1. 1 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

2. 2 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Chapter 29 Neonatal Mechanical Ventilation

3. 3 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Basics of Neonatal Mechanical Ventilation The modern spectrum of modes available for the ventilation of the neonatal patient is very broad. Developments in monitoring, sensing, and computing power have allowed ventilator manufacturers to offer a wide and varied assortment of ventilatory modes.

4. 4 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Modes of Ventilation Continuous Positive Airway Pressure Synchronized Intermittent Mandatory Ventilation (SIMV) Volume Assist Control Time Cycled, Pressure Limited (TCPL) Ventilation Pressure Support (PS) (continues)

5. 5 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Modes of Ventilation (continued) Pressure – SIMV Volume – SIMV Assist Control (AC) Pressure Assist Control Volume Support (VS) Volume Guarantee (VG) Pressure Regulated Volume Control (PRVC)

6. 6 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Indications for Mechanical Ventilation in the Neonate Apnea Refractory hypoxemia Hypercapnia (elevated PaCO 2 )

7. 7 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Underlying Conditions that May Contribute to Respiratory Failure Respiratory distress syndrome (RDS) Drugs given to the mother during labor Aspiration Pulmonary hypoplasia Congenital defects (diaphragmatic hernia, cardiac anomalies) Persistent pulmonary hypertension of the newborn

8. 8 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Newborn Ventilatory Support Concepts Time constants Time cycling I:E Ratio and inspiratory time Pressure limiting Flow rate Proximal sensing

9. 9 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Hazards and Complications of Newborn Mechanical Ventilation Reduced cardiac output Reduced venous return Increased intracranial pressures Barotrauma to the lungs and mediastinum Infection Retinopathy of prematurity

10. 10 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Assessing the Need for Mechanical Ventilation Apgar scores Resuscitation efforts Evidence of aspiration Signs of asphyxia Physical size Appearance

11. 11 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Equipment Requirements Emergency manual resuscitator Intubation supplies Ventilator Noninvasive monitors Heated humidifier The patient circuit

12. 12 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Establishing Ordered Ventilator Settings Mode Rate Flow rate Inspiratory time I:E Ratio Peak inspiratory pressure Tidal volume Oxygen percent PEEP/CPAP level

13. 13 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Alarms High and low inspiratory pressure alarms High and low minute volume alarms High and low tidal volume alarms High and low PEEP/CPAP alarms High and low respiratory rate alarms Gas pressure failure

14. 14 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Patient Monitoring and Assessment Pulmonary Transillumination Cardiac Renal

15. 15 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Ventilator Monitoring Mode F I O 2 Airway pressures Respiratory rate Flow rate Inspiratory time and I:E ratio Temperature Alarm settings

16. 16 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Noninvasive Neonatal Mechanical Ventilation Noninvasive, Nasal CPAP may be indicated for: –Oxygenation failure –Increased work of breathing –The presence of specific disease processes that are believed to respond to noninvasive positive pressure ventilation

17. 17 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Hazards and Complications of Nasal CPAP Hazards and complications include: –Insufficient flow –Insufficient humidity –Excessive flow –Kinking and obstruction of the patient interface –Breakdown of skin integrity at the points of contact between the patient and the interface

18. 18 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Monitoring When assessing a patient, items that should be routinely monitored include: –ABG data –ECG tracings –Breath sounds –Respiratory rate –General patient appearance –Chest x-ray results

19. 19 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. High Frequency Ventilation (HFV) The use of specialty ventilators or ventilator modes to deliver very small tidal volumes at extremely fast rates (greater than 150 breaths per minute) is termed “High Frequency Ventilation” or HFV

20. 20 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. High Frequency Oscillatory Ventilation (HFOV) The Viasys Sensor Medics 3100A utilizes a piston-driven diaphragm system to deliver high frequency breaths in the range of 3 to 15 Hz (180 – 900 breaths per minute)

21. 21 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Gas Exchange Mechanisms Many complicated processes are involved in the exchange of respiratory gasses during HFOV. While some gas exchange remains the result of conventional “bulk flow of gases in and out of the airways,” additional concepts play important roles as well.

22. 22 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Ventilator Controls Ventilation is controlled predominantly through the manipulation of the “Power” control which affects the stroke volume of the piston-driven diaphragm.

23. 23 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Indications HFV is indicated for the treatment and support of patients suffering from two main categories of lung disease: –Those needing lung recruitment –Those suffering from pulmonary air leak

24. 24 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Management Strategies Patients needing lung recruitment –managed with “high volume” strategy Patients suffering from pulmonary air leak – managed with a “low volume” strategy.