Pediatric Respiratory Devices and Equipment

Ready to enhance your understanding of pediatric airway management? Join us for an enlightening session where we unravel the complexities of respiratory care in the Pediatric ICU with our esteemed guest, Assi Tima. With nearly two decades of experience as a respiratory therapist, Assi uncovers the critical importance of mastering respiratory equipment, especially for those new to high-pressure healthcare environments. Learn about the essentials, from the proper setup of flow meters and nasal cannulas to the pivotal role of ventilators and oscillators.

Explore the world of high-flow oxygen therapy under the guidance of our conversation, where we shine a light on non-rebreather masks and high-flow nasal cannulas. Discover the practical nuances that can make a life-saving difference, such as the real oxygen delivery percentages of these devices and the flexibility offered by various interfaces. We share troubleshooting tips that empower healthcare professionals to effectively respond to respiratory challenges and ensure optimal patient outcomes.

Dive deep into the realm of advanced ventilation modes and CO2 monitoring, where cutting-edge technologies, like NAVA, are redefining respiratory support. Our discussion extends to transitioning from conventional ventilation strategies to innovative solutions like oscillators and RAM cannulas. With insights on maintaining equipment integrity and understanding the subtle dynamics of ventilation modes, this episode equips listeners with the knowledge to elevate their respiratory care practices in pediatric and neonatal settings.

Use the link below to follow along with Assi's powerpoint for a visual reference:

https://www.dropbox.com/scl/fi/27dnqwhka3djy71eo4zxu/Respiratory-Devices.pptx?rlkey=2m21j6mg2ih12u7hzj98uux1b&st=rfomd0l7&dl=0

Please take the survey using the link below:
https://ufl.qualtrics.com/jfe/form/SV_8whTtydadAMpx7o

References:

Kline-Tilford, A. M., & Haut, C. (2020). Cases in pediatric acute care: Strengthening clinical decision making. Wiley-Blackwell.

Additional Resources:

PICU Essentials on the App Store (apple.com)

PICU Essentials - Apps on Google Play

Chapters

• 0:00 Pediatric ICU Airway Devices Overview
• 8:30 High Flow Oxygen Therapy Discussion
• 16:46 Respiratory Care Equipment Overview
• 30:39 Ventilation Modes and CO2 Monitoring
• 46:12 Respiratory Therapy Equipment Overview

Transcript

Michael Maymi: 0:00

All right, welcome to our Pediatric ICU podcast. My name is Michael Maymie. I am one of the pediatric nurse practitioners on the unit and I'm joined by Patricia Beck, Christina Carr, who are the management team, along with Amanda and Ashley, our education folks. And today, our guest speaker is Asi. He's one of our amazing respiratory therapists, and has been here for a very long time working in our pediatric ICU, our pediatric floors and the neonatal ICU. Our topic today is going to be on various different airway devices that we can use in our pediatric population, and I'm going to go ahead and let Dr. Well, excuse me, I'll call him Dr, but I'll let Assi go ahead and introduce himself and let him go ahead with his presentation.

Assi Timah: 0:49

Hey guys, my name is Assi Tima and thank you, mike, for giving this opportunity, for this opportunity to actually share my awareness around the respiratory equipment and how it's interacted in our area of practice. I know it can be very overwhelming to people sometimes when they come in contact with this equipment, especially our newer nurses and residents and as well as respiratory therapists, despite seeing them in schools. It could also be very, very overwhelming. So after going through school and then taking a job at UF Health, which gave me an opportunity to see many retro equipment and also put hands on them and make a great experience with it, I took on to the adventure of sharing the minimum knowledge that I've gotten so far with the people that are coming behind me. So this PowerPoint kind of gives a very big picture of the things you can see at the bedside in various facilities and in different units to help ease your knowledge about it. When people talk about them on rounds, if you've never seen them, I give credits at the end of this PowerPoint of some people's pictures that I've used and some of the pictures I've taken from bedside exposures as well. So I would jump right into it. I've been around this field for close to 17 years now I work in this hospital. Next year is going to be my 15 years, so 14 and plus months and, as Mike has said, I have the opportunity to work all of these units. Okay, I'll jump right on it. It says intro to respiratory. Feel free to ask any questions as I go through this PowerPoint by RCT team, of course, which is me. My areas of practice, the past 14 have years the shanes, pete's, pete's, edp ICU, nikhil currently now, which I spend most of my time. Welcome to the Gator nation, of course, big football nation and big, big educated community. You have helped.

Assi Timah: 3:11

So, right off the wall to our patients, you can see the various size of power points of flow meters that we use. You have the low flows in the regular flow meters that runs from 1 liter to 15 liters, which we're used to back our patients. The biggest thing about me showing this in pictures is because it's very easy to confuse them when there's an emergency and the lines are plucked and the bag is plucked in somewhere and you arrived and the bag in the patient. The bag is great, great chest rise, but the patient's saturation is not going up. As a team leader, you want to run your view from the patient all the way to the wall, to make sure that we are plucked onto oxygen, not medical air. So it's very important for us as a team leader or as a participant in a cold situation, the emergency situation, to run right onto the wall and make sure that we are plugged into the right outlet. Now another thing to pay attention is sometimes you can have the wrong the low flow meter plugged in there. The Christmas tree feeds the universe, so it can also feed in a low flow meter and might think that, um, you have the right size of a flow meter into the wall. No, um, so you have to verify and make sure the right side is the one to 15 liters that can effectively inflate our amber bags or our ventilator back to help support ventilation in terms of rescue. So these two pictures, um, would help you think twice and to verify and make sure that we are hooked up to the right size flow meters to the wall Run-through flow meters, christmas trees. We used to have differentiation in Christmas trees. It used to be the yellow one which was hooked up to their air flow airflow meter and the green one to the oxygen, but now we have a universal one which is just clear, which means it could be hooked up to any of them, either airflow meters or oxygen. So pay attention, making sure that again, that flow meter is the right one and the back is hooked up to the correct one in terms of when we come to rescue. So Christmas trees are very universal these days in nature.

