1 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Chapter 19 Mechanical Ventilation of the Neonate and Pediatric Patient

2 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Physiologic Objectives  Manipulate alveolar ventilation  Improve oxygenation  Optimize lung volume  Reduce the work of breathing  Minimize risks associated with ventilator- induced lung injury

3 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Types of Mechanical Ventilation

4 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Types of Mechanical Ventilation (cont.)  Pressure ventilation  Time-cycled pressure limited  Volume ventilation  Calculation of effective tidal volume  Dual control ventilation

5 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Mechanical Ventilation  Flow and pressure waveform patterns  Time constants  Triggering  Pressure sensing  Flow sensing  Motion sensing  Neurally adjusted ventilator assist

6 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Modes of Ventilation  Control  Assist control  (S)IMV  Continuous positive airway pressure  Airway pressure release ventilation

7 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Modes of Ventilation (cont.)  Airway pressure release ventilation  Pressure support  Inverse ratio

8 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Managing Ventilator Settings

9 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Managing Ventilator Settings (cont.)  Manipulating PaCO 2  Frequency I:E I:E  Tidal Volume 4-6 ml/kg in low–birth-weight preemies 4-6 ml/kg in low–birth-weight preemies 5-8 ml/kg in term infants 5-8 ml/kg in term infants 7-10 ml in pediatrics and adolescent patients 7-10 ml in pediatrics and adolescent patients

10 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Variables for Minute Volume

11 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Managing Ventilator Settings  Manipulating PaO 2  Mean airway pressure  Flow rate  Inspiratory time and I:E ratio  Positive end expiratory pressure

12 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Mean Airway Pressure

13 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Flow Rate

14 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Inspiratory Time

15 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Positive End Expiratory Pressure

16 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Patient Ventilator Interface  Impact of the circuit  Compressible volume  Air leak  Dead space  Resistance  Humidification

17 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Air Leak

18 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Complications for Mechanical Ventilation  Overdistention  Cardiovascular complications  Oxygen toxicity  Hypoventilation/hyperventilation

19 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Insufficient Flow

20 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Monitoring During Mechanical Ventilation  Essential aspects of monitoring  Calculation of effective tidal volume  Close observation of the patient  Noninvasive methods of determining oxygenation and ventilation status  Direct measurement of blood gas values

21 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Weaning from Mechanical Ventilation  Initiation  Significant resolution or reversal of the initial pathologic condition  Stable condition  Adequate nutrition  Able to breathe spontaneously

22 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Weaning from Mechanical Ventilation (cont.)  Initiation  Acceptable ventilator settings  Assessment of ventilatory muscle strength  Other weaning parameters

23 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Techniques of Weaning  Basic  CPAP  SIMV  PSV

24 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Exhaled Resistance with ET Tubes

25 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Effectiveness of PSV

26 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Advancing Concepts  Automated regulation of the inspired oxygen (closed loop FIO 2 )  Partial support  Negative pressure ventilation