This document provides an overview of advances in neonatal respiratory care from the 1970s to present day. It discusses the evolution of ventilatory care including the introduction of surfactant replacement therapy in the 1980s, high frequency oscillatory ventilation and nitric oxide therapy in the 1990s, and the increased use of non-invasive respiratory support methods like nasal continuous positive airway pressure, nasal intermittent positive pressure ventilation, and high flow nasal cannula in the 2000s and beyond. The principles of care for extremely low birth weight infants in the first week of life are also outlined, focusing on ventilation strategies to minimize lung injury and optimize outcomes.
Mechanical ventilation dr thasneem araThasneem Ara
1) Mechanical ventilation describes the use of machines to assist or replace spontaneous breathing. It involves delivering oxygen and removing carbon dioxide from the lungs.
2) There are various modes and methods of mechanical ventilation that have evolved over time, including negative pressure ventilation, positive pressure ventilation, and newer high frequency modes.
3) Key parameters of mechanical ventilation include tidal volume, respiratory rate, pressures (PIP, PEEP), and ratios (I:E). Modes include CMV, ACV, SIMV, PSV, and newer advanced modes.
Newer modes of ventilation aim to improve on conventional modes by being "closed loop" and adapting to changes in the patient's lung mechanics and respiratory effort. PRVC is one such mode that maintains a target tidal volume with automatic adjustment of pressure support. Other modes like APRV, PAV, and NAVA aim to improve patient-ventilator synchrony and reduce the work of breathing. Modes like VAPS and ASV use both pressure and volume control to guarantee a minimum tidal volume. Neurally adjusted modes like NAVA base support on neural respiratory drive rather than pressures or flows. Overall, newer modes try to prevent lung injury, asynchrony, and promote faster weaning through closed-loop feedback and adaptation
Mechanical ventilation ppt including airway, ventilator, tubings and connections, nursing management, trouble shooting common problems and issues, suctioning etc.
This document discusses various ventilatory modes and settings used in non-invasive ventilation (NIV). It begins by explaining the unique characteristics of NIV, namely the non-hermetic nature of the system due to leaks, and the variable resistance of the upper airway. It then describes common ventilator modes for NIV including spontaneous, spontaneous-timed, pressure assist control, and timed modes. The document outlines optimal settings for various parameters such as inspiratory and expiratory pressure, pressure support, rise time, inspiratory time and cycling criteria. It emphasizes titrating settings to achieve adequate ventilation while minimizing patient effort and discomfort.
This document discusses patient-ventilator interactions and synchrony. It covers the objectives of mechanical ventilation including safety, efficacy, oxygenation, ventilation, work of breathing, comfort and synchrony. It then discusses three key aspects of patient-ventilator synchrony: breath triggering, flow delivery, and breath termination. For breath triggering, it describes optimal triggering and types of triggering dyssynchrony such as delayed/missed triggers and extra triggering including auto-cycling and double triggering. Flow delivery must be synchronous with patient effort. Breath termination must end when patient effort ends to avoid imposed workload. Dyssynchrony can overload muscles and cause patient discomfort.
This document discusses strategies for liberating patients from mechanical ventilation. It outlines key factors that indicate readiness to wean, including improved respiratory function and organ system stability. Two common approaches to weaning are described: gradual weaning using methods like pressure support ventilation or spontaneous breathing trials followed by extubation if tolerated. Protocols using objective criteria can standardize and expedite the weaning process. Factors that may cause weaning failure include respiratory issues, cardiovascular problems, or infection. Readiness is assessed through measurements of ventilatory drive, muscle strength, and breathing patterns.
Mechanical ventilation provides respiratory support through invasive means. The goals are to optimize gas exchange and clinical status with minimum pressures and oxygen levels. Initial settings for ventilators include PIP, PEEP, rate, FiO2, Ti, I:E ratio, flow rate and MAP. Parameters are adjusted based on the infant's condition and response to improve synchrony and reduce complications like air leaks. Continuous monitoring is needed to optimize ventilation support safely.
The document discusses the process of weaning patients off ventilators. It involves three stages: withdrawing the patient from dependence on the ventilator, removing the tube, and finally removing oxygen support. Several criteria are used to assess patient readiness for weaning, including vital capacity, tidal volume, and rapid shallow breathing index. Different methods of weaning are outlined, including modes like assist-control, IMV, SIMV and modes involving pressure support. Nursing roles involve close monitoring, adjusting support levels, and watching for signs of fatigue or deterioration. Nutrition, pulmonary care and assessing readiness to remove the tube and oxygen are also discussed.
Mechanical ventilation dr thasneem araThasneem Ara
1) Mechanical ventilation describes the use of machines to assist or replace spontaneous breathing. It involves delivering oxygen and removing carbon dioxide from the lungs.
2) There are various modes and methods of mechanical ventilation that have evolved over time, including negative pressure ventilation, positive pressure ventilation, and newer high frequency modes.
3) Key parameters of mechanical ventilation include tidal volume, respiratory rate, pressures (PIP, PEEP), and ratios (I:E). Modes include CMV, ACV, SIMV, PSV, and newer advanced modes.
Newer modes of ventilation aim to improve on conventional modes by being "closed loop" and adapting to changes in the patient's lung mechanics and respiratory effort. PRVC is one such mode that maintains a target tidal volume with automatic adjustment of pressure support. Other modes like APRV, PAV, and NAVA aim to improve patient-ventilator synchrony and reduce the work of breathing. Modes like VAPS and ASV use both pressure and volume control to guarantee a minimum tidal volume. Neurally adjusted modes like NAVA base support on neural respiratory drive rather than pressures or flows. Overall, newer modes try to prevent lung injury, asynchrony, and promote faster weaning through closed-loop feedback and adaptation
Mechanical ventilation ppt including airway, ventilator, tubings and connections, nursing management, trouble shooting common problems and issues, suctioning etc.
This document discusses various ventilatory modes and settings used in non-invasive ventilation (NIV). It begins by explaining the unique characteristics of NIV, namely the non-hermetic nature of the system due to leaks, and the variable resistance of the upper airway. It then describes common ventilator modes for NIV including spontaneous, spontaneous-timed, pressure assist control, and timed modes. The document outlines optimal settings for various parameters such as inspiratory and expiratory pressure, pressure support, rise time, inspiratory time and cycling criteria. It emphasizes titrating settings to achieve adequate ventilation while minimizing patient effort and discomfort.
This document discusses patient-ventilator interactions and synchrony. It covers the objectives of mechanical ventilation including safety, efficacy, oxygenation, ventilation, work of breathing, comfort and synchrony. It then discusses three key aspects of patient-ventilator synchrony: breath triggering, flow delivery, and breath termination. For breath triggering, it describes optimal triggering and types of triggering dyssynchrony such as delayed/missed triggers and extra triggering including auto-cycling and double triggering. Flow delivery must be synchronous with patient effort. Breath termination must end when patient effort ends to avoid imposed workload. Dyssynchrony can overload muscles and cause patient discomfort.
This document discusses strategies for liberating patients from mechanical ventilation. It outlines key factors that indicate readiness to wean, including improved respiratory function and organ system stability. Two common approaches to weaning are described: gradual weaning using methods like pressure support ventilation or spontaneous breathing trials followed by extubation if tolerated. Protocols using objective criteria can standardize and expedite the weaning process. Factors that may cause weaning failure include respiratory issues, cardiovascular problems, or infection. Readiness is assessed through measurements of ventilatory drive, muscle strength, and breathing patterns.
