Management of PatientVentilator System

1
Management of Patient-Ventilator System

• Indications for Ventilatory Support of the
  Neonate Child
• Respiratory Failure
• Hypoxemic respiratory failure
• Hypercapnic respiratory failure
• Mixed respiratory failure

2
Management of Patient-Ventilator System

• Indications for Ventilatory Support of the
  Neonate Child
• Respiratory Failure
• Hypoxemic respiratory failure
• Pa02 lt 50 mm Hg w/ Fi02 of gt 0.6 (despite the use
  of CPAP)
• Decreasing Pa02 w/increase of Fi02
• Accompanied by hypocapnia (lt 30 mm Hg)
• Respiratory alkalemia (pH gt 7.5)

3
Management of Patient-Ventilator System

• Indications for Ventilatory Support of the
  Neonate Child
• Respiratory Failure
• Hypoxemic respiratory failure
• Clinical features
• Agitation
• Tachycardia or Bradycardia
• Cyanosis
• Tachypnea (gt 70-80 bpm neonates/ gt 50 bpm
  children)
• Classical signs of distress in neonates
• Nasal flairing Grunting
• Retractions (substernal, sternal, intercostal,
  suprasternal)

4
Management of Patient-Ventilator System

• Indications for Ventilatory Support of the
  Neonate Child
• Respiratory Failure
• Hypercapnic Respiratory Failure
• PaC02 gt 50 mmHg
• Accompanied by acidemia (pH lt 7.25)
• Clinical signs
• Apneic
• Listless
• Cyanotic
• Bradycardia/Tachycardia may be present

5
Management of Patient-Ventilator System

• Indications for Ventilatory Support of the
  Neonate Child
• Respiratory Failure
• Mixed Respiratory Failure
• Hypoxemia
• Hypercapnia
• Acidemia may be present

6
Management of Patient-Ventilator System

• Indications for Ventilatory Support of the
  Neonate Child
• Clinical Conditions Indicate Mechanical
  Ventilation
• Neurologic alteration
• Apnea of prematurity
• Intracranial hemorrhage (ICH)
• Congenital neuromuscular disorder (Duchennes
  muscular dystrophy)
• Poisoning
• Phrenic nerve paralysis

7
Management of Patient-Ventilator System

• Indications for Ventilatory Support of the
  Neonate Child
• Clinical Conditions Indicate Mechanical
  Ventilation
• Impaired respiratory function
• Respiratory distress syndrome (RDS/ARDS)
• Meconium aspiration syndrome (MAS)
• Pneumonia
• Bronchiolitis
• Brochopulmonary dysphasia (BPD)
• Inhalation injury

8
Management of Patient-Ventilator System

• Indications for Ventilatory Support of the
  Neonate Child
• Clinical Conditions Indicate Mechanical
  Ventilation
• Impaired respiratory function
• Congenital diaphragmatic hernia
• Sepsis
• Atelectasis
• Asthma
• Trauma
• Inhalation injury

9
Management of Patient-Ventilator System

• Indications for Ventilatory Support of the
  Neonate Child
• Clinical Conditions Indicate Mechanical
  Ventilation
• Impaired Cardiovascular function
• Persistent pulmonary hypertension of newborn
  (PPHN)
• Post-resuscitation
• Congenital heart disease
• Shock

10
Management of Patient-Ventilator System

• Indications for Ventilatory Support of the
  Neonate Child
• Clinical Conditions Indicate Mechanical
  Ventilation
• Postoperative
• Central nervous system depression
• Atelectasis

11
Management of Patient-Ventilator System

• Modes of Mechanical Ventilation
• Control
• Control variable does not change
• Volume control compliance or resistance change
  volume constant/pressure changes
• Pressure control compliance or resistance
  change pressure constant/volume changes
• Compliance decreases or resistance increases Vt
  changes

12
Management of Patient-Ventilator System

• Modes of Mechanical Ventilation
• Phase
• Trigger
• Time
• Pressure
• Flow
• Volume
• Limit reached before end of inspiration
• Pressure
• Volume
• Time
• Flow

