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A practical Guide to Neonatal Mechanical Ventilation Second Edition
Step by Step Neonatal Ventilation (A Practical Guide to Neonatal Mechanical Ventilation)
Ahmed Fawzy pediatric cardiologist at Atfal Masr (Abu elrlsh- el talaba) & Elgalaa military hospital.
2"d edition (2015)
~ ~~I~IWL¢o ~
MIDDLE EAST LIBRARIES 01110150022.01001485817 . 01221570154
Step by Step Neonatal Ventilation 2nd edition Edited by Dr. Ahmed Fawzy Pediatric Cardiologist at Atfal Masr ( Abu elrish - el talaba ) & Elgalaa Military Hospital Copyright© 2015
ISBN
978·977·85098·6·1
e_l.l;!':ll ~.)
5375 I 2015 All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means. electronic or mechanical. including photocopying . recording . or any information storage and retrieval system. without permission in writing from the publisher and the author. Permissions may be sought directly from the Publisher.
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MIDDLE EAST LIBRARIES 01110150022.01001485817. 01221570154
Step by step neonatal ventilation
·-'
Chapter
0:-Basic principles of mechanical ventilation .......................... (1- 12)
~
Introduction...................................................................................................... .......
~
Pulmonary mechanics............................................................................................ 2-3
~
Types of ventilation................................................................................................
~ Ventilator as amachine..................... ..................................................................... ~ Parameters of mechanical ventilation.................................................................. ~
Modes of ventilation.............................. ........................ .........................................
1 4 4-5 5-7 8-12
Chapter 8:- Neonatal ventilation step by step (10steps) ........................ (13- 27) ~
Indication of ventilation.......................................................................................... 13 Step (1) prepare ventilator..................................................................................... 13 ~ Step(2) monitors...................................................................................................... 13-14 ~ Step(3) Intubation................................................................................................... 14 ~ Step(4) Goals of ventilatio n................................................................................... 14-17 ~ Step(5) Assessment.................. ..................... .......................................................... 18 ~ Step(6) Changing parameters................................................................................ 18-20 ~ Step(7) Patient care................................................................................................ 20-21 ~ Step(8) Weaning...................................................................................................... 21-22 I> Step(9) Deterioration.............................................................................................. 23-24 ~ Step(lO) Extubation..................... ............................................................................ 25 ~ Complications of ventilation... ................................................................................ 26 ~ Scheme of initial management of neonate with RD............................................ 27 ~
Chapter
~
~
~
8:- Graphics ............................................................................ (28- 44)
A) Scalars (wave form) ............................................................ (29-37) Pressure - Time waveform .......................... . 30-31 Flow- Time waveform ............................................................................................ 32-35 Volume- Time waveform........................................................................................ 36-37
ili
Step by step neonatal ventilation
B) Loops ............................................................................... (38-44} )>
Pressure- Volume loop ............ .................................... ................................. .......... 38-42
)>
Flow - Volume loop .............................................................................. .................. 43-44
Chapter
0:- Arterial blood gases (ABG} ....................................................
(45-50}
)>
Oxygen pressure, oxygen saturation & oxygen content................................... 45-46
)>
ABG interpretation............................................................ ...... ................................
Chapter 8
47-50
:- Chest X-ray(CXR) ...................................... ......... (51-59)
Indications, Basics & Artifacts................................................ ................................. ... 51 Normal chest X-ray ..................... .'................................................................. ............... 52 Common diseases that may need ventilation in newborn ..................................... 53-59
)> )> )>
Chapter
0 :-High Frequanacy ventilation .................................................... (60-66}
Chapter Q:- Non invasive ventilation .......................................................... (67-71} )> )>
Continuous positive pressure ventilatio ................................... ..................... ........67-70 Non invasive positive pressure ventilation ... ........................................................ 70-71
Chapter$ :-Nutritional support of mechanically ventilated patient ....... (72-74) Chapter0 :-lnstruments used during ventilation .................................... (75-79} )> )> )>
)> )> )>
Laryngescope ............................................................................................................... 75 Endotracheal tube ........................ ................................................ .............................. 75-76 Self inflating bag .......................................... ............... ................................................. 77 Face mask.......................................... ........ ...................... ......... .................................... 78 Oxygen mask ..................... ............ ......... ..................................................................... 78 Nasal oxygen catheter ...................................................................................... ...... .... 79
Chapter4D):- Pharmacological adjuncts ....................................................... (80-89) )> )> )> )>
Analgesics ......... ........................................................................ ......... ............ ......... ...... 80-81 Bronchdilators & Respiratory stimulants .................................................................. 81-82 Diuretics ................... ........................................................................ ............................ 83-84 lnotropes ...................................................................................................................... 84-85 iv
Step by step neonatal ventilation } } } }
Skeletal muscle rela xants ........................................................................................... 86-87 Steroids.................................................................................. .................. ..................... 87-88 Sedatives ... ........................ ... ......... ................................. .............................................. 88-89 Pu lmonary vasodilators .............................. ................................................................ 89
Case scenarios ..................................................................................................... (90-91) Refrences .............................................................................................................. (92)
);>
I'll be happy to receive your advices >» plz contact me at :E-mail :- fawzy ped card@yahoo .com mobile :- 01094863939
v
STEP BY STEP NEONATAL VENTILATION
Preface OF zNDEDITION "I ..uutnu u stnnll book nboui "t•ntiluiion •• nu• unt• plt·u~wil?"
