Monthly Archives: May 2017

Tit Bits of Refractory hypoxemia & Journey of ventilator care

 

Much progress has been made in the treatment of neonatal respiratory failure over the past few decades. In particular, antenatal steroids and exogenous surfactant replacement have decreased neonatal mortality and morbidity in premature infants(2), (3), (4). However, lung injury and pulmonary morbidities secondary to mechanical ventilation remain an ongoing problem in the care of premature infants and refractory hypoxemia in infants. Of utmost concern, chronic lung disease (CLD) develops in up to one third of preterm infants who have respiratory distress syndrome (RDS) who receive positive pressure mechanical ventilation HFOV-data suggest that early use of high-frequency ventilation, compared with conventional ventilation; high-frequency oscillatory ventilation is not associated with a poorer neuromotor outcome, rather in few studies early use rather than rescue use has been proven to be having less neuromotor insult at 2 years follow up(1).

There are many randomized control trials available now in today’s era of evidence based medicine, which says improved gas exchange and less treatment failure with HFOV, both in the patients initially allocated to HFOV as a primary mode and in those that failed conventional CMV and crossed over to HFOV too. There was no difference in the incidence of chronic lung disease, IVH, or death between the HFOV & CMV but hospital stay and ICU stay was markedly reduced in HFOV Group(5). Cases like PPHN, air leak syndrome and Congenital diaphragmatic hernia (CDH) claim much better results and response with HFOV when used alone or with Nitric oxide therapy in selected scenarios.

 

In all of above mentioned 4 cases; a considerable benefit of capillary ABG Program was utilized. Capillary ABG for neonates is a well proven method in all developed countries as method of choice in doing ABG is these tiny babies avoiding multiple peripheral arterial pricks. Its unique feature of full panel ABG analysis with lactate and electrolytes in just 60 micro L blood, requiring no additional cost gives a relief to clinician as well as Neonate. Sooner As a next step CIMS kids-Department of pediatric and neonatal critical care is going to support such kind of above said neonates and infants with Nitric oxide therapy in near future.

References:-

  • Neuromotor outcome at 2 years of very preterm infants who were treated with high-frequency oscillatory ventilation or conventional ventilation for neonatal respiratory distress syndrome. Truffert P – Pediatrics – 01-APR-2007; 119(4): e860-5
  • Liggins G.C., Howie R.N.: A controlled trial of antepartum glucocorticoid treatment for prevention of the respiratory distress syndrome in premature infants. Pediatrics 50. 515-525.1972; Citation
  • Crowley P.A.: Antenatal corticosteroid therapy: a meta-analysis of the randomized trials, 1972 to 1994. Am J ObstetGynecol 173. 322-335.1995;
  • Soll R.F.: Prophylactic natural surfactant extract for preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev 2. 2000; CD000511
  • Clark R.H., Yoder B.A., Sell M.S.: Prospective, randomized comparison of high-frequency oscillation and conventional ventilation in candidates for extracorporeal membrane oxygenation. J Pediatr 124. 447-454.1993

CASE 2: Diagnosis, Severe Mechonium aspiration Syndrome with PAH (Pulmonary Arterial Hypertension)

Diagnosis, Severe Mechonium aspiration Syndrome with PAH (Pulmonary Arterial Hypertension)

38 wk, Term, Male child was presented to us at 1st hour of life

With H/O thick MSL, with severe birth asphyxia, with Severe RD and impending respiratory failure. CMV was commenced and he required very high settings on CMV (MAP14, Fio2 of 0.8 giving result to spo2 of 94%). At 26 hour of life he developed massive pneumothorax on CMV. At night 03:00 am Lt. intercostal drain was inserted by using 8 Fr. IC Drainage catheter and pneumothorax was drained successfully.

To avoid further leak and in view of providing lung protective ventilation, child was shifted to HFOV. Insertion femoral arterial line was performed for repeated ABG sampling required. Air leak resolved after 24 hours (Shown in x-rays wide infra) and weaning of ventilation was possible quite faster than expected. On day 3, child was switched on SIMV and child was successfully extubated on day 5 of admission.

