October 25, 2024 • 58 mins
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
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Michael Maymi (00:00):
All right, welcome to our Pediatric ICU
podcast.
My name is Michael Maymie.
I am one of the pediatric nursepractitioners on the unit and
I'm joined by Patricia Beck,Christina Carr, who are the
management team, along withAmanda and Ashley, our education
folks.
And today, our guest speaker isAsi.
(00:21):
He's one of our amazingrespiratory therapists, and has
been here for a very long timeworking in our pediatric ICU,
our pediatric floors and theneonatal ICU.
Our topic today is going to beon various different airway
devices that we can use in ourpediatric population, and I'm
going to go ahead and let Dr.
Well, excuse me, I'll call himDr, but I'll let Assi go ahead
(00:44):
and introduce himself and lethim go ahead with his
presentation.
Assi Timah (00:49):
Hey guys, my name is Assi Tima and thank you, mike,
for giving this opportunity, forthis opportunity to actually
share my awareness around therespiratory equipment and how
it's interacted in our area ofpractice.
I know it can be veryoverwhelming to people sometimes
(01:10):
when they come in contact withthis equipment, especially our
newer nurses and residents andas well as respiratory
therapists, despite seeing themin schools.
It could also be very, veryoverwhelming.
So after going through schooland then taking a job at UF
Health, which gave me anopportunity to see many retro
equipment and also put hands onthem and make a great experience
(01:36):
with it, I took on to theadventure of sharing the minimum
knowledge that I've gotten sofar with the people that are
coming behind me.
So this PowerPoint kind ofgives a very big picture of the
things you can see at thebedside in various facilities
(01:59):
and in different units to helpease your knowledge about it.
When people talk about them onrounds, if you've never seen
them, I give credits at the endof this PowerPoint of some
people's pictures that I've usedand some of the pictures I've
taken from bedside exposures aswell.
So I would jump right into it.
(02:20):
I've been around this field forclose to 17 years now I work in
this hospital.
Next year is going to be my 15years, so 14 and plus months and
, as Mike has said, I have theopportunity to work all of these
units.
Okay, I'll jump right on it.
It says intro to respiratory.
Feel free to ask any questionsas I go through this PowerPoint
(02:50):
by RCT team, of course, which isme.
My areas of practice, the past14 have years the shanes, pete's
, pete's, edp ICU, nikhilcurrently now, which I spend
most of my time.
Welcome to the Gator nation, ofcourse, big football nation and
big, big educated community.
You have helped.
(03:11):
So, right off the wall to ourpatients, you can see the
various size of power points offlow meters that we use.
You have the low flows in theregular flow meters that runs
from 1 liter to 15 liters, whichwe're used to back our patients
(03:32):
.
The biggest thing about meshowing this in pictures is
because it's very easy toconfuse them when there's an
emergency and the lines areplucked and the bag is plucked
in somewhere and you arrived andthe bag in the patient.
The bag is great, great chestrise, but the patient's
saturation is not going up.
As a team leader, you want torun your view from the patient
(03:56):
all the way to the wall, to makesure that we are plucked onto
oxygen, not medical air.
So it's very important for usas a team leader or as a
participant in a cold situation,the emergency situation, to run
right onto the wall and makesure that we are plugged into
the right outlet.
Now another thing to payattention is sometimes you can
(04:16):
have the wrong the low flowmeter plugged in there.
The Christmas tree feeds theuniverse, so it can also feed in
a low flow meter and mightthink that, um, you have the
right size of a flow meter intothe wall.
No, um, so you have to verifyand make sure the right side is
the one to 15 liters that caneffectively inflate our amber
bags or our ventilator back tohelp support ventilation in
(04:38):
terms of rescue.
So these two pictures, um,would help you think twice and
to verify and make sure that weare hooked up to the right size
flow meters to the wallRun-through flow meters,
christmas trees.
We used to have differentiationin Christmas trees.
It used to be the yellow onewhich was hooked up to their air
(05:02):
flow airflow meter and thegreen one to the oxygen, but now
we have a universal one whichis just clear, which means it
could be hooked up to any ofthem, either airflow meters or
oxygen.
So pay attention, making surethat again, that flow meter is
the right one and the back ishooked up to the correct one in
terms of when we come to rescue.
(05:22):
So Christmas trees are veryuniversal these days in nature.
Nasal cannula Very easy toconfuse with high-flow nasal
cannulas and all the nasalcannulas that have been used at
the bedside.
So this nasal cannula, which isthe lowest, lowest flow that we
use, only can carry up to fiveliters of flow.
(05:44):
Once you go past five liters offlow, you need to convert it to
a high flow nasal cannula whichprovides flow and high oxygen
as well High oxygen as well aslimited oxygen depending on the
disease process of the patient.
These nasal cannulas, once youstart running them, especially
in a pediatric world, we reallyencourage people to hook up a
(06:04):
humidifier bottle, like you seeon the side of it, and be
careful and make sure that thishumidifier bottle at the top of
it is punctured before youattach it to the patient.
If not, this thing would blowup and make a mess.
It would not hurt a patient,but it would make a mess in the
room.
You can hook them up withoutthe humidifier bottle to provide
(06:29):
humidity, but it may also causedryness and bleeding to our
patient's nostrils.
So it's very important to hookup a humidifier bottle for our
neonatal and our pediatric.
A venturi mask and a face mask.
A face mask is a basic maskthat can actually be adapted to
(06:51):
use to any patient that isgetting a nebulizer but at the
same time, more specifically, weuse it for a venturi mask, for
venturi oxygen patients.
These venturi patients wouldrun between 24 to 60 percent FL2
.
And the differences on how topick on these is clearly know
(07:13):
that there is color-coded.
It helps you not to confusewhen you go to pick up the
amount of oxygen that is neededto deliver to a specific patient
based upon disease processagain.
So with a venturi mask, whatmakes even though they're all
uniform, what makes thedifference in oxygen is the
amount of air that is entrainedwhen delivering the flow.
(07:34):
As you can see the little jetoffice that at the bottom of the
mask.
This is how much flow isentrained.
The smaller the jet office, thehigher the oxygen, which means
that they're entraining lessroom air.
If you look at the one that isrun at 15 liters, which is a
green one, signifying that we'regetting the most of our oxygen.
(07:56):
So the amount of air that isentrained during this process is
very minimal because of howmuch smaller air is being
entrained during the process.
Of course, at 15 liters, weknow that our patient's flow
(08:20):
that is coming to the patient'smass is coming very, very fast,
giving no time for any kind ofexternal flow to come in, which
is room air, giving no time forany kind of external flow to
come in, which is room air.
Non-rebreather setups Anon-rebreather, we know it's.
We say it's 100%, but researchhas proven that it's basically
just 80%, because you can't havea full seal onto the patient
(08:42):
face with a face mask.
So it's anywhere between 60 to100 um.
So these ones are mostly usedduring emergency, emergency
situations or burn patients thatcome in or a patient that has a
pneumothorax, so you put them anon-rebreather.
Now, setting up anon-rebreather, you plug into
the flow meter, turn the flowmeter to flush, which is 15
(09:05):
liters, and then you put a seal.
You put your finger at the topinside the one-way valve that
connects the bag, the reservoir,onto the patient's face mask.
Make sure the bag is inflatedtotally before you put on your
patient.
(09:29):
These bags do not require ahumidifier once the patient is
hooked up to it.
We've had people in the pasttry to hook up a humidifier.
No, it would not work, it wouldblow up the humidifier borders.
These masks are supposed to behooked up dry.
For emergency purposes andreasons of hooking up patients
to non-rebreather.
We do not need to worry abouthumidification, we need to
rescue the patient and then,once they're stable, then we can
(09:51):
probably set them up on thenext step that they can get
humidification.
You see, on this PowerPoint Idid include simple masks which
run from 40% to 60%, which is alittle bit higher than the venti
mask we just showed.
See, the nasal cannula runsfrom 24% to 44%, starting at one
liter, which is considered 24%,and it goes by increments of
(10:12):
four every liter of flow thatyou 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 allthe way to 44%, which is going
to be five liters.
Nasal cannula Erythritolers thesame weekend it does have a jet
office as well in theirairstrip tracheolers, which I'm
going to show in a minute here.
(10:32):
But let's switch it to highflow nasal cannula.
Once your nasal cannulaconventional nasal cannula was
run from 1 liter to 4 liters orto 5 liters, at that point the
patients need a little bit ofhigher flow.
So we jump from five liters orsix liters.
Some people would push it tosix liters.
We try to keep it at fourliters.
(10:56):
Once you hit five liters wewould go ahead and switch into a
high flow nasal cannula whichdoes not only provide you more
flow but it can also specify FR2from 21% to 100%.
So some of our hyperplastic lowfront patient which probably
needs sometimes just the flow,not the amount of oxygen or our
(11:24):
N, but getting three, four, fiveliters of flow just to help
ventilate them right.
So, um, this powerpoint showsthe setup of a high flow nasal
cannula which has two incrementports.
You have the medical room airand have oxygen that comes on
board in.
Fortunately for this powerpoint, um, our tubings don't really
(11:46):
match up with the yellow and thegreen which are universal
colors of choice for thehospital labor.
This one was kind of a labchoice of high flow.
But again, then you can see thehumidifier at the bottom that
we can actually titrate theoxygen, the heating system to
(12:07):
provide the optimal temperaturethat is needed to a patient to
keep them comfortable as well ashumidify the flow that's going
to the patient.
For the choices of ourinterfaces for our patients.
This is all going to be patientdependence.
A lot of times some patientshave very narrow airways and so
we would use the micropremiesfor the nasal interface and
(12:33):
sometimes we use the largest,depending on what the
requirements are for ourpatients.
So we do have devices that helpus measure them before we place
them on.
So we do have devices that helpus measure them before we place
them on.
As you work in the field, youwould notice that some patients
(12:55):
they could be micropremium butneed a medium or large mass
based upon the size of theirnasal passage High flow still on
our PowerPoint, different onecalled the air flow used on our
pediatric patients Once you hit25, 20 liters in both we want to
switch to air flow setups whichgives up to 60 liters of flow,
(13:16):
which can also be used in adultcare.
So our pediatric patients' highflow usually runs all the way
to 25 liters.
But once we go past that literflow in the smaller interface we
switch them to the averagephase which provide uh, which
can sustain higher flow ofoxygen that comes through this
(13:38):
I'll see before you keep going.
Amanda Bradshaw (13:40):
can I ask a question?
This is amanda.
Hey, I'm the night shiftnursing educator here in the
PICU.
So I just have a couple ofquestions about the high flow,
specifically From a nurse'sperspective.
If they are noticing that theirpatient maybe is having some
increased work of breathing,that sort of thing, but their
stats are still appropriate,what are some things that that
(14:01):
nurse could do to helptroubleshoot 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 intorespiratory issues.
Sometimes, when you look atthose flow, the flow could be.
