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Extracorporeal Membrane Oxygenation (ECMO) Support for Cardiorespiratory Failure
Published in Wayne E. Richenbacher, Mechanical Circulatory Support, 2020
Ralph E. Delius, Angela M. Otto
Ventilator management while on ECMO support varies from program to program as there is no good data supporting one strategy over another. However, some general principles are applicable. Lung “rest” is paramount. As a consequence, the peak inspiratory pressure should be limited to approximately 20 cm H2O. Alveolar recruitment is also necessary and some degree of positive end expiratory pressure should be maintained. The FiO2 is usually dropped to 21–40%. If the patient is on VV bypass a slightly higher FiO2 may be needed to maintain satisfactory oxygenation. Patients on VV support should also have their ventilator settings weaned slowly due to the previously described inefficiency of VV ECMO. The lungs should be allowed to collapse only if a severe air leak is present. Pulmonary physiotherapy, suctioning, bronchoscopy and lavage can be used as needed although caution should be used due to anticoagulation. Typically, bilateral opacification is present on chest roentgenogram for 24–48 hours after initiation of bypass followed by gradual improvement in radiographic appearance. Surfactants may be given as the chest films improve. Some groups also prefer to change to high frequency oscillatory ventilation at this point to improve alveolar recruitment.
Emergency Medicine
Published in Stephan Strobel, Lewis Spitz, Stephen D. Marks, Great Ormond Street Handbook of Paediatrics, 2019
Traditional mechanical ventilation, using high tidal volumes and low PEEP, is likely to induce lung injury in patients with ARDS. However, in ARDS, a ‘lung protective strategy’, optimising PEEP, using a tidal volume of <6 ml/kg, permissive hypercapnia, and pressure limited ventilation with PIP limited to <40 cmH2O has been shown to improve outcome3.
Section 6
Published in Padmanabhan Ramnarayan, MCQs in Paediatrics for the MRCPCH, Part 1, 2017
Curosurf is a natural surfactant from porcine lungs. Antenatal steroids are given intramuscularly 12 hours apart. Either dexamethasone or betamethasone are used and for maximum benefit should be given at least 12 hours prior to delivery. They need to be repeated after a week if preterm delivery is still imminent. Mean airway pressure (MAP) is influenced most by a change in PEEP (positive end-expiratory pressure). Other factors include PIP (peak inspiratory pressure) and inspiratory time. MAP is the chief determinant of oxygénation. Rate affects the minute ventilation and therefore C02 elimination. Pressure-volume curves shift to the right with surfactant (increased compliance of the lung).
Respiratory management in the premature neonate
Published in Expert Review of Respiratory Medicine, 2023
Vikramaditya Dumpa, Indirapriya Avulakunta, Vineet Bhandari
The modality refers to the target or limit variable of the mechanical inflation. There are two modalities of CMV: pressure-controlled (or pressure-limited), and volume-controlled. In pressure-controlled ventilation, a set peak inspiratory pressure (PIP) is delivered and the resultant tidal volume depends upon the lung mechanics and respiratory effort. Since the pressure is constant, the tidal volume changes depending on the pulmonary dynamics and care should be taken to adjust the PIP to avoid excessive tidal volumes and resultant lung injury. In volume-controlled ventilation, a set tidal volume is delivered and the pressure changes in inverse proportion to the lung compliance. However, the tidal volume is measured at the proximal end of the circuit and due to factors, such as compression of gas in the circuit, ETT leak, the delivered tidal volume into the lung is not the same as the set tidal volume. These features made it undesirable to use volume-controlled ventilation in neonates. However, with the advent of newer ventilators with microprocessors that are able to measure the flow at the proximal end of the ETT, and compensate for the circuit and ETT leaks, multiple variations of volume ventilation are now available. Volume targeted ventilation (VTV) is a pressure-limited form of volume ventilation that adjusts the PIP and/or time to target a set tidal volume. Different manufacturers have different terminology to denote VTV for e.g. Volume Guarantee on Dräger®, Pressure-Regulated Volume Control on Servo®, Targeted Tidal Volume Plus on SLE5000®, Volume Ventilation Plus on Puritan Bennett®, etc.
Lung injury caused by aspiration of organophosphorus insecticide and gastric contents in pigs
Published in Clinical Toxicology, 2022
Elspeth J. Hulse, Richard E. Clutton, Gordon Drummond, Adrian P. Thompson, Edwin J. R. van Beek, Sionagh H. Smith, Michael Eddleston
The study was approved by the Institutional Ethical Review Committee. Twenty-six female Gottingen minipigs, mean (±SD) weight 28 (±2) kg, were housed/treated as per Home Office (UK) guidelines. Pigs were terminally anaesthetised and intubated with a TCB Univent endotracheal tube (Fuji systems, Tokyo) to allow bronchial blockage of one lung during instillation of pulmonary mixtures to the contralateral lung [18]. Two pigs were studied simultaneously over 48 h and lungs were ventilated using a mixture of oxygen and medical air (FiO2 0.5) with a tidal volume of 6–8 mL/kg delivered at 15–25 breaths per min. Peak inspiratory pressure (Ppeak) was limited to < 25 cm H2O, positive end expiratory pressure (PEEP) was set at 5 cm H2O and end-tidal CO2 maintained (mean ± SD) at 5.5 ± 0.8 kPa. Maintenance of anaesthesia was achieved with intravenous (IV) propofol (mean 11 (range 7–15) mg/kg/h) and fentanyl (mean 5 (2–12) mcg/kg/h) supplemented as required with IV midazolam.
Can optic nerve sheath diameter assess increased intracranial pressure in pneumoperitoneum and trendelenburg position?
Published in Egyptian Journal of Anaesthesia, 2019
Ghada A. Kamhawy, Fatma M. Khamis, Galal H. El-Said, Nada T. Hassan
The patients were pre-oxygenated for 3 min, general anesthesia was induced by 1 mcg/kg Fentanyl, 2 mg/kg propofol and 0.5 mg/kg atracurium. After confirmation of adequate anesthesia, endotracheal intubation was performed, and a morphine bolus of 0.15 mg/kg was given. Maintenance of anesthesia was done by isoflurane 1–2.5% in air/oxygen adjusted for patient MAC 50 for age. Top-up doses of atracurium 0.1 mg/kg 20–45 min after the initial dose to maintain the neuromuscular block were given. Ventilator settings were standardized, with pressure-controlled ventilation mode, and ventilation was adjusted to deliver a tidal volume of 6–8 ml/kg by setting Peak Inspiratory Pressure (PIP) 30 cm H2O. The respiratory rate (RR) was set at 12/minute with an inspiratory-to-expiratory ratio of 1:2. The RR was adjusted to maintain the end-tidal CO2 between 35 and 40 mmHg.