1. CPAP and SIMV ventilation on neonatals and pediatrics
By: Yazmin Realivasquez and Lisamarie Trombetta
Victor Valley College
2016 Respiratory Therapy Program

2. Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) is primarily indicated for use in treating respiratory distress. CPAP was adapted for infants in the 1970’s as an alternative to the more invasive mechanical ventilation. Its primary function is to establish an open airway. The circuit is structured such that a continuous flow of humidified oxygen in combination with other compressed gases is delivered.

3. Continuous Positive Airway Pressure (CPAP)
CPAP applies continuous positive distending pressure to the airways. CPAP is used during spontaneous breathing to prevent the need for mechanical ventilation. CPAP does not have the same risk of barotrauma as does mechanical ventilation. Also, if nasal prongs are used instead of an endotracheal tube, the chance of infection decreases. Less invasive equals less danger to the patient. Endotracheal tubes often create a ridge in the soft palate of the neonate when the need for mechanical ventilation is lengthy.

4. Methods for Delivering CPAP
CPAP is accomplished by a variety of methods. In one of these, nasopharyngeal prongs that span from the nares to the nasopharynx are used.
Due to their long length, the airway resistance is higher when compared to other methods. Additionally, they are difficult to insert.
The most popular methods utilizes either nasal prongs or a mask.

5. Methods for Delivering CPAP

6. Methods for Delivering CPAP
Endotracheal Tube
Patent airway, airway clearance
Disadvantage: plugging, malacia, infection
Nasal Prongs
Decrease infection, no malacia
Disadvantage = plugging, pressure necrosis, gastric distention
Nasopharyngeal
Pressure necrosis, infection
Face Mask
Temporary measure prior to intubation or for apnea episode

7. Methods for Delivering CPAP

8. Goals of CPAP The main physiological goals of CPAP are to:
increase the functional residual capacity (FRC)
increase compliance
decrease total airway resistance
decrease respiratory rate
It is the actual increase in FRC that allows the other three goals to occur. CPAP physically holds the alveoli and airways open during exhalation thereby increasing the FRC. An increase in FRC leads to improved lung compliance, decreased work of breathing, increased PaO2, and decreased PaCO2.

9. Indications for CPAP Conditions that decrease FRC: Traditional Usage:
weaning from mechanical ventilation
pneumonia, atelectasis, pulmonary edema, thoracotomy, meconium aspiration, increased mucus, respiratory distress syndrome (RDS), RDS Type II/Transient Tachypnea of the Newborn (TTN), left-to-right shunting
Abnormal Physical Assessment:
increased respiratory rate (30- 40%), retractions, grunting, nasal flaring, cyanosis
Abnormal Arterial Blood Gas Values:
PaO2 < 50 Torr at an FIO2 of .60 (with adequate ventilation)
Airway Collapse: tracheobronchial malacia, apnea of prematurity (AOP), obstructive sleep apnea

10. Indications for NCPAP AARC Clinical Guidelines
Increased WOB with retractions, flaring, grunting and cyanosis
Inadequate ABG’s
Presence of poor expansion on CXR
Presence of conditions responsive to CPAP
RDS, Pulmonary edema, atelectasis, apnea, tracheal malacia, TTN

11. Hazards of CPAP
Decreased pulmonary blood flow secondary to compression of pulmonary vessels (generally associated with high pressures)
Reduced cardiac output due to decreased venous return to the heart (also associated with high pressures)
Renal:
Decrease in glomerular filtration rate, decrease in sodium excretion, decrease in urine output
Increase in intracranial pressure (ICP)
Pneumothorax
Nasal obstruction (with nasal prongs)
Gastric distension (orogastric (OG) tube recommended)
Necrosis or erosion of the nasal septum and nasal deformities from the use of nasal prongs
Increase in PVR due to impedence of blood flow

12. Contraindications of CPAP
Untreated air leaks
Cardiovascular instability
Severely apneic patient
Patients who cannot maintain an adequate spontaneous tidal volume
Patients with alveolar instability
Patients with persistent pulmonary hypertension (PPHN)
Increased intracranial pressure that can cause intraventricular hemorrhage (IVH)
Upper airway abnormalities
TEF, choanal atresia (REQUIRE ETT)

13. Methods of Techniques Start at current FIO2 or slightly >
Start at 4-5 cmH2O
Titrate level in 1-2 cmH2O increments until PaO2 is acceptable
Watch pulse oximeter or TCM as well
Maximal level is usually cmH2O
Weaning:
Get FIO2 to 50% or <
Decrease CPAP in 1-2 cmH2O increments
Monitor for stability in vital signs, ABGs, and pulse oximeter
If on ET tube, extubate when CPAP is 2 cmH2O

14. Common Methods
High flow nasal cannula: Although you are not setting a PEEP level, you are setting a flow rate up to 8L at max. The flow will create a expiratory resistance thus creating a small peep level.
Most HFNC start around 2-6 L, it is always heated to body temperature at 100% RH, using a heated humidifier; used as an alternative to CPAP or as a weaning tool from CPAP

15. Pediactric CPAP Pre and Post operatively to support structures
Subglottic stenosis
Cleft palate
Laryngeal papillomas
Neck tumors
Tonsillitis
epiglottitis

16. SIMV Ventilation
Synchronized Intermittent Mandatory Ventilation is a mode of ventilation in which mandatory breaths are given at a preset rate and spontaneous respirations are allowed in between.
The patient’s spontaneous respirations are never interrupted. A timing mechanism in the ventilator senses the appropriate time to give the mechanical breath without interfering with the spontaneous breath.
This mode of ventilation is beneficial to the spontaneously breathing infant who does not require sedation or paralyzation.
Many infant ventilators are not flow or pressure sensitive enough to sense patient triggering at the patient airway, therefore abdominal sensors may be used to sense diaphragmatic and chest wall movement.