It could be a flow issuewhereby the patient is getting
so much flow that they're havinga hard time breathing again.
Resistance of that flow.
So you may want to turn downthe flow for a little bit and
(14:29):
see if that improves their workof breathing.
But if this increased work ofbreathing is coupled with
labored breathing, which meansthat they're not only tachypneic
but they're also retracting andthey are unable to communicate
with you, then they probablyneed a little bit more flow and
maybe other interventions fromproviders to help relax them to
(14:51):
tolerate the flow.
So too much of flow could be aproblem.
Too much of flow can also be asolution.
So it's all going to be patientdependent, based upon your
assessment.
So you're looking at threethings labor, breathing, the
consciousness of the patient towork with the device and also
how much flow are we actuallydelivering to that patient.
(15:13):
Does that answer your question?
Amanda Bradshaw (15:14):
Yes, that does.
So the flow you would kind ofthat 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 strongpaper out there that proves that
high flow provides a level ofPEEP.
We can assess this from theresult that we get by placing
the patients on x-rayimprovement and oxygenation,
which means that we definitelyrecreated some alveoli.
It's not a close PEEP.
Peak in expiratory pressure,which is a definition of PEEP,
(15:47):
can only be measured end-to-end.
So it has to be a closed-loopsystem to actually measure PEEP.
So with high flow it's not aclosed loop.
The patient breathes very, verypassively 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
(16:09):
that PEEP and extra pressure.
So if I Dr Mimi, he can reallyclarify that even more.
Michael Maymi (16:15):
Yeah, I think there's theoretical thoughts
that it may offer about two tofour centimeters of water.
But you're correct, it is veryhard to measure it because if
the child is not breathingthrough their nose, if you don't
have a proper fitting nasalcannula and their mouth is open
and they're crying, they'relosing any pressure that you're
providing.
So, yeah, in theory there issome thoughts that there are
(16:39):
about two to four centimeters,but, like you mentioned, it's
not a closed loop system andyou're not going to get an
accurate reading of what you'reproviding.
Amanda Bradshaw (16:46):
Thanks, amanda.
Assi Timah (16:49):
Thanks, amanda.
So I would proceed in a jumpinto RAM Candler, which, when we
totally exert our effort withhigh flow nasal Candler, we
would jump onto the RAM Candler.
So thank you, dr Mike.
Mamie, you know everyonelistening right here Mike has
(17:10):
been a very strong mentor for mesince I started working at UF
Health and has built a lot ofthe person that I've become
today when it comes to myintervention in respiratory care
.
So I take his advice and hisguidance very, very important
for me.
So high flow when we feel highflow totally.
(17:33):
Our next device we would like tooften try is Ram Canada.
So in the past, before RamCanada was introduced at UF
Health, we used to use CPAP.
What we run into CPAP is thefact that it was hard to find
the right and correct interfacethat would totally seal on our
small faces right, our smallpeople's faces to actually
(17:54):
provide them the amount ofsupport 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 ventilatorsand all those forms of
(18:21):
ventilators that we have in thisstate to actually deliver RAM
Canada support to our patientsand that guarantees better
feeding on their nasal passagesand also provide them the
support that is needed for ourpatients.
Again, the feeding for ourpatient's nasal for REM cannula
is all going to bepatient-dependent, based upon
their nasal passages.
(18:41):
As you can see right, they runfrom neonatal micropremium all
the way to infant.
So we also have the largerinfant cannulas which can
sometimes be used in the NICU,depending on the patient's
requirement and their patientsinterface.
(19:03):
I threw in the trichotopes inthere.
They are there.
It's not something that nursesand artists intervene directly.
These are some things that ourresidents often help set up, but
it's very important to knowwhere to look at your ET tube
markers.
Sometimes you have an ET tubepatient that's intubated.
You come on your ship and thispatient's tube was cut because
(19:27):
it was long and causing a lot ofair trapping and so attending
providers might require also cutthat tube.
We often encourage that if anarch is going to cut an ET tube
to reduce the size, helpventilation.
Please encourage them to tapethat side, that piece, to the
vent so that we can recognizewhat side tube the patient has,
(19:50):
because once it's cut, the sizeof the tube is usually very
close to the connection to thevent area to the teepee area, so
make sure they keep it to thebedside.
The blade is, and all the formsof airways are often by the
bedside, so all the size of theblade is documented into our
chart system so you can alwaysreview to know what sort of
(20:12):
blades were used to intubatethat patient.
Tracheostomy same process as theET tube, often picked by ENT.
Again, we have them.
If you have a patient that hasa tracheostomy.
Very important things over thebedside is an obturator at the
bedside, a size up and a sizedown Things that we need just in
case we lose our airway.
(20:32):
We should be able to feed sizedown because of how rapidly the
cartilage and the stomach canclose.
And if we can't feed this, thesize down, we make sure that our
obturator is placed in there tomaintain that airway, to avoid
a larger incision.
If ENT has to reinstate the um,trick your stomach back into
(20:53):
the into space, back onto theoxygen blender, which is also
what we use at our high flownasal candler.
So this blender is the reason Ithrow this in.
And now we have our color codedon this top one, which is the
blue and or the, the green andthe yellow.
So very important Color codingsuper important because that
(21:16):
helps us not to make mistakes.
Right?
You can see that our blendersthat we use these blenders are
used even on the oscillators.
Right?
This is how we are able to mixup oxygen and deliver a specific
amount of FIO2 to our patientswhile also providing them flow
that is needed for ventilation.
Some of these high flows havetwo flow meters.
(21:38):
Some people usually, you knowyou can find two flow meters and
you ask yourself why do we havetwo flow meters?
With some of our high flowsdesigned, they require those
flow meters to runsimultaneously at a time to
actually entrain flow to providespecific FRO2?
How do you know that?
It's absolutely written to theside of the blender, you would
(21:59):
see.
It would indicate that thisblender requires both flow
meters to run at a time.
So, with that said, how do yourun both of them at the time?
That doesn't mean that bothflows have to be going to the
patient.
You can hook up your AMBU backto the other flow meter and just
hang the back next to it.
You can run it at anywherebetween five to six liters of
flow just to receive theaccurate amount of FR2.
(22:23):
If not, your FR2 would not readaccurate.
You may think you're delivering50%, meanwhile you're only
delivering 25% of FR2.
That's why I throw this blenderthing in there.
Amanda Bradshaw (22:36):
Can I ask another question real quick?
This is Amanda again.
Okay, so what is the maximumhigh flow setting that the
med-surg, like the pediatricmed-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 thehighest amount of FR2 that the
METSIS flow can actually carryis 50%.
When you go past 50% and abovetwo per kilo, usually these
patients are required for closeattention, close attention, and
(23:15):
that's when we usually call ourPICU team to come and assess and
see if they can transport themup into the PICU and where they
can have close attention at thathigh FL2.
Amanda Bradshaw (23:23):
Okay, and then what would be an ideal flow for
a pediatric patient, and maybeeven when would be an ideal flow
to transition them to a regularlow 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 litershigh flow, when you start
dropping past five liters, thetubing compliance of the high
flow would not provide enoughresistance to deliver the amount
(23:58):
of flow that is required bythat patient right.
So at five liters you want tostart thinking of confining them
to a conventional laser can.
Now that's at a pediatric level.
If you go a little lower in theNICU they can go up to one
liter, two liters, but at fiveliters you can comfortably
(24:19):
transition that patient to aconventional nasal cannula.
Amanda Bradshaw (24:22):
Okay, all right , yeah, and then is there an
ideal flow for pediatricpatients to be on.
Assi Timah (24:29):
To start on, Now you're going to have to pay
attention to the work ofbreathing of this patient, right
?
So okay, um, if it is a hypoxicissue, and they can probably
just do fine with two litersnasocam because they're needing
oxygen, um, which is equivalentto 28, but if it is a ventilated
issue, you probably, uh, theyou, you go to five liters
(24:52):
straight and simultaneously.
If that is not working, thenyou come for them straight to
high flow nasal cannula, whichyou have more rooms to work with
at that point in time, whetherto 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 themstraight up on five liters, 25
(25:18):
to 30%, and then, in thatcircumstances, they're getting a
heated humidifier and it'scomfortable, right?
People often call that acomfort flow.
Because of the andhumidification this patient is
getting, we are able to targetthe amount of temperature and
the amount of flow and theamount of FR2.
(25:39):
So at that point we'reproviding every comfort that is
needed for breathing for thepatient.
Amanda Bradshaw (25:45):
Just kind of titrate up according to what
their work of breathing lookslike.
Assi Timah (25:50):
Yes, ma'am.
Now that comes to titration isalso going to be based on.
One of the questions people askis how do I know that this is
optimal flow for this patient?
So you listen to the breathsounds.
If you can hear the flowbilateral, which is stethoscope
it means that you are deliveringan optimized flow and you would
also see that the patient iscomfortable.
Amanda Bradshaw (26:09):
Okay, great.
Assi Timah (26:10):
Thank you, you're very welcome.
V60 ventilator I threw them allbehind the Philips this is a
respiratory ventilator that ismostly used for a patient that
comes from home and they arechronic Sometimes.
The Philips ventilator theycome with it from home and so
this is just to provide themCPAP continue CPAP without any
oxygen blending.
The V60 ventilators we use itsometimes without any oxygen
(26:32):
blending.
The V60 ventilators we use itsometimes for our patients that
are larger than 23 kilos on ourfloors, same as the respirator.
These are all SEPA ventilatorsthat provide continued positive
pressure ventilation for ourpatients.
The LRTV ventilators are homeventilators.
You would often see them in theTrilogy 100 at our bedside for
(26:54):
our patients that are beingprepped to send home.
These ventilators have highcompensation for patients that
are going out on a trek.
Of course, most of them aregoing home on treks, right, so
they compensate for leaks andthey're easily used by parents
at home.
They are quick to set up andquick they they have longer
(27:16):
lasting batteries up to somehowup to five hours of um battery
and you can also blend oxygen.
So I throw this in here justfor your vision purpose.
So when you hear about the v60and the trilogy, this is how
they look like.
Our kids are very versed withthis.
We all train and um in any uh.
Their reps are often available24-7 to help us if needed.
(27:36):
I threw in the ventilator the840 ventilators our servo ends
that are also used in ourfacilities here from our bedside
.
These ventilators the servoends are the most updated system
from the 840s provide accuratecompensation.
You can also deliver nebulizerthrough these ventilators
(27:58):
without attaching any externalequipment that actually impedes
the tubing compliance and theflow to the patient.
You can also deliver NAVAventilation through these new
servo ends.
You can also deliver NAVAventilation through this new
servo end.
So it's a great form ofventilation that you can use to
(28:19):
provide fluid to our patients.
I kind of talked about the setupon here the expiratory filters
versus inspiratory filters.
Important to recognize thisbecause these filters cannot be
interchanged.
Right, the expiratory filtersis always going to be green and
it has water traps in the bottom.