Assi Timah: 5:27

Nasal cannula Very easy to confuse with high-flow nasal cannulas and all the nasal cannulas that have been used at the bedside. So this nasal cannula, which is the lowest, lowest flow that we use, only can carry up to five liters of flow. Once you go past five liters of flow, you need to convert it to a high flow nasal cannula which provides flow and high oxygen as well High oxygen as well as limited oxygen depending on the disease process of the patient. These nasal cannulas, once you start running them, especially in a pediatric world, we really encourage people to hook up a humidifier bottle, like you see on the side of it, and be careful and make sure that this humidifier bottle at the top of it is punctured before you attach it to the patient. If not, this thing would blow up and make a mess. It would not hurt a patient, but it would make a mess in the room. You can hook them up without the humidifier bottle to provide humidity, but it may also cause dryness and bleeding to our patient's nostrils. So it's very important to hook up a humidifier bottle for our neonatal and our pediatric.

Assi Timah: 6:43

A venturi mask and a face mask. A face mask is a basic mask that can actually be adapted to use to any patient that is getting a nebulizer but at the same time, more specifically, we use it for a venturi mask, for venturi oxygen patients. These venturi patients would run between 24 to 60 percent FL2. And the differences on how to pick on these is clearly know that there is color-coded. It helps you not to confuse when you go to pick up the amount of oxygen that is needed to deliver to a specific patient based upon disease process again. So with a venturi mask, what makes even though they're all uniform, what makes the difference in oxygen is the amount of air that is entrained when delivering the flow. As you can see the little jet office that at the bottom of the mask. This is how much flow is entrained. The smaller the jet office, the higher the oxygen, which means that they're entraining less room air. If you look at the one that is run at 15 liters, which is a green one, signifying that we're getting the most of our oxygen. So the amount of air that is entrained during this process is very minimal because of how much smaller air is being entrained during the process. Of course, at 15 liters, we know that our patient's flow that is coming to the patient's mass is coming very, very fast, giving no time for any kind of external flow to come in, which is room air, giving no time for any kind of external flow to come in, which is room air.

Assi Timah: 8:30

Non-rebreather setups A non-rebreather, we know it's. We say it's 100%, but research has proven that it's basically just 80%, because you can't have a full seal onto the patient face with a face mask. So it's anywhere between 60 to 100 um. So these ones are mostly used during emergency, emergency situations or burn patients that come in or a patient that has a pneumothorax, so you put them a non-rebreather. Now, setting up a non-rebreather, you plug into the flow meter, turn the flow meter to flush, which is 15 liters, and then you put a seal. You put your finger at the top inside the one-way valve that connects the bag, the reservoir, onto the patient's face mask. Make sure the bag is inflated totally before you put on your patient.

Assi Timah: 9:29

These bags do not require a humidifier once the patient is hooked up to it. We've had people in the past try to hook up a humidifier. No, it would not work, it would blow up the humidifier borders. These masks are supposed to be hooked up dry. For emergency purposes and reasons of hooking up patients to non-rebreather. We do not need to worry about humidification, we need to rescue the patient and then, once they're stable, then we can probably set them up on the next step that they can get humidification.

Assi Timah: 9:57

You see, on this PowerPoint I did include simple masks which run from 40% to 60%, which is a little bit higher than the venti mask we just showed. See, the nasal cannula runs from 24% to 44%, starting at one liter, which is considered 24%, and it goes by increments of four every liter of flow that you add to the patient, which means at two liters we're at 28%, at three liters we're at 32% and the increments goes on all the way to 44%, which is going to be five liters. Nasal cannula Erythritolers the same weekend it does have a jet office as well in their airstrip tracheolers, which I'm going to show in a minute here. But let's switch it to high flow nasal cannula. Once your nasal cannula conventional nasal cannula was run from 1 liter to 4 liters or to 5 liters, at that point the patients need a little bit of higher flow. So we jump from five liters or six liters. Some people would push it to six liters. We try to keep it at four liters.

Assi Timah: 10:56

Once you hit five liters we would go ahead and switch into a high flow nasal cannula which does not only provide you more flow but it can also specify FR2 from 21% to 100%. So some of our hyperplastic low front patient which probably needs sometimes just the flow, not the amount of oxygen or our N, but getting three, four, five liters of flow just to help ventilate them right. So, um, this powerpoint shows the setup of a high flow nasal cannula which has two increment ports. You have the medical room air and have oxygen that comes on board in. Fortunately for this powerpoint, um, our tubings don't really match up with the yellow and the green which are universal colors of choice for the hospital labor. This one was kind of a lab choice of high flow. But again, then you can see the humidifier at the bottom that we can actually titrate the oxygen, the heating system to provide the optimal temperature that is needed to a patient to keep them comfortable as well as humidify the flow that's going to the patient.

Assi Timah: 12:17

For the choices of our interfaces for our patients. This is all going to be patient dependence. A lot of times some patients have very narrow airways and so we would use the micropremies for the nasal interface and sometimes we use the largest, depending on what the requirements are for our patients. So we do have devices that help us measure them before we place them on. So we do have devices that help us measure them before we place them on.

