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NEONATAL PULMONARY

GRAPHICS:
More Than Just A
Pretty Picture
Steven M. Donn, M.D.

Professor of Pediatrics
Director, Neonatal-Perinatal Medicine
C.S. Mott Children’s Hospital
University of Michigan Health System
DATA
The Pre-Graphics Era

„ Pulmonary mechanics?
„ Lung expansion?
„ Gas trapping?
Early Experience
„ Cumbersome equipment
„ Difficult calibration
„ Limited applicability
Recent Experience
„ Microprocessor-based
„ Technical, but user-friendly
„ Extends “research” tool to
general clinical utility
Neonatal Pulmonary
Mechanics Tests
„ Provide useful clinical
information
„ Help elucidate pathophysiology
„ Give objective evaluation of
treatments
Waveform Monitoring

„ Volume
„ Pressure
„ Flow
Flow Waveform

„ Shapemay identify abnormality


„ Example: high airway resistance
Flow Waveform

„ Identifies type of ventilation


„ Example:
pressure vs. volume
Flow Waveform
Identifies mode of ventilation
„ IMV

„ SIMV

„ Assist/Control
IMV

SIMV

A/C
Flow Waveform:
Gas Trapping

„ Expiratory flow does not


return to baseline
„ Make adjustments
Tidal Volume Waveform

„ Suitability to wean
„ Example:
Effective vs. ineffective
spontaneous breathing
Effect of Inspiratory Time
„ Flow
„ Volume
Pulmonary Mechanics
„ Compliance
„ Resistance
„ Work of Breathing
„ Peak Flows
Compliance

„ Relationship of pressure
and volume
„ Example:
Flattened loops =
poor compliance
Pressure-Volume Loops

„ Compliance
„ Inflation
„ Work of Breathing
„ C20/C Ratio
Pressure-Volume Loops

„ Determine optimal PEEP


Flow-Volume Loops
and Resistance
„ Relationship of volume and flow
„ High resistance = lower flow
for a given volume
„ Seen in MAS, BPD, obstructed
airway
Endotracheal Tube Leaks

„ Volume waveform
„ Pressure-volume loop
„ Flow-volume loop
Large ETT Leaks

„ Baseline drift
„ Loss of PEEP
„ Leak compensation
Turbulence

„ Waveforms
„ Loops
Synchrony

„ IMV
„ SIMV
„ Assist/Control
Flow Cycling

„ “Termination sensitivity”
„ Expiratory trigger
Effect of Cycling Mechanisms

„ Time
„ Flow
Trend Data:
Pressure-Targeted

„ Volume
„ Pressure
Trend Data:
Volume-Targeted

„ Volume
„ Pressure
Case Study - 1
„ 39 wk 3550 g female
„ 24 y/o G2 P1-2 mother
„ Elective repeat cesarean section
„ Apgar scores: 81 95
Case Study - 2

„ Initially
tachypneic, RR = 80
„ Severe expiratory stridor at 30 min
„ Chest radiograph normal
„ CBG: pH 7.07, pCO2 105, pO2 52 (RA)
Case Study - 3
„ Placed in 40% oxygen/humidity
„ Sepsis workup, antibiotics given
„ Transport requested
Case Study - 4
„ Intubated by transport team
„ FiO2 0.3, rate 40, pressure 20/4
„ ABG: pH 7.12, pCO2 85, pO2 180
„ Transferred without difficulty
Case Study - 5
„ ABG: pH 7.33, pCO2 42, pO2 74
„ Chest computed tomography:
Double aortic arch
„ Confirmed at catheterization
„ Successful surgical repair
Double Aortic Arch
„ Most common vascular ring
„ Persistence of right fourth aortic
arch
„ Two arches arise from ascending
aorta, encircle trachea/esophagus,
and join together at descending
aorta.
Pulmonary Graphics

“You can observe a lot


by watching.”
-Yogi Berra