:un,· 11
*Pressure limited:- These ventilators deliver volume of gas until a preset limiting time (PIP)
*Constant flow:- There is continuous flow of oxygen & air in the breathing circuit (during both inspiration & expiration)-7 allowing the infant to breath between mechanical breath & provide CPAP.
******* *Ventilator as amachine:-
-&_
. . . . . . lll::diuc.
1- Soure of air & oxygen (pure o2 100% & compressed air 21 %) 2 Blinder or Mixer 3- Filter-? to inflate air (one of the lost functions of nose by intubation) 4- Humidifier & Wormer -?that humidifies & warms the mixture( do function of nose) 5- Ventilator circuit:- which may include water traps
Page4
Step by step neonatal ventilation
6 Ventilator rate:- There is aknob that obstructs the way of the air & passes it to the patient. The number of activation of this knob per min-? ventilator rate ., PEEP:- (system built in the ventilator to prevent complete exhalation of air at expiration) Acts as the epiglottis which is lost in intubation 8 Screen :-contains
0
Parameters control , Alarms , Manual breath & Graphics
Infection control:- ventilator circuits & humidifier chamber is better to be changed after 5 days of continuous use by apatient.
****** ** *Parameters of mechanical ventilation:-
(!) Peak inspiratory pressure:~ PIP
:- It is the max pressure reached during inspiration
-?It is the lry factor used to deliver tidal volume in pressure ventilation.
-7 PIP should adjusted initially to achieve adequate tidal volume which is reflected by 2- adequate breath sounds
1- Chest expansion
-7 Ventilation of an infant with -!,. lung compliance PIP up to 25 em H£_Q in (preterm)
& 30 em H£_Q in (full term)
-?PIP is -!,.gradually with improvement of lung machine up to 10-12 cmH~o action tPIP
-!,.PIP
advantages
•'• tTV •!• tco2 elimination •!• 1'pao2 •!• tPVR Fewer side effects
Page 5
disadvantages •'• Barotrauma
+ May impede venous return-7COP lnsuffient ventilation
Step by step neonatal ventilation
(DPositive end expiratory pressure:-
~L~·d.. '
r PEEP :- It is the positive pressure applied at the end of expiration to prevent lung
collapse & maintain stability of alveoli. "' PEEP:- can be adjusted as low as 3cm H_?!L& as high as 8 em Hzo (moderate PEEP 4-6 cmH 1o)
8
lnadervent PEEP "auto PEEP":- the chosen PEEP (preset PEEP) may 1' if expiration
time is too short or airway resistance-? air trapping (autoPEEP). action 1'PEEP
Advantages ••• 1' oxygenation - Prevent alveolar collapse - Improves distribution of ventilation Improves ventilation perfusion relatioship
...
~PEEP
Good in weaning & in VLBW
disadvantages •:• ~ gradient between PIP & PEEP-7~ TV •;• Impedes venous return :· May produce co 2 retention & air trapping •:• May 1' PVR May lead to alveolar collapse -?low lung volume.
3 Fraction of inspired O,·. Fio 2:- It is the simplest & most direct mean of improving oxygenation. High Fio 2 esp in preterm may lead retinopathy of prematurity "oxygen toxicity" High Fio 2 also may~ oxygenation?? -7 as during gas exchange N2 keeps alveoli open while o2 is rapidly absorbed by pul capillaries, so if all the air in the alveoli is o2-7 alveolar collapse may occur.
Page6
Step by step neonatal ventilation
@ Respiratory rate:,. RR :-determine minute ventilation (RR x TV) & thus co 2 elimination . ,
A respiratory rate of 40-60 breath/min is usually suffient in most cases ~ it can be decreases to 20 breaths/min , allowing for infant spontaneous breathing during weaning. action 1'RR
-J.,RR
advantages 1'MAP while using lower PIP Good during weaning
disadvantages May lead to -J., TV May lead to insuffient emptying~auto PEEP -J., minute volume so ~1' PIP may be needed to 1'TV~ barotrauma
® Inspiratory time:~ it is usually adjusted between (0.32-0.6 sec) usually 0.32sec depending on pulmonary
mecha nics (compl iance,resistan e & t ime con stant) & monitored through graphics . action 1'Ti
advantages 1'MAP without 1'PIP
disadvantages Inadequate expirat i on~air trapping Long Ti leads to active expiration during inspiratory cycle-} fighting of ventilator~1'
-J., Ti
Useful during weaning Useful in obstructive disease with air trapping
Page 7
incidence of pneumothorax LowTi~ TV May ventilate more dead space Jl • y..1l J...Y- I_,.II ~ effective
Step by step neonatal ventilation
Modes of ventrlatron :-
e c
P~. ~ I;:'I'IH.O;
L L.-
G (, I
'"
b;J,.,
D fforent types of modes of ventilatton depends on 3 pomts:Trigger ~ Patient
~Time B Limit ~ spontaneous~ sinus shaped Pressure limited~ plateau C Cycle ~Time cycled " according to a preset Ti" Flow cycled
Ventilator modes
~
Controlled mechanical ventilation
Assisted ventilation
---------.