Mechanical ventilation provides respiratory support through invasive means. The goals are to optimize gas exchange and clinical status with minimum pressures and oxygen levels. Initial settings for ventilators include PIP, PEEP, rate, FiO2, Ti, I:E ratio, flow rate and MAP. Parameters are adjusted based on the infant's condition and response to improve synchrony and reduce complications like air leaks. Continuous monitoring is needed to optimize ventilation support safely.
The document discusses the process of weaning patients off ventilators. It involves three stages: withdrawing the patient from dependence on the ventilator, removing the tube, and finally removing oxygen support. Several criteria are used to assess patient readiness for weaning, including vital capacity, tidal volume, and rapid shallow breathing index. Different methods of weaning are outlined, including modes like assist-control, IMV, SIMV and modes involving pressure support. Nursing roles involve close monitoring, adjusting support levels, and watching for signs of fatigue or deterioration. Nutrition, pulmonary care and assessing readiness to remove the tube and oxygen are also discussed.
APRV is a ventilation mode that applies CPAP at a high pressure for a prolonged period of time to recruit and maintain lung volume, followed by brief releases to a lower pressure to allow for exhalation and CO2 removal. It aims to preserve spontaneous breathing. APRV is indicated for ARDS management and postoperative atelectasis and has benefits like improved oxygenation and reduced sedation needs but risks include increased work of breathing and worsening of air leaks. Studies comparing APRV to other modes in ARDS patients have found similar outcomes but more research is still needed to determine its full utility.
APRV (Airway Pressure Release Ventilation) is a ventilation mode that applies continuous positive airway pressure (CPAP) for a prolonged high-pressure phase (T high) to recruit and maintain lung volume. It then has a brief low-pressure release phase (T low) where most ventilation and CO2 removal occurs. Compared to conventional ventilation, APRV may cause less ventilator-induced lung injury due to maintaining higher end-expiratory lung volumes without repetitive opening/closing of alveoli. It also allows for spontaneous breathing which improves patient comfort and outcomes. While APRV does not reduce mortality, it can improve other outcomes such as shorter ventilation times and ICU stays.
Presentation of Dr. Lluis Blanch at 10th Pulmonary Medicine Update Course, Cairo, Egypt. Pulmonary Medicine Update Course is organized by Scribe : www.scribeofegypt.com
The document discusses mechanical ventilation in the ICU. It begins with an introduction covering the history and advancements of mechanical ventilation. It then discusses the main indications for mechanical ventilation, which include ventilatory failure and oxygenation failure. Ventilatory failure is defined as the inability to remove adequate carbon dioxide and can be caused by various mechanisms like hypoventilation. Oxygenation failure refers to hypoxemia not responsive to oxygen supplementation and is caused by more severe mechanisms. The document outlines some clinical conditions that warrant mechanical ventilation like respiratory failure, impending respiratory failure, and low output states. It also discusses the basics of mechanical ventilators including phase variables, control variables, and the main modes of volume control and pressure control ventilation.
1) Noninvasive ventilation (NIV) refers to respiratory support provided without an endotracheal tube and allows spontaneously breathing patients. 2) NIV modalities like CPAP and BiPAP raise functional residual capacity and splint alveoli open, reducing work of breathing and increasing oxygen levels. 3) Studies show NIV effectively treats respiratory failure types 1 and 2, pulmonary edema, and as an adjunct in COPD exacerbations by decreasing intubation need, mortality, and length of stay. However, effectiveness in milder COPD, pneumonia, and asthma requires further research.
This document discusses non-invasive ventilation (NIV) in neonates. It begins by defining NIV and describing the different modes including nasal intermittent positive pressure ventilation (NIPPV) and nasal continuous positive airway pressure (NCPAP). It reviews the evidence that NIPPV compared to NCPAP reduces extubation failure rates, failure rates as a primary respiratory mode, and mortality/bronchopulmonary dysplasia. The document provides guidelines for using NIPPV as a primary respiratory mode in preterm infants.
Predictors of weaning from mechanical ventilator outcomeMuhammad Asim Rana
This is a very useful presentation for respiratory therapists and ICU and Emergency physicians. Intended to teach how to assess you patient's readiness for weaning from mechanical ventilator and successful separation from machine.
Initiation of mechanical ventilation and weaningmauryaramgopal
This document discusses mechanical ventilation and weaning. It begins by outlining the purposes and indications for mechanical ventilation. It then describes various modes of mechanical ventilation including controlled mandatory ventilation, assist-control ventilation, synchronized intermittent mandatory ventilation, pressure support ventilation, and continuous positive airway pressure. It also discusses settings for mechanical ventilation such as respiratory rate, tidal volume, PEEP level, and fraction of inspired oxygen. The document provides details on various types, modes, and parameters of mechanical ventilation and weaning.
Hippocrates first described endotracheal intubation in the 5th century BC. Mechanical ventilation progressed through the centuries with innovations like Paracelsus using bellows in 1530 and Vesalius recognizing artificial respiration through tracheostomy in dogs in the 16th century. The development of positive pressure ventilation in the 1950s helped greatly during polio epidemics. Key events included the iron lung in 1929 and intensive use of positive pressure ventilation in Scandinavia and the US in the 1950s. The document outlines the historical aspects and developments of mechanical ventilation from ancient times through the modern era.
The document discusses weaning patients from mechanical ventilation. It defines weaning as the process of withdrawing ventilator support and describes the main steps as assessing patient readiness, using methods like a T-piece trial or pressure support ventilation to gradually reduce support, and monitoring for signs of fatigue or deterioration. Key factors that must be evaluated for readiness include respiratory muscle strength and endurance, ventilatory drive, gas exchange, and hemodynamic status. Nursing plays an important role in explaining the process, monitoring patients, and providing encouragement during weaning trials.
The document discusses the history and evolution of mechanical ventilation from the 1800s to the present day. It covers early negative pressure ventilation techniques, the development of positive pressure ventilation in the 1950s, and the rise of intensive care units in the 1960s. The rest of the document summarizes several modern ventilation modes like pressure support ventilation, bilevel positive airway pressure, airway pressure release ventilation, proportional assist ventilation, and their applications.
Non-invasive ventilation (NIV) provides ventilatory support without intubation through a non-invasive interface like a mask. It is used initially to treat type 2 respiratory failure and prevent need for mechanical ventilation. Benefits include avoiding complications of intubation and improving outcomes by reducing mortality, morbidity, ICU/hospital stay, and costs. NIV is appropriate for patients with acute or acute on chronic respiratory failure who are cooperative, hemodynamically stable, and have an adequate cough reflex. Factors determining success include careful patient selection, skilled application and monitoring, and timely transition to invasive ventilation if needed.
This document provides an overview of non-invasive ventilation (NIV). It discusses the history of NIV, types of ventilators and modes used, interfaces, indications and contraindications. Guidelines are provided on how to start and monitor NIV, including adjusting settings based on patient response. Advantages, disadvantages and complications of NIV are reviewed. Applications of NIV for specific clinical conditions like COPD exacerbation and acute cardiogenic pulmonary edema are covered. The document aims to educate medical professionals on best practices for administering and monitoring patients receiving NIV treatment.
The document discusses weaning patients off mechanical ventilation. It defines weaning as the transition from full ventilator support to spontaneous breathing. Patients can have simple, difficult, or prolonged weaning depending on how many spontaneous breathing trials they require. Daily screening checks if patients meet criteria for an initial spontaneous breathing trial. Successful trials are then followed by extubation. Patients who fail trials should have their causes investigated and corrected before retrying weaning.
