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    Guidelines of Mechanic Ventilation in Newborn Infants

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    Jairo Uriel
    This document provides guidelines for different modes of mechanical ventilation for newborn infants, including definitions, settings, and adjustments. It discusses pressure limited, time-cycled continuous flow ventilation like SIMV and pressure support ventilation. It also covers volume guarantee mode which aims for a set tidal volume by adjusting pressure. Modes associated with volume guarantee include SIMV-VG, PS-VG, and AC-VG. Settings are provided for initiating these modes and subsequent adjustments based on patient response. High frequency oscillatory ventilation is also introduced.

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    Guidelines of Mechanic Ventilation in Newborn Infants

    Uploaded by

    Jairo Uriel
    142 views62 pages
    This document provides guidelines for different modes of mechanical ventilation for newborn infants, including definitions, settings, and adjustments. It discusses pressure limited, time-cycled continuous flow ventilation like SIMV and pressure support ventilation. It also covers volume guarantee mode which aims for a set tidal volume by adjusting pressure. Modes associated with volume guarantee include SIMV-VG, PS-VG, and AC-VG. Settings are provided for initiating these modes and subsequent adjustments based on patient response. High frequency oscillatory ventilation is also introduced.

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    This document provides guidelines for different modes of mechanical ventilation for newborn infants, including definitions, settings, and adjustments. It discusses pressure limited, time-cycled continuous flow ventilation like SIMV and pressure support ventilation. It also covers volume guarantee mode which aims for a set tidal volume by adjusting pressure. Modes associated with volume guarantee include SIMV-VG, PS-VG, and AC-VG. Settings are provided for initiating these modes and subsequent adjustments based on patient response. High frequency oscillatory ventilation is also introduced.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    142 views62 pages

    Guidelines of Mechanic Ventilation in Newborn Infants

    Uploaded by

    Jairo Uriel
    This document provides guidelines for different modes of mechanical ventilation for newborn infants, including definitions, settings, and adjustments. It discusses pressure limited, time-cycled continuous flow ventilation like SIMV and pressure support ventilation. It also covers volume guarantee mode which aims for a set tidal volume by adjusting pressure. Modes associated with volume guarantee include SIMV-VG, PS-VG, and AC-VG. Settings are provided for initiating these modes and subsequent adjustments based on patient response. High frequency oscillatory ventilation is also introduced.

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    Guidelines for Mechanical Ventilation of Newborn Infants

    Maroun J. Mhanna M.D.

    Objectives
    Definitions of different modes of ventilation Pressure Limited, Time-Cycled, Continuous Flow mode of Ventilation Volume Guarantee mode of ventilation High Frequency Oscillatory Ventilation (HFOV)

    Definitions
    CMV A/C SIMV PSV CPAP VG

    CMV
    It is a Continuous Mandatory Ventilation :
    Time controlled Time cycled Pressure limited

    flow ventilation

    A/C
    Assist Control:
    Time-controlled Volume triggered Time cycled Pressure limited Continuous flow

    ventilation that is synchronized with each spontaneous patient breath.

    SIMV
    Synchronized Intermittent Mandatory Ventilation:
    Time controlled Volume triggered Time cycled Pressure limited Continuous flow ventilation that is synchronized with patients spontaneous breathing at a the set ventilation rate.

    PSV
    It is a Pressure Support Ventilation:
    Time controlled Volume triggered Flow cycled Pressure limited

    Ventilation that is synchronized with each spontaneous patient breath

    CPAP
    Continuous Positive Airway Pressure
    Spontaneous breathing with positive airway pressure

    VG
    Volume Guarantee
    Volume controlled ventilation

    The ventilator controls inspiratory pressure in order to deliver the preset tidal volume . It may be combined with A/C, SIMV and PSV

    Airway pressure tracings of the four standard volume preset modes. Thick solid lines represent ventilator breaths and thick dotted lines represent spontaneous breaths. The thin dotted lines refer to what the spontaneous pattern would have been without the ventilator breaths. IMV, intermittent mandatory ventilation; SIMV, synchronized IMV.