13
Management of Patient-Ventilator System

• Modes of Mechanical Ventilation
• Phase
• Cycle ends inspiration
• Flow
• Time
• Pressure
• Volume
• Baselinedefines expiration
• Pressure

14
Management of Patient-Ventilator System

• Partial Ventilatory Support (PVS)
• Indicated for patients capable of maintaining all
  or part of minute ventilation
• CPAP
• PSV
• IMVlow mandatory rates
• SIMV low mandatory rates
• CPAP/IMV primary modes for neonates
• CPAP/SIMV/PSV modes for children

15
Management of Patient-Ventilator System

• Partial Ventilatory Support (PVS)
• CPAP
• Used on spontaneously breathing infants/children
• Increase FRC
• Increases compliance
• Decreases total airway resistance
• Decreases respiratory rate
• Can be administered by nasal prongs, NP tube, or
  ETT

16
Management of Patient-Ventilator System

• Partial Ventilatory Support (PVS)
• CPAP
• Indications
• Decreased FRC
• Pneumonia
• Atelectasis
• Pulmonary edema
• Thoracotomy
• Meconium aspiration
• Increased mucus
• RDS
• TTNB
• Left to right shunting

17
Management of Patient-Ventilator System

• Partial Ventilatory Support (PVS)
• CPAP
• Indications
• Airway Collapse
• Tracheobronchial malacia
• Apnea
• Weaning from Mechanical Ventilation

18
Management of Patient-Ventilator System

• Partial Ventilatory Support (PVS)
• CPAP
• Indications
• Abnormal physical examination
• Increased respiratory rate (30-40)
• Retractions
• Grunting
• Nasal flairing
• Cyanosis
• Abnormal arterial blood gases
• Pa02 lt 50 mmHg of 60 (with adequate ventilation)

19
Management of Patient-Ventilator System

• Partial Ventilatory Support (PVS)
• CPAP
• Effective instituted early in progression of
  disease
• Initial pressures 4-5 cm H20
• Increase in increments of 2 cm H20 to achieve
  desired Pa02
• Successful if
• Fi02 stabilized _at_ lt 0.6 with Pa02 gt 50 Pa02 or
  Sp02 gt 90
• lt WOB
• lt retractions
• Improved nasal flairing and grunting
• Improve aeration on X-ray
• Patient looks more comfortable

20
Management of Patient-Ventilator System

• Partial Ventilatory Support (PVS)
• CPAP
• Nasal CPAP
• Failed if
• Pa02 lt 50 mm Hg despite Fi02 0.8-1.0 on CPAP of
  10-12 mm Hg
• PaC02 gt 60 mm Hg / pH lt 7.25
• Marked retractions on CPAP
• Metabolic acidosis not responding to treatment
• Frequent apneic episodes
• CPAP failure implies the patient requires greater
  support and must be intubated and mechanically
  ventilated

21
Management of Patient-Ventilator System

• Partial Ventilatory Support (PVS)
• CPAP
• Hazards
• High pressures
• Pulmonary blood flow decreased due to compression
  of pulmonary vessels
• Cardiac Output (CO) reduced due to decrease
  venous return to heart
• Renal hazards decrease in glomerular filtration
  rate/Na excretion/urine output
• Pneumothorax, ? ICP, nasal obstruction, gastric
  distention, necrosis or erosion of nasal septum

22
Management of Patient-Ventilator System

• Partial Ventilatory Support (PVS)
• CPAP
• Contraindications
• Do not use in presence of upper airway
  abnormalities
• Choanal atresia
• Cleft palate
• Tracheoesphageal fistula
• Untreated air leaks
• Pneumothorax
• Pneumomediastinum
• Pneumopericardium
• Pulmonary interstitial emphysema (PIE)

23
Management of Patient-Ventilator System

• Partial Ventilatory Support (PVS)
• CPAP
• Contraindications
• Apneic Patients
• Patients can not maintain spontaneous ventilation
• Inadequate spontaneous tidal volume
• Untreated congenital diaphragmatic hernia

