RESPIRATORY

~ Use of an Ambubag

~ Manual Suction if yours breaks

~ Dr Schroth:  Breathing Basics

~ Dr Schroth: Controversies in SMA Respiratory Care

~ Special Respiratory Management in SMA

~ Dr Bach: SMA Type 1, Noninvasive respiratory   
   Management Approach

~ Dr Bach: Ventilation, How it works,
   Techniques for children

~ Dr Bach: Intensive Care Protocol

~ Dr Bach: Outpatient Protocol

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Dr Swoboda's Protocols:

~ RESPIRATORY MANAGEMENT

~ Care Guidelines for Children with Neuromuscular Disease with Acute Respiratory Illness

DR MARY SCHROTH SAYS:

COUGH ASSIST Protocols

  •SETTINGS to use by mask, mouth piece, tracheostomy tube or endotracheal tube.
 –INHALE •Start at +30, increase to +40 cm H2O for 1 sec.
 –EXHALE •Start at –30, increase to -40 cm H2O for 1 sec.
 –PAUSE TIME •1-2 sec.

The Last Straw for NMD Lung Function

  •Viral respiratory infections
–Result in:
 •Increased muscle weakness
 •Increased airway secretions
 •More difficulty breathing

•The answer is not supplemental oxygen!

University of Wisconsin
Cold Care PROTOCOL:

  •Perform every 4 hours:
–Airway clearance     •15 minutes
 –Cough Assist     •4 sets of 5 breaths
–Suction mouth or airway
 –Postural drainage     •15 minutes
–Cough Assist     •4 sets of 5 breaths
 –Suctioning mouth or airway

EXTUBATION

  Extubate when the child is:

1.  afebrile
2.  not requiring supplemental O2
3.  CXR is without atelectasis or infiltrates
4.  off respiratory depressants
5.  airway suctioning is 1 time/hour or less 

•Extubate from reasonable settings:
–a rate similar to the optimal BiPAP rate
–pressures that approximate BiPAP inspiratory
       pressure (15-20) and expiratory pressure (3-6)
 –ideally room air
•Avoid low ventilator rates through ET tube Þ atelectasis
       (lung collapse) and fatigue.
–E.g., CPAP trials are not indicated prior to extubation.

  •Respiratory rate
 –Set to capture breathing effort and rest child
•Example settings:
 –<1 year old, RR=30 (highest rate on BiPAP)
 –1-3 years old, RR=25
 –>3 years old, RR=20-25
 –Teenagers to adult, RR=14-16 and recommend sleep study to titrate.

Technical Aspects

  1).Bilevel positive airway pressure (BiPAP)  
Examples: Respironics Synchrony, ResMed VPAP III, Knightstar

     IPAP: 14-20 cm of H20
   EPAP: 3-6 cm of H20

     Mode: ST (spontaneous timed)

  Respiratory Rate: high enough to capture 
              breathing efforts and rest child.

  Inspiratory Time: depends on pt age and RR

  Rise time: speed of breath delivery

  2) Home mechanical ventilator
   Examples: LP-6+,LP-10, LTV 900 or 950  

  Modes: AC, SIMV PC or SIMV VC

–   pressure ventilation
–  volume ventilation
–  Tidal volume approximately 13-20 ml/kg per
          nasal mask