CPAP/Ventilators To increase PaCO2, decrease tidal volume, which is a function of PIP and RR.

(decrease PIP, decrease RR) To decrease PaCO2, increase tidal volume, so increase PIP or RR To increase PaO2, increase PIP, PEEP, IT or FIO2 To decrease PaO2, decrease any of a Resp rate has no effect on PaO2. PEEP, IT, FIO2 in most cases have no effect on pCO2 (with exceptions) CPAP - improves PaO2 by stabilizing the airway and allowing alveolar recruitment. CO2 retention may result from excessive CPAP. - most commonly, nasal CPAP prongs (also mask, nasopharyngeal, endotracheal) used to resp assistance in mild RDS, or weaning from mech ventilation. - maintains upper airway patency, so useful in apnea of infancy - gastric distension may occur; place OG tube for decompression. - 2-6 cm H20 commonly used. Ventilators Pressure control - Set: support rates commonly set at 20 - 60 breaths/min. Adjust to combine w/ tidal volume to maintain adequate minute ventilation - Set: Inspiratory time commonly 0.25 to 0.5 s. - Set PIP. Initial choice of PIP based on observation of chest wall movement during hand-bag ventilation. Adust to maintain optimum tidal volume, minute ventilation. TV usual 5-7 cc/kg - Set PEEP. Commonly 2-4 cm H2O. - Tidal volume varies, depending on PIP, lung compliance, etc. - Mean airway pressure is a function of rate, IT, PIP and PEEP. It correlates well w/ lung volume. If >10-15 cm H2O on conventional vent, incr risk of air leaks (PTX, interstitial emphysema). MAP of high-freq vent is not strictly compatible w/ MAP of conventional vent. Volume Control - minimizes risk for lung overdistension - Set rate, IT, tidal volume, PEEP - PIP varies according to set TV and lung compliance. - if mean airway pressure exceeds 15 cm H20, consider high-freq ventilation

SIMV (synchronized intermittent mechanical ventilation) - can be used for both pressure- and volume-control ventilators - delivered breaths are sync'ed to infants spontaneous inspirations. Weaning - PIP is weaned first, decrease to maintain normal tidal volume. Decreases in PIP decrease mean airway pressure, and may transiently increase O2 requirements. - FI02 is weaned whenever possible as det by pulse ox and blood gases - weaning to extubation, in one of three ways 1) progressive rate wean: when rate is 10-15/min, extubate. 2) CPAP weaning: wean rate to 5-10, then to Endotracheal CPAP (controversial) 3) weaning assist/control ventilation: all spontaneous breaths are supported by this method (so set rate is not a factor). Wean by successive decreases in PIP. When PIP 10-12, extubate. Iowa Neonatology Handbook: Pulmonary

High Frequency Ventilation (HFV)

Jonathan M. Klein, M.D.
Peer Review Status: Internally Peer Reviewed

I. Introduction: The use of surfactant replacement therapy has helped to decrease neonatal mortality from respiratory distress syndrome (RDS), but the incidence of pulmonary interstitial emphysema (PIE) and bronchopulmonary dysplasia (BPD) in ventilated neonates (700-1350 grams) is still relatively high (PIE 20-25%, BPD 15-19%; U.S. Exosurf Pediatric Study Group 1990). Thus new therapies involving alternative methods of managing respiratory failure are currently being utilized. One of these new therapies is high frequency ventilation. A. HIGH FREQUENCY VENTILATION (HFV): is a new technique of ventilation that uses respiratory rates that greatly exceed the rate of normal breathing. There are three principal types of HFV: 1. High frequency positive pressure ventilation (HPPV, rate 60-150/minute); 2. High frequency jet ventilation (HFJV, rate 100-600); (hooks up to a conventional ventilator)

