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Neonatal and Pediatric Resp Care > Test 3 > Flashcards

Test 3 Flashcards

1
Q

CPAP

A

Spontaneous ventilation with positive pressure applied to the airway throughout the respiratory cycle. Treat oxygenation failure not ventilation

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2
Q

Physiological effects of CPAP

A

Increase FRC, Increase Compliance, Decrease total airway resistance, decrease RR-> decrease WOB, Decrease intrapulmonary shunting (by opening alveoli

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3
Q

FRC

A

Forced residual capacity - normal breathing (decrease when alveoli collapse)

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4
Q

Indications in neonates for CPAP

A
  • PaO2 < 50 on FiO2 60% or more with adequate ventilation
  • Premature infants
  • Apnea of prematurity (tx with caffeine too)
  • Obstructive airway disease
  • Pneumonia
  • Meconium
  • CHF/ Pulmonary edema
  • TTN
  • Paralysis of diaphragm
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5
Q

Contraindications of CPAP

A

PaCO2 >60 and pH <7.25 (not vent. adequately

  • Upper airway abnormalities (cleft)
  • Congenital diaphragmatic hernia
  • Neuromuscular disease, CNS Depression
  • Central or frequent apnea
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6
Q

Hazards and complications of CPAP

A
  1. decrease CO
  2. Decrease renal function
  3. Increase ICP
  4. Barotrauma
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7
Q

Nasal CPAP may result in

A

nasal obstruction or necrosis and gastric distension- can go into esophagus

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8
Q

example of nasopharyngeal tubes

A

LMA

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9
Q

CPAP generators

A

Flow system
stand alone CPAP machines
Mechanical vent-enough flow (flowmeter/generator)
*important to have manometer in line

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10
Q

CPAP has failed if

A
  1. PaO2 < 50 and FiO2 0.8-1.0
  2. CPAP > 8-12
  3. pH > 7.25
  4. Marked retractions/ nasal flaring/ retractions on CPAP: wob
  5. Frequent apnea
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11
Q

Weaning from CPAP

A

Patient with clinical improvement

  1. decrease FiO2 to 0.4-0.6
  2. decreased CPAP by 2cmH2O increments as tolerated by pulse ox or ABGs
  3. At CPAP of 2-3 cmH2O extubate
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12
Q

SiPAP

A 
similar to APRV
-Spontaneous breathing at two levels
-Not synchronized
-Sigh Breath
Ti 1-3 seconds
Rate sets how often
Breaths spontaneously through Ti
2-3 cmH2O above baseline
Recruits alveoli
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13
Q

Indications for BiPAP

A 
Increased WOB (HIGHER RR, RETRACTIONS, PARADOXICAL BREATHING)
Hypoventilation (INCREASED CO2 AND LOW PH)
Airway obstruction (OSA, STRUCTURAL ABNORMALITIES)
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14
Q

BiPAP ventilators

A

Pressure Targeted-typical non-invasive vent. , IPAP and EPAP
Volume Targeted- Becoming more common on NIV, Can use volume vent via mask (dont wean)
Negative Pressure- Usually for chronic disease, not used much anymore

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15
Q

Contraindications of BiPAP

A 
Cardiovascular instability
Nasopharyngeal obstruction
Hemoptysis (frank amnts of blood coughed up)
Lots of oral secretions
Agitation/anxiety
Apnea
Inability to maintain airway
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16
Q

Indications for MV of the neonate and ped pt

A

-Hypoxic Resp Failure
PaO2 <50 on an FiO2 > 60% despite the use of CPAP
PaCO2 <30 and pH >7.25
Nasal flaring, grunting, retractions
-Hypercapnic Resp Failure (dont vent adequately)
PaCO2 > 50 and pH <7.25
Apneic, listless, cyanotic, brandy or tachy
-Mixed also possible
-reversible problem exists

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17
Q

Causes of Mixed respiratory failure

A

Neurological alteration, Impaired resp function, impaired cardiovascular function, Post op

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18
Q

Most common mode for neonates

A

Pressure control ventilation

  • time cycled, pressure limited
  • peak pressure set
  • vairable flow
  • set Ti
  • set rate
  • PEEP
  • No direct control of Vt
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19
Q

Traditional ventilation for adults

A

Volume ventilation

  • set Vt
  • Set flow unless in PRVC
  • Set Ti
  • Set rate
  • No control over peak pressures
  • More susceptible to volume lost to tubing
  • PRVC and VAPS TWO TYPES OF NEW BREATHS (listed under dual control)
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20
Q

