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Interesting PediatricRespiratory Cases:
An Interactive Discussion
Interesting PediatricRespiratory Cases:
An Interactive Discussion
Ira M. Cheifetz, MD, FCCM, FAARCProfessor of PediatricsChief, Pediatric Critical Care
Medical Director, PICUDuke Childrens Hospital
Ira M. Cheifetz, MD, FCCM, FAARCIra M. Cheifetz, MD, FCCM, FAARC
Professor of PediatricsProfessor of PediatricsChief, Pediatric Critical CareChief, Pediatric Critical Care
Medical Director, PICUMedical Director, PICUDuke ChildrenDuke Childrens Hospitals Hospital
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Case 1: PneumoniaCase 1: Pneumonia Previously healthy 4 yo (18 kg) girl presents
with a 5 day h/o URI symptoms, cough, & fever Admitted to the pediatric ward with RLL
pneumonia
Over 48 hours, she develops worseningtachypnea, progressive bilateral infiltrates, and
hypoxia
HR 152, RR 42, SpO2 89% (2 lpm), T 39.5C
Diffuse rales, mod subcostal retractions
Previously healthy 4 yo (18 kg) girl presents
with a 5 day h/o URI symptoms, cough, & fever
Admitted to the pediatric ward with RLL
pneumonia
Over 48 hours, she develops worseningtachypnea, progressive bilateral infiltrates, and
hypoxia
HR 152, RR 42, SpOHR 152, RR 42, SpO22 89% (2 lpm), T 39.589% (2 lpm), T 39.5CC
Diffuse rales, mod subcostal retractionsDiffuse rales, mod subcostal retractions
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Your AssessmentYour Assessment Moderate subcostal retractions, no
supraclavicular retractions, good air exchange
except at R base
Significant crackles on right, minimal crackles
on left, no wheezing
SpO2 85% on 2 lpm via nasal cannulae
CV normal pulses and capillary refill Exam otherwise unremarkable
Moderate subcostal retractions, no
supraclavicular retractions, good air exchange
except at R base
Significant crackles on right, minimal crackles
on left, no wheezing
SpOSpO22 85% on 2 lpm via nasal cannulae85% on 2 lpm via nasal cannulae
CV normal pulses and capillary refill Exam otherwise unremarkable
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Case ProgressionCase Progression Patient is transported to the Pediatric ICU
Worsening respiratory distress
Increased work of breathing
RR 50s, SpO2 92% on 5 lpm
Patient is transported to the Pediatric ICUPatient is transported to the Pediatric ICU
Worsening respiratory distress
Increased work of breathing
RR 50s, SpO2 92% on 5 lpm
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Question #1
What would be your management?
Question #1
What would be your management?
A. Observe closely
B. CPAP
C. Bilevel non-invasive ventilation (i.e., BiPAP)
D. IntubateE. Hope that help arrives soon
A.A. Observe closelyObserve closely
B.B. CPAPCPAP
C. Bilevel non-invasive ventilation (i.e., BiPAP)
D.D. IntubateIntubateE.E. Hope that help arrives soonHope that help arrives soon
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Non-invasive VentilationNon-invasive Ventilation Use of NIV for acute, hypoxic respiratory failureremains controversial
intubation rate, ICU LOS, & ICU mortality Keenan, CCM, 2004 (meta-analysis)
nosocomial pneumonia risk Hess, Respir Care, 2005 (meta-analysis)
Use of NIV for acute, hypoxic respiratory failureUse of NIV for acute, hypoxic respiratory failure
remains controversialremains controversial
intubation rate, ICU LOS, & ICUintubation rate, ICU LOS, & ICU mortalitymortality Keenan, CCM, 2004 (metaKeenan, CCM, 2004 (meta--analysis)analysis)
nosocomial pneumonia risknosocomial pneumonia risk Hess, Respir Care, 2005 (metaHess, Respir Care, 2005 (meta--analysis)analysis)
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Case ProgressionCase Progression Patient is intubated the next morning for
progressive hypoxia.
PC/PS: rate 24 PIP 30 PEEP 12 FiO2 0.60
ABG pH 7.3 PaCO2 55 PaO2 65
PaO2 / FiO2 108
Oxygenation index = 15
OI = (MAP x FiO2) / PaO2
Patient is intubated the next morning forPatient is intubated the next morning for
progressive hypoxia.progressive hypoxia.
