Continuous negative pressure (CNEP)

Used in conditions with increased work of breathing, small airways disease, V/Q mismatching and those infants who may tire easily post extubation.

This mode of support can be easily adjusted/manipulated to suit the individual patients – requirements. Start your CNEP roughly 2cms H2O more than you would CPAP. This level is then adjusted until the increase work of breathing decreases. This will be noted with decreased recession, use of expiratory muscles, metabolic acidosis, stable or falling CO2 and improved oxygenation.

The air within the cuirass can cause the infants to be at risk of temperature loss. It is advisable to dress them in pyjamas or warm clothes, without buttons as these can affect the seal on the cuirass. Or place them under a radiant heater

Once a suitable level of CNEP is found and the patient is n the recovery phase of their illness weaning from CNEP can be initiated by bringing down the level of CNEP and then once at an expectable level taking the patient off for controlled periods. These are gradual lengthened to suit the patient.

CNEP helps improve right ventricular function, especially when used in conjunction to PPV. References: 10, 11, 12, 13, 15.

Ventilation Modes

There are 3 different Ventilation modes available on the Hayek RTX.

There are 2 modes which are triggered by the patient’s respiratory effort, whare are “Respiratory Triggered” and “Respiratory Synchronized”. These modes can be used as pressure support modes and an aid to weaning.

The cause of respiratory failure will determine the mode chosen and the settings programmed.

Normal lung:

Neuromuscular conditions, ventilation during anaesthesia, and ventilation post cardiac surgery (especially in Children), Head and Spinal Injuries references: 10, 11, 12, 13, 13,14, 15, 16, 17, 23, 24, 25, 26, 27, 28, 29, 35, 36, 52

Inspiratory: -21
Expiratory: +7
I:E Ratio: 1:1
Frequency: * see below
* When using synchronised mode set a minimum backup frequency at 10 less than the patient’s spontaneous breathing rate (lowest is 6cpm).

* When using control mode begin by setting frequency at 2-4 breaths above patient’s own spontaneous breathing rate.

Sick lung:

Restrictive

Bronchiolitis** Cardiogenic Pulmonary Oedema, Chronic Obstructive Pulmonary Disease (COPD), Emphysema, CF, references: 39, 45, 46, 49, 53, 54

Inspiratory: -18
Expiratory: +6
I:E Ratio: 1:1
Frequency : 60 cpm in control mode (can be increased up to 120 to improve results where necessary), 40 cpm backup in synchronised.

If necessary it is also possible to increase span and pressures keeping a pressure ratio 3:1

e.g. change -21 +7 or -24 +8

Obstructive

Asthma, bronchiolitis**, PCP, TB Pneumonia

Inspiratory: -24
Expiratory: +8
I:E Ratio: 1:1 or 1:2
Frequency: at spontaneous respiratory rate of patient in control mode, or respiratory rate of patient -10pcm as backup in synchronised mode

Low Compliance/Low Lung Volume

Respiratory Distress Syndrome references: 33, 38, 41, 44

Inspiratory: -30 Expiratory: +10 I:E Ratio: 2:1 Frequency: 40, 50, 60cpm up to 120cpm depending on patient

** The pathophysiology of bronchiolitis means that there are both restrictive and restrictive phases during the disease process.

It should be used when there is atelectasis, excess secretions or CO2 retention.
Divided into two parts

Vibration mode

This mode shakes and thins secretions
Insp/Expiratory: -8 +8
I:E Ratio: 1:1
Frequency: 800cpm *
Time 3-4minutes

* decrease the frequency for more tenacious secretions

Expiratory pressures in vibration mode are defaulted to the same as inspiratory pressures. Higher pressures are tolerated well e.g. +/- 15

Cough mode

This mode assists with expelling the secretions and can act as a mini sustained inflation.
Inspiratory: -25
Expiratory: +15
I:E Ratio: 4:1
Frequency: 50
Time: 3 minutes

The negative pressure can be made more negative as required.
Completion of both modes represents one cycle of secretion clearance mode

Each secretion clearance session should last between 30-60 minutes

It is possible to use higher pressures in cough mode e.g. -35 +25 as tolerated by the patient

It is helpful to introduce one or two cycles every few hours for most infants with bronchiolitis. The number and frequency of cycles can be adjusted according to the severity of the infant’s condition. Occasionally some infants cannot tolerate a full 3 minutes of cough when it is first introduced, in which case the mode setting can be changed earlier. They usually do get used to it fairly quickly.

According to the United States Census Bureau, approximately 320 million people reside in the United States of America and that number is on the rise.

Historical and recent possibilities of high profile pandemic outbreaks have raised awareness of the acute problem of treating and dealing with mass casualty situations. A pandemic is a disease outbreak, potentially reaching all areas of the world.

One particular issue of great concern is the lack of an adequate way to deal with large groups of people requiring ventilation quickly and effectively. The number of ventilators required to save the lives of people stricken with respiratory failure in a pandemic is far greater than the number of ventilators available.

Of the several major influenza pandemic outbreaks in the 20th century, the 1918 influenza was the most deadly. Killing roughly 50 million people worldwide, this 1918 outbreak eliminated a significant number of the world’s population.

During a severe influenza pandemic, many patients with respiratory failure who are able to receive mechanical ventilation may survive, while patients with respiratory failure who do not receive mechanical ventilation are likely to die.
The Center for Disease Control (CDC) assumes that ventilators will be in short supply in many communities prior to or during the peak of a severe influenza pandemic if something is not done.
According to the American Association for Respiratory Care, approximately 62,000 full-feature mechanical ventilators are available in the United States of America. This leaves more than 99% of the United States population without any available form of ventilation in the event of a pandemic outbreak. Current ventilator capacity and usage in the United States is about 75% to 95% utilized with existing cases (COPD, elderly, accident victims, trauma, post surgical, cardiac, etc)

Currently, Endotracheal (ET) intubation is utilized in conjunction with positive pressure ventilation for respiratory support in patients with cardiac or respiratory arrest during emergent situations.

Coupled with the shortage of qualified clinicians capable of managing endotracheal intubation, even with a stockpile of positive pressure ventilators, only a very limited number of patients can be treated.

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