Neonatal Assisted Ventilation. Haresh Modi, M.D. Aspirus Wausau Hospital, Wausau, WI.

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1 Neonatal Assisted Ventilation Haresh Modi, M.D. Aspirus Wausau Hospital, Wausau, WI.

2 History of Assisted Ventilation Negative pressure : Spirophore developed in 1876 with manual device to create negative pressure chamber

3 History of Assisted Ventilation Negative pressure : Dr. Philips Drinker used this idea to develop Iron lung in 1929, So many survived Polio out break Some to date.

4 Woman in iron lung celebrates 60th birthday After contracting polio, Dianne Odell has spent most of her life in machine Updated: 3:37 p.m. CT Feb 21, 2007 Associated Press Report JACKSON, Tenn. - A Jackson woman who contracted polio 57 years ago and continues to rely on an iron lung to breathe recently celebrated her 60th birthday, defying doctors' expectations that she could live so long and so fully. Dianne Odell, who turned 60 last week, is among only 30 to 40 people in the U.S. who depend on the devices.

5 History of Assisted Ventilation Positive Pressure : Respirator Kit used to revive apparently dead by blowing air into the lungs or rectum in 1770s in London

6 History of Assisted Ventilation Positive pressure : The Aerophore pulmonaire :- developed by French Obstetrician for short term ventilation of newborns in 1879

7 History of Assisted Ventilation Positive pressure : The Fell-O Dwyre apparatus developed in New York for intermittent positive pressure ventilation, 1896

8 Neonatal Assisted Ventilation 1. Applied Pulmonary Mechanics 2. Gas Exchange During Assisted Ventilation 3. Ventilator Management 4. Practical Hints For Assisted ventilation

9 Applied Pulmonary Mechanics Pressure Gradient is Required to Overcome 1.Elastic Properties of Lungs and Chest Wall (Compliance) 2. Resistance to Airflow by Airway and Lung Tissue (Resistance)

10 Applied Pulmonary Mechanics Δ Volume (L) Compliance = Δ Pressure (cm H 2 O) In neonate chest wall is very distensible so does not contribute substantial elastic load when compared to lungs. Total compliance Lung compliance In RDS most striking abnormality is DECREASED LUNG COMPLIANCE

11 Applied Pulmonary Mechanics Pressure Gradient is Required to Overcome 1.Elastic Properties of Lungs and Chest Wall (Compliance) 2. Resistance to Airflow by Airway and Lung Tissue (Resistance)

12 Applied Pulmonary Mechanics Resistance is inherent property of lungs to resist airflow Resistance = Δ Pressure(cm H 2 O) Δ Flow (L/Sec) Airway resistance length of airway 1/radius of airway Viscous resistance lung tissue RDS does not contribute to resistance but ET tube does

13 Applied Pulmonary Mechanics Relationship of Compliance and Resistance : Time Constant (sec)= Resistance Compliance Time Constant(sec) = Resistance(30cm H 2 O/L/sec) Compliance(0.004L/cm H 2 O) = 0.12sec 5 = 0.6 seconds

14 Gas Exchange During Assisted Ventilation 1. Carbon Dioxide (CO 2 ) Elimination 2. Oxygen (O 2 ) Uptake

15 Gas Exchange During Assisted Ventilation CO 2 Elimination : Alveolar Ventilation = (Tidal volume Dead space)(frequency) With a pressure ventilator TV determined by (PIP PEEP)

16 Gas Exchange During Assisted Ventilation O 2 Uptake : Mean Airway Pressure(Paw) linear direct relations Paw = PaO2 Regardless of change in FiO 2 Paw optimizes lung volume and ventilation-perfusion matching

17 Gas Exchange During Assisted Ventilation Paw is augmented by : 1. Inspiratory flow (K) 2. Peak Inspiratory Pressure (PIP) 3. I:E Ratio(T I, T E ) 4. Positive End Expiratory Pressure (PEEP) Paw=K(PIP-PEEP)[T I /(T I +T E )]+PEEP

18 1. Flow : Ventilator Management Increase in flow will give square wave ventilation, will Increase Paw and therefore oxygenation. Higher flow is crucial, when T I is shorter

19 Ventilator Management 2. Peak Inspiratory Pressure (PIP) : Δ PIP(Press.Vent.) = Δ TV (Volu.Vent.) Advantages : Disadvantages : 1. O 2 Uptake 1. Barotrauma Air leaks 2. CO 2 Elimination 2. BPD

20 Ventilator Management Ventilator Management 3. I:E Ratio : Reversed I:E Ratio = Paw = Oxygenation No change in TV= No change in AV=No change in PaCO 2

21 Ventilator Management Frequency (Rate) : Rate= AV= CO 2 elimination= PaCO 2 Short TI= TV= MV Short TE=gas trapping= FRC= compliance with over distention= inadverant PEEP=Pneumothorax

22 Ventilator Management 4. PEEP : PEEP(at lower range)= Better recruitment of lungs = PaO 2 PEEP(at higher range)=over distention= Cardiac Output= PaO 2, PaCO 2 PEEP just above Critical closing Pressure prevents atelectesis

23 Gas Exchange During Assisted Ventilation Relative effectiveness of Paw on Pao 2 : 1. PIP &PEEP more than I:E ratio 2. PEEP at higher range is ineffective 3. Paw= Over distention= RL Shunt 4. Paw = Cardiac output

24 Ventilator Management Inspired Oxygen Concentration (FIO 2 ) : When increasing vent. support first increase FIO 2.60 to.70 before increasing pressure which may prevent BPD to When weaning vent. support first decrease FIO 2 to.40 to.50 before decreasing pressure. Pressure should be weaned before weaning FIO 2 further to prevent PTX.

25 Gas Exchange During Assisted Ventilation Summary :-

26 Ventilator Management HFOV : Ventilation above critical closing pressure at PEEP & Paw = PaO 2 P at alveolar level= alveolar ventilation = PaCO 2

27 Practical Hints for Assisted Ventilation Indications for Assisted Ventilation : 1. Respiratory acidosis with ph < 7.20 to Severe hypoxemia, PaO 2 < 50 torr. With FIO 2 > Apnea complicating RDS 4. Persistent Fetal Circulation

28 Practical Hints for Assisted Ventilation Initial Ventilator Settings : Normal RDS PIP cm H 2 O cmh 2 O PEEP 2-3 cmh 2 O 4-5 cmh 2 O Rate per minute per minute I:E Ratio 1:2 to 1:10 1:1 to 1:3

29 Practical Hints for Assisted Ventilation Acceptable Blood Gas Values : ph PaO torr PaCO torr With more maturity even higher PaCO 2 are tolerated as long as ph is maintained above 7.25

30 Practical Hints for Assisted Ventilation Weaning Strategy : 1. First decrease pressure <18 2. FIO 2 < Rate <15 4. CPAP of 3 to 4 to overcome ET resistance

31 Practical Hints for Assisted Ventilation Summary :

32 Practical Hints for Assisted Ventilation

33 Lung Development Significant Milestones : 1. At 3-4 wks. Lung bud from esophagus. 2. At wks. Segmentation of bronchi complete. 3.At wks. Type II pneumatocyte develops. 4.At 24 wks. Onwards surfactant production. 5.At 34 wks onwards PG production. Note : Lung maturity lags behind by 2-4 wks in maternal diabetes.

34 Composition of Surfactant

35 Role of L/S Ratio and PG

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