Introduction
Air Leak Syndrome is a term used to describe a collection of similar pathologies related to air being in pulmonary, pleural and interstitial spaces. The most common cause of air leak syndrome in neonates is inadequate mechanical ventilation of their delicate lungs. The incidence of air leaks in newborns is inversely related to the birth weight of the infants, especially in infants suffering from respiratory distress syndrome and meconium aspiration (Walsh, 2015). Chest tube drainage and/or needle aspiration are necessary in managing pneumopericardium with cardiac tamponade or tension pneumothorax.
To prevent air leak syndrome, gentle ventilation with low pressure, low tidal volume, low inspiratory time, high rate, and
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For pneumothorax, the incidence from 1990-2002 was 13% in babies weighing <1000 grams are at high risk the first day or two after birth. Babies with pulmonary hypoplasia, meconium aspiration syndrome, and respiratory distress syndrome are also at higher risk. Use of NIV/CPAP also increases the risk. An article in the Pediatrics journal cited three cases where children of various ages developed various air leaks from the use of high-flow nasal cannula (HHNC) therapy. The author cited the urgent need to conduct more studies on HHNC and that it should not be used for providing positive distending pressure. Set flows should not exceed the patient’s minute ventilation (Hegde, 2013).
Prevention
Sadly, it should be understood that most of pulmonary air leaks are iatrogenic. Healthcare workers should not be overly aggressive when doing CPR and using the bag mask. Infants’ lungs are fragile and cannot handle being over-ventilated. When using mechanical ventilation, use low pressures low tidal volumes and high respiratory rates. Risk of pneumothorax and pulmonary interstitial emphysema can be reduced by using surfactant.
Pathophysiology
Air leaks are a result of overdistention of the lungs and can cause uneven alveolar ventilation and air trapping. Increased pressures can rupture alveoli or other tissues, allowing air to escape into the interstitial spaces. This air can then travel through perivascular adventitia, causing pulmonary interstitial emphysema. If the air
Air escaped from the lung into the pleural space. Eventually, enough air collected in the pleural space to cause the mediastinum to shift twoard the right. The collapsed left lung, increased intrapleural pressure, and rightward shift make it difficult to ventilate A.W.
Although when it happens, there can be a devastating impact on patients as well as to the multidisciplinary theatre team involved. Consequently, the DAS has produced a consensus set of guidelines for managing failed intubations in adult and paediatric patients, but there are as yet no such nationally-agreed guidelines in obstetrics, therefore each obstetric unit should have their own flowchart with regards to management of failed intubation (Brien and Conlon, 2013). Furthermore, in light of the latest DAS guidelines, several aspects of clinical anaesthetic practise have changed over recent years (Frerk at al, 2015). Amongst the changes are the use of new drugs such as rocuronium and suggamadex and using electronic video-laryngoscopes (Frerk et al, 2015). Further work had also looked at extending the period of apnoea without causing desaturation by optimising the preoxygenation process and adequate patient positioning (Frerk et al, 2015). As a result, updated guidelines for difficult intubations in adult patients were published in 2015; these guidelines provide a flowchart to be used when endotracheal intubation proves difficult or impossible and focus on the central importance of oxygenation while reducing the amount of airway interventions in order to minimize trauma to the delicate airway (Frerk et al, 2015). The main message of the revised guidelines is
The new versus classic BPD features have changed over the years. The approaches to care, including surfactant administration, permissive hypercapnia, and noninvasive ventilation have changed. All these has increased the survival of low birth weight infants as before with classic BPD. The classic BPD was before surfactant and more management techniques, and inflammation and alveolar septal fibrosis. All these changes were associated with oxygen toxicity, infection, and barotrauma.
Premature birth has been linked to a vast array of lungs problems, the earlier the birth the greater risk of health complications(Davis R and Mychaliska G, 2013). A majority of the health problems will affect the infant for the rest of their life (Davis R and Mychaliska G, 2013). Infants born between the canalicular and the saccular period (week 25) have lung development that is unsuitable for gas exchange (Davis R and Mychaliska G, 2013). Two major complications that arise with undeveloped lungs is bronchopulmonary dysplasia, and pulmonary arterial hypertension (Mahgoub L. et al. 2017).
Allen here to speak to you about the most common diseases we see here in the Pediatric Pulmonary Department. I will start by telling you what they are and I am sure you have heard them before. First there is Acute Bronchiolitis (inflammation of the bronchioles). Acute Bronchiolitis is usually accompanied by tachypnea (rapid breathing), chest retraction (sinking in of soft tissues of the chest), and wheezing (whistling or rattling sound on the chest). Next is Tuberculosis (bacterial infection spread through lymph nodes and blood stream into other part of the body). TB is very contagious due to the fact it is airborne. Children are most susceptible to this disease. They can get it by being in contact with someone who has active TB. This disease is very fatal to children as it can result in death. The bad thing about TB is that it can not be detected and it can sometimes lay dormant in the system and never be active, so sometimes we wont ever know if a child has it until they appear sick and get tested for the disease. The last condition we will discuss is Sleep Apnea (interruptions of breathing while sleep). Sleep Apnea occurs when the muscles in the mouth and your tongue relax to the point of blocking your air way, sometimes it causes you to make noise like snoring and other times and blocks your breathing completely to where you can not
The main priority for all the pediatric patient was to make sure they are getting enough air. They needed an open airway. Without an open airway nothing else matters. To help with the patients airways we monitored their O2 sats and if they were low we made sure to apply oxygen, and continue to monitor their sats. Once oxygen was applied we worked on
This could lead to different types of diseases such as; BPD (Bronchopulmonary Dysplasia) , Asthma, or even SIDS (Sudden Infant Death Syndrome). BPD is more commonly found in premature infants but in some cases healthy babies can also get this disease. One of the reasons why BPD is common in premature babies is because their immune systems are weak. BPD is from damage to the lungs caused by mechanical ventilation (respirator) and long-term use of oxygen. This occurs in premature babies because a lot of time they have to be put on oxygen to help them breath until their lungs become stronger. When an infant is diagnosed with a chronic lungs disease it can lead to other types of infections or complications. If a baby has to be put on a ventilator it could cause complications with their lungs. Ventilators force breathing which means that the ventilators will be forcing high oxygen levels into the lungs of an infant or premature baby. This could possibly cause damage to their lungs. Another chronic lung disease that is commonly found in babies is SIDS (Sudden Infant Death Syndrome). SIDS is an unexplained death, it usually happens while the baby is sleeping, it can happen to a healthy baby who is less than a year old. Some physicians say that the cause of SIDS is from the brain stem being defected; the brain stem controls breathing. Out of 60,000
Although, the first example was a result of the In-Patient social worker, it trickled down to Pulmonary as the child is a patient in the clinic.
