Transcript Respiratory Case 3 - ACORN - Acute Care of at

Respiratory Sequence
Case Two
June 2006
ACoRN © 2005
Shawn
• Premature labour at 30 weeks gestation
• Labour progressed rapidly
• At birth: HR > 100 bpm, colour
transitioned to pink with O2, tone slightly
decreased
• Apgar score 61, 85
• Birth weight 1500 grams
Nov 2007
ACoRN © 2005-07
Shawn
• Developed signs of respiratory distress
• Given O2 in the delivery room and
during the transport to the nursery
• He was placed on a radiant warmer in
an oxygen hood with 35% oxygen
Nov 2007
ACoRN © 2005-07
Shawn
•
•
•
•
•
•
•
Pink
RR 88/min and regular, HR 140 bpm
Laboured respiration
SpO2 90%
Well perfused, BP 47/25 mean 33
Tone normal
Temperature 36.4°C
Initiate the ACoRN Process
Nov 2007
ACoRN © 2005-07
Baby at risk
Unwell
Risk factors
Post-resuscitation
requiring stabilization
Resuscitation
Ineffective breathing
Heart rate < 100 bpm
Central cyanosis
Support
Infection
Risk factor for infection
ACoRN alerting sign with *
Clinical deterioration
Respiratory
Laboured respiration*
Respiratory rate > 60/min*
Receiving respiratory support*
Cardiovascular
Pale, mottled, or grey*
Weak pulses or low BP*
Cyanosis unresponsive to O2
Heart rate > 220 bpm
Thermoregulation
T < 36.3 or > 37.2ºC axillary*
Increased risk for
temperature instability
Problem List
Respiratory
Cardiovascular
Neurology
Surgical conditions
Fluid & glucose
Thermoregulation
Infection
?
Fluid & Glucose Management
Blood glucose < 2.6 mmol/L
At risk for hypoglycemia
Not feeding or should not be fed
Sequences
Consider transport
Nov 2007
Neurology
Abnormal tone*
Jitteriness
Seizures*
Surgical Conditions
Anterior abdominal wall defect
Vomiting or inability to swallow
Abdominal distension
Delayed passage of meconium
ACoRN
or imperforate anus
© 2005-07
Respiratory
Laboured respiration *
Respiratory rate > 60/min *
Receiving respiratory support *
Yes
Respiratory Sequence
Recheck patent airway/breathing
Administer O2 as needed to maintain
SpO288-95%
Establish/continue monitors:
- pulse oximetry
- cardiorespiratory
- blood pressure
- oxygen analyzer
Calculate ACoRN Respiratory Score if
spontaneously breathing
Nov 2007
ACoRN © 2005-07
Shawn
Calculate Shawn’s ACoRN Respiratory
Score.
– 35% O2
– RR 75/min, SpO2 92%, centrally pink
– Grunting at rest, moderate sternal and
intercostal retractions
– Breath sounds decreased bilaterally
– 30 weeks gestation
Nov 2007
ACoRN © 2005-07
ACoRN Respiratory Score
Score
0
1
2
40-60/minute
60-80/minute
>80/minute
Oxygen
Requirement1
None
< 50%
> 50%
Retractions
None
Mild to
moderate
Severe
Grunting
None
With
stimulation
Continuous at
rest
Breath sounds
on auscultation
Easily heard
throughout
Decreased
Barely heard
Prematurity
> 34 weeks
30-34 weeks
<30 weeks
Respiratory
rate
Severity :
Nov 2007
<5
5 to 8
>8
ACoRN © 2005-07
Respiratory distress
• Lungs with decreased compliance are
“stiff”.
– Alveoli tend to collapse.
– Areas that are poorly ventilated are unable to
participate in gas exchange.
• Babies attempt to compensate.
– Exaggerated use of the accessory muscles of
breathing to pull air into the lungs during
inspiration.
