Nottingham Neonatal Service – Clinical Guidelines Title: Version: Date: Ratification: Review Date: Approval: Authors: Job title: Consultation: Contact: Distribution: Target Audience: Patients to whom this applies: Risk Managed:
Guideline B1
Mechanical Ventilation in Neonates 2 (Vs 1: April 1994) May 2015 (circulated September 2015) May 2018 Nottingham Neonatal Service, Clinical Guidelines Meeting Dushyant Batra1, Bernard Schoonakker1, Craig Smith1 1. Consultant Neonatologist Nottingham Neonatal Service
[email protected] Nottingham Neonatal Service Staff of the Nottingham Neonatal Service Neonates admitted to the neonatal unit requiring mechanical ventilation Morbidity and Mortality related to Neonatal respiratory disease and its management
Clinical Guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague. Caution is advised when using guidelines after a review date. This guideline has been registered with the Nottingham City Hospital Trust. This policy should be read in conjunction with guidelines covering early care (A8), surfactant therapy (B5), BPD (B8), hypoxic respiratory failure (B6), nitric oxide(B10), HFOV (B9) and CPAP (B15).
Key points: 1. Each ventilated baby should have a clear ventilation strategy, which should be guided by clinical condition, information from bed-side monitoring, regular blood gases and pulmonary graphics. 2. Always check that all equipment is ready before ventilation - ensure that system check and breathing circuit check is done before connecting the baby to the ventilator. 3. If there are problems with ventilation review the patient, consider all possible causes (BOLDPEEP) and involve senior colleagues if unsure or things are not improving.
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Nottingham Neonatal Service – Clinical Guidelines
Guideline B1
Contents Nottingham Neonatal Service – Clinical Guidelines Guideline No B1 .. Error! Bookmark not defined. Glossary .............................................................................................................................. 3 Section 1: Ventilation algorithms ....................................................................................... 4 Section 2: Practical aspects of ventilation .......................................................................... 6 2.1 Introduction and patient groups ........................................................................... 7 2.1.1. Introduction ....................................................................................................... 7 2.1.2. Patient Groups ................................................................................................... 7 2.1.3. Correct assessment of Clinical need for respiratory support ............................ 7 2.1.4. Aims of Intubation and Ventilation .................................................................. 7 2.2 Initiation of ventilation ......................................................................................... 8 2.2.1 Ventilator Choice ............................................................................................... 8 2.2.2 Initiation of Ventilation (Algorithm 1.1) ........................................................... 8 2.3 Continuation of ventilation (Algorithm 1.2) ......................................................... 8 2.4 Weaning ventilation (Algorithm 1.3) .................................................................... 9 2.5 Deterioration on ventilator ................................................................................. 10 2.6 Approach to common alarms .............................................................................. 11 2.7 Extubation ........................................................................................................... 12 Section 3: Ventilation parameters and modes of ventilation ............................................ 12 3.1 Ventilation parameters........................................................................................ 13 3.2 Modes of ventilation ............................................................................................ 14 Section 4: Volume Targeted Ventilation .......................................................................... 15 Section 5: Oxygenation and ventilation physiology ......................................................... 17 5.1 CO2 removal........................................................................................................ 17 5.2 Oxygenation ........................................................................................................ 17 Summary box and level of evidence ......................................................................... 19 Audit points:.............................................................................................................. 19 REFERENCES: ........................................................................................................ 20 APPENDIX 1: ................................................................................................................... 22
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Nottingham Neonatal Service – Clinical Guidelines
Guideline B1
Glossary AC= Assist control ventilation BP= Blood pressure C= Compliance CDH= Congenital diaphragmatic hernia CMV= Continuous mandatory ventilation CPAP= Continuous positive airway pressure CXR= Chest x-ray ECMO= Extracorporeal membrane oxygenation ELBW= Extremely low birth weight ET= Endotracheal FiO2= Fraction of inhaled O2 FRC= Functional residual capacity HFO= High frequency oscillation HIE= Hypoxic ischaemic encephalopathy HR= Heart rate I:E= Inspiratory-expiratory ratio IVH= Intraventricular haemorrhage MAP= Mean airway pressure MV= Minute ventilation NEC= Necrotising enterocolitis NGT= Nasogastric tube OI= Oxygenation index PC= Pressure controlled PS= Pressure support PSV= Pressure support ventilation PEEP= Positive end-expiratory pressure PIP= Peak inspiratory pressure Pmax= Maximum peak inspiratory pressure PPROM= Preterm Prelabour rupture of membranes PVL= Periventricular leukomalacia Raw= Airway resistance RDS= Respiratory distress syndrome RR= Respiratory rate SIMV= Synchronised intermittent mandatory ventilation TC= Time constant Te= Expiratory time Ti= Inspiratory time TV= Tidal volume TVe= Expiratory tidal volume VG= Volume guarantee VILI= Ventilator induced lung injury VTV: Volume targeted ventilation
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Nottingham Neonatal Service – Clinical Guidelines
Guideline B1
Section 1: Ventilation algorithms
ALGORITHM 1.1: INITIATION OF VENTILATION* Does the patient need ventilation? 1. Early care guideline ( 12 hours?
Yes Follow Algorithm 1.2
No Follow Algorithm 1.3
* Use in conjunction with section 2 (See Glossary for details of abbreviations)
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Nottingham Neonatal Service – Clinical Guidelines
Guideline B1
ALGORITHM 1.2: CONTINUATION OF VENTILATION* Q1
Yes
Does the patient need ‘significant’ ventilation? • MAP >12cm of H2O • FiO2 ≥ 50% Examples: • Significant RDS/ Sepsis • Pulmonary haemorrhage • Meconium aspiration • Complex surgical diagnosis like CDH, Eventration, post-operative NEC
Q2
• • • • • •
Use PC-SIMV Consider PC-HFO Back-up rate based on clinical condition to provide adequate ventilation and target pCO2 Consider Surfactant Optimise sedation, consider muscle relaxants Consider adjuvant treatments e.g. Nitric oxide
Go to Q3
No
Time cycled, patient triggered modes usually preferred PC-AC with back up rate typically 30bpm
Can the respiratory rate be delegated to the patient?
Yes
No
Q3 Is the patient: • Stable/ improving • ET tube leak
