pediatric ventilation updates - bapa€¦ · one lung ventilation physiology (2) ventilated lung:...
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Pediatric ventilation updates
F VeyckemansBAPA –SKA RCLeuven, January 2018
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No conflict of interest
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Outline
• Lung protective ventilation ?• The details that count• One-lung ventilation
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Principle : lung protective ventilation ?
Aim: avoiding Ventilator Induced Lung Injury(VILI)
- volotrauma- barotrauma- atelectrauma
- some evidence in adults with ARDS- transposed to adults in OR- adopted in children but no evidence
Low Vt + PEEP ?
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Pressure –controlled ventilation
- better lungrecruitment
- no risk of barotrauma
- more effective if small leak around TT
- but variable Vt
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Volume-controlled ventilation
• risk of barotrauma• reliability of target
volume < 20 ml?
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Pressure-controlled volume-guaranteed
= autoflow, pressure-regulated volume control
• breath-to-breath measure of lung compliance• subsequent PIP modified accordingly= mix of PC and VC ventilation
risk of important variations in Vtwhen compliance changes
may not work if leak around Ttube
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Pressure-support
- ideal with SGAW for short procedure- usable during inhalation induction- preserves spontaneous ventilation- limits decrease in FRC- risk of autotriggering if trigger settings too
low
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Importance of PEEP
- necessary to counteract loss of FRC caused by GA
- keeps lower airway open and decreases atelectasis
- increases lung compliance50% in neonates & infants (6cm H2O)25% in children
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Which ventilator?
1) compensation of the compliance of the breathing system ?
2) any interaction between FG flow and Vt ?
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Effect of uncompensated breathingsystem compliance
Example : 7 kg vs 20 kgcircuit 4 ou 0.7 mL/cmH2O
Vt = 8 mL/kg PIP = 18 cmH2O
Vt + circuit• 7 kg circuit : 56 + (18 x 4) = 128 ml
circuit : 56 + (18 x 0.7) = 69 mL• 20 kg circuit : 160 + (18 x 4) = 232 mL
circuit : 160 + (18 x 0.7)= 173 mL
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Effect of compensatedbreathing system compliance
Example : 7 kg vs 20 kgcircuit 4 ou 0.7 mL/cmH2O
Vt = 8 mL/kg PIP = 18 cmH2O
Vt + circuit• 7 kg circuit : 56 + (18 x 4) = 128 ml
circuit : 56 + (18 x 0.7) = 69 mL• 20 kg circuit : 160 + (18 x 4) = 232 mL
circuit : 160 + (18 x 0.7)= 173 mL
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Interaction FGF with set Vt
In most old ventilatorsadministered MV= set MV + (FGF x I/I+E)
– (vol compliance x RR)
Modern ventilators: interruption or diversion of FGF during Insp
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Pediatr Anesth 1992; 2: 211-5.
FGF L/min 1.5 3 6MV infant 2.12 ± 0.1 2.42 ± 0.2 2.93 ± 0.3
child 5.02 ± 0.3 5.36 ± 0.3 6.07 ± 0.3
PIP infant 20.3 ± 1.3 23.1 ± 1.1 27.8 ± 1.3
child 17.8 ± 0.5 19.4 ± 0.4 22.2 ± 0.5
ETCO2 infant 42.1 ± 2.4 37.4 ± 1.5 31.2 ± 1.3
child 38.9 ± 2.0 36.9 ± 1.6 33.1 ± 1.8
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Which ventilator?
1) compensation of the compliance of the breathing system ?
2) any interactionbetween FG flow and Vt ?
Pre-use test with all components !No compensation for leak around Ttube
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Limit equiment deadspace!
• The smaller the childthe greater the impact of deadspace
• Increased deadspaceincreases gradient betweenpaCO2 and EtCO2
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Heat-moisture exchangers
2017; 27: 1185-92
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Airway pressure
Pressure measured by the ventilator= pressure in the whole system= f resistance of
circuit : , length, compliance, adds onTtube : , kinking, secretionspatient’s lungs: bronchospasm,
external compression
no magic number: look at the child !
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Monitor the results
- thoracic movement- auscultation- SpO2 vs FiO2
- EtCO2: distal sampling• there is always a
difference with PaCO2
• it is unpredictable :if possible check with Pa or Pv or transcutaneous CO2
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Pressure-volume loops
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• 26 neonates 3167 g ± 736 under GA 2015 Melbourne16 laparotomies ventilated with Aisys® GE
• ventilation settings: anesthesiologist in charge• respiratory function monitor (Florian ®)
automatic recording of data
J Pediatr 2017; 184: 51-6
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Results (1)
ideal range
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Results (2)
Aisys® GE overestimated expired Ve by a mean bias of 3 ml/kg (-4.5 to 10.8 !)
because measured close to the expiratory valve of the circuit rather than at the airwayconnection
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Tricks
• I/E: 1/1.5 can be better than 1/2 : volume !
