1、NeonatalMechanicalVentilation,MarkCMammel,MD,UniversityofMinnesotaChildrensHospital,Mechanicalventilation,WhatweneedtodoSupportoxygendelivery,CO2eliminationPreventaddedinjury,decreaseongoinginjuryEnhancenormaldevelopment,Mechanicalventilation,Supportoxygendelivery,CO2eliminationHeadboxO2CannulaO2CPA

2、PIMVIntubation,ventilation,Mechanicalventilation,PreventaddedinjuryMinimizeinvasivetherapyOptimizelungvolumeTargetCO2,O2UseappropriateadjunctsManagefluidsandnutrition,Mechanicalventilation,EnhancenormaldevelopmentManagefluidsandnutritionEncouragepatient-drivensupportMaintainpulmonarytoilet-carefully

3、,Supportdevices,Mechanicalventilation,Keyconcepts:MaintainadequatelungvolumeInspiration:tidalvolumeExpiration:End-expiratorylungvolumeSupportoxygenationandCO2removalOxygenation:adequatemeanairwaypressureCO2removal:adequateminuteventilation,Mechanicalventilation,Keyconcepts:Optimizelungmechanicalfunc

4、tionCompliance:V/PResistance:Flow/PTimeconstant:CxR,BorosSJetal:JPediatr1977;91:794,Mechanicalventilation:Howdoesitwork?,MechanicalVentilation:Modeclassification,A.TriggermechanismWhatcausesthebreathtobegin?B.LimitvariableWhatregulatesgasflowduringthebreath?C.CyclemechanismWhatcausesthebreathtoend?,

5、A,B,C,A.InspiratoryTriggerMechanism,TimeControlledMechanicalVentilationNOpatientinteractionPressureVentilatorsensesadropinpressurewithpatienteffortFlowVentilatorsensesadropinflowwithpatienteffortChestimpedance/AbdominalmovementVentilatorsensesrespiratory/diaphragmorabdominalmusclemovementDiaphragmat

6、icactivityNAVA-Neurallyadjustedventilatoryassist,B.LimitVariable,Pressure,Volume,A,B,B.Volumelimited,A.Pressurelimited,Ti,Ti,C.CycleMechanismWhatcausesthebreathtoend?,A.TimeAllventilatorsB.FlowPressuresupportmodesC.VolumeAdult/pediatricventilators,Pressure,Flow,A,B,Ti,Ti,Volume,C,Ti,Basicwaveforms,T

7、imecycle-fixedTi,Flowcycle-variableTiwithlimit,Mechanicalventilation:Whichvent?,ConventionalDrgerBabylog8000AveaServoiHighfrequencySensorMedicsoscillatorBunnellHFJV,ConventionalVentilation,Modes:CPAP+/-Pressuresupport(PSV)IMV/SIMV+/-Pressuresupport(PSV),volumetargetingAssist/control(PAC)+/-volumetar

8、geting,Continuouspositiveairwaypressure:CPAP,Goal:SupportEELVinspontaneouslybreathinginfant(optimizelungmechanics)Delivery:NeoPuff,otherdedicatedCPAPdevicesHFNCUsingmechanicalventilatorMaybedonenoninvasivelyorviaETtube(HFNCinextubatedpatientsonly)Patients:Newborninfants26wkswithearlydistressInfantsi

9、nNICUwithnewdistressorapneaExtubatedinfants,Continuouspositiveairwaypressure:CPAP,Setup:NeoPuff,otherdedicatedCPAPdevices:NasalpronginterfaceSetPEEP(4-6cmH2Omostcommon)SiPAP:specialtypeofCPAP.Uses2levels,usually2-4cmH2OdifferentHFNCNasalcannulainterface2-4L/minflowMonitoringCPAP:airwaypressuredispla