Assi Timah: 12:52

As you work in the field, you would notice that some patients they could be micropremium but need a medium or large mass based upon the size of their nasal passage High flow still on our PowerPoint, different one called the air flow used on our pediatric patients Once you hit 25, 20 liters in both we want to switch to air flow setups which gives up to 60 liters of flow, which can also be used in adult care. So our pediatric patients' high flow usually runs all the way to 25 liters. But once we go past that liter flow in the smaller interface we switch them to the average phase which provide uh, which can sustain higher flow of oxygen that comes through this I'll see before you keep going.

Amanda Bradshaw: 13:40

can I ask a question? This is amanda. Hey, I'm the night shift nursing educator here in the PICU. So I just have a couple of questions about the high flow, specifically From a nurse's perspective. If they are noticing that their patient maybe is having some increased work of breathing, that sort of thing, but their stats are still appropriate, what are some things that that nurse could do to help troubleshoot before they come and get their RT?

Assi Timah: 14:05

Yeah, so when you have a patient that have increased vocal breathing, that's pretty normal, of course, right. So they're running into respiratory issues. Sometimes, when you look at those flow, the flow could be. It could be a flow issue whereby the patient is getting so much flow that they're having a hard time breathing again. Resistance of that flow. So you may want to turn down the flow for a little bit and see if that improves their work of breathing.

Assi Timah: 14:31

But if this increased work of breathing is coupled with labored breathing, which means that they're not only tachypneic but they're also retracting and they are unable to communicate with you, then they probably need a little bit more flow and maybe other interventions from providers to help relax them to tolerate the flow. So too much of flow could be a problem. Too much of flow can also be a solution. So it's all going to be patient dependent, based upon your assessment. So you're looking at three things labor, breathing, the consciousness of the patient to work with the device and also how much flow are we actually delivering to that patient. Does that answer your question?

Amanda Bradshaw: 15:14

Yes, that does. So the flow you would kind of that would be equivocal to PEEP, am I correct?

Assi Timah: 15:24

So that is kind of a disguised PEEP. But a lot of research. There's no really a strong paper out there that proves that high flow provides a level of PEEP. We can assess this from the result that we get by placing the patients on x-ray improvement and oxygenation, which means that we definitely recreated some alveoli. It's not a close PEEP. Peak in expiratory pressure, which is a definition of PEEP, can only be measured end-to-end. So it has to be a closed-loop system to actually measure PEEP. So with high flow it's not a closed loop. The patient breathes very, very passively so it's very hard to measure PEEP in a high flow, which makes it difficult to really say there is, you know, for any paper to really prove that PEEP and extra pressure. So if I Dr Mimi, he can really clarify that even more.

Michael Maymi: 16:15

Yeah, I think there's theoretical thoughts that it may offer about two to four centimeters of water. But you're correct, it is very hard to measure it because if the child is not breathing through their nose, if you don't have a proper fitting nasal cannula and their mouth is open and they're crying, they're losing any pressure that you're providing. So, yeah, in theory there is some thoughts that there are about two to four centimeters, but, like you mentioned, it's not a closed loop system and you're not going to get an accurate reading of what you're providing.

Amanda Bradshaw: 16:46

Thanks, amanda.

Assi Timah: 16:49

Thanks, amanda. So I would proceed in a jump into RAM Candler, which, when we totally exert our effort with high flow nasal Candler, we would jump onto the RAM Candler. So thank you, dr Mike. Mamie, you know everyone listening right here Mike has been a very strong mentor for me since I started working at UF Health and has built a lot of the person that I've become today when it comes to my intervention in respiratory care. So I take his advice and his guidance very, very important for me. So high flow when we feel high flow totally.

Assi Timah: 17:33

Our next device we would like to often try is Ram Canada. So in the past, before Ram Canada was introduced at UF Health, we used to use CPAP. What we run into CPAP is the fact that it was hard to find the right and correct interface that would totally seal on our small faces right, our small people's faces to actually provide them the amount of support that they needed in terms of PEEP and ventilation. So that was a challenge V60, and we're able to use our 840s and now our air-flow ventilators and all those forms of ventilators that we have in this state to actually deliver RAM Canada support to our patients and that guarantees better feeding on their nasal passages and also provide them the support that is needed for our patients. Again, the feeding for our patient's nasal for REM cannula is all going to be patient-dependent, based upon their nasal passages. As you can see right, they run from neonatal micropremium all the way to infant. So we also have the larger infant cannulas which can sometimes be used in the NICU, depending on the patient's requirement and their patients interface.

Assi Timah: 19:03

I threw in the trichotopes in there. They are there. It's not something that nurses and artists intervene directly. These are some things that our residents often help set up, but it's very important to know where to look at your ET tube markers. Sometimes you have an ET tube patient that's intubated. You come on your ship and this patient's tube was cut because it was long and causing a lot of air trapping and so attending providers might require also cut that tube. We often encourage that if an arch is going to cut an ET tube to reduce the size, help ventilation. Please encourage them to tape that side, that piece, to the vent so that we can recognize what side tube the patient has, because once it's cut, the size of the tube is usually very close to the connection to the vent area to the teepee area, so make sure they keep it to the bedside. The blade is, and all the forms of airways are often by the bedside, so all the size of the blade is documented into our chart system so you can always review to know what sort of blades were used to intubate that patient.

