Mech. Vent Review + strategies Flashcards
What are the physiological objectives for mech. ventilation for neonate/pediatric Pts?
Apnea, not breathing, bagging for a prolonged period of time
Overarching goals:
- To manipulate alveolar ventilation
- Improve oxygenation
- To optimize lung volume
- To reduce WOB
- Minimize risks associated w/vent. induced lung injury (VILI)
- How can you get the Pt. off of the vent
Do pediatrics/neonates have different mech. ventilation complications as adults?
No, they mainly share the same complications
What are risks you have to keep in mind when managing PPV for neonates/peds
- Can decrease venous return and increase pulmonary artery pressures
- Have to limit O2 for babies especially for eyes and vents
means there’s airway complications like damages from
intubation attempts and accidentally going too deep - Infection: keep it clean and sterile, inline suction, and avoid
disconnection to reduce infection and ventilation
associated pneumonia
What are the primary goals of mech. ventilation for neonates/peds?
- Improve O2 delivery
- Eliminate CO2/maintain pH > 7.25
- Reduce WOB
Why aren’t HME’s added to the ventilator circuit for neonates?
They add deadspace, so heated humidity is used instead.
What temperatures should be be used for neonates on mech. ventilation?
35-37C
Which mode of mech. ventilation is the preferred initial choice for neonates?
Volume control (precise volume targets)
What mode of ventilation is typically used for kids?
PRVC or PCCMV adaptative or pressure control
Why wouldn’t you use pressure support for kids?
Their vessels are small, the vent would miss their targets?
When would you use pressure control ventilation for kids?
When plataeu pressure rise, PC is better at maintaining volume. So for conditions like:
- airleak syndromes
- pneumothorax
- PIE
When would you use HFO or Jet Ventilation?
When babes are in troubling.
What are the benefits to using PRVC?
You set a volume target and it can adapt to improvements in patient.
- Allows Target VC
- Control of Ti and Pplat
- Better control of mean airway pressure and distribution of ventilation.
What is a con of using pressure control for children?
Have better control of pressure but you don’t have a VC target.
- their airways are smaller, meaning you need more precision of volumes to not cause VILI or ROP.
What procedure uses pressure control for neonates/kids?
BLES, PC is can be used for surfactant admin.
- Surfactant is thick, if you use PC you need to crank it to send it deep.
What is the Pplat max for adults?
Keep under 30cmH2O
What is the Pplat max for neoantes?
Keep it under 25cmH2O
What is the neonate rule of 5 for mech. ventilation?
Vt: 5 mL/kg
RR: 50
PEEP: 5
What should your Ti goals be for mech. ventilating neonates?
Make sure we hit the inspiratory plateaus, they indicate whether the lungs are being fully filled.
- aim for 0.3-0.4
How to manage high WOB
Increase RR to match or exceed Pts RR.
- The idea is that you want to take over their whole breathing, full control.
What do you do if your PEEP exceeds 6?
CxR to guide further changes
How to manage low oxygenation?
- High FiO2 and increase PEEP
- admin surfactant
ABG targets for infants (>1month) and toddlers (< 2)
- pH (7.3-7.4)
- PaCO2 (30-40)
- PaO2 (80-100)
- HCO2 (20-22)
Generally keep pH above 7.2
What is the PaCO2 for permissive hypercapnia
up to 60
ABG targets for extremally low birth weight (ELBW) babes?
aka <1000gs
- pH above 7.20
- PaCO2 (45-55)
- PaO2 (45-65)
- HCO3 (15-18)
ABG Targets for Very low birth weight (VLBW) < 1.5kg
- pH above 7.2
- PaCO2 (45-55)
- PaO2 (50-70)
- HCO3 (18-20)
ABG targets for children and adults?
- pH (7.35-7.45)
- PaCO2 (35-45)
- PaO2 (80-100)
- HCO3 (22-24)
What is a step up treatment from normal mechanical ventilation for infants?
HFO
What conditions are needed for a patient to transition from vents to HFO/HFV?
- hint the Pts getting worse
- RR<80
- Vt<5ml/Kg
- PIP>25cmH2O
- MAP>12 and/or FiO2>0.40
What pathology is commonly associated/at a higher chance of developing with low birth weight (LBW)?
RDS
- More common because LBW babes are most have less developed lungs
- surfactant deficiency
ABG Targets for a Infant with Respiratory Distress Syndrome (IRDS)?
