Neonatal Options for the 3100A

1. Neonatal Options for the 3100A

2. Neonatal Options for the 3100A • Early Intervention • Pro-Active • Rescue

3. Neonatal Options for the 3100A • Rescue - is a term used to describe the infant that has failed all CMV strategies, and gas exchange continues to deteriorate; or develops airleak and is then transitioned to the oscillator.

4. Neonatal Options for the 3100A • Pro-Active - is a term applied to the infant on CMV that reaches specific thresholds and is then transferred to the 3100A prior to the onset of barotrauma or airleak.

5. Pro-Active • Establish institutional threshold or guideline as to when the 3100A will be implemented. For example: • FiO2 requirement of 60% or greater • PIP requirement equal to or approaching the child’s gestational age (e.g. a 24 wk infant should not require greater pressures than the low 20’s without a concern about resulting airleak.) • Deterioration of ABG’s without improvement following ventilator changes

6. Neonatal Options for the 3100A • Early Intervention - is a term used to describe the application of HFOV to an infant within the first 4 hours of life, or one that has not been conventionally ventilated. Application is usually applied to infants with RDS.

7. Neonatal Strategies • Preterm RDS (Diffuse Alveolar Disease) • Paw set at 1-2 cmH2O higher than CMV’s Paw • Frequency of 15 Hz for less than 1000 gms • Power of 2.0 and then adjust for minimum CWF • Term or Near Term RDS • Paw set at 2-4 cmH2O higher than CMV’s Paw • Frequency of 10 Hz • Power of 2.0 and then adjust for adequate CWF

8. Neonatal Strategies • Airleak (Premature Infant less than 1000 gms) • Pulmonary Interstitial Emphysema (PIE) • Paw set at 1 cmH2O less or equal to CMV’s Paw • Frequency 15 Hz • Power of 2.0 and then adjust for minimal CWF • Gross Airleak • Paw set equal to or 1cmH2O higher than CMV’s Paw • Frequency 15 HZ • Power of 2.0 and then adjust for adequate CWF

9. Neonatal Strategies • Airleak (Term or Near Term Infant) • Gross Airleak with poor inflation • Paw initiated at equal to or 1-2 cmH2O > than CMV’s Paw • Frequency at 10 Hz • Power of 2.5 and then adjust for adequate CWF • Gross Airleak with adequate inflation • Paw set equal to or 1cmH2O < than CMV’s Paw • Frequency at 10 Hz • Power of 2.5 and then adjust for adequate CWF

10. Neonatal Strategies • Focal Pneumonia (non homogeneous) • Paw equal to or 1 cmH2O > than the Paw in CMV • Frequency of 10 down to 8 Hz • Power of 2.5 and then adjust for a good CWF • Infants that present with a patchy or lobar pneumonia on CXR, may not respond as well as those with diffuse lung involvement. If they present with hyperinflation, they may be at risk for airleak.

11. Neonatal Strategies • Meconium Aspiration Syndrome (Diffuse Haze) • Paw at 2-4 cmH2O higher than CMV’s Paw • Frequency of 10 down to 6 Hz • Power at 2.5 and then adjust for good CWF • This type of MAS will respond well to an HFOV trial. The lung is affected by the meconium liquid and produces a chemical pneumonitis/ RDS picture

12. Neonatal Strategies • Meconium Aspiration Syndrome (air trapping) • Paw set equal to Paw of conventional • Frequency of 8 • Power of 2.5 and then adjust for good CWF • Because of the presence of air trapping in this case, too aggressive use of the Paw, can further aggravate it and result in PIE or pneumothoraces. PPHN may also complicate this picture.

13. Neonatal Strategies • Congenital Diaphragmatic Hernia (CDH) • Paw equal to or 1-2 cmH2O > than CMV’s Paw • Dependent predominantly on inflation of lung on non-hernia side. • Frequency 10 Hz • Power of 2.5 and then adjust for adequate CWF • Do not place infant on “HFOV Long Term” if it must transfer to another facility for surgery or ECMO.