Nov 2007
ACoRN © 2005-07
Organization of Care
Problem List
Mild respiratory distress
(ACoRN score < 5) lasting
< 4 hours
Moderate respiratory
distress (score 5 to 8)
Persistent or new
respiratory distress
Consider/adjust
respiratory support
(CPAP or PPV)
Focused history
Physical examination
Review diagnostic tests done
Establish working diagnosis
Nov 2007
Severe respiratory
distress (score > 8)
Apnea or gasping
Receiving ventilation
Intubate if not already
intubated
Optimize ventilation
Vascular access
CXR
Blood gas
Consider immediate consult
ACoRN © 2005-07
Response
Problem List
Mild respiratory distress
(ACoRN score < 5) lasting
< 4 hours
Moderate respiratory
distress (score 5 to 8)
Persistent or new
respiratory distress
Consider/adjust
respiratory support
(CPAP or PPV)
Focused history
Physical examination
Review diagnostic tests done
Establish working diagnosis
Nov 2007
Severe respiratory
distress (score > 8)
Apnea or gasping
Receiving ventilation
Intubate if not already
intubated
Optimize ventilation
Vascular access
CXR
Blood gas
Consider immediate consult
ACoRN © 2005-07
Shawn
Nov 2007
ACoRN © 2005-07
CPAP
• Stabilizes the small airways and chest wall,
and prevents atelectasis at end expiration.
• Improves/maintains oxygenation.
• Decreases the need for endotracheal
intubation and mechanical ventilation in
babies with moderate respiratory distress
and good respiratory effort.
Nov 2007
ACoRN © 2005-07
Contraindications
• Respiratory failure
• TEF/EA, CDH, cleft palate, choanal
atresia
• Abdominal wall defects, gastrointestinal
obstruction, NEC
• Easily agitated or does not tolerate CPAP
(relative)
• Excessive air swallowing (relative)
Nov 2007
ACoRN © 2005-07
CPAP
• Generated by a variety of devices
– ventilator on CPAP mode
– circuits with free flow of gas exiting
through an underwater seal (“bubble
CPAP”) or valve
– infant flow driver
– flow inflating bag and mask (transiently)
– T-piece resuscitator
Nov 2007
ACoRN © 2005-07
Nov 2007
ACoRN © 2005-07
Response
Problem List
Mild respiratory distress
(ACoRN score < 5) lasting
< 4 hours
Moderate respiratory
distress (score 5 to 8)
Persistent or new
respiratory distress
Consider/adjust
respiratory support
(CPAP or PPV)
Focused history
Physical examination
Review diagnostic tests done
Establish working diagnosis
Nov 2007
Severe respiratory
distress (score > 8)
Apnea or gasping
Receiving ventilation
Intubate if not already
intubated
Optimize ventilation
Vascular access
CXR
Blood gas
Consider immediate consult
ACoRN © 2005-07
Next Steps
Problem List
Mild respiratory distress
(ACoRN score < 5) lasting
< 4 hours
Moderate respiratory
distress (score 5 to 8)
Persistent or new
respiratory distress
Consider/adjust
respiratory support
(CPAP or PPV)
Focused history
Physical examination
Review diagnostic tests done
Establish working diagnosis
Nov 2007
Severe respiratory
distress (score > 8)
Apnea or gasping
Receiving ventilation
Intubate if not already
intubated
Optimize ventilation
Vascular access
CXR
Blood gas
Consider immediate consult
ACoRN © 2005-07
Shawn
• The team has completed the Fluid &
Glucose, Thermoregulation and Infection
Sequences.
• A CBC and blood culture were done and
ampicillin and gentamicin ordered.
• An assessment was done of the
resources needed to look after this baby.
Nov 2007
ACoRN © 2005-07
- pulse oximetry
- cardiorespiratory
- blood pressure
- oxygen analyzer
Calculate ACoRN Respiratory Score if
spontaneously breathing
• You re-enter the Respiratory Sequence
because the CXR and blood work results
have returned.
• Where do you re-enter?
Mild respiratory distress
(ACoRN score < 5) lasting
< 4 hours
Moderate respiratory
distress (score 5 to 8)
Persistent or new
respiratory distress
Consider/adjust
respiratory support
(CPAP or PPV)
Reassess diagnosis and
management if unresolved
within 4 hours
Intubate if not already
intubated
Optimize ventilation
Vascular access
CXR
Blood gas
Consider immediate consult
Focused history
Physical examination
Review diagnostic tests done
Establish working diagnosis
TTN
Mild respiratory distress
Severe respiratory
distress (score > 8)
Apnea or gasping
Receiving ventilation
RDS
Consider surfactant
Aspiration
Pneumonia
PPHN
Other
Pneumothorax (1)
Consider chest
drain and
followup CXR
Supportive care
Nov 2007
Repeat ACoRN Respiratory Score if spontaneously breathing
ACoRN © 2005-07
(1)
drainage of a symptomatic
Shawn
• Capillary blood gas:
–
–
–
–
–
pH 7.30
pCO2 49
pO2 45
HCO3 20
BD 3
Interpret the blood gas.