- PaO2 (50-80)
- PaCO2 (40-55)
- pH < 7.25
Managements of Infant Respiratory Distress Syndrome (IRDS)?
The goal is to improve oxygenation.
- Manage/support underlying conditions like hypoxia, lung injury, edemas, or metabolic demands
- Surfactant Replacement
- Consider HFO or Nitric Oxide
why is it helpful to allow permissive hypercapnia in the early delivery of surfctant?
Surfactant delivery may be more successful when the infant’s lungs are already well-ventilated and relatively stable.
- basically easier to do when lungs are not occupied with more work or at risk of/or already at VILI
Why would HFO be helpful with IRDS management?
IRDS = low surfactant = low compliance.
- Stiffer lungs cause PIPs to rise.
- need oscillation pressures to manage that (support PEEP/alveoli)
What should CPAP on babes max out at?
8
What is the cause of Bronchopulmonary Dysplasia (BPD)?
BPD results from treatments given to kids.
- higher risk for younger kids
- those born immature and have aggressive therapy results in lung damage and gets BPD
What are lung protective strategies to prevent BPD for infants?
- Low Vt
- Allow higher PaCO2 (permissive hypercapnia) -> pH (7.20-7.25)
- Aim for lower SpO2 goals (85-90)
- iNO (pulmonary vasodilators)
- Bronchodilators/steroids
- NCPAP if possible (instead of vents)
PPV goals for Bronchopulmonary Dysplasia (BPD)
- Lowest PIP necessary
- PEEP 4-6
- PaO2 above 50mmHg
- PaCO2 50-60mmHg
- Maintain acceptable pH
How does Transient Tachypnea of the Newborn (TTNB) present?
High WOB w/RR 60-80bpm
- remember TTNB is fluid in the lungs.
Treatment for Transient Tachypnea of the Newborn (TTNB)?
Goal is to use PPV to increase development, so theres more surface area for the fluid to move in. CPAP may also help move liquids.
- Oxygen therapy (less than FiO2 0.4)
- CPAP 3-5cmH2O w/higher FiO2
- Rarely requires mech vents
Indications of Pneumonia in newborns?
- Fetal Tachycardia & Low Apgars
- Supplemental O2 required-resuscitation at birth
- Increased WOB, grunting, tachypnea, retractions, nasal flaring, cyanosis, apnea, progressive resp. failure
Managements of pneumonia for infants
- O2 therapy, CPAP , and mech ventilation as required to alleviate WOB
- suction appropriately
what procedure is not recommended for patients w/Meconium Aspiration Syndrome (MAS)?
Intubation. Intubation to suction meconium is a last resort. (intubate and suction w/mec aspirator)
Vent strategies for Meconium Aspiration Syndrome (MAS)?
- mild cases w/usual settings (rule of 5)
- Hyperventilation & hyperoxygenation to induce pulmonary vasodilation if PPHN develops
- Low PaCO2, high PaO2
- HFV as a step up
What are 3 types of Neonatal Apneas?
- Centrally = brain
- Obstructive = blocked airway
- Mix = Brain and obstruction
Management of Neonatal Apnea
Maintain acceptable SpO2.
- Caffeine or theophylline (bronchodilators) can help stimulate the babe
- minimal vent. settings bc theirs no disease present
What are 4 primary air leak syndromes that require early recognition in babes?
- why do we want early diagnosis of this pathologies?
PPV makes these worse if not careful.
- Pulmonary Interstitial Emphysema (PIE)
- Pneumothorax
- Pneumomediastinum
- Subcutaneous Emphysema
Clinical presentation of Air leak Syndromes in infants?
- Sudden deterioration occurs
- Increased RR
- Grunting
- Increased pallor (pale) or cyanosis (shock)
- O/A: Possible Cardiac shift (decrease in affected side or celerity of heart sounds)
Air leak managements for a mild pneumothorax?
O2 therapy at 1
Air leak managements for a Symptomatic pneumothorax?
- Needle Aspiration, Chest tubes
- Low PEEP and min. vent settings
- Consider PCV
Clinical manifestations of Persistent Pulmonary Hypertension of the Newborn (PPHN)
- Rapid O2 saturation changes w/no corresponding changes in FiO2.
- Tachypnea, mild/mod resp. distress w/cyanosis/hypoxemia that is poorly responsive to o2 therapy.
