OSCE. Difficult ventilation in extreme preterm baby

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[00:00:00]Okay. Um This is a 26-weeker gestational age preterm neonate weighing 750 g. He's on conventional mode of ventilation uh due to severe respiratory distress syndrome.

[00:00:12]So, despite FIO2 of 100%, high peak inspiratory pressures and high mean airway pressures, the neonate has persistent hypoxemia and worsening respiratory acidosis.

[00:00:23]So, the neonatologist decides to switch to high-frequency mode of ventilation.

[00:00:27]So, this is the X-ray.

[00:00:30]Is there any note on surfactant therapy and how old is the baby? Sir, it's a 26-weeker, sir, 750 g.

[00:00:36]And the age of the baby? Uh sir, yeah, it is uh within uh uh 6 to 8 hours old, sir.

[00:00:43]Surfactant?

[00:00:45]Uh surfactant initially first uh uh it received two doses of surfactant, sir.

[00:00:49]First dose and 6 hours later another dose was given. Now, currently 12 hours.

[00:00:53]This X-ray was done at 12 Kind of a picture you often see PPROM.

[00:00:57]So, preterm prolonged rupture of membranes if the uh rupture of membranes happened a few weeks earlier, um there's a chance that the baby behaves like a uh closed down lung.

[00:01:08]But, is there any history of PPROM in this situation?

[00:01:11]Uh yes, sir. The uh mother had premature rupture of membranes, sir, for the past uh 3 to 4 days.

[00:01:18]Um I mean, when the lung when the amniotic fluid volume is low, Volume is low, sir. When they took the amniotic fluid sample, it was only 6 Okay. Go ahead. Next slide. Yes, sir.

[00:01:31]So, interpret the following uh ABG, which results prior to the HFOV initiation. The pH was 7.15 and PCO2 was 65 and the partial pressure of oxygen 38, bicarb of 22, sir, base excess of minus four. With 100% FIO2, the saturation is being 85%.

[00:01:50]Okay.

[00:01:51]So, I mean, who wants to answer this?

[00:01:53]Dr. Monica Solanki?

[00:01:55]You want to try?

[00:01:57]Sir, this is respiratory acidosis.

[00:02:01]Okay. So, this baby is very sick because you have not managed to open up the lungs. You saw the X-ray.

[00:02:07]You want to go back to the X-ray and comment on it.

[00:02:11]You want to comment on the X-ray, Dr. Monica Solanki?

[00:02:14]There is homogeneous bilateral homogeneous opacities. Mhm.

[00:02:20]It's like a ground glass opacity. Great for >> opacities, RDS. Grade four RDS and the ET tube is in position, isn't it?

[00:02:28]>> Mhm.

[00:02:29]Okay. So, with this picture, I mean 750 g, 26 week PPROM for 4 days.

[00:02:35]So, it's a very tough situation. This gas is not good before you started high frequency. So, you agree with the decision to start high frequency, right?

[00:02:45]Okay. Go ahead, Dr. Monica.

[00:02:47]And the question is to set the initial HFOV parameters based upon the above ABG and the clinical condition and explain the rationale behind the settings.

[00:02:57]Oh, maybe you could just You could answer it yourself. Yes, sir.

[00:03:02]So, regarding the ABG analysis, it showed severe respiratory acidosis with hypoxemia, which is suggestive of ventilator failure. And the initial HFOV settings we will start usually MAP with P for 2 cm above the conventional ventilation map and the frequency set as 10 to 12 Hz for a better carbon dioxide clearance and amplitude of to start at 30 to 40 cm of water with FIO2 initially to start at 100%. Then titrate based upon the saturation. I time ideally to get it at 0.33 seconds.

[00:03:39]So, this is the classic case where you would be using the lung recruitment strategy because you have a closed down lung.

[00:03:45]You want to open up the lungs. So, later when you get your high frequency module, I think it will be in the next uh next module release.

[00:03:54]So once you review that, you'll understand that to recruit, you start with the setting, but then you keep increasing every 5 to 10 minutes you can increase 2 cm water or even 5 minutes to 3 to 5 minutes.

[00:04:07]If the FiO2 reduces, you stay at that level and monitor. Your aim is to go below uh 30 to 40% FiO2. So you keep increasing the map.

[00:04:17]You may consider another dose of surfactant in this case once you manage to open up the lungs because probably the earlier doses were given when the lung is not inflated well.

[00:04:27]Um again, even though the tube seems to be in position on the X-ray, we don't have the ETCO2 sensor in India. So some of these cases where the lung is totally closed down, it doesn't go with the clinical picture. Sometimes a tube may be in the esophagus and you don't pick it up. So always try to if you don't have the ETCO2 sensor to confirm, you can visualize with a laryngoscope or you can look at the graphics on the ventilator to understand if the tube is really in the airway or not. So that's an important point to remember as well.

[00:04:58]And obviously lung ultrasound also can be used to check both the severity of the X-ray and the tube position as well. I mean, the compared to the arch of aorta, you can compare where the tip of the tube is so that will guide you uh whether the tube is in position in the airway or not.

[00:05:16]So any comments on this any of these cases will be presented Dr. Monica.

[00:05:21]Thank you for taking the effort.

[00:05:25]Thank you, sir.

[00:05:26]Thank you. Any questions or comments or any