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This presentation is not a substitute for reading the user manual individually, and discussing at bedside what is not clear. A human life is hanging at the other end of our competence. Work-up your own opinion, but follow the consultant's preference strictly in setting up the ventilation of the baby.
Values displayed on the top right corner (in small font) are the parameters you planned for the patient. Values under the eyebrow (large font) are the actual delivered parameters to the patient.
Modes of ventilation
CMV OR PTV
CMV = IMV = [SIMV or PTV with trigger disabled] PTV = A/C (baby controls the ventilator rate). PSV = A/C but with Flow cycling (Baby controls the Ti also). SIMV + PSV = detailed in separate slide.
Continuous Mandatory Ventilation: Used most often in the paralyzed or apneic patients. The ventilator rate is set faster than the patient's own breathing rate. Intermittent Mandatory Ventilation: The ventilator rate is lower (less than 30 bpm), therefore the patient gets chance to breathe spontaneously between two controlled breaths.
In both CMV and IMV, breaths are delivered regardless of the patient's effort.
Synchronization is not intended in either of these.
Default trigger sensitivity to detect the patient's breath effort is 2L/min, which will not detect the breathing in any premature baby, and then PTV, SIMV or PSV- all will work as CMV.
Make the trigger (flow sensor) work by decreasing the threshold to 0.4-0.6 in most cases. Orange lines should be visible in the real time graphs.
PTV becomes CMV when trigger is not adjusted below the peak inspiratory flow
Orange lines: depict the neonates breathing efforts in the first 0.2 seconds of the Ti
Ti
Once again the heart of PS is the flow cycling of inspiration. Keep inspiration termination criteria at 5% of the peak insp. flow for neonates.
Pressure support for the non-SIMV breaths should be set initially liberally (start with ~80% of PIP values), and then bring it down to 4-5 mbars above PEEP in 1-2 days if possible.
0 100%
Flow cycling applies only to the non-SIMV breaths that are now getting some extra help during inspiration. The mandatory cycles will follow the set Ti (time cycled).
Its the tidal volume that causes Pneumothorax not the pressure
Set the desired tidal volume at 6 ml/kg, to get best results. Range is 4-6 ml/kg. When choosing in this range, consider:
ET Leak
Measured inspired vol minus measured expired vol. Automatic leak compensation means that ventilator software will display the expiratory tidal volume (Vte) inclusive of the amount that leaked out from the sides of trachea during expiration.
In SLE 5000, there is Automatic Leak Compensation up to 20% if on TTV mode, and 50% in PTV, SIMV and PSV mode. We have to enable it from the options box after selecting the mode of ventilation.
If ET leak is > 50% all the time, most authorities recommend to change ET to a bigger size.
Trigger
Vte (ml) Vmin (Liters)
Leak%
Resistance (cmH2O/l/sec) Compliance (ml/cmH2O) C20/C ratio (ratio) Mean (Airway) Pressure (mbar)
BPM tot: (tot = total), in 1 minute. Trigger: No. of synchronized breaths in last 1 min.
These values, may not be same as the (back-up) rate you have set in PTV or SIMV. In PTV mode, for pCO2 manipulation, look at the number of triggered breaths delivered before changing the ventilator rate.
If it is significantly less than the BPM tot, then increasing the trigger sensitivity will increase the no. of assisted breaths.
Using Standby mode or CPAP mode to evaluate patients actual breathing effort without ET disconnection when flow sensor is not used.
Pressing Standby button for 3 second will suspend ventilation for maximum of 90 sec, although it can restarted any time before 90 sec, by repressing it.
BPM measurement
The ventilator measures BPM in 2 different ways, with or without a flow sensor. With flow sensor: All breaths are counted: Triggered, Spontaneous, and Mandatory. Without flow sensor: Only triggered and mandatory breaths are counted by the pressure sensor located inside the machine.
BPM tot
With flow sensor
No flow sensor
Very high PIP & rate together, in 2.5 size ET (high turbulence).
Compliance (ml/cmH2O)
Acceptable values:
Ratio of compliance during the last 20% of breath cycle to the total compliance.
If this calculated value is less than 0.8 (<1 according to some experts), the lungs are overinflated, therefore PIP should be reduced.
Values of 2-2.5 ml/kg will give you normal pCO2. (This is the anatomical dead space volume in neonates).
Useful as an adjuvant to chest vibration.
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