PC/PS: rate 24 PIP 30 PEEP 12 FiOPC/PS: rate 24 PIP 30 PEEP 12 FiO22 0.600.60
ABG pH 7.3 PaCO2 55 PaO2 65ABG pH 7.3 PaCO2 55 PaO2 65
PaOPaO22 / FiO/ FiO22 108108 Oxygenation index = 15Oxygenation index = 15
OI = (MAP x FiO2) / PaO2
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Question #2
What delivered tidal volume wouldyou choose?
Question #2
What delivered tidal volume wouldyou choose?
A. 4 ml/kg
B. 6 ml/kg
C. 8 m/kg
D. 10 ml/kg
A. 4 ml/kg
B. 6 ml/kg
C. 8 m/kg
D. 10 ml/kg
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Low Tidal Volume Ventilation
The appropriate Vt for pediatric acute lung
injury has never been formally studied.
Thus, the best we can do is extrapolate
from data in the adult ARDS population.
The appropriate Vt for pediatric acute lung
injury has never been formally studied.
Thus, the best we can do is extrapolate
from data in the adult ARDS population.
Volume 342(18) 4 May 2000 pp 1301-1308
Ventilation with Lower Tidal Volumes as Compared with
Traditional Tidal Volumes for Acute Lung Injury and theAcute Respiratory Distress Syndrome
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13 Experts
Yes: 5
No: 8
13 Experts
Yes: 5
No: 8
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ARDS WorsensARDS Worsens Patient is transitioned to HFOV.
MAP 28, Amp 59, 33% insp time, FiO2 0.70 pH 7.25, PaCO2 67, PaO2 65, SaO2 90%
PaO2 / FiO2 93
Oxygenation index = 30
Patient is transitioned to HFOV.Patient is transitioned to HFOV.
MAP 28, Amp 59, 33% insp time, FiOMAP 28, Amp 59, 33% insp time, FiO22 0.700.70 pH 7.25, PaCOpH 7.25, PaCO22 67, PaO67, PaO22 65, SaO65, SaO22 90%90%
PaOPaO22 / FiO/ FiO22 9393
Oxygenation index = 30Oxygenation index = 30
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Question #3
What should be the maximumacceptable PaCO2?
Question #3
What should be the maximumacceptable PaCO2?
A. 55 torrB. 75 torr
C. 95 torr
D. Any PaCO2 as long as the pH is
acceptable
A.A. 55 torr55 torrB.B. 75 torr75 torr
C.C. 95 torr95 torr
D. Any PaCO2 as long as the pH is
acceptable
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Permissive HypercapniaPermissive Hypercapnia Available data support permissive hypercapnia to
minimize vent settings and secondary lung injury
Goal: maintain acceptable pH regardless of PaCO2
Contraindications
increased intracranial pressure reactive pulmonary hypertension
Acute lung injury model (Laffey, AJRCCM, 2000)
hypercapnic acidosis is protective
buffering attenuates its protective effects
Available data support permissive hypercapnia to
minimize vent settings and secondary lung injury
Goal: maintain acceptable pH regardless of PaCO2
Contraindications
increased intracranial pressure reactive pulmonary hypertension
Acute lung injury model (Laffey, AJRCCM, 2000)
hypercapnic acidosis is protectivehypercapnic acidosis is protective
buffering attenuates its protective effectsbuffering attenuates its protective effects
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Question #4
What is the goal SaO2 for yourpatient?
Question #4
What is the goal SaO2 for yourpatient?
A. 95%B. 90 94%
C. 85 89%
D. 80 84%
E. < 80%
A.A.
95%95%B.B. 9090 94%94%
C.C. 8585 89%89%
D.D. 8080 84%84%
E.E. < 80%< 80%
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Permissive HypoxemiaPermissive Hypoxemia Definitive data are lacking in the medical
literature!
Goal maintain a safe level of oxygenation
Maintain adequate O2 delivery
optimize cardiac output measure ABG / MVO2 / serum lactate
Assess end-organ function
mental status (difficult 2 sedation)
renal function / urine output
cardiac function
Definitive data are lacking in the medical
literature!
Goal maintain a safe level of oxygenation
Maintain adequate O2 delivery
optimize cardiac output measure ABG / MVO2 / serum lactate
Assess end-organ function
mental status (difficult 2 sedation)
renal function / urine output
cardiac function
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Question #5
Do you routinely use recruitmentmaneuvers (i.e., sustained inflation)
for pediatric ALI / ARDS?
Question #5
Do you routinely use recruitmentmaneuvers (i.e., sustained inflation)
for pediatric ALI / ARDS?A. Yes
B. No
A.A. YesYes
B.B. NoNo
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Recruitment ManeuversRecruitment Maneuvers Use of RMs remains controversial.