3. High frequency oscillatory ventilation (HFOV, rate 300-3000/minute). The advantage of high frequency oscillatory ventilation as compared to either conventional positive pressure or jet ventilation is its ability to promote gas exchange while using tidal volumes that are less than dead space. The ability of HFOV to maintain oxygenation and ventilation while using minimal tidal volumes allow us to minimize barotrauma and thus reduce the morbidity associated with ventilator management of RDS PaCO2 is primarily regulated by changes in amplitude, not frequency. AMPLITUDE is rough representation of the volume of gas generated by each high frequency pulse through the proportioning valves (maximum generated volume with all 10 valves open is 36 cc). THIS IS NOT THE TIDAL VOLUME DELIVERED! When PaCO2 is no longer responding to changes in amplitude, decreasing frequency may help maximize tidal volumes and blow off CO2. PEEP or MAP: Oxygenation on HFV is directly proportional to MAP which is similar to Conventional MV; however, with HFV almost all of the MAP is generated by PEEP. Thus, during HFV: MAP = PEEP. AT LAC-USC: standard settings on a HF vent: (see notes below for other recommendations) - Inspiratory time is 33% - frequency is 10 Hz - start at low amplitude ie 25, then increase until chest starts to shake. - set MAP to 1-2 above conventional vent MAP... usually 8-9. (in general, when MAP drops below 7, extubate; if MAP rises to 9-11, go to hifreq vent) - we want preemie sats 83-89% - when weaning from high MAP, and a baby is on a lot of fluids, loss of lung pressure may predispose to fluid accumulation in lungs, so watch out for pulmonary overload. - when setting parameters on respiratory orders, make sure desired CO2 matches desired pH. I.e if you want ph to be 7.25, cO2 range should be approx 50-65.

B. INFRASONICS INFANT STAR High-Frequency Ventilator: We are currently using the Infrasonics Infant Star ventilator at a frequency of 15 Hz (900 breaths/minute) in premature infants who develop PIE while on conventional mechanical ventilation. The Infant Star is a flow interrupter, not a true oscillator, but its physiological effects and advantages are similar to those of true oscillators. While on Infant Star, one observes rapid vibration of the infant's chest wall instead of the normal chest wall excursion that is seen with conventional ventilation.

The Infant Star is used for the treatment of pulmonary air leaks, primarily pulmonary interstitial emphysema (PIE) and pneumothorax. HFV with the Infant Star allows gas exchange to occur even while the lung is atelectatic, thus the size of the air leak is diminished, allowing for more rapid resolution of air leak syndromes. Thus, by decreasing the severity of PIE, HFV should allow us to minimize the mortality and morbidity (BPD) associated with barotrauma.

COMPARISON OF HFV TECHNIQUES Technique HFPPV HFJV HFOV Rate/(min) 60-150 100-600 300-3000 Tidal Volume > dead space > dead space < dead space

II. Gas Exchange: During conventional mechanical ventilation or spontaneous respiration, gas exchange occurs because of bulk transport (convective flow) of the O2 and CO2 molecules from the central or conducting airways to the peripheral airways. The volume of inhaled gas must exceed the volume of dead space. A. GAS EXCHANGE DURING HFV: Theories on why ventilation can still occur when using tidal volumes that are less that dead space: 1. Augmented Diffusion; 2. Bulk Axial Flow; 3. Interregional Gas Mixing (Pendelluft); 4. Axial and Radial Augmented Dispersion (Taylor Dispersion); 5. Convective Dispersion. B. INDICATIONS FOR HFV: 1. BAROTRAUMA - pulmonary airleaks. a. PNEUMOTHORAX b. PULMONARY INTERSTITIAL EMPHYSEMA (PIE)

2. Respiratory failure unresponsive to conventional ventilation (compassionate use). C. HFV SETTINGS (Infrasonics INFANT STAR High-Frequency Ventilator) Consult with Staff Neonatologist before instituting high frequency ventilation. 1. FREQUENCY: 15 Hz (900 "breaths per minute") 2. AMPLITUDE: a rough representation of the volume of gas flow in each high frequency pulse or "breath." Adjust the amplitude until you achieve vigorous chest wall vibrations, usually occurs at an amplitude of 20-30. If conventional rate is greater than 60, decrease rate to 40 and increase PEEP by 1 to 2 cm, before adjusting the amplitude. This will give the patient adequate expiratory time for the assessment of vibrations. 3. MAP: Adjust by decreasing conventional rate (by 5 bpm) while increasing PEEP (by 1 cm H2O) until conventional rate is 4 breaths per minute ("sighs") and the MAP becomes approximately equal to the PEEP. IT IS VERY IMPORTANT TO KEEP MAP CONSTANT DURING THE CONVERSION TO HFV TO PREVENT EXCESSIVE ATELECTASIS AND LOSS OF OXYGENATION. The goal being a MAP equal to or slightly (1-3 cm) below the previous MAP. 4. IMV RATE (sighs): The conventional or "sigh" breaths should be similar to the previous settings in terms of PIP, however the inspiratory time should be 0.4 - 0.6 seconds. 5. PEAK PRESSURE (sighs): The PIP is usually set at a pressure equal to MAP +6 cm. D. BLOOD GAS MANAGEMENT: 1. Inadequate oxygenation (low PO2): Manage by increasing the FiO2, increasing the MAP by increasing the PEEP (i.e. PO2 is directly proportional to MAP or by decreasing atelectasis by manually ventilating the infant with an anesthesia bag and then adjusting the "sigh" breaths by increasing either the rate, inspiratory time or PIP of the conventional breaths). IMPORTANT: If oxygenation is lost during weaning when Peepwas decreased, manually "bag" the infant back up to restore lung volumes and reset Peep at 2-3 cm above the previous value. Once adequate oxygenation has been reestablished weaning can begin again, but proceed more slowly with changes in Peep.

