ARE YOU MAKING THE BEST USE OF SLE 5000 VENTILATOR

AIM

•This presentation is not a substitute for reading the user manual individually, and discussing at bedside what is not clear.

•A human life is hanging at the other end of our competence.

•Work-up your own opinion, but follow the consultant's preference strictly in setting up the ventilation of the baby.

WILL YOU BUY A TICKET ON THIS AIRLINE’S FLIGHT?

Which Readings to Record?

Values displayed on the top right corner (in small font) are the parameters you planned for the patient.

Values under the eyebrow (large font) are the actual delivered parameters to the patient.

Modes of ventilation

CMV OR PTV

CMV = IMV = [SIMV or PTV with trigger disabled]

PTV = A/C (baby controls the ventilator rate).

PSV = A/C but with Flow cycling (Baby controls the Ti also).

SIMV + PSV = detailed in separate slide.

HFO and HFO+CMV = presentation will become too lengthy.

CMV & IMV: by definition…

Continuous Mandatory Ventilation: Used most often in the paralyzed or apneic patients. The ventilator rate is set faster than the patient's own breathing rate.

Intermittent Mandatory Ventilation: The ventilator rate is lower (less than 30 bpm), therefore the patient gets chance to breathe spontaneously between two controlled breaths.

In both CMV and IMV, breaths are delivered regardless of the patient's effort.

Synchronization is not intended in either of these.

IMV-CMV FAN CLUB

Complications due to lack of synchronized ventilation are well known.

Adjusting Trigger Sensitivity

Default trigger sensitivity to detect the patient's breath effort is 2L/min, which will not detect the breathing in any premature baby, and then PTV, SIMV or PSV- all will work as CMV.

Make the trigger (flow sensor) work by decreasing the threshold to 0.4-0.6 in most cases.

Orange lines should be visible in the real time graphs.

PTV becomes CMV when trigger is not adjusted below the peak inspiratory flow

Orange lines: depict the neonate’s breathing efforts in the first 0.2 seconds of the Ti

This dip before inspiration assures true triggering Ti

Trigger threshold correctly adjusted

Using SIMV with PS

Once again the heart of PS is the flow cycling of inspiration.

Keep inspiration termination criteria at 5% of the peak insp. flow for neonates.

Pressure support for the non-SIMV breaths should be set initially liberally (start with ~80% of PIP values), and then bring it down to 4-5 mbars above PEEP in 1-2 days if possible.

On selecting SIMV, PS setup is offered in the same window.

On selecting PS with SIMV, these 2 parameter have to be adjusted.

Only for the non-SIMV breaths (free ones, over the set rate), to counter the imposed work of breathing, reducing exhaustion, and the energy expenditure. The mandatory cycles will follow the set PIP.

Flow cycling applies only to the non-SIMV breaths that are now getting some extra help during inspiration. The mandatory cycles will follow the set Ti (time cycled).

0 – 100%

I KNOW EVERY THING. YOUR GIMMICKS DON’T IMPRESS ME.

PSV with Volume Targeted Ventilation

Its user friendly in SLE

This is the only extra dial on screen.

Using TTV (Targeted Tidal Volume)

• This option is available in all modes, best used with PTV for uniformity of delivered tidal volumes (c.f. with SIMV).

• Press it ON,

• Set the desired tidal volume in ml.

• Set the automatic ET leak compensation to 20%

• Let the baby get benefit of auto-weaning of PIP especially after Survanta administration, when compliance increases.

• Contra-indication for TTV: ETT leaks > 20%.

A must read for connoisseurs

Your pneumothorax prevention button

Forget me if you don’t like synchronization.

ET leak compensation, Pressure wave form settings here.

Flow cycling of inspiration in PSV mode

It’s the tidal volume that causes Pneumothorax not the pressure

Set the desired tidal volume at 6 ml/kg, to get best results.

Range is 4-6 ml/kg.

When choosing in this range, consider:

Work of breathing,

pCO2,

Hyperinflation, BPD, MAS.

Pre-existing barotrauma,

Dead space compartment due to prematurity, flow sensor (1 ml).

ET Leak

Measured inspired vol minus measured expired vol.

Automatic leak compensation means that ventilator software will display the expiratory tidal volume (Vte) inclusive of the amount that leaked out from the sides of trachea during expiration.

In SLE 5000, there is Automatic Leak Compensation up to 20% if on TTV mode, and 50% in PTV, SIMV and PSV mode. We have to enable it from the “options” box after selecting the mode of ventilation.