    Pressure Limited, Time-Cycled, Continuous Flow mode of Ventilation

    Pressure Limited, Time-Cycled, Continuous Flow mode of Ventilation


    SIMV: is the most commonly used mode of ventilation. SIMV: Synchronized Intermittent Mandatory Ventilation:
    the ventilator breaths are triggered by patients inspiratory efforts. Patient can breathe between ventilator breaths (but not all breaths are assisted).

    Pressure Limited, Time-Cycled, Continuous Flow mode of Ventilation


    Ventilator settings:
    PIP (Peak Inspiratory Pressure): 15-25 cm of H2O PEEP (Positive End Expiratory Pressure): 3-5 cm of H2O Inspiratory Time: 0.35-0.45 sec Ventilator Rate: 30-40 / min

    Monitoring:
    the generated Tidal Volume (3-5 ml)

    Pressure Limited, Time-Cycled, Continuous Flow mode of Ventilation


    PiP Increase PiP Decrease PEEP Increase PEEP Decrease Rate Increase Rate Decrease I/E Increase I/E Decrease PCO2 Decrease Increase Increase Decrease Decrease Increase Increase Decrease pH Increase Decrease Varies Varies Increase Decrease Decrease Increase PO2 Increase Decrease Increase Decrease Varies Varies Increase Decrease

    Volume Guarantee mode of ventilation

    Volume Guarantee How does it work ?


    The ventilator automatically adjusts the inspiratory pressure according to changes of compliance, resistance or respiratory drive to achieve a set tidal volume.

    Volume Guarantee How does it work ?

    Erin Browne

    Volume Guarantee Advantage


    Volume Guarantee combines the advantages of pressure limited, time cycled, continuous flow ventilation and volume controlled ventilation ! Volume Guarantee is an option and is available for all triggered ventilation modes of the Babylog 8000 : SIMV SIPPV (A/C) PSV

    SIMV-VG

    VG: Volume Guarantee


    It is a time-cycled, pressure limited mode of ventilation with automatic adjustment of the PiP to achieve a target TV It can be used in conjunction with Pressure Support (PS), Assist Control (AC) or Synchronized Intermittent Mandatory Ventilation (SIMV)

    Advantages of VG
    VG: automatically compensates for acute changes in Compliance, resistance and spontaneous respiratory effort. Ventilator alarms when worsening lung compliance (pneumothorax, atelectasis) or resistance (secretions) PiP is weaned automatically with the improvement of the compliance.

    Indications of VG

    patient with respiratory failure especially when lung mechanics are likely to change rapidly.

    Contraindications of VG mode of ventilation

    If endotracheal tube leak > 30%

    Initial Vent settings of VG


    FiO2: 0.21 0.6 TV: 4-5 ml / Kg PEEP: 4-5 cm (based on BW & GA) Rate: 30-40/min (Based on BW &GA. Higher rate for Low BW & GA)

    Initial Vent settings of VG


    Set Ti at 0.35 sec (0.3-4) Set PiP 1-2 cm above the average PIP needed to generate the target TV (if PIP > 25-30 cm: look for a reason)

    Subsequent Changes
    PiP: needs to be adjusted (increments of 1-2 cm) in response to changing lung mechanics If the flow sensor is removed: the delivered pressure will default to the PiP limit. If infant is persistently tachypneic (> 80 breaths/min):
    If PCO2 is low: consider sedation If PCO2 is normal: consider increasing TV (to decrease the work of breathing related to the ET tube)

    Subsequent Changes
    If low TV alarms repeatedly:
    Increase the PiP limits (by 1-2 cm increments) And investigate the cause of the acute change in lung mechanics (secretions, pulmonary edema, PDA, CHF, atelectasis) Consider a blood gas and a chest X-Ray Consider to increase PEEP temporarily with an acute change in compliance (pulmonary edema, atelectasis, pulmonary hemorrhage)