Bring lung to TLC to maximize recruitment,then move down the deflation limb of the
pressure-volume curve to an appropriate
PEEP to prevent de-recruitment No adult outcome data
No pediatric data
Use of RMs remains controversial.Use of RMs remains controversial.
Bring lung to TLC to maximize recruitment,Bring lung to TLC to maximize recruitment,
then move down the deflation limb of thethen move down the deflation limb of the
pressurepressure--volume curve to anvolume curve to an appropriateappropriate
PEEP to prevent dePEEP to prevent de
--recruitmentrecruitment
No adult outcome data
No pediatric data
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Should RMs be routinely performed foradult ARDS pts?
12 Experts
Yes 3
No 9
Abstain 1
Should RMs be routinely performed foradult ARDS pts?
12 Experts
Yes 3
No 9
Abstain 1
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Case 2: TraumaCase 2: Trauma 3 year old unrestrained passenger ejected
from car
Intubated for loss of consciousness
Transported to ED
GCS 5, poorly perfused bruising noted over left chest wall
SpO2 83%; FiO2 1.0
ABG pH 7.25 PaCO2 32 PaO2 43 BE -9
Trauma eval and stabilization in
Emergency Department then to PICU
3 year old unrestrained passenger ejected3 year old unrestrained passenger ejected
from carfrom car
Intubated for loss of consciousnessIntubated for loss of consciousness
Transported to EDTransported to ED
GCS 5GCS 5, poorly perfused, poorly perfused bruising noted over left chest wallbruising noted over left chest wall
SpOSpO22 83%; FiO83%; FiO22 1.01.0
ABG pH 7.25 PaCOABG pH 7.25 PaCO22 32 PaO32 PaO22 43 BE43 BE --99
Trauma eval and stabilization inTrauma eval and stabilization in
Emergency Department then to PICUEmergency Department then to PICU
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Pulm ContusionPulm Contusion
Patient placed on ventilator in PRVC mode
Vt 7 ml/kg rate 20 PIP 31 PEEP 8
FiO2 0.70
ABG pH 7.34 PaCO2 41 PaO2 43
Patient placed on ventilator in PRVC modePatient placed on ventilator in PRVC mode
Vt 7 ml/kg rate 20 PIP 31 PEEP 8Vt 7 ml/kg rate 20 PIP 31 PEEP 8
FiOFiO22 0.700.70
ABG pH 7.34 PaCOABG pH 7.34 PaCO22 41 PaO41 PaO22 4343
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Question #6
Would you administer exogenoussurfactant?
Question #6
Would you administer exogenoussurfactant?
A. Within the first 48 hours
B. If no improvement after 48 hours
C. If no improvement after 7 daysD. Not for this patient
A.A. Within the first 48 hoursWithin the first 48 hours
B.B. If no improvement after 48 hoursIf no improvement after 48 hours
C.C. If no improvement after 7 daysIf no improvement after 7 daysD.D. Not for this patientNot for this patient
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Exogenous SurfactantExogenous Surfactant Exogenous surfactant administration is the
only adjunct therapy that has been shown to
be beneficial for the pediatric ALI / ARDS pt.
Willson, JAMA, 2005
Surfactant was shown to be beneficial whenadministered within 48 hours of onset of ALI.
Exogenous surfactant administration is the
only adjunct therapy that has been shown to
be beneficial for the pediatric ALI / ARDS pt.
Willson, JAMA, 2005
Surfactant was shown to be beneficial whenadministered within 48 hours of onset of ALI.
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Question #7
Would you offer a trial of inhalednitric oxide?
Question #7
Would you offer a trial of inhalednitric oxide?
A. Within the first 48 hoursB. If no improvement after 48 hours
C. If no improvement after 7 daysD. Not for this patient
A.A. Within the first 48 hoursWithin the first 48 hoursB.B. If no improvement after 48 hoursIf no improvement after 48 hours
C.C. If no improvement after 7 daysIf no improvement after 7 daysD.D. Not for this patientNot for this patient
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Question #8
When would you consider a trialof prone positioning?
Question #8
When would you consider a trialof prone positioning?
A. Within the first 48 hoursB. If no improvement after 48 hours
C. If no improvement after 7 daysD. Not for this patient
A.A. Within the first 48 hoursWithin the first 48 hoursB.B. If no improvement after 48 hoursIf no improvement after 48 hours
C.C. If no improvement after 7 daysIf no improvement after 7 daysD.D. Not for this patientNot for this patient
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Inhaled NO / Prone PositionInhaled NO / Prone Position Multiple studies have demonstrated improved
oxygenation for adult and pediatric patients
with the administration of inhaled nitric oxideand prone positioning for acute lung injury.
