Your SlideShare is downloading. ×
iap-ahd-ventilation
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

iap-ahd-ventilation

1,303
views

Published on

Published in: Health & Medicine, Business

0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,303
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
107
Comments
0
Likes
2
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. 5/20/2010
    Dr.NILESH
    1
    VENTILATOR SETTINGS AND CPAP
    Dr. NILESH PANCHAL
  • 2. OVERVIEW OF PRESENTATION
    BASICS OF VENTILATOR
    BASICS OF VENTILATOR SETTINGS
    CPAP
    BUBBLE CPAP
    APPLICATION AND ADVANTAGES OF CPAP
    MONITORING OF CPAP
    COMPLICATIONS OF CPAP
    IN-SUR-E
    5/20/2010
    Dr.NILESH
    2
  • 3. PROBLEMS
    5/20/2010
    Dr.NILESH
    3
    • The functional characteristics of respirators and the ventilation techniques are seldom taught to ICU personnel.
    • 4. The medical literature is filled with unproven statements favoring one new mode of ventilation (usually more invasive) over another.
  • PROBLEMS
    Experiments on normal healthy animals have been often used to extrapolate information for sick newborn infants.Regarding “the standard mechanical ventilation”, there is little uniformity in the selection of ventilator settings among institutions or even within the same hospital.
    5/20/2010
    Dr.NILESH
    4
  • 5. PROBLEMS
    Many infants who could have managed on their own are submitted to the ventilator risks.
    Ventilator management can be worse than the disease.
    We need to learn who, when and why before learning how to use the ventilator.
    5/20/2010
    Dr.NILESH
    5
  • 6. GALIRAL IN LATE 1800“AEROPHORE PULMONAIRE”
    5/20/2010
    Dr.NILESH
    6
    Ö Galiral (late 1800’s) first mechanical device for
    artificial ventilation (‘aerophore pulmonaire’)
  • 7. ALEXANDER GRAHAM BELL FIRST INVENTED NEGATIVE PRESSURE VENTILATION
  • 8. Von Reuss (1914) FIRST described CPAP to resuscitate
    5/20/2010
    Dr.NILESH
    8
  • 9. MECHANICAL VENTILATION STRATEGIES
    CPAP (1969) & NPCPAP (1975)
    Intermittent Mandatory Ventilation (IMV) (1970s)
    Patient-triggered ventilation (1980s-1990s)
    High frequency ventilation (1990s)
    Flow synchronized ventilation (2000)
    Hybrid (Pressure & volume targeted) (VAPS/PRVC) (2000)
    5/20/2010
    Dr.NILESH
    9
  • 10. CONCEPTS OF “T”
    5/20/2010
    Dr.NILESH
    10
  • 11. 5/20/2010
    Dr.NILESH
    11
  • 12. 5/20/2010
    Dr.NILESH
    12
  • 13. Flow will be
    P1 - P2
    R
    5/20/2010
    Dr.NILESH
    13
  • 14. TYPES OF VENTILATORS
    Conventional Ventilators
    Pressure-limited, time-cycled
    Volume-limited, time- cycled
    Patient-triggered ventilation
    High Frequency Ventilators
    High frequency oscillatory ventilator
    High frequency jet ventilators
    5/20/2010
    Dr.NILESH
    14
  • 15. JUGGLARY OF 6 PLAYERS
    PIP (peak inspiratory pressure)
    PEEP (peak end expiratory pressure)
    FiO2 ( fraction of O2)
    R.R. (respiratory rate)
    Ti (inspiratory time)
    Te ( expiratory time)
    5/20/2010
    Dr.NILESH
    15
  • 16. FLOW RATE
    The minimal flow rate is 2.5 times infant’s minute ventilation
    With high flow rate:
    Higher MAP
    Higher incidence of barotrauma
    With low flow rate:
    Higher PCO2 form rebreathing exhaled gas
    May not be high enough to reach PIP
    5/20/2010
    Dr.NILESH
    16
  • 17. Fi O2
    The use of unnecessary high FiO2 increases the risk for pulmonary oxygen toxicity.
    The minimal adequate PaO2 is not known. PaO2 of 50-70 mmHg is generally acceptable.
    Preductal oxygen saturation is a valuable and inexpensive measure to follow.
    5/20/2010
    Dr.NILESH
    17
  • 18. Ti------Te
    TI, TE, I:E ratio, and rate(IMV) are all related
    Example: TI =0.5 sec I:E = 1:1 means, TE =0.5 sec IMV=60