Assi Timah: 20:14

Tracheostomy same process as the ET tube, often picked by ENT. Again, we have them. If you have a patient that has a tracheostomy. Very important things over the bedside is an obturator at the bedside, a size up and a size down Things that we need just in case we lose our airway. We should be able to feed size down because of how rapidly the cartilage and the stomach can close. And if we can't feed this, the size down, we make sure that our obturator is placed in there to maintain that airway, to avoid a larger incision. If ENT has to reinstate the um, trick your stomach back into the into space, back onto the oxygen blender, which is also what we use at our high flow nasal candler. So this blender is the reason I throw this in. And now we have our color coded on this top one, which is the blue and or the, the green and the yellow. So very important Color coding super important because that helps us not to make mistakes. Right? You can see that our blenders that we use these blenders are used even on the oscillators. Right? This is how we are able to mix up oxygen and deliver a specific amount of FIO2 to our patients while also providing them flow that is needed for ventilation.

Assi Timah: 21:35

Some of these high flows have two flow meters. Some people usually, you know you can find two flow meters and you ask yourself why do we have two flow meters? With some of our high flows designed, they require those flow meters to run simultaneously at a time to actually entrain flow to provide specific FRO2? How do you know that? It's absolutely written to the side of the blender, you would see. It would indicate that this blender requires both flow meters to run at a time. So, with that said, how do you run both of them at the time? That doesn't mean that both flows have to be going to the patient. You can hook up your AMBU back to the other flow meter and just hang the back next to it. You can run it at anywhere between five to six liters of flow just to receive the accurate amount of FR2. If not, your FR2 would not read accurate. You may think you're delivering 50%, meanwhile you're only delivering 25% of FR2. That's why I throw this blender thing in there.

Amanda Bradshaw: 22:36

Can I ask another question real quick? This is Amanda again. Okay, so what is the maximum high flow setting that the med-surg, like the pediatric med-surg floor, will accept?

Assi Timah: 22:47

So the pediatric med-SIS flow is based upon weight. Two per kilo is our max and the highest amount of FR2 that the METSIS flow can actually carry is 50%. When you go past 50% and above two per kilo, usually these patients are required for close attention, close attention, and that's when we usually call our PICU team to come and assess and see if they can transport them up into the PICU and where they can have close attention at that high FL2.

Amanda Bradshaw: 23:23

Okay, and then what would be an ideal flow for a pediatric patient, and maybe even when would be an ideal flow to transition them to a regular low flow nasal cannula.

Assi Timah: 23:38

So, technically, once you go past, once you are at five liters of high flow, it's very important to understand that at five liters high flow, when you start dropping past five liters, the tubing compliance of the high flow would not provide enough resistance to deliver the amount of flow that is required by that patient right. So at five liters you want to start thinking of confining them to a conventional laser can. Now that's at a pediatric level. If you go a little lower in the NICU they can go up to one liter, two liters, but at five liters you can comfortably transition that patient to a conventional nasal cannula.

Amanda Bradshaw: 24:22

Okay, all right, yeah, and then is there an ideal flow for pediatric patients to be on.

Assi Timah: 24:29

To start on, Now you're going to have to pay attention to the work of breathing of this patient, right? So okay, um, if it is a hypoxic issue, and they can probably just do fine with two liters nasocam because they're needing oxygen, um, which is equivalent to 28, but if it is a ventilated issue, you probably, uh, the you, you go to five liters straight and simultaneously. If that is not working, then you come for them straight to high flow nasal cannula, which you have more rooms to work with at that point in time, whether to go up or to go down, but I would, in working in pediatric, if you're in the IMC, I would be encouraged to start them straight up on five liters, 25 to 30%, and then, in that circumstances, they're getting a heated humidifier and it's comfortable, right? People often call that a comfort flow. Because of the and humidification this patient is getting, we are able to target the amount of temperature and the amount of flow and the amount of FR2. So at that point we're providing every comfort that is needed for breathing for the patient.

Amanda Bradshaw: 25:45

Just kind of titrate up according to what their work of breathing looks like.

Assi Timah: 25:50

Yes, ma'am. Now that comes to titration is also going to be based on. One of the questions people ask is how do I know that this is optimal flow for this patient? So you listen to the breath sounds. If you can hear the flow bilateral, which is stethoscope it means that you are delivering an optimized flow and you would also see that the patient is comfortable.

Amanda Bradshaw: 26:09

Okay, great.

Assi Timah: 26:10

Thank you, you're very welcome. V60 ventilator I threw them all behind the Philips this is a respiratory ventilator that is mostly used for a patient that comes from home and they are chronic Sometimes. The Philips ventilator they come with it from home and so this is just to provide them CPAP continue CPAP without any oxygen blending. The V60 ventilators we use it sometimes without any oxygen blending. The V60 ventilators we use it sometimes for our patients that are larger than 23 kilos on our floors, same as the respirator. These are all SEPA ventilators that provide continued positive pressure ventilation for our patients. The LRTV ventilators are home ventilators. You would often see them in the Trilogy 100 at our bedside for our patients that are being prepped to send home. These ventilators have high compensation for patients that are going out on a trek. Of course, most of them are going home on treks, right, so they compensate for leaks and they're easily used by parents at home. They are quick to set up and quick they they have longer lasting batteries up to somehow up to five hours of um battery and you can also blend oxygen. So I throw this in here just for your vision purpose. So when you hear about the v60 and the trilogy, this is how they look like. Our kids are very versed with this. We all train and um in any uh. Their reps are often available 24-7 to help us if needed. I threw in the ventilator the 840 ventilators our servo ends that are also used in our facilities here from our bedside. These ventilators the servo ends are the most updated system from the 840s provide accurate compensation. You can also deliver nebulizer through these ventilators without attaching any external equipment that actually impedes the tubing compliance and the flow to the patient. You can also deliver NAVA ventilation through these new servo ends. You can also deliver NAVA ventilation through this new servo end. So it's a great form of ventilation that you can use to provide fluid to our patients.