The expiratory filters, on theother hand, you would notice
(28:39):
that it's hooked up to the bluecircuit, right, blue for oxygen.
So just make sure that when youlook at your vent they are
correctly set up, becausemistakes can occur.
You have your heater thatattach on our ventilator
patients as well.
Then you have differentventilator setup that I use or
(29:03):
the vent settings that I use.
Mostly in our pediatric setupyou have APRV, prvc.
This is just again things thatI throw in there just in case
people want to understand, basedupon whatever facilities you're
working at, what vent settingsare used.
So at our facility here at UFHealth we mostly use pressure
control ventilation, prvc andother terms called VC plus as
(29:25):
well.
What is the difference betweenpressure 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 betweenPRVC and pressure control is the
delta P that is applied or setin the pressure control Mean Y
(29:50):
for PRVC, which is VC plus, isthe volume.
So the difference between thesetwo is volume and delta p, but
every single one of this modehas respiratory set, high time
pressure support, peep and fr2.
Now, with that said, pressurecontrol ventilation, you set
(30:12):
delta P to influence flow right,and so you cap the peak flow
that the patient can get.
Meanwhile, in pressureregulated volume control, you
control the tidal volume, whichis usually 6 to 8 per kilo in
our pediatric environment.
So you set the tidal volume,and the ventilator regulate the
(30:36):
pressure based upon thepatient's demand.
Right, we could go into detailswith these If you have any
questions about this, pressurecontrol, ventilation and
pressure PRVC.
If Mr Mike has any addition tothis, I'll be glad for him to
(30:57):
enlighten us more on this.
Amanda Bradshaw (30:58):
I do have a question about Delta P.
Could you explain a little bitmore 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 thepatient so um, an example uh,
kind of a funny example to putis it's like, it's almost like
you are switching from a littlecorvette to a truck, right?
So, and go by increments.
(31:28):
I go from a corvette.
If I wanted to increase thedelta p, let's say I want to
transport more stuff, I just goahead and take a bigger car.
It takes more load.
So delta P goes by incrementbased upon the need to ventilate
a patient.
So the higher the delta P, themore 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 lookat delta P is the change in
pressure right?
So it's actually the amount ofadditional pressure above PEEP
that you want to hit a higherpeak inspiratory pressure to
ensure that you open the lungsand provide your ventilation
(32:14):
right.
So, in a mode that, when you'retalking about the amount of
pressure given, you think aboutPEEP, that's the bottom pressure
to allow the alveoli to stayopen, your delta P is that
change in pressure that you'regoing 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 clearunderstanding in terms of the
change in pressure versus thepeak pressure.
So yeah, so, Amanda, again it'speak versus delta.
Peak was to PIP.
Amanda Bradshaw (32:52):
Okay.
Assi Timah (32:53):
Perfect NAVA.
So NAVA is?
This is very interestingbecause this is coming to us
very, very new and it has been arevolution in healthcare in
terms of helping supportbreeding for mostly our neonatal
(33:15):
infants.
And now you guys are going tobe seeing it very soon here in
the PQ.
I'm just going to kind of youknow going to have another topic
soon here about NAVR, but I'mjust going to kind of highlight
what it actually is.
It's a neuroadjusted ventilatorassist, which means that it
helps support patients on theirbreathing, but it allows the
(33:40):
patient to actually determinethe peak pressures, allow the
patient to determine when totrigger a flow, allow the
patient to actually pull in moreflow if required, based upon
their compliance right.
So, um, how do we set up anapper?
It's a catheter just like yourfeeding tube that you place in.
Often when we, when we placethem and the patient of the
feeding tube, we usually attachthem at the same level.
(34:03):
Now there is electrical in um,electrical signals that are
between, or electrical how doyou call it design?
The way it's designed has fourto five electrical signals at
the bottom of the navar that youplace them right at the level
of the diaphragm and thesesignals would pick up the
(34:26):
diaphragmatic movement, based onelectrical movement of the
diaphragm, and deliver pressureto the patient based upon the
patient's trigger right.
So a NAVR settings of high.
We set them based uponpatient's requirement.
Now, things that we indicatethat the patient needs NAVR.
If the patient is breathingreally, really fast, with
(34:46):
patients breathing shallow,pulling low or tighter volumes,
we would put them on NAVR.
It would help them overcome.
Or if they're going apneicright, it would help them
overcome their work of breathingand ease of breathing.
It will help them synchronizetheir breathing.
If they're breathing too fast,If they're breathing shallow, it
will help augment the tidalvolume because of the fact that
(35:09):
it would sense this pressure allthe way to the level of the
diaphragm, not just at the levelof the floor as mechanical
ventilation would usuallyprovide.
So we'll have a whole topic onthis and we can talk about how
it's set up and how to pick up acatheter and what else those
catheters can also do.
So just look at it as a form ofventilation that is going to
help ease ventilation and alsogive a lot of power to the
(35:30):
patient, rather than us takingover as a mechanical ventilation
, which we usually do withpressure control and PRVC.
Michael Maymi (35:39):
Yeah, the thing that I like about NAVA that's
fascinating is that as the brainsends the signal to the
diaphragm, the NAVA sensors pickthat up and even if the
patient's not strong enough togenerate that breath, the
ventilator can sense that thepatient wants to take a breath.
It can synchronize with thepatient and we can use NAVA in
(36:01):
both as an invasive mode wherethe patient's intubated, or you
can also use it as anon-invasive mode.
So it really kind of goes intodeeper signaling right.
So if the brain sends theneurotransmission to the
diaphragm and the diaphragm says, hey, there's electrical
activity to move the diaphragm,let's do it right, and it makes
(36:24):
it easier and more comfortablefor the patient.
Amanda Bradshaw (36:26):
So it's more of like a supplemental type.
It's supplementing what they'realready triggering a
supplemental type.
Michael Maymi (36:33):
It's supplementing what they're
already triggering.
No, it's kind of like on ourventilator.
You know we have, uh, thetrigger right and that trigger
can be flow, pressure or volume.
Um, the trigger is actually thenava right.
It's the actual electricalsignal from the brain to the
diaphragm that then tells theventilator okay, we need.
We need to help support thisbreath or initiate a breath,
because it's been too long sincethe last one.
Amanda Bradshaw (36:55):
I see Okay.
Assi Timah (36:59):
Thank you, mr Mike.
I threw in CPAP in therecontinuous positive airway
pressure.
So the reason I threw in CPAPis because of the fact that most
often people would we wouldoften confuse between continuous
positive airway pressure inrelation to PEEP, which is peak
(37:19):
in exposure pressure twodifferent things right.
So you provide a CPAP at.
It's just a flow that got tobreathe against resistance
Meanwhile, the peak in pressureand we talked about it earlier
that you can have to measure itfrom end to end based on a
closed loop system With CPAP.
It's flow that just helps youventilate, helps our patients
ventilate and help them overcomethe work of breathing either
(37:41):
obstruction or resistance, basedupon patient's breathing effort
.
I kind of throw in some faceview of some of the ventilators,
images from a bedside.
As you can see, there's a trueventilator on the patient.
There's no patient's name oranything like that.
(38:02):
It's just an image thatreflects how they're doing on a
ventilator.
That's the patient inpressure-controlled ventilation.
So you can see on that firstimage right there in
pressure-controlled controlventilation we set up delta p
and we set up the peep and inturn the peak pressure is delta
p um.
It gives us the peak pressuresequals to our delta p plus our
(38:25):
peak um.
As you can read in on oursecond 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 ofour image on that screen.
Volume-controlled ventilationAgain another image from a
(38:47):
patient at PRVC on the bedside.
Just images just to show youhow it will reflect my
ventilation.
Now I throw in another form ofentire measurement here CO2
measurement from a sub-Q point.
It's called transcutaneousentire monitor.
Transcutaneous in tightermonitor.
Transcutaneous is a system thatuses electrical again
(39:17):
electrical impulses to measurethe CO2 at the level of the
patient's skin.
So we have electrodes that areplaced on that patient using
stickers and it heats up thespot where it is placed to
measure CO2.
This is usually used in thecase whereby the patient is
probably intubated in a lot oflines and has no access.
It's another form of way tomeasure CO2 and window
ventilator.
From here you can run intoissues whereby if the patient is
(39:39):
adamant they have so much fluidon board.
The reading could really beinaccurate.
Sometimes you have patientsburn patients the skin.
These electrodes cannot stickor the stickers can't stick on
the patient to use electrodes toread the CO2.
So we run into those kinds ofissues, right so, and there you
could run into irregularities,but we're working on getting new
(40:01):
equipment that can that aremore effective, more accurate.
We reduce our place in lines onour patients and monitoring CO2
and wind the ventilator.
This is how the place.
We have little.
We have gels that are placedinto those stickers to make sure
that they don't burn thepatient's skin and they have to
be moved around every four hoursto avoid skin injury as well.
(40:28):
Conventionally, in tidalmeasures, of course, you have
the one that you can actuallydeliver oxygen and monitor
patients on our non-invasivepatients, when we're doing a
procedure, this is often used byanesthesia and our CICU
critical care team when they'redoing unconscious sedation in
(40:49):
the patient that doesn't requireintubation.
On the left side you have theone that is a conventional that
is often used at the end of ourET tubes to monitor intiters
when the patients are intubated.
Any questions on that?
Looking good Again, this isanother patient that is on his
(41:12):
spontaneous breathing.
The ventilator will look allyellow and red waveform, which
shows that there is no assistedbreath from a ventilator.
The ventilator, the patient, isdoing all the work.
All we said was the pressuresupport and the patient is
probably intubated and gettingsupport without any assisted
breaths NAVR, navr.
(41:34):
So when you have a patient thatis NAVR, you would see there's
three on this ventilator screen.
You would see that the patientwhere you would read the nav is
going to be all the way to thebottom right.
Um, it's going to be thewaveform that is purple and you
can see the edi peaks on the.
(41:54):
That is reading at 13.9.
The edi mean is 4.7.
Again, we'll have anotherlecture 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 isour nav and this is how it's set
(42:16):
up.
Um, again, I throw this imageshere for several reasons.
Mr mike already went throughthe whole details but we will
come back onto it whenever timeis given.
These are the differentinterfaces that are used at our
NICU level and also usedsometimes at PIC for smaller
patients interfaces to delivernon-invasive ventilation.
(42:37):
You can use a nasal prongs andyou can also use a mask.
We try to alternate them everysix hours to prevent facial
injuries because of the factthat they're a good sealing
masks that can provide pressureon the patient, but also they
can cause injury because of howmuch strength is used to seal
the facial appearance of ourpatients.
I also throw in the markersthat are used to measure the
(43:00):
face of the patient before theinterfaces are applied Headgears
we use these headgears to helpfasten the pressures on the
patient's faces in order toprovide ventilation to our
patients.
Oscillator so exciting.
