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Intreventions 2 > Non-Invasive Ventilation > Flashcards

Non-Invasive Ventilation Flashcards

1
Q

Use of Non-Invasive Ventilation Frequency

A

Before only CPAP was being used but now BiPAP is on the rise

BiPAP is more effective than CPAP in reducing extubation failure as it will augment ventilation

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2
Q

Advantages of NIV in Infants

A

Reduction in number of infants requiring intubation and ventilation

Shortened course of ventilation by facilitating earlier weaning

Treatment for difficult apneas

Treatment for infants with chronic lung disease

*Further improvements in all of the above seen with BIPAP over CPAP!

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3
Q

Non-Invasive Ventilation Interfaces

A

Typically used without an artificial airway

Nasal prongs and nasal masks most common

*Sizing for the SiPAP machine is very important

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4
Q

SiPAP

A

Will give us a baseline pressure

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5
Q

SiPAP Machine

A

SiPAP is a brand name seen

  • Less expiratory resistance due to the specially designed flow generator (incorporated flip flop gate)
    • The flip flop gate will effective manage the baseline pressure that is delivered to the baby
  • More stable pressures are delivered
    • Provides a baseline pressure
  • Uses a demand system that allows for lower flows to be used
  • Used for spontaneous breathing patients as they will be triggering the BiPAP
    • SiPAP uses the Graesby capsule
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6
Q

Broad Purpose of Non-Invasive Ventilation

A

*The broad purpose of non-invasive ventilation is to treat respiratory dysfunction and restore respiratory gas exchange in a range of clinical settings

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7
Q

Non-Invasive Positive Pressure Ventilation (NPPV)

A

A method of respiratory assistance that involves an external interface and cyclical positive pressure device

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8
Q

Negative Pressure Assisted Ventilation (NPAV)

A

A method of respiratory assistance based on intermittent application of sub atmospheric pressure external to the chest wall through a tank or mold

Used for kyphoscoliosis

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9
Q

Continuous positive airway pressure (CPAP)

A

A method of respiratory assistance based on application of distending flow via external interface to attain a defined constant positive pressure

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10
Q

High-Flow Nasal Cannula (HFNC)

A

A means of respiratory assistance that utilizes a soft nasal cannula interface and high humidified flow source to raise the intraluminal pharyngeal pressure

Will always be humidified

FiO2 is set via a blender

Flow rate is often set to 1 lpm, but can be as high as 5

Very effective

High flow nasal cannula=irritation therapy. Prost does not believe that it is given actual CPAP

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11
Q

Contraindications to NIV

A
  • The need for intubation and mechanical ventilation:
  • Nasal obstruction or severe upper airway malformation
    • Choanal atresia, Cleft palate, TE fistula
  • Severe cardiovascular instability and impending arrest
    • Untreated CDH
  • Unstable respiratory drive with frequent apneic episodes
    • Resulting in desaturation associated with/without bradycardia
    • Ventilatory failure (PaCO2 > 60 mmHg and pH < 7.25)
  • History of recent GI surgery
  • Bronchiolitis is a relative contraindication as hyperinflation may result 2° obstructive airways disease.
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12
Q

NIV Waveforms

A

Variable flow in CPAP systems are seen in machines such as Arabella and are the most desirable

Systems like the Arabella will use a demand system (flip flop gate) and use a lower flow on expiration

Sechrist systems will deliver a constant flow

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13
Q

Does CPAP augument vetilation

A

CPAP does not augment ventilation rather it is an interface that helps with oxygenation and WOB (improve compliance and FRC which in turn improves ventilation)

No matter how perfect we try to make our machines we will get slight ossiclations

Levels 5 and 6 seems to work well for most patients

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14
Q

Important Considerations with NIV

A
  • Prongs/tubes must be checked periodically for patency
    • Can become kinked or occluded with secretions (this is one of the biggest complications)
  • Pressure necrosis, nasal irritation or septal distortion can result
    • Nasal septal breakdown is very common!
    • To minimize/prevent:
    • Make sure they are secured properly!
    • Calgary Health Region switches between mask and the nasal prongs at least Q6h
  • When we use too much PEEP in babies, the capillary bed is so fine if you overinflate the alveoli you impede pulmonary circulation
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15
Q

What will small increases in CPAP do

A

Small increases in CPAP can change lung volumes by 4-6 ml/kg

Because the volumes are so low deadspace is a big problem

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16
Q

BiPhasic Ventilation

A
  • Allows the infant to breath spontaneously at either a high or low pressure
  • User will set RR and inspiratory time
  • BP-NCPAP may be used safety and effectively to assist in weaning from mechanical ventilation
  • However the effectiveness and safety of BP NCPAP compared to NCAPA need to be confirmed in a large multi-center trail
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17
Q

