Indications to Mechanical Ventilation-
Hypoxemic Respiratory Failure
POOR OXYGENATION
- Alkalosis from high RR
- PaO2 <50 on FI02 60%
-Spo2 <90 c supplemental 02 and/or NCPAP
*Babys will be Agitated kicking and Cyanotic
Use CPAP or MV
Indications to Mechanical Ventilation-
Hypercapnic Respiratory Failure
POOR VENTILATION
-Acidosis
-PaCO2 > 50mmHg accompied c pH <7.25
*Babys will be Listless c no movement and Cyanotic
Use MV
Indications to Mechanical Ventilation-
Mixed Respiratory Failure
POOR OXYGENATIOIN AND VENTILATION
- Acidosis
CPAP is the Preferred Method
- Nasal Prongs (NCPAP) is the Preferred device
CPAP - Physical Exam Indication
1. Increased WOB (30% RR increase)
2. Suprasternal and substernal retractions
3. Grunting
4. Nasal Flaring
5. Pale or Cyanotic c Agitation
CPAP - Non Physical Indications
1. Decreased FRC
-PNA, Atelectasis, Pulm Edema, Thoracotomy, Meconium Aspiration, Severe Mucus block, RDS, RDS II (TTHN), L-R Shunt
2. Airway Collaspe
-Tracheobronchial Malacia, Apnea
3. Weaning from Mechanical Vent
4. Abnormal ABG
CPAP Contraindications
1. Upper airway abnormalities: Chonanal Atresia, Cleft Palate, Tracheoesophageal fistula
2. Untreated Airleaks: Pneumo
3. Cardiovascular unstability: BP up or down
4. Can not maintain adequate ventilation: Poor CO2
5. Untreated congenital diaphragmatic he
CPAP Settings
4 to 5 cmH20
Increase in increments of 2 cmH20
No higher than 10 to 12 cmH20
-Keep FIO2 <60% c PaO2 >50 , PaCo2 between 50 to 60mmHg or pH>7.25
Full Support vs. Partial Support
Backup rate > 30= Full Support
Backup rate < 30= Partial Support
Full Support
SIMV = Rate >30
CMV
PCV - Indication for PCV = Plat > 35cmH20, PIP >40cmH20
IRV- Paralyzed and sedated
*If below 10kg, preffered method is PCV
Inital Vent Settings for Neonates
PIP= 15-20 cmH20
PEEP= 3-5 cmH20
FIO2= Keep Pink, Spo2 >90%
Rate= 30 to 40bpm
Flow= 6 to 8 L/min
I time= LBW: 0.25-0.5 sec
Term: 0.5-0.6 sec
I:E= 1:1.5-1:2
Vt= Term: 8-10 ml/kg
6-8 ml/kg
4-6 ml/kg
Inital Vent Settings for Pediatrics
Pplat <35 cmH20
PEEP= 5 cmH20
FIO2= 1.0 or maintain, Spo2 >93%
Rate= Maintain PaCo2 40-48 mmHg
Flow= 25-30 L/min
I time= 1.0 to 1.5 seconds
I:E= 1:2- 1:4 to maintain pt comfort
Vt= Term: 8-10 ml/kg
Sensitivity Settings
1. Pressure Trigger= -1 to -2 cmH20
2. Flow Trigger= 0.15 L/m to 1 L/m
3. Volume Trigger= 3.0 mL
I:E (RR and I-Time)
1. Determine the TCT
- 60/RR
2. Determine the E Time
- I-Time - TCT
3. TE/TI
4. Convert to Ratio (Always gonna have 1 first)
Tuning Factor
Neonates 2ml/cmH20
Adults 3ml/cmH20
Corrected Tidal Volume
Set Vt - (PIP x 2)
Optimal Peep
Set Vt- (PIPx2) / (Plat-Peep)
*Subtract Pplat-PEEP and the smallest number will be optimal PEEP
Auscultation: Diminished
Complaince Change
Ausculation: Rales/Crackles
Secretions/Fuilds
Ausculation: Coarse Rales/Crackles
Large Airway secretions
Needs secretion clearence.. Suction
Ausculation: Medium Rales.Crackles
Middle Airway Secretions
Need mobilization... CPT, PD&P
Ausculation: Fine Rales/Crackles
Lower Airway Secretions
Fuild in Aveoli
CHF, Pulmonary Edema
Need Lasix
Ausculation: Wheezing
Airway Narrowing
Need Bronchodilator
Ausculation: Uni-Laterial Wheezing
Foregin Body Aspiration
Ausculation: Ronchi
Low pitched continous sound
Ausculation: Vasicular
Normal
Ausculation: Adventitous
Abnormal
Percussion: Resonance
Normal Air Sound
Percussion: Flatness
Atelectasis
Percussion: Dullness
Pleural Effusion, PNA
Percuussion: Hyperresonance
Increased Air (Pneumo, emphysema, air-trapping)
CXR Term: Infiltrate
Ill defined radiodensity"
Atelectasis
CXR Term: Consolidation
Soild White Area
Pnueumonia or Pleural Effusion
CXR Term: Hyperlucency
Extra Air
COPD, Asthma, Pneumo
CXR Term: Vascular Markings
Vessels "Absent vascular markings"
Increased = CHF
Absent= Pneumo
CXR Term: Fluffy Infiltrates
Scattered/Diffuse whiteness
