated med- having an RT participate in transports. If an RT is not
ical transport caused a significant deterioration in their available, the transport team should be aware of the RT-
pulmonary function with increasing duration of the trans- related responsibilities during transport, (20) which include
port. Most notably, there was a significant increase in airway the following:
resistance at a given positive end-expiratory pressure. (27) • Check the oxygen and air levels in the cylinders on the
transport bed
Thermoregulation • Ensure that the ventilator circuit is attached and opera-
Temperature variation may occur with both air and ground tional and know how to use different modes of respiratory
transport. Alteration in the environmental temperature support on transport
may be caused by seasonal changes, geographic factors, • Ensure that the transport bag is fully stocked and secured
or alteration in altitude (20). Changes in the external tem- • Bring the appropriate surfactant dose in a cooling pack
perature may alter the infant’s metabolic rate, respiratory and be experienced in surfactant administration
status, and oxygen demand, potentially further compromis- • Bring a portable blood gas machine (if available) and be
ing a hypoxemic infant. To ameliorate these variations as experienced with its use
much as possible, the transport team should take steps such • Check the transport ambulance to ensure that the elec-
as using a warming mattress, using additional clothing, and trical inverter is working properly
removing any wet clothing or dressings in a timely manner. • Check the transport ambulance to ensure that an ade-
quate oxygen supply is available
• Complete transport evaluation form (may be composed of
PROFESSIONAL RESPIRATORY SUPPORT
various metrics such as departure time, arrival time, time
Neonatal transport teams are made up of a varying combi- spent at referring facility, patient temperature at the time
nation of nurses, physicians, and paramedical staff. (14) A of admission to receiving facility).
survey of 335 neonatal transport teams in the United States Although the transport team composition can vary
found 26 different team compositions, (28) with the most greatly, the team’s training seems to be the most important
common being nurse–respiratory therapist (RT)–based factor affecting patient outcomes. The use of specialized
teams. However, not every facility has the capability of transport teams to transfer critically ill pediatric patients was

TABLE 2. Respiratory Care Transport Equipment (47)

Airway Neonatal positive pressure bags with neonatal and infant mask, positive end-expiratory pressure valve,
equipment manometer
Continuous positive pressure airway apparatus; nasal prongs, assorted sizes
Nasal cannula, premature and newborn sizes
Endotracheal tubes (ETTs): 2.5, 3.0, 3.5, 4.0 mm, stylets, (ETT holders/tape to secure ETT)
Laryngoscope with size 00, 0, and 1 blades (extra batteries and extra light)
Capnography/carbon dioxide detector or monitor
Mechanical ventilator with back up circuit
Oxygen and air cylinders with appropriate indicators of in-line pressure and gas content
Flow meters, oxygen tubing and adapters
Oxygen analyzer, pulse oximeter and probes
Laryngeal mask airway—preterm and term (size 0.5 and 1)
Surfactant administration devices
Inhaled nitric oxide and delivery system
Chest tubes—8F, 10F, 12F
Suction Bulb syringe
equipment Suction catheters—5F, 6F, 8F, 10F, 12F
Regulated suction with gauging limiting
Orogastric/nasogastric feeding tube 8F and 10F and 20-mL syringe for orogastric decompression
Mucous suction trap, sterile gloves and sterile water for irrigation
Monitoring Stethoscope, electrocardiography leads, cardiac monitor, pulse oximeter
equipment Glucometer for blood sugar evaluation, blood gas evaluation
Capnography (transcutaneous or in-line)