These can look very scary fromat first sight because of how
(43:21):
big they are and how much noisethey make, but again, it's our
best and the most gentle form ofventilation for patients who
have severe lung injury or willhave underdeveloped lungs, right
?
So if you have a patient that'srequiring so much high
pressures you're heating 40s ofpressures on conventional
ventilation it's time for you toswitch it to an oscillator
which provides gentleventilation.
How do we pick the settings onthe ventilator on a on an
(43:45):
oscillator?
You go onto conventionalventilation.
You look at what the meanairway pressure and you go
between two to three above thatmean airway pressure on
conventional ventilation.
Place it in there.
Now, delta P, which is theamputation, is all going to be
based upon patient's movement ononce you place them on
(44:08):
oscillation.
When it comes to frequency,frequency runs between 6 to 15,
right, depending on thepatient's size.
In our pediatric patients,anywhere between 6 to 8 is 6 to
10 is going to be where we wantto have our amplitude.
Remember our hertz Sorry, ourhertz.
(44:29):
10 is going to be where we wantto have our amplitude.
Remember our heart sorry, how Iheard.
Gotta be careful here becausewith our with a lower heart, we
can actually make our patientjump off the bed right.
So it's all going to beobservation based upon our
assessment.
What we're worried most here,or concerned most, is going to
be the main airway pressure thatwe are delivering to our
patient.
Um, once we place our patient,oscillation and then the
amplitude again is all going tobe based upon what we observe
(44:52):
and based on are we having agood chest wiggle, which
indicates that we areventilating well?
And the beauty of theoscillator is we can also
titrate our FR2.
As you can see at the bottom ofthat image on my PowerPoint,
there is a blender at the bottomthat brings in medical room air
and 100% FL2.
So we can provide specificamount of FL2 and we can also
(45:14):
deliver effective ventilationwhile we oscillate our patient.
Any question on oscillatorreasons?
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 likeyou needed a prescription to
suction the patient onoscillator, and the reason being
that there was an agreement onoptimal airway expansion and
PEEP maintenance when a patientis in oscillation.
But that has since then beenruled out by many articles that
(45:53):
have shown that there's veryminimal effect when you have a
patient on oscillation and yousuction them.
Yes, you can effectivelysuction them If you see water
running down the circuit, if yousee the patient has increased
secretion and desaturatingbefore you go ahead to increase
FR2, which could also causeother 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 clampthe ET tube before we suction
that patient or at alldisconnect?
Assi Timah (46:24):
No, absolutely not.
You shouldn't technically haveto clamp your at2 before you.
Amanda Bradshaw (46:28):
Um, you suction your patient I apologize, not
before suction, butdisconnecting from the um, like
the disconnect before you bagthe patient or anything like
that no, not necessarily.
Assi Timah (46:39):
You don't really have to.
Um there again, there are somebeliefs out there that you would
do recruit so quick when youunplug patient on the of the
oscillation.
Again, some providers willrequire that you do that but to
the best of my experience atbedside in the NICU you don't
have to do that now.
You have some patients that arecan decompensate based upon a
(47:03):
disease process.
Those one we do as much aspossible.
We try to.
If we have to turn the patient,we have to move the patient, in
which we try not to disconnectthem.
But if we have to forintervention purpose, maybe bump
up the oxygen to 100%, let thempre-oxygenate them and then you
can disconnect and do what youhave to do.
Amanda Bradshaw (47:22):
Okay, you just said something about turning the
patient, and so that actuallyleads me into another question
that seems to be pretty popularwith nurses is when you have a
kid on an oscillator, are youable 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 pressureoscillators are becoming a big
issue, or were becoming a bigissue because of the fact that
this patient was left untouchedthe whole time when they were on
oscillator left untouched thewhole time when they were on
oscillator.
In our mode of practice in theNICU, patients are turned every
shift.
(48:11):
You know you can move themaround, you can change their
position and just help relievepressure on one side, and this
circuit allowed to be veryflexible.
There was also the belief thatthey have to stay very rigid and
straight.
That has since been overruledbased upon research and papers
that come out.
It doesn't matter how thecircuit is placed.
Yeah, we try to keep thisstraight as possible, but they
(48:32):
can also be flexible and wouldnot 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 talkingabout, you know, obviously,
transitioning from theconventional vent to the
oscillator and the differentsettings that there are.
So the delta P would be similarto 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 reallydetermine patient's chest
movement with the LTP, but anoscillator 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 airwaypressure.
We generate it based uponpatient's compliance.
So you would look at thereadings of the mean airway
pressure of your ventilator,which often appear.
I can take you back to thescreen here really quick and
(49:45):
show you.
It would often appear at thetop of your readings.
Michael Maymi (49:50):
Your mean airway pressure takes into account many
of your ventilator settings.
So it's actually a measurementfrom the ventilator to let you
know what the mean airwaypressure is.
So it would account.
There's an equation.
I don't remember it off the topof my head.
Equation.
I don't remember it off the topof my head, but it does include
your PEEP, your PIP, your DeltaP and the number of breaths
(50:16):
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 backthis image.
It's right here, you can see,it's generated right there.
It's given to you Once theventilator 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 justpulled up right there and your
patient would have much highermain area pressures, which would
be an indication to movetowards an oscillator, because
you're requiring higherpressures to ventilate and
(50:49):
oxygenate the patient.
So with the oscillator you'regiven tinier breaths with higher
pressures.
Amanda Bradshaw (50:57):
Okay, so if there are mean airway, pressure
on the conventional vent isincreasing.
We're looking at like aworsening 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 yourselfshould 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 ofthrow in jet ventilator in there
, just to you know.
Same thing, jet ventilation isbasically just throw in.
It does the same thing on theoscillator, but the beauty of it
is it's more gentle than anoscillator and it's mostly used
(51:45):
in our NICU population.
It doesn't provide any oxygen,it's just solely for ventilation
.
So we usually attach aconventional ventilation to it
in order to provide accurateoxygenation as well.
Nitric oxide threading used forour PPHN patients.
Those can also be attached to aconventional ventilation.
(52:06):
One oscillator is required fora patient that has PPH in and
they're already been ventilated.
That's a look of nitric oxideand that's often determined
based on patient's requirement.
Chest physiotherapies we havemanual ventilation, manual CPT,
which you cup or hand and do apump top, top top on patients
(52:27):
that have since then been seizedbecause of Kapo syndrome that
some of our therapists werehaving.
So everything has been switchedto manual, which is we can use
a flutter, we can use a G5,which is a pneumatic powered by
electricity.
We can use another pneumaticpowered by PSI from the wall,
from oxygen or air, medical roomair.
(52:51):
We also have a metanib, alsoknown as IPV or IPV, which is
intra-pulmonary positivepressure ventilation, as well
that is used to provide airwayclearance.
Chest wall oscillation All ofthese are things that we use to
help for airway clearance.
I throw that in there as well.
Manual CPT once was used tohelp for airway clearance and
(53:15):
patient had to move from side toside to get this done.
These DNAs we use littlethumpers on our smaller patients
flutters and rubbickers on ourlarger patients which can
actively participate for airwayclearance.
This are the pneumatics that Iuse and they're powered by Ida-A
(53:37):
or oxygen to provideoscillation for airway clearance
.
G5, I throw all of this inthere so that when you see them
on your bedside you canrecognize them.
I throw all of this in there sothat when you see them on your
bedside you can recognize them.
Ippv not more used, but thiswas a form of ventilation that
was actually used.
Apparently it was developed byDr Bird, which Mr Mike maybe can
testify.
(53:58):
I think he used to work here atUF.
He developed this ventilation.
It was used as a ventilator andthen was eventually used as
airway clearance.
But an upgraded one of thesedays is called the Metanet
Airway clearance device.
This is our upgraded one,metanet.
That is often used both oninvasive and non-invasive
(54:19):
patients.
Patients can passively breatheto help provide airway clearance
with this one, or we can hookthem to our conventional
ventilation on two-beddedpatient to provide airway
clearance Good one.
Or we can hook them to ourconventional ventilation on
today the patient to provideairway clearance good form of
oscillation that help vibratethe airway from the inside and
it can help clear our secretionsmore effectively than our
external cpts, um, our vesttherapies, um, also provided by
(54:43):
hiram as well.
These ones you place thepatient on for at least 20 to 30
minutes.
It shakes them up and then youhave to encourage them to do
half-cough.
This is mostly used by our CFpatients or any chronic lung
patients that requires regularairway clearance at home, and
also our neuro patients thathave ineffective airway
clearance due to thediaphragmatic weakness because
of their disease process.
(55:03):
This is a cough assist device.
Cough assist is anotherrespiratory equipment that helps
assist patients that havediaphragmatic weakness that
cannot generate negativepressure to exhale.
This equipment will set thepatients on a negative and
positive pressure based uponpatient tolerance to help them
(55:24):
clear their airways.
So it's basically called theBayside Cough Assist, so you
assist the patients to cough.
Different form of nebulizersthat you often see Small volume
nebulizers that develop largerparticles at the upper airway.
Perinep that generates smallerparticles to deliver medication
(55:46):
at the lower airway.
Erygenes, much more smallermicrons.
They will deliver medicationsat the lower airway as well.
Acorn and the AeroCleps as wellare some of our nebulizers that
you will see used at theirbedside.
What kind of nebulizers can beused for what kind of
medications.
Arches are responsible forthese.
(56:06):
We know it Tobimicin, colistinand DNAs.
We have to use our perinepsbecause of where we want our
medicine to be delivered.
Trig colors these are used bytrig patients to deliver oxygen
and also can be used to delivernebulizers.
Aerogen, very famous these days,used to deliver medication
(56:29):
directly through the ventilationthrough the ventilators, and
also can be used on non-ventedpatients that are getting
continuous nebulizers on highflows or on face mask.
Aerotrambers these are used forMDI medication delivery.
That includes Simbacort,Pomacort, fluvent.
(56:55):
Asthmatic patients use this.
Copd patients use this thatneed a bronchodilator at the
meta dose inhaler form.
These just help enhance themedication delivery without
losing any of the medications,and guarantees more medication
delivery than our nebulizers.
This is just a schedule oftreatments for our CF patients
(57:16):
and their diet caused that comes.
We come to an end of ourrespiratory intro.
I hope you enjoyed it and ifyou have any questions, our NICU
education team is robust andhere to answer your questions.
Thank you for having me on yourprogram tonight or this
afternoon.
Michael Maymi (57:37):
Yeah, Ossie, it's always a pleasure to have you.
You do a great job reallyexplaining all the different
devices that we use, even goingover some of the ventilator
modes that we use in both theICUs and the NICU.
It's always a pleasure.
I'll make sure that we haveyour PowerPoint slide available
so people can follow along withthe podcast.
(57:57):
I think it's very helpful tokind of see some of the things
you were talking about while wewere going through everything.
And again, thank you so muchfor 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 awinning team in town.
Amanda Bradshaw (58:16):
Okay, I have to let everybody know to please
click the link in the show notesto complete the survey too,
please.
