Use Of Strategic National Stockpile . - Pediatric Medicine
Use of Strategic NationalStockpile [SNS] Ventilatorsin the Pediatric PatientInstructional Guidelines withTraining Scenarios2nd Edition (2010)Illinois Emergency MedicalServices for ChildrenDecember 2010
Use of SNS Ventilators in the Pediatric PatientTable of ContentsAcknowledgements . 3Overview and Mechanical Ventilation Review . 5SNS Ventilator Advantages . 6Manufacturers . 6Use of SNS Ventilators in Infants . 7Strategic National Stockpile VentilatorsLP-10 Volume Ventilator with Pressure Limit . 8LP-10 Volume Ventilator “Quick Set Up” . 11LTV-1200 Ventilator. 12LTV-1200 Ventilator “Quick Set Up” . 17UNI-VENT Eagle Portable, Self-Contained Ventilation System . 18UNI-VENT Eagle Ventilation System “Quick Set Up” . 21Selected Additional Non-SNS VentilatorVersaMed iVent . 22Additional InformationTrouble-shooting. 27Concepts of Pediatric Ventilation . 27Practice Scenarios . 29Pediatric Ventilator Reference Materials and Bibliography . 51 Page 1
Use of SNS Ventilators in the Pediatric PatientThis page intentionally left blank. Page 2
Use of SNS Ventilators in the Pediatric PatientAcknowledgementsThis is the 2nd Edition of the Instructional Guidelines for Use of Strategic National Stockpile(SNS) Ventilators in the Pediatric Patient. Development of this 2nd Edition was conductedunder the direction and oversight of Illinois Emergency Medical Services for Children and thePediatric Work Group, Illinois Terrorism Task Force.Illinois Emergency Medical Services for Children is a collaborative program within the IllinoisDepartment of Public Health. The Pediatric Work Group is composed of physicians,nurses, paramedics, pharmacologists, psychologists, state/local health department personnelas well as representatives from key organizations, such as the American Red Cross, IllinoisAssociation of School Nurses, Illinois Chapter of the American Academy of Pediatrics,Illinois College of Emergency Physicians, Illinois Hospital Association, Illinois StateCouncil of the Emergency Nurses Association, Illinois Medical Emergency ResponseTeam, Illinois Nurse Volunteer Emergency Needs Team and Illinois Poison Center, amongothers.Training materials previously developed by a team at Children’s Memorial Hospital, Chicago, ILthrough HRSA and ASPR grant funding, contributed substantially to the development of the firstedition of this document. The practice scenarios were developed by Lynn Chlebanowski, RRT,Children’s Memorial Hospital, Chicago.This 2nd Edition has incorporated information related to the LTV-1200 ventilator along withother additional information.Photographs of the LP-10, LTV-1200 and the Uni-Vent Eagle ventilators were obtained from themanufacturer’s manual.The VersaMed ventilator photographs were provided byLynn Chlebanowski, RRT, Children’s Memorial Hospital, Chicago.Development, printing and distribution of this booklet has been supportedthrough federal funding from the Assistant Secretary for Preparedness and Response(ASPR) Hospital Preparedness Grant Page 3
Use of SNS Ventilators in the Pediatric PatientThis page intentionally left blank. Page 4
Use of SNS Ventilators in the Pediatric PatientUse of SNS* Ventilatorsin the Pediatric Patient*LP-10 Volume Ventilator, LTV-1200 Ventilator and the UNI-VENT Eagle Ventilation SystemOverview & Mechanical Ventilation ReviewThe threat of nature in the form of an influenza illness has accelerated preparations for apotential pandemic flu, which may result in thousands of patients requiring mechanicalventilation.In the wake of a pandemic flu most available ventilators owned by hospitals will be in use,necessitating the delivery of ventilators currently stored in the Strategic National Stockpile[SNS]. In addition to a surge of all patient populations in a pandemic, there may also be manychildren who require respiratory support in hospitals that do not routinely care for children onventilators.This document has been developed for use by clinicians (physicians, nurses and respiratory careproviders) who have baseline knowledge of pulmonary physiology and the concepts