High frequency oscillatory ventilation- BasicsHemraj Soni
High frequency oscillatory ventilation (HFOV) uses very high rates of small pressure variations around a constant distending pressure to ventilate the lungs. It relies on diffusion and other gas exchange mechanisms rather than conventional tidal volumes. HFOV is only used as a rescue therapy for failure of conventional ventilation in term or preterm infants with conditions like PPHN or MAS. Settings are adjusted based on oxygenation and ventilation, with the goal of maximizing lung volume while avoiding overinflation and trauma.
This presentation deals with the basic physics of human ventillation. I have made an effort to clarify most of the venti lingo , so as to make way for further discussions on ventilator use. Hope it turns out to be helpful for you. Thank you.
NIV, or non-invasive ventilation, is a form of ventilation therapy that is applied non-invasively through a mask rather than an endotracheal tube. It is commonly used to treat conditions like COPD exacerbations, pulmonary edema, and respiratory failure. Key settings that must be adjusted include IPAP, EPAP, Ti min/max, trigger sensitivity, and backup rate. Modes include spontaneous, timed, and bi-level positive airway pressure. Proper mask fitting and troubleshooting issues like leaks are important for ensuring effective ventilation. Regular monitoring of parameters like ABGs, SpO2, and ventilation is needed to optimize NIV therapy.
This document discusses the relationship between heart and lung function and the interaction between intrathoracic pressures, lung volumes, and blood flow. It begins by explaining that the cardiovascular and pulmonary systems function to link metabolizing cells to oxygen sources. It then discusses how intrathoracic and intramural pressures impact blood flow through collapsible tubes based on principles of fluid dynamics. Changes in surrounding pressures, such as pleural or pericardial pressure, can impact lung volumes, cardiac preload and afterload, and venous return. Understanding these complex interactions is important for critical care.
This document provides an overview of mechanical ventilation including definitions, modes, settings, and management. It discusses non-invasive ventilation techniques like CPAP and BiPAP as well as various modes of invasive ventilation such as CMV, SIMV, and pressure support. Key variables, advantages, and disadvantages of different modes are explained. Graphs are presented to illustrate concepts like PEEP, auto-PEEP, and the relationship between pressure and volume ventilation. Management considerations for various disease states are also covered.
Basic concepts in neonatal ventilation - Safe ventilation of neonatemohamed osama hussein
Lecture by by dr Muhammad Ezzat Abdel-Shafy MB.BCh, M.Sc Pediatrics Neonatology Sp. , Benha Children Hospital, provided during our Doctors neonatology workshop, 20th of January 2017
Mechanical ventilation graphics provide important information to interpret patient response, disease status, and ventilator function. Scalars plot pressure, volume, or flow over time, while loops plot pressure versus volume or flow versus volume with no time component. Common waveforms include square, ramp, and sine waves. Pressure modes result in square pressure waves while volume modes produce ramp waves. Loops can indicate breath type and assess issues like air trapping, resistance, compliance, and asynchrony. Graphical analysis is a critical tool for ventilator management and optimization.
1) Ventilator graphics display waveforms that facilitate assessment of a patient's condition on mechanical ventilation. The most commonly used graphics are scalars (flow vs time, pressure vs time, volume vs time) and loops (pressure-volume, flow-volume).
2) Scalar graphics show the relationship between flow, volume, or pressure over time. Loops show the relationship between pressure and volume or flow and volume. These graphics provide information about ventilator settings, lung mechanics, and the identification of common issues like airway obstruction or air trapping.
3) Proper analysis of ventilator graphics is essential for optimizing ventilator settings and recognizing abnormalities that may require intervention to improve a patient's ventilation
High frequency oscillatory ventilation- BasicsHemraj Soni
High frequency oscillatory ventilation (HFOV) uses very high rates of small pressure variations around a constant distending pressure to ventilate the lungs. It relies on diffusion and other gas exchange mechanisms rather than conventional tidal volumes. HFOV is only used as a rescue therapy for failure of conventional ventilation in term or preterm infants with conditions like PPHN or MAS. Settings are adjusted based on oxygenation and ventilation, with the goal of maximizing lung volume while avoiding overinflation and trauma.
This presentation deals with the basic physics of human ventillation. I have made an effort to clarify most of the venti lingo , so as to make way for further discussions on ventilator use. Hope it turns out to be helpful for you. Thank you.
NIV, or non-invasive ventilation, is a form of ventilation therapy that is applied non-invasively through a mask rather than an endotracheal tube. It is commonly used to treat conditions like COPD exacerbations, pulmonary edema, and respiratory failure. Key settings that must be adjusted include IPAP, EPAP, Ti min/max, trigger sensitivity, and backup rate. Modes include spontaneous, timed, and bi-level positive airway pressure. Proper mask fitting and troubleshooting issues like leaks are important for ensuring effective ventilation. Regular monitoring of parameters like ABGs, SpO2, and ventilation is needed to optimize NIV therapy.
This document discusses the relationship between heart and lung function and the interaction between intrathoracic pressures, lung volumes, and blood flow. It begins by explaining that the cardiovascular and pulmonary systems function to link metabolizing cells to oxygen sources. It then discusses how intrathoracic and intramural pressures impact blood flow through collapsible tubes based on principles of fluid dynamics. Changes in surrounding pressures, such as pleural or pericardial pressure, can impact lung volumes, cardiac preload and afterload, and venous return. Understanding these complex interactions is important for critical care.
This document provides an overview of mechanical ventilation including definitions, modes, settings, and management. It discusses non-invasive ventilation techniques like CPAP and BiPAP as well as various modes of invasive ventilation such as CMV, SIMV, and pressure support. Key variables, advantages, and disadvantages of different modes are explained. Graphs are presented to illustrate concepts like PEEP, auto-PEEP, and the relationship between pressure and volume ventilation. Management considerations for various disease states are also covered.
Basic concepts in neonatal ventilation - Safe ventilation of neonatemohamed osama hussein
Lecture by by dr Muhammad Ezzat Abdel-Shafy MB.BCh, M.Sc Pediatrics Neonatology Sp. , Benha Children Hospital, provided during our Doctors neonatology workshop, 20th of January 2017
Mechanical ventilation graphics provide important information to interpret patient response, disease status, and ventilator function. Scalars plot pressure, volume, or flow over time, while loops plot pressure versus volume or flow versus volume with no time component. Common waveforms include square, ramp, and sine waves. Pressure modes result in square pressure waves while volume modes produce ramp waves. Loops can indicate breath type and assess issues like air trapping, resistance, compliance, and asynchrony. Graphical analysis is a critical tool for ventilator management and optimization.
1) Ventilator graphics display waveforms that facilitate assessment of a patient's condition on mechanical ventilation. The most commonly used graphics are scalars (flow vs time, pressure vs time, volume vs time) and loops (pressure-volume, flow-volume).
2) Scalar graphics show the relationship between flow, volume, or pressure over time. Loops show the relationship between pressure and volume or flow and volume. These graphics provide information about ventilator settings, lung mechanics, and the identification of common issues like airway obstruction or air trapping.
3) Proper analysis of ventilator graphics is essential for optimizing ventilator settings and recognizing abnormalities that may require intervention to improve a patient's ventilation
High frequency oscillatory ventilation (HFOV) is a type of mechanical ventilation that uses a constant distending pressure (mean airway pressure [MAP]) with pressure variations oscillating around the MAP at very high rates (up to 900 cycles per minute). This creates small tidal volumes, often less than the dead space.
Mechanical ventilation Basics and waveformsHardeep Jogi
This document defines key terms and concepts related to mechanical ventilation. It discusses pressures such as airway opening pressure, intrapleural pressure, transpulmonary pressure, and others. It also describes lung characteristics like compliance and resistance. The document outlines the basics of negative and positive pressure ventilation. It discusses variables that control the ventilator cycle, including triggers, limits, and cycles. Finally, it examines various waveforms produced by mechanical ventilation like pressure/time scalars and esophageal pressure curves.
This document provides an overview of mechanical ventilation, including:
1) How mechanical ventilation helps reduce the work of breathing and restore gas exchange through invasive and noninvasive positive pressure ventilation.
