NEONATAL PULMONARY

8/7/2019 NEONATAL PULMONARY

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NEONATAL PULMONARYGRAPHICS:

More Than Just APretty Picture

Steven M. Donn, M.D.

Professor of PediatricsDirector, Neonatal-Perinatal Medicine

C.S. Mott Childrens HospitalUniversity of Michigan Health System


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DATA
http://images.google.com/imgres?imgurl=http://www.med.umich.edu/lrc/ecgoftheweek/cases/case04/images/answerexplain-ECG.jpg&imgrefurl=http://www.med.umich.edu/lrc/ecgoftheweek/cases/case04/answer01.html&h=338&w=549&sz=50&tbnid=SEUzcJqsxSknsM:&tbnh=80&tbnw=130&hl=en&start=16&prev=/images%3Fq%3DECG%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DGhttp://images.google.com/imgres?imgurl=http://www.cjd.ed.ac.uk/eeg.jpg&imgrefurl=http://www.cjd.ed.ac.uk/investigations.htm&h=2452&w=3091&sz=2649&tbnid=4qlLP3kCmEVL0M:&tbnh=118&tbnw=150&hl=en&start=3&prev=/images%3Fq%3DEEG%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DGhttp://images.google.com/imgres?imgurl=http://www.id.nrcs.usda.gov/snow/images/data/swegraphs/magic.gif&imgrefurl=http://www.id.nrcs.usda.gov/snow/data/current.html&h=436&w=648&sz=21&tbnid=M92ilkTR3qIIOM:&tbnh=90&tbnw=135&hl=en&start=98&prev=/images%3Fq%3Ddata%26start%3D80%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DNhttp://images.google.com/imgres?imgurl=http://www.temis.nl/protocols/o3field/data/forecast/fcst3_np.gif&imgrefurl=http://www.temis.nl/protocols/O3forecast.html&h=507&w=478&sz=83&tbnid=01tgQsklfTcECM:&tbnh=128&tbnw=120&hl=en&start=97&prev=/images%3Fq%3Ddata%26start%3D80%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DNhttp://images.google.com/imgres?imgurl=http://www.primera.com/images/bu-cds.jpg&imgrefurl=http://www.primera.com/backup-archival.html&h=722&w=740&sz=53&tbnid=zAtV6nZVTlWi4M:&tbnh=135&tbnw=139&hl=en&start=87&prev=/images%3Fq%3Ddata%26start%3D80%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DNhttp://images.google.com/imgres?imgurl=https://www.fnmoc.navy.mil/products/OTIS/US058VMET-GIFwxg.OTIS.glbl_sst.gif&imgrefurl=http://www.nawcwpns.navy.mil/~weather/chinalake/weatherlinks.htm&h=551&w=1080&sz=149&tbnid=W8kpo0qDwzr40M:&tbnh=76&tbnw=150&hl=en&start=84&prev=/images%3Fq%3Ddata%26start%3D80%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DNhttp://images.google.com/imgres?imgurl=http://mn.water.usgs.gov/bemidji/gif/field2005/Geoff%2520graphing%2520vapor%2520data.JPG&imgrefurl=http://mn.water.usgs.gov/bemidji/photos.html&h=960&w=1280&sz=266&tbnid=ipWVNWcsB5R8GM:&tbnh=112&tbnw=150&hl=en&start=83&prev=/images%3Fq%3Ddata%26start%3D80%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DNhttp://images.google.com/imgres?imgurl=http://weather.ou.edu/~laufers/wxpics/250.gif&imgrefurl=http://weather.ou.edu/~owl/weather/ua.html&h=600&w=800&sz=38&tbnid=iS5ue8MPcttVgM:&tbnh=106&tbnw=142&hl=en&start=55&prev=/images%3Fq%3Ddata%26start%3D40%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DN


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The Pre-Graphics Era

Pulmonary mechanics?

Lung expansion?Gas trapping?


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Early Experience

Cumbersome equipmentDifficult calibration

Limited applicability


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Recent Experience

Microprocessor-basedTechnical, but user-friendly

Extends research tool to

general clinical utility


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Neonatal PulmonaryMechanics Tests

Provide useful clinicalinformation

Help elucidate pathophysiology

Give objective evaluation oftreatments


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Waveform Monitoring

Volume

PressureFlow


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Flow Waveform

Shape may identify abnormality

Example: high airway resistance


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Flow Waveform

Identifies type of ventilation

Example:pressure vs. volume


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Flow Waveform

Identifies mode of ventilation IMV

SIMV

Assist/Control


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IMV

SIMV

A/C


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Flow Waveform:Gas Trapping

Expiratory flow does not

return to baselineMake adjustments


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Tidal Volume Waveform

Suitability to wean

Example:Effective vs. ineffective

spontaneous breathing


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Effect of Inspiratory Time

Flow

Volume


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Pulmonary Mechanics

ComplianceResistance

Work of Breathing

Peak Flows


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Compliance

Relationship of pressure

and volume

Example:

Flattened loops =poor compliance


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Pressure-Volume Loops

Compliance

InflationWork of Breathing

C20/C Ratio


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Pressure-Volume Loops

Determine optimal PEEP


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Fl V l L


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Flow-Volume Loopsand Resistance

Relationship of volume and flowHigh resistance = lower flow

for a given volume

Seen in MAS, BPD, obstructedairway


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Endotracheal Tube Leaks

Volume waveform

Pressure-volume loopFlow-volume loop


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Large ETT Leaks

Baseline drift

Loss of PEEPLeak compensation


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Turbulence

Waveforms

Loops


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Synchrony

IMV

SIMVAssist/Control


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Flow Cycling

Termination sensitivity

Expiratory trigger


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Effect of Cycling Mechanisms

Time

Flow


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Trend Data:


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Trend Data:

Pressure-Targeted

Volume

Pressure


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Trend Data:


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Trend Data:

Volume-Targeted

Volume

Pressure


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Case Study - 1

39 wk 3550 g female24 y/o G2 P1-2 mother

Elective repeat cesarean sectionApgar scores: 81 95


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Case Study - 2

Initially tachypneic, RR = 80Severe expiratory stridor at 30 min

Chest radiograph normal

CBG: pH 7.07, pCO2 105, pO2 52 (RA)


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Case Study - 3

Placed in 40% oxygen/humiditySepsis workup, antibiotics given

Transport requested


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Case Study - 4

Intubated by transport teamFiO2 0.3, rate 40, pressure 20/4

ABG: pH 7.12, pCO2 85, pO2 180Transferred without difficulty


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Case Study - 5

ABG: pH 7.33, pCO2 42, pO2 74Chest computed tomography:

Double aortic archConfirmed at catheterization

Successful surgical repair


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Pulmonary Graphics

You can observe a lotby watching.

-Yogi Berra

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NEONATAL PULMONARY