• avoid high RR: risk of autoPEEPspurious rebreathing on capnogram
• beware of expired volume measuredin neonates & small infants intubated with uncuffed tubes
pressure-control with PEEP
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Anaesthesia 2017; 72: 214-22
40 infants < 1 y, ASA 1-2Intubated with uncuffed TT, paralysedFiO2 0.4, Vt 8 ml/kg, RR 20-40, I:E 1:2, PEEP 5 cm H2OPulmonary US of each hemithorax divided in 6 zones- 1 min after starting ventilation - at the end of surgery20: recruitment maneuver under US control
after 1st US examination
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Anaesthesia 2017; 72: 214-22
80%25%
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When recruiting ?
after any event that may cause a loss in FRC- disconnection from circuit- suction in TT
after extubation: CPAP by maskimmediately
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One-lung ventilation
Indications :- absolute : protection of other lung* unilateral infection* unilateral hemoptysis* lung lavage for alveolar proteinosis- relative* thoracic surgery (tomy /scopy): surgeon’s needs* decompression of unilateral pulmonary emphysema
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Tracheal anatomy in children
Pediatr Anesth 2017;27:1043-9
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Classic view: the younger, the more vertical & widerthe right bronchus
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One lung ventilation physiology (1)
hypoxic pulmonary vasoconstriction- large interindividual variability- onset and offset are progressive
(interest of preconditioning ?)- dose-dependent inhibition by halogenated
but if < 1 MAC = IV agents
- animal models :perfusion of blocked lung by 50%but HPV is only responsible for 50% of it
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One lung ventilation physiology (2)
ventilated lung: overinflation != cytokines, oxidative stressavoid > 5 ml/kg, high PIP (but resistance to flow !)
high FiO2, long duration
blocked / collapsed lung: surgical trauma +1) recruitment after collapse : cytokines 2) ischemia-reperfusion injury :oxidative stress
CPAP during blocking periodlow FiO2 and gentle pressure during recruitment
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One lung ventilation physiology (2)
ventilated lung: overinflation != cytokines, oxidative stressavoid > 5 ml/kg, high PIP (but resistance to flow !)
high FiO2, long duration
blocked / collapsed lung1) recruitment after collapse : cytokines 2) ischemia-reperfusion injury :oxidative stress
CPAP during blockinglow FiO2 and gentle pressure during recruitment
OLVis non-physiologiccan produce damage to both lungsonly if requiredas short duration as possible
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Protective effect of sevoagainst reperfusion injury ?
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Methylprednisolone 2 mg/kggiven 30 min prior to lung collapse- decreases inflammatory reaction: IL6 IL10- decreases reperfusion injury: Tryptase- reduces increase in lung dynamic resistance
after OLV
Pediatr Anesth 2015; 25: 587-94
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Age
(years)
Tracheal tube
ID (mm)
Fogarty®
(Fr)
Arndt®
(Fr)
Swan-
Ganz (Fr)
Univent
®
Double lumen
(Fr)
0.5-1 3.5-4 3 5 (lat) 4
1-2 4-4.5 4 5 (lat) 5
2-4 4.5-5 5 5 5
4-6 5-5.5 5 5 5
6-8 5.5-6 6 5 5 3.5
8-10 6 + cuff 6 7 7 3.5 26
10-12 6.5 + cuff 6 7 7 4.5 26-28
12-14 6.5-7 + cuff 6 9 7 4.5 32
14-16 7 + cuff 7 9 7 6 35
How to achieve OLV
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blocker
fiberscope
< 2-3 years
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Swan-Ganz catheter: 5 or 7F
Fogarty embolectomy catheter 3, 4 or 5FideallyThru-lumen®
Home-made blockers
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Arndt blocker
5 Fr : 0.5 – 2 ml7 Fr : 2 – 6 ml9 Fr : 4 – 8 ml
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Extraluminal Arndt blocker
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Univent® tube
- 3.5: uncuffedno central lumen in blockerOD 7.5 -8 mm~ 5.5 -6.0 Ttube
- 4.5: cuffedOD 8.5-9 mm~ 6.5 Ttube
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Pressure in balloon !
Measured intracuff pressure does not reliably reflectpressure on the bronchial mucosa
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In vitro: external pressure vs volume
mucosal ischemicthreshold
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Double lumen tubes
• from 8 years• smallest 26 Fr: OK if > 30 kg and > 130 cm• size ~ age x 1.5 +14• usually left-sided
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Control of position
• fiberoptic bronchoscopy
• image intensifier (X-ray): carinadiaphragm mvts
• auscultation
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Ventilating on one lung
- limit IV fluids : keep on the dry side- corticoids:
2 mg/kg methylprednisolone before lung collapse- maintain reflex hypoxic vasoconstriction
halogenated: max 1 MAC and start soon !- mild hypercapnia (paCO2 40-60 mmHg)
small Vt ( < 5 ml/kg) + increased RR + PEEP- at the end: gentle recruitment maneuver
with low FiO2
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Difficult ventilation ?
- During OLV :- blocker slipped into the trachea ?- Ttube blocked by secretions, blood ?- bronchospasm ?- After OLV :- Ttube blocked by secretions, blood ?- pneumothorax ?
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Suggested readings
Anesth Analg 2015; 120: 165-75
Anesth Analg 2015; 121: 302-18
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A new era?
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THRIVE: what is it ?
n = 48 children < 10yinduction of anesthesiaparalyzedbag-mask ventilation FiO2 1after 3 min:- apnea with jaw-thrust time to SpO2 92% = t
- Optiflow® + jaw-thrust2L/kg/min if < 15 kg35L/min if 15-30 kg
stop when 2 x t
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At least double safe apnea time
Stopped by protocol at2 x control time
New option for difficult intubation /ventilation ?
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