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Interventions 3 > Pt getting sicker NEOS (mod 4) > Flashcards

Pt getting sicker NEOS (mod 4) Flashcards

1
Q

Advanced ventilation strategies for neonates

A
  • High Frequency Ventilation (HFV)
  • High Frequency Oscillation (HFO)
  • High Frequency Jet Ventilation (HFJV)
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2
Q

When would a neonate transition to advanced stratgies of ventilation?

A

Unable to maintain adequate oxygenation and ventilation

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3
Q

What is High Frequency Ventilation (HFV)?

A

Mechanical ventilation that uses frequencies greater than 150 bpm and smal tidal volumes (often less than deadspace)

  • frequencies are measured in Hz (cycles per second)
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4
Q

How many breaths are in 1 frequnecy?

A

1 Hz = 1 cycle/second = 1 breath per second = 60bpm

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5
Q

What are the benefits of High frequency ventilation (HFV)?

A

HFV was found to minimize the cardiovascular effects of PPV and improve gas exchange while minimizing peak pressures

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6
Q

What are indications for HFV in adults?

A

No evidence that HFV is better than conventional…but:

  • CHR PnP: when OI > 20 on two ABGs 6hrs apart
  • Acute lung injury (severe oxygenation failure)
  • Ventilation failure
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7
Q

Indications for High Frequency Ventialtion (HFV) in neonates?

A
  • Acute lung injury and ventilation failure
  • upper airway surgery and bronchoscope
  • BP fistula and pulmonary air leaks in neos (PIE)
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8
Q

When is High Frequnecy Ventilation not considered less effective than it normally would be compared to conventional?

A

HFV is considered superior to conventional normally. When surfactant, lung protective stratgies, and NO is used. There is no benefit of HFO over conventional.

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9
Q

When are neonates considered to be in ventilation failure?

A

pH < 7.25 with Vt <6 mL/kg and Plats < 30

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10
Q

How would upper airway surgery and bronchoscopy neonates be ventilated?

A

HFJV because it provides more efficient gas exchange with an open airway

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11
Q

How are BP fistulas or pulmonary air leaks managed in neonates?

A

HFJV is typically used, less bulk flow and less movement is involved with this mode of ventilation

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12
Q

5 approaches to HFV?

A
  1. HFPPV
  2. HFFI
  3. HFPV
  4. HFJV
  5. HFO
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13
Q

What risks is involved when expiration is passive in HFV?

A

There is risk of breath stacking

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14
Q

What type of HFV uses active exhalation?

A

High frequency oscillation (HFO)

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15
Q

How does HFJV work?

A

Combines the use of a jet vent and conventional vent

  • Convetional vent provides PEEP (which is MAP) and +/- sigh breaths
  • The jet vent pulses above this
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16
Q

Methods of HFJV admin?

A
  • Using a specially designed ETT (eg. Hi-Lo Jet ETT)
  • Using a specially designed ETT connector (no re-intubation required) and the Jet Ventilator in addition to the conventional vent
  • Via a trans-tracheal catheter; A crude form; usually present in difficult airway carts
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17
Q

HFJV catheter to ventilation pathway?

A
  • Uses a small bore catheter inserted into the cricothyroid membrane
  • Uses 14-18 gauge small bore injector in which gas is introduced at high pressure (15-50 psi). Gas leaves from a different route.
  • Gas flow interrupted by pneumatic, fluidic or electronically controlled solenoid valves.
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18
Q

Indications for HFJV for infants?

A

RDS, Rescue infants with lung injury, and other reasons:

  • Air leak for reasons other than PIE
  • Meconium Aspiration
  • Pneumonia
  • CDH
  • PPHN
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19
Q

Do frequency changes impact tidal volume (Vt) in HFJV?

A

No, the Ti is constant unlike the oscillator.

  • Frequency changes don’t impact Vt
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20
Q

What benefit does tubing have with HFJV

A

Normal ETT or TT can be used. insert catheter through which jet ventilation can be used

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21
Q

How does the conventional ventilation portion of HFJV function?

A

Background conventional ventilation.

  • Entrained gas
  • maintains PEEP
  • PIP settings may compare to conventional but inspirations are short and fast therefore pressure falls quickly meaning alveolar pressure much lower than peak airway pressure
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22
Q

How much tidal volume (Vt) eliminates anatomic deadspace in HFJV?

A

1 ml/kg of Vt = half the size of anatomic dead space

23
Q

How is inspiration affected by HFJV?

  • is the mode of delivery different?
A

Delivered via High velocity inspiration

  • moves through deadspace gas instead of pushing dead space ahead of fresh gas
24
Q

How is exhaled gas affected by HFJV?

A

Exhaled gas cycles out in a counter current helical flow pattern around incoming gas which helps with clearance of secretions from airway

25
Q

How is ventilation controlled in HFJV?

A

Amplitude produces Vt and controls PaCO2 via frequency (in Hz)

  • Exhalation in HFJV is passive; PEEP is constant if rate low enough to prevent air trapping
  • When Ti is constant, changes in frequency don’t impact Vt (meaning an increased rate will decrease PaCO2)
26
Q

How is oxyegnation controlled in HFJV?

A

FiO2 (on conventional vent) and PEEP (MAP)

27
Q

How do you find optimal MAP on HFJV?

A

Raise the PEEP 1-2 cmH2O above conventional settings.

