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Neo/Peds MV
mechanical ventilation basics
| Question | Answer |
|---|---|
| Characteristics of CF? | Chronic obstruction and infection of a.w.'s. Exocrine pancreatic insufficiency (maldigestion and small bowel obstruction) elevated sweat chloride concentrations |
| Diagnosis of CF | Sweat choloride, CFTR gene analysis, nasal elctrical potential difference, newborn screening |
| Tx of disease? the medications usually given? | SABA, Hpertonic saline (SABA can be mixed together with hupertonic) Vest/flutter/etc, Pulmozyme (not to be mixed) TOBI (always given last) |
| Physiological objectives for neo/ped MV? | decrease VILI, decrease WOB, optimize lung volume, improve oxygenation and manipulate alveolar ventilation |
| Importance of MAP | avg pressure exerted on a.w. and lungs from the beginning of inspiration until the beginning of next inspiration, important tool to monitor babies oxygenation, babies are very much affected by increases with MAP ( increased MAP can lead to hemorrhaging) |
| definition of opening pressure | the lower inflection point, to open an alveolus a certain amount of pressure must be applied to alveoli |
| definition of driving pressure | created by ventilator, difference b/w the PEEP and PIP, basically the delta P responsible for Vt, important for dynamic compliance |
| Normals for Compliance | for a newborn about 2.5 - 5 ml/cmH2o |
| Normals for resistance | about 20 -30 cmH2o/L/sec in a spontaneously breathing neonate, basically driving pressure needed to move gases through aw at a constant flow rate |
| Clinical application of Resistance | the RADIUS of the aw is the most powerful influence on airway resistance, uncuffed tubes in neo/peds means always a leak, always a little loss in volume |
| Factors that increase airway resistance? | Bronchospasm, airway secretions, edema of aw walls, inflammation, ETT or trach tubes |
| Hinski "reasons" for MV (VOPS) | Ventilation, Oxygenation, Protection, Secretions |
| Partial Ventilatory Support modes? | CPAP, PSV, SIMV |
| CPAP for neonates/peds methods of application? | neonates: nasal pharyngeal or nasal prongs Pediatrics: nasal or full face mask |
| Indication for CPAP for neonates | RR greater than 30% of normal, paradoxical chest wall movement, grunting, nasal flaring and cyanosis, CO2 less than 60 and PH greater than 7.25 |
| Contraindications for neonates of CPAP | prolonged apnea, untxd pneumo, hemodynamically unstable, unilateral pulmonary problem, mouth/face abnormalities or post surgery |
| Hazards of CPAP | make PPHN worse, Increased ICP, decreased CO, may be ineffective if neonate weighs less than 1,000-1,200 grams |
| CPAP settings for infants? | "Perfect World" 4-6 cmH2o starting point, flow rate of 8LPM (5cmcpap), higher Fio2 initially (wean down ASAP) increased levels by increments of 1 or2 cm, levels of 8-9 begin to show need for MV and level of 12cmH2o is max pressure attainalbe |
| CPAP weaning? | Pt stable, no incidents of apnea, acceptable ABGs and CXR, decrease Fio2 1% at a time (until 0.4 maybe 0.6) then pressure incrememnts of 1-2 cm H20 until 2-3 cmH2o are reached |
| Si PaP? | "sigh" positive aw pressure, allows infant to breath spontaneously at two seperate CPAP levels |
| Most useful blade type for intubation of neo/peds? | Miller blade: of larger tongue and high epiglottis make straight blade most useful |
| Suctioning parameters | suction level for neonates: -60 t0 -80 larger infants and children : -80 to -100 1 minute of preoxygenation required Peds: 100% o2 Neonates: increase fio2 by 10-15% |
| Most commonly used mode for peds and infants? | infants: PCV-SIMV w/PS Peds: VCV-SIMV or PCV-SIMV both w/ PS |
| Targeted tidal volumes for infants and children? | Infant: 5-7 ml/kg children: 6-8 ml/kg |
| freq and i times? | RR set: 20, actual : 40-60 bpm passsive hyercapnia (45-55 mmhg Co2) Insp times: infants: >0.3 sec older children: up to 1 second |
| Parameters for neonates with normal lungs? | Vt:6-7ml/kg PIP:10-20 cm Frq:10-20 itime: >0.3 sec etime: >0.5 sec PEEP: none unless 2-4 cm Insp Flow:5-8 L/min Fio2:0.4 Flow HAS to be 2X minute ventilation! |
| Parameters for neonates with LOW COMPLIANCE? | Vt:5-7 ml/kg PIP:25-30 cm Freq:30-60 bpm I:E: 1:1 or 1:2 PEEP: 2-4 cm or up to 8-10 cm Insp. flow: 5-8 L/min Fio2: 0.4 (may need to be increased) |
| HFOV freq and settings? | freq: 3-15 Hz, MAP up to 20, power set enought to get a "wiggle", power 2-7 amps, increased power=increased vt |
| Inhaled Nitric Oxide? | selective pulmonary vasodilator, initial dose of 20 ppm, more than 20 does nothing but increase risk of methohemoglobin, decreased SLOWLY bc of High incidence of rebound pulmonary hypertension |
| O. I. (oxygen Index) values and formula? | if OI is >25, indication for INO MAPxFio2% /PaO2 |
| What is ECMO? | prolonged but temporary heart and lung support, used for pts with severe, REVERSIBLE resp/cardiac failure |
| VV ECMO? | Veno-Venous ECMO, pulmonary bypass ONLY, only 1 surgical site(jugular), blood drained and goes back to RA, VVECMO requires good cardiac function, Avoids cannulation of carotid artery Disadvantages: doesn't provide direct circulatory support/systemic 02 |
| VA ECMO? | Veno-arterial ECMO, heart and lungs bypassed, 2 surgical sites (RA and R carotid artery) provides lung and cardiac support, carotid artery doesn't ever heal or work again! Disadvantages: ABG interp, two vessels used |
| Selection criteria for ECMO? | >34 wks gestational age >1.8 Kg REVERSIBLE disease MV for less than 14 days staticus asthmaticus Failure of max medical management (nothings worked) |
| Excluded from ECMO | a lot of neurological problems major IC hemorrage lethal malformation severe neuro injury uncontrollable coagulopathy poor prognosis |
| clincial indications for ECMO | OI >40 on 2 or more ABG Pao2 <40 for 4hrs on 100%fio2 can't fix metabolic acidosis pulmonary or cardiac failure, progressive inability to come off cardiopulmonary bypass |
| ECMO complications | Hemorrhage, CNS damage, SZ, edema, cardiac dysrhythmia, renal failure, hyperbilirubemia, sepsis |
| Pediatric ECMO Managament: Pulmonary? | goals: decrease further lung damage, oxygen toxicity, get "lung rest". Peak Press: limited to 30 cm, Vt 4-6 ml/kg, RR 5-10 bpm, PEEP 12-15, goal Fio2 0.21, CO2 55-65, Spo2 >88%, 3-5 days min for ARDS, NO bagging! |
| Weaning off ECMO? | increasing pts sats, decrease ECMO flow, adequate ABG, Trial off(clamp it, see if baby circulates their own blood), improved BP, perfusion, weaning pressor support, serial ECHOS show improving function |
Created by:
phxgrl
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