NEONATAL VOLUME VENTILATION CLINICAL GUIDELINE V2.0

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Dustin Hubbard
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1 NEONATAL VOLUME VENTILATION CLINICAL GUIDELINE V2.0

2 Summary Commence ventilation Set up ventilator; PTV rate 40, Ti 0.36, TTV 5ml/kg, Trigger sensitivity 0.2, PiP limit 30 mbar Consider SIMV if risk of ongoing tachypnoea Assess working PiP and adjust Pip limit to 5 mbar above this Set lower and upper tidal volume alarm limits to 4 and 8 ml/kg respectively Check blood gas within 1 hour to assess adequacy of ventilation Optimise ventilation Adjust ventilation if necessary by changing tidal volume in 0.5ml/kg increments as required (or by altering rate if using SIMV mode) Troubleshooting 1. Tidal volume not achieved, consider: a. Tube position b. Tube obstruction c. Increasing PiP limit d. Increasing inspiratory time 2. Large leak a. Recalibrate flow sensor b. Upsize Et tube c. Turn off TTV Page 2 of 9

3 1. Aim/Purpose of this Guideline To provide guidance on the standard approach to ventilation of infants on the neonatal unit. 2. The Guidance Volume ventilation in preterm infants has been shown in systematic review to lead to a significant reduction in combined death/ bronchopulmonary dysplasia, duration of ventilation, pneumothoraces, hypocarbia and periventricular leukomalacia/severe intraventricular haemorrhage when compared to conventional pressure limited ventilation. The following is a simple guide to commencing volume ventilation in neonates. Volume ventilation uses a fixed target tidal volume decided by the clinician with the ventilator providing varying peak inspiratory pressures (PIP) to achieve this each breath. The SLE 5000, names this mode Targeted Tidal Volume (TTV). TTV is the suggested mode in preterm infants with homogenous lung disease (i.e. surfactant deficiency lung disease). In heterogeneous lung disease, TTV may be less effective than pressure-limited ventilation. Commencing TTV 1. Select PTV with a backup rate of 40bpm, this will support every breath. For some infants SIMV may be more appropriate to avoid over ventilation. 2. Use an inspiratory time of 0.36 seconds for preterm babies. 3. Set trigger sensitivity to 0.2 (may need to be increased if auto-triggering ) 4. Turn on TTV. 5. Set leak compensation to 20% 6. Tidal volume of 5ml/kg is normally an appropriate starting point; 4 8ml/kg are minimum and maximum volumes. 7. Input the tidal volume you have calculated. 8. A PIP limit of 30 mbar for a premature baby on arrival to the neonatal unit is suggested. 9. Note the working PIP (average delivered PIP) 10. Then reset the PIP limit 5 mbar above the working PIP. 11. Set lower and upper tidal volume alarm limits to 3.5-8ml/kg respectively. 12. Check to see whether the tidal volume desired is being delivered. 13. If not reaching desired volume consider tube position and leak, tube disconnection, tube obstruction, and then increasing PIP limit, or possibly increasing inspiratory time. 14. If there is a large leak, recalibrate or change flow sensor prior to upsizing tube as the sensor may be providing an inaccurate reading. 15. Perform a blood gas as usual to assess adequacy of ventilation. 16. If not adequate, increase targeted tidal volume by 0.5ml/kg increments with repeated gases until satisfactory. 17. If respiratory rate is >60, consider changing to SIMV with TTV to avoid over ventilation. Page 3 of 9

4 This mode is normally self-weaning with the pressure required to give the target volume, reducing as the baby improves. If tidal volume has previously been set higher than 5ml/kg, then consider weaning to 4-5ml/kg. Once the baby is receiving 4 5ml/kg tidal volume with mean airway pressure consistently < 9-10 mbar, check caffeine loaded if appropriate and consider extubation. 3. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Key changes in practice recommended by guidance Dr Chris Warren Consultant Paediatrician Audit Lead Audit To be included in neonatal clinical audit programme Findings reported to the directorate audit meeting / governance meeting As dictated by audit findings Child Health Directorate Audit and Clinical Guidelines meeting Dr Paul Munyard, Consultant Paediatrician Required changes to practice will be identified and actioned within 3 months of audit. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 4 of 9