But, no study has demonstrated improvedsurvival with either therapy for acute lung
injury.
Multiple studies have demonstrated improved
oxygenation for adult and pediatric patients
with the administration of inhaled nitric oxideand prone positioning for acute lung injury.
But, no study has demonstrated improvedsurvival with either therapy for acute lung
injury.
Inhaled Nitric OxideDobyns, Pediatr, 1999
Dellinger, Crit Care Med, 1998
Inhaled Nitric Oxide
Dobyns, Pediatr, 1999
Dellinger, Crit Care Med, 1998
Prone PositioningCurley, JAMA, 2005
Guerin, JAMA, 2004
Gattinoni, NEJM, 2001
Prone Positioning
Curley, JAMA, 2005
Guerin, JAMA, 2004
Gattinoni, NEJM, 2001
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Question #9
At what settings would you initiateHFOV?
Question #9
At what settings would you initiateHFOV?
A. OI 17, MAP 18, PIP 30, FiO2 50%B. OI 22, MAP 22, PIP 32, FiO2 65%
C. OI 38, MAP 27, PIP 37, FiO2 80%
D. Would not use HFOV
A.A. OI 17, MAP 18, PIP 30, FiOOI 17, MAP 18, PIP 30, FiO22 50%50%B.B. OI 22, MAP 22, PIP 32, FiOOI 22, MAP 22, PIP 32, FiO22 65%65%
C.C. OI 38, MAP 27, PIP 37, FiOOI 38, MAP 27, PIP 37, FiO22 80%80%
D.D. Would not use HFOVWould not use HFOV
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Pediatric HFOVPediatric HFOV
Arnold, Crit Care Med, 1994.Arnold, Crit Care Med, 1994.
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DISCUSSIONDISCUSSION
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Case 3: Status AsthmaticusCase 3: Status Asthmaticus 12 year old female with known history of asthma
PMHx: 2 prior PICU admits; never intubated
On ED arrival
obvious respiratory distress
SpO2 84% (RA); BP 110/57; HR 142; RR 48
Triage nurses rushes patient to a room and
STAT pages you
12 year old female with known history of asthma12 year old female with known history of asthma
PMHx: 2 prior PICU admits; never intubatedPMHx: 2 prior PICU admits; never intubated
On ED arrivalOn ED arrival
obvious respiratory distressobvious respiratory distress
SpOSpO22 84% (RA); BP 110/57; HR 142; RR 4884% (RA); BP 110/57; HR 142; RR 48
Triage nurses rushes patient to a room andTriage nurses rushes patient to a room and
STAT pages youSTAT pages you
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Initial ManagementInitial Management Your initial assessment
SpO2 85% (RA); HR 151; RR 54
distant wheezing
poor air exchange
moderate subcostal & intercostal retractions
FiO2 via face mask started at 0.60
Solumedrol (1 mg/kg) IV ordered
Your initial assessmentYour initial assessment
SpOSpO22 85% (RA); HR 151; RR 5485% (RA); HR 151; RR 54
distant wheezingdistant wheezing
poor air exchangepoor air exchange
moderate subcostal & intercostal retractionsmoderate subcostal & intercostal retractions
FiOFiO22 via face mask started at 0.60via face mask started at 0.60
Solumedrol (1 mg/kg) IV orderedSolumedrol (1 mg/kg) IV ordered
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Question #10
Which of the following would youdo next?
Question #10
Which of the following would youdo next?
A. Obtain an ABG
B. Start continuous albuterol at 20 mg/hr
C. Start continuous albuterol at 40 mg/hr
D. Start non-invasive ventilation
E. Emergently intubate
A.A. Obtain an ABGObtain an ABG
B.B. Start continuous albuterol at 20 mg/hrStart continuous albuterol at 20 mg/hr
C.C. Start continuous albuterol at 40 mg/hrStart continuous albuterol at 40 mg/hr
D.D. Start nonStart non--invasive ventilationinvasive ventilation
E.E. Emergently intubateEmergently intubate
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Status AsthmaticusStatus Asthmaticus
Continuous albuterol started at 40 mg/hr
Patient initially with improved air exchange on
auscultation
Continues to have increased WOB but slightly
improved Intern sends med student to obtain ABG
obviously unsuccessful
Patient now complains that she cannot
breathe
Continuous albuterol started at 40 mg/hrContinuous albuterol started at 40 mg/hr
Patient initially with improved air exchange onPatient initially with improved air exchange on
auscultationauscultation
Continues to have increased WOB but slightlyContinues to have increased WOB but slightly
improvedimproved Intern sends med student to obtain ABGIntern sends med student to obtain ABG
obviously unsuccessfulobviously unsuccessful
Patient now complains that she cannot
breathe
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Question #11
Would you offer a trial of heliox beforeintubation?