CPAP

A

Spontaneous breathing can be supported with CPAP, which is a mode that maintains constant pressure above baseline throughout inspiration and expiration

CPAP works by maintaining inspiratory and expiratory pressure above ambient, which will improve FRC and static lung compliance

Patient need to maintain adequate minute volume while breathing spontaneously because ventilatory support is not provided

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18
Q

Indications of CPAP

A
  • Arterial oxygenation is inadequate despite elevated FiO2
    • Usually accompanied with signs of respiratory distress
    • PaO2 is less than 50 mmHg while the infant is breathing FiO2 of 0.60
    • Provided that Minute Ventilation is adequate
      • PaCO2 is 50 mmHg and pH is 7.25
  • Abnormalities on the physical examination
    • Tachypnea (30% above normal), retractions, grunting, nasal flaring, cyanosis or pale, agitation
    • Poorly expanded and/or infiltrated lungs on CXR
  • A condition responsive to CPAP plus one of the above
  • Very low birth weight babies at risk for RDS (+ surfactant)
  • For administration of NO to spontaneously breathing babies
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19
Q

General Categories of Conditions that Use CPAP

A

Respiratory Distress

Abnormal Breathing Pattern

Lung Diseases

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20
Q

Conditions that Use CPAP

Respirtory Distress

A

Tachypnea

Retractions or accessory muscle use

Grunting

Nasal Flaring

Head Bobbing

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21
Q

Conditions that Use CPAP

Abnormal Breathing Pattern

A

Apnea of prematurity

Obstructive sleep apnea

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22
Q

Conditions that Use CPAP

Lung Diseases

A

Decreased lung volumes

Pneumonia

Tracheomalacia

Pulmonary Edema

RDS

Atelectasis

TTNB

Tracheal malacia or other airway abnormality

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23
Q

Conditions that Use CPAP

Other

A

Post extubation failure

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24
Q

Objectives in Use of Non-Invasive Mechanical Ventilation in Pediatrics

A

The primary objective of NPPV are to decrease the WOB and improve respiratory gas exchange

  • Decreased WOB manifested by
    • Decreased RR
    • Decreased retractions
    • Decreased use of accessory muscle of breathing
  • Improved respiratory gas exchange manifested by
    • Decreased arterial PaCO2
    • Increased arterial PaO2
    • Increased arterial pH
  • Increased FRC
  • Increased patency of oral pharyngeal airway and decrease intrinsic auto PEEP
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25
Q

Acute Respiratory Disorders in Neonatal and Pediatric Patients Responsive to NPPV

A

Early phase ARDS

Acute chest syndrome

Congenital Heart disease

Complicated community acquired pneumonia

Pulmonary edema

Fat or bone marrow embolism

Status asthmatics

Post extubation respiratory distress

Acute pulmonary hemorrhage

Near drowning lung injury

Acute lung aspiration syndrome

Bronchiolitis

Acute respiratory distress post bone marrow transplantation

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26
Q

Factors Informing the Success or Failure of NPPV in Treatment of Acute Respiratory Distress in Children

A
  • Assignment of skilled personnel to monitor and manage critically ill child
  • Availability of appropriate NPPV equipment and monitoring devices
  • Level of postnatal development and status of airway protective reflexes
  • Exclusion of children with rapidly evolving:
    • Hypoxemia
    • Cardiovascular instability
    • ARDS
    • Severe asthma
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27
Q

Methods of Applying CPAP

A
  • Nasal prongs
    • Most common
  • Nasal pharyngeal prongs
    • Only progress to nasal pharyngeal if it is thought that the infants apneas will be relived by stimulation of the nasal pharynx by the flow.
  • Non-invasive nasal masks
  • Nasal pharyngeal tubes
    • Trimmed ETT
  • ETT
    • Don’t do this for long periods clinically due to the WOB imposed by the tube. It will be done short term (< 2 hours generally) to assess if patient is ready to be extubated.
  • Can also temporarily apply it with a JR bagger and mask
28
Q

Methods of Applying CPAP

Arabella System

A

This is the most common method seen to provide NIV to the infant

Can use nasal prongs or nasal mask

Increasing use of simple nasal prongs to deliver flow and pressure to neonates

Applications of some CPAP and flow may help with apnea and bradycardia prevention

