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University of Minnesota Children’s Hospital. Neonatal Mechanical Ventilation. Mark C Mammel, MD. OF MINNESOT A. Mechanical ventilation. What we need to do Support oxygen delivery, CO 2 elimination Prevent added injury, decrease ongoing injury Enhance normal development.

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neonatal mechanical ventilation

University of Minnesota

Children’s Hospital

Neonatal Mechanical Ventilation

Mark C Mammel, MD

OF MINNESOTA

mechanical ventilation
Mechanical ventilation
  • What we need to do
    • Support oxygen delivery, CO2 elimination
    • Prevent added injury, decrease ongoing injury
    • Enhance normal development
mechanical ventilation3
Mechanical ventilation
  • Support oxygen delivery, CO2 elimination
    • Headbox O2
    • Cannula O2
    • CPAP ± IMV
    • Intubation, ventilation
mechanical ventilation4
Mechanical ventilation
  • Prevent added injury
    • Minimize invasive therapy
    • Optimize lung volume
    • Target CO2, O2
    • Use appropriate adjuncts
    • Manage fluids and nutrition
mechanical ventilation5
Mechanical ventilation
  • Enhance normal development
    • Manage fluids and nutrition
    • Encourage patient-driven support
    • Maintain pulmonary toilet- carefully
mechanical ventilation7
Mechanical ventilation
  • Key concepts:
    • Maintain adequate lung volume
      • Inspiration: tidal volume
      • Expiration: End-expiratory lung volume
    • Support oxygenation and CO2 removal
      • Oxygenation: adequate mean airway pressure
      • CO2 removal: adequate minute ventilation
mechanical ventilation8
Mechanical ventilation
  • Key concepts:
    • Optimize lung mechanical function
      • Compliance: ∆V/∆P
      • Resistance: ∆Flow/∆P
      • Time constant: C x R
slide10

Boros SJ et al:

J Pediatr1977; 91:794

mechanical ventilation mode classification
Mechanical Ventilation:Mode classification

A. Trigger mechanism

  • What causes the breath to begin?

B. Limit variable

  • What regulates gas flow during the breath?

C. Cycle mechanism

  • What causes the breath to end?

B

C

A

slide14

A. Inspiratory Trigger Mechanism

  • Time
    • Controlled MechanicalVentilation – NO patient interaction
  • Pressure
    • Ventilator senses a drop in pressure with patient effort
  • Flow
    • Ventilator senses a drop in flow with patient effort
  • Chest impedance / Abdominal movement
    • Ventilator senses respiratory/diaphragm or abdominal muscle movement
  • Diaphragmatic activity
    • NAVA- Neurally adjusted ventilatory assist
slide15

B. Limit Variable

Ti

Ti

Pressure

A. Pressure limited

Volume

B. Volume limited

A

B

slide16

C. Cycle MechanismWhat causes the breath to end?

Ti

Ti

Ti

  • A. Time
    • All ventilators
  • B. Flow
    • Pressure support modes
  • C. Volume
    • Adult / pediatric ventilators

Pressure

Flow

Volume

A

B

C

slide20

Mechanical ventilation:

Which vent?

  • Conventional
    • Dräger Babylog 8000
    • Avea
    • Servo i
  • High frequency
    • SensorMedics oscillator
    • Bunnell HFJV
conventional ventilation
Conventional Ventilation
  • Modes:
    • CPAP
      • +/- Pressure support (PSV)
    • IMV/SIMV
      • +/- Pressure support (PSV), volume targeting
    • Assist/control (PAC)
      • +/- volume targeting
continuous positive airway pressure cpap
Continuous positive airway pressure: CPAP
  • Goal:
    • Support EELV in spontaneously breathing infant (optimize lung mechanics)
  • Delivery:
    • NeoPuff, other dedicated CPAP devices
    • HFNC
    • Using mechanical ventilator
    • May be done noninvasively or via ET tube (HFNC in extubated patients only)
  • Patients:
    • Newborn infants ≥26 wks with early distress
    • Infants in NICU with new distress or apnea
    • Extubated infants
continuous positive airway pressure cpap23
Continuous positive airway pressure: CPAP
  • Setup:
    • NeoPuff, other dedicated CPAP devices:
      • Nasal prong interface
      • Set PEEP (4-6 cm H2O most common)
        • SiPAP: special type of CPAP. Uses 2 levels, usually 2-4 cm H2O different
    • HFNC
      • Nasal cannula interface
      • 2-4 L/min flow
    • Monitoring
      • CPAP: airway pressure displayed and alarmed
      • HFNC: none
slide24