2. Inadequate ventilation (high PCO2): Manage by increasing the AMPLITUDE (i.e., PCO2 is inversely proportional to AMPLITUDE). E. COMPLICATIONS OF HFOV: 1. ATELECTASIS: treat by increasing the rate or PIP of the conventional breaths ("sighs"); 2. INCREASED MOBILIZATION OF SECRETIONS: treat by increasing frequency of suctioning of ETT as needed; 3. HYPOTENSION: treat by lowering MAP by decreasing PEEP, if other methods such as volume and positive inotropic agents have been inadequate. F. WEANING: 1. Reduce the amplitude of the oscillations by 3 units per change (Q1-2h) until the PCO2 rises. After a change in AMPLITUDE, always observe the chest wall to confirm that it is still vibrating, if vibrations have ceased the AMPLITUDE is too low and thus should be reset at the previous setting. A minimal AMPLITUDE tends to occur around 12-14 units. 2. Once oxygenation is adequate (FIO2 less than 0.70) slowly lower the MAP by decreasing the PEEP by 1 cm H2O per change (Q4-8h). Minimal HFOV settings tend to be reached around a MAP of 7 cm with an O2 requirement that is less than 40%. At this point depending on the patient, you can remain on the HFOV while the patient grows, you can convert the patient back to convention ventilation at a low respiratory rate (usually 15-20 bpm), or you can extubate the patient to Nasal CPAP.

Iowa Neonatology Handbook: Procedures

Insertion of Umbilical Vessel Catheters

Iowa Neonatology Fellows Peer Review Status: Internally Peer Reviewed

I. Umbilical artery catheters (UAC), are used primarily for monitoring blood pressure and obtaining samples for blood gases. In order to maintain the patency of the catheter, a saline and dextrose solution is infused through the line. Drugs and other solutions, including parenteral nutrition solutions, should be given through a venous line (peripheral or central), unless discussed with the staff physician. II. Umbilical vein catheters (UVC), are used for exchange transfusions, monitoring of central venous pressure, and infusion of fluids (when passed through the ductus venosus and near the right atrium); and for emergency vascular access for infusions of fluid, blood products or medications. III. Before the procedure is begun, the correct depth of the umbilical artery catheter insertion should be estimated (see #7 below). Gloves and goggles (or eyeglasses) should be worn. A sterilized umbilical catheterization tray with the necessary instruments and drapes is available in the nursery. After opening the tray, alcohol and sterile syringes, stopcocks, catheters and saline will be placed on it. Sterile technique must be observed; the use of goggles (or eyeglasses) is recommended. IV. An umbilical catheter with a single end hole may be used for the catheterization of either umbilical artery or vein. On certain occasions, it may be advantageous to place a multi-port UVC. Infants with a birth weight of less than 1.5 kg will usually require a 3.5-Fr catheter for arterial catheterization. 5-Fr catheters are used for arterial placement in larger infants or umbilical venous placement regardless of infant size. V. Catheters (4 and 5-Fr) with PaO2 monitoring capability (Neocath) are also available for umbilical artery catheterization . This device allows continuous monitoring of PaO2. Additionally, multiple-lumen catheters and catheters with oxygen saturation measurement capabilities for determination of SVO2 are available for umbilical vein catheterization where clinically indicated. VI. If a luer-lock adapter is not present on the catheter end, approximately 9 cm of the wide end of the catheter can be cut off and a blunt end needle inserted. The 3.5-Fr catheter requires a 20-gauge and the 5-Fr catheter an 18-gauge blunt needle. A sterile stopcock is then attached and the system flushed with saline. VII. External measurements are made to determine how far the catheter should be inserted. In a high setting, the arterial catheter tip should be positioned between the sixth and tenth thoracic vertebrae on chest x-ray. This can be achieved by inserting the catheter 1 cm more than the infant's umbilical-to-shoulder length. A low-lying catheter should have the tip at the third to fourth lumbar vertebra. VIII. The infant's abdomen and cord are cleaned with alcohol. The alcohol should be sparingly applied to prevent pooling under the infant's back and buttocks. The area is then

