PARDS--Beyond the Basics Part 3 with Dr. Nadir Yehya: Non-conventional Modes of Ventilation
Jan 16, 2023
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Dr. Nadir Yehya, an expert in pediatric respiratory failure, discusses non-conventional ventilation modes like APRV and oscillation in ARDS patients. The podcast explores the advantages and considerations of these modes, as well as their effectiveness and limitations. It also delves into treatment options for pediatric patients with refractory ERDS, including the use of the oscillator and potential ECMO cannulation.
Non-conventional modes of ventilation for pediatric respiratory failure include Nova, Oscillator, APRB, and high-frequency percussive ventilation, each with its own advantages and considerations.
APRV is effective for oxygenation rescue and lung recruitment in patients with stiff lungs, while the Oscillator provides sustained recruitment and improved oxygenation but may have hemodynamic and pulmonary challenges.
Deep dives
Modes of Ventilation for Oxygenation and Ventilation Failure
When conventional mechanical ventilation is not effectively oxygenating and ventilating a patient, several alternative ventilation modes can be considered. These include Nova, Oscillator, APRB, and high-frequency percussive ventilation. Nova is typically more suitable for non-invasive cases or weaning, while APRB prioritizes oxygenation rescue and uses periodic dumps to facilitate CO2 removal. The Oscillator excels in oxygenation and sustained recruitment but may have potential risks such as sedation requirements and poor pulmonary toilet. High-frequency percussive ventilation can address hypercarbia and secretion issues, making it effective in cases with significant secretion burdens. The choice of mode relies on the individual patient's condition and response to treatment.
APRV for Oxygenation Rescue
APRV (Airway Pressure Release Ventilation) is a suitable mode for oxygenation rescue. It allows for comfortable spontaneous breathing while improving VQ matching with prolonged eye times. By setting appropriate pressures and eye times, APRV can effectively recruit the lung, especially in patients with stiff lungs who experience recruitment failure with conventional modes. The patient on APRV should be able to tolerate comfortable tachypnea as it is a characteristic of the mode. Careful monitoring of heart rate and FiO2 is necessary to gauge the patient's response.
The Oscillator for Sustained Recruitment and Oxygenation
The Oscillator serves as a powerful ventilation mode for sustained recruitment and oxygenation. It provides an infinite eye time, allowing for continuous increased pressure and prolonged recruitment. The Oscillator can be ideal for patients with severely stiff lungs who do not respond well to other modes. It offers an advantage in oxygenation but may impact hemodynamics, necessitate higher sedation, and pose challenges in pulmonary toilet. Its recruitment properties are unmatched, making it a valuable option for patients with severely compromised lung function.
High-Frequency Percussive Ventilation for Hypercarbia and Secretion Management
High-frequency percussive ventilation is a suitable ventilatory mode for patients with refractory hypercarbia and significant secretion burdens. By combining the percussive properties with high-frequency gas delivery, this mode effectively breaks up secretions and supports CO2 removal. High-frequency percussive ventilation can be a practical alternative to jet ventilation, which may have limitations in size and airway secretion management. It prioritizes CO2 elimination while assisting with adequate oxygenation. The mode should be considered when patients require gas exchange improvement and have a significant burden of secretions.
Dr. Yehya is a graduate of the University of California at Berkeley and the University of California at Los Angeles School of Medicine. After completing pediatrics training at Children’s Hospital of Los Angeles, he completed his pediatric critical care fellowship at Children’s Hospital of Philadelphia (CHOP), and joined the faculty after graduation in 2011. He is currently an Assistant Professor of Anesthesiology and Critical Care and Pediatrics at the Perelman School of Medicine at the University of Pennsylvania and an attending physician in the pediatric intensive care unit at CHOP.
Dr. Yehya’s research interests encompass all aspects of pediatric respiratory failure, with a particular emphasis on pediatric acute respiratory syndrome (ARDS) and mechanical ventilation. ARDS consists of sudden, severe flooding of the lungs in response to an inflammatory insult causing difficulty breathing, frequently requiring mechanical ventilation. Sepsis is a leading cause of ARDS in children. His long-term goal is better characterization of ARDS in children and to test therapies designed to improve outcomes. His NIH-funded work is assessing the utility of specific plasma biomarkers in pediatric ARDS, with subsequent proteomic characterization and testing in pre-clinical models. Dr. Yehya has several active studies involving biomarkers, clinical epidemiology, and pathophysiological mechanisms in the field of pediatric ARDS, and is involved in several multicenter and multinational collaborations.
Objectives:
After listening to this episode, learners should be able to:
Understand the role of heated high-flow nasal cannula and non-invasive mechanical ventilation in the management of pediatric acute respiratory distress syndrome (PARDS).
Recognize the potential for patient self-inflicted lung injury in PARDS.
Recognize high-risk situations when non-invasive mechanical ventilation is relatively contraindicated in favor of intubation and mechanical ventilation.
Acknowledgement: Thank you to Dr. Nick Bartel for his help in creating learning objectives for this series.
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Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.comfor detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.
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