    PS-VG

    PSV: Pressure Support Ventilation


    This is a time-cycled, pressure limited synchronized mode Each spontaneous breath is supported A back up rate is set to maintain adequate support in case of apnea (40/min in term infants and 40-50/min in preterm infants). Inspiration is ended when inspiratory flow declines to 15% of peak flow. Inspiratory hold is eliminated and the chance of active expiration against positive pressure is minimized

    Advantages of PSV
    The infant has more control over his respiratory pattern PSV maintains optimal Ti

    Indication of PSV

    Any patient with respiratory failure

    Contraindications of PSV

    Atelectasis, and the need for a prolonged Ti (>0.2 sec).

    Initial Vent settings for PSVG


    FiO2: 0.21 0.6 TV: 4-5 ml / Kg PEEP: 3-6 cm Rate: 30-50/min Set Ti at 0.4 sec for infants < 1000 g Set PiP 1-2 cm above the PIP needed to generate the target TV.

    Working Principle of PSV


    The ventilator supports each breath of the patient The inspiratory pressure support determines the amount WOB supplied by the ventilator TI is automatically adjusted to the patient's inspiratory time

    Pressure Support Ventilation Progress of Weaning by PSV

    Pinsp

    PEEP

    PSV: Working Principle of Breath Termination

    Erin Browne

    PSV: "ETT-Leakage can be a problem

    No Termination !

    leakage flow
    termination criteria Onset of inspiration

    LAPS Leak Adapted Pressure Support

    leakage flow
    Onset of inspiration

    termination criteria automatically adapted to leak flow

    Onset of expiration

    Pressure Support Ventilation "Let the patient decide !"


    Let your patient decide over Start of Inspiration Depth of Inspiration Duration of Inspiration Frequency / Pattern of Respiration Minute Volume

    Pressure Support Ventilation "Let the patient decide !"


    This leads to total synchrony less fighting the ventilator less need for sedation slower rates larger volumes lower MAP at same MV adequate training for respiratory muscles ability to sigh

    Pressure Support Ventilation Clinical Benefits


    Lower / more effective WOB Lower Oxygen Cost of Breathing Endurance training of the diaphragm Shorter time of weaning Compensation of added WOB due to Resistance of ET-tube and Patient Circuit

    Pressure Support Ventilation Clinical Benefits


    Reduction of active expiration More natural pattern of breathing Lower incidence of Pneumothoraces Improved patient comfort Stimulation of spontaneous breathing

    AC-VG

    AC-VG
    Assist Control Volume Guarantee The ventilator supports each breath of the patient with a preset volume and inspiratory time Risk of hyperventilation and hypocapnea

    Modes associated with VG


    SIMV-VG:
    Decreases PIP (auto-wean) Abnormal PCO2 (in 4-8%) Increased WOB in comparison to AC-VG

    PS-VG:
    Decreases PIP Infants with a strong resp. drive are liable to hyperventilation Reduces acute inflammatory responses in RDS

    Modes associated with VG


    AC-VG:
    Assist Control Volume Guarantee Decreases PiP Increases the risk of hyperventilation (low PCO2 in 20%)

    VG ventilation Subsequent Adjustments


    Tidal Volume: may need to be adjusted by 0.5 ml/kg:
    If the PaCO2 is high: increase the TV If the PaCO2 is low: decrease the TV (DO NOT decrease the TV < 3 ml/kg (risk of atelectasis) If the PaO2 or Pulse oxymetry is low: increasing the TV may increase the min ventilation and improve oxygenation.

    VG ventilation Subsequent Adjustments


    PIP limit: may need to be adjusted by 1-2 cm of H2O:
    The targeted TV is not met: the ventilator alarm will display LOW TV: increase the PIP limit. If the Flow sensor is removed: (such as during administration of surfactant or a nebulized medication, the working pressure defaults to the PIP limits): decrease PIP limit to match the average working pressure (that was needed to generate the targeted TV).