Nov 2007
pH
PCO2
BD
Interpretation
↓
↑
N
Respiratory
acidosis
↓
N
↑
Metabolic
acidosis
↑
↓
N
Respiratory
alkalosis
↑
N
↓
Metabolic
alkalosis
ACoRN © 2005-07
Name, date/time, R/L
How would you
describe the
lung fields
Any air leaks?
How much can
you see of the
heart border and
hemidiaphragms
Is the size
and shape
of the heart
normal?
Nov 2007
Centered, exposure?
Where is the
stomach
bubble?
Can you see
an ETT? Tip
and carina?
Any objects?
Where?
Any bony
abnormalities?
ACoRN © 2005-07
(ACoRN score < 5) lasting
< 4 hours
distress (score 5 to 8)
Persistent or new
respiratory distress
distress (score > 8)
Apnea or gasping
Receiving ventilation
Specific Diagnosis
Consider/adjust
respiratory support
(CPAP or PPV)
Vascular access
CXR
Blood gas
Consider immediate consult
Focused history
Physical examination
Review diagnostic tests done
Establish working diagnosis
TTN
Mild respiratory distress
Reassess diagnosis and
management if unresolved
within 4 hours
Intubate if not already
intubated
Optimize ventilation
RDS
Consider surfactant
Aspiration
Pneumonia
PPHN
Other
Consider chest
drain and
followup CXR
Supportive care
Repeat ACoRN Respiratory Score if spontaneously breathing
Optimize oxygenation
Optimize respiratory support (adjust ventilator/CPAP settings,
wean, or discontinue)
Nov 2007
Pneumothorax (1)
(1)
drainage of a symptomatic
penumothorax takes
precedence over returning to
the Problem List
ACoRN © 2005-07
Consider/adjust
respiratory support
(CPAP or PPV)
Intubate if not already
intubated
Optimize ventilation
Specific Management
Vascular access
CXR
Blood gas
Consider immediate consult
Focused history
Physical examination
Review diagnostic tests done
Establish working diagnosis
TTN
Mild respiratory distress
Reassess diagnosis and
management if unresolved
within 4 hours
RDS
Consider surfactant
Aspiration
Pneumonia
PPHN
Other
Consider chest
drain and
followup CXR
Supportive care
Repeat ACoRN Respiratory Score if spontaneously breathing
Optimize oxygenation
Optimize respiratory support (adjust ventilator/CPAP settings,
wean, or discontinue)
Nov 2007
Pneumothorax (1)
(1)
drainage of a symptomatic
penumothorax takes
precedence over returning to
the Problem List
ACoRN © 2005-07
(CPAP or PPV)
Optimize ventilation
Vascular access
CXR
Blood gas
Consider immediate consult
Specific Management
Focused history
Physical examination
Review diagnostic tests done
Establish working diagnosis
TTN
Mild respiratory distress
Reassess diagnosis and
management if unresolved
within 4 hours
RDS
Consider surfactant
Aspiration
Pneumonia
PPHN
Other
Consider chest
drain and
followup CXR
Supportive care
Repeat ACoRN Respiratory Score if spontaneously breathing
Optimize oxygenation
Optimize respiratory support (adjust ventilator/CPAP settings,
wean, or discontinue)
Nov 2007
Pneumothorax (1)
(1)
drainage of a symptomatic
pneumothorax takes
precedence over returning to
the Problem List
ACoRN © 2005-07
Shawn
• ACoRN Respiratory Score is still 7
• SpO2 is 90%
• 35% oxygen on CPAP of 5 cm H2O
What do you do?
Nov 2007
ACoRN © 2005-07
• One hour later, the Primary Survey shows
….