This document discusses guidelines for weaning patients from mechanical ventilation. It begins by defining weaning as the process of withdrawing ventilatory support, which can be done abruptly or gradually. Approximately 75% of patients can be weaned abruptly if their underlying condition has improved. The remaining 25% require a more gradual weaning process. Common weaning techniques discussed include T-piece trials, pressure support ventilation, and synchronized intermittent mandatory ventilation. Predictors of weaning success mentioned include the rapid shallow breathing index and daily screening of patients' condition and respiratory status. The document emphasizes that weaning should only begin once the underlying illness necessitating ventilation has significantly improved.
Mechanical Ventilation Cheat Book for Internal Medicine ResidentsThe Medical Post
This short cheat book talks about basic concepts and physiology of artificial ventilation and also elaborates on point guided approach in maneuvering different modes of mechanical ventilation. Consider this as a basic overview and is intended for all internal medicine residents.
NurseReview.Org - Introduction to Mechanical VentilationNurse ReviewDotOrg
This document provides an overview of mechanical ventilation, including indications for use, key terms, types of ventilation modes, complications, and weaning from ventilation support. It describes positive pressure ventilation as the primary method, using controlled and supportive ventilation modes. Controlled modes deliver set tidal volumes and rates while supportive modes rely on patient triggering. Complications include ventilator-induced lung injury from excessive pressures or volumes and ventilator-associated pneumonia. Successful weaning depends on patient stability in ventilation, oxygenation, cardiovascular function and psychological state.
Weaning from mechanical ventilation is the process of gradually transferring breathing from the ventilator to the patient. It must be individualized and involves assessing patient readiness using criteria like clinical stability, adequate oxygenation and pulmonary function. Weaning success means unassisted breathing for 48 hours after removal from the ventilator. Patients are classified as having simple, difficult or prolonged weaning based on time to successful extubation. Factors that can cause weaning failure include increased airway resistance, decreased lung compliance, and respiratory muscle fatigue due to conditions like cardiac dysfunction, diaphragm weakness or endocrine abnormalities.
Bpd,nnf kerala,march 2019 - Dr Karthik Nageshkarthiknagesh
This document provides information about Dr. N. Karthik Nagesh, including his professional designations, affiliations, awards, publications, and special interests in neonatal intensive care and respiratory disorders. It also includes summaries of current strategies for the prevention and management of bronchopulmonary dysplasia (BPD) in preterm infants, such as the use of antenatal steroids, continuous positive airway pressure (CPAP), minimal invasive surfactant therapy, targeted volume ventilation, and inhaled steroids.
Niv current trends karthik nagesh,2019 - Dr Karthik Nageshkarthiknagesh
This document provides an overview of various modes of non-invasive ventilation that can be used to support respiration in neonates, including advantages and disadvantages. It discusses nasal continuous positive airway pressure (NCPAP), nasal intermittent positive pressure ventilation (NIPPV), high flow nasal cannula (HFNC) therapy, nasal high frequency oscillatory ventilation (nHFOV), and neurally adjusted ventilatory assist (NAVA). The document summarizes the physiological rationale and evidence from studies comparing the different non-invasive modalities. It provides guidance on clinical situations where each mode may be indicated. The overall focus is on using the least invasive respiratory support possible to minimize lung injury and risk of chronic lung disease in preterm neon
APRV is a ventilation mode that applies CPAP at a high pressure for a prolonged period of time to recruit and maintain lung volume, followed by brief releases to a lower pressure to allow for exhalation and CO2 removal. It aims to preserve spontaneous breathing. APRV is indicated for ARDS management and postoperative atelectasis and has benefits like improved oxygenation and reduced sedation needs but risks include increased work of breathing and worsening of air leaks. Studies comparing APRV to other modes in ARDS patients have found similar outcomes but more research is still needed to determine its full utility.
APRV (Airway Pressure Release Ventilation) is a ventilation mode that applies continuous positive airway pressure (CPAP) for a prolonged high-pressure phase (T high) to recruit and maintain lung volume. It then has a brief low-pressure release phase (T low) where most ventilation and CO2 removal occurs. Compared to conventional ventilation, APRV may cause less ventilator-induced lung injury due to maintaining higher end-expiratory lung volumes without repetitive opening/closing of alveoli. It also allows for spontaneous breathing which improves patient comfort and outcomes. While APRV does not reduce mortality, it can improve other outcomes such as shorter ventilation times and ICU stays.
Presentation of Dr. Lluis Blanch at 10th Pulmonary Medicine Update Course, Cairo, Egypt. Pulmonary Medicine Update Course is organized by Scribe : www.scribeofegypt.com
The document discusses mechanical ventilation in the ICU. It begins with an introduction covering the history and advancements of mechanical ventilation. It then discusses the main indications for mechanical ventilation, which include ventilatory failure and oxygenation failure. Ventilatory failure is defined as the inability to remove adequate carbon dioxide and can be caused by various mechanisms like hypoventilation. Oxygenation failure refers to hypoxemia not responsive to oxygen supplementation and is caused by more severe mechanisms. The document outlines some clinical conditions that warrant mechanical ventilation like respiratory failure, impending respiratory failure, and low output states. It also discusses the basics of mechanical ventilators including phase variables, control variables, and the main modes of volume control and pressure control ventilation.
1) Noninvasive ventilation (NIV) refers to respiratory support provided without an endotracheal tube and allows spontaneously breathing patients. 2) NIV modalities like CPAP and BiPAP raise functional residual capacity and splint alveoli open, reducing work of breathing and increasing oxygen levels. 3) Studies show NIV effectively treats respiratory failure types 1 and 2, pulmonary edema, and as an adjunct in COPD exacerbations by decreasing intubation need, mortality, and length of stay. However, effectiveness in milder COPD, pneumonia, and asthma requires further research.
This document discusses non-invasive ventilation (NIV) in neonates. It begins by defining NIV and describing the different modes including nasal intermittent positive pressure ventilation (NIPPV) and nasal continuous positive airway pressure (NCPAP). It reviews the evidence that NIPPV compared to NCPAP reduces extubation failure rates, failure rates as a primary respiratory mode, and mortality/bronchopulmonary dysplasia. The document provides guidelines for using NIPPV as a primary respiratory mode in preterm infants.
Predictors of weaning from mechanical ventilator outcomeMuhammad Asim Rana
This is a very useful presentation for respiratory therapists and ICU and Emergency physicians. Intended to teach how to assess you patient's readiness for weaning from mechanical ventilator and successful separation from machine.
Initiation of mechanical ventilation and weaningmauryaramgopal
This document discusses mechanical ventilation and weaning. It begins by outlining the purposes and indications for mechanical ventilation. It then describes various modes of mechanical ventilation including controlled mandatory ventilation, assist-control ventilation, synchronized intermittent mandatory ventilation, pressure support ventilation, and continuous positive airway pressure. It also discusses settings for mechanical ventilation such as respiratory rate, tidal volume, PEEP level, and fraction of inspired oxygen. The document provides details on various types, modes, and parameters of mechanical ventilation and weaning.
Hippocrates first described endotracheal intubation in the 5th century BC. Mechanical ventilation progressed through the centuries with innovations like Paracelsus using bellows in 1530 and Vesalius recognizing artificial respiration through tracheostomy in dogs in the 16th century. The development of positive pressure ventilation in the 1950s helped greatly during polio epidemics. Key events included the iron lung in 1929 and intensive use of positive pressure ventilation in Scandinavia and the US in the 1950s. The document outlines the historical aspects and developments of mechanical ventilation from ancient times through the modern era.
