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jminski last won the day on May 20

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About jminski

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    Respiratory therapist
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    Childrens HospitalHSC; U of M
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    Wpg Mb Canada

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  1. This is an older abstract we did years ago when little was understood on vg Evaluation of Volume Guarantee (VG) Ventilation Strategy utilizing the Drager 8000 Plus on babies most likely to develop Bronchopulmonary Dysplasia (BPD). John Minski R.R.T., Lewis Rempel S.R.T., Ron Heese R.R.T., Mary Seshia MBChB., Univ. of Manitoba, Canada. Background: As part of the Evidence-based Practice Implementation and Change (EPIC) Collaboration in Canada, we examined our current ventilatory strategies in those babies most likely to develop BPD (<32 weeks GA) from birth and continuing through 36 weeks post menstrual age (PMA). Health Science Centre, Winnipeg (HSC), began using the Babylog ventilator in 1995; by 1997 all ventilators used were upgraded to version 5.0 allowing us to incorporate VG with pulmonary graphics; all ventilators were mounted with a laptop computer to allow for continuous monitoring of pulmonary graphics. To reduce ventilator-induced lung injury we aimed to reduce volutrauma by using the VG option. This strategy begins in the resuscitation room (RR) where babies have either no or <1min. hand ventilation, are placed directly to VG, and administered surfactant via the closed system. VG continues through the transport and ventilator management in the NICU, with no interruption (i.e. no hand ventilation, or pressure limited ventilation). One early evaluation (1997) of a limited implementation of this strategy and reported by the Canadian Neonatal Network demonstrated a favourable outcome for babies <32wks GA. As a result of this evaluation we standardized the following ventilation strategies. To minimize potential hand ventilation, in the RR the Babylog is fully operational (except for the set VG) prior to intubation. Once the newborn is determined to need mechanical ventilation(MV), and the weight obtained, the VG is set with standard settings of 3.5 -5.0 ml/kg on Assist Control (AC)+ VG, set rate of 50 breaths per min., PEEP 5-7cmH2O, Ti 0.25-0.35sec, and FiO2 1.0. Surfactant is mostly given on the AC+ VG mode with Ti and PEEP optimized utilizing pulmonary graphics, and FiO2 adjusted to maintain O2 Sats. between 88 and 94%. We have an exit strategy to HFV if at any VG the required PIP is >25 or MAP ³12 cmH2O regardless of oxygen requirements. Once some recovery is demonstrated and there is adequate respiratory drive, the baby is switched to Pressure Support Ventilation (PSV) +VG mode. This is continued to extubation. Criteria for extubation include PSV+VG, PIP £14 and PEEP 5- 6 cmH2O. All babies transition to NCPAP 6-8 cmH2O and then progress to low flow O2 (0.3-0.5 lpm) by nasal cannula via a blender if continued 02 therapy is required. Objective: For babies most likely to develop BPD, to evaluate our current ventilator strategies, which include the exclusive use of a targeted tidal volumes (AC+VG and PSV+VG) for those babies on conventional ventilation (Babylog 8000 Plus). Design: A retrospective chart audit at HSC of babies <32 weeks GA, born between July 03 and May 04 who received MV and/or CPAP. The audit included outcome (death, BPD{O2 dependence at 36 weeks PMA}, pneumothorax), mode of ventilation, ventilator parameters and all blood gases in the RR , days 1,2,3 ,7,14,28 and 36 weeks PMA. Results: Forty nine charts were audited. 