NEO - U2 flashcards combined (9/79)

Physiology of alveoli in regards to surfactant

Alveoli lined w/ fluid that is separated by surfactant that reduces the surface tension proportionally to alveolar size. Without it, would need more pressure to expand + promotes lung collapse.

Physiology of surfactant

Phospholipid made by type II pneumocytes.

Antenatal steroids

Decreased RDS as it accelerates development of I and II pneumocytes which influences lung growth + surfactant production, used w/I 24h of therapy.

Surfactant fxn

1. prevents collapse and capillary leakage into alveoli

2. lessens WoB

3. optimizes SA and compliance

4. protects epithelium + helps clearance of foreign material + infection

Diseases affecting surfactant

1. RDS, MAS, ARDS, CDH, CF

2. pulm hemorrhage

3. infections

4. surfactant protein deficiency

How to treat RDS?

1. prophylaxis (as close to birth as possible w/ risk of uneven distribution if CXR not performed)

2. rescue treatment (performed if diagnosis confirmed and can be repeated)

3 kinds of surfactant and doses?

1. Poractant alpha (Porcine! 2.5mL/kg → 1.25mL/kg repeat)

2. Calfactant (Calves! 3mL/kg)

3. Beractant (Bovine! 4mL/kg)

Give intermittently half > bag > half

INSURE

During deliveries: intubate > surfactant > extubation!

Patient position

KEEP MIDLINE + SUPINE for even distribution, don’t move!

How many people are needed @bedside to monitor?

Requires multiple providers @bedside (1 to surf, deliver breaths and monitor vitals)

Complications

1. bradycardia

2. hypoxia

3. obstruction

4. apnea

5. distribution to 1 lung

Happen due to provider not adjusting equipment appropriately to changing pulmonary mechanics

Other applications for surfactant

1. pulm hemorrhage (bc it inactivates surfactant)

2. MAS (given early in pt)

3. pneumonia + sepsis (decreases need for ECMO)

4. hernia

5. extracorpeal membrane oxygenation

6. ARDS

7. bronchiolitis

8. asthma

9. CF

MATH!

PorCaBer (2.5→1.5, 3, 4)

NEO - depth (kg+6)

PEDS - size = (age/4) + 4 | depth = (3 x size)

NAVA settings

NAVA level x (edi peak - edi min) = PS setting

Set apnea setting! 2-8s, baby more fragile would be set on 2s.

Set NAVA level based off of edi peak/how much baby needs it, as baby controls it due to NAVA being a supportive setting.

Based off of feeding tube NOT ETT.

ETT sizing

1000 for 2.5
1000-2000 for 3 (1-2, 3!)

MS SAID

Mismatch
Shunt

Secretion
Alveolar hypoventilation
Inhalation (low FiO2)
Diffusion defect

Indications for respiratory failure

1. hypoxemia

2. hypercarbia

3. NM disease

Hypoxemia hypercarbia specifics for resp. failure 

Peds: PaO2 <60mmHg on FiO2 >0.60
          PaCO2 >50-60mmHg w/ pH <7.30

NICU: PaCO2 >60mmHg w/ pH <7.20

MS MAID

Intubation equipment:

Monitor
Sxn

Mechanical ventilation
Airway
IV access
Drugs

ETT sizes

Neo: depends on weight

Peds: mm = (yr / 4) + 4, IF CUFFED = 0.5mm smaller

ETT estimated depth

Neo: <3kg = kg + 6

Peds: 3 * ETT

Type of blade to use

Neo: miller/straight blades

Peds: Mac for >25kg

Shapes of larynx and epiglottis in kids and how to help visualize?

Larynx is more anterior in child than adult and the epiglottis is omega shaped. This causes the epiglottis to need to be lifted out of view by putting pt in sniffing position.

Do you preox the baby when intubating?

YES 100% and +5 PEEP

How long should try intubating?

Limit attempts to <30 seconds.

ETT placement confirmation types (4)? gold standard measurements for peds vs neos?

1. capnography (waveform preferred for peds)

2. mist in tube

3. chest auscultation (not accurate)

4. GOLD STANDARD: CXR (^1-2 in peds, T3 for neos)

What do high ETT cuff pressures cause?

>20cmH2O causes ischemia and necrosis of tracheal mucosa

Best alternative for difficult airways?

LMAs!

Do you sxn neonates before extubation?