All right, welcome to our Pediatric ICU
podcast.
My name is Michael Maymie.
I am one of the pediatric nursepractitioners on the unit and
I'm joined by Patricia Beck,Christina Carr, who are the
management team, along withAmanda and Ashley, our education
folks.
And today, our guest speaker isAsi.
(00:21):
He's one of our amazingrespiratory therapists, and has
been here for a very long timeworking in our pediatric ICU,
our pediatric floors and theneonatal ICU.
Our topic today is going to beon various different airway
devices that we can use in ourpediatric population, and I'm
going to go ahead and let Dr.
Well, excuse me, I'll call himDr, but I'll let Assi go ahead
(00:44):
and introduce himself and lethim go ahead with his
presentation.
Assi Timah (00:49):
Hey guys, my name is Assi Tima and thank you, mike,
for giving this opportunity, forthis opportunity to actually
share my awareness around therespiratory equipment and how
it's interacted in our area ofpractice.
I know it can be veryoverwhelming to people sometimes
(01:10):
when they come in contact withthis equipment, especially our
newer nurses and residents andas well as respiratory
therapists, despite seeing themin schools.
It could also be very, veryoverwhelming.
So after going through schooland then taking a job at UF
Health, which gave me anopportunity to see many retro
equipment and also put hands onthem and make a great experience
(01:36):
with it, I took on to theadventure of sharing the minimum
knowledge that I've gotten sofar with the people that are
coming behind me.
So this PowerPoint kind ofgives a very big picture of the
things you can see at thebedside in various facilities
(01:59):
and in different units to helpease your knowledge about it.
When people talk about them onrounds, if you've never seen
them, I give credits at the endof this PowerPoint of some
people's pictures that I've usedand some of the pictures I've
taken from bedside exposures aswell.
So I would jump right into it.
(02:20):
I've been around this field forclose to 17 years now I work in
this hospital.
Next year is going to be my 15years, so 14 and plus months and
, as Mike has said, I have theopportunity to work all of these
units.
Okay, I'll jump right on it.
It says intro to respiratory.
Feel free to ask any questionsas I go through this PowerPoint
(02:50):
by RCT team, of course, which isme.
My areas of practice, the past14 have years the shanes, pete's
, pete's, edp ICU, nikhilcurrently now, which I spend
most of my time.
Welcome to the Gator nation, ofcourse, big football nation and
big, big educated community.
You have helped.
(03:11):
So, right off the wall to ourpatients, you can see the
various size of power points offlow meters that we use.
You have the low flows in theregular flow meters that runs
from 1 liter to 15 liters, whichwe're used to back our patients
(03:32):
.
The biggest thing about meshowing this in pictures is
because it's very easy toconfuse them when there's an
emergency and the lines areplucked and the bag is plucked
in somewhere and you arrived andthe bag in the patient.
The bag is great, great chestrise, but the patient's
saturation is not going up.
As a team leader, you want torun your view from the patient
(03:56):
all the way to the wall, to makesure that we are plucked onto
oxygen, not medical air.
So it's very important for usas a team leader or as a
participant in a cold situation,the emergency situation, to run
right onto the wall and makesure that we are plugged into
the right outlet.
Now another thing to payattention is sometimes you can
(04:16):
have the wrong the low flowmeter plugged in there.
The Christmas tree feeds theuniverse, so it can also feed in
a low flow meter and mightthink that, um, you have the
right size of a flow meter intothe wall.
No, um, so you have to verifyand make sure the right side is
the one to 15 liters that caneffectively inflate our amber
bags or our ventilator back tohelp support ventilation in
(04:38):
terms of rescue.
So these two pictures, um,would help you think twice and
to verify and make sure that weare hooked up to the right size
flow meters to the wallRun-through flow meters,
christmas trees.
We used to have differentiationin Christmas trees.
It used to be the yellow onewhich was hooked up to their air
(05:02):
flow airflow meter and thegreen one to the oxygen, but now
we have a universal one whichis just clear, which means it
could be hooked up to any ofthem, either airflow meters or
oxygen.
So pay attention, making surethat again, that flow meter is
the right one and the back ishooked up to the correct one in
terms of when we come to rescue.
(05:22):
So Christmas trees are veryuniversal these days in nature.
Nasal cannula Very easy toconfuse with high-flow nasal
cannulas and all the nasalcannulas that have been used at
the bedside.
So this nasal cannula, which isthe lowest, lowest flow that we
use, only can carry up to fiveliters of flow.
(05:44):
Once you go past five liters offlow, you need to convert it to
a high flow nasal cannula whichprovides flow and high oxygen
as well High oxygen as well aslimited oxygen depending on the
disease process of the patient.
These nasal cannulas, once youstart running them, especially
in a pediatric world, we reallyencourage people to hook up a
(06:04):
humidifier bottle, like you seeon the side of it, and be
careful and make sure that thishumidifier bottle at the top of
it is punctured before youattach it to the patient.
If not, this thing would blowup and make a mess.
It would not hurt a patient,but it would make a mess in the
room.
You can hook them up withoutthe humidifier bottle to provide
(06:29):
humidity, but it may also causedryness and bleeding to our
patient's nostrils.
So it's very important to hookup a humidifier bottle for our
neonatal and our pediatric.
A venturi mask and a face mask.
A face mask is a basic maskthat can actually be adapted to
(06:51):
use to any patient that isgetting a nebulizer but at the
same time, more specifically, weuse it for a venturi mask, for
venturi oxygen patients.
These venturi patients wouldrun between 24 to 60 percent FL2
.
And the differences on how topick on these is clearly know
(07:13):
that there is color-coded.
It helps you not to confusewhen you go to pick up the
amount of oxygen that is neededto deliver to a specific patient
based upon disease processagain.
So with a venturi mask, whatmakes even though they're all
uniform, what makes thedifference in oxygen is the
amount of air that is entrainedwhen delivering the flow.
(07:34):
As you can see the little jetoffice that at the bottom of the
mask.
This is how much flow isentrained.
The smaller the jet office, thehigher the oxygen, which means
that they're entraining lessroom air.
If you look at the one that isrun at 15 liters, which is a
green one, signifying that we'regetting the most of our oxygen.
(07:56):
So the amount of air that isentrained during this process is
very minimal because of howmuch smaller air is being
entrained during the process.
Of course, at 15 liters, weknow that our patient's flow
(08:20):
that is coming to the patient'smass is coming very, very fast,
giving no time for any kind ofexternal flow to come in, which
is room air, giving no time forany kind of external flow to
come in, which is room air.
Non-rebreather setups Anon-rebreather, we know it's.
We say it's 100%, but researchhas proven that it's basically
just 80%, because you can't havea full seal onto the patient
(08:42):
face with a face mask.
So it's anywhere between 60 to100 um.
So these ones are mostly usedduring emergency, emergency
situations or burn patients thatcome in or a patient that has a
pneumothorax, so you put them anon-rebreather.
Now, setting up anon-rebreather, you plug into
the flow meter, turn the flowmeter to flush, which is 15
(09:05):
liters, and then you put a seal.
You put your finger at the topinside the one-way valve that
connects the bag, the reservoir,onto the patient's face mask.
Make sure the bag is inflatedtotally before you put on your
patient.
(09:29):
These bags do not require ahumidifier once the patient is
hooked up to it.
We've had people in the pasttry to hook up a humidifier.
No, it would not work, it wouldblow up the humidifier borders.
These masks are supposed to behooked up dry.
For emergency purposes andreasons of hooking up patients
to non-rebreather.
We do not need to worry abouthumidification, we need to
rescue the patient and then,once they're stable, then we can
(09:51):
probably set them up on thenext step that they can get
humidification.
You see, on this PowerPoint Idid include simple masks which
run from 40% to 60%, which is alittle bit higher than the venti
mask we just showed.
See, the nasal cannula runsfrom 24% to 44%, starting at one
liter, which is considered 24%,and it goes by increments of
(10:12):
four every liter of flow thatyou 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 allthe way to 44%, which is going
to be five liters.
Nasal cannula Erythritolers thesame weekend it does have a jet
office as well in theirairstrip tracheolers, which I'm
going to show in a minute here.
(10:32):
But let's switch it to highflow nasal cannula.
Once your nasal cannulaconventional nasal cannula was
run from 1 liter to 4 liters orto 5 liters, at that point the
patients need a little bit ofhigher flow.
So we jump from five liters orsix liters.
Some people would push it tosix liters.
We try to keep it at fourliters.
(10:56):
Once you hit five liters wewould go ahead and switch into a
high flow nasal cannula whichdoes not only provide you more
flow but it can also specify FR2from 21% to 100%.
So some of our hyperplastic lowfront patient which probably
needs sometimes just the flow,not the amount of oxygen or our
(11:24):
N, but getting three, four, fiveliters of flow just to help
ventilate them right.
So, um, this powerpoint showsthe setup of a high flow nasal
cannula which has two incrementports.
You have the medical room airand have oxygen that comes on
board in.
Fortunately for this powerpoint, um, our tubings don't really
(11:46):
match up with the yellow and thegreen which are universal
colors of choice for thehospital labor.
This one was kind of a labchoice of high flow.
But again, then you can see thehumidifier at the bottom that
we can actually titrate theoxygen, the heating system to
(12:07):
provide the optimal temperaturethat is needed to a patient to
keep them comfortable as well ashumidify the flow that's going
to the patient.
For the choices of ourinterfaces for our patients.
This is all going to be patientdependence.
A lot of times some patientshave very narrow airways and so
we would use the micropremiesfor the nasal interface and
(12:33):
sometimes we use the largest,depending on what the
requirements are for ourpatients.
So we do have devices that helpus measure them before we place
them on.
So we do have devices that helpus measure them before we place
them on.
As you work in the field, youwould notice that some patients
(12:55):
they could be micropremium butneed a medium or large mass
based upon the size of theirnasal passage High flow still on
our PowerPoint, different onecalled the air flow used on our
pediatric patients Once you hit25, 20 liters in both we want to
switch to air flow setups whichgives up to 60 liters of flow,
(13:16):
which can also be used in adultcare.
So our pediatric patients' highflow usually runs all the way
to 25 liters.
But once we go past that literflow in the smaller interface we
switch them to the averagephase which provide uh, which
can sustain higher flow ofoxygen that comes through this
(13:38):
I'll see before you keep going.
Amanda Bradshaw (13:40):
can I ask a question?
This is amanda.
Hey, I'm the night shiftnursing educator here in the
PICU.
So I just have a couple ofquestions about the high flow,
specifically From a nurse'sperspective.
If they are noticing that theirpatient maybe is having some
increased work of breathing,that sort of thing, but their
stats are still appropriate,what are some things that that
(14:01):
nurse could do to helptroubleshoot 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 intorespiratory issues.
Sometimes, when you look atthose flow, the flow could be.
It could be a flow issuewhereby the patient is getting
so much flow that they're havinga hard time breathing again.