Augmented modes
Intermittent positive pressure ventilation
PageS
pressure support
Step by step neonatal ventilation
CD Controlled mechanical ventilation (CMV) :.r All breaths are initiated & delivered by ventilator .r The patient takes no active role in ventilation .r {Time triggered"' Pressure limited,, Time cycled} cont:rolled Mode ( - , . .- T a l r g - VenttlaUon )
(2) Assisted ventilation (A/CMV , PTV):./ The machine senses when patient begins inspiration & responds by delivering
mechanical breath according to ventilator settings. ~ All
breaths are initiated by patient & delivered by ventilator , but with a minimum
mandatory rate . ./ {Patient triggered
Ill
pressure support,, time cycled} D
Time · Cycled
Flow
Pr.
Set PC level
uro Volume
(\____ (\____ Page9
Step by step neonatal ventilation
® Intermittent Mandatory Ventilation:./ Some breaths are given by ventilator (Mechanical) breath at preset interval & some spontaneous by baby.
(( Synchronized intermittent Mandatory ventilation (SIMV) )) :./ The same as IMV but with " synchronization"
-7 the mechanical breath is synchronized
to the patient ventilator pattern . ./ There is aminimal delay "window" before ventilator give (mechanical breath) to allow sensation of patient breath & trigger.
S%MVMode ("'
-e T. . . . . .
¥-a.t-...
@ Pressure support :The patient breaths spontaneously, controlling his RR-7Trigger ,, length of inspiration
& expiration-7cycle
& the ventilator will
t
& support pressure to a preset pressure.
{Patient triggered, pressure limited,, flow cycled} This mode may be used alone (all breaths initiated & ended by the patient with pressure support from ventilator) or it may be in combination with SIMV.
Page 10
Step by step neonatal ventilation
® Continuous positive airway pressure (CPAP):CPAP ...
__·-
Cfft
,.--.,
/
y
["
r /
''..0
@ Pressure support volume guarantee (PSVG}:In this mode the pressure is limited, with a set tidal volume"' this pressure will sta ir up to meet this tidal volume. ( PIP is preset & TV also -j if baby gets this tidal volume before reaching this PIP-j the machine wi ll give him just t he pressure wich allows him to get the TV not necessary the preset PIP so it provides less incidence of barotraumas). Mode characteristic advantages use 1- Assisted Full mechanical breath For patients Comfortable control is delivered ,either with very mode that (A/CMV} triggered by patients weak provide lots of respiratory respiratory effort" if support not suffient-j the effort-j as his preset mechanical rate breaths are is ma intained fully automatically supported 2-SIMV -Preset mechanical Most common -Synchronized breaths delivered mode used in with patient -Weanable with in an interval based neonate on preset RR -j ventilator allows spontaneous breath at part of interval. - Any other breath during cycle are not supported.
Page 11
disadvantages -Not a weanable mode as patient is fully supported -Can lead to hyperventilation -7 as patient makes the rate. -Any other breaths of cycle are not supported so not good during fighting
Step by step neonatal ventilation
3-Pressure support (PS)
Supports each spontaneous breath with a preset pressure
In spontanuously breath patient ~it helps overcoming resistance of
-Weanable -Helps in overcoming ETI resistance
Can't be used in patient who are not spontaneously breath
En 4-SIMVwith Ch.ch of 2 previous modes PS
Useful in most Advantages of Avoid circumstances both 2 modes disadvantages of previous 2 modes
N.B :- Recruitment is a strategy aimed at re-expanding collapsed lung tissue, and then maintaining high PEEP to prevent subsequent 'de-recruitment'. In order to recruit collapsed lung tissue, sufficient pressure must be imposed to exceed the critical opening pressure of the affected lung BYj PEEP gradually till saturation is improved so we are above the critical closing point of alveoli>
Page 12
Step by step neonatal ventilation
Chapter TWO Neonatal ventilation "step by step"
10 steps
(A) When to ventilate?? (Indications of ventilations):1- ~~Y~r:.~_r_~~pjr~~.QrYJ_I'!~!:Iffi~r._~Y • Severe respiratory acidosis (pco 2 1evel > 60-65 mmHg or PH< 7.20-7.25 • Severe hypoxemia with Pao 2 60 & subcostal & intercostals retractions.
2- f:.l!~~rro~IY.P-r~!~!m!l~9_1!~~~~;: • Where surfactant delivery
3- ~Q.!l_g~_I!I~-~1_~_11Q!!1_i!U~-~ ~: • Diaphragmatic hernia • Craniofacial abnormalities
4- ~~!ltr_~tfY..~!:I.Q~t~!: .....................................................•..................................
(B) How to ventilate??
0
Prepare Ventilator:-
• Connect 0 2 ,air & other parts of ventilator in their places • Connect humidifier & wait until its temp is adjusted • Connect breathing circuit • Switch ventilator & be sure that there is no air leak • Adjust settings
f) Prepare Monitors:• Pulse oximeter • Bp cuff
• Oxygen analyser Page 13
Step by step neonatal ventilation
•
Blood gas analyser
•
Ecg monitoring
•
Portable X-ray machine
e lntubatton :•
After intubation try to keep head of baby in constant degree of slight extention
•
Be sure that the breathing circuit is not pulling or pushing the ETT, Put a dressing under the circuit to support it
• Observe chest inflation •
Auscultate chest to be sure of air inflation & that it is bilateral & equal
• Observe pulse oximeter & try to keep saturation between 90 -95% •
Do chest X-ray to check position of the tube.