NO! cause derecruitment/decreased FRC

Extubation complications

1. MC: sore throat/hoarseness

2. stridor

3. breath hold (smaller bebes)

4. RUL atelectasis

Accidental self extubation

MOVING PT + TUBE W/O HOLDING AIRWAY!

also done by improper securement, sedation or restraints

Indications to be trach’d

1. not being extubated

2. UA obstruction

3. prolonged vent

4. pulm hygiene (dysphagia, NMD)

Trach tubę type

Smallest UNCUFFED size that provides ventilation, w/ peds tubes normally being single lumen.

How long are they sutured for and when can 1st trach change be done?

sutured for 7 days, trach change done 5-7 days post-op

Trach care

routine trach tubę changes (to prevent infection) and parents must learn how to do home care (changing, CPR, sxn and cleaning)

Decannulation process

Pt. must have underlying problem resolved + capped/PMV for most/all waken hours

Done by downsizing > daytime capping trials > capped sleep study > decannulation.

Suctioning

Instil saline or other meds then either NT, bulb or closed tracheal sxn.

What pressure do you sxn at?

80-100mmHg

All 8 different modes:

1. VC

2. PC

3. SIMV/VG

4. SIMV/PC

5. PRVC

6. ACVG

7. NAVA

8. PS

VC mode definition and why choose it?

Sets VOLUME with control over Ve and VT.

PC mode definition and why choose it?

Sets PRESSURE (PIP) but loses control over volume, as it can set a peak inspiratory pressure that causes the tidal volume to vary.

Allows better control for those with fragile lungs or issues with compliance, as the pressure is not the variable. 

SIMV/VG

Sets target VOLUME and RATE by adjusting pressure for mandatory support, supporting pt's spontaneous breaths with PS. Each mandatory breath has a consistent VT through set pressures.

Often used for weaning or recovery to support the pt.

SIMV/PC

Opposing to SIMV/VG: mandatory AND spont. breaths are controlled w/ pressure, meaning no guaranteed volume.

Used to support the baby to spontaneously breathe while maintaining some support through pressure.

PRVC and ACVG

Utilize PC to target a volume, w/ only difference is the brand/company of the ventilator. PIP is manipulated but done to reach a desired volume.

Used as the pressure utilized makes sure to be adjusted as minimally as possible to reach the volume required, being used to protect the lungs from trauma.

NAVA

Uses electrical responses to trigger vent to assist the pt’s breathing, following pt’s resp. drive, being completely dependent on the patient's neural drive and stability.

Can only be used if the patient is triggering their own breaths, being used for weaning the patient.

PS

Fully support/assist mode as the pt. triggers all the breaths, but supported by a set pressure.

Used for weaning due to it being a fully supportive mode. 

Goals and Objectives (3)

1. Safety (gas exchange, lung protection)

2. comfort (synchrony, healthy ratio of vent support to own pt effort)

3. liberation (minimize vent time + adverse events)

Clinical indications

1. neurological issues (hypotonia, apnea, seizures (airway protection!), central hypoventilation, tumors, TBI, drug overdose)

   1. neuromuscular disorders (MG, GB, SCI, diaphragm paralysis)

2. Surgical (omphalocele/gastroschitis, neuro-tube defects, postops)

3. cardiovascular (sepsis (hypotension due to vasodilation), PPHN, cardiomyopathy, shock)

common situations for mech ventilation

1. restrictive (RDS, CDH, pneumonia, ARDS, scoliosis, CW, rib cage issues)

2. obstructive (MAS, BPD, choanal atresia, airway disorders, LTB, epiglottitis, tracheomalacia, asthma, CF, bronchiolitis)

3. pulmonary hypoplasia (CDH, oligohydarminos)

Conventional mechanical ventilation

Establish normal pattern of RR and VT for required Ve.

Changing RR = changes I:E and Ve.

CMV

All breaths MANDATORY, meaning every breath will breathe in the set VT, including VCCMV → VCAC and PCCMV → PCAC

IMV

MANDATORY and SPONTANEOUS breaths, mandatory are set while the spontaneous are not breathed at set rate. VC-IMV → VCSIMV and PC-IMV → PC-SIMV

CSV

all breaths are SPONTANEOUS, supported with a backup rate if apnea happens. PC-CSV → CPAP PSV

Drager VN500

PC-AC: every insp effort triggers a synchronized mandatory breath through setting Pinsp or variable P controls Vt

PC-SIMV: spont breaths supported w/ PS and are NOT volume guaranteed as Pt controls the Ti, volume and RR of spont breathing. Set RR does NOT set a back up rate.