2) The basics of monitoring pressure, volume, flow, and pressure-time curves at the bedside.
3) Important considerations for mechanical ventilation including potential adverse effects on hemodynamics, lungs, and gas exchange.
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 of ventilator settings and their clinical application. It begins with the objectives and provides background on pulmonary physiology including lung volumes, compliance, resistance, and time constants. It then covers types of respiratory failure and diseases that impact compliance and resistance. The remainder focuses on ventilator settings like FiO2, PIP, PEEP, rate, Ti/Te ratio, flow and their significance. Manipulations to optimize oxygenation and CO2 elimination are discussed along with the advantages and disadvantages of increasing various settings. The goal of assisted ventilation is to achieve adequate oxygenation and CO2 elimination while minimizing risks of barotrauma.
1. High frequency ventilation (HFV) uses small tidal volumes and high respiratory rates to ventilate patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). HFV aims to recruit and protect the injured lung better than conventional mechanical ventilation (CMV).
2. Two main types of HFV are high frequency oscillatory ventilation (HFOV) and high frequency jet ventilation (HFJV). HFOV uses a piston to displace gas at 180-900 breaths per minute, while HFJV uses gas jets at 240-480 bpm.
3. Early intervention with HFV may improve outcomes compared to using it as a rescue therapy after prolonged CMV fails. Matching the
Non-invasive ventilation (NIV) delivers ventilatory support through a mask without using an invasive tracheal tube. The document discusses the history and development of NIV, benefits in pediatric patients, indications, contraindications, modes, and key points for successful use of NIV. It provides details on using NIV to treat acute hypoxemic and chronic hypercapnic respiratory failures in children. Close monitoring and criteria for escalating to invasive ventilation if NIV fails are also reviewed.
Mechanical Ventilation in COPD Lecture presented by Dr Lluis Blanch at Venti Cairo Mechanical Ventilation Course held on 14-15 November at Cairo, Egypt.
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.
Placental respiratory gas exchange and fetal oxygenationmaricar chua
This document summarizes oxygen transport from the atmosphere to fetal tissues. It describes how oxygen diffuses across membranes in the lungs, placenta, and fetal tissues. While fetal oxygen levels are lower than maternal levels, high fetal cardiac output and blood flow to organs maintains oxygen delivery. The placenta facilitates gas exchange through a villous tree structure that increases surface area from stem to terminal villi. Fetal growth restriction is associated with a smaller, less developed placenta and lower umbilical oxygen levels. In response to acute hypoxia, the fetus redistributes blood flow to favor the brain and heart. Though oxygen therapy increases maternal oxygen levels, there is a smaller corresponding increase in fetal oxygen levels due to the placent
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.
Mechanical ventilation in neonates by dr naved akhterDr Naved Akhter
Mechanical ventilation is used to support gas exchange and clinical status in neonates. The goals are to maintain sufficient oxygenation and ventilation until the underlying disease resolves, while protecting the lungs from damage. Modes of ventilation include mandatory, SIMV, assist/control, and pressure support. Parameters like tidal volume, PIP, PEEP, and FiO2 are adjusted based on blood gas levels to optimize oxygenation and ventilation. Ventilator graphics and pulmonary monitoring are used to assess patient-ventilator interaction and guide management.
Non-Invasive Ventilation for Preterm InfantsMark Weems
This document discusses non-invasive ventilation techniques for preterm infants. It begins with a brief history of ventilation methods, including early attempts at non-invasive oxygen delivery and invasive techniques like intubation that introduced complications. More recent non-invasive methods described include high-flow nasal cannula (HFNC), nasal continuous positive airway pressure (NCPAP), and non-invasive positive pressure ventilation (NIPPV). Several studies comparing these techniques are summarized, finding that NCPAP and well-designed NIPPV protocols can reduce the need for intubation and the risk of bronchopulmonary dysplasia compared to early intubation and ventilation. Precise delivery of pressures using the Ram Cannula interface is also discussed.
The document discusses basic principles of mechanical ventilation including factors that can lead to ventilatory failure, airway resistance, lung compliance, hypoventilation, V/Q mismatch, intrapulmonary shunting, and diffusion defects. It also covers different types of ventilator waveforms including pressure, volume, flow and pressure/volume loops which can be used to assess a patient's respiratory status and response to therapy.
This document discusses mechanical ventilation waveforms. It begins by stating the objectives are to discuss commonly used waveforms, their applications, and combined waveforms. It then provides an outline and introduction on waveforms and how they represent ventilator data graphically over time or against each other. The majority of the document discusses specific commonly used waveforms including pressure-time, flow-time, and volume-time curves and how to interpret each to evaluate the patient and ventilator settings.
Recruitment Maneuvers in ARDS Dr Chennamchetty Vijay KumarVizae Kumar Chennam
This document discusses recruitment maneuvers for mechanically ventilated patients. It begins with a case study of a patient presenting with respiratory failure. It then provides definitions and the physiological rationale for recruitment maneuvers, including how alveolar collapse occurs in ARDS. Different types of recruitment maneuvers are described, as well as factors that influence their effectiveness. Clinical trials on recruitment maneuvers are summarized, which found no significant reduction in mortality but some improvement in secondary outcomes. Limitations of recruitment maneuvers are discussed, such as potential hemodynamic effects. The document concludes with emphasizing the complexity of lung recruitment and ongoing controversies regarding recruitment maneuvers.
This document discusses pediatric ventilation basics including anatomy, physiology, pathophysiology, and terminology. Key points include: the pediatric airway is smaller and more anteriorly placed; children have higher oxygen needs and lower tolerance for hypoxia; compliance is lower in children; and ventilator settings like tidal volume, rate, inspiratory time, and PEEP must be adjusted for pediatric patients. Common pediatric lung conditions and how they impact pulmonary function tests and the ventilation/perfusion ratio are also reviewed.
The document discusses the history and techniques of assisted ventilation. It begins by describing early negative pressure devices like the Spirophore and Iron Lung. It then covers developments in positive pressure ventilation including early devices from the 1700s-1800s and discusses key aspects of applying ventilation support to neonates including: applied pulmonary mechanics regarding compliance and resistance, optimizing gas exchange through adjustments to factors like peak pressure, PEEP, and flow; ventilator management strategies; and practical hints for initial settings and weaning.
El documento describe brevemente la historia del tratamiento con CPAP en neonatología, sus principios fisiológicos y aplicación clínica. Explica que el CPAP mantiene abiertas las vías respiratorias aplicando presión positiva continua, mejorando la oxigenación y preveniendo el colapso pulmonar. Finalmente, resume las indicaciones, aplicación y complicaciones potenciales del tratamiento con CPAP nasal en recién nacidos.
High frequency oscillatory ventilation (HFOV) is a type of mechanical ventilation that uses a constant distending pressure (mean airway pressure [MAP]) with pressure variations oscillating around the MAP at very high rates (up to 900 cycles per minute). This creates small tidal volumes, often less than the dead space.
Mechanical ventilation Basics and waveformsHardeep Jogi
This document defines key terms and concepts related to mechanical ventilation. It discusses pressures such as airway opening pressure, intrapleural pressure, transpulmonary pressure, and others. It also describes lung characteristics like compliance and resistance. The document outlines the basics of negative and positive pressure ventilation. It discusses variables that control the ventilator cycle, including triggers, limits, and cycles. Finally, it examines various waveforms produced by mechanical ventilation like pressure/time scalars and esophageal pressure curves.
This document provides an overview of mechanical ventilation, including:
1) How mechanical ventilation helps reduce the work of breathing and restore gas exchange through invasive and noninvasive positive pressure ventilation.
2) The basics of monitoring pressure, volume, flow, and pressure-time curves at the bedside.
3) Important considerations for mechanical ventilation including potential adverse effects on hemodynamics, lungs, and gas exchange.
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 of ventilator settings and their clinical application. It begins with the objectives and provides background on pulmonary physiology including lung volumes, compliance, resistance, and time constants. It then covers types of respiratory failure and diseases that impact compliance and resistance. The remainder focuses on ventilator settings like FiO2, PIP, PEEP, rate, Ti/Te ratio, flow and their significance. Manipulations to optimize oxygenation and CO2 elimination are discussed along with the advantages and disadvantages of increasing various settings. The goal of assisted ventilation is to achieve adequate oxygenation and CO2 elimination while minimizing risks of barotrauma.