Nov 2007
ACoRN © 2005-07
Respiratory
Laboured respiration*
Respiratory rate > 60/min*
Receiving respiratory support*
Cardiovascular
Pale, mottled, or grey*
Weak pulses or low BP*
Cyanosis unresponsive to O2
Heart rate > 220 bpm
Infection
Risk factor for infection
ACoRN alerting sign with *
Clinical deterioration
Thermoregulation
T < 36.3 or > 37.2ºC axillary*
Increased risk for
temperature instability
Problem List
Respiratory
Cardiovascular
Neurology
Surgical conditions
Fluid & glucose
Thermoregulation
Infection
Fluid & Glucose Management
Blood glucose < 2.6 mmol/L
At risk for hypoglycemia
Not feeding or should not be fed
Sequences
Neurology
Abnormal tone*
Jitteriness
Seizures*
Nov 2007
Surgical Conditions
Anterior abdominal wall defect
Vomiting or inability to swallow
Abdominal distension
Delayed passage of meconium
or imperforate anus ACoRN © 2005-07
Shawn
Re-calculate the ACoRN Respiratory
Score based on the following information:
–
–
–
–
–
Nov 2007
respirations are 70/minute
SpO2 90% in 65% oxygen on CPAP
grunting continuously
moderate retractions
breath sounds decreased to bases
ACoRN © 2005-07
Score
0
1
2
40-60/minute
60-80/minute
>80/minute
Oxygen
Requirement1
None
< 50%
> 50%
Retractions
None
Mild to
moderate
Severe
Grunting
None
With
stimulation
Continuous
at rest
Breath
sounds on
auscultation
Easily heard
throughout
Decreased
Barely heard
Prematurity
> 34 weeks
30-34 weeks
<30 weeks
Respiratory
rate
Score :
Nov 2007
<5
5 to 8
>8
ACoRN © 2005-07
Shawn
Complete the Respiratory Sequence
as far as possible.
Nov 2007
ACoRN © 2005-07
Organization of Care
Problem List
Mild respiratory distress
(ACoRN score < 5) lasting
< 4 hours
Moderate respiratory
distress (score 5 to 8)
Persistent or new
respiratory distress
Consider/adjust
respiratory support
(CPAP or PPV)
Focused history
Physical examination
Review diagnostic tests done
Establish working diagnosis
Nov 2007
Severe respiratory
distress (score > 8)
Apnea or gasping
Receiving ventilation
Intubate if not already
intubated
Optimize ventilation
Vascular access
CXR
Blood gas
Consider immediate consult
ACoRN © 2005-07
Response
Problem List
Mild respiratory distress
(ACoRN score < 5) lasting
< 4 hours
Moderate respiratory
distress (score 5 to 8)
Persistent or new
respiratory distress
Consider/adjust
respiratory support
(CPAP or PPV)
Focused history
Physical examination
Review diagnostic tests done
Establish working diagnosis
Nov 2007
Severe respiratory
distress (score > 8)
Apnea or gasping
Receiving ventilation
Intubate if not already
intubated
Optimize ventilation
Vascular access
CXR
Blood gas
Consider immediate consult
ACoRN © 2005-07
Respiratory support:
• Continue CPAP or
• Initiate mechanical ventilation
Nov 2007
ACoRN © 2005-07
Mechanical ventilation
Indications for initiation include
• ineffective respiration at any time
• respiratory Score > 8
• respiratory Score 5 to 8 with clinical
deterioration
• respiratory acidosis: pH ≤ 7.25, PCO2 ≥ 55
• increase in FiO2 despite CPAP
• alternative to CPAP for transport
• surfactant administration
Nov 2007
ACoRN © 2005-07
Indications for ventilation HERE ?
• Increased oxygen requirements from 35
to 65%
• Increase in Respiratory Score 7 → 8 (?)
• Considering surfactant administration
• Gestational age and birth weight
Nov 2007
ACoRN © 2005-07
Next Steps
Problem List
Mild respiratory distress
(ACoRN score < 5) lasting
< 4 hours
Moderate respiratory
distress (score 5 to 8)
Persistent or new
respiratory distress
Consider/adjust
respiratory support
(CPAP or PPV)
Focused history
Physical examination
Review diagnostic tests done
Establish working diagnosis
Nov 2007
Severe respiratory
distress (score > 8)
Apnea or gasping
Receiving ventilation
Intubate if not already
intubated
Optimize ventilation
Vascular access
CXR
Blood gas
Consider immediate consult
ACoRN © 2005-07
Premedication for intubation
Who administers premedication prior to
intubation?
What must you have available prior to
administering premedication?
Nov 2007
ACoRN © 2005-07
Exhaled CO2 detector
• placed between the ETT
connector and the
manual bagging system
• cycles with respiration
from purple to yellow
when it comes in contact
with CO2
Nov 2007
Purple
Yellow
ACoRN © 2005-07
Mechanical ventilation
• Goals:
– assist ventilation
– improve oxygenation
Nov 2007
ACoRN © 2005-07
Problem List
Mild respiratory distress
(ACoRN score < 5) lasting
< 4 hours
Moderate respiratory
distress (score 5 to 8)
Persistent or new
respiratory distress
Consider/adjust
respiratory support
(CPAP or PPV)
Focused history
Physical examination
Review diagnostic tests done
Establish working diagnosis
Severe respiratory
distress (score > 8)
Apnea or gasping
Receiving ventilation
Intubate if not already
intubated
Optimize ventilation
Vascular access
CXR
Blood gas
Consider immediate consult
What does “optimize ventilation” mean?
