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Mechanical Ventilation

Mechanical Ventilation. Mary P. Martinasek BS, RRT Director of Clinical Education Hillsborough Community College. Goals of Mechanical Ventilation. Normalization and maintenance of blood gases Prevention of iatrogenic complications Support patient’s respiratory needs. ABG.

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Mechanical Ventilation

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  1. Mechanical Ventilation Mary P. Martinasek BS, RRT Director of Clinical Education Hillsborough Community College

  2. Goals of Mechanical Ventilation • Normalization and maintenance of blood gases • Prevention of iatrogenic complications • Support patient’s respiratory needs

  3. ABG pH = 7.35 - 7.45 paCO2 = 35 - 45 mmHg paO2 = 50 - 80 mmHg Avoid high O2 sats if delivering O2

  4. Common terms • PIP = Peak Inspiratory Pressure • Peep = Positive End Expiratory Pressure • Frequency = rate of ventilation (20 – 40 bpm) • I – time = Inspiratory time (.2 - .8 seconds) • MAP = Mean airway pressure • Tidal Volume = amount of air inhaled in a single breath • Minute Ventilation

  5. Neonatal Ventilation • Time Cycled and Pressure Limited Ventilation • Inspiration is stopped when the selected inspiratory time has been reached • PIP is the maximum amount of pressure exerted on the patient’s airway during the inspiration • Initial values = 16-20 cmH20 of PIP • Good chest rise and Good breath sounds

  6. Neonatal Ventilation • Peep = Positive pressure maintained in the patient’s airway during expiration • Prevents collapsed alveoli • Increases FRC • Improves compliance • Improves oxygenation • Decreases intrapulmonary shunting • Allows for lower PIPs to be used

  7. CPAP vs PEEP • Same distending alveolar pressure • PEEP is used in conjunction with ventilator rate • CPAP is used in spontaneously breathing patient

  8. Methods of administering CPAP • Endotracheal Tube • Patent airway, airway clearance • Disadvantage: plugging, malacia, infection • Nasal Prongs • Decrease infection, no malacia • Disadv. = plugging,pressure necrosis, gastric distention • Nasopharyngeal • Pressure necrosis, infection • Face Mask • Temporary measure prior to intubation or for apnea episode

  9. Most popular method • High flow nasal cannula

  10. ET - CPAP in Pediatrics • Pre and Post operatively to support structures • Subglottic stenosis • Cleft palate • Laryngeal papillomas • Neck tumors • Tonsillitis • epiglottitis

  11. Indications for NCPAPAARC Clinical Guidelines • Increased WOB with retractions, flaring, grunting and cyanosis • Inadequate ABG’s • Presence of poor expansion on CXR • Presence of conditions responsive to CPAP • RDS, Pulmonary edema, atelectasis, apnea, tracheal malacia, TTN

  12. Contraindications to NCPAPGuidelines • Upper airway abnormalities • TEF, choanal atresia • Severe cardiovascular instability and impending arrest • Unstable respiratory drive • Ventilatory failure

  13. Hazards of NCPAP • Air leaks • Ventilation Perfusion Mismatch • CO2 retention and increased WOB • Increase in PVR due to impedence of blood flow • Nasal irritation with septal distortion • Pressure necrosis • Nasal mucosal damage due to inadequate humidification

  14. MAP • Most powerful influence on oxygenation • Average pressure exerted on the airway and lungs for the entire breath cycle • Affected by: PIP,PEEP,I-Time, Rate • High levels can lead to decreased CO, pulmonary hypoperfusion and barotrauma

  15. Physiologic Deadspace • Physiologic = anatomic + alveolar • Anatomic = Gas that fills the airways and never participates in gas exchange • Alveolar = gas that goes to unperfused alveoli and thus never participates in gas exchange • Nl physiologic Vd in neonate = 2cc/kg

  16. Flow rate • Flow rate used determines the type of wave pattern • Goal is to set flow to allow maximum diffusion time without causing turbulent flow • Diffusion time is the length of time that the gas is in contact with the alveoli

  17. Indications for Vent Support • Respiratory Failure • Hypoxemic respiratory failure • PaO2 less than 50 on FIO2 greater than 60 • Hypercapnic respiratory failure • PaCO2 greater than 50 and pH less than 7.25 • Mixed respiratory failure • Both hypoxemia and hypercapnia

  18. Initial Setting on neonatal vent • Time cycled – Pressure Limited ventilator • PIP set 15 – 20 cm H20 • Peep set 3 – 5 cm H2O • Rate set 20 – 40 bpm • Flow set 6 – 8 lpm • I time set .3 - .5 seconds for LBW and .5 - .8 seconds for larger infants

  19. Settings • PIP – good chest excursion, good lung aeration • Vt in pressure control = PIP – PEEP • Vt in pressure control changes with change in compliance and resistance • PIP set – change only with changes in compliance and resistance in 2 cm increments

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