First stabilization measures include light taktike stimulation head positioning and suction of the mouth and the nose, as required, followed by O2 supplementation ontinuous airway pressure (CPAP) Non-invasive positive pressure ventilation (NIPPV) Bag ventilation through mask or mechanical ventilation newborns with by any of the above measures oxygen can be supplied, require careful cardiac examination to exclude a congenital heart defect and treatment with high-frequency, oscillatory ventilation, nitric oxide, an extracorporeal membrane oxygenation (ECMO), or both. Oxygen O2 should be given via a nasogastric tube, face mask or O2-hood in such an O2 concentration that in preterm infants a PaO2 of 50-70 mmHg, and in the newborn of 50-80 mmHg or an O2 saturation of 90-94% is achieved in preterm infants and 92-96% in newborns. A higher PaO 2 carries the risk of retinopathy. A low PaO2 in premature infants is sufficient to ensure a full saturation of Hb, as the fetal Hb has a higher affinity for O2 (retinopathy of prematurity). It does not matter, is administered in the manner in which O2, it has dampened in any case and be warmed (36-37 ° C) to prevent cooling down and drying of secretions and bronchospasm. In newborns who need a proportion of inspired O2 (FiO2) ? 40%, arterial Umbilikalkatheter is placed (UAC) to measure blood gases. Can not happen, the blood pressure and blood gases are monitored through an arterial cannula. Newborns who do not respond to all these treatments that require liquid to improve cardiac output and are candidates for CPAP, bag or mask ventilation (40-60 breaths / min). If an infant can not be oxygenated or a longer lasting bag and mask ventilation needed, it should be intubated and mechanically ventilated. Very premature newborns (z. B. <28 weeks of gestation or <1000 g) are normally ventilated immediately after birth so that they can receive preventive surfactant therapy. Since the cause of respiratory distress in newborns often is a bacterial sepsis, it is common in newborns who have a very high O2 demand to create blood cultures and administer antibiotics until the culture results are available. Continuous Positive Airway Pressure (CPAP) Continuous Positive Airway Pressure (CPAP) provides O2 with a positive pressure of 5-7 mm H2O. This keeps the alveoli open and improves oxygenation by decreasing which is shunted by atelectatic surfaces of blood volume, while the child is breathing spontaneously. CPAP can be provided by a nasal cannula, or other various apparatuses; CPAP also can be administered in endotracheal intubation via a conventional ventilator, wherein the respiratory rate is set to zero. CPAP is indicated when a Fio2? is 40% necessary to achieve an acceptable saturation with PaO2 (50-70 mmHg) in infants with respiratory distress and the time period is limited (z. B. atelectasis, light respiratory distress syndrome, pulmonary edema). In these infants CPAP can prevent a required mechanical ventilation. Noninvasive positive pressure ventilation (NIPPV) NIPPV (mechanical ventilation at a glance: Noninvasive positive pressure ventilation (NIPPV)) provides a positive pressure ventilation using nasal prongs or nasal masks. You may be unsynchronized synchronized (d. H triggered by the inspiratory effort of the child.) Or. NIPPV can provide a backup rate and increase the spontaneous breathing of a child. The peak pressure can be set to the desired limits. It is particularly useful in patients with apnea, to facilitate extubation and prevent atelectasis. Mechanical ventilation tracheal tubes are mechanical ventilation required (Restoring and Backing up the airways: endotracheal tube) tracheal tubes with a diameter of 2.5 mm (the smallest size) are typically used for infants <1250 g. 3 mm for infants from 1250 to 2500 g 3.5 mm for infants> 2500 g During intubation should be administered a precaution O2. Orotracheal intubation is preferred. Orotracheal intubation is preferred. The tube should be inserted so that the 7 cm mark in infants weighing 1 kg on the lip 8 cm mark in infants with 2 kg of 9 cm mark in infants properly placed with 3 kg of the endotracheal tube is when its tip can be scanned by the front bronchial wall at the upper border of the sternum. It should look something halfway between clavicle and Karina on the chest x-ray, approximately at the level of the second thoracic vertebra. If location or continuity are doubtful, the tube should be removed, the child again ventilated through a mask and tube are placed again. In a sudden deterioration of the ventilatory situation (sudden change of oxygen saturation, blood gases, blood pressure or blood circulation), the tube should be immediately checked for its location and consistency. Ventilation equipment can apply the respiratory gas, either at a predetermined pressure or a predetermined volume. They are either assisted controls (AC, while the ventilator is set so that it outputs a full breath during each inhalation of the patient) or set with an intermittent, mandatory ventilation (IMV, wherein the ventilator a number of breaths in a certain time period outputs and the patient can breathe himself therebetween without triggering the breathing apparatus). You can also use a normal or high respiratory rate work (400-900 breaths / min). The optimal type of ventilation depends on the reaction of the infant. Certain volume ventilators are with changing lung resistance considered useful for older children (eg. As in bronchopulmonary dysplasia), as they ensure a secure tidal volume with each breath and thus allow adequate ventilation. The AC mode is often used to treat less severe lung disease and for reducing the ventilator dependency, whereby a small increase in airway pressure or a small volume of gas with any spontaneous breathing is possible. Hochdruckjetventilation, oscillating and flow-interrupting ventilators are in extremely preterm infants used (<28 weeks) and in some infants with air leaks, enhanced atelectasis or pulmonary edema (pulmonary edema). The initial ventilator settings