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NEONATAL PULMONARYGRAPHICS:
More Than Just APretty Picture
Steven M. Donn, M.D.
Professor of PediatricsDirector, Neonatal-Perinatal Medicine
C.S. Mott Childrens HospitalUniversity of Michigan Health System
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DATA
http://images.google.com/imgres?imgurl=http://www.med.umich.edu/lrc/ecgoftheweek/cases/case04/images/answerexplain-ECG.jpg&imgrefurl=http://www.med.umich.edu/lrc/ecgoftheweek/cases/case04/answer01.html&h=338&w=549&sz=50&tbnid=SEUzcJqsxSknsM:&tbnh=80&tbnw=130&hl=en&start=16&prev=/images%3Fq%3DECG%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DGhttp://images.google.com/imgres?imgurl=http://www.cjd.ed.ac.uk/eeg.jpg&imgrefurl=http://www.cjd.ed.ac.uk/investigations.htm&h=2452&w=3091&sz=2649&tbnid=4qlLP3kCmEVL0M:&tbnh=118&tbnw=150&hl=en&start=3&prev=/images%3Fq%3DEEG%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DGhttp://images.google.com/imgres?imgurl=http://www.id.nrcs.usda.gov/snow/images/data/swegraphs/magic.gif&imgrefurl=http://www.id.nrcs.usda.gov/snow/data/current.html&h=436&w=648&sz=21&tbnid=M92ilkTR3qIIOM:&tbnh=90&tbnw=135&hl=en&start=98&prev=/images%3Fq%3Ddata%26start%3D80%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DNhttp://images.google.com/imgres?imgurl=http://www.temis.nl/protocols/o3field/data/forecast/fcst3_np.gif&imgrefurl=http://www.temis.nl/protocols/O3forecast.html&h=507&w=478&sz=83&tbnid=01tgQsklfTcECM:&tbnh=128&tbnw=120&hl=en&start=97&prev=/images%3Fq%3Ddata%26start%3D80%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DNhttp://images.google.com/imgres?imgurl=http://www.primera.com/images/bu-cds.jpg&imgrefurl=http://www.primera.com/backup-archival.html&h=722&w=740&sz=53&tbnid=zAtV6nZVTlWi4M:&tbnh=135&tbnw=139&hl=en&start=87&prev=/images%3Fq%3Ddata%26start%3D80%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DNhttp://images.google.com/imgres?imgurl=https://www.fnmoc.navy.mil/products/OTIS/US058VMET-GIFwxg.OTIS.glbl_sst.gif&imgrefurl=http://www.nawcwpns.navy.mil/~weather/chinalake/weatherlinks.htm&h=551&w=1080&sz=149&tbnid=W8kpo0qDwzr40M:&tbnh=76&tbnw=150&hl=en&start=84&prev=/images%3Fq%3Ddata%26start%3D80%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DNhttp://images.google.com/imgres?imgurl=http://mn.water.usgs.gov/bemidji/gif/field2005/Geoff%2520graphing%2520vapor%2520data.JPG&imgrefurl=http://mn.water.usgs.gov/bemidji/photos.html&h=960&w=1280&sz=266&tbnid=ipWVNWcsB5R8GM:&tbnh=112&tbnw=150&hl=en&start=83&prev=/images%3Fq%3Ddata%26start%3D80%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DNhttp://images.google.com/imgres?imgurl=http://weather.ou.edu/~laufers/wxpics/250.gif&imgrefurl=http://weather.ou.edu/~owl/weather/ua.html&h=600&w=800&sz=38&tbnid=iS5ue8MPcttVgM:&tbnh=106&tbnw=142&hl=en&start=55&prev=/images%3Fq%3Ddata%26start%3D40%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DN -
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The Pre-Graphics Era
Pulmonary mechanics?
Lung expansion?Gas trapping?
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Early Experience
Cumbersome equipmentDifficult calibration
Limited applicability
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Recent Experience
Microprocessor-basedTechnical, but user-friendly
Extends research tool to
general clinical utility
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Neonatal PulmonaryMechanics Tests
Provide useful clinicalinformation
Help elucidate pathophysiology
Give objective evaluation oftreatments
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Waveform Monitoring
Volume
PressureFlow
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Flow Waveform
Shape may identify abnormality
Example: high airway resistance
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Flow Waveform
Identifies type of ventilation
Example:pressure vs. volume
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Flow Waveform
Identifies mode of ventilation IMV
SIMV
Assist/Control
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IMV
SIMV
A/C
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Flow Waveform:Gas Trapping
Expiratory flow does not
return to baselineMake adjustments
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Tidal Volume Waveform
Suitability to wean
Example:Effective vs. ineffective
spontaneous breathing
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Effect of Inspiratory Time
Flow
Volume
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Pulmonary Mechanics
ComplianceResistance
Work of Breathing
Peak Flows
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Compliance
Relationship of pressure
and volume
Example:
Flattened loops =poor compliance
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Pressure-Volume Loops
Compliance
InflationWork of Breathing
C20/C Ratio
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Pressure-Volume Loops
Determine optimal PEEP
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Fl V l L
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Flow-Volume Loopsand Resistance
Relationship of volume and flowHigh resistance = lower flow
for a given volume
Seen in MAS, BPD, obstructedairway
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Endotracheal Tube Leaks
Volume waveform
Pressure-volume loopFlow-volume loop
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Large ETT Leaks
Baseline drift
Loss of PEEPLeak compensation
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Turbulence
Waveforms
Loops
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Synchrony
IMV
SIMVAssist/Control
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Flow Cycling
Termination sensitivity
Expiratory trigger
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Effect of Cycling Mechanisms
Time
Flow
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Trend Data:
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Trend Data:
Pressure-Targeted
Volume
Pressure
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Trend Data:
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Trend Data:
Volume-Targeted
Volume
Pressure
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Case Study - 1
39 wk 3550 g female24 y/o G2 P1-2 mother
Elective repeat cesarean sectionApgar scores: 81 95
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Case Study - 2
Initially tachypneic, RR = 80Severe expiratory stridor at 30 min
Chest radiograph normal
CBG: pH 7.07, pCO2 105, pO2 52 (RA)
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Case Study - 3
Placed in 40% oxygen/humiditySepsis workup, antibiotics given
Transport requested
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Case Study - 4
Intubated by transport teamFiO2 0.3, rate 40, pressure 20/4
ABG: pH 7.12, pCO2 85, pO2 180Transferred without difficulty
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Case Study - 5
ABG: pH 7.33, pCO2 42, pO2 74Chest computed tomography:
Double aortic archConfirmed at catheterization
Successful surgical repair
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Pulmonary Graphics
You can observe a lotby watching.
-Yogi Berra