5 Appendix 1. Governance Information Document Title Date Issued/Approved: May 2018 Neonatal Volume Ventilation Clinical Guideline V2.0 Date Valid From: May 2018 Date Valid To: May 2021 Directorate / Department responsible (author/owner): Contact details: Stuart Maxwell ST1 Paediatrics, Chris Warren ST8 Paediatrics, Paul Munyard, Consultant Paediatrician. Brief summary of contents Neonatal volume ventilation - CLINICAL GUIDELINE Suggested Keywords: Target Audience Executive Director responsible for Policy: Neonatal Ventilation, Neonate, TTV, Volume ventilation RCHT CFT KCCG Executive Director Date revised: April 2018 This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Neonatal Volume Ventilation V1.0 Paediatric Consultants Neonatal Audit and Guidelines Meeting Divisional Manager confirming approval processes Name and Post Title of additional signatories Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Sam Probets Not Required {Original Copy Signed} Name: {Original Copy Signed} Internet & Intranet Intranet Only Page 5 of 9

6 Document Library Folder/Sub Folder Links to key external standards Related Documents: Training Need Identified? Clinical / Neonatal None Wheeler K, Klingenberg C, McCallion N, Morley CJ, Davis PG. Volume-targeted versus pressure-limited ventilation in the neonate. Cochrane Database of Systematic Reviews 2010, Issue 11 Fox G, Hoque, N, Watts T. Volumetargeted ventilation. In: Oxford Handbook of Neonatology. Oxford University Press 2010 No Version Control Table Date Version No Summary of Changes Changes Made by (Name and Job Title) April 2015 V1.0 Initial issue April 2018 V2.0 Update of flow chart Chris Warren, Paediatric Consultant All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 6 of 9

7 Appendix 2. Initial Equality Impact Assessment Form This assessment will need to be completed in stages to allow for adequate consultation with the relevant groups. Name of Name of the strategy / policy /proposal / service function to be assessed V2.0 Directorate and service area: Is this a new or existing Policy? Child Health Department Existing Name of individual completing assessment: Telephone: Chris Warren Policy Aim* To support staff on the Neonatal Unit and improve consistency of practice. Who is the strategy / policy / proposal / service function aimed at? 2. Policy Objectives* See above. 3. Policy intended Outcomes* See section *How will you measure the outcome? Clinical Audit. 5. Who is intended to benefit from the policy? 6a Who did you consult with Staff and patients Workforce Patients Local groups External organisations Other b). Please identify the groups who have been consulted about this procedure. Please record specific names of groups What was the outcome of the consultation? Page 7 of 9

8 7. The Impact Please complete the following table. If you are unsure/don t know if there is a negative impact you need to repeat the consultation step. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence Age Sex (male, female, trans-gender / gender reassignment) Race / Ethnic communities /groups Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions. Religion / other beliefs Marriage and Civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major this relates to service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No x 9. If you are not recommending a Full Impact assessment please explain why. Page 8 of 9

9 Signature of policy developer / lead manager / director Chris Warren Date of completion and submission 25/04/2018 Names and signatures of members carrying out the Screening Assessment 1. Chris Warren 2. Human Rights, Equality & Inclusion Lead Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD This EIA will not be uploaded to the Trust website without the signature of the Human Rights, Equality & Inclusion Lead. A summary of the results will be published on the Trust s web site. Signed Chris Warren Date 25/04/2018 Page 9 of 9

Volume Targeted Ventilation on the Neonatal Unit

Volume Targeted Ventilation on the Neonatal Unit This guidance does not override the individual responsibility of health professionals to make appropriate decision according to the circumstances of the individual patient in consultation with the patient