CLD, volumen gurarantee

[Zsofia Dombi]

Dear All, 

I would like to ask about your experience with volumen guaranteed mechanical ventillation  in case of early onset CLD. 

We have 24 weeker, who is now 2 weeks old, and having bronchospasms, typical XR signs of CLD, and spontaneous hypoxemic episodes. 

We try  to wean her from MV, but her weight  and irregular respiratory activity makes the thing trickier.

I was thinking about lowering the PIP, and TV to prevent the further damage, she recieves supportive care for the CLD. 

I would like to read your experience. Thank you for your answers. 

[Hamed]

Thanks for sharing your 24wk`s case. To truly be able to give advice, its better to share the current setting which the baby is on her Sats and transCO2. From your question, she is now on conventional ventilation (AC or SIMV) without VG. You have several ventilation maneuvers you can follow:

1- If the ventilator you are using does not have VG, use PIPs which give you volumes of 4~5.5 ml/kg, however, if you have a big leak around the ET tube, it will be hard to follow volumes and you will depend then on your blood gas CO2 or transcu. Co2  or end tidal CO2  and saturation to give a sufficient PIP.

2- if the ventilator has VG, adjust your volumes as above at 4~5.5 /kg the ventilator will provide PIPs to give your selected volumes. Again if the ET tube has a big leak, VG will not work and then you better switch the VG off and do as in # 1 , Or you can change the ET tube with a wider one.

3- In our unit we keep these ELGANs during the first 3 days of life on A/C (after giving surfactant  and if intubated) to lower the risk of IVH, then we switch to HFO for several days using gentle ventilation settings until the MAP drops to 10 or 9 in room air, then we consider switching to A/C again or just go down on the MAP and extubate from HFO.

Lastly, you mentioned hypoxic episodes, to decrease that start Caffeine and if you are using SIMV switch to AC.

Good luck.

 

[tarek]

@Hamed

Thanks a lot

You are always embressed me with your nice and valuable comments.

Regarding AC for 3 days then HFOV really it surperized me a lot

You are doing this for every ELGAN on ventilator or selected cases

And what is the rationale behind this

@Zsofia Dombi

Thanks for sharing 

May i ask you is there is any hyperinflation in the x ray

And what is your protocol regarding starting hydrochlorothiazide or dexamethazone for such cases

[Zsofia Dombi]

Sorry for my late answer and thanks for yours. 

At our ward we are doing mostly SIMV+PSV+VL. In this case the leak around the tube was 0-5%, so I tried SIPPV+VG, but her FiO2 need increased from 0.25 to 0.4 so I returned to original way. 

The next day she was accidentally extubated, what she tolerated well, so I tried on DuoPAP, but after 12 hours she developed severe CO2-retention, so dropped back to SIMV+PSV+VL. The interesting and unfortunate thing was that, she became septic after that.  For stabilisation after the reintubation she needed higher pressures, like 6/20 PEEP/PIP. 

A week later, sepsis cured, I started the dexamethason course again. At our ward we start usually with 0.1mg/kg/24 and after 3 days giving half of it, and after next 3 days the half of halfs. I know its not an evidence based protocol., but usually it works for us. 

The next day after extubation, she had again 12 hours on DuoPAP, than back to the MV owing to several deep desaturations. But this time for good oxigenisation she needs HFOV now. 

So I'm really concerned with her case.  There was no significant hyperinflation on the x-rays. 

@Hamed It'ts really interesting for me as well the initial A/C than HFOV mode, could you explain?  Thank you!

[Hamed]

@tarek and @Zsofia Dombi

You are very much welcome, I hope I could be of any help.

Concerning@tarek questions: Yes, this our policy for ELGANs, and majority of cases follow through the policy smoothly. However, as you know you could have the preterm on conventional ventilation (CMV) (A/C or SIMV) within the first 3days, and due to uncontrolled high PC02 in blood gas on CMV the mode is changed to HFO, without really making enough effort for troubleshooting and adjuesting the settings on CMV.

I think that majority of preterms could be ventilated with A/C if you are comfortable with changing in the different components of the ventilator`s settings.

This policy was implemented due a group of weak evidence: 1- The peak for IVH development is within the first 3 days of life. + 2- HFO has a slightly higher risk of IVH, and severe IVH. ==> Thus we try to avoid HFO during the first 3 days of life. On the other hand, CMV has a slightly higher risk of BPD,  ROP and CLD/death at 36wks corrected age. Thus we shift to HFO after the first 3 days of life.

Another opinion can state, that really all the evidence of increased risks on both arms are so low ranging from 0.02 to 0.05, and thus it doesn't really make a major difference to switch from one mode to another.  Well may answer would be, It really depends on which mode you and your colleagues in the unit are comfortable with. This is true so long as your preterm has a homogeneous lung, but once it has a significantly heterogeneous lung eg PIEs or has a lot of secretions due to infection you will have to contemplate which ventilator and which mode is best for your patient. eg: in PIEs: HFO low frequency and  low MAP with accepting higher FIO2. Or if a lot of secretions the Jet-HFV could be the best choice.

@Zsofia Dombi

Concerning CPAP, it would be always nice to mention how high was the PEEP. There are many reasons for CPAP failure, setting a low PEEP or unable to reach the desired PEEP (eg: try closing the baby`s moth with a pacifier), poor nursing care of CPAP, unfit nasal prong (try nasal mask), evolving BPD, PDA, increased apnea,  and sepsis.

Your departments dexamethason course sounds like a modified DART protocol for extubating babies who are stuck on ventilators for more than 7 to 21 days, if I follow you correctly your unit is using a total dose of dexamethason of 0.53 mg/kg over 10 days.

It is smaller than what is used in some units in Canada which is a total dose of 0.89 mg/kg over 10 days.

Best of luck.

 

 

 

[marime65]

and why use vafo? Have you had experience in using pressure support ventilation (PSV)?

 

[tarek]

PSV is the worst choice for VLBW babies

 

[Zsofia Dombi]

To Hamed:  Yes, we always try to optimize the nCPAP with the optimal size of the mask/prong, prone-positioning, closing the mouth with pacifier or some chin strap. 

I'm interested, how much PEEP do you use, maximal on NIV, e.g. before stating a CPAP-failure. 

How permissive are you with Co2 and pH? We tolerate the pH til 7.2 and Co2 usually til 70 with pH above 7.20. 

In our case, our ELGAN baby is now on NIV for a couple of days, so I hope we took a great step forward. 

Thank you for your answers!

[Francesco Cardona]

23 hours ago, tarek said:

PSV is the worst choice for VLBW babies

 

We have used PSV with success in VLBW infants as well.

[flavia]

Hi,

in my opinion isn't very important wich ventilation you use, but the most important thing is the 'open lung strategy'. If you use this strategy you can use HFOV or A/C + VG indifferently.

best regards

Flavia Petrillo

NICU - Di Venere Hospital

Bari, Italy

 

 

 

[nashwa]

Hamed... Can I ask what's average duration ELBW babies staying on mech ventilation in your unite ? Which start first if baby stuck on ventilator diuretic or DART and which dose??