1. 5/20/2010 Dr.NILESH 1 VENTILATOR SETTINGS AND CPAP Dr. NILESH PANCHAL

2. OVERVIEW OF PRESENTATION BASICS OF VENTILATOR BASICS OF VENTILATOR SETTINGS CPAP BUBBLE CPAP APPLICATION AND ADVANTAGES OF CPAP MONITORING OF CPAP COMPLICATIONS OF CPAP IN-SUR-E 5/20/2010 Dr.NILESH 2

5. PROBLEMS Many infants who could have managed on their own are submitted to the ventilator risks. Ventilator management can be worse than the disease. We need to learn who, when and why before learning how to use the ventilator. 5/20/2010 Dr.NILESH 5

6. GALIRAL IN LATE 1800“AEROPHORE PULMONAIRE” 5/20/2010 Dr.NILESH 6 Ö Galiral (late 1800’s) first mechanical device for artificial ventilation (‘aerophore pulmonaire’)

7. ALEXANDER GRAHAM BELL FIRST INVENTED NEGATIVE PRESSURE VENTILATION

8. Von Reuss (1914) FIRST described CPAP to resuscitate 5/20/2010 Dr.NILESH 8

9. MECHANICAL VENTILATION STRATEGIES CPAP (1969) & NPCPAP (1975) Intermittent Mandatory Ventilation (IMV) (1970s) Patient-triggered ventilation (1980s-1990s) High frequency ventilation (1990s) Flow synchronized ventilation (2000) Hybrid (Pressure & volume targeted) (VAPS/PRVC) (2000) 5/20/2010 Dr.NILESH 9

10. CONCEPTS OF “T” 5/20/2010 Dr.NILESH 10

11. 5/20/2010 Dr.NILESH 11

12. 5/20/2010 Dr.NILESH 12

13. Flow will be P1 - P2 R 5/20/2010 Dr.NILESH 13

14. TYPES OF VENTILATORS Conventional Ventilators Pressure-limited, time-cycled Volume-limited, time- cycled Patient-triggered ventilation High Frequency Ventilators High frequency oscillatory ventilator High frequency jet ventilators 5/20/2010 Dr.NILESH 14

15. JUGGLARY OF 6 PLAYERS PIP (peak inspiratory pressure) PEEP (peak end expiratory pressure) FiO2 ( fraction of O2) R.R. (respiratory rate) Ti (inspiratory time) Te ( expiratory time) 5/20/2010 Dr.NILESH 15

16. FLOW RATE The minimal flow rate is 2.5 times infant’s minute ventilation With high flow rate: Higher MAP Higher incidence of barotrauma With low flow rate: Higher PCO2 form rebreathing exhaled gas May not be high enough to reach PIP 5/20/2010 Dr.NILESH 16

17. Fi O2 The use of unnecessary high FiO2 increases the risk for pulmonary oxygen toxicity. The minimal adequate PaO2 is not known. PaO2 of 50-70 mmHg is generally acceptable. Preductal oxygen saturation is a valuable and inexpensive measure to follow. 5/20/2010 Dr.NILESH 17

18. Ti------Te TI, TE, I:E ratio, and rate(IMV) are all related Example: TI =0.5 sec I:E = 1:1 means, TE =0.5 sec IMV=60 Ideally, the choose of TI should be dependent on the time constant (Tc) of the respiratory system. 5/20/2010 Dr.NILESH 18

19. PIP Depends on Cl and Raw It should be adjusted until adequate but not excessive chest excursion is noted. If infant remains hypoxic in the face of good chest excursion, it is important to exclude CHD and PPHN. 5/20/2010 Dr.NILESH 19

20. PIP If PIP is too low: tidal volume will be low, leading to intra-pulmonary shunts and hypoxia If PIP is too high: the lung will be hyperinflated causing barotrauma PVR will be elevated venous return will be impeded 5/20/2010 Dr.NILESH 20

21. PIP Hypoxemia   PIP Observe chest excursion in every ventilated patient Sudden deterioration of the patient with decreased chest excursion denotes an airway or pneumothorax problems rather than compliance changes. 5/20/2010 Dr.NILESH 21

22. PEEP Excessively high PEEP: will overdistend the alveoli will decrease the compliance will cause barotrauma will impede the venous return 5/20/2010 Dr.NILESH 22

23. EFFECTS OF SETTINGS 5/20/2010 Dr.NILESH 23

24. Continuous positive airway pressure ( CPAP ) GREGORY IN 1971 _ ENDOTRACHEAL CPAP IN PRE –TERM WITH RDS KATTIWINKEL _ NASAL PRONGE FOR CPAP CPAP FORGOTTEN Mr. J. WUNG from columbia university used nasal pronge cpap and shown decreased incidence of BPD 5/20/2010 Dr.NILESH 24

25. ROLE OF CPAP Start early nasal prong CPAP for any: tachypnea retraction grunting oxygen requirement Early use of CPAP changes the severity and duration of illness. 5/20/2010 Dr.NILESH 25

26. HOW CPAP WORKS PREVENTS COLLAPSE OF ALVEOLI STABILIZES THE CHEST WALL SPLINTS OPEN AIRWAY STRETCHES LUNG AND PLEURA INCEASES THE OXYGENATION AND VENTILATION 5/20/2010 Dr.NILESH 26