1. High frequency ventilation (HFV) uses small tidal volumes and high respiratory rates to ventilate patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). HFV aims to recruit and protect the injured lung better than conventional mechanical ventilation (CMV).
2. Two main types of HFV are high frequency oscillatory ventilation (HFOV) and high frequency jet ventilation (HFJV). HFOV uses a piston to displace gas at 180-900 breaths per minute, while HFJV uses gas jets at 240-480 bpm.
3. Early intervention with HFV may improve outcomes compared to using it as a rescue therapy after prolonged CMV fails. Matching the
Non-invasive ventilation (NIV) delivers ventilatory support through a mask without using an invasive tracheal tube. The document discusses the history and development of NIV, benefits in pediatric patients, indications, contraindications, modes, and key points for successful use of NIV. It provides details on using NIV to treat acute hypoxemic and chronic hypercapnic respiratory failures in children. Close monitoring and criteria for escalating to invasive ventilation if NIV fails are also reviewed.
Mechanical Ventilation in COPD Lecture presented by Dr Lluis Blanch at Venti Cairo Mechanical Ventilation Course held on 14-15 November at Cairo, Egypt.
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.
Placental respiratory gas exchange and fetal oxygenationmaricar chua
This document summarizes oxygen transport from the atmosphere to fetal tissues. It describes how oxygen diffuses across membranes in the lungs, placenta, and fetal tissues. While fetal oxygen levels are lower than maternal levels, high fetal cardiac output and blood flow to organs maintains oxygen delivery. The placenta facilitates gas exchange through a villous tree structure that increases surface area from stem to terminal villi. Fetal growth restriction is associated with a smaller, less developed placenta and lower umbilical oxygen levels. In response to acute hypoxia, the fetus redistributes blood flow to favor the brain and heart. Though oxygen therapy increases maternal oxygen levels, there is a smaller corresponding increase in fetal oxygen levels due to the placent
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.
Mechanical ventilation in neonates by dr naved akhterDr Naved Akhter
Mechanical ventilation is used to support gas exchange and clinical status in neonates. The goals are to maintain sufficient oxygenation and ventilation until the underlying disease resolves, while protecting the lungs from damage. Modes of ventilation include mandatory, SIMV, assist/control, and pressure support. Parameters like tidal volume, PIP, PEEP, and FiO2 are adjusted based on blood gas levels to optimize oxygenation and ventilation. Ventilator graphics and pulmonary monitoring are used to assess patient-ventilator interaction and guide management.
Non-Invasive Ventilation for Preterm InfantsMark Weems
This document discusses non-invasive ventilation techniques for preterm infants. It begins with a brief history of ventilation methods, including early attempts at non-invasive oxygen delivery and invasive techniques like intubation that introduced complications. More recent non-invasive methods described include high-flow nasal cannula (HFNC), nasal continuous positive airway pressure (NCPAP), and non-invasive positive pressure ventilation (NIPPV). Several studies comparing these techniques are summarized, finding that NCPAP and well-designed NIPPV protocols can reduce the need for intubation and the risk of bronchopulmonary dysplasia compared to early intubation and ventilation. Precise delivery of pressures using the Ram Cannula interface is also discussed.
The document discusses basic principles of mechanical ventilation including factors that can lead to ventilatory failure, airway resistance, lung compliance, hypoventilation, V/Q mismatch, intrapulmonary shunting, and diffusion defects. It also covers different types of ventilator waveforms including pressure, volume, flow and pressure/volume loops which can be used to assess a patient's respiratory status and response to therapy.
This document discusses mechanical ventilation waveforms. It begins by stating the objectives are to discuss commonly used waveforms, their applications, and combined waveforms. It then provides an outline and introduction on waveforms and how they represent ventilator data graphically over time or against each other. The majority of the document discusses specific commonly used waveforms including pressure-time, flow-time, and volume-time curves and how to interpret each to evaluate the patient and ventilator settings.
Recruitment Maneuvers in ARDS Dr Chennamchetty Vijay KumarVizae Kumar Chennam
This document discusses recruitment maneuvers for mechanically ventilated patients. It begins with a case study of a patient presenting with respiratory failure. It then provides definitions and the physiological rationale for recruitment maneuvers, including how alveolar collapse occurs in ARDS. Different types of recruitment maneuvers are described, as well as factors that influence their effectiveness. Clinical trials on recruitment maneuvers are summarized, which found no significant reduction in mortality but some improvement in secondary outcomes. Limitations of recruitment maneuvers are discussed, such as potential hemodynamic effects. The document concludes with emphasizing the complexity of lung recruitment and ongoing controversies regarding recruitment maneuvers.
This document discusses pediatric ventilation basics including anatomy, physiology, pathophysiology, and terminology. Key points include: the pediatric airway is smaller and more anteriorly placed; children have higher oxygen needs and lower tolerance for hypoxia; compliance is lower in children; and ventilator settings like tidal volume, rate, inspiratory time, and PEEP must be adjusted for pediatric patients. Common pediatric lung conditions and how they impact pulmonary function tests and the ventilation/perfusion ratio are also reviewed.
The document discusses the history and techniques of assisted ventilation. It begins by describing early negative pressure devices like the Spirophore and Iron Lung. It then covers developments in positive pressure ventilation including early devices from the 1700s-1800s and discusses key aspects of applying ventilation support to neonates including: applied pulmonary mechanics regarding compliance and resistance, optimizing gas exchange through adjustments to factors like peak pressure, PEEP, and flow; ventilator management strategies; and practical hints for initial settings and weaning.
El documento describe brevemente la historia del tratamiento con CPAP en neonatología, sus principios fisiológicos y aplicación clínica. Explica que el CPAP mantiene abiertas las vías respiratorias aplicando presión positiva continua, mejorando la oxigenación y preveniendo el colapso pulmonar. Finalmente, resume las indicaciones, aplicación y complicaciones potenciales del tratamiento con CPAP nasal en recién nacidos.
The document discusses the basics of neonatal ventilation. It explains that ventilation is used to provide oxygenation, remove carbon dioxide, and assist breathing in neonates. Key parameters discussed include peak inspiratory pressure, positive end expiratory pressure, compliance, resistance, tidal volume, and minute volume. Different modes of ventilation are also summarized, including their advantages and limitations. The importance of synchronization between the ventilator and patient's breathing is emphasized to reduce work of breathing and other complications.
Швейцарсько-українська програма «Здоров'я матері та дитини»: Огляд історії пр...MCH-org-ua
Презентація Мартіна Рааба на Національній підсумковій конференції за результатами впровадження Програми (Київ, 23 квітня 2015 р.)
http://motherandchild.org.ua/ukr/event/768
Monitoring: approaches, achievements and perspectivesMCH-org-ua
Presentation at the National Capitalization conference of the Swiss-Ukrainian Mother and Child Health Programme (Kyiv, Ukraine, April 23, 2015)
http://motherandchild.org.ua/eng/event/768
Використання симуляційних технологій для розробки електронних навчальних модулівMCH-org-ua
Володимир Краснов. Доповідь на Міжнародній конференції «Симуляційне навчання в медицині» (Київ, 19-20 березня 2015 р.)
http://motherandchild.org.ua/ukr/SimConf-2015
Моніторинг: підходи, досягнення та перспективиMCH-org-ua
Презентація на Національній підсумковій конференції за результатами впровадження україно-швейцарської Програми "Здоров’я матері та дитини" (Київ, 23 квітня 2015 р.)
http://motherandchild.org.ua/ukr/event/768
Підготовка медичних кадрів для закладів перинатальної допомогиMCH-org-ua
Доповідь на міжнародній конференції «Сучасні підходи до виходжування глибоконедоношених дітей» (Київ, 5-6 березня 2013 р.)
http://motherandchild.org.ua/ukr/event/307
eHealth (електронна охорона здоров’я) та медичні інформаційні системи MCH-org-ua
Презентація на Національній підсумковій конференції за результатами впровадження україно-швейцарської Програми "Здоров’я матері та дитини" (Київ, 23 квітня 2015 р.)
http://motherandchild.org.ua/ukr/event/768
Тренінги з ведення акушерських невідкладних ситуацій та їх значення для робот...MCH-org-ua
Martina Gisin. Доповідь на Міжнародній конференції «Симуляційне навчання в медицині» (Київ, 19-20 березня 2015 р.)
http://motherandchild.org.ua/ukr/SimConf-2015
Tips and pitfalls of setting up a simulation centerMCH-org-ua
This document provides tips and potential pitfalls for setting up a simulation center. It discusses defining the mission, vision, and functional needs such as the type of training and target groups. Key considerations include the types of rooms needed like clinical simulation rooms, control rooms, and debriefing rooms. Equipment needs from medical supplies and manikins to audiovisual systems must be carefully planned. A multidisciplinary project team should be assembled and a budget developed that acknowledges the high costs of establishing and maintaining a simulation center. Common mistakes involve inadequate storage, furniture, and faculty training programs.