    Ideally, the choose of TI should be dependent on the time constant (Tc) of the respiratory system.
    5/20/2010
    Dr.NILESH
    18
  • 19. PIP
    Depends on Cl and Raw
    It should be adjusted until adequate but not excessive chest excursion is noted.
    If infant remains hypoxic in the face of good chest excursion, it is important to exclude CHD and PPHN.
    5/20/2010
    Dr.NILESH
    19
  • 20. PIP
    If PIP is too low:
    tidal volume will be low, leading to
    intra-pulmonary shunts and hypoxia
    If PIP is too high:
    the lung will be hyperinflated causing barotrauma
    PVR will be elevated
    venous return will be impeded
    5/20/2010
    Dr.NILESH
    20
  • 21. PIP
    Hypoxemia   PIP
    Observe chest excursion in every ventilated patient
    Sudden deterioration of the patient with decreased chest excursion denotes an airway or pneumothorax problems rather than compliance changes.
    5/20/2010
    Dr.NILESH
    21
  • 22. PEEP
    Excessively high PEEP:
    will overdistend the alveoli
    will decrease the compliance
    will cause barotrauma
    will impede the venous return
    5/20/2010
    Dr.NILESH
    22
  • 23. EFFECTS OF SETTINGS
    5/20/2010
    Dr.NILESH
    23
  • 24. Continuous positive airway pressure ( CPAP )
    GREGORY IN 1971 _ ENDOTRACHEAL CPAP IN PRE –TERM WITH RDS
    KATTIWINKEL _ NASAL PRONGE FOR CPAP
    CPAP FORGOTTEN
    Mr. J. WUNG from columbia university used nasal pronge cpap and shown decreased incidence of BPD
    5/20/2010
    Dr.NILESH
    24
  • 25. ROLE OF CPAP
    Start early nasal prong CPAP for any:
    tachypnea
    retraction
    grunting
    oxygen requirement
    Early use of CPAP changes the severity and duration of illness.
    5/20/2010
    Dr.NILESH
    25
  • 26. HOW CPAP WORKS
    PREVENTS COLLAPSE OF ALVEOLI
    STABILIZES THE CHEST WALL
    SPLINTS OPEN AIRWAY
    STRETCHES LUNG AND PLEURA
    INCEASES THE OXYGENATION AND VENTILATION
    5/20/2010
    Dr.NILESH
    26
  • 27. COMPONENTS OF CPAP
    GAS SOURCE
    PRESSURE GENERATOR
    PATIENT INTERFACE / DELIVERY SYSTEM
    5/20/2010
    Dr.NILESH
    27
  • 28. CPAP PRESSURE GENERATORS
    CONTINUOUS FLOW DEVICES
    • INFANT VENTILATOR
    • 29. BUBBLE CPAP
    VARIABLE FLOW DEVICES(assist in exhalation)
    • INFANT FLOW DRIVER
    • 30. SiPAP
    5/20/2010
    Dr.NILESH
    28
  • 31. BUBBLE CPAP
    FLOWMETERWATER
    5/20/2010
    Dr.NILESH
    29
    FLOW METER
  • 32. 5/20/2010
    Dr.NILESH
    30
  • 33. 5/20/2010
    Dr.NILESH
    31
  • 34. ADVANTAGES OF BUBBLE CPAP
    SIMPLE
    EASY TO PRPARE
    COST EFFECTIVE
    EFFECTIVE IN PRETERM WITH RDS
    DECREASED CHANCES OF BPD
    EASY TO IDENTIFY AIR LEAK FROM NASAL PRONGES
    5/20/2010
    Dr.NILESH
    32
  • 35. HOW TO INITIATE NASAL CPAP
    USE CORRECT SIZE OF NASAL PRONGE
    NASAL PRONGE SHOULD NOT TOUCH NASAL SEPTUM
    FIX THE NASAL PRONGE BY STRIP OR ADHESIVE PLAST
    SNIFFING POSITION OF THE BABY
    FIX NASAL PRONGE TO CIRCUIT OF CPAP
    APPLY PULSE OXYMETER
    5/20/2010
    Dr.NILESH
    33
  • 36. INCA
    5/20/2010
    Dr.NILESH
    34
    HUDSON
    INCA
    FISCHER AND PAYKEL
  • 37. HUDSON NASAL PRONGE SIZE
    size 0 for < 700 g
    size 1 for 700-1000 g
    size 2 for 1000-2000 g
    size 3 for 2000-3000 g
    size 4 for 3000-4000 g
    size 5 for > 4000 g
    5/20/2010
    Dr.NILESH
    35
  • 38. Attach the oxygen tubing to the flow meter, and connect the tubing to the humidifier
    Set the flow meter to deliver 5 – 10 liters per minute
    5/20/2010
    Dr.NILESH
    36
  • 39. 5/20/2010
    Dr.NILESH
    37
    Choose appropriate size nasal prongs and attach them to the corrugated tubing
    Secure measuring tape to the outlet bottle containing 0.25% acetic acid or sterile water, with the 7 cm mark at the base
    Empty fluid to the 0 mark