Question #11
Would you offer a trial of heliox beforeintubation?
A. Yes
B. No
A.A. YesYes
B.B. NoNo
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Gas DensitiesGas Densities
Relative density of He-O2 and N2-O2
mixtures compared with 100% O2.
Relative density of He-O2 and N2-O2
mixtures compared with 100% O2.
Oppenheim-Eden, Chest, 2001.Oppenheim-Eden, Chest, 2001.
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Principles of Gas FlowPrinciples of Gas Flow
Because of its lower density than N2 or O2,
heliox would be predicted to improve gas
flow through a narrowed orifice.
Reynolds number (Re = VD / )
Re > 4000 = turbulent flow Re < 2100 = laminar flow
Because of its lower density than N2 or O2,
heliox would be predicted to improve gas
flow through a narrowed orifice.
Reynolds number (Re = VD / )
Re > 4000 = turbulent flow Re < 2100 = laminar flow
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Turbulent Gas FlowTurbulent Gas Flow
Occurs in constricted passages
Flow rate = k P
gas density yields gas flow.
Thus, heliox improves turbulent gas
flow.
Occurs in constricted passages
Flow rate = k P
gas density yields gas flow.
Thus, heliox improves turbulent gas
flow.
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Asthma and HelioxAsthma and Heliox
Both groups received methylprednisolone 125 mg IV
inhaled albuterol 2.5 mg nebs x 2
After 20 minutes of therapy
Heliox group PEF 58.4% N2-O2 group PEF 10.1%
Both groups received methylprednisolone 125 mg IV
inhaled albuterol 2.5 mg nebs x 2
After 20 minutes of therapy
Heliox group PEF 58.4% N2-O2 group PEF 10.1%
Kass, Chest, 1999.Kass, Chest, 1999.
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Asthma and HelioxAsthma and Heliox
Kass, Chest, 1999.Kass, Chest, 1999.
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A-a GradientA-a Gradient
Schaeffer, CCM, 1999.Schaeffer, CCM, 1999.
0
50
100
150
200
250
300
0
50
100
150
200
250
300
* p= 0.003* p= 0.003
BaselineBaseline 2 hrs2 hrs
**
controlhelioxcontrolheliox
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Asthma and OxygenationAsthma and Oxygenation
FiO2 in the heliox treated group
decreased from 0.810.25 to
0.370.27 after 2 hours of therapy.
(p= 0.0008)
This study rejects the idea that aminimum of 40% helium must be
used to obtain a therapeutic effect.
FiO2 in the heliox treated group
decreased from 0.810.25 to
0.370.27 after 2 hours of therapy.
(p= 0.0008)
This study rejects the idea that aminimum of 40% helium must be
used to obtain a therapeutic effect.
Schaeffer, CCM, 1999.Schaeffer, CCM, 1999.
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The Spiral EffectThe Spiral Effect
some
heliox
some
heliox
improve gas
exchange
improve gas
exchange
decrease
FiO2
decrease
FiO2
increase
heliox
concentration
increase
heliox
concentration
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But.But. What if your patient does not improve with heliox
or if you do not have heliox at your institution?
Then, probably intubate. Patient intubated with 6.5 cuffed ETT without
difficulty (not by the med student)
Patient is being hand ventilated with FiO2 1.0.
Patient is transferred to the PICU.
What if your patient does not improve with heliox
or if you do not have heliox at your institution?
Then, probably intubate.Then, probably intubate. Patient intubated with 6.5 cuffed ETT withoutPatient intubated with 6.5 cuffed ETT without
difficulty (not by the med student)difficulty (not by the med student)
Patient is being hand ventilated with FiOPatient is being hand ventilated with FiO2 1.0.1.0.
Patient is transferred to the PICU.Patient is transferred to the PICU.
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Question #12
What ventilator mode would bemost appropriate?
Question #12
What ventilator mode would bemost appropriate?