• Stabilize baby for Yz h, then do blood gases to judge your settings •
If baby is not sedated during intubation, sedation is given
•
A highly qualified nurse is continuously observing the baby & filling the charts
• Start combination of antibiotics jlr.JI t"
Initial Settings
0 •
r
J.,WJ
.--:--h c angmg parameters 0
~
===-----
~ pat1ent care
weanmg & extu b' atron 0
Goals of venttlatton ( ventilation stratagies):The strategy of ventilation depends on :-
1- Type of the disease (obstructive restrictive normal lung) I
1
2- Size of the baby e.g premature 1-2 kg 111 full term 3.5 kg 3- The resulted blood ga~es & need to its repair
Page 14
Step by step neonatal ventilation
Example
•
Small term infant ( < 1000 gm)
~
mild permissive hypercarbia may be followed to
minimize lung injury
•
Patient with severe chronic lung disease gases with Paco 2 60-65mmHg & Sao 2 > 88%
•
In contrast, a patient with PPHN might have agoal ( PH> 7.45, Paco 2 < 30, Pao 2 100)
may be acceptable.
In attempt to attenuate hypoxic hypoxic pulmonary VC.
**
Su~ested
initial ventilator stratagies for common neonatal res~irato~
disorders:Disease 1- RDS
2- MAS
3- PPHN
4- Apnea of prematurity
Initial setting *Rapid rate~ 60/min * Moderate PEEP 4-5 cmH 20 *low PIP (10-20) cmH 20 * Ti 0.3-0.4 sec * Tidal volume 4-6ml/kg *Relatively rapid rate (40-60/min) *low to moderate PEEP (3-5) *Ti 0.3 , I:E ratio>1:3 *if gas trapping occurs,-(, Ti or -(,PEEP *Higher rate 50-75/min *PIP 15-25cmH2 o(PIP -(, pul vascular resistance) *low PEEP(3-4cmH 2o) (high PEEP may 1'PVR) *Ti 0.3-0.4 *high Fio 2 (80-100%) *relatively slow rate 10-15 *minimal peak pressure 7-15 *low PEEP (3cm H2o) *Fioz usually< 25%
Page 15
Blood gases target *PH 7.25 - 7.35 *Pao 2 50-70 mmHg *Paco 2 45-55 mmHg
*PH 7.3-7.4 *Pao2 60-SOmmHg *Paco 2 35-45mmHg *PH7.35-7.45 *Pao2 70-100 *Paco 2 35-45
*PH 7.25-7.35 *PaozS0-70 *paco2 55
Step by step neonatal ventilation
*PH 7.25-7.35
5- Broncho pulmonary dysplasia
*Slow rate 20-40 * moderate PEEP 4-5 *lowest PIP required 10-20 *Ti 0.4-0.7
*Paco 2 55+
6- Congenital diaphragmatic hernia
*lowest PIP suffient for chest excrusion * relatively rapid rate (40-80) * Moderate PEEP (4-5) * short Ti 0.3 0.5
*PH> 7.25
*Pao 2 50-70
*Pao2 50-70mmHg *Paco 2 45- 65 mmHg N.B:- sicker neonates may need less aggressive goals for oxygenation as long as preductal SP0 2 >85%
7- Hypoxic ischemic encephalopathy
lliill
*Rate 30-45/min or slower according to spontaneous rate
*PH 7.35-7.45
*PIP 15-25 cmH 20 *low moderate PEEP 3-4
*Paco 2 35-45 mmHg
*pao 2 60 -80 mmHg
*Fio 2 to maintain Spo 2
* General notes about settings:1- General initiation setting can be used the then change according to response
Fio 2 =50% or more 2
~
11
PIP= 12-15
Max PIP
~
II
PEEP=4-5
11
Ti = 0.3-0.5
settings~ 26omH,o 33-40w -728cm H2o
>33w (5-7 cc/kg)
3-®~ start at minimum( 4-5 )em H2o ~-
1' to (6-7) if Fio 2 needed> 60% You may reach( 8-10 em) H20 if needed
Page 16
Step by step neonatal ventilation
Start low at 40 %
4-
Then adjust to maintain target Spo 2 If Sao 2 6) without 1'PIP.
Page 18
Step by step neonatal ventilation
•:• If hypercarbia with normoxemia Firstly :- try to
1' RR
-
"wash
cot-- - then try to -J,. PEEP " -J,. C0 2 retention"
Finally -J,. Ti to allow good expiration & co 2 wash .
.,l.,.lo
1'Fio 21 1'rate,1'pressure, RECRUITMENT OJ.)/
;....! JiloliJ
Then we should consider :);>
VIPr
Iube problems :- blocked tube , leak-? insert large ETI, & try ventilation by Am bu.
).> ~atient
problems :- incorrect academia -?ABG hypotension-?BP hypoglycemia-?RBS
);>
Yentilator problems:- check the machine
);>
!ncorrect diagnosis or complications of ventilation :*pneumothorax
*pulmonary edema ,fluid overload
*CHD
*pulmonary he
*lchge
*Septisemia
(CXR ,CRP , CBC, crUS , ECHO)
./ Then
= 1' pressure ( it is better to be alive with risk than dead with hypoxia) Page19 - -
Step by step neonatal ventilation ./ 1' Rate (very fast r a t e ) - more synchronization & paralyzation of baby with ms relaxant . ./ Finally, another mode of ventilation e.g HFiOV.