CASE 1 (CIMS Neonatal & Paediatric Critical Care Services)

CIMS Neonatal & Paediatric Critical Care Services

We are sharing our use of SLE5000 (HFOV) with one of the most recommended technology which has unique feature of combining conventional mode with HFOV-providing ability to switch over to CMS to HFOV and vise versa.

Case 1 :

Diagnosis – Severe RDS (HMD) 26 weaker/900gms/male/aga with severe grunting presented at 32 hours of life with 60% Oxygen saturation and gasping respiration. Intubation was performed and ventilation was commenced (CMV).Child had extremely non compliant lungs with severe acidosis with Ph of 6.7 and Pco2 of 72 with Pao2 of 46.Rescue surfactant was given immediately but very transient response was achieved being late presentation. Commenced on HFOV with MAP of 18, Delta P of 40 and fio2 of 90 %. Gradually, child started improving lung recruitment was better on X-ray on day 3 of ventilation. Weaning was soon started with ABG analysis at 2,8,14 and 20 hours of starting HFOV and henceforth 8-12 hourly once ABG as per need clinically. On day (4) settings were minimal on HFOV with MAP of 10,Delta P of 25 and

Fi02 of 0.45.We switched over to CMV mode and continued weaning on traditional SIMV+PC mode for 3 days, sooner child was prepared for extubation which was successful.

Discussion –disease with Homogenous lung damage like HMD, ARDS can have best result with HFOV if used early in the setting how it was used in these patients. Newer Modalities and mode of HFOV like HFOV+CPAP is getting a wide acceptance during weaning of such patient and same was used in above patient for approximately 26 hours before extubation by Naso pharyngeal tube in situ. Recent data says that early and protocol based use of HFOV is not associated with any adverse outcome rather neurodevelopment is unaffected at all (1).

References:-

> Neuromotor outcome at 2 years of very preterm infants who were treated with high-frequency oscillatory ventilation or conventional ventilation for neonatal respiratory distress syndrome. Truffert P – Pediatrics – 01-APR-2007; 119(4): e860-5 (1)

> Soll R.F.: Prophylactic natural surfactant extract for preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev 2. 2000; CD000511 (4)

 

 

 

 

 

CIMS Neonatal & Paediatric Critical Care Services

CIMS kids-Department of paediatric and neonatal critical care is committed to serve all kids who are in their critical phase of life during Treatment of various diseases requiring critical care. We share experience of HFOV in 4 extremely critical neonates and infants  where neonates/infants got excellent recovery in a significantly rapid time frame.

 

High Frequency ventilation- A name in paediatric critical care ; which drew lot of attention and proven its efficacy in extremely sick lungs due it’s unique feature of lung protective ventilation using very high respiratory rates (Between 3.5 to 15 hertz (210 – 900 breaths per minute) and very small tidal volumes (usually below anatomical dead space) by stretching alveoli at required PEEP.

Out of many type of HFV (High frequency ventilation); Oscillation is proven to be the best among other modes like HFJV (Jet), HFFI (Flow interruption). We are sharing our use of SLE5000 (HFOV) with one of the most recommended technology which has unique feature of combining conventional mode with HFOV-providing ability to switch over to CMS to HFOV and vise versa.

Which is specifically useful in neonatal patients in difficult weaning.

Where should it be used? : It is used in patients who have refractory hypoxemia that cannot be corrected by normal mechanical ventilation such as is the case in the following disease processes: i.e. HMD, Pneumothoraces (air leak), ARDS, ALI and other oxygenation diffusion issues i.e. RSV pneumonia, pulmonary hemorrhage etc. In some neonatal patients, HFOV may be used as the first-line ventilation mode due to the high susceptibility of the premature infant to lung injury from conventional ventilation.

 

More in next post..

How to perform CPR

How to perform CPR

The victim should lie on a flat, hard surface. The place should not be crowded.

 

Follow the Chain of survival

One thing to remember is, assuming that you are alone, when you find someone down, first establish if they really need CPR: are they breathing? do you see any signs of movement?

Remember to look, listen and feel, for any signs of movement, for breath sounds and for air movement by placing your ear over their mouth.

 

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