10、yedandalarmedHFNC:none,EarlyCPAP,ColumbiaPresbyterian,500-1500gmInfants:VariationinCLD,*,*,*,*,*p0.0001,VanMarteretal.Pediatrics2000;105:1194-1201,%,Intermittentmandatoryventilation:IMV/SIMV,Goal:SupportEELVandimproveVeinspontaneouslybreathinginfantrequiringintubationEliminatebreath-breathvolumevari

11、ation,cerebralbloodflowabnormalities,allowpatientcontrolviasynchronizationofSOMEbreathsDelivery:UsingmechanicalventilatorMaybedonenoninvasivelyorviaETtubePatients:NewborninfantsrequiringintubationExtubatedinfantswithpersistentdistress,IntermittentMandatoryVentilation:IMV/SIMV,Setup:ETtubeinterfaceVa

12、riables:Rate-range15-60bpm;alwayssynchronizedVolume-targetvolume4-7mL/kgPressure-Setpeakpressurelimit(usually30cmH2O).Pressurethenadjustbasedonvolume.SetPEEP5-7cmH2OTime-setTiat0.30.5secbasedonptsizeMonitoringDynamic.Multiplealarmsettings.Allmeasuredandcalculatedparametersmaybedisplayedandtrended,IM

13、V-unsynchronized,Impactofsynchronization,Assist/control:PAC,Goal:SupportEELVandimproveVeinapneicorspontaneouslybreathinginfantrequiringintubationEliminatebreath-breathvolumevariation,cerebralbloodflowabnormalities,allowpatientcontrolviasynchronizationofALLbreathsDelivery:UsingmechanicalventilatorDon

14、eviaETtubePatients:Newborninfantsrequiringintubation,Assist/control:PAC,Setup:ETtubeinterfaceVariables:Rate-setminimumacceptablerate,40-60bpm;actualratedependsonpatienteffortVolume-targetvolume4-7mL/kgPressure-Peakpressure:Setlimit(usually30cmH2O).Pressurethenadjustbasedonvolume.PEEP:5-7cmH2OTime-se

15、tTimaximumat0.30.5secbasedonptsize.ActualTivarieswithlungmechanics.TevarieswithrateMonitoringDynamic.Multiplealarmsettings.Allmeasuredandcalculatedparametersmaybedisplayedandtrended,Assist/control-fullsynchronization,ConventionalVentilation,Variables-Whatdoeswhat?Minuteventilation(Ve):PaCO2Ve=RRxVtV

16、tchangeswithchanginglungmechanicsToolstochange:PIP,PEEP,Ti,TeOxygenation:PaO2,SaO2Meanairwaypressure(Paw)Oxygenationvarieswithlungvolume,injuryToolstochange:PIP,PEEP,Ti,Te,ConventionalVentilation,Variables-Whatdoeswhat?Minuteventilation(Ve):PaCO2Ve=RRxVtVtchangeswithchanginglungmechanicsToolstochang

17、e:PIP,PEEP,Ti,Te,AssessmentofVt:PAC(novolumetarget),AssessmentofVt:PAC,improvedC,AssessmentofVt:PAC+V,impC-nolimit,BorosSJ,etal.Pediatrics74;487:1984,ConventionalVentilation,MammelMC,etal.ClinChestMed1996;17:603,ConventionalVentilation,Variables-Whatdoeswhat?Oxygenation:PaO2,SaO2Meanairwaypressure(P

18、aw)Oxygenationvarieswithlungvolume,injuryToolstochange:PIP,PEEP,Ti,Te,LungVolume,OptimizelungvolumeDefineopeningpressure,closingpressure,optimalpressure:dependentonestimationoflungvolumeProblems:nousefulbedsidetechnologytomeasureeitherabsoluteorchangeinlungvolume,Pmax,Popt,PclPop,Pressure,Volume,LungVolume,OptimizelungvolumeSaO2asvolumesurrogate,TingayDGetal.AmJRespCritCareMed2006;173:414,AssessmentofPawTiadjustment,AssessmentofPawPEEPadjustment,AssessmentofPawPIPadjustment,AssessmentofPawRateadjustment,NeonatalMechanicalVe