N.B - How to make synchronization between baby & ventilator??? 1- usage of trigger ventilator SIMV 2- Sedation 3- 1'RR just above baby's spontanuous
~
--------------------------------------~
f) Patient care:·
~ Routine care \
Intermittent care Suctioning
1- Routine care:- (blood gases, HR, RR, BP, ECG) 2- Intermittent care:- *access breath sound & verify chest rise. *ETI placement & security * Suction patient if needed
* Aeriolized bronchodilator if needed *X-ray monitoring * Lab monitoring (Hb, RBS, Electrolytes ca + ) ~ 2
*wt monitoring * others like Echo & cr US 3- Suctioning:-
1
- 1' 1' Fio 2 to 1'infant oxygenation -Dissconect tube -1inject Y, ml normal saline
-1 use bag or vent to
distribute saline for Y, -Determine length of catheter according to length of tube-1suction -1reconnect circuit-1raise Fio 2for while -MAS usually needs frequent suctioning,RDS Needs little. Page 20
Step by step neonatal ventilation
Oweaning:-
~ Weaning means decreasing the parameters of the ventilator, till very low
CJ settings that allow switching to CPAP or even extubation. ~
~
1-when you put ababy on ventilator, try to keep saturation between 90-95 , if the spo 2 jump to 99 -100%
~ -J,Fio2 by 5 or even 10 in patients' with normal
lung or mildely damaged lung. ( it is important to keep spo 2 around 95 especially in preterms) 2-Since, the most we are afraid of are pressure, they are usually the cause of barotraumas & BPD, So ((once there are stable readings of BG & clinical conditions for 12h, start to -k the PIP by (2cmH 2o) & ,J, PEEP by (lcm H,o) till 3cm Hzo ..... alternating with ,J, VR (ventilator rate) to let the patient breath spontaneously when the VR is low the infant generally can be placed on CPAP)) I
I
1-Fio2 < 40% 2-low ventilator rate 3-infant has an efficient spontaneous respiratory drive 4-infant weighting >2kg~whenVR(20-25 cycle/min) & pressure( 20/3) cir less & establishing regular respiratory pattern (switchable baby)
Page 21
Step by step neonatal ventilation
5-lnfant (very small, premature) with VR (20 cycle/min) & pressure (15/3) can' t switch to CPAP as they may not sustain adequat e respiration-J, so gradually -J, VR -.!.- 20 -7 (15, 10 , 5)-7 thus avoid prolonged apnea & keep Ti (0.3 -0.4) as longer may delay weaning process ..cljj
._.b
4-?:l.J.lJ
"--':1.;-o:>!_, ' 40 is an indication of ECMO.
- -- - -- - - -- - - -- - Page 26
Step by step neonatal ventilation
Scheme of initial management of neonate with RD
-Place 30-40% o2 -place on 40-50%
-close observation
/~
-Nasa l CPAP 5-6 em H2o -consider intubation & surfactant
improves
'!'distress
-catheterization -ABG is done & CXR
wean slowly
Pao 2 (50-70mmHg)
pao 2< 50mmHg
pao2 >SOmmHg
Paco 2(40-50mmHg)
pacoz (40-5-mmHg)
paco2 >60mmHg
PH 7.25-7.45
PH 7.30- 7.45
PH< 7.25
l
t
j Close observation
1'Fio2 or CPAP
Mechanical ventilation
Repeat ABG after lh
repeat ABG after lh
Give surfactant
Consider Surfactant
Page 27
Step by step neonatal ventilation
Chapter three Ventilator graphic
Grap hics
...........
-,
-.-
'
LOOPS
Scha lars Wave fo rms
\ -->
,,
I
I
'
1-Fiow /Time
1-Pressure I Vo lume
2-Pressure I Time
2-Fiow I Volume
3-Vo lu me I Ti me
-
....
- - - - - -- - -- -- - - Page 28
--~
Step by step neonatal ventilat ion
>---=~=~;:;;;;Sc:::r~-'a_rs_"w_a_v_e_fo_rm-1c:: :; ,===:::. ; 1
_
_
-
• -
1.,
~
"
f.,,J_. ,
.
\
,..
1
I
r
...
Step by step neonatal ventilation
3- Determine Inspiratory cycle off:-
0 f'l
lima
100'11.
60% tJme
4· Detect air trapping & auto PEEP:-
c:
£ ~L---~~------~.-~~~~~-------:T~mw--+ ~
u:.
When expiratory flow doesn't retum to base line. inspiration starts before exp ends .. ..
- - - --
- - - -- - - - - - - Page 34
. .. and
Step by step neonatal ventilation
6- Resistance & bronchodilators ·Before
After
T1me
PEI'R
To aaaess response to bronchodllatorthorapy, .... 1. An increase in peak expiratory flow r11to. 2. The expiratory curve should return to beHI Ine sooner
7- Response to bronchodilator:1\FTE ~
"'S.o Flow I Time waveform is used to detect*:./ Identify type of ventilation ./ Determine Inspiratory cycle off ./ Detecting air trapping & auto PEEP ./ Identify if Ti is suitable or not ./ Inadequate inspiratory flow ./ Resistance & bronchodilators response.
