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Neonatal Mechanical Ventilation

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by

Ahmed Arafa

on 26 September 2016

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Transcript of Neonatal Mechanical Ventilation

Mechanical Ventilation
Mechanical Ventilation
Assist/control (PTV)
+/- volume targeting

IMV/SIMV
+/- Pressure support

CPAP
+/- Pressure support
to Sum up ...
Ventilator Graphics
neonatal
mechanical
ventilation


Maintain adequate lung volume
Inspiration: tidal volume
Expiration: End-expiratory lung volume

Support oxygenation and CO2 removal
Oxygenation: adequate mean airway pressure & FIO2
CO2 removal: adequate minute ventilation

Basics
Key Concepts:
Key Concepts:
Optimize lung
Mechanical
function
Compliance (C): ∆V/∆P
Resistance (R): ∆P/∆F
Time constant: C x R


Modes
SCALARS
LOOPS
Flow/Time
Pressure/Time
Volume/Time
Pressure-Volume
Flow-Volume
SCALARS
Pressure\Time curve
CMV
ACMV/PTV
SIMV
SIMV + PS
Flow\Time Scalars
Volume\Time Curve
LOOPS
Pressure-Volume
Flow-Volume
Pressure-Volume Relationship
P-V Loop
Angel
Insp. & Exp. Limps
Shape
Air Trapping (auto-PEEP)
Causes
Insufficient expiratory time
Early collapse of unstable alveoli/airways during exhalation

How to Identify it on the graphics
Pressure wave: while performing an expiratory hold, the waveform rises above baseline.
Flow wave: the expiratory flow doesn’t return to baseline before the next breath begins.
Volume wave: the expiratory portion doesn’t return to baseline.
Flow/Volume Loop: the loop doesn’t meet at the baseline
Pressure/Volume Loop: the loop doesn’t meet at the baseline
Leaks
Causes
Expiratory leak: ETT cuff leak , chest tube leak, BP fistula, NG tube in trachea
Inspiratory leak: loose connections, ventilator malfunction, faulty flow sensor

How to ID it
Pressure wave: Decreased PIP
Volume wave: Expiratory side of wave doesn’t return to baseline
Flow wave: PEF decreased
Pressure/Volume loop: exp side doesn’t return to the baseline
Flow/Volume loop: exp side doesn’t return to baseline

How to fix it
Check possible causes listed above
Do a leak test and make sure all connections are tight
Airway Resistance Changes
Causes
Bronchospasm
ETT problems (too small, kinked, obstructed, patient biting)
High flow rate
Secretion build-up
Damp or blocked expiratory valve/filter
Water in the HME

How to Identify it on the graphics
Pressure wave: PIP increases, but the plateau stays the same
Flow wave: it takes longer for the exp side to reach baseline/exp flow rate is reduced
Volume wave: it takes longer for the exp curve to reach the baseline
Pressure/Volume loop: the loop will be wider. Increase Insp. Resistance will cause it to bulge to the right. Exp resistance, bulges to the left
Flow/Volume loop: decreased exp flow with a scoop in the exp curve

How to fix
Give a treatment, suction patient, drain water, change HME, change ETT, add a bite block, reduce PF rate, change exp filter
Compliance Changes
Decreased compliance
Causes
ARDS
Atelectasis
Abdominal distension
CHF
Consolidation
Fibrosis
Hyperinflation
Pneumothorax
Pleural effusion

How to Identify it on the graphics
Pressure wave: PIP and plateau both increase
Pressure/Volume loop: lays more horizontal
Compliance Changes
Increased compliance
Causes
Emphysema
Surfactant Therapy

How to Identify it on the graphics
Pressure wave: PIP and plateau both decrease
Pressure/Volume loop: Stands more vertical (upright)
Remember!
Waveforms and loops are graphical representation of the data generated by the ventilator.

Typical Tracings
Pressure-time
Flow-time
Volume-time
Loops
Pressure-Volume
Flow-Volume

Assessment of pressure, flow and volume waveforms is a critical tool in the management of the mechanically ventilated patient.
When to Ventilate !!
Tube Resistance
Tissue Resistance
Radius of the airway
Length of the airway
Flow rate
Density & Viscosity of gas breathed
Severe Respiratory Insufficiency
Severe respiratory acidosis
Severe hypoxemia
Severe persistant apnea , apnea of prematurity
Severe RD with RR > 60 & subcostal & intercostals retractions.
Extreme Preterm Neonates
For surfactant delivery
Congenital Anomalies
Diaphragmatic hernia
Craniofacial abnormalities
Central Cyanosis
Flow Sensor
CPT Dr. Ahmed Arafa
Department of Pediatrics
& Neonatology
Volume
Pressure
Pressure + Volume Guarantee
Physiology
Ventilation
Perfusion
Diffusion
Alveolar Ventilation
NOT the case
in Newborn !!
Stiff
lung
Chest wall
compliance
Abdominal
compliance
Persistent Poor Oxygenation
Anemia
Hypotension / Shock
Low CO (HR x SV)
Lung over distention
Compromise venous return
Compress inter-alveolar vessels
Weaning
Oxygenation Index (OI)

OI=Paw x Fi02 x 100/Pa02

Paw
=Mean airway pressure
Fi02
= Fractional concentration of inspired oxygen
Pa02
= Partial pressure of oxygen

OI of
25 to 40
indicates insufficient ventilation with existing mode of support
OI of
> 40
indicates respiratory failure
Routine Ventilator Management & Care
Ventilator Management Protocol
1. Wean
Fi02 for Sp02
above 93 to 94%
2.
ABG
one hour after intubation
AM PM schedule (12 hourly)
After major ventilator settings change
20 min after extubation
3.
Pulse oximetry
on all patients
End tidal carbon dioxide
(EtCO2)

Graphics
monitoring if available
4.
Monitor
respiratory rate, breath sounds, retractions, color
5.
Chest X-ray
every day/alternate day/as needed depending on the pathology and clinical status
Respiratory Care Protocol
1.
Position change
2 hourly (right chest tilt/left chest tilt/supine/prone position)
2.
Suction
4 hourly and as needed (in line suction)
3.
Physiotherapy
8 hourly (percussion, vibration and postural drainage)
4.
Nebulization
(in line nebulization)
5.
Disposable circuit
change only if visibly soiled
6.
Humidification
(in line/disposable humidifier)
Full transcript