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Choice of Oscillator & Jet Ventilator (15 min) Choice of High Flow & Nasal CPAP (20 to 30 min) Trials in 2008 PowerPoint Presentation
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Choice of Oscillator & Jet Ventilator (15 min) Choice of High Flow & Nasal CPAP (20 to 30 min) Trials in 2008 - PowerPoint PPT Presentation


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Respiratory Highlights 2008 BWH NICU Nursing Blitz. Choice of Oscillator & Jet Ventilator (15 min) Choice of High Flow & Nasal CPAP (20 to 30 min) Trials in 2008 of CPAP & SIPAP (5 min) 4. ROP Data & O2 Saturation Alarms (10 min).

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Presentation Transcript
slide1

Respiratory Highlights 2008

BWH NICU Nursing Blitz

  • Choice of Oscillator & Jet Ventilator (15 min)
  • Choice of High Flow & Nasal CPAP(20 to 30 min)
  • Trials in 2008 of CPAP & SIPAP

(5 min)

4. ROP Data & O2 Saturation Alarms

(10 min)

slide7

Intracranial Blood Pressure Elevated

Elevated Intrathoracic

Pressure

( High PEEP & Paw)

Venous Return Impeded

Hepatic Veins Dilated

slide8

HFV Pressure Attenuation

Amplitude may attenuate around a fixed Paw

20

O

2

CV

cm H

15

10

Tracheal

Pressure

HFOV

5

HFJV

0

Proximal

Distal

Airways

Paw

slide9

Exhalation with HFOV

  • Active exhalation, as with high-frequency oscillation (HFO), can lead to gas trapping by lowering intraluminal pressure disproportionately below pressure in surrounding alveoli, thereby collapsing more proximal airways before exhalation is complete.
  • For that reason, users of HFO typically operate at higher mean airway pressures than those used with HFJV.
  • Elevating the baseline pressure during HFO, "splints" the airways open while gas is actively withdrawn from alveoli.
slide10

Exhalation with HFJV

CO2

CO2

CO2

CO2

  • During HFJV, exhaled gas swirls outward around the incoming gas.
  • The exhaled gas sweeps through the CO2-rich deadspace gas.

CO2

CO2

  • This action may help evacuate CO2 and enhance ventilation.
  • Small VT is readily exhaled without trapping during short exhalation time.
slide11

CHOKE POINTS may develop when:

  • airways lack structural strength  
  • the chest is squeezed  
  • gas is sucked out of the airway
slide12

+

PEEP

+

+

+

  • Back pressure (High PEEP/Paw) may splint open the airway and allow gas to exit

+

the 6 jet fundamentals
The 6 Jet Fundamentals
  • HFJV P (PIP - PEEP)  PaCO2
    • HFJV Rate is secondary
  • FRC and MAP  PaO2
  •  PEEP to avoid hyperventilation and hypoxemia
  • If  CV Rate  oxygenation, PEEP is probably too low
  •  CV settings whenever possible
    • Especially when airleaks are a concern
  •  FiO2 before PEEP until FiO2 < 0.5
slide14

Ventilation and HFJV

25

PIP

20

15

P

10

PEEP

5

0

time

Raising PIP or lowering PEEP VT which PCO2

slide15

Recruitment Strategy for RDS

  • Find the Critical Opening Pressure of the alveoli
  • Optimize PEEP to stabilize the alveoli
  • Reduce PIP as recruitment proceeds
  • HFJV may reduce volutrauma in surfactant deficient lungs
slide16

HFJV - RDS Study Summary*

  • HFJV reduced the incidence of BPD at 36 wks PCA.
  • HFJV reduced PIP and P compared to CV.
  • HFJV "optimal-volume strategy" resulted in less hypo- carbia and better oxygenation than low-volume strategy.
  • HFJV "optimal-volume strategy" was associated with lower incidence of severe neuroimaging abnormalities compared to low-volume strategy.

* Keszler, et al. Peds 1997; 100:593-599.

hfo hfjv

HFO / HFJV

  • choice
  • PIE despite HFO
  • Air leak syndromes
  • Excessive secretions
  • Hemodynamic compromise
  • When HFOV fails

choice

High PIP & FiO2 conventional

PIE per CXR

Need for nitric oxide

When Jet fails

slide18

Oxygenation –

  • HFO
    • FiO2
    • MAP
  • Jet-Particularly effective with non-homogeneous disease.
    • FiO2
    • PEEP
    • CV rate
    • CV PIP
    • CV I time
slide19

Ventilation –

  • Jet
    • Raise PIP
    • Raise rate
    • Change PEEP
  • HFO
    • Amplitude
    • MAP to optimize position on inflation curve
    • Rate (lower to drop PaCO2)
slide20

Bubble CPAP

HF Nasal

Cannula

slide21

RDS, apnea &

post-extubation support

http://www.surfneon.com/cpapbwh.swf

slide22

B

U

B

B

L

E

C

P

A

P

slide24

DuoDerm

  • Nare protection from CPAP prongs
  • Nasal seal for CPAP prongs
slide26

CPAP

design

slide27

for a

contented

family…

CPAP

design

slide28

“On the basis of our findings, we suggest that high-flow nasal cannula should not be used as a routine replacement for CPAP therapy.”

slide31

Tight cannula obstructs nares.

Cannula flow will not meet baby’s flow demand.

Flow directed into nasopharynx not at stable pressure

slide32

Anatomic variants of nare size & structure alter

cannula seal. Clinically relevant pressure is achieved

only on the smallest of babies.

slide33

Poor humidification

  • Airway dysfunction
  • mucocilliary transport
  • Increased fluid osmolarity
  • Promotion of bronchospasm
  • secretion viscosity
  • Impaired nutrition
  • Impaired growth
  • Mucosal injury
  • infection
slide37

Maine Med Portland

St/ Margaret’s Dorchester

slide38

MY SAT

LIMITS ARE:

HIGH: 93

LOW: 85

  • Ford S. Leick-Rude MK, Meinert K, Anderson B, Sheehan M, Haney B, Leeks S, Simon S, Jackson J. Overcoming Barriers to Oxygen Saturation Targeting. Pediatrics 2006 118 Suppl 2:S177-186
  • Phelps, D., Goldsmith, JP, Retinopathy of Prematurity Hot Topics Dec. 4, 2007