This document discusses ventilator settings and CPAP. It provides an overview of basics of ventilators and ventilator settings. CPAP is described as preventing alveolar collapse, stabilizing the chest wall, and splinting the airway open. Different types of CPAP generators and components are outlined. Bubble CPAP is discussed as a simple and cost effective method. Advantages, initiation, monitoring and complications of CPAP are summarized. Factors in determining ventilator settings and their effects are also reviewed.

1. 5/20/2010Dr.NILESH1VENTILATOR SETTINGS AND CPAPDr. NILESH PANCHAL

2. OVERVIEW OF PRESENTATIONBASICS OF VENTILATORBASICS OF VENTILATOR SETTINGSCPAPBUBBLE CPAPAPPLICATION AND ADVANTAGES OF CPAPMONITORING OF CPAPCOMPLICATIONS OF CPAPIN-SUR-E5/20/2010Dr.NILESH2

3. PROBLEMS5/20/2010Dr.NILESH3The 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. PROBLEMSExperiments 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. 5/20/2010Dr.NILESH4

5. PROBLEMSMany 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.5/20/2010Dr.NILESH5

6. GALIRAL IN LATE 1800“AEROPHORE PULMONAIRE” 5/20/2010Dr.NILESH6Ö Galiral (late 1800’s) first mechanical device forartificial ventilation (‘aerophore pulmonaire’)

7. ALEXANDER GRAHAM BELL FIRST INVENTED NEGATIVE PRESSURE VENTILATION

8. Von Reuss (1914) FIRST described CPAP to resuscitate5/20/2010Dr.NILESH8

9. MECHANICAL VENTILATION STRATEGIESCPAP (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)5/20/2010Dr.NILESH9

10. CONCEPTS OF “T”5/20/2010Dr.NILESH10

11. 5/20/2010Dr.NILESH11

12. 5/20/2010Dr.NILESH12

13. Flow will beP1 - P2 R5/20/2010Dr.NILESH13

14. TYPES OF VENTILATORSConventional VentilatorsPressure-limited, time-cycledVolume-limited, time- cycledPatient-triggered ventilationHigh Frequency VentilatorsHigh frequency oscillatory ventilatorHigh frequency jet ventilators5/20/2010Dr.NILESH14

15. JUGGLARY OF 6 PLAYERSPIP (peak inspiratory pressure) PEEP (peak end expiratory pressure) FiO2 ( fraction of O2)R.R. (respiratory rate)Ti (inspiratory time)Te ( expiratory time)5/20/2010Dr.NILESH15

16. FLOW RATEThe minimal flow rate is 2.5 times infant’s minute ventilationWith high flow rate:Higher MAPHigher incidence of barotraumaWith low flow rate: Higher PCO2 form rebreathing exhaled gasMay not be high enough to reach PIP5/20/2010Dr.NILESH16

17. Fi O2The 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.5/20/2010Dr.NILESH17

18. Ti------TeTI, 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. 5/20/2010Dr.NILESH18

19. PIPDepends on Cl and RawIt 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.5/20/2010Dr.NILESH19

20. PIPIf PIP is too low: tidal volume will be low, leading to intra-pulmonary shunts and hypoxiaIf PIP is too high: the lung will be hyperinflated causing barotrauma PVR will be elevatedvenous return will be impeded5/20/2010Dr.NILESH20

21. PIPHypoxemia   PIP Observe chest excursion in every ventilated patientSudden deterioration of the patient with decreased chest excursion denotes an airway or pneumothorax problems rather than compliance changes.5/20/2010Dr.NILESH21

22. PEEPExcessively high PEEP:will overdistend the alveoliwill decrease the compliancewill cause barotraumawill impede the venous return5/20/2010Dr.NILESH22

23. EFFECTS OF SETTINGS5/20/2010Dr.NILESH23

24. Continuous positive airway pressure ( CPAP )GREGORY IN 1971 _ ENDOTRACHEAL CPAP IN PRE –TERM WITH RDSKATTIWINKEL _ NASAL PRONGE FOR CPAP CPAP FORGOTTENMr. J. WUNG from columbia university used nasal pronge cpap and shown decreased incidence of BPD5/20/2010Dr.NILESH24

25. ROLE OF CPAPStart early nasal prong CPAP for any:tachypnea retractiongruntingoxygen requirementEarly use of CPAP changes the severity and duration of illness. 5/20/2010Dr.NILESH25

26. HOW CPAP WORKSPREVENTS COLLAPSE OF ALVEOLISTABILIZES THE CHEST WALLSPLINTS OPEN AIRWAYSTRETCHES LUNG AND PLEURAINCEASES THE OXYGENATION AND VENTILATION5/20/2010Dr.NILESH26

27. COMPONENTS OF CPAPGAS SOURCEPRESSURE GENERATORPATIENT INTERFACE / DELIVERY SYSTEM5/20/2010Dr.NILESH27

28. CPAP PRESSURE GENERATORSCONTINUOUS FLOW DEVICES INFANT VENTILATOR

29. BUBBLE CPAPVARIABLE FLOW DEVICES(assist in exhalation)INFANT FLOW DRIVER

30. SiPAP5/20/2010Dr.NILESH28

31. BUBBLE CPAPFLOWMETERWATER5/20/2010Dr.NILESH29FLOW METER

32. 5/20/2010Dr.NILESH30

33. 5/20/2010Dr.NILESH31

34. ADVANTAGES OF BUBBLE CPAPSIMPLEEASY TO PRPARECOST EFFECTIVEEFFECTIVE IN PRETERM WITH RDSDECREASED CHANCES OF BPDEASY TO IDENTIFY AIR LEAK FROM NASAL PRONGES5/20/2010Dr.NILESH32

35. HOW TO INITIATE NASAL CPAPUSE CORRECT SIZE OF NASAL PRONGENASAL PRONGE SHOULD NOT TOUCH NASAL SEPTUMFIX THE NASAL PRONGE BY STRIP OR ADHESIVE PLASTSNIFFING POSITION OF THE BABYFIX NASAL PRONGE TO CIRCUIT OF CPAP APPLY PULSE OXYMETER5/20/2010Dr.NILESH33

36. INCA5/20/2010Dr.NILESH34HUDSONINCAFISCHER AND PAYKEL

37. HUDSON NASAL PRONGE SIZEsize 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 5/20/2010Dr.NILESH35

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 5/20/2010Dr.NILESH36

39. 5/20/2010Dr.NILESH37Choose 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 CPAPNCPAP 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 NCPAP5/20/2010Dr.NILESH38

44. MONITORINGOnce 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 condition5/20/2010Dr.NILESH39

47. 5/20/2010Dr.NILESH40Recommended 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. ThermoregulationCOMPLICATIONSDo not take CPAP lightly!Pulmonary air leaksExcessive pressure- compromise o2Abdominal distensionHypotensionLocal – excoriation, scarring, deformity5/20/2010Dr.NILESH41

53. 5/20/2010Dr.NILESH42

54. COMPLICATION Suction the mouth, nose and pharynx q 3 hr For symptomatic infants more frequent suctioning may be needed5/20/2010Dr.NILESH43

55. COMPLICATIONMoisten 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 clearance5/20/2010Dr.NILESH44