Presentation on theme: "Acute Care Transport from Neonate to Adult"— Presentation transcript:
1Acute Care Transport from Neonate to Adult ByJeff HeltborgRespiratory Clinical SpecialistLegacy Emanuel and Randall Children’s HospitalPortland , Oregon
2ObjectivesIdentify types of patients that would benefit from this style of ventilation.Explore nitric oxide delivery and aerosolized epoprostenol with this device and feasibility.Explore continuous nebs with this device
9Transporting with high Frequency Ventilators Not easy(logistics)Usually use large amounts of gasSmall percentage of transports
10High Frequency Percussive Ventilation HFPV -High Frequency Percussive Ventilation (HFPV) is a hybrid form of high frequency ventilation.-This concept of pneumatic diffusive / convective protocols is not related to high frequency vibration, jet insufflation or electronically controlled crank or magnetically servoed dynamic oscillators.
11The Phasitron; The patient interface A Sliding Venturi“floating” exhalation valveEntrains during inspiratoryEntrains up to 1:5Pneumatic clutch – “feels” backpressureOpen to ambient during expiratoryFlow to pressure / pressure to flow converter7ms transition penaltyAllows theoretical rates up to 7200 bpm
18Sinusoidal Bronchotron INITIAL SETTINGS for patients<5 kg. Conventional BreathPIP (pulsatile flow) 14-20For chest expansionFIO2As NeededINSPIRATORY TIME1 secondEXPIRATORY TIMERESPIRATORY RATE30 bpmHigh Frequency BreathPULSE FREQUENCY600bpm + 75Oscillatory Peep6 <5 kg.
19Decrease PaCO2, onlyIncrease pulsatile flow (pip) in steps of 2 cmH2O. Remember pressure at carina is 1/3 lower than what is set on ventilatorCheck for cuff leak if applicable. Decreased CO2 with increased leak. (variable results)19
20Increase PaO2 onlyCheck patient; (hemodynamic status, blood, fluid levels etc)Increase FiO2Increase Oscillatory CPAP (peep); 2cmH2O steps, max for neonatesIncrease Pulsatile flow in increments of two as long as CO2 is not too lowWith this check Pulmonary Artery pressure, Blood Pressure, Heart rate, O2 Saturation, Mean Airway pressure.20
21Increase PaO2 AND drop PaCO2 Increase pulsatile flow (pip)in 2 cm increments. Will potentially increase Map.21
23A 840 gm baby delivered via stat c-section for poor fetal tones. The child was intubated with 2.5 ett post poor effort during resuscitation.UAC placed with difficulty.Initial gas=7.11, CO2=85, PO2=48, bicarb=19You get called to transport patient back
24Patient placed on Drager babylog. Settings are:mode- psv/vg rr=50, vt=4.5, peep=5, fio2=70%, Sao2=88Pt’s uac = 7.20, CO2=75,PO2=60,Bicarb=20While we were driving there they gave surfactant and now they have to bag the baby as they can’t keep the saO2 elevated.You walk in and they are bagging the 60 bpm, with a pip of 30 and varying peep.
25What settings should we use? We place the patient on the sinosoidal bronchotron.What settings should we use?
27Settings You Manipulate Initial settings:Settings you don’t generally manipulateHigh frequency percussive rate=Conventional Rate=30Inspiratory and expiratory time for conventional rate=1 second for each parameterSettings You ManipulatePulsatile flow-16 (or 14 with gentle chest rise)Peep-6FiO2-variable for SaO2 goals (in this case 60%)With first abg and following abg’s watch for hyper ventilation.This ventilator is very efficient in removing CO2.
28First blood gas= ph-7.18, CO2-79, O2-68, Bicarb-20 Sa02=89 What do we manipulate?Increase Pulsatile flow by two.Leave every thing else the same.Next abg=ph-7.27, CO2-60, O2-44, Bicarb-21 Sao2=80What do we manipulate?Increase Peep by two to 8 or increase fiO2 depending on management style for fiO2 above 60%.
29Term MeconiumTerm infant with thick meconium that was precipitously delivered.Resuscitation went poorly and now child is two days old and on 3100 A with NO and stuck on 90%.Abg=7.24,CO2=80,O2=393100A settings=map-20, delta p-46, hz-8, NO=20ppm.We will transport this patient for possible ECMO
311st thoughtTry to match settings. With transport bronchotron Primarily the same map if possible.Initial Settings:Percussive rate-500, convective rate-30,Inspiratory and expiratory time-1 secondPulsatile flow(pip)-26 look for gentle chest risePeep-10, FiO2=90%, NO=20ppmLook at the mean on the guage and watch bp. Grab a chest x- ray if there is time.
32Initial abg =7.29, CO2=60, O2=29, SaO2=80 What do we manipulate?Do we have chest rise?If yes then just increase the peep by two, if not then increase both the pulsatile flow and the peep by two.In this case, not much chest rise so did bothNext abg=7.30, CO2=56, O2=32, SaO2=82Patient’s bp drops significantly and sao2=45%
33What to doWe started bagging and gave fluid bolus and increased both our dopamine and dobutamine levels.Once fluid bolus in, then placed back on ventilator and same settings. X-ray is back and does not show overdistension.Sao2 is now 88%. Grabbed one more gas, packed up and got the heck out of Dodge while we could.
38How about aerosolized continuous epoprostenol (Veletri)?
39How big can a patient be?In 2009 we initiated mobile ECMO for adult patients with H1N1.Three weeks later after decision was made we received our first transport request.First patient was 300 pound 34 y.o. male on 3100 B oscillator with nitric.3100 B map=40, delta p=96, hz =3 pt’s sao2=84%
40How do you match those settings 3100 settings: Map=40 , amplitude = 96, hz=3Bronchotron settings to match map:Pulsatile flow =56, osclilatory cpap (peep)=18High freq. rate=500, convective rate=15 map=36I time = 2 seconds E time = 2 secondsSao2 increases to 96% in 15 minutes.Not the end of the story (never is)
41Adult Mobile Ecmo and adult Rescue Ventilator Transports In the last 4 years we have done over 36 mobile ECMO transports and /or Adult rescue Ventilator Transports.Well what does it look like?
56ConclusionPercussive ventilation can be used on transport with the bronchotron for a variety of patients to include neonates from 800 grams to 300 pound adults.Accelerated laminar flow is an effective way to remove both debris and CO2 from the lung while positively affecting oxygenation.