Choice of Oscillator & Jet Ventilator (15 min) Choice of High Flow & Nasal CPAP (20 to 30 min) Trials in 2008

1. Respiratory Highlights 2008 BWH NICU Nursing Blitz • Choice of Oscillator & Jet Ventilator (15 min) • Choice of High Flow & Nasal CPAP(20 to 30 min) • Trials in 2008 of CPAP & SIPAP (5 min) 4. ROP Data & O2 Saturation Alarms (10 min)

2. HFO ChoiceOscillator Jet

3. Pressure/Volume

4. NEJM Sept. 13, 2007, Malhotra

7. Intracranial Blood Pressure Elevated Elevated Intrathoracic Pressure ( High PEEP & Paw) Venous Return Impeded Hepatic Veins Dilated

8. HFV Pressure Attenuation Amplitude may attenuate around a fixed Paw 20 O 2 CV cm H 15 10 Tracheal Pressure HFOV 5 HFJV 0 Proximal Distal Airways Paw

9. Exhalation with HFOV • Active exhalation, as with high-frequency oscillation (HFO), can lead to gas trapping by lowering intraluminal pressure disproportionately below pressure in surrounding alveoli, thereby collapsing more proximal airways before exhalation is complete. • For that reason, users of HFO typically operate at higher mean airway pressures than those used with HFJV. • Elevating the baseline pressure during HFO, "splints" the airways open while gas is actively withdrawn from alveoli.

10. Exhalation with HFJV CO2 CO2 CO2 CO2 • During HFJV, exhaled gas swirls outward around the incoming gas. • The exhaled gas sweeps through the CO2-rich deadspace gas. CO2 CO2 • This action may help evacuate CO2 and enhance ventilation. • Small VT is readily exhaled without trapping during short exhalation time.

11. CHOKE POINTS may develop when: • airways lack structural strength   • the chest is squeezed   • gas is sucked out of the airway

12. + PEEP + + + • Back pressure (High PEEP/Paw) may splint open the airway and allow gas to exit +

13. The 6 Jet Fundamentals • HFJV P (PIP - PEEP)  PaCO2 • HFJV Rate is secondary • FRC and MAP  PaO2 •  PEEP to avoid hyperventilation and hypoxemia • If  CV Rate  oxygenation, PEEP is probably too low •  CV settings whenever possible • Especially when airleaks are a concern •  FiO2 before PEEP until FiO2 < 0.5

14. Ventilation and HFJV 25 PIP 20 15 P 10 PEEP 5 0 time Raising PIP or lowering PEEP VT which PCO2

15. Recruitment Strategy for RDS • Find the Critical Opening Pressure of the alveoli • Optimize PEEP to stabilize the alveoli • Reduce PIP as recruitment proceeds • HFJV may reduce volutrauma in surfactant deficient lungs

16. HFJV - RDS Study Summary* • HFJV reduced the incidence of BPD at 36 wks PCA. • HFJV reduced PIP and P compared to CV. • HFJV "optimal-volume strategy" resulted in less hypo- carbia and better oxygenation than low-volume strategy. • HFJV "optimal-volume strategy" was associated with lower incidence of severe neuroimaging abnormalities compared to low-volume strategy. * Keszler, et al. Peds 1997; 100:593-599.

17. HFO / HFJV • choice • PIE despite HFO • Air leak syndromes • Excessive secretions • Hemodynamic compromise • When HFOV fails choice High PIP & FiO2 conventional PIE per CXR Need for nitric oxide When Jet fails

18. Oxygenation – • HFO • FiO2 • MAP • Jet-Particularly effective with non-homogeneous disease. • FiO2 • PEEP • CV rate • CV PIP • CV I time

19. Ventilation – • Jet • Raise PIP • Raise rate • Change PEEP • HFO • Amplitude • MAP to optimize position on inflation curve • Rate (lower to drop PaCO2)

20. Bubble CPAP HF Nasal Cannula

21. RDS, apnea & post-extubation support http://www.surfneon.com/cpapbwh.swf

22. B U B B L E C P A P

24. DuoDerm • Nare protection from CPAP prongs • Nasal seal for CPAP prongs

25. Bruised Nasal Septum /Mepitac use under Cannulaide

26. CPAP design

27. for a contented family… CPAP design

28. “On the basis of our findings, we suggest that high-flow nasal cannula should not be used as a routine replacement for CPAP therapy.”

31. Tight cannula obstructs nares. Cannula flow will not meet baby’s flow demand. Flow directed into nasopharynx not at stable pressure

32. Anatomic variants of nare size & structure alter cannula seal. Clinically relevant pressure is achieved only on the smallest of babies.

33. Poor humidification • Airway dysfunction • mucocilliary transport • Increased fluid osmolarity • Promotion of bronchospasm • secretion viscosity • Impaired nutrition • Impaired growth • Mucosal injury • infection

34. Trial:Airlife CPAP & BIPAP

35. CPAP

36. SIPAP

37. Maine Med Portland St/ Margaret’s Dorchester

38. MY SAT LIMITS ARE: HIGH: 93 LOW: 85 • Ford S. Leick-Rude MK, Meinert K, Anderson B, Sheehan M, Haney B, Leeks S, Simon S, Jackson J. Overcoming Barriers to Oxygen Saturation Targeting. Pediatrics 2006 118 Suppl 2:S177-186 • Phelps, D., Goldsmith, JP, Retinopathy of Prematurity Hot Topics Dec. 4, 2007