Nov 2007
ACoRN © 2005-07
Suggested initial settings
Parameter
PIP (cmH20)
PEEP (cmH20)
f (per min)
tI (sec)
% oxygen1
Flow (L/min)
Preterm
baby or LBW
baby with
lung disease
Term baby
with lung
disease
Normal lungs
(for example,
apnea with no
lung disease)
18 to 20
20 to 25
15
5
5
3 to 4
40 to 60
40 to 60
30 to 40
0.3
0.3 to 0.4
0.3 to 0.4
As needed
As needed
Room air
6 to 8
10 to 15
6 to 10
Titrate oxygen for target saturations 88 to 95%1
Nov 2007
ACoRN © 2005-07
Problem List
Mild respiratory distress
(ACoRN score < 5) lasting
< 4 hours
Moderate respiratory
distress (score 5 to 8)
Persistent or new
respiratory distress
Consider/adjust
respiratory support
(CPAP or PPV)
Focused history
Physical examination
Review diagnostic tests done
Establish working diagnosis
Nov 2007
Severe respiratory
distress (score > 8)
Apnea or gasping
Receiving ventilation
Intubate if not already
intubated
Optimize ventilation
Vascular access
CXR
Blood gas
Consider immediate consult
ACoRN © 2005-07
Next Steps
Problem List
Mild respiratory distress
(ACoRN score < 5) lasting
< 4 hours
Moderate respiratory
distress (score 5 to 8)
Persistent or new
respiratory distress
Consider/adjust
respiratory support
(CPAP or PPV)
Focused history
Physical examination
Review diagnostic tests done
Establish working diagnosis
Nov 2007
Severe respiratory
distress (score > 8)
Apnea or gasping
Receiving ventilation
Intubate if not already
intubated
Optimize ventilation
Vascular access
CXR
Blood gas
Consider immediate consult
ACoRN © 2005-07
Shawn
• Repeat blood gas:
pH = 7.28
pCO2 = 51
pO2 = 40
Bicarb = 21
BD = 3
Interpret the blood gas.
Nov 2007
pH
PCO2
BD
Interpretation
↓
↑
N
Respiratory
acidosis
↓
N
↑
Metabolic
acidosis
↑
↓
N
Respiratory
alkalosis
↑
N
↓
Metabolic
alkalosis
ACoRN © 2005-07
Nov 2007
ACoRN © 2005-07
(ACoRN score < 5) lasting
< 4 hours
distress (score 5 to 8)
Persistent or new
respiratory distress
distress (score > 8)
Apnea or gasping
Receiving ventilation
Specific Diagnosis
Consider/adjust
respiratory support
(CPAP or PPV)
Vascular access
CXR
Blood gas
Consider immediate consult
Focused history
Physical examination
Review diagnostic tests done
Establish working diagnosis
TTN
Mild respiratory distress
Reassess diagnosis and
management if unresolved
within 4 hours
Intubate if not already
intubated
Optimize ventilation
RDS
Consider surfactant
Aspiration
Pneumonia
PPHN
Other
Consider chest
drain and
followup CXR
Supportive care
Repeat ACoRN Respiratory Score if spontaneously breathing
Optimize oxygenation
Optimize respiratory support (adjust ventilator/CPAP settings,
wean, or discontinue)
Nov 2007
Pneumothorax (1)
(1)
drainage of a symptomatic
penumothorax takes
precedence over returning to
the Problem List
ACoRN © 2005-07
(ACoRN score < 5) lasting
< 4 hours
distress (score 5 to 8)
Persistent or new
respiratory distress
distress (score > 8)
Apnea or gasping
Receiving ventilation
Specific Diagnosis & Management
Consider/adjust
respiratory support
(CPAP or PPV)
Vascular access
CXR
Blood gas
Consider immediate consult
Focused history
Physical examination
Review diagnostic tests done
Establish working diagnosis
TTN
Mild respiratory distress
Reassess diagnosis and
management if unresolved
within 4 hours
Intubate if not already
intubated
Optimize ventilation
RDS
Consider surfactant
Aspiration
Pneumonia
PPHN
Other
Consider chest
drain and
followup CXR
Supportive care
Repeat ACoRN Respiratory Score if spontaneously breathing
Optimize oxygenation
Optimize respiratory support (adjust ventilator/CPAP settings,
wean, or discontinue)
Nov 2007
Pneumothorax (1)
(1)
drainage of a symptomatic
penumothorax takes
precedence over returning to
the Problem List
ACoRN © 2005-07
Surfactant administration
• Surfactant administration re-expands the
alveoli, improving gas exchange.