- pre and post ductal SpO2 > 10% diff
Management of Persistent Pulmonary Hypertension of the Newborn (PPHN)
Need to decrease PVR and increase pulmonary blood flow, the goal is to dilate the pulmonary artery:
- O2 to promote pulmonary vasodilation (lower PCO2 in the lungs will dilate)
- Surfactant if related to RDS
- iNO to treat PA Vasoconstriction
- restrict handling/suctioning
- Intubation/vent or HFOV to vent to normal PaCO2/pH (if necessary), followed by ECMO in severe cases
What is the main purpose of Lung Volume Recruitment (LVRM)?
- Alveolar oxygenation when on the vent
- non-vent is to aid secretion clearance and alveolar oxygenation.
- Prevent decruitment
How do Lung Volume Recruitment Maneuvers improve oxygenation for non-vented Pts?
Increases surface area for O2 to diffuse.
- avoids lung injury by ventialting Pts. below inflection point.
- Inflection point increases lung compliance, PEEP, and Plateau Pressures.
- A con though physiolgic dead space increaess bc not invovled in gas exchange?
When does decruitment occur?
When a Pt. is disconnected from a circuit, pressure is released.
What factor is important to stabilize and maintain inflation of alveoli?
PEEP is most important factor in maintaining inflation of of alveoli
What can assist in determining optimal peep?
looking at the upper and lower inflection points on a pressure volume curve.
Indications for a Lung Volume Recruitment Maneuver (LVRM)?
- AKA when would you do them?
- After disconnecting Pt from vent.
- After suctioning
- Evidence of atelectasis
What are contraindications for Lung Volume Recruitment Maneuvers (LVRM)?
Chest tubes or air leaks
- evidences of barotrauma, pneumothorax, subcutaneous emphysema, pulmonary insertsistal emphysema
- Air trapping with COPD and high pressures makes it worse
What are the 2 main components of a Lung Volume Recruitment Maneuver (LVRM) procedure?
Sustained inflation and Intermittent sighs
What is sustained inflation and how long is it?
CPAP for 30 seconds.
- Applies high amount of CPAP
- Amount of CPAP depends on weight of kid
- Helps reopen regions
What are Intermittent sighs?
Slow big breaths to maximize lung inflation and improve lung compliance.
- on vents, set regular RR and Vt. there is a option to give big breaths every 10 seconds.
What should you monitor during a LVRM procedure?
SpO2, EtCO2, HR AND low inflection point analysis of pressure-volume curve.
- any major changes should be charted
- Discontinue if Pt desaturates or HR changes by 20%
Mechanical Ventilation Indications PaCO2
PaCO2 > 55mmHg
Mechanical ventilation indications pH?
pH < 7.25
PF ratio mechanical ventilation indications
PF ratio < 200
Goals of mechanical ventilation?
- Reverse hypoxemia
- Reverse severe acute respiratory acidosis
- Relieve WOB,
- Improve CO
- Decrease ICP
- Stabilize chest
- Decrease myocardial O2 demand
IBW males?
50 + 2.3 (height in inches - 60)
IBW females
45.5 + 2.3 (in. - 60)
what does it mean when the the following is described:
- Larynx funnel shaped
cricoid more narrow and prone to obstructions
what does it mean when the the following is described:
- Anterior/ higher glottic opening
harder to visualize cords on intubation
What does it mean when the Cartilage is more compliant?
Higher collapse risk (tracheomalacia)
Risks of a larger tongue?
collapse easily against posterior pharynx
Risks of Larger tonsils and adenoids
Bleeding easily, inflammation can obstruct
What increases risk of tearing and swelling?
Fragile mucosa
Un VCCMV, increasing RR will cause
Increase in only PIP and MAP
Controlled settings in VCCMV
- Rate
- FLow
- Vt
- Ti pause
- PEEP
Trigger in VC
Time/patient
Cycle in VC without pause?
volume
Cycle in VC with pause?
Time
Limit in VC?
Flow/volume
Benefits of pressure control?
- Improve oxygenation
- Better control of pressures
- Better distribution of ventilation
Trigger PC
Time/ patient
Limit PC
Pressure
Cycle in PC
Time
Set settings PC
- PC level
- Rate
- Ti
- PEEP
- FiO2
- Sensivity
What does it mean when there is no pressure equilibration on flow waveform?
Flow will not reach 0, meaning that the entire set pressure did not enter lungs
Square flow waveform would change Ti in volume control
Shorter
If compliance increases, what would happen to volumes in PC, PRVC, and VC?