A. Volume control with square waveform
B. Pressure control with variable flow
C. PRVC with variable flowD. High frequency ventilation
A.A. Volume control with square waveformVolume control with square waveform
B.B. Pressure control with variable flowPressure control with variable flow
C.C. PRVC with variable flowPRVC with variable flowD.D. High frequency ventilationHigh frequency ventilation
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Pressure ScalarPressure Scalar
Pressure(cm H2O)Pressure(cm H2O)
Constant,
Square Wave
Constant,
Square WaveVariable,
Decelerating Wave
Variable,
Decelerating Wave
00
PIPPIP
PawPaw
Q #13
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Question #13
Which of the following settingswould you use?
Question #13
Which of the following settingswould you use?
A. Vt 12 ml/kg, rate 12, PEEP 5
B. Vt 8 ml/kg, rate 18, PEEP 5
C. Vt 6 ml/kg, rate 24, PEEP 5
A.A. Vt 12 ml/kg, rate 12, PEEP 5Vt 12 ml/kg, rate 12, PEEP 5
B.B. Vt 8 ml/kg, rate 18, PEEP 5Vt 8 ml/kg, rate 18, PEEP 5
C.C. Vt 6 ml/kg, rate 24, PEEP 5Vt 6 ml/kg, rate 24, PEEP 5
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Asthma and Mech VentilationAsthma and Mech Ventilation
6 ml/kg has been shown to be the ideal tidal
volume only for adult ALI / ARDS.
Use long expiratory time ventilation which oftenrequires a larger tidal volume and low set
ventilatory rate.
Goal should be to transition to Pressure SupportVentilation with goal of extubation as soon as
possible.
6 ml/kg has been shown to be the ideal tidal
volume only for adult ALI / ARDS.
Use long expiratory time ventilation which oftenUse long expiratory time ventilation which oftenrequires arequires a largerlarger tidal volume and low settidal volume and low set
ventilatory rate.ventilatory rate.
Goal should be to transition to Pressure SupportGoal should be to transition to Pressure SupportVentilation with goal of extubation as soon asVentilation with goal of extubation as soon as
possible.possible.
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DISCUSSIONDISCUSSION
Case 4:Case 4:
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Case 4:
Patient-Ventilator Interactions
Case 4:
Patient-Ventilator Interactions 10 mo old infant; 28 weeks prematurity
Intubated for viral pneumonia
HR 172, RR 65, BP 82/45, afebrile
SIMV / PS rate 24, PIP 28, PEEP 7, FiO2 0.50
ABG: pH 7.25 / PaCO2 64 / PaO2 68
Infant is very agitated
Nurse requests additional sedation/analgesia
10 mo old infant; 28 weeks prematurity10 mo old infant; 28 weeks prematurity
Intubated for viral pneumoniaIntubated for viral pneumonia
HR 172, RR 65, BP 82/45, afebrileHR 172, RR 65, BP 82/45, afebrile
SIMV / PSSIMV / PS rate 24, PIP 28, PEEP 7, FiOrate 24, PIP 28, PEEP 7, FiO22 0.500.50
ABG: pH 7.25 / PaCOABG: pH 7.25 / PaCO22 64 / PaO64 / PaO22 6868
Infant is very agitatedInfant is very agitated
Nurse requests additional sedation/analgesiaNurse requests additional sedation/analgesia
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Question #14Question #14
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Question #14
Why is the patient agitated?
Question #14
Why is the patient agitated?A. Inadequate sedation / analgesia
B. Trigger insensitivityC. Flow dys-synchrony
D. Inadequate PEEP
E. Inadequate tidal volume
A.A. Inadequate sedation / analgesiaInadequate sedation / analgesia
B.B. Trigger insensitivityTrigger insensitivityC.C. Flow dysFlow dys--synchronysynchrony
D.D. Inadequate PEEPInadequate PEEP
E.E. Inadequate tidal volumeInadequate tidal volume
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Question #15Question #15
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Question #15
Why is the patient agitated?
Question #15
Why is the patient agitated?A. Inadequate sedation / analgesia
B. Trigger insensitivity
C. Flow dys-synchrony
D. Inadequate PEEP
E. Inadequate tidal volume
A.A. Inadequate sedation / analgesiaInadequate sedation / analgesia
B.B. Trigger insensitivityTrigger insensitivity
C.C. Flow dysFlow dys--synchronysynchrony
D.D. Inadequate PEEPInadequate PEEP
E.E. Inadequate tidal volumeInadequate tidal volume
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DISCUSSIONDISCUSSION
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DISCUSSIONDISCUSSION