Imagine a parent’s worst fear: Their child is critically ill and clinging to life. Now imagine that child has to be quickly moved to another hospital. Having a child transported by ambulance or airlifted to another facility can add significant stress to an already overwhelming scenario.
Neonatal pediatric critical care transport teams often encounter parents during some of the most difficult and scariest moments of their lives. They can help ease these parents’ fears by staying on the cutting edge of technology and medical advances for the care of their most critically ill respiratory patients.
The neonatal pediatric transport team at St. Joseph’s Children’s Hospital, based in Tampa, consists of a registered nurse, a registered respiratory therapist (RRT), and a paramedic. All team members are required to have a minimum of two years of experience, advanced cardiac life support, basic life support, pediatric advanced life support, STABLE certification, and neonatal resuscitation program certifications.
In addition, nurses and respiratory therapists must meet requirements mandated by the state as well as additional requirements determined by their medical director. These high standards ensure the team’s ability to provide high-quality care for patients from the smallest neonate to adult-size pediatrics.
Having an RRT on the team is one way it differs from many traditional EMS units. The RRT is able to focus closely on the airway and breathing portion of the primary survey, thus eliminating delays in airway management and delivering more focused care for the younger population.
St. Joseph’s neonatal pediatric transport team is often called on by providers to assist with difficult airways that require advanced management skills. Team members complete continuing education and train in the operating room with anesthesiologists for neonatal and pediatric intubations. They attend high-risk deliveries and assist with intubations of neonatal patients being cared for in the Level IV NICU at St. Joseph’s Women’s Hospital.
Respiratory therapists must complete additional training and meet requirements in all aspects of airway management, including proficiency in the placement of laryngeal mask airways, surfactant administration, and operation of endotracheal tube induction devices (e.g., bougies).
Respiratory therapists are specially trained on each ventilator. Neonatal and pediatric patients require close monitoring of ventilator settings and monitored values such as peak inspiratory pressures and exhaled tidal volumes.
Due to their smaller size and anatomy, children’s lung compliance and requirements for ventilation can often change during transport. The respiratory therapist can assess, implement, and evaluate these changes in status, allowing for better patient outcomes and fewer adverse effects such as volutrauma, barotrauma, pulmonary interstitial emphysema, and pneumothorax.
The St. Joseph’s Children’s Hospital’s neonatal pediatric transport team employs highly specialized ventilators capable of caring for the entire range of pediatric patients. The RRT provides mechanical ventilation using the Crossvent 2i+ and MVP-10 (from Bio-Med Devices) for the neonatal population and the ReVel (Vyaire Medical) for pediatric patients.
The Crossvent 2i+ provides a wide variety of modes, such as continuous mandatory ventilation (CMV), utilizing constant flow, assist control, synchronized intermittent mechanical ventilation, continuous positive airway pressure (CPAP), and pressure support. This ventilator can deliver tidal volumes ranging from 5–750 mL per breath and respiratory rates of 5–150 breaths per minute.
The MVP-10 is a pneumatically powered ventilator that provides CMV and CPAP driven by flow. This allows the RRT to match the patient’s current ventilator settings and facilitate a smooth transition from the hospital ventilator to the transport team’s ventilator.
The ReVel is a compact, lightweight transport ventilator ideal for the pediatric population. The RRTs are also trained in its secondary settings, allowing them to run nebulized breathing treatments in line with the ventilator, which increases patient comfort.
A heated high-flow nasal cannula (HHFNC) is another advance that aids in the care of the smallest patients. As a specialty care team, we have implemented heated high-flow oxygen therapy on transports to bridge the gap between traditional nasal cannula therapy and more complex treatments such as CPAP, bilevel positive airway pressure (BiPAP), and mechanical ventilation.
The ability to deliver the heated and humidified higher flows from 10–60 lpm and variable oxygen titrations allows for noninvasive treatment of a wide variety of diseases that manifest as respiratory distress. HHFNC delivery to the pediatric population decreases anxiety and stress from the more invasive modalities, which increases comfort and satisfaction.
St. Joseph’s neonatal pediatric transport team also carries specialized breathing gases used to treat varying disease processes. Inhaled nitric oxide (iNO) is used in the treatment of hypoxic respiratory failure for neonates at a gestation of 35 weeks or greater.
Hypoxic respiratory failure can manifest from persistent pulmonary hypertension, aspiration syndrome, respiratory distress syndrome, pneumonia, sepsis, congenital diaphragmatic hernia, and congenital cardiac defects.
Using this inhaled gas therapy in combination with mechanical ventilation and/or oxygen therapy allows for transport of hypoxic patients who would otherwise be too unstable for transport. Patients suffering from marked hypoxia due to a wide variety of diseases (e.g., acute respiratory distress syndrome, overwhelming sepsis, pulmonary hypertension) are also treated with iNO therapy.
In November 2017 we added a new transport ambulance to our fleet. This ambulance has state-of the-art electronic systems for regulation of air and oxygen as well as a dual stretcher system that allows the transport of multiple patients at once.
Along with these features, the new ambulance can house and deliver inhaled heliox to patients. This technology will aid the treatment of patients with status asthmaticus refractory to oxygen therapy.Heliox is a mixture of helium and oxygen that works differently than traditional therapy of oxygen and nitrogen. Because helium has a lower density than nitrogen, heliox allows for a more laminar airflow pattern, which permits increased flow rates in the compromised and smaller airways of the asthmatic patient. The team’s respiratory therapist is trained in proper use, setup and delivery of these specialized gas therapies.
Finally, the neonatal pediatric transport team can transport patients on extracorporeal membrane oxygenation (ECMO), a heart and lung bypass machine, with its ambulance. The circuit removes carbon dioxide from the blood and oxygenates the blood before returning it to the body. This bypass of the heart and lungs allows the affected organs to heal until the body is ready to be weaned off the treatment. These patients also may require iNO.
The larger ambulance accommodates up to six team members, including the physician, perfusionist, registered nurse and respiratory therapist, for the safe transport of critically ill pediatric patients who need ECMO.
Overall, specialty care teams play a vital role in the world of emergency medical services as an extension of the intensive care units and emergency rooms they serve. Advanced therapies, expert knowledge, provider experience, and appropriate equipment allow such specialty care teams to deliver high-quality care where it’s needed most.
Christina Bailey, RRT-NPS, Kevin Fazendin, RRT-NPS, C-NPT, Christopher Hall, MA, RRT-NPS, C-NPT, Sherrie Jones, RRT, C-NPT, Katie Rincon, RRT, and Shari Stewart, RRT-NPS, C-NPT, are members of the neonatal pediatric transport team at St. Joseph’s Children’s Hospital in Tampa. Danielle Nelski, BSN, RN, C-NPT, and Babette Bailey, BSN, RN, CCRN, provided editorial guidance for this article.