ofventilation and who may find themselves working with ventilators that are not used on a dailybasis. The intent is to provide clinicians with a quick reference for Just-in-Time training and setup of the SNS Ventilators (as of 2010).Mechanical Ventilation is indicated in pandemic flu for acute respiratory failure, defined asinsufficient oxygenation, insufficient alveolar ventilation, or both. The principal benefits ofmechanical ventilation are improved gas exchange and decreased work of breathing. Mechanicalventilation can be volume, pressure, flow or time-limited.Volume-limited Ventilation: Inspiration ends after delivery of a present tidal volume. Theairway pressure is variable and related to compliance, airway resistance, and tubing resistance.Volume limited modes of mechanical ventilation include assist control and synchronizedintermittent mandatory ventilation.Pressure-limited Ventilation: Inspiration ends when a present maximum airway pressure isreached. The tidal volume is variable and related to compliance, airway resistance, and tubingresistance. Minute ventilation cannot be guaranteed as a consequence of the variable tidalvolume.Flow-limited Ventilation: A preset airway pressure is delivered once the ventilator istriggered. Inspiration ends when the inspiratory flow decreases to a predetermined percentageof its peak value. Pressure support is the mode of ventilation that is typically flow-limited. Page 5
Use of SNS Ventilators in the Pediatric PatientTime-limited Ventilation: Inspiration ends after a present inspiratory duration.The level of ventilatory support is determined by the modes and other settings. In most casesassist control tends to provide the most support, synchronized intermittent mandatoryventilation offers the widest range of support and pressure support would provide the leastamount of support.Settings to consider when providing mechanical ventilation include trigger mode and sensitivity,respiratory rate, tidal volume, positive end –expiratory pressure (PEEP), flow rate, flow pattern,and fraction of inspired oxygen (FiO2). During volume-limited ventilation, the clinician sets thetidal volume and it remains constant. In pressure-limited ventilation, the tidal volume is variableand is directly related to the inspiratory pressure level and compliance, but indirectly related tothe resistance of the ventilator.SNS Ventilator Advantages PortableEasy to set upElectrical or battery poweredCan ventilate without high pressure sourceVolume ventilators (but pressure can be limited)ManufacturersThese guidelines are based on manufacturer specifications and recommendations.www.PuritanBennet.com (LP-10)www.carefusion.com (LTV1200)www.impactinstrumentation.com (UNI-VENT)www.versamed.com (VersaMed iVent) Page 6
Use of SNS Ventilators in the Pediatric PatientUse of the SNS Ventilators in InfantsEach of the SNS ventilators can be utilized in the pediatric patient. The table below outlineskey information regarding use of each of these ventilators specifically in the infant population.Weight limitations and lowest tidal volume delivery is listed below for each ventilator, alongwith information related to pressure ventilation, circuit considerations and sensitivity. Be sureto also consider accessing manufacturer information when utilizing these ventilators in neonatesand infants.LP10LTV 1200Eagle UniventVersaMed iVentVolumeVentilation10 kg patient weightlimitation; Lowesttidal volume - 100 mlVentilator designedto work withpatients as small as5 kgLowest tidalvolume available is10 ml5 kg patient weightlimitation; Lowest tidalvolume is 50 mlPressureVentilationPossible to limitvolume breaths toventilate infantssmaller than 10 kg;however, volumesthen unknown.Has pressureventilationcapabilities. Infantstraditionallyventilated withPressure modes.Possible to limitvolume breathswith plateaupressure. Volumescan be measured.Has pressure ventilationcapabilities. Infantstraditionally ventilated withPressure modes.CircuitConsiderationsPediatric circuitsavailable.Pediatric circuitsavailable.Pediatric circuitsavailable.Only one size circuitavailable (ped/adult).Volume lost to the circuitmay make ventilation ofinfants smaller than 10 kgdifficult even in pressure.SensitivityPressure trigger only.Difficult for infants topressure triggerbreath.Pressure and Flowtrigger available.Flow trigger easierfor infants to triggerbreath.Pressure triggeronly. Difficult forinfants to pressuretrigger breath.Pressure and Flow triggeravailable. Flow triggereasier for infants to triggerbreath. Page 7
