New-housestaff-MV

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Neonatal Mechanical Ventilation,Mark C Mammel,MD,OF MINNESOT,A,University of Minnesota,Childrens Hospital,Mechanical ventilation,What we need to do,Support oxygen delivery,CO,2,elimination,Prevent added injury,decrease ongoing injury,Enhance normal development,Mechanical ventilation,Support oxygen delivery,CO,2,elimination,Headbox O,2,Cannula O,2,CPAP IMV,Intubation,ventilation,Mechanical ventilation,Prevent added injury,Minimize invasive therapy,Optimize lung volume,Target CO,2,O,2,Use appropriate adjuncts,Manage fluids and nutrition,Mechanical ventilation,Enhance normal development,Manage fluids and nutrition,Encourage patient-driven support,Maintain pulmonary toilet-carefully,Support devices,Mechanical ventilation,Key concepts:,Maintain adequate lung volume,Inspiration:tidal volume,Expiration:End-expiratory lung volume,Support oxygenation and CO,2,removal,Oxygenation:adequate mean airway pressure,CO,2,removal:adequate minute ventilation,Mechanical ventilation,Key concepts:,Optimize lung mechanical function,Compliance:V/P,Resistance:Flow/P,Time constant:C x R,Boros SJ et al:,J Pediatr1977;91:794,Mechanical ventilation:How does it work?,Patient,Exhalation,Patient,Inspiration,Mechanical Ventilation:Mode classification,A,.,Trigger mechanism,What causes the breath to begin?,B,.,Limit variable,What regulates gas flow during the breath?,C,.,Cycle mechanism,What causes the breath to end?,A,B,C,A.Inspiratory Trigger Mechanism,Time,Controlled,Me,chanical,Ventilation NO patient interaction,Pressure,Ventilator senses a drop in pressure with patient effort,Flow,Ventilator senses a drop in flow with patient effort,Chest impedance/Abdominal movement,Ventilator senses respiratory/diaphragm or abdominal muscle movement,Diaphragmatic activity,NAVA-Neurally adjusted ventilatory assist,B.Limit Variable,Pressure,Volume,A,B,B.,Volume limited,A.,Pressure limited,T,i,T,i,C.Cycle MechanismWhat causes the breath to end?,A.Time,All ventilators,B.Flow,Pressure support modes,C.Volume,Adult/pediatric ventilators,Pressure,Flow,A,B,T,i,T,i,Volume,C,T,i,Basic waveforms,Time cycle-fixed Ti,Flow cycle-variable Ti with limit,Mechanical ventilation:,Which vent?,Conventional,Drger Babylog 8000,Avea,Servo i,High frequency,SensorMedics oscillator,Bunnell HFJV,Conventional Ventilation,Modes:,CPAP,+/-Pressure support(PSV),IMV/SIMV,+/-Pressure support(PSV),volume targeting,Assist/control(PAC),+/-volume targeting,Continuous positive airway pressure:CPAP,Goal:,Support EELV in spontaneously breathing infant(optimize lung mechanics),Delivery:,NeoPuff,other dedicated CPAP devices,HFNC,Using mechanical ventilator,May be done noninvasively or via ET tube(HFNC in extubated patients only),Patients:,Newborn infants 26 wks with early distress,Infants in NICU with new distress or apnea,Extubated infants,Continuous positive airway pressure:CPAP,Setup:,NeoPuff,other dedicated CPAP devices:,Nasal prong interface,Set PEEP(4-6 cm H,2,O most common),SiPAP:special type of CPAP.Uses 2 levels,usually 2-4 cm H,2,O different,HFNC,Nasal cannula interface,2-4 L/min flow,Monitoring,CPAP:airway pressure displayed and alarmed,HFNC:none,Early CPAP,Columbia Presbyterian,500-1500 gm Infants:Variation in CLD,*,*,*,*,*,p0.0001,Van Marter et al.,Pediatrics,2000;105:1194-1201,%,Intermittent mandatory ventilation:,IMV,/SIMV,Goal:,Support EELV and improve V,e,in spontaneously breathing infant requiring intubation,Eliminate breath-breath volume variation,cerebral blood flow abnormalities,allow patient control via synchronization of SOME breaths,Delivery:,Using mechanical ventilator,May be done noninvasively or via ET tube,Patients:,Newborn infants requiring intubation,Extubated infants with persistent distress,Intermittent Mandatory Ventilation:,IMV,/SIMV,Setup:,ET tube interface,Variables:,Rate-range 15-60 bpm;always synchronized,Volume-target volume 4-7 mL/kg,Pressure-Set peak pressure limit(usually 30 cmH,2,O).Pressure then adjust based on volume.Set PEEP 5-7 cmH,2,O,Time-set T,i,at 0.3 0.5 sec based on pt size,Monitoring,Dynamic.Multiple alarm settings.All measured and calculated parameters may be displayed and trended,IMV-unsynchronized,Impact of synchronization,Assist/control:PAC,Goal:,Support EELV and improve V,e,in apneic or spontaneously breathing infant requiring intubation,Eliminate breath-breath volume variation,cerebral blood flow abnormalities,allow patient control via synchronization of ALL breaths,Delivery:,Using mechanical ventilator,Done via ET tube,Patients:,Newborn infants requiring intubation,Assist/control:PAC,Setup:,ET tube interface,Variables:,Rate-set minimum acceptable rate,40-60 bpm;actual rate depends on patient effort,Volume-target volume 4-7 mL/kg,Pressure-,Peak pressure:Set limit(usually 30 cmH,2,O).Pressure then adjust based on volume.,PEEP:5-7 cmH,2,O,Time-set T,i,maximum at 0.3 0.5 sec based on pt size.Actual T,i,varies with lung me