Pulmonary Edema
CXR Term: Butterfly wings
White butterfly shape
Pulmonary Edema
CXR Term: Ground Glass
Reticulogranular ARDS/IRDS
CXR Term: Honeycomb Pattern
Reticulogranular ARDS/IRDS
Waveforms: Shift to Right
Decrease in Complaince
Waveforms: Shift to Left
Increase in Comlpaince
Waveforms: Duck Bill
Overdistension - to correct you must decrease Vt
Waveforms: Airleak
Loop never goes back to baseline
Waveforms: Sawtooth look
Exhalation side sawtooth apperance= secretions in tubing and AW
Flow time waveforms
Increased Ti/Flow = Increased Vt
Flow time Waveforms
Flow x time= Vt
Ventilator Management
Volume Ventilator
Vt
- 8 to 10 ml/kg
- Once reached - increase RR
Ventilator Management
Pressure Control= Ventilation(PaCO2)
PIP: Increasing PIP will increase Volume
-Direct Relationship
-Adjust until PIP = 15
RR: Will fix PaCO2 the quickest
-Adjust in 2-5bpm... no drastic changes
I-Time: More gas movement/more CO2 elimination
*VT= I-Time x Flow (Sec)
Flow: Increased Flow=Incre
High Frequency Ventilation
Classied in Hz Ranges
Delivers small Vt at High Rates
mPaw= OXYGENATION
Hz= VENTILATION
Amp/Power= VENTILATION
HFV = Hertz (Rate)
1 Hz= 60 cpm
Affects= Ventilation (PaCO2)
HFV= Amp/Power/Driving Pressure/DeltaP
Mimicks Vt
-#1 Parameter to change to affect PaCO2
- Bring down a High PaCO2 =
Decrease Hz to Increase Amp
- Strength/Depth of Asculation
Affects = Ventilation (PaCO2)
HFV = mPaw
Affects= Oxygenation (PaO2)
HFV= Indications
- Resp Failure that does not respond to Conv. MV
- Pulm Airleaks
- PPHN
- CDH
- IRDS
HFV= Hazards
- Airway Obstruction
- CWF = Chest wiggle factor
- ETT = obstruction or malpositioned tube
HFV= Monitor Closely For
- Signs of Pallor
- Cyanosis
- Bradycardia
- Hypotension
-Increased WOB
HFPPV - High Frequency Postive Pressure Ventilation
-Passive Exhalation
- 1 to 2.5 Hz
- Vt may exceed deadspace
HFJV - High Frequency Jet Ventilation
-Passive Exhalation
- 4 to 11 Hz
- Used in conjunction c Conventional Vents
- Occasional Sigh helps stimulate production of surfactant & prevent microatelectasis
- Deliver PEEP
- Delivers continous flow of gas
- Need to re-intubate
HFOV- High frequency Osc. Ventilator
-Active Exhalation
- 8-30 Hz (Can go to 50)
Advantage= PIP dont fluctuate- alveoli constantly stay open
Surfactant Replacement
Composition:
Phospholipids (80%)
Proteins (10%)
Indications
1. Prophylactic
2. Therapeutic (Rescue)
Surfactant - Prophylactic
High risk patients
- Infants born before 32 weeks
- Weighing less than 1300 gms
- L/S Ratio < 2:1
Absence of PG in the amnoitic fluid
* Infant recieves the surfant as quickly as possible right after delivery
Surfactant - Therapeutic (Rescue)
Given after signs of developing RDS
-WOB, Grunting, nasal flaring, retractions
-Increased Oxygen requirements
-CXR evidence of RDS
* Also effective in PNA and Meconium Aspiration
Surfactant - Exosurf
Synthetic
5 ml/kg
Surfactant - Survanta
Calf
4 ml/kg
Surfactant - Infasurf
Calf
3 ml/kg
Surfactant - Curosurf
Pig
2.5 ml/kg
Surfactant reduces the severity of:
RDS
Pulmonary air leaks
Development of BPD (Baby COPD)
Monitoring the Neonate
1. UAC
2. Arterial Sample
3. TCM
4. CBG
5. Transillumination
ABG "Safe Range" Neonate
PaO2 = 50 to 70 mmHg
PCO2 = 35 to 45 mmHg
pH = 7.35 to 7.45
*Acceptable pH range = 7.30 - 7.50
ABG "Safe Range" Pediatric
PaO2 = 85 to 100 mmHg (sea lvl)
55 to 80 mmHg
PCO2 = 35 to 45 mmHg
pH = 7.35 to 7.45
*Acceptable pH range = 7.30 - 7.50
CO2 Electrode
Severinghaus
O2 Electrode
Clark
pH Electrode
Sanz
Weaning of Neonate
PIP = wean to 15-18 cmH20 ( 1-2 cmH20 increm.)
PEEP = 3-5 cmH20 (1-2 cmH20 increm)
RR= < 10bpm (1-5bpm increm)
FIO2 = 0.3 to 0.4 (1-5% increm)
Weaning of Pediatric
FIO2 = < 40
PEEP= < 5 cmH20
RR= 3-5bpm to support spont breathing
PSV = 5cmH20 (May be discontinued if pt can maintain spont Vt