Use of SNS Ventilators in the Pediatric PatientVENTILATOR INFORMATIONLP-10 Volume Ventilator with Pressure Limit Volume ventilator (A/C or SIMV)Volume is measured with spirometer (no LED readout)Minimum Vt – 100 mlCan limit breath by using pressure limit control (volume is no longer guaranteed)No pressure supportPeak airway pressures measured by manometerPEEP is set on external valveBATTERY LIFE Internal battery 30 min – 1 hour External – approximately 10 hours Page 8
Use of SNS Ventilators in the Pediatric PatientSETTINGS Set Mode (A/C or SIMV) Set Rate Set Tidal Volume (10 ml/kg) Set Inspiratory Time (typically 0.7 – 1.0 sec) Set PEEP (typically start at 5cwp) Determine Sensitivity (set based on pressure below PEEP) Set AlarmsCIRCUIT SET UPOXYGEN DELIVERY Lower FiO2 can be bled from front of vent Higher FiO2 require oxygen enrichment kit and is bled in from back Requires external analyzer to measureTIDAL VOLUME CONSIDERATIONS Set at 10 ml/kg Some volume lost to circuit Volume measured with spirometer Minimum 100 ml Can limit using pressure limit control (volume no longer guaranteed) Peak pressure measured on manometerPEEP Set on external valve Turn spring loaded valve to set desired PEEP Value seen on manometer Page 9
Use of SNS Ventilators in the Pediatric PatientUPPER FRONT PANELLOWER FRONT PANEL Page 10
Use of SNS Ventilators in the Pediatric PatientLP- 10 Ventilator“Quick Set Up”Mode SIMV or Assist ControlVolume 10ml/kg (measured by spirometer)Breath rate Set age appropriateInspiratory Time (0.7-1.0 second)FiO2Back of machine- O2 enrichment kit Capable of delivering 100% Set liter flow (not 10 lpm) Analyze FiO2Front of machine- Bleed O2 into circuit Highest FiO2 approximately 40% Adjust liter flow and analyzePEEP External PEEP valve located on circuit exhalation valve; dial in desired PEEP pressureAlarms Set based on average Peak Inspiratory PressureLow Alarm Limit 5 cwp below Peak Inspiratory PressureHigh Alarm Limit 10 cwp above Mechanical Breaths Peak Inspiratory PressureBattery Life Internal Battery 30 minutes to 1 hour; External battery 10 hours Page 11
Use of SNS Ventilators in the Pediatric PatientLTV 1200 VentilatorADVANTAGES Portable Easy to set up Electrical or battery powered Can ventilate without high pressure source Can volume or pressure ventilate Has pressure support Allows for non-invasive ventilation Can use in patients greater than 5 kgBATTERY LIFE Internal battery lasts approximately 60 minutes Small external battery pack lasts approximately 3 hours Large external battery pack lasts approximately 9 hoursFILTERS Fan filter should be cleaned or replaced when soiled Inlet filter should be cleaned or replaced when soiled Page 12
Use of SNS Ventilators in the Pediatric PatientCIRCUITS Adult and pediatric circuits available External exhalation valveOXYGEN DELIVERY Can run off internal turbine at 21% Low oxygen source provides oxygen based on liter flow and minute volume; requiresoxygen analyzer High pressure oxygen source allows precise FiO2 to be set on ventilatorPOWER SOURCESource and charge levels External Power : Green – external power acceptable;Amber – external power level low Charge Status: Green – internal battery fully charged;Amber – battery not fully charged;Red – battery cannot be charged Battery Level: Green – battery fully charged;Amber – battery low; Red – battery emptyVENT CHECKOUT MENU Ventilator checkout test required before placing on patientPress and hold select button and press on/standby buttonRemove PTNT appears; clear alarm and display will read Vent CkPress select for each testAlarm – verify audible alarmDisplay – verify all lights and LED displaysControl – press each control button and verify control name displayed; turn control knobLeak – occlude proximal end and press selectVent inop test Page 13