The document discusses weaning patients from mechanical ventilation. It defines weaning as the process of withdrawing ventilator support and describes the main steps as assessing patient readiness, using methods like a T-piece trial or pressure support ventilation to gradually reduce support, and monitoring for signs of fatigue or deterioration. Key factors that must be evaluated for readiness include respiratory muscle strength and endurance, ventilatory drive, gas exchange, and hemodynamic status. Nursing plays an important role in explaining the process, monitoring patients, and providing encouragement during weaning trials.
The document discusses the history and evolution of mechanical ventilation from the 1800s to the present day. It covers early negative pressure ventilation techniques, the development of positive pressure ventilation in the 1950s, and the rise of intensive care units in the 1960s. The rest of the document summarizes several modern ventilation modes like pressure support ventilation, bilevel positive airway pressure, airway pressure release ventilation, proportional assist ventilation, and their applications.
Non-invasive ventilation (NIV) provides ventilatory support without intubation through a non-invasive interface like a mask. It is used initially to treat type 2 respiratory failure and prevent need for mechanical ventilation. Benefits include avoiding complications of intubation and improving outcomes by reducing mortality, morbidity, ICU/hospital stay, and costs. NIV is appropriate for patients with acute or acute on chronic respiratory failure who are cooperative, hemodynamically stable, and have an adequate cough reflex. Factors determining success include careful patient selection, skilled application and monitoring, and timely transition to invasive ventilation if needed.
This document provides an overview of non-invasive ventilation (NIV). It discusses the history of NIV, types of ventilators and modes used, interfaces, indications and contraindications. Guidelines are provided on how to start and monitor NIV, including adjusting settings based on patient response. Advantages, disadvantages and complications of NIV are reviewed. Applications of NIV for specific clinical conditions like COPD exacerbation and acute cardiogenic pulmonary edema are covered. The document aims to educate medical professionals on best practices for administering and monitoring patients receiving NIV treatment.
The document discusses weaning patients off mechanical ventilation. It defines weaning as the transition from full ventilator support to spontaneous breathing. Patients can have simple, difficult, or prolonged weaning depending on how many spontaneous breathing trials they require. Daily screening checks if patients meet criteria for an initial spontaneous breathing trial. Successful trials are then followed by extubation. Patients who fail trials should have their causes investigated and corrected before retrying weaning.
This document discusses guidelines for weaning patients from mechanical ventilation. It begins by defining weaning as the process of withdrawing ventilatory support, which can be done abruptly or gradually. Approximately 75% of patients can be weaned abruptly if their underlying condition has improved. The remaining 25% require a more gradual weaning process. Common weaning techniques discussed include T-piece trials, pressure support ventilation, and synchronized intermittent mandatory ventilation. Predictors of weaning success mentioned include the rapid shallow breathing index and daily screening of patients' condition and respiratory status. The document emphasizes that weaning should only begin once the underlying illness necessitating ventilation has significantly improved.
Mechanical Ventilation Cheat Book for Internal Medicine ResidentsThe Medical Post
This short cheat book talks about basic concepts and physiology of artificial ventilation and also elaborates on point guided approach in maneuvering different modes of mechanical ventilation. Consider this as a basic overview and is intended for all internal medicine residents.
NurseReview.Org - Introduction to Mechanical VentilationNurse ReviewDotOrg
This document provides an overview of mechanical ventilation, including indications for use, key terms, types of ventilation modes, complications, and weaning from ventilation support. It describes positive pressure ventilation as the primary method, using controlled and supportive ventilation modes. Controlled modes deliver set tidal volumes and rates while supportive modes rely on patient triggering. Complications include ventilator-induced lung injury from excessive pressures or volumes and ventilator-associated pneumonia. Successful weaning depends on patient stability in ventilation, oxygenation, cardiovascular function and psychological state.
Weaning from mechanical ventilation is the process of gradually transferring breathing from the ventilator to the patient. It must be individualized and involves assessing patient readiness using criteria like clinical stability, adequate oxygenation and pulmonary function. Weaning success means unassisted breathing for 48 hours after removal from the ventilator. Patients are classified as having simple, difficult or prolonged weaning based on time to successful extubation. Factors that can cause weaning failure include increased airway resistance, decreased lung compliance, and respiratory muscle fatigue due to conditions like cardiac dysfunction, diaphragm weakness or endocrine abnormalities.
Bpd,nnf kerala,march 2019 - Dr Karthik Nageshkarthiknagesh
This document provides information about Dr. N. Karthik Nagesh, including his professional designations, affiliations, awards, publications, and special interests in neonatal intensive care and respiratory disorders. It also includes summaries of current strategies for the prevention and management of bronchopulmonary dysplasia (BPD) in preterm infants, such as the use of antenatal steroids, continuous positive airway pressure (CPAP), minimal invasive surfactant therapy, targeted volume ventilation, and inhaled steroids.
Niv current trends karthik nagesh,2019 - Dr Karthik Nageshkarthiknagesh
This document provides an overview of various modes of non-invasive ventilation that can be used to support respiration in neonates, including advantages and disadvantages. It discusses nasal continuous positive airway pressure (NCPAP), nasal intermittent positive pressure ventilation (NIPPV), high flow nasal cannula (HFNC) therapy, nasal high frequency oscillatory ventilation (nHFOV), and neurally adjusted ventilatory assist (NAVA). The document summarizes the physiological rationale and evidence from studies comparing the different non-invasive modalities. It provides guidance on clinical situations where each mode may be indicated. The overall focus is on using the least invasive respiratory support possible to minimize lung injury and risk of chronic lung disease in preterm neon
hhhfnc 2019,karneocon,vijayapura - Dr Karthik Nageshkarthiknagesh
High Flow Nasal Canula (HFNC) therapy in Neonates - Applications discusses the use of HFNC therapy in neonates as an alternative to invasive ventilation and CPAP. It provides an overview of the evidence and clinical settings where HFNC is indicated. It describes how HFNC works and guidelines for its use. The document also discusses some of the problems with more invasive forms of ventilation and how HFNC aims to provide respiratory support in a less invasive manner.
High Flow Nasal Cannula - Grand Rounds 2018Jason Block
This document discusses the benefits and optimal use of high flow nasal cannula (HFNC) in the emergency department. It finds that HFNC is comfortable for patients, improves oxygenation, and decreases respiratory rate. It can be used effectively in both the ED and ICU to treat hypoxemic respiratory failure without hypercapnia. HFNC may reduce intubation and mortality compared to conventional oxygen therapy. It also maintains oxygenation during intubation and is preferable to other devices for preoxygenation. However, HFNC should be used cautiously for cardiogenic pulmonary edema and COPD given limited evidence.
This document provides an overview and discussion of CPAP (continuous positive airway pressure) usage in neonates. It begins with three case scenarios of premature infants admitted to the NICU and then poses the question of initial management. The bulk of the document discusses CPAP, including definitions, history, types, advantages/disadvantages, devices, effects, indications, contraindications, essentials, monitoring, complications, weaning and more. Studies on CPAP usage in Bangladesh and methods of weaning are also summarized.