Page 35
Step by step neonatal ventilation
@ Volume/ Time waveform:-
*Importance:1- Air leak:- Exhalation doesnot reach baseline (as not all the air enter in inspiration sensed during expiration due to the leak)
e
j A - exhalat1 o n that does not return to 7ero
- - - - - - - - - - - - - - - - Page 36
Step by step neonatal ventilation
2- Setting appropriate PIP & Ti to get desired TV :-
Short I
l 3- Guides for weaning :P CV .. S IM V
::
A G
4- Active exhalation :-
\l~ume(m l )
l
- - - - - - -- - -- - - -- - Page 37
Step by step neonatal ventilation
CD Pressure /Volume loop:-
II
&.a4
l~•• • l
won
... *Different shapes of P-V loop according to type of breathing:-
0
> p(cm H20
Control
Spontaneous
isted
../ Controlled = anticlockwise
+ tail
../ Assisted = anticlockwise ../ Spontaneous =clockwise
Page 38
Step by step neonatal ventilation
J-
The point where the curve begins in pressure limb is the PEEP:-
Vol~•
(m l)
*Importance:1- Airway resistance :-
•As
n_: ~itll£1nC» IUIIat car. tile indicatioN of HI'Y'n 1-When conventional ventilation fails
* PIP> 20-22 em H2o in preterm infant * PIP> 28-30cm H2o in term infant 2-Persistant pulmonary hypertension of newborn 3-Congenital diaphragmatic hernia 4-Pulmonary hypoplasia 5-Meconium aspiration when deterioration is suspected 6- Any other parenchymal lung disease when high peak pressure is needed. - -- -- - - - - - - -- - Page61
Step by step neonatal ventilation
Initial settings
Depends upon the condition being treated . E.g:- For RDS in preterm MAP>» Increase by 2 em H2o on conventional settings FI0 2»> Same as conventional settings Frequancy>>>10 Hz Amplitude(ilP)>»increase until chest visibility shaking- liP 20-40 em N.B» For high lung volume to recruit atletic alveoli, may need to increase MAP to 6-8 em H20 on conventional MAP. S~•lllll gtNti#IIJ utii#IIJB IH diii#/MI di~MB#B
Disease
MAP
Diffuse alveolar preterm Diffuse alveolar term
2 above CM V 2-6 above CMV 2-6 above CMV =CMV
Non homogenous e.g MAS diffuse Non homogenous e.g MAS with air trapping Non homogenous e.g Focal pneumonia Uniform pulmonary hypoplasia Focal pulmonary hypoplasia PIE Pneumothorax
Frequancy Amplitude (Hz) 10-15 Minimal CWM 10 Good CWM 10
Good CWM
6-10
Good CWM
=OR 1-2 above CMV =CMV
8-10
Good CWM
5-10
1-2 above CMV $CMV
6-10
Minimal CWM Good CWM
6-10
$CMV
10
CMV=conventional mechanical ventilation
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Minimal CWM Minimal CWM
Notes May need to>MAP& amplitude May need to >MAP& amplitude Usually high amplitude is needed >60
High amplitude may be needed Amplitude Paw in CMV with Z em H2o *Increase MAP by 1-4 em H2 0 to achieve
lmprovl,.. ventilation
adequate lung volume
'To improve ventilation first increase
*optimal lung volume is determined by increase
amplitude
Sao, allowing FlO, To be weaned
*if no improvement, consider decreasing
*Ma intain MAP till FI0 2 is 60% then wean MAP
frequance
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Step by step neonatal ventilation
Chapter Seven Non Invasive ventilation
This chapter covers methods of assisted ventilat ion without an endotracheal tube & using interfaces either just at the nares or sealing the entire nose with a mask. So why this type of ventilation is used & preferred over traditional ventilation if intubation is not necessary? .. . or by another way what are the adverse effects of endotracheal tube?? * Bypass upper airway * Loss the ability to grunt * Increase resista nee * Portal of entery of infection * Interference with clearance of secretion. * Airway damage * Baro & volutrauma
Types of non invasive ventilation
1- Continuous Postive Airway Pressure (CPAP) 2- Continuous Negative Expiratory Pressure (CNEP) 3- Non Invasive Postive Pressure ventilation (NIPPV) 4- High Flow Nasal cannu la
Continuous Postive Airway Prssure (CPAP)
A techn ique of airway management that maintains positive intrapulmonary pressure in the lung during spontaneous breathing - -- - - -- - - -- - - - Page 67
Step by step neonatal ventilation
I. The purpose of Nasopharyngeal CPAP is to reduce the morbidity due to barotrauma and subglottic stenosis from having a neonate intubated and mechanically ventilated because of resp iratory failure or apnea.
II. Indications for NPCPAP:A. Apnea of Prematurity- obstructive and/or mixed apnea. B. Respiratory Distress (i.e., tachypnea, and/or retractions) - RDS, TIN and chronic lung disease (CPIP and BPD) . C. Weaning from the ventilator.
Ill. Types of NPCPAP:A. Nasopharyngeal Tube - an endotracheal tube whose tip is placed in the nasal pharynx.
1. Advantages: a. May be used on any size infant. b. Minimal risk of nasal septum necrosis. c. Easy to place infant in any position. d. Preferred method at UIHC.
