Podcast 70 - Pediatric Ventilation with the Hamilton T1
Here are the show notes for Podcast 70 - Pediatric Mechanical Ventilation with the Hamilton T1. We discuss a lot about waveforms, and waveforms are incredibly important to safe pediatric mechanical ventilation. You might check out this post first; "Ventilator Waveform Anatomy - The Basics You Gotta Know".
1) CIRCUIT CHOICE
There is a good amount of overlap in circuit size. Neonatal circuit covers up to 30 kg, adult/pedi for >3 kg.
Rule of thumb, 10 kg and down should use neonatal circuit
Advantage of neonatal circuit is less deadspace and the 90-degree connector on the end.
2) STARTING SETTINGS
Smaller airways need more time to exhale than adults. Start with an I:E of 1:3 unless obstructive pathology, then shoot for higher (like 1:4 or 1:5...but use the flow waveform to determine the right balance of Inspiratory time and Rate). In all patients, use caution with I:E less than 1:2 ... watch flow waveform carefully.
Be careful with respiratory rate. Increasing rate increases deadspace ventilation and alveolar ventilation equally. Increasing tidal volume increases alveolar ventilation while leaving deadspace ventilation constant. As a rule of thumb, don't exceed a rate of 40 on a >3kg infant without careful thought .
Use the Hamilton start-up screen to recommend a starting rate based on patient weight. (See Table A-5 in T1 manual; simplified version below.
Consensus Pediatric ARDS recommendations: start with tidal volumes of 5-8 ml/kg, max target plat 28 or less, monitor PIP if using pressure mode, severe ARDS may require PEEP of 15 or higher. Imber 2019 seems to indicate tidal volumes of 10 ml/kg are safe in pediatric patients.
3) RUTHLESS DEAD SPACE ELIMINATION
Check out this earlier post for a thorough discussion. Must be able to recognize signs of CO2 rebreathing on the capnography waveform (tailing, lifting baseline).
Set up a blanket roll to support your circuit.
Eliminate the "tower of terror" and minimize the amount of gadgets you attach to the ETT.
4) USE CUFFED ETTs
Check leak using vLeak or comparing VTI and VTE (benefit to vLeak is that it averages across several breaths).
vLeak is on the Monitoring tab, page 2. You might consider setting this as a monitored parameter on the home screen
Be prepared to switch out an uncuffed ETT for a more appropriately-sized cuffed ETT to maintain oxygenation.
5) OBSTRUCTIVE/RESTRICTIVE PATIENTS
SXLLM​Don't forget RSV/bronchiolitis falls into this category
Start with the flow waveform. Make sure the patient is able to completely exhale before starting the next breath.
Use flow waveform to set RR. You may be able to set it faster than you think. Again, to reference our waveform post; don't leave baseline on the table: use it all up to optimize minute volume.
You may actually need to extend the inspiratory time to get air past the obstruction. Many times the solution to obstructive patients is a moderate TI and slow RR.
Utilize a percussive squeeze: disconnect, two hands on chest, help facilitate exhalation. Particularly effective on pediatric patients.
Continuous nebulization with Aerogen. Don't forget IM and/or IV Epi for severe bronchospasm. Start that Magnesium and steroids early.
MXLLS​​
6) EQUIPMENT
Aerogen nebulizer - can't recommend enough for nebulizing with NIV, HFNC, spontaneous respiration, or mechanical ventilator. Smaller particulate size for better deposition. Electric; no gas introduced into circuit.
Look into COMFIT and Neo-fit for ETT securement
Appropriate sized items for true pedi/neo teams:
- 6FR and 10FR soft suction
- 6FR and 10FR gastric tubes
- 6FR and 10 FR bougies and stylets
- Pedi/neonatal decompression needles (18g 1.75" procedure needle that can be attached to syringe for aspiration, made of FEP polymer that does not collapse when warmed to body temp)
- Something smaller than a Pedi-Mate (such as a BabyPod, ACR, or Neo-Mate)
- Warming mattress / Transwarmer
- Continuous temp monitoring probes
7) OXYGEN CONSUMPTION
Recently improved with a software upgrade.
The Hamilton now uses 4 lpm bias flow with the neonatal circuit, and 3 lpm on the adult/ped circuit.
Simply click system tab and look at O2 consumption rate.
You can use this app we built to calculate oxygen duration in common airframes, based on the Hamilton consumption rate.
And that's it! There is a lot more we can learn from pediatric respiratory therapists, intensivists, and transport clinicians. We would welcome any additional insights and feedback from the FOAMed community. Hopefully this brings up some good discussion points for you and your program.
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FoamFrat or the author has no conflicts of interest, or benefit to recommending specific products or equipment.