Resistance of that flow.
So you may want to turn downthe flow for a little bit and
(14:29):
see if that improves their workof breathing.
But if this increased work ofbreathing is coupled with
labored breathing, which meansthat they're not only tachypneic
but they're also retracting andthey are unable to communicate
with you, then they probablyneed a little bit more flow and
maybe other interventions fromproviders to help relax them to
(14:51):
tolerate the flow.
So too much of flow could be aproblem.
Too much of flow can also be asolution.
So it's all going to be patientdependent, based upon your
assessment.
So you're looking at threethings labor, breathing, the
consciousness of the patient towork with the device and also
how much flow are we actuallydelivering to that patient.
(15:13):
Does that answer your question?
Amanda Bradshaw (15:14):
Yes, that does.
So the flow you would kind ofthat 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 strongpaper out there that proves that
high flow provides a level ofPEEP.
We can assess this from theresult that we get by placing
the patients on x-rayimprovement and oxygenation,
which means that we definitelyrecreated some alveoli.
It's not a close PEEP.
Peak in expiratory pressure,which is a definition of PEEP,
(15:47):
can only be measured end-to-end.
So it has to be a closed-loopsystem to actually measure PEEP.
So with high flow it's not aclosed loop.
The patient breathes very, verypassively 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
(16:09):
that PEEP and extra pressure.
So if I Dr Mimi, he can reallyclarify that even more.
Michael Maymi (16:15):
Yeah, I think there's theoretical thoughts
that it may offer about two tofour centimeters of water.
But you're correct, it is veryhard to measure it because if
the child is not breathingthrough their nose, if you don't
have a proper fitting nasalcannula and their mouth is open
and they're crying, they'relosing any pressure that you're
providing.
So, yeah, in theory there issome thoughts that there are
(16:39):
about two to four centimeters,but, like you mentioned, it's
not a closed loop system andyou're not going to get an
accurate reading of what you'reproviding.
Amanda Bradshaw (16:46):
Thanks, amanda.
Assi Timah (16:49):
Thanks, amanda.
So I would proceed in a jumpinto RAM Candler, which, when we
totally exert our effort withhigh flow nasal Candler, we
would jump onto the RAM Candler.
So thank you, dr Mike.
Mamie, you know everyonelistening right here Mike has
(17:10):
been a very strong mentor for mesince I started working at UF
Health and has built a lot ofthe person that I've become
today when it comes to myintervention in respiratory care
.
So I take his advice and hisguidance very, very important
for me.
So high flow when we feel highflow totally.
(17:33):
Our next device we would like tooften try is Ram Canada.
So in the past, before RamCanada was introduced at UF
Health, we used to use CPAP.
What we run into CPAP is thefact that it was hard to find
the right and correct interfacethat would totally seal on our
small faces right, our smallpeople's faces to actually
(17:54):
provide them the amount ofsupport 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 ventilatorsand all those forms of
(18:21):
ventilators that we have in thisstate to actually deliver RAM
Canada support to our patientsand that guarantees better
feeding on their nasal passagesand also provide them the
support that is needed for ourpatients.
Again, the feeding for ourpatient's nasal for REM cannula
is all going to bepatient-dependent, based upon
their nasal passages.
(18:41):
As you can see right, they runfrom neonatal micropremium all
the way to infant.
So we also have the largerinfant cannulas which can
sometimes be used in the NICU,depending on the patient's
requirement and their patientsinterface.
(19:03):
I threw in the trichotopes inthere.
They are there.
It's not something that nursesand artists intervene directly.
These are some things that ourresidents often help set up, but
it's very important to knowwhere to look at your ET tube
markers.
Sometimes you have an ET tubepatient that's intubated.
You come on your ship and thispatient's tube was cut because
(19:27):
it was long and causing a lot ofair trapping and so attending
providers might require also cutthat tube.
We often encourage that if anarch is going to cut an ET tube
to reduce the size, helpventilation.
Please encourage them to tapethat side, that piece, to the
vent so that we can recognizewhat side tube the patient has,
(19:50):
because once it's cut, the sizeof the tube is usually very
close to the connection to thevent area to the teepee area, so
make sure they keep it to thebedside.
The blade is, and all the formsof airways are often by the
bedside, so all the size of theblade is documented into our
chart system so you can alwaysreview to know what sort of
(20:12):
blades were used to intubatethat patient.
Tracheostomy same process as theET tube, often picked by ENT.
Again, we have them.
If you have a patient that hasa tracheostomy.
Very important things over thebedside is an obturator at the
bedside, a size up and a sizedown Things that we need just in
case we lose our airway.
(20:32):
We should be able to feed sizedown because of how rapidly the
cartilage and the stomach canclose.
And if we can't feed this, thesize down, we make sure that our
obturator is placed in there tomaintain that airway, to avoid
a larger incision.
If ENT has to reinstate the um,trick your stomach back into
(20:53):
the into space, back onto theoxygen blender, which is also
what we use at our high flownasal candler.
So this blender is the reason Ithrow this in.
And now we have our color codedon this top one, which is the
blue and or the, the green andthe yellow.
So very important Color codingsuper important because that
(21:16):
helps us not to make mistakes.
Right?
You can see that our blendersthat we use these blenders are
used even on the oscillators.
Right?
This is how we are able to mixup oxygen and deliver a specific
amount of FIO2 to our patientswhile also providing them flow
that is needed for ventilation.
Some of these high flows havetwo flow meters.
(21:38):
Some people usually, you knowyou can find two flow meters and
you ask yourself why do we havetwo flow meters?
With some of our high flowsdesigned, they require those
flow meters to runsimultaneously at a time to
actually entrain flow to providespecific FRO2?
How do you know that?
It's absolutely written to theside of the blender, you would
(21:59):
see.
It would indicate that thisblender requires both flow
meters to run at a time.
So, with that said, how do yourun both of them at the time?
That doesn't mean that bothflows have to be going to the
patient.
You can hook up your AMBU backto the other flow meter and just
hang the back next to it.
You can run it at anywherebetween five to six liters of
flow just to receive theaccurate amount of FR2.
(22:23):
If not, your FR2 would not readaccurate.
You may think you're delivering50%, meanwhile you're only
delivering 25% of FR2.
That's why I throw this blenderthing in there.
Amanda Bradshaw (22:36):
Can I ask another question real quick?
This is Amanda again.
Okay, so what is the maximumhigh flow setting that the
med-surg, like the pediatricmed-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 thehighest amount of FR2 that the
METSIS flow can actually carryis 50%.
When you go past 50% and abovetwo per kilo, usually these
patients are required for closeattention, close attention, and
(23:15):
that's when we usually call ourPICU team to come and assess and
see if they can transport themup into the PICU and where they
can have close attention at thathigh FL2.
Amanda Bradshaw (23:23):
Okay, and then what would be an ideal flow for
a pediatric patient, and maybeeven when would be an ideal flow
to transition them to a regularlow 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 litershigh flow, when you start
dropping past five liters, thetubing compliance of the high
flow would not provide enoughresistance to deliver the amount
(23:58):
of flow that is required bythat patient right.
So at five liters you want tostart thinking of confining them
to a conventional laser can.
Now that's at a pediatric level.
If you go a little lower in theNICU they can go up to one
liter, two liters, but at fiveliters you can comfortably
(24:19):
transition that patient to aconventional nasal cannula.
Amanda Bradshaw (24:22):
Okay, all right , yeah, and then is there an
ideal flow for pediatricpatients to be on.
Assi Timah (24:29):
To start on, Now you're going to have to pay
attention to the work ofbreathing of this patient, right
?
So okay, um, if it is a hypoxicissue, and they can probably
just do fine with two litersnasocam because they're needing
oxygen, um, which is equivalentto 28, but if it is a ventilated
issue, you probably, uh, theyou, you go to five liters
(24:52):
straight and simultaneously.
If that is not working, thenyou come for them straight to
high flow nasal cannula, whichyou have more rooms to work with
at that point in time, whetherto 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 themstraight up on five liters, 25
(25:18):
to 30%, and then, in thatcircumstances, they're getting a
heated humidifier and it'scomfortable, right?
People often call that acomfort flow.
Because of the andhumidification this patient is
getting, we are able to targetthe amount of temperature and
the amount of flow and theamount of FR2.
(25:39):
So at that point we'reproviding every comfort that is
needed for breathing for thepatient.
Amanda Bradshaw (25:45):
Just kind of titrate up according to what
their work of breathing lookslike.
Assi Timah (25:50):
Yes, ma'am.
Now that comes to titration isalso going to be based on.
One of the questions people askis how do I know that this is
optimal flow for this patient?
So you listen to the breathsounds.
If you can hear the flowbilateral, which is stethoscope
it means that you are deliveringan optimized flow and you would
also see that the patient iscomfortable.
Amanda Bradshaw (26:09):
Okay, great.
Assi Timah (26:10):
Thank you, you're very welcome.
V60 ventilator I threw them allbehind the Philips this is a
respiratory ventilator that ismostly used for a patient that
comes from home and they arechronic Sometimes.
The Philips ventilator theycome with it from home and so
this is just to provide themCPAP continue CPAP without any
oxygen blending.
The V60 ventilators we use itsometimes without any oxygen
(26:32):
blending.
The V60 ventilators we use itsometimes for our patients that
are larger than 23 kilos on ourfloors, same as the respirator.
These are all SEPA ventilatorsthat provide continued positive
pressure ventilation for ourpatients.
The LRTV ventilators are homeventilators.
You would often see them in theTrilogy 100 at our bedside for
(26:54):
our patients that are beingprepped to send home.
These ventilators have highcompensation for patients that
are going out on a trek.
Of course, most of them aregoing home on treks, right, so
they compensate for leaks andthey're easily used by parents
at home.
They are quick to set up andquick they they have longer
(27:16):
lasting batteries up to somehowup to five hours of um battery
and you can also blend oxygen.
So I throw this in here justfor your vision purpose.
So when you hear about the v60and the trilogy, this is how
they look like.
Our kids are very versed withthis.
We all train and um in any uh.
Their reps are often available24-7 to help us if needed.
(27:36):
I threw in the ventilator the840 ventilators our servo ends
that are also used in ourfacilities here from our bedside
.
These ventilators the servoends are the most updated system
from the 840s provide accuratecompensation.
You can also deliver nebulizerthrough these ventilators
(27:58):
without attaching any externalequipment that actually impedes
the tubing compliance and theflow to the patient.
You can also deliver NAVAventilation through these new
servo ends.
You can also deliver NAVAventilation through this new
servo end.
So it's a great form ofventilation that you can use to
(28:19):
provide fluid to our patients.
I kind of talked about the setupon here the expiratory filters
versus inspiratory filters.
Important to recognize thisbecause these filters cannot be
interchanged.
Right, the expiratory filtersis always going to be green and
it has water traps in the bottom.
