2. 1.Choice of Oscillator & Jet Ventilator (15 min) 2.Choice of High Flow & Nasal CPAP (20 to 30 min) 3.Trials in 2008 of CPAP & SIPAP (5 min) 4. ROP Data & O2 Saturation Alarms (10 min) Respiratory Highlights 2008 BWH NICU Nursing Blitz

3. HFO Choice Oscillator Jet

4. Pressure/Volume

5. NEJM Sept. 13, 2007, Malhotra

8. Intracranial Blood Pressure Elevated Venous Return Impeded Elevated Intrathoracic Pressure ( High PEEP & Paw) Hepatic Veins Dilated

9. HFJV HFOV CV Paw 10 15 20 5 0 Tracheal Pressure cm H 2 O Airways Proximal Distal HFV Pressure Attenuation Amplitude may attenuate around a fixed Paw

10. Active exhalation, as with high-frequency oscillation (HFO), can lead to gas trapping by lowering intraluminal pressure disproportionately below pressure in surrounding alveoli, thereby collapsing more proximal airways before exhalation is complete. For that reason, users of HFO typically operate at higher mean airway pressures than those used with HFJV. Elevating the baseline pressure during HFO, "splints" the airways open while gas is actively withdrawn from alveoli. Exhalation with HFOV

11. During HFJV, exhaled gas swirls outward around the incoming gas. The exhaled gas sweeps through the CO 2 -rich deadspace gas. This action may help evacuate CO 2 and enhance ventilation. Exhalation with HFJV CO 2 Small VT is readily exhaled without trapping during short exhalation time.

12. airways lack structural strength the chest is squeezed gas is sucked out of the airway CHOKE POINTS may develop when:

13. Back pressure (High PEEP/Paw) may splint open the airway and allow gas to exit PEEP + + + + +

14. The 6 Jet Fundamentals 1.HFJV  P (PIP - PEEP)  PaCO 2 HFJV Rate is secondary 2.FRC and MAP  PaO 2 3.  PEEP to avoid hyperventilation and hypoxemia 4.If  CV Rate  oxygenation, PEEP is probably too low 5.  CV settings whenever possible Especially when airleaks are a concern 6.  FiO 2 before PEEP until FiO 2 < 0.5

15. 0 20 15 10 5 25 PEEP PIP P time Ventilation and HFJV Raising PIP or lowering PEEP V T which PCO 2

16. Recruitment Strategy for RDS Find the Critical Opening Pressure of the alveoli Optimize PEEP to stabilize the alveoli Reduce PIP as recruitment proceeds HFJV may reduce volutrauma in surfactant deficient lungs

17. HFJV - RDS Study Summary * HFJV reduced the incidence of BPD at 36 wks PCA. HFJV reduced PIP and  P compared to CV. HFJV "optimal-volume strategy" resulted in less hypo- carbia and better oxygenation than low-volume strategy. HFJV "optimal-volume strategy" was associated with lower incidence of severe neuroimaging abnormalities compared to low-volume strategy. * Keszler, et al. Peds 1997; 100:593-599.

18. HFO / HFJV choice High PIP & FiO2 conventional PIE per CXR Need for nitric oxide When Jet fails choice PIE despite HFO Air leak syndromes Excessive secretions Hemodynamic compromise When HFOV fails

19. HFO –FiO2 –MAP Jet- Particularly effective with non-homogeneous disease. –FiO2 –PEEP –CV rate –CV PIP –CV I time Oxygenation –

20. HFO –Amplitude –MAP to optimize position on inflation curve –Rate (lower to drop PaCO2) Jet –Raise PIP –Raise rate –Change PEEP Ventilation –

21. HF Nasal Cannula Bubble CPAP

22. RDS, apnea & post-extubation support http://www.surfneon.com/cpapbwh.swf

23. BUBBLECPAPBUBBLECPAP

25. DuoDerm Nare protection from CPAP prongs Nasal seal for CPAP prongs

26. Bruised Nasal Septum /Mepitac use under Cannulaide

27. CPAP design

28. CPAP design for a contented family…

29. “On the basis of our findings, we suggest that high- flow nasal cannula should not be used as a routine replacement for CPAP therapy.”

32. Tight cannula obstructs nares. Cannula flow will not meet baby’s flow demand. Flow directed into nasopharynx not at stable pressure

33. Anatomic variants of nare size & structure alter cannula seal. Clinically relevant pressure is achieved only on the smallest of babies.

34. Poor humidification Airway dysfunction mucocilliary transport Increased fluid osmolarity Promotion of bronchospasm secretion viscosity Impaired nutrition Impaired growth Mucosal injury infection

35. Trial: Airlife CPAP & BIPAP

36. CPAP

38. Maine Med Portland St/ Margaret’s Dorchester

39. Ford S. Leick-Rude MK, Meinert K, Anderson B, Sheehan M, Haney B, Leeks S, Simon S, Jackson J. Overcoming Barriers to Oxygen Saturation Targeting. Pediatrics 2006 118 Suppl 2:S177-186 Phelps, D., Goldsmith, JP, Retinopathy of Prematurity Hot Topics Dec. 4, 2007 MY SAT LIMITS ARE: HIGH: 93 LOW: 85