Dual control

A

PRVC and VAPS

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21
Q

Triggering, sensors at airway add deadspace and weight

A
  • flow
  • pressure
  • motion, detects chest/ abdominal movement
  • neural detects diaphragm signals
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22
Q

Pressure-Flow Relationship

A

Not usually measured
But increase in Raw will decrease Vt
Factors that cause increase Raw:
-Bronchospasm (bronchodilator)
-Airway secretions (suction)
-Inflammation (antibiotics, anti-inflammatory)
-Artificial airways (use largest possible)

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23
Q

Setting the vent: mode (infant)

A

Cpap if oxygenation only problem (PaCO2 <40)
Low SIMV if spontaneous breathing (PaCO2 < 50)
High SIMV or CMV if retaining CO2 (PaCO2 >50)
High frequency vent if no relief with above
(or surfactant replacement therapy, NO administration, ECMO)

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24
Q

Setting the vent : mode (peds)

A

Much like adult only smaller Vt (6-8)
CPAP if adequate CO2 (PaCO2 < 40)
SIMV low rates if some breathing
SIMV high rates or CMV if need more support

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25
Q

Peak inspiratory pressure (PIP, PAP, Pmax, etc)

A

Neonate 15-20cmH2O check for beaking and adjust setting

-pediatric set to achieve desired vt

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26
Q

Set rate

A

Neonate: start 40-60

term: start 25-40
pediatric: set to achieve desired Co2

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27
Q

Set PEEP

A

start 5cmH2O

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28
Q

Set FiO2

A

Neonate: keep baby pink, use TCM or Pox to keep within normal limits
Pediatric: PaO2 and or SpO2 normal limits, 100% if need for short times

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29
Q

Set Inspiratory Time

A

Low birth weight infants: 0.25 to 0.4
Term infants: 0.6-1.2
Comfort level also

30
Q

Set I:E ratio

A

1:1.5 to 1.2

always check ratio when changing rate

31
Q

Decreased compliance, stiff lungs

A

Crackles
decreased chest wall excursion
decreased slope of pressure volume loop
decreased tidal vol

32
Q

Increased airway resistance

A

increased secretions
wheezes/ rhonchi
Reduced tidal volumes on same pressure-suction-stiff lungs?

33
Q

Changing PaCO2

A

Primary: rate, 2-5 bpm per change
secondary: peak pressure, set by lung volume (watch returned volumes), watch chest excursion. Flow rate, increased flow increases Vt (watch returned volumes)

34
Q

Changing PaO2

A

Primary: fio2 up to 60%

secondary: increase mean airway pressure
- PEEP: 5cmH2O start, increase 3-5
- Increase I time
- Increase rate

35
Q

Wean infant to

A

FiO2 wean to < 0.4-0.5
PEEP wean by 1-2 increments to <8cmH2O
PIP wean by 1-2 to <30cmH2O
Rate wean by 1-5 to <20bpm

36
Q

Wean Pediatric to

A

FiO2 <40%
PEEP < 5cmH2O
Rate to zero (CPAP) with or without PSV, take ETT size into account

37
Q

Extubation Success indicators

A 
Vt 3-4 ml/kg
FiO2 <30%
MAP <5cmH2O
Oxygen Index (fiO2/ PaO2) x 100 <1.4
-leak text
38
Q

High Frequency Ventilation (HFV)

A

Small tidal volumes, even tidal volumes below anatomic dead space
high rates 150-3000bpm
uses lower peak pressures
has not been proven to be significantly better than conventional ventilation
use with surfactant therapy there is less BPD

39
Q

Indications for HFV

A

RDS when conventional ventilation fails
-airleaks/pneumothorax
PIE

40
Q

Contraindications of HFV

A

COPD

Non-homogenous lung disease; leads to overdistention of good lung tissue

41
Q

Hazards of HFV

A

Mucus pluggin
Decreased CO
Increased incidence of IVH
Difficult to assess breath sounds and heart sounds

42
Q

Theory of how HVF works

A

Flow goes down the inside of the tube and out the outside of the tube
-alveoli have different time constants and this mode inflates all alveoli better

43
Q

Types of HVF

A

High Frequency jet ventilation (HFJV)

High Frequency Oscillatory Ventilation (HFOV or HFO)

44
Q

HFJV, HFFI, HFOV

A

All use bias flow
like all T piece that acts as the source of the gas blown in with the bursts of gas allow for spontaneous breathing with the HFV

45
Q

HFJV

A 
4-11 Hz (240-660 bpm)
Pulse of gas to airway
-special adaptor to ETT or special ETT
--triple lumen: one for jet bursts, one to measure pressure in lungs, one for CV
-Jet draws in air around the jet
46
Q