Assi Timah: 28:22

I kind of talked about the setup on here the expiratory filters versus inspiratory filters. Important to recognize this because these filters cannot be interchanged. Right, the expiratory filters is always going to be green and it has water traps in the bottom. The expiratory filters, on the other hand, you would notice that it's hooked up to the blue circuit, right, blue for oxygen. So just make sure that when you look at your vent they are correctly set up, because mistakes can occur. You have your heater that attach on our ventilator patients as well. Then you have different ventilator setup that I use or the vent settings that I use. Mostly in our pediatric setup you have APRV, prvc. This is just again things that I throw in there just in case people want to understand, based upon whatever facilities you're working at, what vent settings are used. So at our facility here at UF Health we mostly use pressure control ventilation, prvc and other terms called VC plus as well.

Assi Timah: 29:26

What is the difference between pressure control ventilation and PRVC, pressure control, ventilation and PRVC? They all have pressure setup, i-time pressure support, ventilation or pressure support, peep and FRT. The only difference between PRVC and pressure control is the delta P that is applied or set in the pressure control Mean Y for PRVC, which is VC plus, is the volume. So the difference between these two is volume and delta p, but every single one of this mode has respiratory set, high time pressure support, peep and fr2. Now, with that said, pressure control ventilation, you set delta P to influence flow right, and so you cap the peak flow that the patient can get. Meanwhile, in pressure regulated volume control, you control the tidal volume, which is usually 6 to 8 per kilo in our pediatric environment. So you set the tidal volume, and the ventilator regulate the pressure based upon the patient's demand. Right, we could go into details with these If you have any questions about this, pressure control, ventilation and pressure PRVC. If Mr Mike has any addition to this, I'll be glad for him to enlighten us more on this.

Amanda Bradshaw: 30:58

I do have a question about Delta P. Could you explain a little bit more about what that actually is?

Assi Timah: 31:06

So you look at Delta P as a way to open the airway for more flow to come into the patient so um, an example uh, kind of a funny example to put is it's like, it's almost like you are switching from a little corvette to a truck, right? So, and go by increments. I go from a corvette. If I wanted to increase the delta p, let's say I want to transport more stuff, I just go ahead and take a bigger car. It takes more load. So delta P goes by increment based upon the need to ventilate a patient. So the higher the delta P, the more flow goes into the patient to blow out CO2. Okay, does it make sense?

Amanda Bradshaw: 31:49

Yes, it does make sense.

Michael Maymi: 31:52

So, amanda, if you don't mind me interjecting real quick, another way to look at delta P is the change in pressure right? So it's actually the amount of additional pressure above PEEP that you want to hit a higher peak inspiratory pressure to ensure that you open the lungs and provide your ventilation right. So, in a mode that, when you're talking about the amount of pressure given, you think about PEEP, that's the bottom pressure to allow the alveoli to stay open, your delta P is that change in pressure that you're going to need to give to meet your peak inspiratory pressure.

Amanda Bradshaw: 32:33

Okay.

Assi Timah: 32:36

Okay, Thank you, Mike. That gives a more clear understanding in terms of the change in pressure versus the peak pressure. So yeah, so, Amanda, again it's peak versus delta. Peak was to PIP.

Amanda Bradshaw: 32:52

Okay.

Assi Timah: 32:53

Perfect NAVA. So NAVA is? This is very interesting because this is coming to us very, very new and it has been a revolution in healthcare in terms of helping support breeding for mostly our neonatal infants. And now you guys are going to be seeing it very soon here in the PQ. I'm just going to kind of you know going to have another topic soon here about NAVR, but I'm just going to kind of highlight what it actually is.

Assi Timah: 33:29

It's a neuroadjusted ventilator assist, which means that it helps support patients on their breathing, but it allows the patient to actually determine the peak pressures, allow the patient to determine when to trigger a flow, allow the patient to actually pull in more flow if required, based upon their compliance right. So, um, how do we set up a napper? It's a catheter just like your feeding tube that you place in. Often when we, when we place them and the patient of the feeding tube, we usually attach them at the same level. Now there is electrical in um, electrical signals that are between, or electrical how do you call it design? The way it's designed has four to five electrical signals at the bottom of the navar that you place them right at the level of the diaphragm and these signals would pick up the diaphragmatic movement, based on electrical movement of the diaphragm, and deliver pressure to the patient based upon the patient's trigger right. So a NAVR settings of high. We set them based upon patient's requirement.

Assi Timah: 34:40

Now, things that we indicate that the patient needs NAVR. If the patient is breathing really, really fast, with patients breathing shallow, pulling low or tighter volumes, we would put them on NAVR. It would help them overcome. Or if they're going apneic right, it would help them overcome their work of breathing and ease of breathing. It will help them synchronize their breathing. If they're breathing too fast, If they're breathing shallow, it will help augment the tidal volume because of the fact that it would sense this pressure all the way to the level of the diaphragm, not just at the level of the floor as mechanical ventilation would usually provide. So we'll have a whole topic on this and we can talk about how it's set up and how to pick up a catheter and what else those catheters can also do. So just look at it as a form of ventilation that is going to help ease ventilation and also give a lot of power to the patient, rather than us taking over as a mechanical ventilation, which we usually do with pressure control and PRVC.

Michael Maymi: 35:39

Yeah, the thing that I like about NAVA that's fascinating is that as the brain sends the signal to the diaphragm, the NAVA sensors pick that up and even if the patient's not strong enough to generate that breath, the ventilator can sense that the patient wants to take a breath. It can synchronize with the patient and we can use NAVA in both as an invasive mode where the patient's intubated, or you can also use it as a non-invasive mode. So it really kind of goes into deeper signaling right. So if the brain sends the neurotransmission to the diaphragm and the diaphragm says, hey, there's electrical activity to move the diaphragm, let's do it right, and it makes it easier and more comfortable for the patient.