17. Goals of Mechanical Ventilation:
Normalization and maintenance of blood gases and acid- base balance (ventilation and oxygenation)
Prevention of iatrogenic complications: Barotrauma and volutrauma
Careful regulation of rate and pressures: infection, use sterile technique during suctioning,
Sedation, pharmacologic sedation and analgesia as needed to reduce anxiety and pain.
Support of the Patient’s Respiratory Needs

18. SIMV MODES Mandatory rate is set
The start of the breath is synchronized with the inspiratory effort of the patient
Three types of SIMV available
All have pressure support available which allows them to breathe spontaneously at a preset pressure if they want more breaths than are set with the mandatory rate

19. SIMV Pressure Control + PS
Set pressure and PEEP
Set rate is guaranteed
Set inspiratory time
If patient wants to breathe spontaneously more than set respiratory rate, they can do so and set their own inspiratory time
The spontaneous breaths can be pressure limited independently of the mandatory set pressure
Can be used as a weaning mode

20. SIMV Volume Control + PS
Set tidal volume, PEEP
Set rate
Set inspiratory time
Spontaneous breaths are pressure supported at set desired pressure

21. SIMV PRVC + PS Set tidal volume, PEEP Set rate Set inspiratory time
Spontaneous breaths are pressure supported at set pressure desired
Less chance of over-ventilation than with straight PRVC because patient can breathe spontaneously between mandatory breaths

22. General Settings:
Initial settings for PIP during pressure ventilation may be derived from blood gases drawn while hand-bagging the infant. Adjustments can be made according to the results of the gases and considering the frequency and pressure and FIO2 at which the infant was being ventilated manually. When placing the infant on volume ventilation, the initial settings are usually chosen based on minute ventilation requirements. Volume is calculated at 4-8 ml/kg. Rates are generally although ultimately determined by ventilation measurements.
Literature suggests initial settings of:
PIP cmH2O
PEEP 3-5 cm H2O
Frequency 40
Flow rate 6-8 LPM
I-time of 0.5
I:E 1:1.5 or 1:2

23. General Settings
Flow rates are generally set between 8 and 12 LPM. Eight for the infants weighing 500 grams and twelve for those appropriate for gestational age (AGA) term infants-somewhere in-between for the others. PEEP ranges from 3 to 5 cmH2O during conventional ventilation based on the FIO2 requirements of the infant. Also, during pulmonary hemorrhage, PEEP may be increased to tamponade the bleed.
Peep = Positive pressure maintained in the patient’s airway during expiration; typically set between 3-5 cmH2O in most babies due to low FRC. Rarely do you go above 6 or below 3.
Prevents collapsed alveoli
Increases FRC
Improves compliance
Improves oxygenation
Decreases intrapulmonary shunting
Allows for lower PIPs to be used
Same distending alveolar pressure
PEEP is used in conjunction with ventilator rate

24. Indications for Initiating Mechanical Ventilation
Increased PaCO2 with a pH less than , PaO2 less than 50mmHg despite the use of CPAP and FIO2s .60 or greater than with grunting, flaring, retractions, cyanosis and agitation.
Neurologic conditions that compromise the drive to breathe:
Apnea of prematurity (AOP)
Intracranial hemorrhage (IVH or ICH)
Drug depression, Congenital neuromuscular disorders. RDS, Meconium aspiration syndrome (MAS), Pneumonia, Bronchopulmonary dysplasia (BPD), Bronchiolitis, Diaphragmatic hernia, Sepsis, Decreased lung volume as seen on chest x-ray, Persistent Pulmonary Hypertension (PPHN), Post-resuscitation, Congenital Heart Disease, Shock, Postoperative with impaired ventilatory function

25. Hazards of Mechanical Ventilation
Oxygen:
Oxygen toxicity, hyaline membranes (Infant Respiratory Distress Syndrome), BPD (Bronchopulmonary dysplasia), Retinopathy of prematurity (ROP)
PEEP and CPAP:
Excessive pressures, hypoventilation from excessive FRC, decreased cardiac output, barotrauma

26. Hazards of Mechanical Ventilation
Peak Inspiratory Pressure:
Barotrauma;
Air leaks such as:
Pneumothorax, Pneumomediastinum, Pneumopericardium, Pulmonary interstitial emphysema (PIE)
Bronchopulmonary dysplasia
Hyperinflation:
Hyperventilation, Respiratory alkalosis, Hemodynamic depression

27. Hazards of Mechanical Ventilation
Respiratory rate:
Respiratory alkalosis, Air leaks, Decreased ventilation-to-perfusion ratios, Increased intrapleural pressure, Decreased pulmonary perfusion, Diminished cardiac output
Hypoxic-ischemic injuries:
Intracranial hemorrhage, Gastric distension, Complications of endotracheal intubation

28. Work Cited
Dunn MS, Reilly MC. “Approaches to the initial respiratory management of preterm neonates.” Pediatric Respiratory Review Mar. 4(1):2-8. Review.
EME Electro Medical Equipment Ltd. < infant_flow.asp>.
Polin, R.A, R. Sahni. “Newer experience with CPAP.” Seminar on Neonatology Oct. 7(5):
1/greenougha_01.html
Jhonny Marquez. Neonate Guidelines 2012 Final May 21, 2013