Early Management on NICU

It is important to prepare the cot space in advance to ensure minimal handling and interruption to CPAP/ ventilation. The early management of these babies are described in the PRIME TIME 2014 guideline


Further management of ventilated babies: Flow chart 2014

Most babies who have received antenatal steroids and surfactant require minimal ventilation and FiO2 in the first few hours. Consider Volume guarantee ventilation. If your PIP is greater than 18 cm and FiO2 >0.4, consider complications such as pneumothorax, congenital pneumonia, ET tube in the right main bronchus, surfactant administration in one lung etc. Request an early chest X-ray in this situation and if there is still evidence of surfactant deficient lung disease repeat surfactant dose. You do not need to wait for 12 hours to repeat surfactant dose.


Wean ventilation as tolerated using the principle of permissive hypercapnia (Ph >7.25, pCO2 <8kpa).


Do not start morphine routinely. If heading for extubation load with caffeine


Management of babies on nasal CPAP:


On arrival:


Apply infant flow nasal CPAP 5-6cmH2O immediately. Try not to take the baby off the Neopac CPAP until the infant flow driver is set up. Then transfer directly


Allow   permissive hypercapnia  paCO2 up to 7-8.5 kPa (50-64mmHg)


Allow   FiO2 to go up to 0.4

But only after you have checked:


  • The prongs are in the nose


  • They are the right size


  • The neck is slightly extended


  • The nose has been cleared (suctioned)


  • Baby is nursed prone/ or side to side


  • You have tried higher pressures 8-9 cm H2O or more.


Criteria for reventilating babies on nasal CPAP:


Intubate and ventilate if there is any of the following:


  • FiO2 > 0.4 to maintain sats > 91% (after initial stabilisation)


  • PaCO2 > 8kPa (60 mmHg) (capillary gases can be used)


  • Apnoea  unresponsive to stimulation

or frequent: > 6 in 6 hrs needing stimulation

or severe: more than 1 episode of bag & mask


  • Acidosis (after initial stabilisation)

Arterial pH <7.25 and PaCO2 > 8 kPa (60 mmHg)


Consider other causes for respiratory deterioration apart from prematurity (e.g. pneumothorax, diaphragmatic hernia, pulmonary hypoplasia, pneumonia, congenital lung anomaly, neuromuscular problem)