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Neonatal mechanical ventilation

Neonatal ventilation

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Neonatal mechanical ventilation

  1. 1. Neonatal Mechanical Ventilation
  2. 2. Introduction: • Introduction in 1960’s one of major inventions in Neonatology. • Along with Antenatal steroids and Surfactant replacement ,ventilation played imp role in increasing neonatal survival. • Although life saving it may cause BPD.
  3. 3. Benefits of MV: • Improve Gas exchange, by lung recruitment to improve V/Q matching. • Decrease WOB • CO2 removal in babies with respiratory depression and apnea.
  4. 4. Indications for Ventilation: • Respiratory Acidosis,pH<7.2 and PaCO2> 60 mm Hg. • Hypoxia PaO2<50 mmHg. • Recurrent Apnea. • Downes score> 7.
  5. 5. Common Conditions: • RDS • Apnea of Prematurity. • Septicemia-Pneumonia • Post operative recovery. • PPHN • MAS • Congenital pulmonary or cardiac anomalies(CDH).
  6. 6. Types of : • CMV: Exchange of gas in bulk similar to tidal volume Initiation of breath-Ventilator (CMV or IMV) Patient Tidal volume regulation- PC VC Breath is terminated- Volume Time . Flow regulated. • HFV: small volume of gas at extremely rapid rate(300- 1500) 290 Modes on 33 Ventilators . One ventilator- Care fusion Avea ,offers choice of 44 different modes
  7. 7. Initiation of Breath:  Synchronised Ventilation:(Patient triggered) -SIMV -A/C Ventilation -Pressure support ventilation(PSV) -NAVA  CMV or IMV. Increase in death rate using SIMV(RR-1.19) No difference in air leak,IVH,BPD,extubation failure Shorter duration of Ventilation in SIMV(Mean difference -35 hrs)
  8. 8. Assist Control SIMV
  9. 9. SIMV Mode:
  10. 10. PSV +SIMV vs SIMV PSV+SIMV REDUCES WOB & INCREASES Minute Ventilation. LESS LIKELY TO REQUIRE MV @ 28 DAYS COMPLICATION RATES NO DIFFERENCE
  11. 11. Flow Sensor and Modes:
  12. 12. NAVA Observational studies have shown better synchrony, less PIP and sedation with similar ABG Further research needed to determine effects on outcome
  13. 13. Modes in our Ventilator: SLE 5000 GE CARESCAPE
  14. 14. Modality: • Pressure limited : PC-SIMV PC-A/C PC-PSV • Volume targeted VC VG PRVC
  15. 15. Pressure Limited Ventilation: • TCPL ventilators are MC used Neonatal ventilators. • Amount of pressure during inspiration is set(PIP). • TV delivered depends on PIP,Ti,Compliance and synchrony.
  16. 16. Pressure control Waveform:
  17. 17. Pressure Limited Ventilation(TCPL): Advantages • Relatively easy to use and less costly. • Continues flow of gas in circuit allows for spontaneous breathing. • PIP and MAP can be adjusted to optimize gas exchange and minimize lung injury Disadvantages • Variation in TV from breath to breath • Increased WOB during spontaneous breaths • Poor synchrony decreased O2,increase CO2,de TV,de MV(overcome with synchronization)
  18. 18. Volume Targeted Ventilation: • Provides consistent TV resulting in less lung injury. • In 2011,volume targeted ventilation had replaced pressure limited ventilation in 25 of 50 neonatal tertiary units. • Volume control & Volume Guarantee
  19. 19. Volume Controlled Ventilation: • Set TV (4-6ml/kg) is delivered by variation in PIP. • RR and max Ti are set. • Measure TV delivered to circuit ,No compensation for ET tube leaks
  20. 20. Volume Control Waveform:
  21. 21. Volume guarntee(VG): • Modified pressure targeted ventilation. • Addition of microprocessor that adjusts the pressure to ensure Targeted Tidal Volume(TTV). • TV,Ti,Max PIP is set • Flow sensor senses ex TV to adjust pressure for next few breaths.
  22. 22. Volume Guarantee waveform:
  23. 23. Controlling Volume ,a better mode? • Costly and needs more expertise. • Lower rate of death and BPD(RR-0.73). • Reduced rate of Air leak(RR-0.46),days of ventilation,Hypocarbia and neurologic injury(RR-0.48)
  24. 24. Volume targeted ventilation with either SIMV or A/C using modified TCPL ventilators with TTV of 4-6ml/kg with permissive hypercarbia should be initial mode of ventilation
  25. 25. Ventilator settings and strategies:
  26. 26. Parameters in Conventional ventilation: • Mode of ventilation • PIP • PEEP • Flow • Inspiratory time(Ti) • Fio2 • Rate. • Trigger • Tidal Volume(TTV) • I:E ratio
  27. 27. Setting PIP: • PIP is the primary factor used to deliver tidal volume • PIP required mainly depends on the compliance of lungs • Useful clinical indicator of adequate PIP is gentle chest rise with every vent breath. • If compliance is normal, initiate with 12-14 If abnormal, check chest rise on hand ventilation
  28. 28. Setting PIP: Insufficient PIP • Insufficient ventilation • Decreased oxygenation • Generalized atelectasis High PIP • Increased barotraumas (air leaks) • Increased BPD • Impede venous return/ cardiac output
  29. 29. Setting PEEP: • Adequate PEEP improves FRC & V/Q mismatch • PEEP levels between 3 – 6 improve oxygenation & well tolerated
  30. 30. Setting PEEP: • Choices are between 3 - 6 • If FRC is expected to be: normal: 3 moderately reduced: 4 severly reduced: 5 – 6 • Low PEEP-Atelectotrauma Co2 retention due to V/Q mismatch • High PEEP-Decrease lung compliance Impede venous return/ shock Pulmonary air leaks
  31. 31. • RR is one of the primary determinants of MV, thus CO2 elimination • No conclusive evidence for appropriate RR • In SIMV mode ventilatory rate may not affect ABG as much as anticipated • Choices are between 20 to 60 • Considerations are: - work of breathing - Is there asynchrony: need for overdrive? - pressure requirement ?
  32. 32. Setting FiO2: • Choices are between 21-100% • Target is Pa02 of 50-70 mm Hg with Spo2 of 88-95%. • If lung compliance is good start with 21-25% • Other lung conditions start with FiO2 50%
  33. 33. • Very rapid rate may cause insufficient inspiratory time and decreased tidal volume • May lead to inadvertent PEEP and gas trapping due to inadequate expiration • CO2 retention, impaired cardiac output High RR • Low RR
  34. 34. Setting Ti: • The respiratory system time constant determines optimal Ti & Te • Ideal Ti = 3 x time constant • An Ti of 0.3 – 0.4 sec is commonly used • In conditions like MAS – shorter Ti (0.25sec) • In severe ARDS / Pulmonary hemorrhage prolonged Ti (0.5 sec)
  35. 35. Setting Flow: • Adequate flow rate is required for the ventilator to deliver the desired PIP & waveform • Minimum flow rate of about 3 times the infants MV • Flows of 4 -10 L/min are sufficient for most infants
  36. 36. Mean Airway Pressure:
  37. 37. How to Increase MAP • 1. Increase inspiratory flow rate • 2. Increase peak inspiratory pressure • 3. Increase inspiratory time • 4. Increase PEEP
  38. 38. Increasing Oxygenation:
  39. 39. Increasing Ventilation(PaCO2)

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Neonatal ventilation

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