are estimated depending on the severity of the respiratory disorder. The typical settings for an infant with a moderate respiratory distress syndrome are: FiO 2 = 40%; Inhalation time (IT) = 0.4 s; Ausatemzeit = 1.1 s; IMV or AC frequency = 40 breaths / min; Peak Inspiratory Pressure (PIP) = 15 cm H2O for low birth weight and up to 25 cm H2O for term infants; Positive End-Expiratory Pressure (PEEP) = 5 cm H2O. These settings oxygenation of the child, the movements of the chest wall, the breathing patterns and patient effort and the arterial or capillary blood gases can be customized. The PaCO2 can be reduced by increasing the minute volume, either by increasing the total volume (increase or decrease in PIP PEEP) or an increase in the respiratory rate. PaO2 is increased by a higher FiO2, or a higher mean airway pressure (higher PIP, PEEP or respiratory rate or prolonged IT). Patient-ventilators are often used to synchronize the output by the fan breath with the beginning of the spontaneous breath of the patient. It seems that this may reduce ventilation time and reduce barotrauma. A pressure sensitive, air-filled balloon connected to a pressure transducer (Graseby capsule) and is fixed on the abdomen of the child just below the xiphoid process, can detect the start of the diaphragmatic contractions. A mounted by means of a tube adapter flow or temperature sensor can register the start of spontaneous breathing. Ventilation pressures and volumes should be as low as possible in order to prevent barotrauma and bronchopulmonary dysplasia. An increase in PaCO2 is tolerable as long as the pH ? 7.25 (allowed hypercapnia) remains. Similarly, a PaO2 of only 40 mmHg is permissible as long as the blood pressure is normal and not metabolic acidosis. Concomitant treatment of mechanical ventilation is in some patients in Paralytika sedation nitric Paralytika (z. B. vecuronium, or pancuronium bromide 0.03-0.1 mg / kg iv every 1-2 h continuously [with a Pancuroniumtestdosis from 0.02 mg / kg in the newborn]) and sedatives (eg. B. fentanyl every 2-4 h or midazolam 0.05-0.15 mg / kg iv over 5 minutes every 2-4) may be 1-4 ug / kg iv h facilitate endotracheal intubation and quietly hold the child so that the spontaneous movements and breaths do not interfere with optimal ventilation. These drugs should be used selectively, since paralyzed children require more fan support and thus increases the risk of barotrauma. Inhaled nitric oxide (5-20 ppm) can be used for a refractory hypoxia when a pulmonary constriction to this contributes hypoxia (eg. B. idiopathic pulmonary hypertension, pneumonia [pneumonia in neonates] or congenital diaphragmatic hernia [diaphragmatic hernia]), and may use ECMO prevent (ventilatory support in newborns and infants: Extracorporeal membrane oxygenation (ECMO)). A weaning from mechanical ventilation can be carried out as soon as the breathing condition improves. The infant can be weaned by a tapering off. FiO2 inspiratory pressure rate continuous-flow fans with a positive pressure allow the child to breathe spontaneously against PEEP, while the ventilation rate is lowered. The rate is reduced when the infant takes a greater proportion of the work of breathing. Infants who maintain adequate oxygenation and ventilation at lower settings, typically tolerate a extubation. The final step in the weaning off the ventilator is the application of nasal or nasopharyngeal continuous positive airway pressure (CPAP or NIPPV), and finally, if necessary, the administration of humidified O2 to the incubator or via a nasal cannula. Children with very low birth weight can be better weaned from mechanical ventilation usually when methylxanthines (eg. Aminophylline, theophylline, caffeine) are administered simultaneously. Methylxanthines are centrally active substances that stimulate the respiratory center and can apnea and bradycardia that delay weaning from the ventilator decrease. Caffeine is preferred because it is better tolerated, easier to administer, safer and requires less monitoring. Corticosteroids, once used routinely for weaning from the ventilator and the treatment of chronic lung diseases, are no longer recommended in premature infants, because the risks outweigh (z. B. reduced growth, developmental delay) the benefits. The only exception is for terminally ill children; in this case, but parents should be informed about the benefits and risks. Complications of the more common complications of mechanical ventilation in newborns include pneumothorax asphyxia due to an obstruction of the endotracheal tube Ulceration, erosion or narrowing of the airway structures by adjacent pressure bronchopulmonary dysplasia Extracorporeal membrane oxygenation (ECMO) ECMO is a form which is used in children of cardiopulmonary bypass, which can not be adequately oxygenated by conventional respirators or ventilated. The selection criteria vary from center to center. In general, the child should be in a reversible disease suffer (z. B. persistent, pulmonary hypertension [Persistent pulmonary hypertension of the newborn], congenital diaphragmatic hernia, massive pneumonia) and <7 days have been mechanically ventilated. After systemic heparinization the blood circulates through a large-bore catheter from the internal jugular vein to the membrane oxygenator, which serves as an artificial lung, which removes CO2 and supplies O2 saturated blood. oxygenated blood then flows back to the internal jugular vein (veno-venous ECMO) or the carotid arteries (venoarteriale ECMO). The venoarterial ECMO is used when both breathing and the circulation (eg. As in a massive sepsis) must be supported. The flow rate can be adjusted to the desired O2 saturation and the desired blood pressure. ECMO is contraindicated in children <34 weeks and <2 kg due to the risk of intraventricular hemorrhage under the systemic heparinization. Complications thromboembolism, air embolism, neurological (stroke, seizures) or hematological include (z. B. hemolysis, neutropenia, thrombocytopenia) problems and cholestatic jaundice.