Внесок Програми у систему безперервної медичної освіти в УкраїніMCH-org-ua
Презентація на Національній підсумковій конференції за результатами впровадження україно-швейцарської Програми "Здоров’я матері та дитини" (Київ, 23 квітня 2015 р.)
http://motherandchild.org.ua/ukr/event/768
Новаторські підходи до навчання медичних працівників та адміністраторів закла...MCH-org-ua
Презентація на Національній підсумковій конференції за результатами впровадження україно-швейцарської Програми "Здоров’я матері та дитини" (Київ, 23 квітня 2015 р.)
http://motherandchild.org.ua/ukr/event/768
Recent Advances in NIV
1) Non-invasive positive pressure ventilation (NIPPV) can effectively treat acute respiratory failure without the need for intubation in conditions like COPD, obesity, and neuromuscular diseases.
2) Different interfaces like facial masks, nasal masks, and helmets can be used for NIPPV, with nasal masks generally better tolerated than other options.
3) NIPPV reduces mortality and need for intubation compared to standard oxygen therapy alone in acute exacerbations of COPD and cardiogenic pulmonary edema.
4) Factors like pH, comorbidities, respiratory rate and effort predict success or failure of NIPPV. Close monitoring is needed in cases with higher
Neuroprotection in preterm infants: hope or utopy?MCH-org-ua
International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)
seminar on hfv - high frequency ventilation dr saimaDr. Habibur Rahim
This document summarizes a seminar on high frequency ventilation (HFV). It includes two case scenarios and outlines the history, types, mechanisms, settings, monitoring, and strategies for different lung diseases when using HFV. HFV uses small tidal volumes and high rates to prevent lung injury from mechanical ventilation. It aims to operate in the "safe window" between overdistension and collapse. Settings like mean airway pressure, amplitude, and frequency are adjusted based on goals of lung recruitment and avoidance of barotrauma. Complications can include irritation, hemodynamic effects, air trapping, and overinflation.
Weaning and Extubation: A Pediatric Prespective Dr.Mahmoud Abbas
This document discusses weaning and extubation in pediatrics. It defines weaning as transitioning from ventilatory support to spontaneous breathing, and extubation as separating a patient from their ventilator. Successful weaning and extubation means maintaining effective gas exchange without mechanical support. Factors that indicate readiness for weaning include improving underlying conditions, adequate gas exchange, no undue burden on respiratory muscles, and the ability to sustain spontaneous ventilation as support decreases. Spontaneous breathing trials can assess readiness for extubation. Protocols for weaning and criteria for extubation can help optimize outcomes in pediatrics.
Pulmonary hypertension in neonates (PPHN) occurs when the fetal circulation pattern persists after birth, causing right-to-left shunting of blood and hypoxemia. It has a mortality rate of over 50% without ECMO treatment. Current management involves optimizing oxygenation through various ventilation strategies like hyperventilation, high frequency ventilation, inhaled nitric oxide, and ECMO. While outcomes have improved, PPHN still carries risks of mortality and long-term morbidity so careful monitoring and a multimodal approach are important.
The document discusses various topics related to mechanical ventilation including:
1. Ventilation strategies for acute respiratory distress syndrome (ARDS) including low tidal volumes, optimal positive end-expiratory pressure, and prone positioning.
2. Ventilation modes and settings should be tailored to the individual patient's condition and aim to prevent ventilator-induced lung injury.
3. Non-invasive ventilation can be considered for certain patients with COPD or asthma to avoid intubation if criteria are met.
Ventilatory support in special situations balamugeshDang Thanh Tuan
This document summarizes ventilation strategies for different clinical situations including ARDS, COPD, asthma, and bronchopleural fistula. It discusses ventilator settings such as tidal volume, PEEP, FiO2 and prone positioning that are recommended for ARDS. Non-invasive ventilation options for COPD and asthma exacerbations are also reviewed. Intubation criteria and strategies to deliver aerosol treatments during mechanical ventilation are provided. Managing air leak through bronchopleural fistula with techniques like differential lung ventilation or chest tube use is outlined.
Presented by Dr.Nial Ferguson at Pulmonary Medicine Update Course held at Cairo, Egypt. Pulmonary Medicine Update Course is the leading Pulmonary Critical Care event in Egypt. Organized by Scribe www.scribeofegypt.com
This document provides information on two case scenarios involving neonatal respiratory distress. Case 1 involves a very preterm infant with respiratory distress syndrome requiring mechanical ventilation. The infant has persistent respiratory distress and acidosis despite conventional ventilation settings. Case 2 involves an infant with congenital diaphragmatic hernia exhibiting respiratory distress at birth. The document then provides an overview of high frequency ventilation including its mechanisms, indications, settings, monitoring and complications. Evidence is presented from a randomized controlled trial showing a benefit of high frequency oscillatory ventilation over conventional ventilation for very preterm infants.
This document discusses various adjunctive treatments for acute respiratory distress syndrome (ARDS). It covers ventilatory strategies beyond lung protective ventilation including prone positioning, liquid ventilation, high frequency ventilation, and extracorporeal membrane oxygenation. It also discusses hemodynamic management including fluids and vasopressors. Selective pulmonary vasodilators, surfactant replacement therapy, anti-inflammatory strategies, antioxidants, and anticoagulants are mentioned as potential adjunct treatments for ARDS. Prone positioning is described in more detail as one strategy that can improve oxygenation in ARDS patients.
Respiratory distress is common in preterm infants and can have serious consequences. It is defined as the presence of tachypnea, retractions, or grunting. Common causes include respiratory distress syndrome (RDS) due to surfactant deficiency. Assessment involves evaluating respiratory rate, work of breathing, oxygen needs and chest x-ray findings. Management consists of supportive care including oxygen supplementation, monitoring, antibiotics if indicated. Surfactant replacement therapy improves outcomes in RDS but can increase risk of apnea. Non-invasive respiratory support with CPAP is preferred over mechanical ventilation when possible.
High frequency ventilation (HFV) uses very high rates of breathing (2.5-15 Hz) combined with low tidal volumes (0.5-5 ml/kg). There are several types of HFV including high frequency oscillatory ventilation and high frequency jet ventilation. HFV works through mechanisms like convection, pendelluft effect, and molecular diffusion to improve gas exchange with small tidal volumes. It allows adequate gas exchange and oxygenation using lower airway pressures, reducing the risk of lung injury. Settings like mean airway pressure, amplitude, and frequency are adjusted based on the patient's oxygenation and ventilation needs. HFV is effective for various lung conditions but requires careful monitoring to optimize outcomes.
Lung protective strategies,2019 - Dr Karthik Nageshkarthiknagesh
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.
This document discusses respiratory physiology in infants and children compared to adults. Some key points:
1) Infants have higher lung compliance and lower chest wall compliance than adults, making them more susceptible to reductions in functional residual capacity under anesthesia. Positive end-expiratory pressure is important to prevent atelectasis.
2) Ventilatory responses to hypoxemia and hypercapnia are blunted in infants compared to adults. General anesthesia can further depress these responses.
3) Infants rely more on active expiration mechanisms like laryngeal braking and diaphragmatic activity to maintain functional residual capacity versus passive mechanisms in adults.
