Oxygenation and Ventilation Management

Oxygenation and Ventilation Management
The goal is to inflate the lungs while minimizing pressure-related lung injury by utilizing rate over pressure and oxygen toxicity, while tolerating mild hypoxemia and allow for permissive hypercarbia during the pre-operative period. Avoid dramatic increases or decreases in support Current evidence does not favor pressure vs. volume modes. There is no goal tidal volume for infants with congenital diaphragmatic hernia (CDH). Pressure control modes are generally used Target PEEP is 3 - 5 cmH₂O, lower PEEP may be used to augment tidal volume while not increasing PIP. Use caution when adjusting PEEP > 5 cmH₂O for oxygenation purposes Aim for preductal saturation between 85 - 95%, arterial pCO₂ levels between 45 - 65 mmHg, and goal pH between 7.20 - 7.40 Permissive hypercapnia is supported as a means for achieving improved survival with minimization of lung injury Within the first 2 hours following birth, SpO₂ levels > 70% are acceptable with satisfactory organ perfusion (pH > 7.20), and adequate ventilation (PaCO₂ < 65 mmHg) > 2 hours following birth, preductal saturation levels should be kept between 85 - 95% (levels of 80% may be acceptable on an individual basis, if pH > 7.20, lactate levels < 3 mmol/L, and urine output > 1 mL/kg/h [indications of organ perfusion]) Post-ductal SpO₂ is not recommended. If used, do not fret over post-ductal SpO₂ split. SpO₂ > 70% can be acceptable Avoid oxygen toxicity by decreasing FiO₂ based on the guidance of the saturation levels parameters provided Conventional mechanical ventilation (CMV) is recommended as the initial ventilation strategy Gentle intermittent mandatory ventilation (IMV) is recommended as the initial ventilation mode A T-piece should be used with the ventilator to avoid inadvertent overdistension of the lungs Start FiO₂ at 40% Wean for preductal saturation > 95%
Ventilator Settings	PIP	PEEP	Respiratory Rate	Inspiratory Time	Tidal Volume
Initial	< 25 cmH₂O	3 - 5 cmH₂O	30 - 60	0.3 - 0.4	2 - 5 mL/kg
Weaning	As long as pCO₂< 50 mmHg, settings may be reduced Wean PIP before rate depending upon tidal volumes to keep goal CO₂ Start FiO₂ weaning after 6 hours of life if the infant is stable Wean by 2 - 3% every hour to maintain preductal saturations > 90% Hold weaning of FiO₂ at 30% until the infant has demonstrated stability and consistent high oxygen saturations Monitor for lability after weaning Follow serial lactate measurements (rising lactate is a sign of end-organ hypoperfusion or hypoxia)
High-Frequency Oscillatory Ventilation (HFOV)
May be used as a rescue therapy if CMV fails (failure to improve over 30 minutes with conventional ventilation while maximizing sedation, positioning, suctioning, and/or failure to oxygenate despite use of conventional ventilation [in conjunction with iNO when appropriate]) or if the infant has a pneumothorax If a PIP > 25 cmH₂O is required to achieve pCO₂ and saturation levels within the targeted range, treatment modalities such as HFOV or ECMO should be considered. If PIP > 28 cmH₂O transition to HFOV If mean airway pressure > 16, consider ECMO
HFOV Settings	Mean Airway Pressure (MAP)	Frequency (Hz)	Amplitude	Goal Rib Expansion
Initial	12 - 14 cmH₂O (generally two above conventional ventilator MAP)	10 - 12 Hz (due to pulmonary hypoplasia associated with CDH, higher Hz is preferred for lung protection)	30 - 40 cmH₂O	8 - 10 ribs on contralateral side
Nitric Oxide (iNO) Considerations
Inhaled nitric oxide (iNO) is contraindicated in left ventricle dysfunction, left atrium enlargement, small left-sided structures, and cardiac anomalies dependent upon right to lefy ductal shunting An iNO trial may be considered if the echocardiogram demonstrates right to left atrial shunting that is not responding to other management options AND the infant's SpO₂< 85% persistently. Adequate lung recruitment is required for an iNO trial If starting iNO, the ECMO and surgical team should be made aware One hour following initiation, assess for iNO response (PaO₂increase > 10 mmHg or reduction in FiO₂ > 10% while maintaining goal saturations) [CMH iNO Guidelines] If responding, recommend maintaining infant on iNO through surgical repair; if not on ECMO If there is no response to iNO based on echocardiographic assessment or other clinical and laboratory findings, iNO should be discontinued. It is not necessary to wean iNO

References

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These pathways do not establish a standard of care to be followed in every case. It is recognized that each case is different, and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare a pathway for each. Accordingly, these pathways should guide care with the understanding that departures from them may be required at times.

Oxygenation and Ventilation Management

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