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found to improve survival rates and to reduce the number of SPECIAL CONSIDERATIONS
unplanned events during transport of critically ill pediatric
Interfacility neonatal transport occurs frequently for pri-
patients. (29)
mary respiratory issues but special consideration should
be given to clinical situations in which the respiratory
PRETRANSPORT INFANT STABILIZATION system is not the main reason for transport. However,
the transport team should anticipate the possibility of
It is essential to stabilize a sick neonate before transport to
respiratory complications as potential sequelae of other
help maintain normothermia, adequate oxygenation and
underlying diagnoses.
perfusion, and euglycemia throughout the transport. (30)
The acronym “TOPS” (temperature, oxygenation [airway
and breathing], perfusion, and sugar) can serve as a quick Use of Prostaglandin
reminder of stabilization requirements before transferring Evaluation for a suspected congenital heart disease remains
an infant to a tertiary center. (30) a common reason for neonatal transfer to a tertiary care
1. Arrival responsibilities: Assess infant’s temperature, center. A continuous prostaglandin E1 infusion is vital in
airway, breathing, circulation, and blood sugar. maintaining the patency of the ductus arteriosus in ductal-
2. Temperature: Correct hypothermia (eg, warm clothing, dependent cardiac lesions. Common side effects of prosta-
portable heating mattress) if present before transport. glandin E1 are hypoventilation and apnea, affecting 7.7% to
3. Oxygenation 20% of infants. (31)(32)(33) Establishment of a secure airway
a. Airway: Assess airway for presence of secretions and before initiating prostaglandin E1 therapy and interfaci-
suction, if needed; assess need for shoulder/neck lity transport should be considered to decrease the risk of
roll; secure ETT if intubated. transport complications.
b. Breathing: Assess for respiratory distress; assess
whether infant requires respiratory support and/or Concern for Seizure Activity
ventilation; assess recent blood gas and chest The highest incidence of seizures in the pediatric pop-
radiograph; verify ETT placement and chest tube ulation is seen during the neonatal period. The need for
function, if applicable; adjust vent support, as indi- subspecialty support for antiseizure medications and
cated; determine if surfactant is indicated (if so, management of the underlying causes often requires
prepare for change in compliance after administra- transport to a tertiary care center. Symptoms of seizure
tion; if FiO2 decreases after administration, assess activity include involuntary movements of the extremi-
breath sounds because pressure might need to be ties, apnea, and autonomic function alterations in the
decreased as well). heart rate, blood pressure, or oxygenation. In addition,
4. Perfusion/circulation: Assess heart rate, blood pressure, most antiepileptic drugs have sedative effects that can be
and urine output; verify and check all intravenous (IV) significant enough to depress respiratory drive. (34)(35)
fluid infusions and any medication infusions; adjust (36) The need for respiratory support during transport
fluids and medications as indicated; verify that all lines should be anticipated before leaving the referring hospital
are secured for transport. and should take into account the infant’s seizure symp-
5. Sugar: Check blood glucose level; if glucose <40 mg/dL toms and severity as well as the dose of antiepileptic
(2.2 mmol/L), give an IV bolus of 2 mL/kg of 10% drugs.
dextrose in water, and then assess patency of the IV tube,
increase maintenance glucose infusion, and obtain Use of Analgesics and Sedatives
another blood glucose level to determine response and Opioids and benzodiazepines are often administered as
next steps. analgesics and/or sedatives to treat an underlying problem
6. Transport personnel: Receive report from referring or to stabilize a neonate before transport. The desired
hospital; update parents; obtain consent for transport; clinical effects must be balanced with both the consequen-
provide parents with contact information at tertiary tial clinical effects and the side effects of these medications.
center. Infants are at risk for oversedation and/or respiratory
7. Equipment: Verify all equipment needed and its correct depression when receiving these medications. (35)(37)
functioning. This should occur before going to the The need for respiratory support to offset these effects
referral hospital and before leaving the referring hospital should be anticipated during evaluation and stabilization
with the patient (Table 2). before transport to the tertiary center.