Ventilator-associated pneumonia (VAP) remains a big drawback within the hospital setting, with terribly high morbidity, mortality, and cost. Some people tend to perform an evidence-based review of the literature that specializes in clinically relevant pharmacological and non-pharmacological interventions to prevent VAP. Thanks to the importance of this condition the implementation of preventive measures is predominant within the care of mechanically ventilated patients. There is proof that these measures decrease the incidence of VAP and improve outcomes within the intensive care unit. A multidisciplinary approach, continuing
Continuous Positive Airway Pressure or CPAP as it is known, uses forced air to keep a patients airway open. It has common uses that most people are familiar with such as sleep apnea. But it also used in emergency and hospitals routinely to treat sicknesses such as congestive heart failure. In this essay I will give a brief history on CPAP, a basic overview of its anatomy and the some of the many uses of CPAP and health benefits.
The first ventilator induced lung injury that I want to discuss is pulmonary barotrauma. Pulmonary barotrauma is a lung complication caused by too much positive pressure forced into the lungs by a mechanical ventilator. Pulmonary barotrauma occurs when the alveolar begins to rupture due to elevated transalveolar pressure. Transalveolar pressure is a function of both the tidal volume and the overall compliance of the lungs. Researchers use plateau pressures to get an estimation of transalveolar pressure. Plateau pressures can be used as a tool to help measure for the risk of pulmonary barotrauma. Researchers have discovered that plateau pressures less than 30 cmH2O have shown to reduce the cause of pulmonary barotrauma. Guy W. Soo wrote
Necrosis of the cells in the small, lower airways occurs, and mucous secretions are increased (Conquest, Cremonesini, & Neill, 2013). Because of the ciliary damage in the infants’ lungs, it is almost impossible for the secretions to be cleared. Bronchiolar level obstruction is caused by these mucosusal secretions, as is desquamation of the dead skin cells and edema (Conquest, Cremonesini, & Neill, 2013). Plugs of soughed, necrotic epithelium and fibrin in the airways will cause partial or total obstruction to airflow, making it very difficult for he infant to exhale which will consequently result in air becoming trapped and will reduce gaseous exchange (Conquest, Cremonesini, & Neill, 2013).
Negative pressure ventilation relies on the ability to move the chest wall. Negative pressure ventilation (NPV) has also been used in treatment in CCHS patients, however it has been linked to upper airway obstruction during sleeping. Nasal mask ventilation has also been proven in children who are older than 7 years of age with a dependency on nocturnal ventilation. This is the preferred mode of ventilatory support by parents and patients.[32]
I would choose pressure controlled - continuous mandatory ventilation (PC-CMV) for this patient. I would set up the ventilator with the following settings: initial PIP of 20 cm H2O and once patient is attached, I would adjust the PIP to 10 cm H2O above the determined plateau pressure, tidal volume at 90 ml (patient’s IBW is 14.5 kg and the recommended VT is 5 - 8 ml/kg), frequency at 30 (recommended is 20 - 35 for a toddler), FiO2 at 100%, PEEP at the recommended pressure of +5 cm H2O, and inspiratory time of 0.6 seconds (recommended is 0.6 - 0.7) (Walsh 335). I would also add heated humidity to the circuit via a heated pass-over humidifier set at 37 degrees Celsius. The alarm settings would be the following: humidifier high temperature alarm at 38 degrees C. and low temperature alarm at 30 degrees C., high pressure alarm set to 10 cm H2O above PIP and low pressure alarm set to 5 - 10 cm H2O below PIP, low exhaled tidal volume alarm set to 80 ml (10 - 15% below set tidal volume), high PEEP set to 7 cm H20 and low PEEP alarm set to 3 cm H2O (2 - 3 cm H2O above and below set PEEP), high respiratory rate alarm set to 42 and low respiratory rate set to 18 (40% above and below the set rate) (Cairo 106-109).
Respiratory distress syndrome (RDS) is a common lung disorder that mostly affects preterm infants. RDS is caused by insufficient surfactant production and structural immaturity of the lungs leading to alveolar collapse. Clinically, RDS presents soon after birth with tachypnea, nasal flaring, grunting, retractions, hypercapnia, and/or an oxygen need. The usual course is clinical worsening followed by recovery in 3 to 5 days as adequate surfactant production occurs. Research in the prevention and treatment of this disease has led to major improvements in the care of preterm infants with RDS and increased survival. However, RDS remains an important cause of morbidity and mortality especially in the most preterm infants. This chapter reviews the most current evidence-based management of RDS, including prevention, delivery room stabilization, respiratory management, and supportive care.