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Outline
Physiological Concepts
Pediatric Considerations
Work of Breathing (WOB)
PAO2 = PIO2 -
PACO
Total
Lung Capacity
Functional
Residual Capacity
Vital Capacity
Liters
6
Inspiratory Reserve Volume
4
Tidal Volume
Residual Volume
PA > Pa > Pv
Zone 2
Pa> PA > Pv
Zone 3
Pa> Pv > PA
PEEP
Definition
Pressure-Volume Relationships
100
Chest wall
Lung TLC
75
50
Chest wall
and lung
25
FRC
0
-40
-20
0
20
Pressure (cm H20)
40
At high lung
volumes, compliance
of the resp system
is decreased p-v
curve flattens
as it becomes fully
distended
Airway
Chest Wall
60
50
40
Diaphragm
Intercostal Muscle
30
20
10
Premature
Term
> 2 Years
Cote CJ, Ryan JF, Todres ID et al. A practice of anesthesia for infants
and children. 2nd ed. Philadelphia: WB Saunders, 1993.
Outline
Physiological Concepts
Pediatric Considerations 9
Work of Breathing (WOB)
P = Flow x Resistance
FLOW
RESISTANCE
VOLUME
COMPLIANCE
Compliance = Volume
Pressure
Volume
Pressure =
+ flow x resistance
Compliance
Physiologic
Work
Elastic work to
expand lungs and
chest wall and flow
resistive work to
overcome airway
resistance
Imposed
Work
Resistive work
imposed by
breathing
apparatus (e.g.
endotracheal tube,
breathing circuit,
and ventilators
demand-flow system)
Exp
WOB P
WOB P + V
VT
WOB V
PAW
Pes
TIME
Methods
For WOB data, airway pressure and flow
rate were measured at the proximal end of
the ET tube using a differential flow
transducer.
Intrapleural pressure was measured using an
esophageal catheter.
The transducers and esophageal catheter
were connected to a Bicore CP-100
pulmonary monitor.
Methods
Ventilator
HME
Esophageal
Pressure
(PES )
PNEUMOTACHOGRAPH
(Measurement of VolumeandFlowrate)
0
0
0
Bicore CP-100
Volume
Flowrate
PES
WOB-Campbell Diagram
100
Elastic work
Physiologic
Work CL
Work imposed by
the breathing app.
-40
-30
50
VT
I
-20 -10
35
10
FRC
% Vital Capacity
CCW
Imposed work
**122%
*87%
1
WOBT
J/L
0.8
SV 300
Bird
0.6
0.4
0.2
0
PEEP 0
PEEP 3
cm H2O
* p=0.028
**p=0.028
Sanders RC, Thurman TL, Holt,SJ, Taft K and Heulitt MJ. Work of Breathing
Associated with Pressure Support Ventilation in Two Different Ventilators.
Pediatric Pulmonology. 32:62-70, 2001
1.4
1.2
**144%
*125%
1
WOBT
J/L
0.8
SV 300
Bird
0.6
0.4
* p=0.043
**p=0.028
0.2
0
PEEP 0
PEEP 3
Sanders RC, Thurman TL, Holt,SJ, Taft K and Heulitt MJ. Work of Breathing
Associated with Pressure Support Ventilation in Two Different Ventilators.
Pediatric Pulmonology. 32:62-70, 2001
To Pig
HME
To Ventilator
pneumotach
SV300
Carrier demodulators
Transducer
ZERO SPAN
CD 15
CD 15
2 10
3 11
4 12
5 13
6 14
Digital
Analog
Analog Channels
7 15
8 16
POWER
BUSY
0
BIOPAC Systems, Inc.