Early CPAP

  • Columbia Presbyterian

500-1500 gm Infants: Variation in CLD

*

%

*

*p<0.0001

*

*

Van Marter et al. Pediatrics 2000;105:1194-1201

intermittent mandatory ventilation imv simv
Intermittent mandatory ventilation: IMV/ SIMV
  • Goal:
    • Support EELV and improve Ve in spontaneously breathing infant requiring intubation
    • Eliminate breath-breath volume variation, cerebral blood flow abnormalities, allow patient control via synchronization of SOME breaths
  • Delivery:
    • Using mechanical ventilator
    • May be done noninvasively or via ET tube
  • Patients:
    • Newborn infants requiring intubation
    • Extubated infants with persistent distress
intermittent mandatory ventilation imv simv26
Intermittent Mandatory Ventilation: IMV/ SIMV
  • Setup:
    • ET tube interface
    • Variables:
      • Rate- range 15-60 bpm; always synchronized
      • Volume- target volume 4-7 mL/kg
      • Pressure- Set peak pressure limit (usually 30 cmH2O). Pressure then adjust based on volume. Set PEEP 5-7 cmH2O
      • Time- set Ti at 0.3 – 0.5 sec based on pt size
    • Monitoring
      • Dynamic. Multiple alarm settings. All measured and calculated parameters may be displayed and trended
assist control pac
Assist/control: PAC
  • Goal:
    • Support EELV and improve Ve in apneic or spontaneously breathing infant requiring intubation
    • Eliminate breath-breath volume variation, cerebral blood flow abnormalities, allow patient control via synchronization of ALL breaths
  • Delivery:
    • Using mechanical ventilator
    • Done via ET tube
  • Patients:
    • Newborn infants requiring intubation
assist control pac30
Assist/control: PAC
  • Setup:
    • ET tube interface
    • Variables:
      • Rate- set minimum acceptable rate, 40-60 bpm; actual rate depends on patient effort
      • Volume- target volume 4-7 mL/kg
      • Pressure-
        • Peak pressure: Set limit (usually 30 cmH2O). Pressure then adjust based on volume.
        • PEEP: 5-7 cmH2O
      • Time- set Ti maximum at 0.3 – 0.5 sec based on pt size. Actual Ti varies with lung mechanics. Te varies with rate
    • Monitoring
      • Dynamic. Multiple alarm settings. All measured and calculated parameters may be displayed and trended
conventional ventilation32
Conventional Ventilation
  • Variables- What does what?
    • Minute ventilation (Ve): PaCO2
    • Ve = RR x Vt
      • Vt changes with changing lung mechanics
      • Tools to change: PIP, PEEP, Ti, Te
    • Oxygenation: PaO2, SaO2
    • Mean airway pressure (Paw)
      • Oxygenation varies with lung volume, injury
      • Tools to change: PIP, PEEP, Ti, Te
conventional ventilation33
Conventional Ventilation
  • Variables- What does what?
    • Minute ventilation (Ve): PaCO2
    • Ve = RR x Vt
      • Vt changes with changing lung mechanics
      • Tools to change: PIP, PEEP, Ti, Te
conventional ventilation37
Conventional Ventilation
  • Boros SJ, et al. Pediatrics 74;487:1984
  • Mammel MC, et al. Clin Chest Med 1996;17:603
conventional ventilation38
Conventional Ventilation
  • Variables- What does what?
    • Oxygenation: PaO2, SaO2
    • Mean airway pressure (Paw)
      • Oxygenation varies with lung volume, injury
      • Tools to change: PIP, PEEP, Ti, Te
lung volume
Lung Volume
  • Optimize lung volume
    • Define opening pressure, closing pressure, optimal pressure: dependent on estimation of lung volume
    • Problems: no useful bedside technology to measure either absolute or change in lung volume

Pmax

Popt

Volume

Pcl Pop

Pressure

lung volume41
Lung Volume
  • Optimize lung volume
    • SaO2 as volume surrogate

Tingay DG et al. Am J Resp Crit Care Med 2006;173:414

mechanical ventilation47
Mechanical ventilation
  • What we know: general
    • Support affects pulmonary, neurologic outcomes
      • Greater impact at lower GA
      • VILI is real
      • Less is usually more
mechanical ventilation48
Mechanical ventilation
  • What we need to know
    • Who needs support?
    • Who needs what support?
      • Risk/benefit for various modalities
    • When (how) do you wean/stop support?