This document provides an overview and discussion of continuous positive airway pressure (CPAP) support for newborns. It begins with three case scenarios of newborns admitted to the neonatal intensive care unit. It then asks what the initial management would be for these cases, and the response would be CPAP support. The document proceeds to define CPAP and discuss its history, types, advantages and disadvantages, devices used, how it works, indications, contraindications, essentials of application and monitoring, complications, removal procedures, and failure. Key points emphasized include using the lowest effective pressure and oxygen needed, gradual weaning, and monitoring vital signs and blood gases to ensure adequacy of support.
HFNC therapy is an alternative to CPAP for respiratory support of neonates. It works by flushing the nasal passages and removing exhaled gases, reducing dead space and resistance. HFNC provides a dynamic distending pressure of 3-5 cm H2O. It is indicated for mild respiratory dysfunction post-extubation or as an alternative to CPAP. Evidence shows HFNC has similar efficacy to CPAP with no differences in rates of reintubation, treatment failure, death or chronic lung disease when used for primary support or post-extubation. HFNC allows for a longer duration of non-invasive respiratory support.
This document provides an overview of a seminar on CPAP in neonatal practice. It includes two case scenarios of premature infants with respiratory distress and then outlines what CPAP is, the history of its use, types of CPAP devices, how CPAP works, indications and contraindications for its use, essentials of providing CPAP including monitoring infants on CPAP and managing complications. Studies are summarized that show benefits of CPAP for preventing morbidity and mortality in premature infants as well as its use after extubation. Guidelines are provided on initiating, maintaining and weaning infants from CPAP support.
This document discusses various methods for delivering continuous positive airway pressure (CPAP) to neonates, including underwater bubble CPAP, variable flow nasal prongs, and newer technologies like SiPAP and Vapotherm. It notes that while different CPAP methods aim to improve outcomes, more clinical data is still needed to determine their safety and effectiveness compared to conventional CPAP. The document also advocates for renewed use of transcutaneous CO2 monitoring to help guide ventilation and avoid potentially harmful swings in blood gas levels.
Presentation by Dr. S.K Jindal on "PAP Therapy" | Jindal Chest ClinicJindal Chest Clinic
Positive airway pressure (PAP) therapy is a sleep apnea treatment that uses compressed air to support the airway. It involves wearing a mask and a portable machine blowing pressurized air into the upper airway through a tube connected to the mask. This positive airflow prevents apnea collapse and allows normal breathing. In this presentation "PAP Therapy" has been described including its use, indications, complications, etc. For more information, please contact us: 9779030507.
Biphasic Cuirass Ventilation for Respiratory Failure and ARDSGary Mefford RRT
There is a great deal of information that points to the potential efficacy of BCV for acute and chronic respiratory failure as well as ARDS. Some is gathered here with a discussion of the open lung concept with BCV.
This document discusses high flow nasal cannula (HFNC) and humidification. It provides an overview of HFNC, including how it works and key points. HFNC can deliver high levels of oxygen and is well tolerated by patients. It has several benefits over traditional oxygen masks, including better washout of dead space and more consistent oxygen delivery. The document reviews indications, contraindications and complications of HFNC. It also discusses evidence on using HFNC to prevent intubation in respiratory failure, as peri-intubation support, and for post-extubation therapy. Risks, cleaning and questions around HFNC are also addressed.
The document describes a case of a preterm infant born at 33 weeks gestation with low birth weight and respiratory distress. It then provides information on assessing and managing respiratory distress in newborns, including different scoring systems, delivery room management for preterm infants, and various modalities of non-invasive respiratory support such as nasal prongs, nasal CPAP, and high-flow nasal cannula. Key points discussed include initiating CPAP early for signs of respiratory distress and adjusting settings based on patient response and blood gas values.
This document discusses the management of persistent pulmonary hypertension of the newborn (PPHN) in resource-limited settings. It provides an overview of the pathophysiology of PPHN and reviews various treatment strategies including oxygen, nitric oxide, sildenafil, bosentan, magnesium sulfate, milrinone, and prostacyclin. While treatments like nitric oxide and ECMO are effective, access is limited in many settings. The document therefore focuses on evaluating evidence and practical experience for using more available therapies like sildenafil, vasopressin, and supportive care measures for managing PPHN in resource-constrained environments.
This document discusses the use of non-invasive ventilation (NIV) as a physiotherapeutic approach. It defines NIV as the delivery of oxygen via a face mask without an endotracheal tube. NIV works by creating positive airway pressure to force air into the lungs, reducing respiratory effort. There are two main types of NIV: non-invasive positive pressure ventilation and negative pressure ventilation. The document then discusses specific NIV techniques like CPAP and BiPAP and their indications. It also covers contraindications and how NIV can be used to manage acute respiratory failure, improve secretion removal, exercise capacity, and treat chronic respiratory failure.
How do I safely ventilate my patient inOT.pptxchandra talur
There are several key points regarding safe ventilation of patients in the operating theatre:
1. Mechanical ventilation can cause harm if not done properly, so the goal is to open just enough lung to provide adequate oxygen while avoiding ventilator-induced lung injury.
2. Large tidal volumes, low PEEP, and high FiO2 have been shown to increase the risk of postoperative pulmonary complications, so a lung protective strategy is recommended.
3. Surrogates like plateau pressure, driving pressure, and static compliance can help assess lung stress and strain in the absence of direct measurements and guide ventilation settings to prevent overdistention and volutrauma.
This document provides an overview of continuous positive airway pressure (CPAP) therapy for newborns, including:
- CPAP is a noninvasive respiratory support that applies positive pressure to prevent alveolar collapse. It is commonly used for preterm infants with respiratory distress.
- The presentation outlines what CPAP is, how it works, indications and contraindications for its use, guidelines for initiation and weaning, complications, and recent advancements.
- Proper use and monitoring of CPAP can help stabilize respiratory status for infants with conditions like respiratory distress syndrome, while avoiding complications such as nasal injury, gastric distention, or pneumothorax.
The document describes three case scenarios involving newborn infants with respiratory distress. The first case involves an infant born at 30 weeks gestation who developed respiratory distress soon after birth and was normothermic, euglycemic, and had good reflexes and activity. The second case involves an infant born at 31 weeks gestation who was started on oxygen and later developed progressive respiratory distress, with CPAP initiated after the Downe's score reached 5 at 3 hours of age. The third case involves an infant born at 30 weeks gestation who was initially put on CPAP but required increased settings and eventually surfactant and mechanical ventilation due to inability to maintain saturation on CPAP. The document seeks management recommendations for each case.
Weaning from mechanical ventilation and extubation by dr tareqtareq rahman
Weaning from mechanical ventilation and extubation requires careful assessment of patient readiness and involves gradually reducing ventilator support. While no single protocol can predict successful weaning in all cases, clinical judgment and experience are important. Early weaning when possible can reduce risks like nosocomial infection and improve patient outcomes. Factors such as respiratory status, hemodynamics, oxygen needs and sedation levels must be optimized before attempting weaning through slowly reducing settings on the ventilator. Noninvasive respiratory support like nasal CPAP is preferred after extubation over headbox oxygen. Caffeine, corticosteroids and chest physiotherapy may also improve chances of successful extubation.
Similar to Lung protective strategies,2019 - Dr Karthik Nagesh (20)
Surfactant journey,nnk,oct 2017 - Dr Karthik Nageshkarthiknagesh
This document summarizes Dr. Karthik Nagesh's experience with surfactant therapy in India, beginning in the early 1990s. It describes some of Dr. Nagesh's early experiences using surfactant procured from other countries to treat neonatal respiratory distress syndrome. It then outlines how surfactant therapy became more established in India through clinical trials, workshops to educate others, and the eventual commercial availability of surfactants in India. The document provides several cases that demonstrated the benefits of surfactant therapy for reducing the need for oxygen and ventilation support.