4) Airway resistance is higher in infants due to smaller airway diameter
This document provides information on basic mechanical ventilation. It discusses various indications for mechanical ventilation including conditions like pneumonia, ARDS, pulmonary edema, and neuromuscular disorders. It then describes the basic components and functions of a mechanical ventilator including volume change, time, gas flow, and pressure difference. Key parameters like compliance, PEEP, and I:E ratio that are important for mechanical ventilation are explained. Different ventilator modes are outlined including pressure control, volume control, SIMV, and PSV. Settings like tidal volume, pressure, and respiratory rate that should be optimized are also reviewed.
High frequency ventilation ppt dr vinit patelVINIT PATEL
HIGH FREQUENCY VENTILATOR FOR NEONATES
NEONATAL VENTILATOR
PPHN,MECHANICAL VENTILATION,ADVANCE VENTILATION,NITRIC OXIDE,SLE 5000,SENSOR MEDICS
DR VINIT PATEL
This document discusses factors to consider when removing a patient from mechanical ventilation (weaning). It outlines criteria to assess patient readiness, including respiratory function, oxygenation, hemodynamics, neurological status, secretions and comorbidities. Complications of failed weaning are also described. Key considerations involve addressing sedation, electrolyte imbalances, infection/inflammation and optimizing cardiac, nutritional and acid-base status.
1. The patient has been on mechanical ventilation for 14 days following surgery and is now being considered for weaning and extubation.
2. However, he remains sedated and is difficult to arouse, which will impair his respiratory drive and ability to protect his airway.
3. Additionally, he has edema in his lower limbs and abdomen which may interfere with ventilation and the ability to wean from the ventilator. Gradual reduction of sedation and careful monitoring will be needed.
This document provides information on Acute Respiratory Distress Syndrome (ARDS), including its history, definitions, pathophysiology, management, and related concepts like ventilator-induced lung injury. Some key points:
- ARDS was first described in 1967 and its definition has evolved, with the most widely used being the Berlin Definition from 2012.
- It is characterized by diffuse pulmonary edema and inflammation due to direct lung injury or indirect causes like sepsis.
- Management focuses on treating the underlying cause, protective lung ventilation with low tidal volumes, permissive hypercapnia, prone positioning, and recruitment maneuvers.
- Adjunctive techniques aim to prevent ventilator-induced lung injury from
Acute Respiratory Distress Syndrome (ARDS) is a life-threatening lung condition caused by injury to the lungs. It can develop rapidly and cause inflammation and fluid buildup in the lungs. The key points are:
- ARDS was first described in 1967 and definitions have evolved over time to improve diagnosis. The Berlin Definition from 2012 is currently used.
- Common causes include pneumonia, aspiration, trauma, sepsis, and multiple transfusions. The condition progresses through exudative, proliferative, and fibrotic phases as the lungs attempt to heal.
- Management focuses on treating the underlying cause, protective lung ventilation with low tidal volumes, permissive hypercapnia, prone positioning, and fluid restriction
Similar to Nonivasive Respiratory Support - NIV, High Frequency Ventilation - HFV (20)
Presentation by Andrei Romancenco at the International conference on Simulation-based training in medicine (Kyiv, Ukraine, March 19-20, 2015)
http://motherandchild.org.ua/eng/SimConf-2015
Система впровадження та реалізації симуляційного навчання в Одеському націона...MCH-org-ua
Володимир Артьоменко. Доповідь на Міжнародній конференції «Симуляційне навчання в медицині» (Київ, 19-20 березня 2015 р.)
http://motherandchild.org.ua/ukr/SimConf-2015
Стандартизація медичних практик в акушерстві та неонатологіїMCH-org-ua
Презентація на Національній підсумковій конференції за результатами впровадження україно-швейцарської Програми "Здоров’я матері та дитини" (Київ, 23 квітня 2015 р.)
http://motherandchild.org.ua/ukr/event/768
Telemedicine and electronic inventory: experience of the regionsMCH-org-ua
Presentation at the National Capitalization conference of the Swiss-Ukrainian Mother and Child Health Programme (Kyiv, Ukraine, April 23, 2015)
http://motherandchild.org.ua/eng/event/768
Presentation at the National Capitalization conference of the Swiss-Ukrainian Mother and Child Health Programme (Kyiv, Ukraine, April 23, 2015)
http://motherandchild.org.ua/eng/event/768
Efficient Management: Success Stories of Partner FacilitiesMCH-org-ua
Presentation at the National Capitalization conference of the Swiss-Ukrainian Mother and Child Health Programme (Kyiv, Ukraine, April 23, 2015)
http://motherandchild.org.ua/eng/event/768
Continuous post-graduate medical education at the local level: results and ma...MCH-org-ua
Presentation at the National Capitalization conference of the Swiss-Ukrainian Mother and Child Health Programme (Kyiv, Ukraine, April 23, 2015)
http://motherandchild.org.ua/eng/event/768
Towards better health outcomes: Experiences and conclusions from the MCHPMCH-org-ua
This document summarizes experiences and conclusions from the MCHP (Maternal and Child Health Program) on improving health outcomes. It discusses implementing a quality of care framework at the facility and health systems levels, including modernizing infrastructure, promoting continuous medical education focused on practical skills, integrating new evidence into care through clinical practice guidelines and protocols, and putting patients at the center. It also covers using information systems to drive change and governance through management training and decentralization to strengthen institutions. The outlook calls for developing a more team-oriented and learning culture oriented towards patient needs through knowledge sharing and integrating new knowledge on an ongoing basis.
Заради кращих результатів в охороні здоров’я: Досвід та висновки Програми “Зд...MCH-org-ua
Презентація на Національній підсумковій конференції за результатами впровадження україно-швейцарської Програми "Здоров’я матері та дитини" (Київ, 23 квітня 2015 р.)
http://motherandchild.org.ua/ukr/event/768
Телемедицина та електронна інвентаризація: досвід областейMCH-org-ua
Презентація на Національній підсумковій конференції за результатами впровадження україно-швейцарської Програми "Здоров’я матері та дитини" (Київ, 23 квітня 2015 р.)
http://motherandchild.org.ua/ukr/event/768
Ефективне управління: історії успіху партнерських закладівMCH-org-ua
Презентація на Національній підсумковій конференції за результатами впровадження україно-швейцарської Програми "Здоров’я матері та дитини" (Київ, 23 квітня 2015 р.)
http://motherandchild.org.ua/ukr/event/768
Безперервна післядипломна медична освіта на місцевому рівні: результати впров...MCH-org-ua
Презентація на Національній підсумковій конференції за результатами впровадження україно-швейцарської Програми "Здоров’я матері та дитини" (Київ, 23 квітня 2015 р.)
http://motherandchild.org.ua/ukr/event/768
Benefits and value of simulation societiesMCH-org-ua
Presentation by Stefan Gisin at the International conference on Simulation-based training in medicine (Kyiv, Ukraine, March 19-20, 2015)
http://motherandchild.org.ua/eng/SimConf-2015
Team training matters for patient outcomeMCH-org-ua
Presentation by Stefan Gisin at the International conference on Simulation-based training in medicine (Kyiv, Ukraine, March 19-20, 2015)
http://motherandchild.org.ua/eng/SimConf-2015
Структура програми симуляційного навчанняMCH-org-ua
Ана Рейнольдс (Ana Reynolds). Доповідь на Міжнародній конференції «Симуляційне навчання в медицині» (Київ, 19-20 березня 2015 р.)
http://motherandchild.org.ua/ukr/SimConf-2015
Ефективне симуляційне навчання: як ми можемо допомогти?MCH-org-ua
Лукас Опіц (Lucas Opitz). Доповідь на Міжнародній конференції «Симуляційне навчання в медицині» (Київ, 19-20 березня 2015 р.)
http://motherandchild.org.ua/ukr/SimConf-2015
Лукас Опіц (Lucas Opitz). Доповідь на Міжнародній конференції «Симуляційне навчання в медицині» (Київ, 19-20 березня 2015 р.)