VG: volume guarantee, allowing constant VT w/ changing comp + res, reducing pressure load to lungs

Initial settings for premature infant
(RR, VT, PIP, Ti, PEEP, FiO2, Trig, PS)

Weight: <2kg

RR: 30-50
Vt: 4-6mL/kg
PIP: 18-25 (adjust to target VT)
Ti: 0.25-0.4
PEEP: +3-5
FiO2: 10% higher than pre intubation
Trig: 0.2-0.5
PS: 6-10 (adjust to target VT)

Initial setting for infant
(RR, VT, PIP, Ti, PEEP, FiO2, Trig, PS)

Weight: 2-10kg

RR: 25-40
VT: 5-6mL/kg
PIP: 18-25 (adjust to target VT)
Ti: 0.4-0.5
PEEP: +5-7
Trig: 0.20-0.5
PS: 6-10 (Adjust to target VT)

Initial settings for toddler/child

Weight: 10-40kg

RR: 15-25
VT: 6-8mL/kg
PIP: 18-25 (adjust to target VT)
Ti: 0.5-0.8
PEEP: +5-7
Trig: 1.0-2.0
PS: 6-10 (adjust to target VT)

FiO2 for preterm, term and PPHN risk pt

Preterm: 88-92%

Term: 90-95%

PPHN risk: 92-97%

Alarm settings

High MV: 3x set MV

Low MV: 20% set MV

To increase or decrease PaO2

Increase or decrease FiO2, PEEP or PIP

To increase or decrease PaCO2

Decrease or increase RR, PIP, VT

What equals PS above PEEP?

Nava level * (edi peak - edi min)

Do you always humidify your pt?

ALWAYS to 37C.

When do you change pt circuit

Q30 or when soiled/malfunctioning

Complications of mech vent

1. trauma (volu, atelec, baro)

2. reduced QT

3. O2 toxicity

4. hypo/erventilation

DOPE

troubleshooting mechanism

Displaced tube
Obstruction
Pneumothorax
Equipment

What setting mostly drives oxygenation?

PEEP or MAP

What value mostly drives ventilation?

PIP or delta P

How do RR and Ti affect I:E ratio?

Increased RR or Ti decreases Te

How do lung compliance changes affect ventilation?

Change in volume delivered

HFJV inspiration vs expiration 

Inspiration “jets” down CENTER of airway (least res.), bypassing DS to distal airways.

Expiration is “displaced” by new breaths coming in (think of it swirling around the inhalation jet arrow), being passive and constant.

how does HFJV work?

PC but really fast, being a high freq, time-cycled, PC vent, with insp and exp. happening together (bidirectional flow)

Jet breath rinses alveoli, displacing old gas toward trachea and new gas towards alveoli, and bypasses dysfxnal alveoli.

Primary control of ventilation for HFJV? What happens to that control as it goes lower in the airway?

PIP/deltaP! Most Pt use 25-35cmH2O w/ worsened disease using 35-55.
deltaP and MAP are reduced the further air goes down: UA loses 30% of set PIP and LA loses 10% of set PIP, while the PEEP remains stable.

How much pressure is attenuated per set PIP?

set 50 = lose 5, 40 = 4, etc.

HFOV

Imagine a sound wave delta P is like amplitude and RR is like frequency, and the space under the wave/curve is the VT.

To increase ventilation: increase deltaP or decrease RR

HFOV vs HFJV

HFOV - active exhalation, RR measured in hertz going from 5-15hz to 300-900bpm, MAP, amplitude/deltaP is similar to PIP and has a fixed I:E

HFJV - RR 240-660 but doesn’t go above 420(?), runs in tandem with conventional vent, set iTime so variable I:E, compliant circuit

Is the servo P, V or F? Increase? Decrease?

Servo is a monitored value of PRESSURE; however, P drives F, F drives V and V drives ventilation, so it responds same as V in context of PC ventilation.

Increased servo P = improved compliance, increased leak, less Raw and removal of secretions,.
Decreased servo P = increased Raw, secretions, worse compliance, right mainstream ETT and kinked obstructed jet circuit. BAD!

MV equation

RR x VT²

What happens to PEEP and MAP when amplitude attenuates in HFJV vs HFOV?

HFJV - PEEP stays same, MAP declines

HFOV - PEEP increases, MAP stays same