27. COMPONENTS OF CPAP GAS SOURCE PRESSURE GENERATOR PATIENT INTERFACE / DELIVERY SYSTEM 5/20/2010 Dr.NILESH 27

30. SiPAP5/20/2010 Dr.NILESH 28

31. BUBBLE CPAP FLOWMETERWATER 5/20/2010 Dr.NILESH 29 FLOW METER

32. 5/20/2010 Dr.NILESH 30

33. 5/20/2010 Dr.NILESH 31

34. ADVANTAGES OF BUBBLE CPAP SIMPLE EASY TO PRPARE COST EFFECTIVE EFFECTIVE IN PRETERM WITH RDS DECREASED CHANCES OF BPD EASY TO IDENTIFY AIR LEAK FROM NASAL PRONGES 5/20/2010 Dr.NILESH 32

35. HOW TO INITIATE NASAL CPAP USE CORRECT SIZE OF NASAL PRONGE NASAL PRONGE SHOULD NOT TOUCH NASAL SEPTUM FIX THE NASAL PRONGE BY STRIP OR ADHESIVE PLAST SNIFFING POSITION OF THE BABY FIX NASAL PRONGE TO CIRCUIT OF CPAP APPLY PULSE OXYMETER 5/20/2010 Dr.NILESH 33

36. INCA 5/20/2010 Dr.NILESH 34 HUDSON INCA FISCHER AND PAYKEL

37. HUDSON NASAL PRONGE SIZE size 0 for < 700 g size 1 for 700-1000 g size 2 for 1000-2000 g size 3 for 2000-3000 g size 4 for 3000-4000 g size 5 for > 4000 g 5/20/2010 Dr.NILESH 35

38. Attach the oxygen tubing to the flow meter, and connect the tubing to the humidifier Set the flow meter to deliver 5 – 10 liters per minute 5/20/2010 Dr.NILESH 36

39. 5/20/2010 Dr.NILESH 37 Choose appropriate size nasal prongs and attach them to the corrugated tubing Secure measuring tape to the outlet bottle containing 0.25% acetic acid or sterile water, with the 7 cm mark at the base Empty fluid to the 0 mark Place the end of the corrugated tube into the water to a depth of 5 cm to create 5 cm of CPAP

41. Maintaining an optimal airway

42. Maintaining a patent CPAP delivery circuit

43. Prevention of complications which may arise from NCPAP5/20/2010 Dr.NILESH 38

45. Observe the infant q 1 hr over the first 4 hours of life, and then q 3-4 hr thereafter while on NCPAP.

46. Any infant experiencing significant respiratory distress while on NCPAP requires closer observation for change in condition5/20/2010 Dr.NILESH 39

48. Pre ductal oxygen saturation

49. Cardiovascular status (HR, BP, perfusion)

50. GI status (abdominal distention, bowel sounds)

51. Neurological state (tone, activity, responsiveness)

53. 5/20/2010 Dr.NILESH 42

54. COMPLICATION Suction the mouth, nose and pharynx q 3 hr For symptomatic infants more frequent suctioning may be needed 5/20/2010 Dr.NILESH 43

56. It may be necessary to pass the suction catheter more than once to ensure adequate airway clearance5/20/2010 Dr.NILESH 44

57. COMPLICATION 5/20/2010 Dr.NILESH 45 To prevent gastric distention: Assess the infant’s abdomen regularly Pass an oro-gastric tube to aspirate excess air before feeds q 2-4 hr An 8 Fr oro-gastric tube may be left indwelling to allow for continuous air removal

58. 5/20/2010 Dr.NILESH 46

59. WHEN TO WEAN FiO2 0.21 No respiratory distress No significant apnea/bradycardiaepisodes 5/20/2010 Dr.NILESH 47

60. SUMMARY Use the checklist Keep the airway clear Avoid shortcuts Think ‘low resistance’ Clinical assessment vs. lab values Monitor pre-ductal saturation 5/20/2010 Dr.NILESH 48

61. TO CONCLUDE Gentle & poor man’s ventilation Easy to set up & minimal training Save babies with RDS in developing countries vs headbox O2 Lots of unanswered questions yet – Optimal device Ideal pressure 5/20/2010 Dr.NILESH 49

62. 5/20/2010 Dr.NILESH 50 Should we Administer Surfactant & Extubate Immediately to NCPAP? (INSURE) NCPAP & prophylactic surfactant (vs. CMV and prophylactic surfactant) NCPAP-Surf decreased the number of infants ventilated at 7 days and the duration of O2 therapy (Dani et al). NCPAP and prophylactic surfactant (and rapid extubation) vs. NCPAP (with later treatment if needed). Earlier use of surfactant decreased the need for CMV (Verder & Reininger). In preterm infants (> 1250g) RDS, CMV & surfactant offers no advantage vs. NCPAP (no surfactant) (Texas Research Study Group)

63. 5/20/2010 Dr.NILESH 51 DOES CPAP APPLICABLE TO OUR NICU?

64. NO 5/20/2010 Dr.NILESH 52

65. 5/20/2010 Dr.NILESH 53

66. 5/20/2010 Dr.NILESH 54

67. 5/20/2010 Dr.NILESH 55

68. THANK YOU 5/20/2010 Dr.NILESH 56