29
Q

Do you set flow or pressure in CPAP

A

With CPAP set the flow to get the pressure you need (you don’t set pressure because of the leaks)

30
Q

Bubble CPAP

A

You put gas through bubbles which we think will make an oscillator effect through vibration

So we are getting CPAP and vibration therapy (ossiliation)

The level of CPAP is not as effect as what it is on SiPAP

31
Q

Monitoring the Patient on NIPPV

A
  • ABG
  • TcK (PCO2 & PO2)
  • SpO2
  • RR
  • HR
  • WOB
  • With non invasive ventilation there is much less hard data such as Vt and monitor interaction variables
  • Transcutaneous monitoring needs to be re calibrated often.
    • If you are doing a blood gas make sure to re-calibrate it and then do the blood gas
32
Q

ABG of Normal Preterm Infant (5 Days)

A

pH- 7.35-7.45

PCO2- 35-45

PO2- 85-100

HCO3- 22-26

BE- -2 to +2

33
Q

ABG of Normal Preterm Infant (5 Days)

A

pH- 7.34 to 7.42

PCO2- 32 to 41

PO2- 62 to 92

HCO3- 19 to 23

BE- -5.8 to -1.2

34
Q

ABG of Normal Term Infant at 5 Hours

A

pH- 7.31 to 7.37

PCO2- 32 to 39

PO2- 62 to 86

HCO3- 18 to 21

BE- - 6 to -2

35
Q

ABG of Normal Preterm Infant at 1-5 Hours

A

pH- 7.29-7.37

PCO2- 39-56

PO2- 52-68

HCO3- 22-23

BE- -5 to -2.2

36
Q

Wht will happen to the ABG if the baby is crying

A

If they are crying and are vigorous they will be more acidotic

37
Q

ABG of Very Low Body Weight

28-40 Week GA

A

pH Greater than or equal 7.25

PCO2 45-55

PO2 50-70

HCO3- 18-20

SpO2 85-92

38
Q

ABG of Extremely Low Body Weight

<28 Week GA

A

pH Greater than or equal 7.25

PCO2 45-55

PO2 45-65

HCO3- 15-28

SpO2 85-92

39
Q

PowerPoint Initiation of CPAP

A

CPAP is initiated at levels of 4-5 cmH2O

40
Q

CPAP can in increased up to 10 cmH2O Provided the following

A

*These are also what we look at to assess how well CPAP is working

  • Stabilization of FiO2requirements 0.60 with PaO2levels >50 mmHg or the presence of Clinically acceptable non-invasive monitoring of O2(PtcO2) while maintaining an adequate VE as indicated by PaCO2of 50-60 and pH 7.25
  • Reduced WOB as indicated by decreased RR, retractions, grunting, and nasal flaring
  • Improvements in lung volumes and appearance of lung as indicated by chest radiograph
  • Improvement in patient comfort as assessed by the bedside caregiver
41
Q

BiPhasic Mode Basic Settings

A

6/9

7/10

Rate: 20

Ti: 1 sec.

Separation of 3 cmH2O

42
Q

Settings for BP-NCPAP

FiO2 >0.5

A

Upper CPAP 10

Lower CPAP 7

43
Q

Settings for BP-NCPAP

FiO2 0.30-0.5

A

Upper CPAP 9

Lower CPAP 6

44
Q

Settings for BP-NCPAP

FiO2<0.30

A

Upper CPAP 8

Lower CPAP 5

45
Q

Settings for NCPAP

FiO2 <0.30

A

CPAP 5

46
Q

Settings for NCPAP

FiO2 0.30-0.5

A

CPAP 6

47
Q

Settings for NCPAP

FiO2 >0.5

A

CPAP 7

48
Q

BiPhasic Mode Basic Settings

A

6/9

7/10

Rate: 20

Ti: 1 sec.