24
Management of Patient-Ventilator System

• Partial Ventilatory Support (PVS)
• CPAP
• Weaning from CPAP
• Signs of clinical improvement
• Decrease Fi02 increments of 0.05 until Fi02
  reaches 0.4
• Decrease CPAP increments of 2 cm H20 until 2-3 cm
  H20
• CPAP device removed replace with appropriate
  Fi02

25
Management of Patient-Ventilator System

• CPAP
• Pro
• Improves oxygenation by maintaining FRC
• Con
• Impairs ventilation by increasing FRC and
  increasing the work of breathing (baby has to
  exhale against pressure/flow)

26
Pressure Support Ventilation

• Patient efforts are supplemented with pressure
• Indicated for patients in whom a greater Vt and
  lower rate are desired during spontaneous
  breathing
• Also used to overcome ETT resistance
• Tidal volume depends on the PS level and the lung
  compliance/airway resistance
• BiPAP is PS with PEEPIPAP and EPAP are set and
  the difference between them determines the Vt

27
Pressure Support Ventilation

• Volume Support is a variation of PS that allows
  for a Vt guarantee
• If compliance changes, the ventilator will
  automatically adjust the PS level to maintain the
  target Vt
• Pro
• Can increase spontaneous Vt and decrease WOB
• Con
• No mandatory breaths
• Weaning gradually decrease PS down to 5, then
  extubate

28
IMV/SIMV

• Mandatory breaths are provided, but the patient
  can breathe spontaneously between the mandatory
  breaths
• The time available for spont breathing depends on
  the mandatory rate set
• SIMV synchronizes the timing of the mandatory
  breaths, avoiding breath stacking
• When rates are gt30-40, this really becomes a full
  support mode rather than a partial support mode

29
Full Ventilatory Support

• These modes provide all of the required minute
  ventilation
• CMV (AKA AC)
• Each breath is the same
• Can be either volume or pressure controlled
• Volume ventilation is rarely used in the NICU
• Pressure controlled ventilation is the norm
• May occasionally use inverse ratio pressure
  ventilation in patients who cant be oxygenated
  any other way

30
Setting Initial Parameters

• Mode
• Neonates
• Hypoxemic respiratory failure
• Choose a mode that increases MAP, such as CPAP
• CPAP is used as long as the patient has adequate
  spontaneous ventilation
• Hypercapnic respiratory failure
• Choose a mode that increases minute ventilation,
  such as SIMV or CMV)
• Peds
• Ventilation is similar to adult ventilation, but
  with lower Vt and higher rate

31
Initial Parameters, cont

• PIP
• Pressure limit doesnt stop inspiration, it just
  limits pressure to a pre-set levelwhen PIP is
  reached, extra flow is vented to keep the
  pressure constant
• Neonates
• Start at 15-20 cm H2O and adjust based on
  clinical signs such as chest movement, BS, and
  ABG
• Peds
• Start at 15-20 cm H2O and increase to obtain a Vt
  of about 8 ml/kg
• Maintain plateau pressure lt35 cm H2O

32
Initial Parameters, cont

• Rate
• Neonates
• Start at 30-40 and adjust for PaCO2
• Peds
• If child is lt1 year, start around 30
• If child is 1-5 years old, start around 20
• If child is gt5, start at 12-20
• Adjust for PaCO2
• Some baby vents set the rate by setting the IE
  ratioin this case, to make a rate change you
  have to either change It or Et or bothServo
  vents allow you to adjust rate and the Et
  automatically changes when you do this

33
Initial Parameters, cont

• Sensitivity
• We NEVER lock a patient outalways set the
  sensitivity so the patient can trigger a breath
• Pressure trigger -1 to -3 cm H2O
• Flow trigger 0.15 3 lpm
• Volume trigger 3.0 ml (Drager Babylog only)
• PEEP
• Start at 3-5 cm H2O
• FiO2
• The amount needed to keep the baby pink and SpO2
  gt90
• With cyanosis, CV instability, trauma use 100