2. Disadvantages: a. May become occluded or plugged with secretions despite suctioning b. Higher resistance to spontaneous breathing.
B. Nasal Prongs:1. Advantages: a. Easier to apply (less traumatic). b. Lower resistance to spontaneous breathing
2. Disadvantages: a. Easily dislodged from nares. b. Nasal septal necrosis c. Difficult t o position infant.
c.Face mask CPAP 1-Advantage:less dislodgement
2- Disadvantage makes baby irritable
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Step by step neonatal ventilation
IV. Complications of NPCPAP: A. Pneumothorax - minimize incidence by using minimal pressure needed to accomplish aims. B. Nasal irritation - mucosal swelling or erosion, excessive nasal dilatation or septal necrosis. Minimize by proper positioning of infant and alternating nares every 5 to 7 days. C. Abdominal distention and feeding intolerance»orogastric tube may be left.
Contraindications of using NCPAP:1- The need for ventilation because of respiratory failure 2- Upper airway abnormalities e.g Cleft palate- Choana I atresia
3- Tracheoesophageal fistula 4- Diaghragmatic Hernia 5- Severe Cardiovascular instability
Initiation of NCPAP:1- Correctly set up & maintain low resistance delivary circuit 2- Assure minimal pressure leak 3- Maintain optimal airway 4- Flow between 5-10 L/m 5- Pressure 5 em H2o 6- Change circuit weekly 7- Snug fitting hat & nasal pronge 8- Continuous monitoring Monitering:-
1- Observe baby after 1 hour over 1'' four hours, then after 3-4 hours 2- Monitor respiratory status (RR, work of breathing)
3- Monitor cardiovascular status (HR,BP,Perfusion) 4- Monitor neurological status (Tone, activity, respnsivness) 5- Monitor Gl status (abdominal distention, Bowel sounds)
6- Preductal oxygen saturation 7- Thermoregulation
8- Adequate humidification of the circuit Weaning:1- Fl0 2 < 30% 2- Oxygen saturation >90% 3- No significant apnea & bradycardia episodes 4- No respiratory distress 5- Hemodynamically & neurologically stable - - - - - - - - -- -- - - Page 69
Step by step neonatal ventilation
Insure approach In infants with signs of RDS,. intubation,.& Surfactant therapy followed by Rapid extubation to NCPAP with later selective surfactant administration was associated with lower incidence of mechanical ventilation.
is a proprietary name of Respironics, Inc. for continuous positive airway pressure (CPAP) with pressure support breaths. It is used during noninvasive positive pressure ventilation . It delivers a preset inspiratory positive airway pressure (IPAP) during inspiration and expiratory positive airway pressure (EPAP). BiPAP can be described as a continuous positive airway pressure system with a time-cycled or flow-cycled change of the applied pressure level.
Ventilation (NIPPV)
Some rules about NIPPV:-/ NIPPV can be used outside ICU or at home in patients who required long term nocturnal support for sleep related breathing disorders -/ NIPPV is of potential benefit in acutely critically-ill pediatric patients with acute respiratory distress -/ NIPPV may improves the hemodynamics & respiratory work of patients with chronic lung disease -/ Experienced staff should be available to avoid delay of extubation if needed -/ NIPPV reduces the duration of ventialtory support with its complications. -
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Step by step neonatal ventilation
Clinical use of NIPPV:•
Cardiogenic pulmonary edema
•
Hypoxic respiratory failure
•
Weaning
•
Post surgery
•
Asthma
Adavantages of NIPPV:•
Allows patient to maintain normal functions (Speech-Eating)
•
Helps to avoid the risks & complications related to intubation,sedation.
Complications of NIPPV:•
Collapse of the upper airway in negative pressure ventilation
•
Brusis & Erosions to face & nasal septum
•
Abdom inal distension with high pressures
Contraindications of NIPPV:•
Hemodynamical or neurologicaly unstable or very thick secretions
Initial settings:•
IPAP 8-12 em H2 o
•
PEEP 3-Scm H2 o
•
Adjust inspiredoxygen to keep sats >90%
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Chapter Eight Nutritional Support of mechanically ventilated Baby
The objective of advanced respiratory care in the neonate is to enable the premature or critically ill infant to survive in the best possible health and with the best possible neurodevelopmental outcome. Expert nutritional support is recognized as a key factor in promoting the survival and good long-term health and development of infants who require intensive care, including assisted ventilation The medical problems that contribute to the need for assisted ventilation-such as prematurity, infection, birth defects,and a host of cardiopulmonary issues-also increase the challenges of providing good nutritional support. Infants who require assisted ventilation may have immature or abnormal gastrointestinal function . They face the threat of suboptimal oxygen delivery to the tissues involved in absorption, digestion, and metabolic processing of ingested nutrients, and they often face limitations in the tolerance and processing of parenterally delivered nutrients. Good nutritional support improves the survival prospects of premature and critically ill infants and may affect the long-term outcome of the survivors. Brain growth and neurodevelopmental outcome are influenced by the quantity and quality of nutrition provided to premature and ill infants during their critical early postnatal weeks. For infants who require assisted ventilation, the harmful effects of malnutrition on lung developmentrespiratory muscle functionand lung mechanics are of great importance. Probably as a result of these effects, undernourished infants are thought to be more susceptible to bronchopulmonary dysplasia .