Preterm immunisation 2018,6 oct ,south neocon- Dr Karthik Nageshkarthiknagesh
Preterm infants are at increased risk of morbidity and mortality from vaccine-preventable diseases. However, routine immunization of preterms is often delayed. The document discusses evidence that preterm infants can mount protective immune responses to vaccines according to their chronological age. While antibody levels may sometimes be lower in preterms, the majority achieve levels associated with protection. The safety and efficacy of individual vaccines in preterms is reviewed. The benefits of vaccinating medically stable preterms according to routine schedules outweigh potential risks like transient apnea.
Preterm immunisation 2018 - Dr Karthik Nageshkarthiknagesh
This document discusses vaccination in preterm infants. It notes that preterm infants are at higher risk of morbidity and mortality from vaccine-preventable diseases. However, vaccination of preterms is often delayed. The document summarizes evidence that preterm infants can mount protective immune responses when vaccinated according to their chronological age, regardless of gestational age or birth weight. It addresses specific concerns about the safety and efficacy of various vaccines in preterm populations such as BCG, polio, hepatitis B, pertussis and others. Overall, the document advocates for vaccinating medically stable preterm infants according to routine schedules in order to provide them protection from serious diseases.
Problems in late preterm babies, iap bps,bangalore,webinar, 20-5-20 - Dr Kart...karthiknagesh
This document discusses problems faced by late preterm newborns, including respiratory issues, thermoregulation difficulties, and hypoglycemia. It provides epidemiological data on the increasing rates of late preterm births and their associated higher morbidity and mortality compared to full-term infants. Specific problems faced by late preterm infants are outlined, such as transient tachypnea of the newborn, respiratory distress syndrome, and feeding difficulties. Strategies for prevention and management of complications are discussed, including use of kangaroo mother care and dextrose gel to treat hypoglycemia.
Neuroprotection strategies for newborns ,2018 - Dr Karthik Nageshkarthiknagesh
This document provides information about Dr. N. Karthik Nagesh, his qualifications and experience in neonatology. It then summarizes his presentation on strategies for perinatal neuroprotection in newborns. These include antenatal steroids, magnesium sulfate, delayed cord clamping, therapeutic hypothermia, caffeine, kangaroo care and investigational therapies like melatonin and erythropoietin. The goal is to help newborns, especially preterms and those with birth asphyxia, have intact survival by preventing brain injury. Future areas of research discussed include preventing preterm birth and better identifying babies at risk of hypoxic ischemic encephalopathy.
Jaundice 2019, salem cme - - Dr Karthik Nageshkarthiknagesh
This document discusses bilirubin encephalopathy (kernicterus) and the bilirubin-induced neurological dysfunction (BIND) spectrum. It covers the pathogenesis, risk factors, clinical features, evaluation, management with phototherapy, and guidelines for phototherapy in term and preterm infants. Key points include the need to prevent excessive bilirubin levels to avoid encephalopathy, the use of total serum bilirubin or transcutaneous bilirubin measurements to guide treatment, and following AAP guidelines for phototherapy thresholds based on gestational age and risk factors.
Hypothermia for neonates, india , ppt - Dr Karthik Nageshkarthiknagesh
This document discusses hypoxic ischemic brain injury in newborns. It describes the pathophysiology as primary energy failure caused by hypoxia/ischemia leading to immediate neuronal death, and secondary energy failure hours to days later caused by reperfusion injury and free radical formation, leading to delayed apoptotic cell death. Whole body cooling is described as an effective therapeutic intervention to reduce brain injury if initiated within 6 hours of the hypoxic ischemic insult and maintained at 33.5°C for 72 hours. The benefits, methods, and monitoring of therapeutic hypothermia are summarized.
Hie treatment, 2019, kar pedicon,davangere - Dr Karthik Nageshkarthiknagesh
Erythropoietin shows promise for reducing brain damage from neonatal hypoxic-ischemic encephalopathy (HIE). Several clinical trials have found that erythropoietin administered to infants with HIE results in less MRI-detected brain injury and improved neurodevelopmental outcomes. A current phase III trial is evaluating whether high-dose erythropoietin given with therapeutic hypothermia can reduce death or disability in infants with moderate to severe HIE. Erythropoietin appears to be a safe and potentially effective adjunctive treatment for HIE, but larger trials are still needed to determine optimal dosing and administration strategies.
Fungal sepsis,final,nnf kerala,kims,2019 - Dr Karthik Nageshkarthiknagesh
This document summarizes key information on fungal infections in newborns. It finds that invasive candidiasis is most common in extremely low birth weight infants. Risk factors include central lines, prolonged antibiotic use, and TPN. Diagnosis relies on detecting Candida in blood or other sterile sites. Early treatment with antifungals like amphotericin B or fluconazole is important to prevent complications. Prophylaxis with fluconazole may benefit high-risk infants to reduce invasive infections.
Erythropoetin in hie,iap neocon, pune,2018 - Dr Karthik Nageshkarthiknagesh
Erythropoietin shows promise for reducing brain injury in neonatal hypoxic ischemic encephalopathy (HIE). Clinical trials show that high doses of erythropoietin given with therapeutic hypothermia may result in less MRI-detected brain injury and improved motor outcomes at 1 year for infants with HIE. A current phase III trial is evaluating whether high dose erythropoietin can reduce death or neurodevelopmental disability when given with hypothermia. Additional studies are still needed to determine the optimal dosing, timing, and duration of erythropoietin administration for HIE treatment, especially in low and middle-income countries.
Dengue article kn 2019 - Dr Karthik Nageshkarthiknagesh
1) The document discusses ethical considerations regarding medical treatment decisions for infants with conditions like anencephaly that cannot be benefited by available therapies. It argues that not providing predictably futile treatments in such cases can be ethically and legally justified.
2) It references a 1983 report from the President's Commission that discussed situations where parents may want treatment even if deemed futile by physicians, and that providers should respect such requests if they don't cause suffering. Individual providers could decline if they found the treatment personally offensive.
3) The second document discusses the possibility of missing neonatal dengue cases transmitted from infected mothers. It describes two cases where screening at birth was negative but infants later developed severe dengue symptoms. It
Current status of neonatal intensive care in india, karthik nagesh n,archives...karthiknagesh
The document summarizes the current status of neonatal intensive care in India. It finds that while neonatal intensive care has grown significantly in India over the last decade due to increased private sector investment and some government initiatives, there remains a large disparity between care available to wealthy, urban populations and poor, rural populations. The government has launched programs to expand basic newborn care services, but more investment is still needed to bridge this gap and achieve national targets for reducing neonatal mortality rates, particularly in rural areas that still lack even basic newborn care services. Overall, neonatal intensive care has advanced in India but major inequities persist in access to lifesaving care for newborns.
Bind neuro neocon 2018 - Dr Karthik Nageshkarthiknagesh
This document discusses bilirubin-induced neurologic dysfunction (BIND) and chronic bilirubin encephalopathy. It covers the diagnosis and outcomes of these conditions, as well as prevention strategies. Some key points:
- BIND represents a spectrum of minor neurologic manifestations that can occur with moderate hyperbilirubinemia exposure. It includes subtle processing disorders, disturbances in visual-motor skills, and speech/language abnormalities.