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 ACUTE RESPIRATORY DECOMPENSATION angiocatheter in the second intercostal space in the
midclavicular line or fourth intercostal space
Although interfacility transport has been demonstrated to
anterior to the midaxillary line.
improve overall outcomes and care of critically ill neo-
ii. When no more air can be withdrawn, remove the
nates, transport is not without risk. An acute decompen-
needle.
sation in an infant’s clinical status may be encountered by
iii. If there is an ongoing leak, the team can consider
transport teams despite stabilizing a patient before trans-
keeping an angiocatheter in place with the distal
port. The underlying cause of an acute respiratory decom-
end of tubing placed under sterile water to create a
pensation should be recognized and addressed as quickly
seal (44) or attached to a Heimlich valve via tubing;
as possible to minimize mortality and morbidity during
however, experience with this technique is neces-
transport. The most common respiratory issues that can
sary before applying it during transport.
occur are:
iv. Placement of a chest tube may be required.
1. Accidental extubation
3. Pulmonary hemorrhage
a. Signs and symptoms: Decreased oxygen saturation,
a. Signs and symptoms: Fresh blood or blood-tinged
bradycardia, and increased work of breathing unre-
secretions in the ETT; increased work of breathing,
sponsive to increased respiratory support and suc-
increased ventilatory requirements.
tioning; absent or diminished breath sounds bilaterally;
b. Management
absent color change seen on carbon dioxide detector.
i. Suctioning.
b. Management
ii. Increase positive end expiratory pressure.
i. Removal of ETT and initiation of bag-mask
iii. Consider blood component therapy, if available.
ventilation.
iv. Consider administration of 1:10,000 epinephrine
ii. Suctioning of secretions.
via ETT. Dosing varies in different studies from 0.1
iii. Reintubation if possible during transit. If not
mL/kg to 0.5 mL. (45) (46)
possible, continue bag-mask ventilation until the
ambulance or flight can be stopped to facilitate
reintubation. SUMMARY
iv. Alternatively, a laryngeal mask airway (LMA) may
• Various types of respiratory modalities are available for
be placed. According to the International Liaison
use during transport of a critically ill infant.
Committee on Resuscitation and European
• A thorough clinical assessment of the patient, taking
Resuscitation Council guidelines, LMAs may be
additional comorbidities into account, will help guide the
used in late preterm infants and term infants
patient’s respiratory needs for transport.
weighing more than 2,000 g. (38)(39) However,
• It is important to be prepared for a possible clinical
LMAs have been successfully placed in low-
deterioration in the patient by bringing the appropri-
birthweight infants (1,000–1,500 g) during
ate equipment and having adequate and appropriate
delivery room resuscitation and in preterm
staffing.
infants (>29 3/7 weeks’ gestation). (40)(41) The
role of LMA in neonatal transport has been described
in multiple case reports, but no randomized con-
trolled trials have compared its effectiveness with American Board of Pediatrics
other means of respiratory support. (42)(43). Neonatal-Perinatal Content
2. Pneumothorax Specification
a. Signs and symptoms: Decreased oxygen saturation,
• Know the issues in the organization of perinatal care (eg,
bradycardia, and hypotension, and increased work of regionalization, transport, practice guidelines, benchmarking
breathing unresponsive to increased respiratory sup- data, quality improvement).
port and suctioning; asymmetric breath sounds or
chest expansion; translucency of chest cavity on
transillumination of affected side.
b. Management References
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 39. Wyllie J, Bruinenberg J, Roehr CC, Rüdiger M, Trevisanuto D, 43. Trevisanuto D, Verghese C, Doglioni N, Ferrarese P, Zanardo V.
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NeoReviews Quiz
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1. A male infant is born at 32 weeks’ gestational age at a hospital without the capacity to NOTE: Learners can take
support infants receiving mechanical ventilation for longer than several hours. The infant NeoReviews quizzes and
initially has spontaneous breathing but progresses to have increasing respiratory distress claim credit online only
over the first hour after delivery. The infant is requiring continuous positive airway pressure at: http://Neoreviews.org.
(CPAP) and increasing fraction of inspired oxygen (Fio2) support. A transport team from a
To successfully complete
higher level NICU is mobilized to accept the patient. As the decision to intubate and
2019 NeoReviews articles
provide surfactant is being made, which of the following factors is an appropriate
for AMA PRA Category 1
consideration?
CreditTM, learners must
A. If the infant was exposed to antenatal steroids, surfactant is contraindicated. demonstrate a minimum
B. Because avoidance of intubation is a high priority, surfactant in this scenario is best performance level of 60%
administered with the use of nebulization through heated humidified nasal or higher on this
cannula. assessment, which
C. Studies have consistently shown that surfactant administered just before trans- measures achievement of
port is associated with a 25% incidence of pneumothorax. the educational purpose
D. Nasal CPAP often paradoxically increases the risk of intubation in early respiratory and/or objectives of this
distress syndrome. activity. If you score less
E. The health care professionals administering surfactant should have the technical than 60% on the
and clinical expertise to administer surfactant safely, and in particular, should pay assessment, you will be
close attention to the potential complication of hyperventilation. given additional
2. An infant born at 29 weeks’ gestational age has respiratory distress syndrome and is opportunities to answer
receiving nasal CPAP. Arrangements are being made for the infant to be transported to a questions until an overall
higher level of care. Which of the following statements about this clinical scenario is correct? 60% or greater score is
A. Because of the infant’s gestational age, CPAP is not a safe mode of support during achieved.
transport. This journal-based CME
B. Lower Fio2 requirement during CPAP before surfactant administration is a highly activity is available
predictive factor in the potential for successful extubation after the intubation, through Dec. 31, 2021,
surfactant, extubation (INSURE) procedure. however, credit will be
C. Once the decision to apply CPAP has been made and appears to be working, the recorded in the year in
infant should continue to receive CPAP and not be intubated during transport, and which the learner
the positive end-expiratory pressure increased as needed up to 10 cm H2O. completes the quiz.
D. Blood gas measurement for infants receiving CPAP would be advised either at
stabilization or 30 minutes after starting CPAP.
E. Because of the potential for tachycardia, infants receiving CPAP during transport
should not receive caffeine until they have been stabilized in the receiving hospital.
3. An infant born at 32 weeks’ gestational age at a hospital without a NICU is being prepared
for transport. In the delivery room, the infant receives CPAP via mask for several minutes 2019 NeoReviews now is
for apnea which subsequently resolved. The infant has mild respiratory distress and is approved for a total of 10
receiving nasal cannula oxygen. The chest radiograph shows a small pneumothorax on Maintenance of
the right side. Which of the following concerning air leak in this population is correct? Certification (MOC) Part 2
A. Long inspiratory time, high peak pressures, and large tidal volumes are risk factors credits by the American
for pulmonary air leak. Board of Pediatrics
B. Nitrogen washout is an effective treatment that should be implemented before through the ABP MOC
transport for all patients with pneumothorax who require support. Portfolio Program.
C. Air transport may be a preferred mode because of the likelihood that air leak will Complete the first 5 issues
reduce with higher altitudes. or a total of 10 quizzes of
D. Although a chest tube may ultimately be beneficial, placement should be post- journal CME credits,
poned until admission to the NICU, as transport will likely lead to unplanned achieve a 60% passing
removal because of movement. score on each, and start
E. Higher mean airway pressure will facilitate air leak evacuation by pushing the air claiming MOC credits as
into interstitial spaces. early as May 2019.