    Place the end of the corrugated tube into the water to a depth of 5 cm to create 5 cm of CPAP
  • 40. SUCCESS OF CPAP
    NCPAP is successful when meticulous
    attention is paid to both the infant and to
    the NCPAP Delivery System. This involves
    vigilance in:
    • Monitoring the infant’s condition
    • 41. Maintaining an optimal airway
    • 42. Maintaining a patent CPAP delivery circuit
    • 43. Prevention of complications which may arise from NCPAP
    5/20/2010
    Dr.NILESH
    38
  • 44. MONITORING
    • Once NCPAP is applied, the infant’s condition must be monitored frequently
    • 45. Observe the infant q 1 hr over the first 4 hours of life, and then q 3-4 hr thereafter while on NCPAP.
    • 46. Any infant experiencing significant respiratory distress while on NCPAP requires closer observation for change in condition
    5/20/2010
    Dr.NILESH
    39
  • 47. 5/20/2010
    Dr.NILESH
    40
    Recommended monitoring:
    • Respiratory status (RR, work of breathing)
    • 48. Pre ductal oxygen saturation
    • 49. Cardiovascular status (HR, BP, perfusion)
    • 50. GI status (abdominal distention, bowel sounds)
    • 51. Neurological state (tone, activity, responsiveness)
    • 52. Thermoregulation
  • COMPLICATIONS
    Do not take CPAP lightly!
    Pulmonary air leaks
    Excessive pressure- compromise o2
    Abdominal distension
    Hypotension
    Local – excoriation, scarring, deformity
    5/20/2010
    Dr.NILESH
    41
  • 53. 5/20/2010
    Dr.NILESH
    42
  • 54. COMPLICATION
    Suction the mouth, nose and pharynx
    q 3 hr
    For symptomatic infants more frequent suctioning may be needed
    5/20/2010
    Dr.NILESH
    43
  • 55. COMPLICATION
    • Moisten the nares with normal saline or sterile water to lubricate the catheter and loosen dry secretions.
    • 56. It may be necessary to pass the suction catheter more than once to ensure adequate airway clearance
    5/20/2010
    Dr.NILESH
    44
  • 57. COMPLICATION
    5/20/2010
    Dr.NILESH
    45
    To prevent gastric
    distention:
    Assess the infant’s abdomen regularly
    Pass an oro-gastric tube to aspirate excess air before feeds q 2-4 hr
    An 8 Fr oro-gastric tube may be left indwelling to allow for continuous air removal
  • 58. 5/20/2010
    Dr.NILESH
    46
  • 59. WHEN TO WEAN
    FiO2 0.21
    No respiratory distress
    No significant apnea/bradycardiaepisodes
    5/20/2010
    Dr.NILESH
    47
  • 60. SUMMARY
    Use the checklist
    Keep the airway clear
    Avoid shortcuts
    Think ‘low resistance’
    Clinical assessment vs. lab values
    Monitor pre-ductal saturation
    5/20/2010
    Dr.NILESH
    48
  • 61. TO CONCLUDE
    Gentle & poor man’s ventilation
    Easy to set up & minimal training
    Save babies with RDS in developing countries vs headbox O2
    Lots of unanswered questions yet –
    Optimal device
    Ideal pressure
    5/20/2010
    Dr.NILESH
    49
  • 62. 5/20/2010
    Dr.NILESH
    50
    Should we Administer Surfactant & Extubate
    Immediately to NCPAP? (INSURE)
    NCPAP & prophylactic surfactant (vs. CMV and prophylactic
    surfactant) NCPAP-Surf decreased the number of infants
    ventilated at 7 days and the duration of O2 therapy (Dani et al).
    NCPAP and prophylactic surfactant (and rapid extubation) vs.
    NCPAP (with later treatment if needed). Earlier use of
    surfactant decreased the need for CMV (Verder & Reininger).
    In preterm infants (> 1250g) RDS, CMV & surfactant offers no
    advantage vs. NCPAP (no surfactant) (Texas Research Study Group)
  • 63. 5/20/2010
    Dr.NILESH
    51
    DOES CPAP APPLICABLE TO OUR NICU?
  • 64. NO
    5/20/2010
    Dr.NILESH
    52
  • 65. 5/20/2010
    Dr.NILESH
    53
  • 66. 5/20/2010
    Dr.NILESH
    54
  • 67. 5/20/2010
    Dr.NILESH
    55
  • 68. THANK YOU
    5/20/2010
    Dr.NILESH
    56

×