MP100
UIM100A
Millennia XKU 300MHZ
SV 300
a b
c
Maximum flow
15.0000
Flow
Start of deflection of flow
pressure
Volume
Insp. Flow
5.00000
Insp. Pressure
Exp. Pressure
Pressure
Exp. Flow
17.500
18.000
0.00000
Vent signal
18.500
19.000
seconds
Flow, and Pressure are signals received from pneumotach, Flow is integrated for Volume
Insp. Flow, Exp. Flow, Insp. Pressure and Exp. Pressure are signals received from the SV 300 Ventilator
Vent Signal is a signal received from the ventilator to indicate patient trigger
cm H20
10.0000
Insp
Exp
WOB P
WOB P + V
VT
WOB V
PAW
Pes
TIME
a b
235 ms
15.0000
Flow
10.0000
Insp. Flow
5.00000
cm H20
pressure
Volume
Insp. Pressure
Exp. Pressure
Pressure
-.38 cmH20
0.00000
Exp. Flow
Vent signal
17.500
18.000
18.500
seconds
19.000
Sanders RC, Thurman TL, Holt,SJ, Taft K and Heulitt MJ. Work of Breathing
Associated with Pressure Support Ventilation in Two Different Ventilators.
Pediatric Pulmonology. 32:62-70, 2001
139 ms
341 ms
10.0000
5.00000
Volume
Pressure
0.00000
-2.48 cmH20
1.5000
cm H20
pressure
Flow
2.0000
seconds
-5.00000
2.5000
3.0000
Flow, and Pressure are signals received from pneumotach, Flow is integrated for Volume
Sanders RC, Thurman TL, Holt,SJ, Taft K and Heulitt MJ. Work of Breathing
Associated with Pressure Support Ventilation in Two Different Ventilators.
Pediatric Pulmonology. 32:62-70, 2001
Maximum flow
~ 440 ms
Maximum pressure
10.0000
Flow
5.00000
Volume
0.00000
1.5000
2.0000
seconds
2.5000
-5.00000
cm H20
pressure
Outline
Physiological Concepts 9
Pediatric Considerations 9
Work of Breathing (WOB) 9
Initial Settings for Mechanical Ventilation
Ventilatory Failure
A
clinical diagnosis!
Apnea
PaCO2 > 60 (in patient with previous
normal lungs)
Vital capacity < 15 ml/kg
Dead space/tidal volume ratio> 0.6
Hypoxia
Cyanosis despite FiO2 > 0.6
PaO2 < 70 torr with FiO2 > 0.6
Hemodynamic Instability
Hemodynamic Instability
7.6
7.5
250
7.4
200
7.3
150
7.2
100
7.1
Extubated
50
6.9
PaCO2
PaO2
pH
3-13-06
3-16-06
3-18-06
3-21-06
25
20
BNP Level
>54,000
Fluid Balance
+ 450 ml
15
10
Lasix, Bumex
Metalozone
IVF
Outline
Physiological Concepts 9
Pediatric Considerations 9
Work of Breathing (WOB) 9
Initial Settings for Mechanical Ventilation
300
*Oxygenation
ALI PaO2/FiO2 < 300
ARDS PaO2/FiO2 < 200
250
200
150
100
* regardless of PEEP
50
4 7 10 13 16 19 22 25 28 31 34 37 40 43
Time (Days)
ALI Case #1
ALI Case #1
ALI Case #2
ALI Case #2
ALI Case #2
ALI Case #2
600
500
400
300
200
100
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43
Time (Days)
Comparison of P/F
Comparison
of Ratios
P/F Ratios
350
300
BM PF Ratios
JM PF Ratios
PaO
2 /FiO
22 Ratios
PaO
Ratios
2 / FiO
250
200
150
100
50
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43
Time (Days)
Objectives
Support oxygenation and ventilation
while avoiding ventilator-induced injury.
Goals
Peak Inspiratory Pressure (PIP) < 35 cm H2O
Tidal Volume (TV): 6-8 ml/kg
Newborn
One year to 12 years
Adolescent-Adult
0.6 second
0.7 second
1.0 second
< 1 year
30 - 35
1-6 years
25 - 30
> 6 years
20 25
(Rates need to be lower in pts with obstructive lung
disease)
Induction of
anesthesia
20-30
minutes
4
hours
7
hours
Off
Bypass
Ranieri, VM et al. Time-course of impairment of respiratory mechanics
after cardiac surgery and cardiopulmonary bypass. Crit Care Med 1999;
27:1454-1460 .
HLHS Case
Hypoplastic
Left Heart
Sano Shunt
HLHS Case
Pre-operative
CXR
Post-operative
CXR
HLHS Case
POD #1
CXR
POD #3
CXR
Cardiopulmonary Bypass
Congenital Heart Disease
120
110
100
100
150
175
Summary
Go Gators!!