Practical Nutriional Recommendations:1- Parenteral Feeding and Fluid and Electrolyte Management:Infants who are ill enough to require assisted ventilation should begin to receive intravenous fluids as soon as possible after birth but certainly within the first hour. The initial infusion should consist of 5% or 10% dextrose Sodium is added by the second day to deliver 2.5 to 3.5 mmol/kg/day, provided the serum sodium concentration is not elevated. - - - - - -- - -- - - - - Page72
Step by step neonatal ventilation
Potassium chloride is also added to the infusion on day 2, to give 2 to 2.5 mmol/kg/day, provided the serum potassium concentration is normal and urination is well established. On the second or third day of life, the infusion rate is usually increased to deliver maintenance volumes . Intravenous calcium supplementation should be started if the infant has signs that are attributed to hypocalcemia (tremulousness, seizures, apnea, or cardiac arrhythmia). Calcium supplementation should also be considered if the serum ionized calcium concentration falls below 3.5 mg/dl in an infant who is receiving little or no enteral intake. Respiratory alkalosis due to hyperventilation increases the risk of hypocalcemic tetany. Most infants who require assisted ventilation should be given parenteral amino acids, minerals, and vitamins beginning as soon as possible but certainly within 24 hours of birth. The only exception should be an infant who can safely be fed significant volumes of milk or formula soon after birth and whose feedings are likely to be advanced within several days to a volume sufficient to support growth.
· 2- Enteral Feeding Although extra caution is advised in the enteral feeding of infants who require assisted ventilation, intragastric gavage can be safely attempted in most cases. If a ventilated infant has ((( a soft, non distended abdomen and audible bowel sounds,hemodynamlcaly stable , No large doses of lnotropes)))>» then nasogastric or orogastric gavage feeding may be attempted . Smal volumes and cautious progression ofmfeedings a ·e advisable, because aspiration would bJ particularly harmful in an infant who already requires mechanical ventilation. The presence of an uncuffed endotracheal tube would offer only partial protection from the hazard of aspiration. The first feeding should consist of maternal colostrums orinfant formula . A volume of 2 ml/kg would generally be appropriate for the first feeding of a ventilated infant. The stomach should be aspirated for residual contents 3 hours later. If the stomach is empty or nearly so, the feeding can be repeated. This process is repeated every 3 hours. The feedings may be increased once daily by an increment not to exceed 20 ml/kg/day. The gastric residual volume is recorded every 3 hours. If it is more than 10% of the volume of the previous feeding (or 1 ml, whichever is larger) is present, the infant should be examined. If significant residuals are found repeatedly, feedings should be -
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Step by step neonatal ventilation
stopped and the patient carefully evaluated for signs of systemic infection, necrotizing enterocolitis, and intestinal obstruction. If enteral feeding is successful, the rate of intravenous feeding should be reduced to keep the total fluid intake the same or to allow a slight increase appropriate for advancing postnatal age. When an infant no longer requires assisted ventilation or continuous positive airway pressure, has achieved stablecardiorespiratory status, and has demonstrated adequate sucking and swallowing of secretions, nipple feedings may be introduced. The transition to oral feedings typically requires more time for infants who required assisted ventilation and those who were most premature at birth.
COMPARISON OF PEEDIN& METHODS FOR V£NTILATOR DEPENDANT INFANTS:-
Method
Advantages
Risks
PEf ohml vein
'l·:t ·:l~penc.;r.l en Cl L1ction 'I·J :lanser ef asJ:iraliC•1 Low m'ecU·:n risk
infJnt thErmal nj phy;ieleg c I''€SI Ptrsonnel effc·n te stacl and main:1 r ,nfusion Ris PH=6.9, severe RD , Baby was ventilated on pressure limited time cycled mode » & setting were changed several time according to ABG,CXR, &clinical status >>the baby now is on high setting & not improved , causes of chronic deterioration of aventilated baby was revised then » Putting baby on HFV was decided.
1-What are the initial settings for this case?? 2- What are the advantages & disadvantages og HFOV?? 3-Continuous monitoring & nurse care is so important in acase on HFV.,explain???.
.... ... · .... .............................. ........................ l'age 91
Step by step neonatal ventilation
Relrences
1- Goldsmith, joy.Assisted ventilation of the neonate.51h edition. USA: Elsevier Saunder,2011 . 2- Cloherty j.,Eishenwald,Hansen &Stark.Manual of neonatalcare.71h edition.Lippincott Williams & Wilkins,2012 3- Donn & Sinha. Manual of neonatal respiratory care.3'd edition.Springer,2012. 4- Ismail S,Abdulfattah H.Basic Neonatology.2"d edition,2008. 5- Lynelle N.Management of mechanically ventilated patient.2"d edition. Elsevier Saunder,2007. 6- Singhi S. Basic pediatric intensive care.2nd edition.Peepee,2007. 7- Khilnani P. Pediatric & neonatal mechanical ventilation.Jaypee brothers,2006. 8- Hennessey I& japp A. Arterial blood gases made easy. Elsevier,2009. 9- Ministry of health. Neonatal care protocol for hospital physicians. 2010. 10-Park M . Pediatric cardiology for practitioners.51h edition. Mosby Elsevier,2008