The expiratory filters, on theother hand, you would notice
(28:39):
that it's hooked up to the bluecircuit, right, blue for oxygen.
So just make sure that when youlook at your vent they are
correctly set up, becausemistakes can occur.
You have your heater thatattach on our ventilator
patients as well.
Then you have differentventilator setup that I use or
(29:03):
the vent settings that I use.
Mostly in our pediatric setupyou have APRV, prvc.
This is just again things thatI throw in there just in case
people want to understand, basedupon whatever facilities you're
working at, what vent settingsare used.
So at our facility here at UFHealth we mostly use pressure
control ventilation, prvc andother terms called VC plus as
(29:25):
well.
What is the difference betweenpressure 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 betweenPRVC and pressure control is the
delta P that is applied or setin the pressure control Mean Y
(29:50):
for PRVC, which is VC plus, isthe volume.
So the difference between thesetwo is volume and delta p, but
every single one of this modehas respiratory set, high time
pressure support, peep and fr2.
Now, with that said, pressurecontrol ventilation, you set
(30:12):
delta P to influence flow right,and so you cap the peak flow
that the patient can get.
Meanwhile, in pressureregulated volume control, you
control the tidal volume, whichis usually 6 to 8 per kilo in
our pediatric environment.
So you set the tidal volume,and the ventilator regulate the
(30:36):
pressure based upon thepatient's demand.
Right, we could go into detailswith these If you have any
questions about this, pressurecontrol, ventilation and
pressure PRVC.
If Mr Mike has any addition tothis, I'll be glad for him to
(30:57):
enlighten us more on this.
Amanda Bradshaw (30:58):
I do have a question about Delta P.
Could you explain a little bitmore 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 thepatient so um, an example uh,
kind of a funny example to putis it's like, it's almost like
you are switching from a littlecorvette to a truck, right?
So, and go by increments.
(31:28):
I go from a corvette.
If I wanted to increase thedelta p, let's say I want to
transport more stuff, I just goahead and take a bigger car.
It takes more load.
So delta P goes by incrementbased upon the need to ventilate
a patient.
So the higher the delta P, themore 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 lookat delta P is the change in
pressure right?
So it's actually the amount ofadditional pressure above PEEP
that you want to hit a higherpeak inspiratory pressure to
ensure that you open the lungsand provide your ventilation
(32:14):
right.
So, in a mode that, when you'retalking about the amount of
pressure given, you think aboutPEEP, that's the bottom pressure
to allow the alveoli to stayopen, your delta P is that
change in pressure that you'regoing 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 clearunderstanding in terms of the
change in pressure versus thepeak pressure.
So yeah, so, Amanda, again it'speak versus delta.
Peak was to PIP.
Amanda Bradshaw (32:52):
Okay.
Assi Timah (32:53):
Perfect NAVA.
So NAVA is?
This is very interestingbecause this is coming to us
very, very new and it has been arevolution in healthcare in
terms of helping supportbreeding for mostly our neonatal
(33:15):
infants.
And now you guys are going tobe seeing it very soon here in
the PQ.
I'm just going to kind of youknow going to have another topic
soon here about NAVR, but I'mjust going to kind of highlight
what it actually is.
It's a neuroadjusted ventilatorassist, which means that it
helps support patients on theirbreathing, but it allows the
(33:40):
patient to actually determinethe peak pressures, allow the
patient to determine when totrigger a flow, allow the
patient to actually pull in moreflow if required, based upon
their compliance right.
So, um, how do we set up anapper?
It's a catheter just like yourfeeding tube that you place in.
Often when we, when we placethem and the patient of the
feeding tube, we usually attachthem at the same level.
(34:03):
Now there is electrical in um,electrical signals that are
between, or electrical how doyou call it design?
The way it's designed has fourto five electrical signals at
the bottom of the navar that youplace them right at the level
of the diaphragm and thesesignals would pick up the
(34:26):
diaphragmatic movement, based onelectrical movement of the
diaphragm, and deliver pressureto the patient based upon the
patient's trigger right.
So a NAVR settings of high.
We set them based uponpatient's requirement.
Now, things that we indicatethat the patient needs NAVR.
If the patient is breathingreally, really fast, with
(34:46):
patients breathing shallow,pulling low or tighter volumes,
we would put them on NAVR.
It would help them overcome.
Or if they're going apneicright, it would help them
overcome their work of breathingand ease of breathing.
It will help them synchronizetheir breathing.
If they're breathing too fast,If they're breathing shallow, it
will help augment the tidalvolume because of the fact that
(35:09):
it would sense this pressure allthe way to the level of the
diaphragm, not just at the levelof the floor as mechanical
ventilation would usuallyprovide.
So we'll have a whole topic onthis and we can talk about how
it's set up and how to pick up acatheter and what else those
catheters can also do.
So just look at it as a form ofventilation that is going to
help ease ventilation and alsogive a lot of power to the
(35:30):
patient, rather than us takingover as a mechanical ventilation
, which we usually do withpressure control and PRVC.
Michael Maymi (35:39):
Yeah, the thing that I like about NAVA that's
fascinating is that as the brainsends the signal to the
diaphragm, the NAVA sensors pickthat up and even if the
patient's not strong enough togenerate that breath, the
ventilator can sense that thepatient wants to take a breath.
It can synchronize with thepatient and we can use NAVA in
(36:01):
both as an invasive mode wherethe patient's intubated, or you
can also use it as anon-invasive mode.
So it really kind of goes intodeeper signaling right.
So if the brain sends theneurotransmission to the
diaphragm and the diaphragm says, hey, there's electrical
activity to move the diaphragm,let's do it right, and it makes
(36:24):
it easier and more comfortablefor the patient.
Amanda Bradshaw (36:26):
So it's more of like a supplemental type.
It's supplementing what they'realready triggering a
supplemental type.
Michael Maymi (36:33):
It's supplementing what they're
already triggering.
No, it's kind of like on ourventilator.
You know we have, uh, thetrigger right and that trigger
can be flow, pressure or volume.
Um, the trigger is actually thenava right.
It's the actual electricalsignal from the brain to the
diaphragm that then tells theventilator okay, we need.
We need to help support thisbreath or initiate a breath,
because it's been too long sincethe last one.
Amanda Bradshaw (36:55):
I see Okay.
Assi Timah (36:59):
Thank you, mr Mike.
I threw in CPAP in therecontinuous positive airway
pressure.
So the reason I threw in CPAPis because of the fact that most
often people would we wouldoften confuse between continuous
positive airway pressure inrelation to PEEP, which is peak
(37:19):
in exposure pressure twodifferent things right.
So you provide a CPAP at.
It's just a flow that got tobreathe against resistance
Meanwhile, the peak in pressureand we talked about it earlier
that you can have to measure itfrom end to end based on a
closed loop system With CPAP.
It's flow that just helps youventilate, helps our patients
ventilate and help them overcomethe work of breathing either
(37:41):
obstruction or resistance, basedupon patient's breathing effort
.
I kind of throw in some faceview of some of the ventilators,
images from a bedside.
As you can see, there's a trueventilator on the patient.
There's no patient's name oranything like that.
(38:02):
It's just an image thatreflects how they're doing on a
ventilator.
That's the patient inpressure-controlled ventilation.
So you can see on that firstimage right there in
pressure-controlled controlventilation we set up delta p
and we set up the peep and inturn the peak pressure is delta
p um.
It gives us the peak pressuresequals to our delta p plus our
(38:25):
peak um.
As you can read in on oursecond 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 ofour image on that screen.
Volume-controlled ventilationAgain another image from a
(38:47):
patient at PRVC on the bedside.
Just images just to show youhow it will reflect my
ventilation.
Now I throw in another form ofentire measurement here CO2
measurement from a sub-Q point.
It's called transcutaneousentire monitor.
Transcutaneous in tightermonitor.
Transcutaneous is a system thatuses electrical again
(39:17):
electrical impulses to measurethe CO2 at the level of the
patient's skin.
So we have electrodes that areplaced on that patient using
stickers and it heats up thespot where it is placed to
measure CO2.
This is usually used in thecase whereby the patient is
probably intubated in a lot oflines and has no access.
It's another form of way tomeasure CO2 and window
ventilator.
From here you can run intoissues whereby if the patient is
(39:39):
adamant they have so much fluidon board.
The reading could really beinaccurate.
Sometimes you have patientsburn patients the skin.
These electrodes cannot stickor the stickers can't stick on
the patient to use electrodes toread the CO2.
So we run into those kinds ofissues, right so, and there you
could run into irregularities,but we're working on getting new
(40:01):
equipment that can that aremore effective, more accurate.
We reduce our place in lines onour patients and monitoring CO2
and wind the ventilator.
This is how the place.
We have little.
We have gels that are placedinto those stickers to make sure
that they don't burn thepatient's skin and they have to
be moved around every four hoursto avoid skin injury as well.
(40:28):
Conventionally, in tidalmeasures, of course, you have
the one that you can actuallydeliver oxygen and monitor
patients on our non-invasivepatients, when we're doing a
procedure, this is often used byanesthesia and our CICU
critical care team when they'redoing unconscious sedation in
(40:49):
the patient that doesn't requireintubation.
On the left side you have theone that is a conventional that
is often used at the end of ourET tubes to monitor intiters
when the patients are intubated.
Any questions on that?
Looking good Again, this isanother patient that is on his
(41:12):
spontaneous breathing.
The ventilator will look allyellow and red waveform, which
shows that there is no assistedbreath from a ventilator.
The ventilator, the patient, isdoing all the work.
All we said was the pressuresupport and the patient is
probably intubated and gettingsupport without any assisted
breaths NAVR, navr.
(41:34):
So when you have a patient thatis NAVR, you would see there's
three on this ventilator screen.
You would see that the patientwhere you would read the nav is
going to be all the way to thebottom right.
Um, it's going to be thewaveform that is purple and you
can see the edi peaks on the.
(41:54):
That is reading at 13.9.
The edi mean is 4.7.
Again, we'll have anotherlecture 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 isour nav and this is how it's set
(42:16):
up.
Um, again, I throw this imageshere for several reasons.
Mr mike already went throughthe whole details but we will
come back onto it whenever timeis given.
These are the differentinterfaces that are used at our
NICU level and also usedsometimes at PIC for smaller
patients interfaces to delivernon-invasive ventilation.
(42:37):
You can use a nasal prongs andyou can also use a mask.
We try to alternate them everysix hours to prevent facial
injuries because of the factthat they're a good sealing
masks that can provide pressureon the patient, but also they
can cause injury because of howmuch strength is used to seal
the facial appearance of ourpatients.
I also throw in the markersthat are used to measure the
(43:00):
face of the patient before theinterfaces are applied Headgears
we use these headgears to helpfasten the pressures on the
patient's faces in order toprovide ventilation to our
patients.
Oscillator so exciting.
These can look very scary fromat first sight because of how
(43:21):
big they are and how much noisethey make, but again, it's our
best and the most gentle form ofventilation for patients who
have severe lung injury or willhave underdeveloped lungs, right
?