- Risk factors for BIND/encephalopathy include prematurity, hemolysis, complications, and individual infant vulnerability. Diagnosis involves assessments of neuromotor signs, muscle tone, reflexes, and neurobehavior over time.
- Prevention strategies include promoting
Approaches to non invasive respiratory support in preterm - Dr Karthik Nageshkarthiknagesh
This document discusses various approaches to non-invasive respiratory support for preterm infants, including nasal continuous positive airway pressure (NCPAP), high-flow nasal cannula (HFNC), nasal intermittent mandatory ventilation (NIMV), and neurally adjusted ventilatory assist (NAVA). While non-invasive approaches can reduce the need for intubation and invasive ventilation, none have been shown to decrease the risk of bronchopulmonary dysplasia. The benefits and risks of each approach are described.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
Kosmoderma Academy, a leading institution in the field of dermatology and aesthetics, offers comprehensive courses in cosmetology and trichology. Our specialized courses on PRP (Hair), DR+Growth Factor, GFC, and Qr678 are designed to equip practitioners with advanced skills and knowledge to excel in hair restoration and growth treatments.
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
10 Benefits an EPCR Software should Bring to EMS Organizations Traumasoft LLC
The benefits of an ePCR solution should extend to the whole EMS organization, not just certain groups of people or certain departments. It should provide more than just a form for entering and a database for storing information. It should also include a workflow of how information is communicated, used and stored across the entire organization.
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
7. Problems With Invasive Ventilation
• Consequences of presence of endotracheal tube
– ↑infection/inflammation- VAP
– VILI
– Local trauma to trachea, larynx
• Subglottic stenosis
• Need for postnatal steroids
– Need for emergency reintubation
• Consequences of bypassing the larynx
– Loss of humidification
– Disruption of normal adaptive breathing
NIPPV reduces endotrauma, ADC F&N 2008
11. Chronic Lung Disease
Etiologic Associations
Predisposed Baby
•Immaturity
•Family History
•RDS
Severe Lung
Disease
•PDA
•Fluid Overload
•PIE
Contributory Factors
•Infection
•Surfactant
Abnormalities
•Disturbance of
Elastase/Protease
High Level of
Respiratory
Support
•Oxygen
Toxicity,
•Baro-
volutrauma
12. Lung Injury- VILI
Bland RD et al.
Am J Physiol Lung cell
Mol physiol’
Control lung After 24hrs of invasive ventilation
BPD
13. How does injury from MV occur?
• Volutrauma
• Too much stretch at maximum lung capacity
• Atelectotrauma
• Opening and closing of areas of lung at low
tidal volumes
• Both generate an inflammatory response
14. Capillary leak
A syndrome of
inflammation
Diffuse
alveolar
epithelial
damage
Breakdown of
endothelial
barrier
Interstitial
edema
Proteinaceous
alveolar
flooding
Type 2 cell
Apoptotic
Type 1 cell
Pathophysiology of Acute Lung Injury in HMD
Acute Lung Injury in
Preterms
Acute Lung Injury
23. Noninvasive ventilation/respiratory
support
Providing respiratory support with an
interface which is above the level of glottis
A bridge between autonomous breathing and
mechanical ventilation
Modes of respiratory support
CPAP
NIPPV
24. COIN* Trial
• 610 infants, 25 to 28 weeks
• Distress at 5 minutes of life
• CPAP or Ventilation
• Surfactant only if intubation and criteria for this
not pre-specified
• In CPAP group
– Only 46% required intubation in first 5 days
– Nearly 50% escaped surfactant
Early Rescue CPAP
*CPAP or Intubation and Ventilation without surfactant (CPAP
or Intubation (COIN Trial)) ,Morley CJ et al,2008
Grade A
25. CPAP is an alternative to intubation and surfactant in
preterm infants (Grade A)
• 1316 infants, 24 to 27 weeks
• CPAP vs. Intubation and
Surfactant at birth
• For CPAP group surfactant
was given
– If intubated at birth
– Failed CPAP i.e. FiO2>50%
Prophylactic CPAP
• In CPAP group
– 33% did not receive
surfactant
– 83% got intubated
– Lesser need for
ventilation in first 7
days
“SUPPORT” trial,NEJM,2010
26. Both SUPPORT and COIN trials support
CPAP alone a safe alternative to
intubation and surfactant
Primary outcome was Death or BPD
•Intubation rates of 83% and 46% Only
• 33% and 50% lesser need of surfactant
29. • Helps clear lung fluid at birth
• Helps establish and maintain lung aeration
• Improves oxygenation
• Conserves surfactant
• Decreases upper & lower airway resistance
• Improves the compliance of stiff lungs
• Regularises and slows respiratory rate
• Reduces apnoea
• Reduces lung injury and inflammation
• Reduces energy expenditure
• Reduces the need for ventilation
CPAP is a very effective respiratory support for
preterms…Proven!
30. EARLY CPAP IN RDS in babies breathing
spontaneously
• Improves FRC & lung volume
• Prevents progressive atelectasis
• Avoids need for intubation / ventilation
• Minimises volutrauma & lung injury
•Reduces need for tertiary transfer of babies with RDS
•The use of CPAP with early rescue surfactant should be
considered in babies with RDS in order to reduce need
for MV (A)
•Cochrane Systematic Review 2008 , European Guidelines,2007
31. Patient interfaces for CPAP
Hudson’s prongs
Bi-nasopharyngeal
prongs
Short bi-nasal
prongs
Argyle
prongs
Masks
CPAP Delivery
Systems
• Ventilator
CPAP
• Bubble CPAP
• Variable flow
CPAP
32. CPAP versus Intubation
Reduction of mechanical ventilation (MV) and
trends toward reduction in the incidence of
Bronchopulmonary Dysplasia (BPD).
Morley CJ, Davis PG, Doyle LW, Brion LP, Hascoet JM, Carlin JB; COIN Trial. N Engl J
Med. 2008;358(7):700–708
Finer NN, Carlo WA, Walsh MC, et al; SUPPORT Study Group. N Engl J Med.
2010; 362(21): 1970–1979
33. How does NIV work?
CPAP
• ↑FRC
• Stabilization of the
chest wall
• ↓in airway
resistance
• Improvement in lung
volume and
oxygenation
NIPPV
• ↑in MAP allowing
better recruitment
of alveoli
• ↓work of breathing
• ↑in Vt and minute
volume
• Improving the
respiratory drive
35. NIPPV- as primary mode
Study Inclusion Control group Outcome(s) in NIPPV
Santin et al’04 28-34 wks
gestation
SIMV ↓ Duration of O2
exposure
↓ Length of stay
**Bhandari et al’
07
600-1250 gms SIMV ↓ Death/BPD
Comparison with mechanical ventilation
Comparison with CPAP
Kugelman et al 07 < 34 wks CPAP
↓ need for intubation
(25% vs. 49%)
↓ BPD
(2% vs. 17%)
Grade A
Karthik Nagesh N. Editorial-
Neonatal intensive Care. Journal of Neonatology 2006, Volume : 20, Issue : 3.Online ISSN : 0973-2187.
Print ISSN : 0973-2179.