Amanda Bradshaw: 36:26

So it's more of like a supplemental type. It's supplementing what they're already triggering a supplemental type.

Michael Maymi: 36:33

It's supplementing what they're already triggering. No, it's kind of like on our ventilator. You know we have, uh, the trigger right and that trigger can be flow, pressure or volume. Um, the trigger is actually the nava right. It's the actual electrical signal from the brain to the diaphragm that then tells the ventilator okay, we need. We need to help support this breath or initiate a breath, because it's been too long since the last one.

Amanda Bradshaw: 36:55

I see Okay.

Assi Timah: 36:59

Thank you, mr Mike. I threw in CPAP in there continuous positive airway pressure. So the reason I threw in CPAP is because of the fact that most often people would we would often confuse between continuous positive airway pressure in relation to PEEP, which is peak in exposure pressure two different things right. So you provide a CPAP at. It's just a flow that got to breathe against resistance Meanwhile, the peak in pressure and we talked about it earlier that you can have to measure it from end to end based on a closed loop system With CPAP. It's flow that just helps you ventilate, helps our patients ventilate and help them overcome the work of breathing either obstruction or resistance, based upon patient's breathing effort. I kind of throw in some face view of some of the ventilators, images from a bedside. As you can see, there's a true ventilator on the patient. There's no patient's name or anything like that. It's just an image that reflects how they're doing on a ventilator. That's the patient in pressure-controlled ventilation. So you can see on that first image right there in pressure-controlled control ventilation we set up delta p and we set up the peep and in turn the peak pressure is delta p um. It gives us the peak pressures equals to our delta p plus our peak um. As you can read in on our second image, when you have an assist bread that says a, so um, the nine plus five gives fourteen. That you can see at the top of our image on that screen. Volume-controlled ventilation Again another image from a patient at PRVC on the bedside. Just images just to show you how it will reflect my ventilation.

Assi Timah: 38:52

Now I throw in another form of entire measurement here CO2 measurement from a sub-Q point. It's called transcutaneous entire monitor. Transcutaneous in tighter monitor. Transcutaneous is a system that uses electrical again electrical impulses to measure the CO2 at the level of the patient's skin. So we have electrodes that are placed on that patient using stickers and it heats up the spot where it is placed to measure CO2. This is usually used in the case whereby the patient is probably intubated in a lot of lines and has no access. It's another form of way to measure CO2 and window ventilator.

Assi Timah: 39:36

From here you can run into issues whereby if the patient is adamant they have so much fluid on board. The reading could really be inaccurate. Sometimes you have patients burn patients the skin. These electrodes cannot stick or the stickers can't stick on the patient to use electrodes to read the CO2. So we run into those kinds of issues, right so, and there you could run into irregularities, but we're working on getting new equipment that can that are more effective, more accurate. We reduce our place in lines on our patients and monitoring CO2 and wind the ventilator. This is how the place. We have little. We have gels that are placed into those stickers to make sure that they don't burn the patient's skin and they have to be moved around every four hours to avoid skin injury as well.

Assi Timah: 40:28

Conventionally, in tidal measures, of course, you have the one that you can actually deliver oxygen and monitor patients on our non-invasive patients, when we're doing a procedure, this is often used by anesthesia and our CICU critical care team when they're doing unconscious sedation in the patient that doesn't require intubation. On the left side you have the one that is a conventional that is often used at the end of our ET tubes to monitor intiters when the patients are intubated. Any questions on that? Looking good Again, this is another patient that is on his spontaneous breathing. The ventilator will look all yellow and red waveform, which shows that there is no assisted breath from a ventilator. The ventilator, the patient, is doing all the work.

Assi Timah: 41:23

All we said was the pressure support and the patient is probably intubated and getting support without any assisted breaths NAVR, navr. So when you have a patient that is NAVR, you would see there's three on this ventilator screen. You would see that the patient where you would read the nav is going to be all the way to the bottom right. Um, it's going to be the waveform that is purple and you can see the edi peaks on the. That is reading at 13.9. The edi mean is 4.7. Again, we'll have another lecture fully on the nav where we can go into details. Um, if you were to run by, uh, um, by event letter and you saw there the images and you're like, what is the purple on the bottom? The purple line or waveform is our nav and this is how it's set up. Um, again, I throw this images here for several reasons. Mr mike already went through the whole details but we will come back onto it whenever time is given.

Assi Timah: 42:28

These are the different interfaces that are used at our NICU level and also used sometimes at PIC for smaller patients interfaces to deliver non-invasive ventilation. You can use a nasal prongs and you can also use a mask. We try to alternate them every six hours to prevent facial injuries because of the fact that they're a good sealing masks that can provide pressure on the patient, but also they can cause injury because of how much strength is used to seal the facial appearance of our patients. I also throw in the markers that are used to measure the face of the patient before the interfaces are applied Headgears we use these headgears to help fasten the pressures on the patient's faces in order to provide ventilation to our patients.

Assi Timah: 43:13

Oscillator so exciting. These can look very scary from at first sight because of how big they are and how much noise they make, but again, it's our best and the most gentle form of ventilation for patients who have severe lung injury or will have underdeveloped lungs, right? So if you have a patient that's requiring so much high pressures you're heating 40s of pressures on conventional ventilation it's time for you to switch it to an oscillator which provides gentle ventilation. How do we pick the settings on the ventilator on a on an oscillator? You go onto conventional ventilation. You look at what the mean airway pressure and you go between two to three above that mean airway pressure on conventional ventilation. Place it in there.