• It also
– decreases the incidence of pneumothorax
– decreases the need for more aggressive
ventilation and shortens the duration of
ventilation
– decreases development of chronic lung
disease
– improves survival
Nov 2007
ACoRN © 2005-07
Surfactant administration
• Surfactant is given
directly into the trachea
via the endotracheal tube
• The dose is 4 to 5 mL/kg
(depending on the type of
brand)
Nov 2007
ACoRN © 2005-07
Surfactant administration risks
• desaturation or bradycardia
– usually resolves by slowing rate of
administration
– may need to temporarily increase % inspired
oxygen and level of ventilator support
• ETT obstruction
• pneumothorax
• inadvertent administration to one lung
Nov 2007
ACoRN © 2005-07
Post surfactant administration
• closely monitor
– chest expansion
– SpO2, % inspired oxygen
– blood gases
• wean ventilator settings
Nov 2007
ACoRN © 2005-07
Other uses for surfactant
• Decision to administer surfactant in
babies with MAS should be taken with
great caution as these babies may
deteriorate due to labile pulmonary
hypertension.
Nov 2007
ACoRN © 2005-07
Shawn
• 5 mL/kg surfactant is administered
(5 x 1.5 kg = 7.5 mL).
• During administration, Shawn’s
SpO2 reading falls to 80%.
What would you do?
Nov 2007
ACoRN © 2005-07
Shawn
• Post surfactant administration,
Shawn looks comfortable in 35%
oxygen with SpO2 of 93%.
• His blood gas result is:
pH 7.30, pCO2 45, pO2 55, BD 3
Is Shawn’s ventilation optimized?
Nov 2007
ACoRN © 2005-07
(CPAP or PPV)
Optimize ventilation
Vascular access
CXR
Blood gas
Consider immediate consult
Specific Management
Focused history
Physical examination
Review diagnostic tests done
Establish working diagnosis
TTN
Mild respiratory distress
Reassess diagnosis and
management if unresolved
within 4 hours
RDS
Consider surfactant
Aspiration
Pneumonia
PPHN
Other
Consider chest
drain and
followup CXR
Supportive care
Repeat ACoRN Respiratory Score if spontaneously breathing
Optimize oxygenation
Optimize respiratory support (adjust ventilator/CPAP settings,
wean, or discontinue)
Nov 2007
Pneumothorax (1)
(1)
drainage of a symptomatic
penumothorax takes
precedence over returning to
the Problem List
ACoRN © 2005-07
The Respiratory Sequence
Respiratory
Laboured respiration *
Respiratory rate > 60/min *
Receiving respiratory support *
A lerting signs
Yes
Respiratory Sequence
Recheck patent airway/breathing
Administer O2 as needed to maintain
SpO2 88-95%
Establish/continue monitors:
- pulse oximetry
- cardiorespiratory
- blood pressure
- oxygen analyzer
Calculate ACoRN Respiratory Score if
spontaneously breathing
C ore steps
O rganization of care
Mild respiratory distress
(ACoRN score < 5) lasting
< 4 hours
Moderate respiratory
distress (score 5 to 8)
Persistent or new
respiratory distress
R esponse
N ext steps
S pecific diagnosis
S pecific management
Consider/adjust
respiratory support
(CPAP or PPV)
Reassess diagnosis and
management if unresolved
within 4 hours
Intubate if not already
intubated
Optimize ventilation
Vascular access
CXR
Blood gas
Consider immediate consult
Focused history
Physical examination
Review diagnostic tests done
Establish working diagnosis
TTN
Mild respiratory distress
Severe respiratory
distress (score > 8)
Apnea or gasping
Receiving ventilation
RDS
Consider surfactant
Aspiration
Pneumonia
PPHN
Other
Supportive care
Repeat ACoRN Respiratory Score if spontaneously breathing
Optimize oxygenation
Optimize respiratory support (adjust ventilator/CPAP settings,
wean, or discontinue)
Nov 2007
Problem List
No
Pneumothorax (1)
Consider chest
drain and
followup CXR
(1) drainage
of a symptomatic
penumothorax takes
precedence over returning to
the Problem List
ACoRN © 2005-07
Questions?
Nov 2007
ACoRN © 2005-07