http://motherandchild.org.ua/ukr/SimConf-2015
Nonivasive Respiratory Support - NIV, High Frequency Ventilation - HFV
1. Nonivasive Respiratory Support - NIV
High Frequency Ventilation - HFV
Iwona Maroszyńska
Department of Neonatal Intensive Care and Congenital Malformations
Memorial Institute of Polish Mother‟s Health Center
Київ 2013
3. • High chest compliance • Newborn‟s chest
– Bone underdevelopment – More cylindrical
– Intercostal muscles – Shorter intercostal muscles
– Sleep REM – Diaphragm horizontal position
• Muscles tone
• Ineffective respiratory effort
• Low lung compliance
– Surfactant insufficiency
– Fewer terminal airspaces
– More stroma
VT ↓; f↑; grunting
4. • Elastic recoil (compliance/elastance)
– The tendency of stretched object to return to their original shape
• Inspiratory muscles relaxation during exhalation
• Chest wall
• Diaphragm recoil
• Lungs
– Surfactant, bone development
• Viscous resistance
– Fewer terminal airspaces
– More stroma
5. lung-chest wall system = pressure-volume characteristic (lung + chest wall)
FRC - outward recoil force of the chest wall = inward elastic forces of the lung
(resting state of the respiratory system)
8. Pulmonary vascular resistance
Pa Palv Pv
*** * **
Pa Palv Pv
*** ** *
Pa Palv Pv
III ** *** *
I
II
Modified from West JB: Respiratory Physiology:
The Essentials, 2nd ed. Baltimore, Williams & Wilkins, 1979, p. 39
.
9. Pulmonary vascular resistance
LV preload ↓
shunt I Pa Palv Pv
** *** *
PTV
FRC
Hakim TS, Michel RP, Chang HK (1982) Effect of lung inflation on pulmonary vascular
resistance by arterial and venous occlusion. J Appl Physiol 53(5):1110–1115
10. - Good conditions for the contact of blood and endothelial cells
- High blood flow
- Well developed microcirculation
- Low perfusion pressure
- Highly represented macrophage system
- Direct contact with the external environment - colonization
11. Disadvantages of Ventilation via ETT
• Cardiovascular and cerebrovascular instability during ventilation
• Complication of ETT
– Subglotic stenosis
– Tracheal lesions
• Acute and chronic lung damage
– Volutrauma
– Barotrauma
– Shear
• Infection
• If you do not ventilate en infant, it‟s hard to cause BPD
16. Target fraction of FiO2
• Retrospective study
– To retrospectively evaluate if HVS is associated with better oucome
– FiO2 ≤ 0,25
– FiO2 > 0,25
• No - 28 vs 23
• GA < 26,1 vs 25,9 hbd
• Birth weight 603 vs 703
J Matern Fetal Neonatal Med. 2011 in press
Tana M et all
Unexpected effect of recruitment procedure on lung volume measured by respiratory inductive plethysmography (RIP)
during high frequency oscillatory ventilation (HFOV) in preterm neonates with respiratory distress syndrome
(RDS).
17. Target fraction of FiO2
• Results
– MAP – 12,8 vs 11,2
– FiO2 - 0,25 vs > 0,25
– Extubation – 3,5d vs 9 d (p=0,005)
– Oxygen - 488 d vs 1109 d (p=0,02)
– Mechanical ventilation 187 vs 525 (p=0,03)
– Surfactant > 1 dose 1 vs 6 (p=0,04)
– BPD - NS
J Matern Fetal Neonatal Med. 2011
Tana M et all
Unexpected effect of recruitment procedure on lung volume measured by respiratory inductive
plethysmography (RIP) during high frequency oscillatory ventilation (HFOV) in preterm neonates with
respiratory distress syndrome (RDS).
18. What is the HFV ?
• HFV
– Complex process of mixing gases
– Normal human lung > 170/min
• Small tidal volume
– VT < anatomic dead space 1-3ml/kg
• Very rapid ventilator rates
– > 4 x physiological respiratory rate
– 2 - 20 Hz = 120 – 1200 breaths/min.
• MAP
– HFV > CMV
19. Back to the physiology…
• Alveolar ventilation
– VA = VT – VD
• HFV
– VT ≤ VD → VT – VD ≤ 0
– VA ≤ 0
20. HFV vs CMV
• VT
– Const. f ≤ 25 -30/min. > 30/min. VT ↓
• Valv = (VT – VD) x f
– F > 75/min. ↓ → VA = VT2f
– f > 75/min. - VT determined by Ti
Using conventional infant ventilators at unconventional rates
Pediatrics. 1984 Oct;74(4):487-92.
• Flow
Boros SJ, Bing DR, Mammel MC, Hagen E, Gordon M
• VT
• Amplitude ↑
• PIP – PEEP
• f↑ → VT↓
• MAP
• PIP ; PEEP
21.
22. Why HFV?
• VT < VD 1-3ml/kg
• Possibility of independent management of the oxygenation and
ventilation
• Preservation of normal lung architecture even when using high MAP
• Optimal lung inflation
– The lung volume at which the recruitable lung is open but not
overinflated
23.
24. PIP – 25 cmH2O
PEEP – 5 cmH2O
I : E – 1 : 2 > 75/min 1 :1
F = 10 L/min
Boros SJ, Bing DR, Mammel MC, et al: Pediatrics 74:487, 1984
PIP – 25 cmH2O
PEEP – 5 cmH2O
I:E–1:2
Mammel MC, Bing DR: Clin Chest Med 17:603, 1996
25. Consepts of gas transport….
• Convection ventilation or bulk flow
• Taylor dispersion and molecular diffusion
– A high velocity of gas travels down the center of a tube, leaving
the molecules on the periphery unmoved
– High flow facilitates diffusion
• Pendelluft effect
– Regional differences in time constants for inflation and deflation
cause gas to recirculate among lung
– Open lung allows to gas recirculate between alveoli
• Cardiogenic mixing
29. Study Year Study disign Results
60 – 150 breaths/min
Observational: Sjostrand V 2000 adults and children HFPPV adequate
1977
Acta Anesthesiol Scand and 32 neonates with respiratory support
RDS
24 neonates with RDS
Observational: Bland RD
1980 60 – 110 breaths/min, Improved outcome
Crit Care Med
volume preset vent.
673/346 preterms BPD ND, IVH↑, PVL↑,
HiFi study 1989
750-2000g Air leak↑
M-RCT (OCTAVE) 346 neonates
Oxford Region Controlled Trial of Artificial
1991 HFPPV vs CMV HFPPV ↓ air leak
Ventilation study group
Arch Dis Child
60 vs 20 - 40
CMV trend ↓ BPD w
Pardou A 22 neonates, HFFI 28 dobie i 36 tyg.
1993
Int Care Med rescue therapy 63% vs 80%; 25% vs
40%
284 neonates
Thome U (RCT) 1999 24-29hbd < 1000g Infant Star ↑ air leak
HFV Inf Star
30. BPD
28 days; 36 weeks PMA
Study group/
Trial 28 – 30 d 36 PMA HLVS Surfaktant
HFV
RCT CO 83 ≤ 1750
Clark RH HFOF SM/CV – 27
1992 HFOV SM – 30 P=0,008 P=0,013
RMCT (Provo)
125 < 35 weeks
Gerstmann 100%
(1500;30,9) P < 0,05 P < 0,05 36 PMA
DR redosing
HFOF SM – 64
1996
RMCT 499
100% (4)
Courtney < 1200g P = 0,046 all
redosing
2002 HFOV SM - 244
31.
32. • N=273
• GA – 24 -29
• Birth weight < 1000g
• Randomization
– 142 min - 145 min
• HFOV
– Reduction of surfactant doses - 30% vs 64%
– Higher incidence IVH 24% vs 14%
Moriette G et al. Pediatrics 2001,107:363-72.
