iap-ahd-ventilation

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iap-ahd-ventilation

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

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