If ET leak is > 50% all the time, most authorities recommend to change ET to a bigger size.

Selecting pressure wave form: “RISE TIME”

In brief:

• Square wave: for stiff lungs.

• Sinus wave: for healthier lungs.

• We have to select the pressure wave pattern from “options” menu.

• Default setting is towards the square wave in SLE 5000.

Shifting from HFO to Conventional. Do not press the confirm button without correcting the PEEP to 4 or 5 cmH2O, otherwise the PaW of HFO will be delivered as PEEP in convention ventilation.

Consequences may not be pleasant.

Measured values on right hand column.

Ti

BPM tot:

Trigger

Vte (ml)

Vmin (Liters)

Leak%

Resistance (cmH2O/l/sec)

Compliance (ml/cmH2O)

C20/C ratio (ratio)

Mean (Airway) Pressure (mbar)

HFO VTe (Vol. of Oscillation in ml)

DCO2: Gas Transport Coefficient

MY LEARNING CURVES OF OUR VENTILATOR MACHINES

bear cub 750

Measured values: Tidal Volume Vte (ml)

• Acceptable values:

• FT neonate is 4-8 ml/kg

• Preterm infant: 4 –6ml/kg.

Measured values: Minute volume Vmin (L)

• Acceptable Minute Volume:

• FT newborn is 200 - 400 ml/kg.

• Preterm: 200- 300 ml/kg

• Useful for guessing over or under ventilation before BGA is done.

BPM tot: (tot = total), in 1 minute. Trigger: No. of synchronized breaths in last 1 min.

• These values, may not be same as the (back-up) rate you have set in PTV or SIMV.

• In PTV mode, for pCO2 manipulation, look at the number of triggered breaths delivered before changing the ventilator rate.

• If it is significantly less than the BPM tot, then increasing the trigger sensitivity will increase the no. of assisted breaths.

Using Standby mode or CPAP mode to evaluate patients actual breathing effort without ET disconnection when flow sensor is not used.

• Pressing Standby button for 3 second will suspend ventilation for maximum of 90 sec, although it can restarted any time before 90 sec, by repressing it.

• Ventilator maintains MAP during this period to avoid derecruitment.

• Those on low settings, CPAP mode will be safer to manually assess the spontaneous breathing.

BPM measurement

• The ventilator measures BPM in 2 different ways, with or without a flow sensor.

• With flow sensor: All breaths are counted: Triggered, Spontaneous, and Mandatory.

• Without flow sensor: Only triggered and mandatory breaths are counted by the pressure sensor located inside the machine.

BPM tot

No flow sensor

With flow sensor

Measured values: Resistance (cmH2O/L/sec)

• Acceptable:

• ET 2.5: 130 to150.

• ET 3 - 3.5: 50-80.

• Very high values (eg 300 or more) should never be neglected.

• Common reasons:

• Kinked or partially blocked ET,

• ET impinging on carina,

• Recent suvanta administration,

• Thick secretions in the airway,

• Severe BPD or MAS

• Very high PIP & rate together, in 2.5 size ET (high turbulence).

Changing the neck position will solve the problem

Compliance (ml/cmH2O)

Acceptable values:

Normal FT, not on ventilator: 2-2.5

Good for extubation: > 1

C20/C ratio for over-distension

Ratio of compliance during the last 20% of breath cycle to the total compliance.

If this calculated value is less than 0.8 (<1 according to some experts), the lungs are overinflated, therefore PIP should be reduced.

Compliance of the last 20% of breath

Total lung compliance

Beaking also denotes over-distension

Mean (Airway) Pressure (mbar)

• This parameter (along with the FiO2) is the summary of what you are doing to the baby.

• Suggestion: MAP should be recorded in the BGA chart. Currently its not.

HFO VTe (Vol. of Oscillation) in ml

• Volume of air moved in (and out) with each oscillator piston movement.

• Delta P is an indirect representation of this volume.

• Values of 2-2.5 ml/kg will give you normal pCO2. (This is the anatomical dead space volume in neonates).

• Useful as an adjuvant to chest vibration.

DCO2: Gas Transport Coefficient

• DCO2 = VT2 X F

• Values around 80 per kg will result in normocarbia.

• Useful when chest is not visible due to bandage; or when gross edema with tense ascites causes poor vibrations.

THANKS