Assi Timah: 44:00

Now, delta P, which is the amputation, is all going to be based upon patient's movement on once you place them on oscillation. When it comes to frequency, frequency runs between 6 to 15, right, depending on the patient's size. In our pediatric patients, anywhere between 6 to 8 is 6 to 10 is going to be where we want to have our amplitude. Remember our hertz Sorry, our hertz. 10 is going to be where we want to have our amplitude. Remember our heart sorry, how I heard. Gotta be careful here because with our with a lower heart, we can actually make our patient jump off the bed right. So it's all going to be observation based upon our assessment. What we're worried most here, or concerned most, is going to be the main airway pressure that we are delivering to our patient.

Assi Timah: 44:45

Um, once we place our patient, oscillation and then the amplitude again is all going to be based upon what we observe and based on are we having a good chest wiggle, which indicates that we are ventilating well? And the beauty of the oscillator is we can also titrate our FR2. As you can see at the bottom of that image on my PowerPoint, there is a blender at the bottom that brings in medical room air and 100% FL2. So we can provide specific amount of FL2 and we can also deliver effective ventilation while we oscillate our patient. Any question on oscillator reasons?

Amanda Bradshaw: 45:20

Yeah, I do have a couple of questions about oscillators From a nursing again, are you able to suction this patient that's on the oscillator?

Assi Timah: 45:30

Good question. In the past it used to be like you needed a prescription to suction the patient on oscillator, and the reason being that there was an agreement on optimal airway expansion and PEEP maintenance when a patient is in oscillation. But that has since then been ruled out by many articles that have shown that there's very minimal effect when you have a patient on oscillation and you suction them. Yes, you can effectively suction them If you see water running down the circuit, if you see the patient has increased secretion and desaturating before you go ahead to increase FR2, which could also cause other issues you want to go ahead and suction that patient. There shouldn't be a problem.

Amanda Bradshaw: 46:15

Okay. Would it be necessary to clamp the ET tube before we suction that patient or at all disconnect?

Assi Timah: 46:24

No, absolutely not. You shouldn't technically have to clamp your at2 before you.

Amanda Bradshaw: 46:28

Um, you suction your patient I apologize, not before suction, but disconnecting from the um, like the disconnect before you bag the patient or anything like that no, not necessarily.

Assi Timah: 46:39

You don't really have to. Um there again, there are some beliefs out there that you would do recruit so quick when you unplug patient on the of the oscillation. Again, some providers will require that you do that but to the best of my experience at bedside in the NICU you don't have to do that now. You have some patients that are can decompensate based upon a disease process. Those one we do as much as possible. We try to. If we have to turn the patient, we have to move the patient, in which we try not to disconnect them. But if we have to for intervention purpose, maybe bump up the oxygen to 100%, let them pre-oxygenate them and then you can disconnect and do what you have to do.

Amanda Bradshaw: 47:22

Okay, you just said something about turning the patient, and so that actually leads me into another question that seems to be pretty popular with nurses is when you have a kid on an oscillator, are you able to turn that kid to prevent there used to be, like this, huge concern about moving patient and oscillator.

Assi Timah: 47:51

No, that is not a concern anymore because of the fact that the pressure oscillators are becoming a big issue, or were becoming a big issue because of the fact that this patient was left untouched the whole time when they were on oscillator left untouched the whole time when they were on oscillator. In our mode of practice in the NICU, patients are turned every shift. You know you can move them around, you can change their position and just help relieve pressure on one side, and this circuit allowed to be very flexible. There was also the belief that they have to stay very rigid and straight. That has since been overruled based upon research and papers that come out. It doesn't matter how the circuit is placed. Yeah, we try to keep this straight as possible, but they can also be flexible and would not affect patients' support in ventilation.

Amanda Bradshaw: 48:38

Okay, all right, and then I just want to kind of go back to you were talking about, you know, obviously, transitioning from the conventional vent to the oscillator and the different settings that there are. So the delta P would be similar to which setting on the oscillator?

Assi Timah: 48:59

Delta P would be similar to amplitude. Sorry, yeah, amplitude right, but it's not directly reflecting what you came up. Conventional ventilation, right, right On conventional ventilation, you can't really determine patient's chest movement with the LTP, but an oscillator you can determine it with an amputee.

Amanda Bradshaw: 49:19

Okay, and then mean airway pressure would be similar to which setting?

Assi Timah: 49:25

On conventional ventilation. We don't set a mean airway pressure. We generate it based upon patient's compliance. So you would look at the readings of the mean airway pressure of your ventilator, which often appear. I can take you back to the screen here really quick and show you. It would often appear at the top of your readings.

Michael Maymi: 49:50

Your mean airway pressure takes into account many of your ventilator settings. So it's actually a measurement from the ventilator to let you know what the mean airway pressure is. So it would account. There's an equation. I don't remember it off the top of my head. Equation. I don't remember it off the top of my head, but it does include your PEEP, your PIP, your Delta P and the number of breaths you're taking.

Amanda Bradshaw: 50:16

That all accounts for your mean airway pressure.

Assi Timah: 50:18

Okay, perfect. And I just kind of pull back this image. It's right here, you can see, it's generated right there. It's given to you Once the ventilator generates all of that based on patient compliance.

Michael Maymi: 50:28

You would read it as you read at the top of the screen of that image that I just pulled up right there and your patient would have much higher main area pressures, which would be an indication to move towards an oscillator, because you're requiring higher pressures to ventilate and oxygenate the patient. So with the oscillator you're given tinier breaths with higher pressures.