Prospective randomized multicenter comparison of high-frequency oscillatory ventilation and conventional
ventilation in preterm infants of less than 30 weeks with respiratory distress syndrome
33. Meata-
Trials 28 – 30 d 36 PMA HLVS Surfaktant
analysis
Cools F RR – 0,5 RR – 0,44
16 trials ND
1999 CI: 0,32, 0,78 CI: 0,16, 0,73
Hendreson-
or death 28-30 days
Smart DJ Trend toward
6 trials trend toward RR – 0,5 Similar to
2000 decreasing
Rand. – 12h decreasing CI: 0,36, 0,76 HLVS
Cochrane: in HFV
in HFV Death or BPD
CD000104
Hendreson-
Smart DJ NNT 17
Results the Results
2003 10 trials Or death
same the same
Cochrane: NNT - 20
CD000104
Hendreson-
Smart DJ 15 trials
ND borderline 36 PMA
2007 3585 ND
significance
Cochrane: neonates
CD000104
35. • HVLS in HFV - ND
• HFOV
• Not used LPS in CV
• Randomization 2 – 6 hours
• I:E–1:2
• Air leaks – more frequently in HFOV
36.
37. • Secondary end points
– Gross pulmonary air leaks
• pneumothorax, pneumomediastinum, pneumopericardium
– Any pulmonary air leaks ↑*
• Gross pulmonary air leaks + PIE
– PDA – surgical ligation ↓
– ROP > 2 ↓*
– Final extubation HFOV < CV
38. • Ventilator type ND
– Sensormedics vs others vs „flow interrupter”
– HVLS
• Trials with HLVS
– Lower target of FiO2
• Time of randomization
– Death or BPD or neurological event
•1 – 4 h vs after 4h: HFOV (p=0,01)
39. No of trials – 15
• Outcome measures
– Death
– BPD at 36 weeks PMA
• Other variables
– Type of ventilator
• 11 – HFOV
– 7 – Sensormedics
• 2 – HFJV
• 2 - HFFI
– Ventilation strategies applied in the HFV and CV treatment groups
– Time on mechanical ventilation before randomization
41. Neurological outcome
IVH, PVL
Study group/ IVH
Trial PVL
HFV Grades: 3,4
RMCT
HiFi No – 673/327 26 vs 18 12 vs 7
1989 750g – 2000g P = 0,02 P = 0,05
ND (HiFi)
RR 1.31, Fixed:
Cools F 95% CI: 1.04, 1.66
16 trials Random: RR 1.34, ND
1999
(95%
CI: 1.05, 1.70
42. Longterm neurological outcome
Study group/ No Pulmonary Neurodevelopmental
Trial
HFV followed up function outocome
386 (77%) 16 – 24 m.
RMCT 673/327
ND Bayley score > 83
HiFi 750 – 2000g 432 (82%)
(No 223-43%) no major defect
1989 Surv. - 524
CV ↓ (54% vs 65%)
1 year
RMCT
92/46 BPD in chest x Developmenta delay –
Ogawa 91 (100%)
750 - 2000 –ray 9% in both groups
1993
2% vs 4% ND
RMCT
125 < 35
(Provo)
Available 79
Gerstmann 69 (87%) ND ND
(1500;30,9)
DR
HFOF SM – 64
1996
MRCT 428 – 73%
797/400 22-28 month
UKOS 373 – In 9% sever
Surv. 592 40%
Marlow N „window” 38% other disabilities
23 – 28 PMA ND
2006 (211vs217)
43. HFOV – indications
• Air leak syndromes
– Pulmonary interstitial emphysema ( PIE)
– bronchopleural or tracheoesophageal fistula
• Until at least 24 hours after the air leak resolved
48. HFOV strategy
Optimal
lung volume strategy
MAP
MAP 2-3 cmH2O in 1-2 cmH2O steps
Frequency - 10 Hz
above the CMV until
oxygenation improves
Aim: to maximise recruitment of alveoli
49. HFOV strategy
Low
volume strategy
Adjust amplitude
MAP equal to the to get an adequate Frequency - 10 Hz
CMV
chest wall vibration.
Aim: to minimise lung trauma
50. HFOV strategy
• Obtain an early blood gas and adjust settings as appropriate
• Obtain chest radiograph to assess inflation
– Initial at 1-2 hrs
• baseline lung volume on HFOV (aim for 8 ribs).
– A follow-up in 4-6 hours
• to assess the expansion
– Repeat chest radiography with acute changes in patient condition
• Reduce MAP
– chest radiograph shows evidence of over-inflation (> 9 ribs)
51. Poor Over Under Over
Oxygenation Oxygenation Ventilation Ventilation
Increase FiO2 Decrease FiO2 Increase Amplitude Decrease Amplitude
Decrease Frequency Increase Frequency
Decrease MAP
Increase MAP (1-2Hz) (1-2Hz)
(1-2cmH2O)
if Amplitude Maximal if Amplitude Minimal
52. Weaning
• Reduce FiO2 to < 40% before weaning MAP (except overinflation)
• Reduce MAP in 1-2cm H2O increments to 8-10 cm H2O
• Air leak syndromes (low volume strategy)
– Reducing MAP takes priority over weaning the FiO2
• Wean the amplitude
• Do not wean the frequency
• Discontinue weaning when MAP 8-10 cm H2O and Amplitude 20-25
• Infant is stable, oxygenating well and blood gases are satisfactory
– extubation to CPAP or switched to conventional ventilation
53. Suctioning
• Indications
– diminished chest wall movement (chest wobble)
– elevated CO2 and/or worsening oxygenation
– visible/audible secretions in the airway
• Avoid in the first 24 hours of HFOV, unless clinically
indicated.
• In-line suctioning must be used
• Press the STOP button briefly while quickly inserting and
withdrawing suction catheter (PEEP is maintained)
54. 2006 OPEN FORUM Abstracts
OPEN VERSUS CLOSED SUCTION DELIVERY DURING HIGH FREQUENCY
OSCILLATORY VENTILATION (HFOV)
Dennis Gaudet, RRT; Matthew P. Branconnier, RRT, EMT; Dean R. Hess, PhD,
RRT, FAARC. Massachusetts General Hospital and Harvard Medical School,
Boston MA.
55. Summary.…
• HFV is an effective treatment modality in a variety of clinical
situations
• The most important contribution of HFOV is that it helped clinicians
overcome the fear of using adequate distending airway pressure
• The most important is to achieve optimal lung volume, I:E – 1:2
• When used in appropriately selected patients with the optimal
volume recruitment strategy and careful attention to avoide
hypocapnia, HFOV is capable of reducing the incidence of CLD
• Recent meta-analyses have suggested that surfactant, antenatal
steroids, and improvements in conventional mechanical ventilation
with the use of lung-protective strategies have eliminated any
advantages of HFV as a primary mode of ventilation
56. Nasal Ventilation: How does it work?
• Increase in FRC
– Alveolar recruitment due to higher MAP
– Decrease in intrapulmonary shunt
– Protection of surfactant
– Increases alveolar surface area for gas exchange
• Improves oxygenation
• Increase in VT and minute volume
57. NIV - History
• August Ritter von Reus 1914
– Bubble CPAP
• 1940s
– High altitude flying
• 1967
– PEEP was added to MV
• 1960s
– Neonates PEEP=0
58. NIV - History
• Harrison (1968)
– Grunting was producing positive end expiratory pressure (PEEP)
• Gregory (1971)
– Clinical use of CPAP in premature neonates with hyaline membrane
disease (RDS)
• Avery (1987)
– The lowest incidence of BPD, at Columbia where they used much more
CPAP
• Nasal Continuous positive airway pressure (NCPAP)
– By far the most commonly used form of NIV in neonates today
59. When is NIV used ?
After birth
After extubation
To treat apnea
60. Nasal CPAP Delivering Devices
• Components
– Circuit for continuous or variable flow of inspired gases
• Continuous flow – gas flow generated and directed against the
resistance of the expiratory limb
– Nasal interface
• single or bi-nasal prongs (Argyle & Hudson), mask, NP tube
– Device to generate positive airway pressure
61. Know Your CPAP
• Continuous flow: flow constant irrespective of phase of
respiration
– Ventilator generated CPAP (conventional CPAP)
– Bubble: CPAP varied by immersion of expiratory tubing
• Flow varies with immersion depth and affects CPAP
• Variable flow: CPAP varied by varying the flow rate
– Infant flow, Arabella, Aladdin
– Bi-level (“SiPAP”)
Courtnay SE et al; Pediatr Pulmonol; 36; 2003
Lipsten F et al; J Perinatol; 2005
Boumecid H et al; Arch Dis Chid Fetal Neonatal; 2007
62. Conventional Ventilator CPAP vs. Infant Flow CPAP
for Extubation (n=162)
Extubation Failure Rate:
Conv. CPAP= 38.1%
IF-CPAP= 38.5%
Infant Flow CPAP is as effective as conventional CPAP
Stefanescu BM et al. (Winston-Salem, NC) Pediatrics 2003
63. Infant Flow Driver CPAP
Pressure is generated by Varying the Flow Rate
• Reduced work of breathing
• Maintains uniform pressure
Fluidic Flip or Coanda Effect
64.