- Volumes would increase (if not equilibration)
- Pressures would decrease in PRVC and PC
If compliance decreases, what would happen to volumes in PC, PRVC, and VC?
- Volumes will decrease in PC (if no equilibration)
- Pressure will increase in PRVC and VC
PRVC benefits?
MV control and pressure control
Limits pressure lungs are exposed to (uses lowest pressure needed. )
better distribution of ventilation and improved oxygenation.
Trigger PRVC
time patient
Limit PRVC
Pressure limited volume cycled
Cycle in PRVC
Time
PS trigger?
Patient
PS limit
limit
Cycle PS
Flow/patient cycled
How do you fix autopeep
- Increase flow or Te
- Reduce MV
- Reduce Ti
- Reduce RR
What increases mean airway pressure (MAP)?
- PEEP
- PC
- Volumes
- Increased RR with not locked I:E
Pressure change in absolute pressure control?
Will effect volumes when you change the delta.
Ex (PEEP 5 Abs 30, change to PEEP 7 abs 30 will decrease the delta by 2.- smaller driving pressure will reduce the volumes)
ph increase calculation (Correct acidosis)
PaCo2 - ( (pH goal - pH present) / 0.01)
pH decrease calculation ( correct alkalosis)
PaCo2 + ( (pH present - pH goal) / 0.01)
Premature ABG goals
> 7.25 / 45-55 / 45-65 / 15-18
Term neonates ABG goals
> 7.25 / 45-55 / 50-70 / 18-20
Term- 2yr ABG goals
7.3-7.5 / 30-40 / 80-100 / 20-22
Ped and adult ABG goals
7.35-7.45 / 35-45 / 80-100 / 22-26
Mechanical ventilator Pediatrics Settings
Ideally PRVC
- Vt 5-7ml/kg - 6ml/kg is a good place to start
- PEEP 5
- FiO2 match
- Ti ~ 0.6-1.2 (depending on age)
- RR 20-35 toddler, 20-30 child, 12-20 older child
Mechanical ventilator preemie settings
- RR 40-60
- 4-6ml/kg
- Ti 0.25-0.4
- PEEP 5
- FiO2 10% above blender set
Term neo ventilator settings
RR 25-40
Vt 4-6
Ti 0.3-0.5
PEEP 5
FiO2 10% above blender set
Preductal target
60-65 1 min
65-70 2min
70-75 3min
75-80 4 min
80-85 5 min
85-95 10min
Post birth questions
TERM TONE BREATHING
Indications for CPAP NRP
Grunting, high WOB, Low O2
indications for PPV NRP
APneic, gasping, HR <100bpm
CPAP settings to start NRP
+5, FiO2 0.30
PPV settings NRP
PIP 20 / 5 PEEP
FiO2 0.21-0.30 depending on GA
Sign of good ventilation?
Increasing HR
FiO2 set >35wks gestation
21% O2
FiO2 <35wks gestation
21-30% O2
Intubation indications NRP
Prolonged PPV
- HR is decreasing even with
-ventilation correction steps - CPR <60bpm
- CDH
- Surfactant administration
What to do if Hr is still 60-100bpm
Assess chest ventilation effectiveness.
- Good ventilation = rising HR
What to do if HR is under 60bpm
Try to get 30sec effective ventilation.
Once effective, and still under 60bpm, do chest compressions and 100% FiO2.
When is APGAR conducted
1 and 5 min
10min if 5min is less than 6
When does grunting occur?
on expiration to try and keep airways from collapsing
- Babes do this to maintain FRC
Types of CPAP
- Mechanical ventilators
- Bubble CAP
- SiPAP
- high flow NP at 8lpm
Start SIPAP levels
4-6cmH2O
When would you transition or switch CPAP to mechanical ventilation?
- Increased WOB
- Decreasing pH
- PaCO2 > 60mmhg
- High FiO2 requirements
frequent apnea with cyanosis
Indicators of a comfortable infant on CPAP
Comfortable infant
reduced RR
Minimal or no chest retractions
SpO2 88-95%
Improvement of chest radiograph appearance
Reduction in severity and apneic episodes
When to consider weaning of CPAP
Low WOB
Low FiO2
What to wean first on CPAP?
Turn down FiO2 in increments until <0.25, and then reduce the CPAP by 1cmh2o.
alternate weaning each one until at CPAP 4 and FiO2 0.21
When can yo take an infant off CPAP
Low WOB on CPAP 4 and FiO2 0.21
risks with uncuffed tubes
Increased aspiration risk
- Easily kinked, causing increased resistance
- Helps minimize aspiration and prevents tube occlusion
What can retained secretions lead to?
