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Lung Disease and Ventilator Strategies in Necrotizing Enterocolitis
Published in David J. Hackam, Necrotizing Enterocolitis, 2021
Jegen Kandasamy, Namasivayam Ambalavanan
Infants with difficulty in oxygenation or carbon dioxide ventilation on conventional mechanical ventilation (either pressure limited or volume targeted) are often placed on high-frequency ventilation (usually high-frequency oscillatory ventilation [HFOV] or high-frequency jet ventilation [HFJV]) as a “rescue” therapy. The usual strategy in using high-frequency ventilation is to use a “high-volume strategy” that involves starting with a mean airway pressure slightly higher than that required on conventional ventilation (e.g., 10% to 20% higher or 2 to 3 cm H2O higher) and adjust MAP slowly higher (in steps of 1 to 2 cm H2O) until oxygenation improves. The FiO2 is then gradually weaned. If FiO2 has been weaned sufficiently, this implies that alveolar recruitment has been adequate. After FiO2 has been weaned sufficiently (e.g., less than 30% to 50%, depending upon the severity of lung disease), the MAP can be weaned slowly. A slow MAP wean is important, as lung derecruitment may occur, necessitating an increase in MAP again. During high-frequency ventilation, the amplitude (on HFOV) or delta pressure (on HFJV) is adjusted to create an adequate “chest wiggle” signifying sufficient tidal volume and minute ventilation. Currently, there is no evidence to suggest whether one mode of ventilation—either HFOV or HFJV—is superior to the other (22). Most clinicians prefer to use HFOV for larger preterm infants (e.g., >1 kg) or those with more severe anasarca, and HFJV for smaller preterm infants (<1 kg).
The management of major injuries
Published in Ashley W. Blom, David Warwick, Michael R. Whitehouse, Apley and Solomon’s System of Orthopaedics and Trauma, 2017
The treatment of ALI/ARDS remains mainly supportive and includes the management of precipitating causes. A large prospective study, supported by the National Heart Lung and Blood Institute in the USA, has shown that the use of low tidal volume ventilatory strategies (6 mL/kg) and limited plateau pressure (<30 cm H2O) was effective in reducing the mortality rate from 40% to 31%. Other measures to improve oxygenation – (e.g. prone positioning, high-frequency ventilation, nitrous oxide inhalation and extracorporeal life support) have limited success in improving overall outcome.
Respiratory Failure after Surgery or Trauma
Published in Stephen M. Cohn, Matthew O. Dolich, Complications in Surgery and Trauma, 2014
Joseph J. DuBose, James V. O’Connor
Although several methods of high-frequency ventilation exist (viz., high-frequency oscillatory ventilation [HFOV], high-frequency jet ventilation, and high-frequency positive-pressure ventilation), all employ a similar physiologic principle. In HFOV, oxygenation at a given FiO2 is proportional to the mean airway pressure (Paw) and the resultant lung volume. The Paw is adjusted either by changing the resistance at the end of the bias flow circuit or by changing the rate of bias flow. Ventilation is controlled by changes in the amplitude of the oscillating membrane (DP). With this method of ventilation, the tidal volume and frequency are inversely related. Hence, the level of carbon dioxide can be reduced by increasing the DP, decreasing the frequency, or both. Because both inspiration and expiration are active events, the incidence of dynamic hyperinflation is reduced.
Emerging approaches in pediatric mechanical ventilation
Published in Expert Review of Respiratory Medicine, 2019
Duane C Williams, Ira M Cheifetz
Understanding the physiologic implications of driving pressure on outcome in those with ARDS may provide greater insight into approaches to improve morbidity rather than focusing on peak/plateau pressures alone.Bedside non-invasive monitoring technology, such as ETCO2, VCO2, esophageal pressure monitoring, and electrical impedance tomography may improve efficiency in care and potentially outcomes.There is a possibility that assist ventilation modes may improve patient-ventilator synchrony, thus minimizing the need for pharmacologic sedation.The use of high frequency ventilation as well as proning for those with pediatric ARDS requires further investigation.Targeting therapy to specific biomarkers has been the ‘holy grail’. Continued investigation may finally provide additional insight into the pathophysiology of severe ARDS as well as potential therapeutic management approaches.Optimal early nutrition may augment lung healing in those with lung injury.
Habilitation of very preterm infants at a Post Acute Care Inpatient Rehabilitation (PACIR) center after neonatal intensive care unit (NICU) discharge
Published in Developmental Neurorehabilitation, 2019
Meenakshi Singh, Boriana Parvez, Agnes Banquet, Jordan S Kase
Despite having similar birth characteristics and clinical courses defined by the NTISS scores, cases had a significantly greater incidence of neonatal morbidities primarily related to the respiratory system. They had a higher prevalence of BPD and higher use of iNO and high-frequency ventilator support. The duration of respiratory support was significantly longer among cases (70 vs. 22 days; p < 0.001). The postnatal administration of steroids in an attempt to improve pulmonary mechanics was used more frequently among cases (63% vs. 33%; p value 0.003). Cases had more total number of respiratory infections (2 vs. 0; p < 0.001) and total number of infections excluding respiratory infections (4 vs. 2; p value 0.047).
Extracorporeal membrane oxygenation in critically ill neonatal and pediatric patients with acute respiratory failure: a guide for the clinician
Published in Expert Review of Respiratory Medicine, 2021
Briana L. Scott, Desiree Bonadonna, Caroline P. Ozment, Kyle J. Rehder
After establishing ECMO, the goal of ventilator management is to further avoid VILI. Pediatric patients presenting with respiratory failure requiring extracorporeal support are a heterogenous population. As a result, there is little consensus on ventilator management of this population. ELSO guidelines recommend a low rate, low plateau inspiratory pressure (< 25 cm H2O), FiO2 < 30% and a positive end expiratory pressure (PEEP) set to any level [21]. Many institutions advocate for initiation of ‘rest settings’. For V-A ECMO, the authors’ institution typically uses a rate of 10 breaths/min, a driving pressure of 10 cm H2O, PEEP of 10–12 cm H2O and FiO2 < 30% to optimize chances at lung recovery while minimizing ventilator-induced lung injury. A subgroup of patients on ECMO, particularly those on V–V ECMO, require higher ventilator settings to achieve adequate gas exchange given limitations of ECMO support, patient demand, or patient comfort. High-frequency ventilation and airway pressure-release ventilation have both been successfully used as lung protective strategies in pediatric patients with respiratory failure on ECMO [21,22]. With appropriate attention to lung protection, specific ventilator settings (other than FiO2) are not associated with mortality, ECMO-free days, or ventilator-free days [23]. If pulmonary leak exists, ventilator pressures may be decreased further or the patient may be extubated until the leak seals, despite knowing this can further contribute to atelectasis in addition to the primary lung pathology. Tracheostomy decreases the risk of pneumonia, allows for lighter sedation, and may facilitate ambulation, particularly for patients awaiting lung transplantation, however bleeding with this procedure can be a significant risk in the anticoagulated ECMO patient [21]. Historically, recruitment maneuvers were used as means to hasten convalescence in preparation to separate from extracorporeal support. This is controversial due to the paucity of evidence to support such maneuvers. Slow careful recruitment maneuvers with incremental and decremental PEEP have been recommended by the Pediatric Acute Lung Injury Consensus Conference (PALICC) for pediatric patients with acute respiratory distress syndrome (ARDS), however sustained inflation is not recommended [24,25].