Use of SNS Ventilators in the Pediatric PatientBUTTON CONTROLSOn/Standby, Breath & Mode Selection, Manual Breath, Silence Reset, Manual Breath, LowPressure O2, Insp/Exp Hold, Control Lock Turn a feature on or off (i.e. Control Lock) Toggle between two features (Volume or pressure ventilation) Perform a function (manual breath)CHANGING PARAMETERSRate, Tidal Volume, Pres. Control cmH2O PEEP, Insp. Time sec, Pres. Support cmH2O PEEP, PEEP Push button of parameter to be changed Turn Set Value knob to desired change Push button of parameter a second time to confirm changeMODESAssist Control – Volume or Pressure, SIMV – Volume or Pressure, CPAP/PSV, NPPVVOLUME VENTILATION Assist Control or SIMVSIMV has pressure support for spontaneous breathsInspiratory Time setSet PEEP on ventilatorPRESSURE VENTILATION Assist Control or SIMV SIMV has pressure support for spontaneous breaths Inspiratory Time set. If set time limits at a lower than desired value, switch mode tovolume ventilation and increase tidal volume. Return to pressure mode and increaseinspiratory time. Set PEEP on ventilator Page 14
Use of SNS Ventilators in the Pediatric PatientPRESSURE SUPPORT/CPAP Set mode to SIMV Turn rate off Set pressure support PEEPNPPV PEEP is EPAP Pressure Support is IPAPALARMS High Pres. Limit Low Pressure Low Min. Vol.SENSITIVITY Breaths are flow triggeredValues set 1 to 9The lower the number, the easier the vent is to triggerIf the O2 Conserve feature is on, the vent is pressure triggeredEXTENDED FEATURESAlarm options, Presets, Transducer Autozero, Real-Time Transducer Data, Event Trace,Ventilator Maintenance, Ventilator Checkout Tests, Ventilator Options and SpontaneousBreathing Trial.Access menus by pressing and holding the Select button; turn the Set Value Knob until youreach the desired menu. Press select. Use the Set Value Knob to advance through the choiceswithin the menu and press select to choose value to set. When finished, scroll until you reachthe Exit option.The following three Extended Feature menus are commonly used for setting up the ventilator:VENTILATOR OPTIONS Variable Rise Time – Rise time settings 1-9 (1 fastest rise time; 9 slowest rise time). Page 15
Use of SNS Ventilators in the Pediatric Patient Variable Flow Termination – Allows user to select percentage of peak flow used to cyclePressure Support breaths to exhalation. Range: 10% to 40% Variable Time Termination – Allows user to select maximum inspiratory time allowed forPressure Support breath to cycle to exhalation. Breath cycles based on time if reachedbefore flow reaches set peak flow percent. Pressure Control Flow Termination – Allows Pressure Control breath to cycle toexhalation based on percentage of peak flow instead of inspiratory time if that flow isreached before the set time. Range: 10% to 40%. Leak Compensation – When enabled, compensates for leak up to 6 lpm if leak is stableand there is no autocycling. O2 Flush – Allows operator to increase FiO2 to 100% for up to 3 minutes.ALARM OPTIONSAllows user to set additional alarm options. Alarm VolumeApnea IntervalHigh Pressure Alarm DelayLow Peak Pressure AlarmHigh frequencyHigh PEEPLow PEEPPATIENT QUERY Patient Query can be turned on or off Patient Query On gives choice for Same Patient or New Patient when vent powered on Select New Patient to choose patient size: Infant, Pediatric or AdultVIEWING MEASURED PARAMETERSPressing selecting button once allows you to view monitored values such as PIP, MAP, PEEP, f,Vte, VE, I:E Page 16
Use of SNS Ventilators in the Pediatric PatientLTV-1200 “Quick Set Up”Preuse Vent Op/Leak test/NewPatient/Patient SizeMode SIMV, Assist Control (A/C), PressureSupport-CPAP, NPPVVolume 10 ml/kgBreath Rate Set age appropriatePEEP Set on MachineFiO2 High pressure source – set oxygen on vent (capable of delivering 100%) Low pressure source – adjust liter flow and analyzeAlarms Low Pressure – Set 5 cwp below average spontaneous Peak Inspiratory Pressure High Pressure – Set 10 cwp below average Peak Inspiratory Pressure Low Min. Vol. – Set 1 lpm below average minute volumeExt. Features Safe to use defaults provided appropriate size patient selectedBattery Life Internal Battery 1 hour; Small external battery 3 hours; Large external battery 9 hours Page 17
