Here is the CXR when the baby's MAP was 12:
Here is the CXR when the MAP was 8:
Clearly the hyperexpansion and air trapping are much worse on the second CXR with a lower MAP.
Per @Miguel Pantoja we increased the MAP from 8 to 10 and have now weaned to 80% with SpO2 in the low 90s. We will continue to wean FiO2 until we reach a nadir, then slowly increase the MAP to a maximum of 12, while trying to wean the amplitude, then we will try and be patient and let the lungs heal if oxygenating and ventilating reasonably well. Ideally, I would like to get the amplitude to no more than 2x the MAP. I have a CXR ordered for the early morning and will try and post it hear to show the difference.
Truly thankful for everyone who has contributed to this thread.
we have started seeing a push from anesthesia towards using microcuffed ETT at delivery
Our CVICU service uses these ETT for their patients and don't have any adverse outcomes but they are only intubated for a short time
Do any of you have experience on this matter?
The literature I find is from anesthesia papers and seems to be favorable but refers to the perioperative period
Getting with the Times.docx
I think that if you go too low in the MAP air trapping could go worse as intrinsic PEEP is higher than your MAP. In my patient we had to use Milrinone to support heart function and norepinephrine in 2 suspected VAP with haemodynamic deterioration.
Here I send a chest xray of my patient. Good luck! And remember steroids, I think they helped a lot.
We got the Hz down to 6, but our first attempt to wean the amplitude resulted in a pretty significant respiratory acidosis.
What is really strange is that in spite of weaning the MAP from its original 14 to now 8, the hyperexapnsion by CXR is getting worse. I speculate that the air leak is not healing at all, and we essentially have thousands of little tension pneumothoraces surrounding what little areas of gas exchange the baby has; I wouldn't really call them alveoli at 24 weeks.
Awaiting an echo now to assess shunting and see if an argument can be made to increase contractility with milrinone.