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Neo/Peds MV

mechanical ventilation basics

Characteristics of CF? Chronic obstruction and infection of a.w.'s. Exocrine pancreatic insufficiency (maldigestion and small bowel obstruction) elevated sweat chloride concentrations
Diagnosis of CF Sweat choloride, CFTR gene analysis, nasal elctrical potential difference, newborn screening
Tx of disease? the medications usually given? SABA, Hpertonic saline (SABA can be mixed together with hupertonic) Vest/flutter/etc, Pulmozyme (not to be mixed) TOBI (always given last)
Physiological objectives for neo/ped MV? decrease VILI, decrease WOB, optimize lung volume, improve oxygenation and manipulate alveolar ventilation
Importance of MAP avg pressure exerted on a.w. and lungs from the beginning of inspiration until the beginning of next inspiration, important tool to monitor babies oxygenation, babies are very much affected by increases with MAP ( increased MAP can lead to hemorrhaging)
definition of opening pressure the lower inflection point, to open an alveolus a certain amount of pressure must be applied to alveoli
definition of driving pressure created by ventilator, difference b/w the PEEP and PIP, basically the delta P responsible for Vt, important for dynamic compliance
Normals for Compliance for a newborn about 2.5 - 5 ml/cmH2o
Normals for resistance about 20 -30 cmH2o/L/sec in a spontaneously breathing neonate, basically driving pressure needed to move gases through aw at a constant flow rate
Clinical application of Resistance the RADIUS of the aw is the most powerful influence on airway resistance, uncuffed tubes in neo/peds means always a leak, always a little loss in volume
Factors that increase airway resistance? Bronchospasm, airway secretions, edema of aw walls, inflammation, ETT or trach tubes
Hinski "reasons" for MV (VOPS) Ventilation, Oxygenation, Protection, Secretions
Partial Ventilatory Support modes? CPAP, PSV, SIMV
CPAP for neonates/peds methods of application? neonates: nasal pharyngeal or nasal prongs Pediatrics: nasal or full face mask
Indication for CPAP for neonates RR greater than 30% of normal, paradoxical chest wall movement, grunting, nasal flaring and cyanosis, CO2 less than 60 and PH greater than 7.25
Contraindications for neonates of CPAP prolonged apnea, untxd pneumo, hemodynamically unstable, unilateral pulmonary problem, mouth/face abnormalities or post surgery
Hazards of CPAP make PPHN worse, Increased ICP, decreased CO, may be ineffective if neonate weighs less than 1,000-1,200 grams
CPAP settings for infants? "Perfect World" 4-6 cmH2o starting point, flow rate of 8LPM (5cmcpap), higher Fio2 initially (wean down ASAP) increased levels by increments of 1 or2 cm, levels of 8-9 begin to show need for MV and level of 12cmH2o is max pressure attainalbe
CPAP weaning? Pt stable, no incidents of apnea, acceptable ABGs and CXR, decrease Fio2 1% at a time (until 0.4 maybe 0.6) then pressure incrememnts of 1-2 cm H20 until 2-3 cmH2o are reached
Si PaP? "sigh" positive aw pressure, allows infant to breath spontaneously at two seperate CPAP levels
Most useful blade type for intubation of neo/peds? Miller blade: of larger tongue and high epiglottis make straight blade most useful
Suctioning parameters suction level for neonates: -60 t0 -80 larger infants and children : -80 to -100 1 minute of preoxygenation required Peds: 100% o2 Neonates: increase fio2 by 10-15%
Most commonly used mode for peds and infants? infants: PCV-SIMV w/PS Peds: VCV-SIMV or PCV-SIMV both w/ PS
Targeted tidal volumes for infants and children? Infant: 5-7 ml/kg children: 6-8 ml/kg
freq and i times? RR set: 20, actual : 40-60 bpm passsive hyercapnia (45-55 mmhg Co2) Insp times: infants: >0.3 sec older children: up to 1 second
Parameters for neonates with normal lungs? Vt:6-7ml/kg PIP:10-20 cm Frq:10-20 itime: >0.3 sec etime: >0.5 sec PEEP: none unless 2-4 cm Insp Flow:5-8 L/min Fio2:0.4 Flow HAS to be 2X minute ventilation!
Parameters for neonates with LOW COMPLIANCE? Vt:5-7 ml/kg PIP:25-30 cm Freq:30-60 bpm I:E: 1:1 or 1:2 PEEP: 2-4 cm or up to 8-10 cm Insp. flow: 5-8 L/min Fio2: 0.4 (may need to be increased)
HFOV freq and settings? freq: 3-15 Hz, MAP up to 20, power set enought to get a "wiggle", power 2-7 amps, increased power=increased vt
Inhaled Nitric Oxide? selective pulmonary vasodilator, initial dose of 20 ppm, more than 20 does nothing but increase risk of methohemoglobin, decreased SLOWLY bc of High incidence of rebound pulmonary hypertension
O. I. (oxygen Index) values and formula? if OI is >25, indication for INO MAPxFio2% /PaO2
What is ECMO? prolonged but temporary heart and lung support, used for pts with severe, REVERSIBLE resp/cardiac failure
VV ECMO? Veno-Venous ECMO, pulmonary bypass ONLY, only 1 surgical site(jugular), blood drained and goes back to RA, VVECMO requires good cardiac function, Avoids cannulation of carotid artery Disadvantages: doesn't provide direct circulatory support/systemic 02
VA ECMO? Veno-arterial ECMO, heart and lungs bypassed, 2 surgical sites (RA and R carotid artery) provides lung and cardiac support, carotid artery doesn't ever heal or work again! Disadvantages: ABG interp, two vessels used
Selection criteria for ECMO? >34 wks gestational age >1.8 Kg REVERSIBLE disease MV for less than 14 days staticus asthmaticus Failure of max medical management (nothings worked)
Excluded from ECMO a lot of neurological problems major IC hemorrage lethal malformation severe neuro injury uncontrollable coagulopathy poor prognosis
clincial indications for ECMO OI >40 on 2 or more ABG Pao2 <40 for 4hrs on 100%fio2 can't fix metabolic acidosis pulmonary or cardiac failure, progressive inability to come off cardiopulmonary bypass
ECMO complications Hemorrhage, CNS damage, SZ, edema, cardiac dysrhythmia, renal failure, hyperbilirubemia, sepsis
Pediatric ECMO Managament: Pulmonary? goals: decrease further lung damage, oxygen toxicity, get "lung rest". Peak Press: limited to 30 cm, Vt 4-6 ml/kg, RR 5-10 bpm, PEEP 12-15, goal Fio2 0.21, CO2 55-65, Spo2 >88%, 3-5 days min for ARDS, NO bagging!
Weaning off ECMO? increasing pts sats, decrease ECMO flow, adequate ABG, Trial off(clamp it, see if baby circulates their own blood), improved BP, perfusion, weaning pressor support, serial ECHOS show improving function
Created by: phxgrl