  • stabilize patient using CMV of 5bpm and FiO2 getting stable SaO2 and than switching to CPAP
28
Q

Monitoring display settings for HFJV (via Bunnel Lifepulse)

A

Monitoring Display

  • PIP
  • Delta P (PIP-PEEP)
  • PEEP
  • Servo pressure
  • MAP

Pinch (Jet) valve on/off light

  • Front top-left panel
  • Indicates communication between the ventilator and pinch valve on patient box
  • LED lights up on inspiration
29
Q

HFJV alarm display (Bunnell lifepulse)

A
  • Servo pressure; (+1 cmH2O over present value)
  • Paw (+1.5 cmH2O)
  • High PIP (>5cmH2O for 2 sec or > 10 cmH2O for 30 sec)
  • Loss of PIP (< 25% of PIP)
  • Reset, ready light and alarm silence (60 secs)
30
Q

Which alarms are for the back lit display?

A
  • High PIP
  • Jet valve fault
  • Ventilator fault
  • Low gas pressure
  • Cannot meet PIP
  • Loss of PIP
31
Q

Control Parameters on HFJV (Bunnell Lifepulse)

A
  • PIP (8-50 cmH2O)
  • Rate (240-660 insufflations/min)
  • Jet on Time (Itime 0.02-0.034)
  • on/off ratio (i.e 1:1.2 to 1:12) -> Ti/I:E can be set constant
  • NOW display (current operator settings)
  • NEW display (preview changes)
32
Q

What is High Frequency Oscillation (HFO)?

A

A mode that uses a bias flow past the airway and either a piston, high frequency speaker (diaphragm) or rotating valve to provide oscillation’s

  • Requires a specialized machine to provide HFO
33
Q

How does HFO differ from other HFV techniques

A
  • Expiration is active
  • Gas flow is sinusodial
  • Bulk flow rather than jet pulsations are delivered
  • Vt is less than deadspace
34
Q

Main control parameters for HFO?

A
  • FiO2
  • MAP
  • Amplitude
  • Frequency
  • Ti% or I:E
  • Bias flow
  • Ve = f x Vt^2
35
Q

Is the tidal volume (Vt) in HFO less than deadspace?

A

Yes; ṾE = f x VT2

  • VT: 0.8 to 2.0 ml/kg (less than deadspace!!)
  • Still results in effective CO2 elimination due to the gas transport mechanisms involved in HFV
  • The tidal volume is the bigger factor in the MV!
36
Q

Mechanism of gas exchange in HFO? (5 reasons)

A
  1. Bulk convection
  2. Pedelluft gas movement (pressure gradients)
  3. Asymmetric velocity profiles (streaming) -> fresh gas introduction
  4. Taylor dispersion (help dispersion of gas)
  5. Cariogenic Oscillation (assist gas movement)
37
Q

How does Pendelluft gas movement explain HFO gas flow?

A

Gas moving from one lung unit to another due to difference in resistance and compliance

38
Q

How does Asymmetric Velocity Profiles (streaming) describe how HFO works?

A

Gas in the centre moves faster than gas at periphery

  • Also bi-directional gas movement (at the centre O2 moves into the lungs while at the periphery CO2 moves out)
  • Describes why fresh gas can move to a greater depth in the lungs than predicted by the tidal volume delivered
39
Q

How does gas transport work in conventional ventilation?

A

Bulk gas flow/convection

40
Q

How does the Taylor Dispersion describe HFO mechanisms?

A

High velocity gas movement enhances the development of turbulence in the conducting airways

  • This encourages dispersion of gas, both laterally and centrally
41
Q

How does cardiogenic oscillation describe gas movement in HFO?

A

Oscillations of the circulatory system assist gas movement, especially at high frequencies

42
Q

How is MAP created in HFO?

A

Continuous bias flow of within the system

43
Q

Control panel and settings for HFO?

A
44
Q

Control parameters that affect oxygenation in HFO?

A

MAP = Lung volume (FRC)

  • FiO2
  • MAP
  • TI%
45
Q

What is alveolar ventilation defined as in conventional ventilation?

A

F x Vt

46
Q

Alveolar ventilation defined as in HFV?

A

f x Vt^2

  • therefore, changes in volume delivery have the most significant affect on CO2 elimination in FV
47
Q

3 main controls for CO2 removal in HFO?***

A
  1. Frequency (Hz): Decrease frequency volume (changes. MV)
  2. Amplitude (change in P): Increase Amplitudes volume
  3. Ti% - Insp. times volume
  • if all are maxed out, Maxing bias flow and deflating cuff could further help CO2 removal (confirm??)
48
Q

Why would you want to increase Vt over RR to improve pH in COPD/Asthma patients?

A

Increasing RR could decrease TE causing air trapping

49
Q

Can tidal volume be manipulated to lower air trapping?

A

Yes lower Vt if air trapping is present

50
Q

How is Respiratory rate (RR) affected by a fixed I:E set?

A

This means IE ratio will not change even if you change RR.

  • Only Ti and Te will be adjusted to maintain IE set.
  • Therefore no changes in MAP
51
Q

How is Ti% affect the I:E ratio?

A

Ti% is same as I:E ratio

  • no change MAP as long as these won’t change
52
Q

If I:E ratio set is fixed, how does the RR compensate?

A

RR increases, meaning TCT decreases.

  • The Ti and Te thus preoperationally drop
  • Ti set @ PIP set
  • Te @ PEEP set
  • Ti and Te decrease when RR is increased
53
Q

How is mean airway pressure affected by Ti% and I:E set if they’re fixed?

A

No changes to MAP as long as they don’t change

  • Caveat: if the total rr (not set) increases, the MAP increases bc the patient is spontaneously breathing
54
Q
A

Interventions 3 (19 decks)

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