14. Neonatal Strategies • Pulmonary Hypoplasia ( i.e., uniform Hydrops) • Paw equal to the same Paw of CMV • Increase Paw until maximum saturation of 93% • Frequency of 15 Hz for < 1000 gms • Frequency of 10 Hz of > 1000 gms • Power of 2.0 and then adjust for minimal CWF

15. Neonatal Strategies • Prior to the use of the 3100A for Lung Hypoplasias, assess: • CXR for the degree of lung inflation • ABG’s for indication of gas exchange • Determine if PPHN exists and to what degree • Cardiac status • Access to ECMO

16. Neonatal Strategies • REMEMBER- • The 3100A requires use of disease specific strategies • Application for diseases other than those indicated and application of an inappropriate strategy, will not result in positive outcomes. • CWF stands for Chest Wiggle Factor, which may be described as a visible vibration of the chest wall from the shoulders to the umbilicus • % Inspiratory Time is set to 33% for all strategies. Increasing the % I-Time may increase gas trapping.

17. Clinical Tips for Neonatal Strategies • Guideline is for initial starting point. If O2 saturation does not improve within 5-10 min., increase the Paw until the saturation is 88-93%. • Increase Paw until you see a rise in CVP or signs of decreased systemic blood flow • Obtain a Chest X-Ray for observation of lung expansion to 8-9 posterior ribs or decreased opacification

18. Clinical Tips for Neonatal Strategies • Once oxygenation improves, maintain that Paw and monitor the child for changes in perfusion. • Wean FiO2 to 60% or less, re-check x-ray • if diaphragm expansion is 9 rib level or more, decrease the Paw 1 cmH2O • if diaphragm expansion is 8 to 8-1/2 rib level, continue to wean FiO2 and monitor hemodynamics

19. Clinical Tips for Neonatal Strategies • Initial Paw in airleak is dependent on the inflation of the non air leak lung. The unaffected lung must be normalized for volume expansion. • Accept less than optimal ABG’s UNTIL the airleak resolves. • May see some evidence of atelectasis with the low lung volume strategy. Once no further leak from the chest tube is seen for 24 hrs, gently recruit the collapsed lung and begin weaning.

20. Clinical Tips for Neonatal Strategies • The use of Transcutaneous CO2 is extremely helpful for preventing hyperventilation and dropping the CO2 too rapidly. • Infants less than 1000 gms will often hyperventilate at 10 Hz and minimal Chest Wiggle. If so, increase the frequency. • Hypoventilation - increase amplitude by 2 cmH2O increments until the Chest Wiggle is optimal or decrease frequency. The Chest Wiggle should be limited to the thorax.

21. Clinical Tips for Neonatal Strategies • Use the 3100A to treat PIE the moment it is suspected or evidence of PIE on CXR is seen. The earlier application has better outcomes than following severe bilateral involvement. • DO NOT aggressively increase Paw. This results in further worsening of PIE and trapped gas. • Accept saturations of 87 - 90% initially and use higher FiO2’s and PaCO2’s until evidence of PIE resolution • is seen.

22. Clinical Tips for Neonatal Strategies • The CDH patient with high PaCO2’s may be initially stabilized on the oscillator until the child can be transported for ECMO and/or surgery. • CXR rib inflation criteria normally used, does not apply to hypoplastic syndromes. Acceptable inflation may be as low as 6 ribs. Look at lung fields for lucency, and diaphragms for flatness. • e.g. Lung fields clear, diaphragms slightly flattened at 7 ribs, Paw should be left alone or decreased

23. Clinical Tips for Neonatal Strategies • A chest x-ray is needed prior to the initiation of HFOV, to assure that the appropriate strategy is applied for an MAS patient. • ECMO needs to be immediately available if the patient fails HFOV. • The onset of PPHN, airleak, or decreased CO may prevent a positive outcome with HFOV alone.

24. Clinical Tips for Neonatal Strategies • The oscillator is used for hypoplasia syndrome to protect the abnormally developed, small lungs and maintain ventilation. • A transient improvement may be seen and then failure, which may be due to an insufficient amount of lung tissue or the onset of PPHN. • HFOV as a rescue tool may not be effective in cases of hypoplasia. Early management with HFOV, to prevent barotrauma and acidosis, may improve outcomes.