44 babies received MV, 5 required only CPAP. Mean GA was 28wks, BWt 1193g. five babies died and 4 developed BPD. None developed a pneumothorax. Mode, ventilatory parameters (medians), and all pCO2 values (median and interquartile range) from birth until death or extubation are shown in the table. Conclusion: Our 10% rate of BPD in this sample of babies <32 weeks GA requiring MV and or CPAP compares favourably to that reported by others. Our strategy of early surfactant, minimal hand ventilation and avoidance of volutrauma through the utilization of VG with low tidal volumes contributes to this. Day of life Mode(n) Set VG (ml/kg) Set Rate (bpm) Spont. Rate (bpm) pCO2(mmHg) Median (1st,3rd quartile) PIP (cmH2O) PEEP (cmH2O) MAP (cmH2O) FiO2 (%) RR AC (36) 4 42 60 52 (46,63) 20 6 8.5 40 1 AC (30) PSV(6) JET (1) HFO (2) 4.1 3.9 48 15 360 450 59 48 42 (39,48) 44 (37,45) 53 (53,54) 51 (45,57) 19 11 21 28 (DP) 6 6 9 8.4 7.3 12 12 27 22 63 29 2 AC (21) PSV(6) JET (2) HFO (2) 4.0 3.9 40 15 360 450 50 60 45 (42,48) 43 (42,46) 46 (38,50) 43 (38,58) 15 11 21 26.5 (DP) 6 6 9 8.4 6.5 10.5 27 21 63 29 3 AC(19) PSV(6) JET (2) HFO (1) 4.0 3.9 41 15 270 420 50 45 48 (44,50) 41 (36,48) 44 (40,51) 43 (43,43) 16 11 21 23 (DP) 6 6 6 7.3 6.9 7.9 11.5 21 21 61 31 7 AC(12) PSV(3) JET (1) HFO (2) 4.5 4.2 50 15 270 420 55 58 54 (52,54) 54 (54,56) 41 (40,51) 53 (52,53) 17 20 24 (DP) 6 6 7 8 8.4 9.9 12.5 27 26 76 40 14 AC (6) JET (6) 3.9 40 360 50 55 (53,56) 53 (45,53) 15 19 6 8 7.9 9.5 25 38 28 AC (5) PSV (1) Jet (2) 4.2 3.9 30 15 310 55 56 56 (53,63) 38 (38,38) 50 (48,53) 13 9 26 6 5 8 7.4 5.8 10.3 23 24 50 36wks PMA PSV (1) 3.9 15 56 38 (38,38) 9 5 5.8 22
  2. We have trialed the device , our trial conclusion was this device was what we were not looking for . Yes ventilator NIPPV or only 3 or more Peep pressure ( think max is 15 cmh2o) , very similar to bilevel on the sipap . The hfv has passive expiration thus its more in line like a jet ventilator than oscillator.
  3. We have had good outcomes utilizing conventional ventilation A/C + Vg set at 3 -3.5 ml/kg originally with 8000 + now the Vn , peep starting at 7-8 , rate 50 , we have an early exit to High frequency JET ventilation ( Bunnell Jet Life Pulse USA) jet rate set at 240 bpm peep 8 or greater ,on time of o.o2. the jet allows for the use of optimal chest expansion (higher peeps) but lower MAP than required with Hfov , the Bunnell has only active inspiration , expiration is passive , the lower jet rate allows for I:E rations 1 to 12 , passive expiration allows the lower MAP and allows for optimal ventilation in non homogenic lung diseases We do not use HFOV. I believe one of our students presented an abstract on our experience and more lasts year at the meeting in England . We also utilize ino if required. We are not an Ecmo center. Winnipeg Manitoba Canada
  4. Has anyone know where I could find safety data if using Vg with HFOV and the VN 500 ventilator , there seems to some sites utilizing this style of HFOV but I am unable to find any prelim data on safety and clincal use.
  5. I would like for others to comment on this question. For infants older than lets say 3 days old if they are to arrest in the nicu which sequence for cpr would be most approriate. The nrp 3:1 ratio or pals 15:2 (2 person)? When does nrp guidlines stop and pals begin? For our most complicated babies who may be in nicu for months this can be an issue. It is also an issue for training of staff who work in this area and it can be very confussing for those staff who work wards/picu and nicu? Please comment.
  6. Please the leoni plus is a new ventilator to north america , I have be told that it is very simular to the Babylog even has a vg type mode. would anyone like to share their experiences with this ventilator. In my nicu we use vg option always so the leoni plus vz mode would be it's counter point. Thank you:
  7. I would like to add to the question about differnt types of Oscillators used clinically, My qusetion is on the Babylog HFOV mode , this mode also has a fixed I:E ratio of about 1 : 1.2 ( I believe), I :E ratios in old papers of 1:1 showed concerning out comes ( airleaks , IVH) is any one concerned who uses these ocillators have any concerns about the I:E ratio , and is there any positive papers out there on any HFO device other than the Sensormedics( 1:2 ratio)?
  8. We have found with our experience with babies who require some what lenghtly ncpap coarse, that rotating between the nprongs and the nasal masks really helps( q4-8 hrs). We often see babies go weeks with little minimal problems with this application of the therapy.
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