    VG ventilation Subsequent Adjustments


    If persistent tachypnea (RR> 80/min):
    If PaCO2 is normal: Consider increasing TV target (even if PaCO2 and pH are normal, in this situation the infant usually generates a TV larger then the targeted TV). Tachypnea suggests increased work of breathing. If PaCO2 is low: Consider sedation

    VG ventilation Subsequent Adjustments


    If PIP has to be increased substantially and repeatedly:
    Verify that the TV measurement is accurate: assess patients chest rise, obtain a blood gas Determine the cause of the acute change in lung mechanics: examine the patient, obtain a chest XRay.

    High Frequency Oscillatory Ventilation (HFVO)

    High Frequency Oscillatory Ventilation (HFVO)


    Provides Vt less than the anatomic dead space Commonly used frequencies of 10 to 15 Hz. Active expiration is an intrinsic part of their design

    HFVO (Indications)
    Pulmonary air leaks, including PIE (Pulmonary Interstitial Emphysema) Respiratory failure and/or hypoxemia on conventional ventilators

    HFVO (Initial Settings) Mean Airway Pressure (MAP)


    MAP : controls oxygenation Preterm Infants:
    In diffuse alveolar disease: Conventional ventilator (CV) MAP plus 1-2 cm H2O. In PIE/air leak: Same CV MAP (or less)

    Term Infants:
    In diffuse alveolar disease CV MAP plus 2 to 4 cm H2O In PIE/ air leak: Same CV MAP

    HFVO (Initial Settings) Amplitude

    Amplitude: controls ventilation It should be set at 10-30 cm H2O Adjust upward in 2-4 cm H2O Increments until chest wall vibrates visually

    HFVO (Initial Settings) Frequency


    1 Hz = 60 breaths / min Increasing frequency: increased PCO2 Decreasing frequency: decreased PCO2 and increased oxygenation BW < 1000 grams: start at 15 Hz. BW 1000-2000 grams: start at 12 Hz. BW > 2000 grams: start at 10 Hz. Term Infant with Meconium Aspiration Pneumonia: start at 6-10 Hz.

    HFVO (Management)
    Obtain a chest X-Ray within 1 hour of initiation of HFVO to ascertain degree of lung expansion ( 8-9 posterior ribs) Consider chest X-Ray after changing MAP by 4 cm of H2O or FiO2 by > 10-20%.

    HFVO (Management: To change PCO2)


    To change PCO2: Adjust Amplitude
    Increasing amplitude: will decrease PCO2. Decreasing amplitude: will increase PCO2.

    If PCO2 too high check for:


    Pneumothorax Mechanical obstruction , ET placement Atelectasis Need for sedation / paralysis.

    HFVO (Management: To change PO2)


    To change PO2: adjust
    FiO2 MAP (increasing MAP will increase PO2 unless lungs are over-expanded). Suction

    If PO2 too low: check for Pneumothorax Mechanical obstruction, ET placement Atelectasis / hypotension Need for sedation / paralysis

    HFVO (Weaning: if adequate PO2)


    Start weaning FiO2 If FiO2 < 60%: decrease MAP by 1 cm every 6-12 hours (correlate with chest X-Ray to evaluate lung expansion). If MAP 7-9 cm of H2O: consider switching to a conventional mode of ventilation or extubation.

    HFVO (Weaning: if adequate PCO2)

    Wean amplitude by 2-5 cm of H2O till


    Desired PCO2 is reached Or patient is ready to be switched to a conventional mode of ventilation Or ready for extubation

    Conclusions
    Definitions of different modes of ventilation Pressure Limited, Time-Cycled, Continuous Flow mode of Ventilation Volume Guarantee mode of ventilation High Frequency Oscillatory Ventilation (HFOV)

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