When is HFJV used

A

in tandem with conventional ventilation
-conventional vent supplies sighs for development of surfactant, PEEP, and continous flow for the air entrained by the jet

47
Q

HFOV or HFO

A

8-15Hz
Piston or pump or diaphragm (loud speaker)
uses positive and neg pressure
bias flow is driven into the ETT by the oscilator
Expired air flows out with the same bias flow
uses traditional ETT
can use with CV or spontaneously breathing pt

48
Q

Before placing pt on HFV

A

get CXR
Give surfactant
Stabilize as much as possible so infant is not needing stimulation when first place on place monitors

49
Q

After placing on HFV

A

monitor CO and fluid balance

sedate

50
Q

Settings HFJV

A

Start at 7hz
I time 0.2 seconds
PIP at 90% or 10 above PIP on CV
Reduce CV rate and increase PEEP until Mean airway pressure same as CV
May keep min CV rate to maintain CO2 and reduce atelectasis (ie 4bpm)

51
Q

Setting HFOV

A

no gradual reduction of CV, just place on HFOV
two strategies
Optimal lung volume strategy (RDS)
-10Hz for > 750 g, 15hz for <750g
Ti 33%
Set mean airway pressure 1-2 higher than on CV, until PaO2 OK
Change in pressure for adequate chest wall movement
check CXR for adequate expansion (diaphragm at 8th or 9th rib)

52
Q

Adjusting settings HFV

A

To decrease CO2 increase Amplitude
to increase O2 increase Mean airway pressure (PEEP)
Usually dont adjust Hz

53
Q

Wean HFV

A

Wean MAP in increments of 0.5 to 1.0 slowly

wean as long as FiO2 remains under 0.3

54
Q

Diseases used with HFV

A

Pulmonary Interstitial Emphysema (PIE)

Pulmonary air embolism (rare)

55
Q

PIE

A

Air dissects throughout the interstitial tissue of the lungs

56
Q

PIE caused by long term use of

A

HIGH PIP
PEEP
Prolonged Inspiratory time

57
Q

PIE pathology

A

Interstitial air compresses small airways and vessels —> V/Q mismatch

58
Q

Tx of mod to severe PIE

A

Prevent, decrease pressures, Selective intubation of the unaffected lung, HFV

59
Q

ECMO/ ECLS

A

Extracorporeal Membrane Oxygenation

Extracorporeal Life Support

60
Q

What decreases the amount of ECMO being used

A

HFV and iNO because the neonates can be managed well with these two therapies

61
Q

Diagnosis of ECMO

A 
PPHN persistent pulmonary hypertension of newborn
MAS (meconium aspiration)
RDS
Sepsis
Congenital Diaphragmetic hernia
Air leak Syndromes
62
Q

PPHN

A

Pulmonary vascular bed remains constricted due to low O2 content
pressure remain high in the right side of the heart continuing the fetal circulation through the ductus arteriosus and the foreman ovale. thus deoxygenated blood is shunted to the left heart and out to the body

63
Q

Criteria of ECMO

A 
Oxygen index > 40 on Conventional Ventilation
Oxygen Index >60 on HFOV
Reversible lung disease
Absense of congenital anomalies
32 week gestational age min
no major intraventricular hemorrhage
64
Q

Venoarterial system

A

blood from right atrium back through aortic arch used to circulate blood through body

65
Q

Types of ECMO

A

Venoarterial system

Venovenous system

66
Q

Venovenous system

A

blood from and back through right atrium
only oxygenates and removes CO2 does not circulate blood
not as efficient as V-A

67
Q

ECMO System

A 
Pumps to move blood
Membrane oxygenator and CO2 remover
Some add hemofilter for hemodialysis
circuits need to be primed
blood heater before returning to pt
cannulas to place in veins and arteries
anticoagulation to prevent clotting
68
Q

Monitoring pt on ECMO

A

Oxygenation assessed by SvO2 (75%) and/or SpO2 (>90%)
Sedate not paralyzed
Ultrasound of head looking for bleeding
Minimal ventilation: FiO2 21-40% , peak pressures 20-25, PEEP 4-10, RR 5-10

69
Q

An 27 week gestiational age, 900g, male infant is intubated and given surfactant replacement therapy. The lung compliance is expected to increase rapidly. Which type of mechanical ventialtion would you recommend?

A

.

70
Q

Indications for HFV

A

RDS when conventional ventilation fails
Airleaks/pneumothorax
PIE

71
Q

Calculate Hz

A

.

Neonatal and Pediatric Resp Care (4 decks)

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