Alveolar recruitment and HFOV

[ferac]

Dear Colleagues,

An request from Ecuador:

I would like him to help us to design a strategy of alveolar

recruitment early for RDS and if it is possible to use of entrance

HFOV for this same illness.

Sincerely,

Fernando Agama C.

Neonatology

Hospital Dr. "Enrique Garcés"

Quito-Ecuador

[Guest Dolphine liu]

Hi

you can raise pressure 2 cmH2O every time and observe the spo2 reaction,if spo2 raise you can reduce fio2 ,until fio2 less than 40%.

[DR Ramlawi]

In the abscence of and no impending airleak, you add 2-4 cm H20 to the MAP of the failing conventional ventilator to start with as a MAP on the HFOV,then you can increase your MAP by 2cm if the needed fio2 is still higher than 40%, and you have to do a chest X-ray to the baby by 30-50 min from starting HFOV, your goal is to have the lungs well inflated ie the coupula of the right diaphragm about the 9th or 10th rib- counting posteriorly

[Guest sameera_reddy]

Theren are different ways of managing RDS ON HFOV,ie. it can be the initial starting mode or as a step up mode.I f you are initiating on HFOV START CDP/MAP at 10 and with a frequency of 10 hz ,wait for 30 min and get an x-ray and ABG and decide what you want to do further.MAP can be increased in increments of 2 after you have reached an FiO2 OF 1.On x-ray you should see 8-10 rib spaces posteriorly,keep an hawk eye on BP as hyperexpansion can start showing effects on this and above all make sure the intravascular volume is adequate before you initiate HFOV.

[ferac]

Thank you for their interest.

Another important point when we use the entrance HFOV in the RDS it is the administration of the substance surfactant. We would like to know if their combined administration can hinder the setting in practice of the entrance HFOV for the SDR.

Thank you ahead of time

[DR Ramlawi]

Usually babies with RDS are not ventilated electively by HFOV except if they fail while on Conventional ventilation after being given surfactant.Surfactant has to be given as early as possible in infants with RDS,

Administering Surfactant early may times makes the baby ventilation very easy with conventional ventilators and avoid the needs for HFOV.

If the baby clinical and radiological findings are consistent with RDS and baby is already on HFOV;then you should give surfactant "if available",to do this you take the infant off th HFOV and you give surfactant in quartiles under Ambu Bagging over 2-5 min ,once you finished giving surfactant and the endotracheal tube is clear from surfactant;then you can connect the infant back to the HFOV, you may need to increase the MAP temporary by 2cm for 2-5 min .After giving surfactant ;lungs dynamics will improve witin 5-15 min and you should wean on both the MAP if the fio2 dropped to less than 40%,and wean on Delta P if the chest wiggling started to be exagerated or blood gas that should be done within 30 min showed PCO2 less than 45 mmHg

Good Luck

[Guest sameera_reddy]

Thank you for their interest.

Another important point when we use the entrance HFOV in the RDS it is the administration of the substance surfactant. We would like to know if their combined administration can hinder the setting in practice of the entrance HFOV for the SDR.

Thank you ahead of time

[Guest sameera_reddy]

Ina preterm with RDS ,Initiation of conventional ventilation and giving early Surfactant is the main stay of treatment.HFOV is used only if conventional ventilation fails or if airleak occurs or PIE develops.There is no group I am aware of doing HFOV And Surfactant as the first line tratment.There is no hindrance to settings if Surfactant is given with HFOV but technically if you disconnect the ventilator or use a side port to administer Surfactant there will be loss of recruitment of alveoli ie.while on HFOV never disconnect during sick phase and use only side port for even suctioning-Dr.Sameera

[ferac]

Thanks to all for their interest.

A point that I find important to discuss it is the fact of beginning a conventional ventilation in a newborn with RDS with a value X of PIP (ie. 20 cm), a value x of PEEP (ie. 6 cm) with a breathing frequency of 40 breathings per minute and that with a inspiratory time of 0,5 sg, they give a MAP of 10,66.

On the other hand, it could begin directly in the same baby with HFOV, with a MAP of 11 or 12 cm and a delta P or width of 100%, to verify the number of spaces intercostales and the values of gases in blood.

In the second case, we should consider that although the MAP is higher, it doesn't happen the opening and closing of the alveoli in each breathing, but a constant pressure in the one that only acts the oscillator. Although they don't seem to exist conclusive studies that support their initial use, this could not it be a less aggressive strategy with the breathing tract of the newborn?