36. SURFACTANTs still needed...Inspite of
…ANS/DR-CPAP/INSURE/NIV/HHHFNC
• Surfactant replacement therapy has proven
effective in reducing mortality and pulmonary
morbidity, including pneumothorax
Seger N, Soll R. Animal derived surfactant extract for treatment of respiratory
distress syndrome. Cochrane Database Syst Rev. 2009;(2):CD007836
37. Surfactants
Synthetic
• Protein Free…Exosurf
• Protein
Containing…Surfaxin-
Lucinactant
Natural (Animal derived)
Bovine
• Minced Lung Extract…Survanta
(Beractant), Alveofact (Bovactant)
• Lung Lavage Extract…bLES*
Infasurf(Calfactant)
Porcine
Minced Lung Extract…Curosurf
(Poractant alfa)
Goat…NA (Trial is currently on in India)
*Neosurf
38. European Consensus Guidelines on the Management of
RDS – 2016 Update
Recommendations
• Babies with RDS should be given a natural
surfactant preparation(A)
• A policy of early rescue surfactant should be
standard(A)
• Poractant alfa in an initial dose of 200mg/kg is
better than 100mg/kg of poractant alfa or
beractant for rescue therapy(A)
39. IN-SU-RE
(1) Loading dose of caffeine citrate (20 mg/kg)
(2) Morphine (0.2 mg/kg) for analgesia
(3) Thiopental (2–5 mg/kg) for sedation
(4) Oral intubation
(5) Surfactant through the endotracheal tube
(6) Naloxone administration (0.1 mg/kg) just before
extubation
(7) MV until respiratory stability
(8) Extubation to CPAP
Bohlin K, Henckel E, Blennow M. International perspectives: Surfactant Without
Assisted Ventilation: the Scandinavian perspective. Neoreviews. 2008;9(12):e555–e561
40. IN-SU-RE
• Reduction in the need for further intubation
and MV has been reported….Advantage
• Need for premedication, secondary effects
such as hypotension, and the difficulty in
extubation for a substantial number of
infants….Disadvantage
Escobedo MB, Gunkel JH, Kennedy KA, et al; Texas Neonatal Research Group. Early surfactant for neonates with
mild to moderate respiratory distress syndrome: a multicenter, randomized trial. J Pediatr. 2004;144(6):804–808
Reininger A, Khalak R, Kendig JW, et al. Surfactant administration by transient intubation in infants 29 to 35 weeks’
gestation with respiratory distress syndrome decreases the likelihood of later mechanical ventilation: a randomized
controlled trial. J Perinatol. 2005;25(11):703–708
41. IN-SU-RE technique
Stevens et al. Cochrane 2007
Reduction in mechanical ventilation,
BPD, mortality
Always combine with early CPAP
Grade A
Grade A
42. Minimally Invasive Surfactant Therapy
• These techniques have included administration of
exogenous surfactant by
• Brief tracheal catheterization,
• Aerosolization, and laryngeal mask.
• Of these, the methods involving brief tracheal
catheterization have been most extensively studied,
with surfactant administered by using both a
flexible feeding tube and a semi-rigid vascular
catheter
43. STEPS IN MIST
Neonate with RDS on CPAP with FiO2 > 30-40%
Pre-medicate with Caffeine,
Optional: Atropine, Sucrose analgesia (Avoid narcotic analgesia)
Maintain nasal CPAP throughout with FiO2 adjusted as per pre-ductal
SpO2
Gastric feeding tube is inserted into the trachea with or without using
Magill forceps under direct laryngoscope vision
Surfactant ( 100- 200 mg/kg) is administered over 30-60 minutes with the
infant breathing spontaneously.
45. Less Invasive Surfactant Administration…The
Future
• Surfactant administration by minimally
invasive methods that allow for spontaneous
breathing might be safer and more effective
than administration with endotracheal
intubation and mechanical ventilation in
preterms ‘at risk’ or with RDS
American Academy of Pediatrics ,July 2014, VOLUME 15 / ISSUE
46. IMV – ‘Unsynchronised’
Ventilator Breaths
Baby’s Breaths
Synchronisation by Sedatives,Muscle relaxants.
Synchrony becomes a random event !!!
Ventilator Breaths
47. ‘Trigger’ signal sensors ( PTV)
• Abdominal
movements
• Thoracic
impedance
• Airway flow - Heated
wire anemometer
• Airway pressure
• GOOD Baby Brain
• GOOD Sensors
• GOOD Airway
48. S+IMV
• Inspiration of baby
synchronized to
ventilator breath
• Patient continues to
breath between
ventilator breaths
• Ventilator rate can be
fixed
Ventilator Breaths
Baby’s
Breaths
Baby’s Breaths
49. Assist/ Control Mode**
• All Baby breaths are
synchronized
• All spontaneous
efforts are detected
and assisted (Assist)
• Back up rate ensures
ventilation in apnoeic
baby (Control)
** Also called SIPPV
Baby’s Breaths
Ventilator Breaths
BUT expiration Asynchrony
51. Pressure Support Ventilation (PSV)
• Mimics spontaneous breath
• Vent. breath triggered by airway flow due to
patient’s effort
• Vent. breath terminated by reducn. in flow
• Hence patient has control on Ti and rate
• Only “pressure support” is provided
52. *Volume Guarantee ( VG )
• Set Tidal Volume ,
PEEP
–4-5 ml / kg
• PIP variable
and
depends on
lung compliance
• How does the
Ventilator measure
the volume ?
• By flow
• In expiration
*Volume Controlled Ventilation
53. Volume Targetted Ventilation
Uses Lesser PIP once
Lungs Improve
• Relatively constant Tidal
Volumes
• Prevention of
Overdistension and
Volume Trauma- Sudden
changes in Compliance
• Automatic-Weaning
• Compensation for
Variable Respiratory
Drive
Grade A ( Cochrane,2011)
54. VENTILATION STATERGY
• Ventilation strategy- As lung compliance changes rapidly during RDS and
its treatment, volume targeted ventilation appears to be
appropriate.
• Cochrane review reported 21% reduction in death/BPD for VTV
compared to pressure limited MV.*
• Cochrane review on elective use of HFOV soon after intubation
showed significant reduction in death/BPD at 36-37 weeks PMA
or discharge and in BPD alone.*
EARLY BPD
* Klingenberg C, Wheeler KI, McCallion N, et al. Volume-targeted versus pressure limited
ventilation in neonates. Cochrane Database Syst Rev 2017;10:CD003666.
*Cools F, Offringa M, Askie LM. Elective high frequency oscillatory ventilation versus
conventional ventilation for acute pulmonary dysfunction in preterm infants. Cochrane
Database Syst Rev 2015:CD000104
55. Synchronized Noninvasive Positive Pressure
Ventilation
• Neurally Adjusted Ventilatory Assist (NAVA), a
technique that utilizes the electrical activity of the
diaphragm to trigger mechanical breaths
• Has been shown to improve patient-ventilator
interaction and synchrony even in the presence of
large air leaks
56.
57. Which babies might benefit from HFOV?
• Elective HFOV
• Selective HFOV
• Rescue HFOV
If Conventional Ventilation Fails/Ineffective…Severe Air Leaks,PIE
58. Prevention of Lung Injury
• Don’t ventilate if you
can avoid it!
• Early CPAP
• IN-SU-RE
• Nasal Ventilation
• Caffeine
• Permissive
Hypercapnia
59. Journal of Neonatology,2015,July-Aug,In
Print
Guest Editorial
…“This last decade has shown enough
evidence that non invasive modalities like
nasal CPAP and NIV work even better in the
extremely preterm , with hardly any need for
intubation and ventilation except to
administer surfactant by the INSURE
protocol. Most of our care, as we now tend to
look after smaller and more preterm babies,
is focused on being ‘gentler’ in our
ventilation strategies to prevent lung injury
and chronic lung disease.”…
N. Karthik Nagesh,2015
KMC