65. CPAP Interfaces
Argyle Prongs Hudson Prongs Nasopharyngeal
Catheter
Nasal mask
Nasal Cannula
Inca Prongs
R ~ F L / r4
66. Bi-Nasal vs Single Prong CPAP in ELBWI
Bi-Nasal Prongs Single Prong
p
(n=41) (n=46)
BW, g mean (SD) 790 (140) 816 (125) NS
GA 26 (1.9) 26 (1.9) NS
Age at extubation, days,
3 (1-9) 3 (1-6) NS
Median, IQ range
Extubation Failures 24 % 57 % 0.005
In < 800 g 24 % 88 % <0.001
Reintubation in < 800 g 18 % 63 % 0.023
Bi-Nasal Prongs are more effective than Single Prong
Davis P et al. (Melbourne) Arch Dis Child 2001
67. Single-prong vs double-prong NCPAP ventilation: effect on
extubation failure
De Paoli A: Cochrane Database Rev; 2008; CD002977
68. NCPAP at birth
• Intubation in the delivery room was reduced from 84% to 40%
» Linder W et al.; Pediatrics; 1999;
• Intubation in the delivery room was reduced from 89% to 33%
» Aly H et al.; Pediatrics; 2004;
• Lack of RCT
– „…the dramatic effect of CPAP (was) observed after a brief period of treatment in
all patients.”
» Novogroder et al.; J Pediatrics: 1973
• „…Although one or two such (RCT) studies of CPAP would be
welcome, many more „would be foolish.”
71. What to do when NCPAP fails?
when should the neonate be intubated ?
• NCPAP – Faillure rate -20 -80%
• Definition of CPAP faillure
– FiO2 > 0,6 → 0,75
– FiO2 > 0,35 – 0,4
– COIN trial
• FiO2 > 0,6; pH < 7,25; PaCO2 > 60mm
• Apneic episodes > 6/6hour requiring stimulation or >1 requiring PPV
72. NIPPV
• Added positive pressure inflation to a background of
NCPAP
• How NIPPV improve clinical outcomes
– PIP results in only a slight increase in VT when delivered during
spontaneous breathing
– Occasionally lead to chest inflation when delivered during apneic
period
» Owen LS et al.; Arcg Dis Child Fetal Neonatal Ed; 2011
73. sNIPPV in Preterm Infants with RDS
sNIPPV -242; nCPAP - 227;
NCPAP sNIPPV
P
(n=227) (n=242)
Birth Weight, g 964 183 863 198 < 0.001
Gestational Age, wks 27.9 2.4 26.4 1.7 < 0.001
Antenatal Steroids, % 92 94 0.274
Surfactant Rx, % 68 85 < 0.001
BPD, Total population 25 % 35 % 0.028
BPD in 500-750 g 67 % 43 % 0.031
BPD in 751-1000 g 23 % 35 % 0.097
BPD in 1001-1250 g 14 % 21 % 0.277
sNIPPV when compared to NCPAP was associated with decreased
BPD, BPD/Death, NDI, and NDI/Death
Bhandari V et al. Pediatrics 2009
76. •NIPPV
• Lower risk of respiratory faillure
• Apnea
• Respiratory acidosis
• Increased oxygen requirements
To prevent reintubation
Davis PG; Cachrane Database Rev. 2001; CD003212
77. S-NIPPV and NS-NIPPV
• NCPAP vs S-NIPPV vs NS-NIPPV (20-40/min)
– VT, minute ventilation, gas exchange – ND
– S-NIPPV
• Less inspiratory effort
• Better infant – ventilator interaction
– NS-NIPPV – no advantage over NCPAP
» Chang HY et al; Pediatr Res; 2011
78. Neurally Adjusted Ventilatory Assist (NAVA)
• Electrical activity of the diaphragm (Edi) is used for
controlling ventilation in Neurally Adjusted Ventilatory
Assist
• NAVA ventilation mode may be used both as invasive
and non-invasive ventilation
• Timing and amount of delivered pressure is controlled by
patient
• One condition must be met – spontaneous breathing
79. • Edi catheter (6 Fr) is introduced through nostril and
placed according to the formula
• Edi catheter positioning was adjusted by means of ECG
display
• After appropriate placement sufficient Edi signal could be
detected
83. HFNC – high flow nasal cannulae
• Flow rates exceeding 1L/min
– Initial support for early respiratory distress
– Postextubation support
– Step-down therapy from NCPAP
• HFNC interfaces
– Vapotherm
– Optiflow (pressure- relief valve in circuit)
• Open systems with leak at the nose and mouth
• Heated and humidified gas, blending and oxygen and air
84. HFNC – high flow nasal cannulae
• Pressure generated – unpredictable
– 0,3 cm outer diameter, flow rate 2L/min
• Mean esophageal pressure – 9,8 cm H2O
» Locke RG; pediatrics, 1993
– Recent studies
• Pressure ≤ NCPAP
» Kubica ZJ et al; Pediatrics 2008
» Spence KL et al.; J Perinatol; 2008
» Wilkinson DJ et al.; J Perinatol: 2008
86. How much supporting pressure should be used
•NIPPV
•PIP as on MV or slighty
above
•Respiratory rate – 20-40
Davis PG: 2003; Cochrane Database Rev; CD000143
87. Suggested Weaning Guidelines During Nasal Ventilation
• Wean every 6–12 h
• Wean PIP first
• When PIP is at 10, then wean rate
• When rate is at 10, wean to NCPAP
• When patient is stable
– NCPAP of ± 5 cm H2O for 6–12 h
• wean to heated nasal cannula with flow rates of < 2 LPM.
88. Contraindication to NIV
• Progressive respiratory faillure or with poor respiratory drive
– High oxygen requirement
– PCO2 > 60mmHg
– pH < 7,25
– Apnea, bradycardia, desaturation do not responded to NCPAP
• Congenital malformations
– Choanal atresia
– Cleft plate
– Congenital diaphragmatic hernia
– Tracheoesophageal fistula
– Gastroschisis
• Severe cardiovascular instability
89. NIPPV - Complications
• Malpositioned nasal cannulae
– Variable flow CPAP system
– Airway obstruction by secretion
• Inadvertent PEEP – air leaks
– High ventilatory rate
– Too short expiratory time
– Minimal or no lung disease (high compliance)
• Carbon dioxide retention
– Alveolar overdistantion
• Increase work of breathing, PVR↑, CO↓
• Decrease urine output
– Too short expiratory time
90. NIPPV - Complications
• Decreased gastrointestinal blood flow - „CPAP belly”
– Abdominal distention
• Placement of orogastric tube
– NEC – not confirmed
– Gastric perforation - not confirmed
• Skin trauma Fischer C et al (Switzerland). Arch Dis Child 95: F447-F451; 2010
91. Summary
• NCPAP reduces respiratory instability and the need for
extra support after intubation
• NCAP reduces the rate of apnea
• NIPPV may augment the benefits of NCPAP
• Binasal prongs are better than single nasal prongs
• Used NCPAP after delivery may prevent or at least
diminish respiratory distress
92. • It does not matter what ventilator we choose but …
• How to provide respiratory support
93. • The art of medicine is to achieve optimal lung volume in
neonates with respiratory disorders
• CPAP is one method many clinicians believe best
achieves optimal lung inflation with resultant good
oxygenation and ventilation without the use of an
endotracheal tube
94. ECMO – instead of ventilators?
• Low volume of circuit
• Possibility to provide without hyalinization and trough
thin cannulas
• Even then Optimal Lung Volume in neonates with
surfactant insufficiency will be necessary