Vol. 20 No. 4 APRIL 2019 e211

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 4. An infant born at 40 weeks’ gestational age is diagnosed with meconium aspiration
syndrome and persistent pulmonary hypertension. Because of the need for higher level of
care, arrangements are made for transport. Inhaled nitric oxide is initiated after increasing
pressures and Fio2 during mechanical ventilation. Which of the following is most likely
to be reduced because of the addition of inhaled nitric oxide treatment?
A. Mortality.
B. Need for extracorporeal membrane oxygenation.
C. Hospital length of stay.
D. Hospital-acquired infection.
E. Anemia.
5. An infant born at 39 weeks’ gestational age is noted to have mild respiratory distress and
evaluation leads to a diagnosis of hypoplastic left heart syndrome. The infant is receiving
nasal cannula oxygen and a peripheral intravenous line is placed. Prostaglandin is started
to maintain patency of the ductus arteriosus. Arrangements for transport to a cardiac
center are made. Which of the following is an important consideration for transport of
this infant receiving prostaglandin?
A. Low pressures for respiratory support and avoidance of intubation are suggested
because of the high risk of pneumothorax in this population.
B. Inhaled nitric oxide is an important consideration for supplementing current
therapy to improve pulmonary vascular dilation.
C. The most frequent side effect of prostaglandin in newborns is seizures.
D. Because hypoventilation and apnea are common side effects, establishment of a
secure airway before initiating prostaglandin therapy and transport should be
considered to decrease the risk of transport complications.
E. Optimal perfusion will be achieved by using high Fio2.

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 Neonatal Respiratory Support on Transport
Gillian Brennan, Jill Colontuono and Christine Carlos
NeoReviews 2019;20;e202
DOI: 10.1542/neo.20-4-e202

Updated Information & including high resolution figures, can be found at:
Services http://neoreviews.aappublications.org/content/20/4/e202
References This article cites 42 articles, 12 of which you can access for free at:
http://neoreviews.aappublications.org/content/20/4/e202.full#ref-list-
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 Neonatal Respiratory Support on Transport
Gillian Brennan, Jill Colontuono and Christine Carlos
NeoReviews 2019;20;e202
DOI: 10.1542/neo.20-4-e202

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
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