draped so that only the cord is exposed. IX. Tie a piece of umbilical tape around the base of the umbilical cord tightly enough to minimize blood loss but loosely enough so that the catheter can be passed easily through the vessel. X. Using a surgical blade, the cord is cut cleanly 1.0 to 2.0 cm from the skin. XI. The cord is stabilized with a forceps or hemostat, and the vessels identified. The single, large, thin walled oval vein can readily be distinguished from the two smaller, thickwalled round arteries (see diagram). XII. The arteries are usually constricted, so that the lumens appear pinpoint in size. By gently inserting the closed tips of the curved iris forceps into the lumen of the artery until the cut end of the artery is at the bend in the forceps, and then allowing the spring of the forceps to gently spread the tips, the artery can be dilated. XIII. Grasping the catheter between the thumb and forefinger or with a forceps, the catheter can be inserted into the lumen of the dilated artery. Supporting the stump is usually necessary. Once the catheter has ben inserted, it may encounter resistance at the level of the anterior abdominal wall or at the bladder. This resistance can usually be overcome by application of gentle steady pressure. Repeated probing movements or excessive pressure must be avoided. If unsuccessful, wait 2-3 minutes until the vasospasm ceases, or attempt the other umbilical artery. XIV. After the catheter is advanced the appropriate distance, the position of the catheter should be confirmed by x-ray. If, after sterile technique has been broken, the catheter is found to be in the wrong position, it can only be pulled back--IT MUST NEVER BE ADVANCED. XV. Observe both legs for evidence of blanching, cyanosis or mottling. If a "blue leg" develops (presumably from vasospasm), the catheter should be removed or carefully observed for a short period of time to allow for resolution of the impaired circulation. XVI. After placement of the catheter, a purse-string suture is placed around the umbilicus taking care not to puncture the catheter. XVII. The procedure for catheterization of the umbilical vein is similar; differences are as follows: A. Remove any visible clots from the lumen of the vein with forceps. B. Never leave the catheter open to atmospheric pressure. The abdominal venous system is under negative pressure; with a deep inspiration air can enter the catheter with resultant air embolism. C. For administration of fluid, the venous catheter must be in the inferior vena cava, just below the right atrium.Inserting the catheter two-thirds of the shoulder-to-umbilicus distance is a good estimate. A catheter in the portal venous system must not be used for the administration of fluids or medications and should be removed. D. For the purpose of an exchange transfusion, the catheter should be advanced only until there is a free flow of blood, but never more the 8 cm in the full term infant. This catheter

should be used only for withdrawal of blood (see section on Exchange Transfusion). E. If code medications and/or fluid need to be given in the delivery room, a UVC should be placed and advanced only until there is a free flow of blood as in "D" above. XVIII. To sample blood from an umbilical catheter, withdraw 1 ml of blood into a sterile syringe, keeping the syringe perpendicular to the infant. this will cause the blood to settle near the tip of the syringe. The tip of the syringe should be kept sterile, and not placed in the infant's incubator or bed. XIX. The blood sample is then withdrawn into a second syringe and the initially withdrawn blood reinfused and the system flushed with a small amount of saline until free of blood. XX. The alcohol should be washed off with sterile water after the procedure is completed. This is important to prevent clinical burns, especially in very small infants. XXI. Heparin is not routinely added to the IV solution, except with the use of the Neocath. Whether the use of heparin decreases the incidence of thrombolitic complications has not been well studied. XXII. The umbilical artery catheter is removed slowly when it is no longer needed. With proper care, the catheter need not be changed for the duration of its use.