Separation of 3 cmH2O

49
Q

Non-Invasive Ventilation in Pediatrics

Objectives For Respiratory Disorders

A

Decreased WOB

Increased ventilation

Increased FRC

Upper airway patency

50
Q

Non-Invasive Ventilation in Pediatrics

Objectives For Chronic Disorders

A

Theses have not been proven conclusively

Improve quality of sleep

Reduce daytime symptoms

Decrease CO2

Prevent atelectasis

Maintain FRC

Increase lung compliance

Rest respiratory muscles

51
Q

Non-Invasive Ventilation in Pediatrics

Respiratory Distress

A

There is not a lot of randomized controlled trails to show the effectiveness of non-invasive ventilation as treatment for respiratory distress

However when used in the right setting for hypoxemic and/or hypercarbic patients can be beneficial

52
Q

Non-Invasive Ventilation in Pediatrics

Acute Care Settings

A
  • Early ARDS
  • Pneumonia
  • Pulmonary edema
  • Post op upper airway obstruction
  • Atelectasis
  • Hypercarbic CF exacerbation
  • Asthma with hypoxemia
  • Post extubation distress
  • Near drowning
  • Acute decompensating of NMD-SMA, Duchenne’s MD
53
Q

Non-Invasive Ventilation in Pediatrics

Chronic Care Settings

A
  • Neuromuscular Diseases
    • Spinal muscle atrophy (SMA)
    • Duchenne’s
  • Rib cage and chest wall anomalies
    • Restrictive lung diseases
  • Advanced CF
  • Central alveolar hypoventilation
  • Laryngotracheomalacia
  • Chronic upper airway obstruction
  • Morbid obesity
54
Q

Pediatric Positive Pressure Devices

Pressure Targeted

A
  • BiLevel/BiPAP
    • BiLevel is pressure support
  • When there is a high WOB we will use pressure support rather than CPAP
  • Same as in adults
  • Will have IPAP and EPAP
55
Q

Pediatric Positive Pressure Devices

Pressure Targeted Advantages

A

Leak compensation

Spontaneous and time modes

56
Q

Pediatric Positive Pressure Devices

Volume Targeted

A

Portable home ventilators

Most devices do not have a pressure support feature

Do not trigger well or support spontaneous breathing

Set up so Vt is greater than physiologic Vt

57
Q

NPPV Modes

A

Same as adult modes

CPAP

Spontaneous

Timed

Spontaneous/Timed

58
Q

Pediatric NPPV Interfaces

A

Similar to adults

Nasal pillows, masks

Face masks reserved for critically ill

59
Q

Ped NIV – Complications/Contraindications

A
  • Skin irritation
  • Nasal dryness
  • Eye irritation
  • Aspiration
  • Reflux
  • Leaks
  • Cardiovascular instability
    • Absolute contraindication
60
Q

Factors Unique to Pediatric Patients that Promote Complications of NPPV

A
  • Aspiration
    • Immaturity of airway protective reflexes
  • Reflux
    • Impaired gastroesophageal sphincter function during infancy
  • Upper Airway Obstruction
    • Anatomical factors
    • Difficulty clearing secretions
  • Large oral leak
    • Tendency to mouth breath
  • Agitation
    • Anxiety, incomplete understanding, developmental disorders
61
Q

Monitoring Effectiveness in NIPPV in Peds

A
  • Decreased WOB
  • Improvements in Respiratory Gas Exchange
  • Increase in FRC
  • Maintenance of Upper Airway Patency
62
Q

Monitoring Effectiveness in NIPPV in Peds

Decreased WOB

A

Assess during the physical assessment

Looking for a decrease in RR, retractions, and use of accessory muscles

Not reliable in young children and infants with neuromuscular and central disorders

63
Q

Monitoring Effectiveness in NIPPV in Peds

Improvements in Respiratory Gas Exchange

A
  • Assessed via Pulse oximetry while looking for acute improvements in SpO2
    • Not a reliable metric in the assessment of hypoventilation
    • Interpretation obscured by concurrent O2 treatment
  • Assessed through blood gas sampling
    • Increase in pH, decrease in PaCO2, increase PaO2
    • PaCO2 may not decrease for hours if at all in some disorders
    • It is an invasive measure
  • End-Tidal CO2 Monitoring
    • Acute reduction in end tidal CO2
    • High background flow in NPPV circuit can wash out expired CO2
  • Transcutaneous CO2 Monitoring
    • Subacute reduction in transcutaneous CO2 monitoring
    • Accuracy dependent on careful electrodes placement
    • Changes lag minutes behind change in actual PaCO2
64
Q

Monitoring Effectiveness in NIPPV in Peds

Increase in FRC

A

Assessed through a routine chest radiography to see an increased lung expansion, decreased atelectasis

Difficult to accomplish during therapy

Changes can lag days behind

65
Q

Monitoring Effectiveness in NIPPV in Peds

Maintenance of Upper Airway Patency

A
  • Assess through sleep polysomnography to look for sub-actute reduction in the number of airway-occlusive episode to decrease with the degree of thoracoabdominal asynchrony
  • Not amendable to acute clinical setting

Intreventions 2 (19 decks)

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