So if you have a patient that'srequiring so much high
pressures you're heating 40s ofpressures on conventional
ventilation it's time for you toswitch it to an oscillator
which provides gentleventilation.
How do we pick the settings onthe ventilator on a on an
(43:45):
oscillator?
You go onto conventionalventilation.
You look at what the meanairway pressure and you go
between two to three above thatmean airway pressure on
conventional ventilation.
Place it in there.
Now, delta P, which is theamputation, is all going to be
based upon patient's movement ononce you place them on
(44:08):
oscillation.
When it comes to frequency,frequency runs between 6 to 15,
right, depending on thepatient's size.
In our pediatric patients,anywhere between 6 to 8 is 6 to
10 is going to be where we wantto have our amplitude.
Remember our hertz Sorry, ourhertz.
(44:29):
10 is going to be where we wantto have our amplitude.
Remember our heart sorry, how Iheard.
Gotta be careful here becausewith our with a lower heart, we
can actually make our patientjump off the bed right.
So it's all going to beobservation based upon our
assessment.
What we're worried most here,or concerned most, is going to
be the main airway pressure thatwe are delivering to our
patient.
Um, once we place our patient,oscillation and then the
amplitude again is all going tobe based upon what we observe
(44:52):
and based on are we having agood chest wiggle, which
indicates that we areventilating well?
And the beauty of theoscillator is we can also
titrate our FR2.
As you can see at the bottom ofthat image on my PowerPoint,
there is a blender at the bottomthat brings in medical room air
and 100% FL2.
So we can provide specificamount of FL2 and we can also
(45:14):
deliver effective ventilationwhile we oscillate our patient.
Any question on oscillatorreasons?
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 likeyou needed a prescription to
suction the patient onoscillator, and the reason being
that there was an agreement onoptimal airway expansion and
PEEP maintenance when a patientis in oscillation.
But that has since then beenruled out by many articles that
(45:53):
have shown that there's veryminimal effect when you have a
patient on oscillation and yousuction them.
Yes, you can effectivelysuction them If you see water
running down the circuit, if yousee the patient has increased
secretion and desaturatingbefore you go ahead to increase
FR2, which could also causeother 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 clampthe ET tube before we suction
that patient or at alldisconnect?
Assi Timah (46:24):
No, absolutely not.
You shouldn't technically haveto clamp your at2 before you.
Amanda Bradshaw (46:28):
Um, you suction your patient I apologize, not
before suction, butdisconnecting from the um, like
the disconnect before you bagthe patient or anything like
that no, not necessarily.
Assi Timah (46:39):
You don't really have to.
Um there again, there are somebeliefs out there that you would
do recruit so quick when youunplug patient on the of the
oscillation.
Again, some providers willrequire that you do that but to
the best of my experience atbedside in the NICU you don't
have to do that now.
You have some patients that arecan decompensate based upon a
(47:03):
disease process.
Those one we do as much aspossible.
We try to.
If we have to turn the patient,we have to move the patient, in
which we try not to disconnectthem.
But if we have to forintervention purpose, maybe bump
up the oxygen to 100%, let thempre-oxygenate them and then you
can disconnect and do what youhave to do.
Amanda Bradshaw (47:22):
Okay, you just said something about turning the
patient, and so that actuallyleads me into another question
that seems to be pretty popularwith nurses is when you have a
kid on an oscillator, are youable 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 pressureoscillators are becoming a big
issue, or were becoming a bigissue because of the fact that
this patient was left untouchedthe whole time when they were on
oscillator left untouched thewhole time when they were on
oscillator.
In our mode of practice in theNICU, patients are turned every
shift.
(48:11):
You know you can move themaround, you can change their
position and just help relievepressure on one side, and this
circuit allowed to be veryflexible.
There was also the belief thatthey have to stay very rigid and
straight.
That has since been overruledbased upon research and papers
that come out.
It doesn't matter how thecircuit is placed.
Yeah, we try to keep thisstraight as possible, but they
(48:32):
can also be flexible and wouldnot 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 talkingabout, you know, obviously,
transitioning from theconventional vent to the
oscillator and the differentsettings that there are.
So the delta P would be similarto 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 reallydetermine patient's chest
movement with the LTP, but anoscillator 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 airwaypressure.
We generate it based uponpatient's compliance.
So you would look at thereadings of the mean airway
pressure of your ventilator,which often appear.
I can take you back to thescreen here really quick and
(49:45):
show you.
It would often appear at thetop of your readings.
Michael Maymi (49:50):
Your mean airway pressure takes into account many
of your ventilator settings.
So it's actually a measurementfrom the ventilator to let you
know what the mean airwaypressure is.
So it would account.
There's an equation.
I don't remember it off the topof my head.
Equation.
I don't remember it off the topof my head, but it does include
your PEEP, your PIP, your DeltaP and the number of breaths
(50:16):
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 backthis image.
It's right here, you can see,it's generated right there.
It's given to you Once theventilator 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 justpulled up right there and your
patient would have much highermain area pressures, which would
be an indication to movetowards an oscillator, because
you're requiring higherpressures to ventilate and
(50:49):
oxygenate the patient.
So with the oscillator you'regiven tinier breaths with higher
pressures.
Amanda Bradshaw (50:57):
Okay, so if there are mean airway, pressure
on the conventional vent isincreasing.
We're looking at like aworsening 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 yourselfshould 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 ofthrow in jet ventilator in there
, just to you know.
Same thing, jet ventilation isbasically just throw in.
It does the same thing on theoscillator, but the beauty of it
is it's more gentle than anoscillator and it's mostly used
(51:45):
in our NICU population.
It doesn't provide any oxygen,it's just solely for ventilation
.
So we usually attach aconventional ventilation to it
in order to provide accurateoxygenation as well.
Nitric oxide threading used forour PPHN patients.
Those can also be attached to aconventional ventilation.
(52:06):
One oscillator is required fora patient that has PPH in and
they're already been ventilated.
That's a look of nitric oxideand that's often determined
based on patient's requirement.
Chest physiotherapies we havemanual ventilation, manual CPT,
which you cup or hand and do apump top, top top on patients
(52:27):
that have since then been seizedbecause of Kapo syndrome that
some of our therapists werehaving.
So everything has been switchedto manual, which is we can use
a flutter, we can use a G5,which is a pneumatic powered by
electricity.
We can use another pneumaticpowered by PSI from the wall,
from oxygen or air, medical roomair.
(52:51):
We also have a metanib, alsoknown as IPV or IPV, which is
intra-pulmonary positivepressure ventilation, as well
that is used to provide airwayclearance.
Chest wall oscillation All ofthese are things that we use to
help for airway clearance.
I throw that in there as well.
Manual CPT once was used tohelp for airway clearance and
(53:15):
patient had to move from side toside to get this done.
These DNAs we use littlethumpers on our smaller patients
flutters and rubbickers on ourlarger patients which can
actively participate for airwayclearance.
This are the pneumatics that Iuse and they're powered by Ida-A
(53:37):
or oxygen to provideoscillation for airway clearance
.
G5, I throw all of this inthere so that when you see them
on your bedside you canrecognize them.
I throw all of this in there sothat when you see them on your
bedside you can recognize them.
Ippv not more used, but thiswas a form of ventilation that
was actually used.
Apparently it was developed byDr Bird, which Mr Mike maybe can
testify.
(53:58):
I think he used to work here atUF.
He developed this ventilation.
It was used as a ventilator andthen was eventually used as
airway clearance.
But an upgraded one of thesedays is called the Metanet
Airway clearance device.
This is our upgraded one,metanet.
That is often used both oninvasive and non-invasive
(54:19):
patients.
Patients can passively breatheto help provide airway clearance
with this one, or we can hookthem to our conventional
ventilation on two-beddedpatient to provide airway
clearance Good one.
Or we can hook them to ourconventional ventilation on
today the patient to provideairway clearance good form of
oscillation that help vibratethe airway from the inside and
it can help clear our secretionsmore effectively than our
external cpts, um, our vesttherapies, um, also provided by
(54:43):
hiram as well.
These ones you place thepatient on for at least 20 to 30
minutes.
It shakes them up and then youhave to encourage them to do
half-cough.
This is mostly used by our CFpatients or any chronic lung
patients that requires regularairway clearance at home, and
also our neuro patients thathave ineffective airway
clearance due to thediaphragmatic weakness because
of their disease process.
(55:03):
This is a cough assist device.
Cough assist is anotherrespiratory equipment that helps
assist patients that havediaphragmatic weakness that
cannot generate negativepressure to exhale.
This equipment will set thepatients on a negative and
positive pressure based uponpatient tolerance to help them
(55:24):
clear their airways.
So it's basically called theBayside Cough Assist, so you
assist the patients to cough.
Different form of nebulizersthat you often see Small volume
nebulizers that develop largerparticles at the upper airway.
Perinep that generates smallerparticles to deliver medication
(55:46):
at the lower airway.
Erygenes, much more smallermicrons.
They will deliver medicationsat the lower airway as well.
Acorn and the AeroCleps as wellare some of our nebulizers that
you will see used at theirbedside.
What kind of nebulizers can beused for what kind of
medications.
Arches are responsible forthese.
(56:06):
We know it Tobimicin, colistinand DNAs.
We have to use our perinepsbecause of where we want our
medicine to be delivered.
Trig colors these are used bytrig patients to deliver oxygen
and also can be used to delivernebulizers.
Aerogen, very famous these days,used to deliver medication
(56:29):
directly through the ventilationthrough the ventilators, and
also can be used on non-ventedpatients that are getting
continuous nebulizers on highflows or on face mask.
Aerotrambers these are used forMDI medication delivery.
That includes Simbacort,Pomacort, fluvent.
(56:55):
Asthmatic patients use this.
Copd patients use this thatneed a bronchodilator at the
meta dose inhaler form.
These just help enhance themedication delivery without
losing any of the medications,and guarantees more medication
delivery than our nebulizers.
This is just a schedule oftreatments for our CF patients
(57:16):
and their diet caused that comes.
We come to an end of ourrespiratory intro.
I hope you enjoyed it and ifyou have any questions, our NICU
education team is robust andhere to answer your questions.
Thank you for having me on yourprogram tonight or this
afternoon.
Michael Maymi (57:37):
Yeah, Ossie, it's always a pleasure to have you.
You do a great job reallyexplaining all the different
devices that we use, even goingover some of the ventilator
modes that we use in both theICUs and the NICU.
It's always a pleasure.
I'll make sure that we haveyour PowerPoint slide available
so people can follow along withthe podcast.
(57:57):
I think it's very helpful tokind of see some of the things
you were talking about while wewere going through everything.
And again, thank you so muchfor 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 awinning team in town.
Amanda Bradshaw (58:16):
Okay, I have to let everybody know to please
click the link in the show notesto complete the survey too,
please.
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