Amanda Bradshaw: 50:57

Okay, so if there are mean airway, pressure on the conventional vent is increasing. We're looking at like a worsening compliance picture.

Michael Maymi: 51:06

Absolutely, and the typical mean airway pressure is usually in the single digits, somewhere between 5, 7.

Amanda Bradshaw: 51:18

But when you start hitting 12 to 15, then you're starting to ask yourself should this patient benefit from the oscillator? Perfect Okay.

Assi Timah: 51:25

Thank you, I kind of throw in. Thank you, mr Mike, I kind of throw in jet ventilator in there, just to you know. Same thing, jet ventilation is basically just throw in. It does the same thing on the oscillator, but the beauty of it is it's more gentle than an oscillator and it's mostly used in our NICU population. It doesn't provide any oxygen, it's just solely for ventilation. So we usually attach a conventional ventilation to it in order to provide accurate oxygenation as well.

Assi Timah: 51:58

Nitric oxide threading used for our PPHN patients. Those can also be attached to a conventional ventilation. One oscillator is required for a patient that has PPH in and they're already been ventilated. That's a look of nitric oxide and that's often determined based on patient's requirement.

Assi Timah: 52:18

Chest physiotherapies we have manual ventilation, manual CPT, which you cup or hand and do a pump top, top top on patients that have since then been seized because of Kapo syndrome that some of our therapists were having. So everything has been switched to manual, which is we can use a flutter, we can use a G5, which is a pneumatic powered by electricity. We can use another pneumatic powered by PSI from the wall, from oxygen or air, medical room air. We also have a metanib, also known as IPV or IPV, which is intra-pulmonary positive pressure ventilation, as well that is used to provide airway clearance. Chest wall oscillation All of these are things that we use to help for airway clearance. I throw that in there as well. Manual CPT once was used to help for airway clearance and patient had to move from side to side to get this done.

Assi Timah: 53:20

These DNAs we use little thumpers on our smaller patients flutters and rubbickers on our larger patients which can actively participate for airway clearance. This are the pneumatics that I use and they're powered by Ida-A or oxygen to provide oscillation for airway clearance. G5, I throw all of this in there so that when you see them on your bedside you can recognize them. I throw all of this in there so that when you see them on your bedside you can recognize them. Ippv not more used, but this was a form of ventilation that was actually used. Apparently it was developed by Dr Bird, which Mr Mike maybe can testify. I think he used to work here at UF. He developed this ventilation. It was used as a ventilator and then was eventually used as airway clearance. But an upgraded one of these days is called the Metanet Airway clearance device. This is our upgraded one, metanet. That is often used both on invasive and non-invasive patients. Patients can passively breathe to help provide airway clearance with this one, or we can hook them to our conventional ventilation on two-bedded patient to provide airway clearance Good one. Or we can hook them to our conventional ventilation on today the patient to provide airway clearance good form of oscillation that help vibrate the airway from the inside and it can help clear our secretions more effectively than our external cpts, um, our vest therapies, um, also provided by hiram as well. These ones you place the patient on for at least 20 to 30 minutes. It shakes them up and then you have to encourage them to do half-cough. This is mostly used by our CF patients or any chronic lung patients that requires regular airway clearance at home, and also our neuro patients that have ineffective airway clearance due to the diaphragmatic weakness because of their disease process. This is a cough assist device. Cough assist is another respiratory equipment that helps assist patients that have diaphragmatic weakness that cannot generate negative pressure to exhale. This equipment will set the patients on a negative and positive pressure based upon patient tolerance to help them clear their airways. So it's basically called the Bayside Cough Assist, so you assist the patients to cough.

Assi Timah: 55:35

Different form of nebulizers that you often see Small volume nebulizers that develop larger particles at the upper airway. Perinep that generates smaller particles to deliver medication at the lower airway. Erygenes, much more smaller microns. They will deliver medications at the lower airway as well. Acorn and the AeroCleps as well are some of our nebulizers that you will see used at their bedside.

Assi Timah: 56:02

What kind of nebulizers can be used for what kind of medications. Arches are responsible for these. We know it Tobimicin, colistin and DNAs. We have to use our perineps because of where we want our medicine to be delivered. Trig colors these are used by trig patients to deliver oxygen and also can be used to deliver nebulizers.

Assi Timah: 56:25

Aerogen, very famous these days, used to deliver medication directly through the ventilation through the ventilators, and also can be used on non-vented patients that are getting continuous nebulizers on high flows or on face mask. Aerotrambers these are used for MDI medication delivery. That includes Simbacort, Pomacort, fluvent. Asthmatic patients use this. Copd patients use this that need a bronchodilator at the meta dose inhaler form. These just help enhance the medication delivery without losing any of the medications, and guarantees more medication delivery than our nebulizers. This is just a schedule of treatments for our CF patients and their diet caused that comes. We come to an end of our respiratory intro. I hope you enjoyed it and if you have any questions, our NICU education team is robust and here to answer your questions. Thank you for having me on your program tonight or this afternoon.

Michael Maymi: 57:37

Yeah, Ossie, it's always a pleasure to have you. You do a great job really explaining all the different devices that we use, even going over some of the ventilator modes that we use in both the ICUs and the NICU. It's always a pleasure. I'll make sure that we have your PowerPoint slide available so people can follow along with the podcast. I think it's very helpful to kind of see some of the things you were talking about while we were going through everything. And again, thank you so much for taking the time out and helping us with this.

Amanda Bradshaw: 58:07

Yeah, I appreciate you answering all the questions. Thanks so much.

Assi Timah: 58:11

Thank you so much. Thank you for having me. It's a pleasure being part of a winning team in town.

Amanda Bradshaw: 58:16

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