34
Initial Parameters, cont

• Flow
• Some baby vents require you to set a flow rate,
  like on a flowmeter, to deliver the breath
• Its usually set at 6-8 lpm and then adjusted
  based on the patient you want the flow high
  enough so that the PIP is achieved, but not so
  high that the PIP is achieved too early in the
  breathideally, the baby should just reach the
  PIP as the It elapses
• You dont have to do this on the Servo vent on
  this ventilator, flow is a function of It, PIP,
  and patient effort and is automatically adjusted

35
Initial Parameters, cont

• Inspiratory Time
• Must consider the time constant when setting this
  parameter, as well as the disease process
• RDS and other low C conditions need a longer It
  but expiratory time constants are decreased and
  less time needed for exhalation
• BPD and asthma (and other dx with airtrapping)
  require longer expiratory time

36
Initial Parameters, cont

• IE Ratio
• Once the rate and It are set, the IE ratio is
  determined by these settingsshoot for 12
• Becomes increasingly important as rates are
  increased
• Tidal volume
• Not set in pressure ventilationdepends on lung
  characteristics and the driving pressure
  (difference between PIP and PEEP)
• Children are usually volume ventilated at 8-10
  ml/kg

37
Volume vs Pressure Ventilation

• Neonates are pressure ventilated
• Children less than 10kg are also usually pressure
  ventilated
• Children gt10kg may be either volume or pressure
  ventilated
• When pressure ventilating, you can monitor volume
  delivery and adjusting PIP or It will affect Vt
  delivery

38
Changing PaCO2

• Change the driving pressure (difference between
  PIP and PEEP) or the rate
• Changes in PIP are usually by 2 cm H2O at a
  timerate is increased by 2-5 bpm at a time
• Usually, if chest movement is adequate then PaCO2
  is controlled by rate changes
• If volume ventilating, Vt is not usually
  adjustedcontrol PaCO2 with the rate

39
Changing PaO2

• Primary Parameters
• Change FiO2, PEEP, and/or MAP (depends on the
  ventilator you are using)
• PEEP is changed by 2 cm H2O at a time
• FiO2 is changed by 5 at a time
• MAP is changed by 2 at a time
• Secondary Parameters
• It increasing It increases diffusion time
• Rate increasing rate blows off CO2 and
  increases O2
• PIP increasing PIP blows off CO2 and increases
  O2

40
Hazards of MV

• Hazards of O2, PEEP, and CPAP
• Oxygen toxicity
• Absorption atelectasis
• ROP
• BPD
• Barotrauma
• Decreased cardiac output

41
Hazards, cont

• PIP
• Barotrauma
• BPD
• Rate/IE
• Resp alkalosis
• Air leaks/barotrauma
• Decreased V/Q
• Decreased cardiac output

42
Hazards, cont

• General
• Infection
• IVH
• Gastric distension
• Intubation complications

43
Weaning/Extubation

• Wean FiO2 to 0.40
• Wean by 2-5 at a time
• Wean this before other parameters
• Wean PEEP to 3-4 cm H2O
• Wean by 1-2 cm H2O at a time
• Wean PIP
• Wean by 1-2 cm H2O at a time down to 12
• Wean rate
• Wean by 1-5 bpm at a time down to 20
• Once baby is on minimal settings, extubate

44
Failure to wean

• Signs of weaning failure
• Tachycardia
• Bradycardia
• Pallor
• Retractions
• Hypercapnia
• Cyanosis
• If weaning fails, place baby back on the
  parameters used before weaning was attempted and
  treat cause of failure

45
Extubation

• Infant and pediatric tubes are uncuffedif
  theres no leak around the ETT during a mandatory
  breath, theres probably edema presentbe
  prepared to give racemic epi
• Babies may be extubated to CPAP or to a nasal
  cannula
• Peds patients should be weaned to minimal
  settings and then extubated, usually to a nasal
  cannula