Presentation on theme: "Advances in Mechanical Ventilation & Respiratory Therapy"— Presentation transcript:
1Advances in Mechanical Ventilation & Respiratory Therapy
2Your Host for this Lecture Chad J. Pezzano MA, RT, RRT-NPSPediatric/Neonatal Clinical InstructorCardio-Respiratory ServicesAlbany Medical Center
3I will be discussing new innovations in surfactant therapy DisclosureI have interest inLMA North America - provided supplies for studyOny (Infasurf) - provided educational grant for study“Randomized Controlled Trial of Surfactant Delivery via Laryngeal Mask Airway (LMA) Versus Endotracheal Tube”I will be discussing new innovations in surfactant therapy
4Goals & ObjectivesProvide both useful and useless information during this lecture.Discuss new innovations in respiratory technology.Learn about the vast changes occurring with mechanical ventilation.Discuss why invasive mechanical mechanical ventilation may soon be a thing of the past.Enjoy this lecture and have fun!
6Liquid Ventilation (LV) History Perfluorocarbons first synthesized during the development of the atomic bomb (Manhattan Project)Kylstra 1962 – early mice experiments with oxygenated salineClark 1966 – PFC’s experiment with mice1989 Preterm neonatal studies conductedLeach 1996 multi-center preterm infant study
7Liquid Ventilation History Cont. Bartlett et al 1997 conducted randomized controlled adult trial of PLV.Kacmarek et al 2006 larger adult study of patients who had ARDS.
8What are Perfluorocarbons? Chemically and biologically inertClear and odorlessUndergo no metabolism in kidneys or liverOxygen carrying capacity can be three times more than blood.Toxicity has been shown in some studies.
9What are the advantages of LV? Improves oxygenationImproved lung complianceAnti-inflammatory effectsAlveolar and endobronchial lavage
10Types of LV Total liquid ventilation (TLV) Lungs filled with PFC to a volume which is equivalent to the patients functional residual capacity (approximately 30 ml/kg).A liquid ventilator is used to generate tidal breathing.A respiratory rate of 4 – 5 bpm is used for optimal CO2 clearance.Tidal volumes range from 15 – 20 ml/kg.Partial liquid ventilation (PLV)Tracheal instillation of PFC’s in combination with gas ventilation.Continuous mechanical ventilation and rotating dose will decrease oxygenation index after 15 ml/kg of perflubron.
18Surfactants Current indications (on-label uses): Treatment and Prevention for RDS in Neonates (Infasurf and Survanta).Treatment for RDS in Neonates (Curosurf and Surfaxin KL4).
19Surfactant Traditionally used in neonates for RDS Delivery method involves the patient being intubated and surfactant delivered intratracheally.Investigations have been conducted over the past 15 years on Pediatric and Adult Patients.Theoretically there is an implication for adult patients.ARDSDirectIndirect
20Pediatric/Adult Surfactant Administration Calfactant for Direct Acute Respiratory Distress Syndrome (CARDS Study); Wilson et al 2008 – 2012.Multicenter RCT involving hospitals in North America, South Korea, Australia, Canada, Israel, and New ZealandCompared Calfactant vs PlaceboPrimary outcome- mortality rateSecondary outcome – ventilator free daysInclusion Criteria: Respiratory failure due to diffuse infectious pneumonia, aspiration, near drowning, smoke inhalation or industrial gasStudy terminated recently.
21Current Surfactant Studies Current studies for alternative delivery methods:Delivery via LMAAlbany Medical CenterUniversity of MinnesotaPotential future studiesNebulized delivery
22Future of Surfactant Research If you would understand anything, observe its beginning and its development - Aristotle
35Neurally Adjusted Ventilatory Assist (NAVA) Mode of ventilation exclusively on the Servo i Ventilator.NAVA gives the user access to information concerning both the patient’s ability to breathe and the status of the central nervous system.NAVA delivers assist in proportion to and in synchrony with the patient’s respiratory efforts, as reflected by the Edi signal.
36Ideal Technology vs. Current Technology Central nervous systemPhrenic nerveVentilatorDiaphragm excitationDiaphragm contractionChest wall, lung and esophageal responseAirway flow, pressure and volume changesCurrent TechnologyBedside feedback for the RT
37Poor Timing: Asynchrony during SIMV (Infants) 37
38Ineffective triggering predicts increased duration of mechanical ventilation* Marjolein de Wit, MD, MS; Kristin B. Miller, MD; David A. Green, MD; Henry E. Ostman, MD;Chris Gennings, PhD; Scott K. Epstein, MDConclusions: Ineffective triggering is a common problem earlyin the course of MV and is associated with increased morbidity,including longer MV duration, shorter VFS, longer length of stay,and lower likelihood of home discharge.(Crit Care Med 2009; 37: 000–000)
42NAVA Ideal Technology vs. Current Technology Ideal Technology Central nervous systemPhrenic nerveNAVAVentilatorDiaphragm excitationBedside feedback for the RTDiaphragm contractionChest wall, lung and esophageal responseAirway flow, pressure and volume changesCurrent TechnologyBedside feedback for the RT
48Parts Needed for NAVA 1. NAVA software 2. Edi Module 3. Edi Cable 4. Edi Catheter5. Servo I ventilator
49What we know so far about NAVA: Improves patient ventilator interactionProvides efficient respiratory muscle unloading even at high levels of assistMay provide protective ventilation based on reflexesAdapts to altered respiratory drive and reflexesMay prevent disuse atrophyAllows on-line monitoring of respiratory drive49
50Reference: Critical Care Medicine 2010 Vol Reference: Critical Care Medicine 2010 Vol. 38, No 10 (Supplement) S555 – S558