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    • Hi! We used the Sensormedics with low-volume-strategy alot in case of pie. Then we we lost a lot of our "old" colleagues and a lot of Knowledge concerning the hfov got lost. I think the sensormedics is a very powerful machine which also can do a lot of harm in inexperienced hands. Therefore we switched to conventionale mechanical ventilation combined with taping of the chest - we use low tidal volumes, very short insp. time (0,1 - 0,2 s). We try to establish a stable situation with NAVA as soon as possible (without any evidence, but good experinces).  
    • I also believe higher Frequencies should be used in this patient - this is taken from Zannin et al. on the use of different frequencies https://www.nature.com/articles/pr2017151.pdf: At lower frequencies - a lot more pressure reaches (and damages) the alveoli. This is dampened a lot more at higher frequencies (>12-15 Hz): so even if you set higher pressures - a lot less reaches the alveoli, but ventilation remains same. We have used this approach in a few patients. In the end it was a combination of using the minimal ventilation (accepting lower Sats and higher CO2s) acceptable, giving steroids & extubating as soon as possible - even if that necessitated reintubation in some cases. In one sided PIE we have also used thoracic bandaging to limit lung excursions. In two cases we have also resected the destructed lobe to allow for better ventilation of the rest of the lung with success. Taken from the paper of Zannin et al. You can see that lower set P (pressure) levels at low frequencies lead to a lot higher alveolar pressures than if higher frequencies are used. This means you are injuring the lungs more by using lower frequencies - even if you think you are using lower pressures. In comparison a pressure set at 40 at a freq of 15 Hz leads to lower alveolar pressure.
    • Sad day. In spite of our best efforts, we have been unable to get this baby to ventilate and oxygenate. This morning, on a MAP of 10.5, this was the CXR: Last night we tried a mixture of milrinone and dobutamine to increase cardiac output and open the pulmonary vascular bed, but this made our oxygenation and ventilation worse. We stopped those meds and the baby did fairly well overnight with respect to his blood gases, and we were able to wean the amplitude somewhat. The echo yesterday showed a small PFO shunting left to right, but otherwise, no significant pathology.  Throughout the morning and the afternoon, his oxygen saturation and ventilation worsened, necessitating we increase his amplitude to levels higher than last night. This was a CXR from the early evening: As compared to yesterday, the PIE has gone from micro to macro, and the hyperexpansion remains in spite of modest MAPs. This CXR was on a MAP of 11, amplitude of 32 and a Hz of 6. Baby was on 100% FiO2 and saturations were in the 60s.  During the course of this disease process, I have been retrospectively reviewing the train of events. The mother was admitted with bulging bags at 23 weeks gestation, and in labor. Her labor was stopped with MgSO4 and indocin. She received a full course of betamethasone and was started on antibiotics soon after admission.  Baby delivered vaginally a week later, within intact membranes and was intubated in the delivery room. All resuscitation was performed, surfactant administered, lines in place, antibiotics started, and the top of the isolette was down within 60 minutes.  Looking at the PiPs, they dropped to low 20s after surfactant, but then began rising again at about 16 hrs of life. The FiO2 was between 21-25% during this time and the MAPs on volume-targeted ventilation (5 mL/kg) remained at around 7 mmHg. PEEP was at 5 mmHg. At 16 hrs of life, the PiPs climbed to the high 20s/low 30s. Because the supplemental FiO2 need was minimal, a second dose of surfactant was not given. Retrospectively, I can see evidence of PIE as early as the second day of life.  My question today was: should we be basing our administration of surfactant less on FiO2 and MAPs and more on PiPs? Any thoughts?
    • Thank you I realized that my post was not clear the question should read”do any of you intubate the CDH babies with micro cuffed ETT from the delivery and do you see any adverse outcomes when you have used them for a longer period” that would imply following the minimal leak guidelines thank you all so much 
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