Increased resistance
Increased WOB
Hypoxemia, hypercapnea, atelectasis and infection
What to do if patient vagals or decreased SpO2 whie suctioning
STOP STAY STABLE
- stop suctioning, put back on ventilator at same settings, and treat
PEA characteristics
No palpable pulse
- Rate may be slow or fast
- ECG may display normal or wide QRS
- May be caused by reversible conditions (H/T)
Ett size estimate
age in years / 4 + 4
Cardiopulmonary compromise and HR <60bpm
Chest compressions and epinephrine admin
Cardiopulmonary compromise with HR > 60bpm
Atropine or epinephrine.
What is Cardiopulmonary compromise according to ACLS?
- Hypotension
- Acutely altered mental status
- Signs of shock
Bradycardia medications
- Epinephrine- for everyone
- Atropine for vagal response and heart blocks
- Dopamine??
Tacycardia medication
Adenosine
Amiodarone
Procainamide
Treatment of sinus tachycardia
Treat underlying cause (pain, anxiety)
Treatment of stable SVT
Vagal maneuvers and adenosine
Treatment of unstable SVT
- Synchronized cardioversion and adenosine
- Vagal maneuvers while waiting
Cardioversion dose
0.5 - 2.0 J/kg (0.5-1 first does)
Stable VT treatment
Adenosine and possible amiodarone or procainamide
Unstable VT treatmet
Cardioversion
Characteristics of Sinus tachycardia
- HR <180
- Normal P waves and PRI
- Narrow QRS
- Variable R-R interva;
SVT characteristics
HR > 180
Infant showing signs of CHF
Ped showing signs of palpatations
Abrupt onset
What are indications for mechanical ventilation?
- Apnea/cessation of breathing
- Acute ventilatory failure (pH <7.30, PaCO2 > 50)
- Impending failure (Primary, Secondary)
- Inability to oxygenate
What affect does PPV or PEEP have on intrapleural pressures and CO?
PEEP increases intrapleural pressures and dampens venous return/decreases CO
What affect does PEEP have on compliance?
PEEP increases lung compliance by shifting the compliance curve.
- Too much = overdistension
What affect does PEEP have on dead space
PEEP increases FRC and in turn increases deadspace with COPD and normal lungs
Does PEEP increase or decrease intrapulmonary shunt?
PEEP decreases intrapulmonary shunt.
- Keeps alveoli open for better V/Q matching
How does PEEP affect preload?
PEEP is used to decrease right side preload in CHF/Cor pulmonale patients
- PEEP lowers/dampens venous return
What is optimal PEEP if hemodynamics are stable?
Optimal PEEP is 15
What is Primary impending failure associated with?
Pulmonary related
- ARDS
- Pneumonia
- Pulmonary Emboli
What is Secondary Impending Failure associated with?
(Non Pulmonary)
- Sepsis
- Muscle Fatigue
- Nutritional deficiencies
- Chest Injury
- Thoracic Abnormalities
- Neurological Disease
Trigger/cycle/limit for all vent settings?
What are 3 opposing forces of resistance to ventilation?
Opposing Forces:
- Elastic Resistance - surface tension, lung complaince
- Non-Elastic Resistance - airway resistance, tissue resistance
- Inertia - during ventilation effort - thorax is moved
What are characteristics of HFO?
- Inspiration is positive pressure (opposite of normal, its being pushed in)
- Exhalation is negative pressure (push and pull)
- Force of oscillation = delta pressure
- Resistance to bias flow = MAP
- Keeps lungs in state of hyperinflation
- Does not affect surfactant levels like conventional ventilation
Indications for HFO?
- Ards/ RDS in babes
- BP fistula
What does ventilation in HFO depend on?
- Rate (increasing rate will further drop Vt when amplitude is minimal)
- Delta Pressure/ Amplitude
- Bias Flow → controls MAP
- Increasing pressure (amplitude) and bias flow increase Vt
- CO2 elimination is inversely related to rate (decrease rate to increase CO2 elimination)
- Lower rates allow for greater Vt delivery time (larger Vt)
What does oxygenation depend on in HFO?
Depends on MAP
- Greater MAP = greater FRC and PEEP
- Longer I times = Increase MAP (low rates)
- Increased Bias Flow = Increased MAP