Use of SNS Ventilators in the Pediatric PatientUNI-VENT Eagle Portable, Self-ContainedVentilation System Volume ventilator (A/C or SIMV)Volume (set/delivered) is measured on LCD screenMinimum Vt – 10mlCan limit breath by using pressure plateau control (volume is no longer guaranteed)No pressure supportPeak airway pressures measured on LCD screenPEEP is set on vent (each push of button 1 cwp)BATTERY LIFE Compressor use – 3 hours External gas source – 12 hours Page 18
Use of SNS Ventilators in the Pediatric PatientCIRCUIT SET UP: Connect 22mm corrugated hose to ventilator GAS OUT fitting Connect green TRANSDUCER HOSE to ventilator TRANSDUCER hose barb (Green) Connect clear EXHALATION VALVE HOSE to Ventilator EXHALATION VALVE hosebarb (clear)OXYGEN DELIVERY Can run off internal compressor for 21% High pressure air/O2 hose for oxygen delivery FiO2 set on control panel Measured on screenBASIC SET UP1. Select a Mode of Operation2. Set a Ventilation Rate3. Set an Inspiration Time,or I:E Ratio default4. Set a Tidal Volume5. Set an Fi026. Set the High and LowLimit Pressure Alarms Page 19
Use of SNS Ventilators in the Pediatric PatientTIDAL VOLUME CONSIDERATIONS Set at 10 ml/kg Some volume lost to circuit Can set lower tidal volumes than the LP10 (as low as 10 ml) Set/Delivered measured on screenPEEP Set directly on vent Each push of button equals 1 cwp of PEEPASSESSMENT Chest rise Breath sounds Respiratory Rate Work of Breathing Pressures required to deliver volume ABG/TCM/SaO2 Page 20
Use of SNS Ventilators i
Mechanical Ventilation is indicated in pandemic flu for acute respiratory failure, defined as insufficient oxygenation, insufficient alveolar ventilation, or both. The principal benefits of mechanical ventilation are improved gas exchange and decreased work of breathing. Mechanical ventilation can be volume, pressure, flow or time-limited.
implementation of the Chemical Stockpile Emergency Preparedness Program (CSEPP) and for the Recovered Chemical Warfare Materiel (RCWM) Program support functions, which includes the assessment and destruction of suspected non-stockpile chemical warfare materials in the United States.
In July 1996, we reported that 8 years after the Chemical Stockpile Emergency Preparedness Program's (CSEPP) inception, Alabama communities near Anniston Army Depot were not fully prepared to respond to a chemical stockpile emergency because they lacked critical items.1 Given the lack of progress in Alabama's CSEPP and prior CSEPP
The Chemical Stockpile Emergency Preparedness Program (CSEPP) has been evaluating emergency response exercises at the eight Chemical Stockpile storage sites since 1992. The results of these exercises have been entered into a user-friendly database, described in An Analysis of
As you requested, we reviewed the Chemical Stockpile Emergency Preparedness Program (CSEPP) for the Oregon and Washington communities surrounding the Umatilla Chemical Depot. This program was created to protect the public in the event of an accident during destruction of the chemical weapons stockpile. You wanted to know whether the
The Chemical Stockpile Emergency Preparedness Program (CSEPP) enhances emergency planning and preparedness for the unlikely event of an accidental release of chemical weapons agent from any of seven1 U.S. Army chemical weapons storage depots in the continental United States (depots shown in Fig. 1). Until the U.S. stockpile is destroyed, it .
In July 1996, we reported that 8 years after the Chemical Stockpile Emergency Preparedness Program's (CSEPP) inception, Alabama communities near Anniston Army Depot were not fully prepared to respond to a chemical stockpile emergency because they lacked critical items.1 Given the lack of progress in Alabama's CSEPP and prior CSEPP
This report responds to your request that we review the Army's Chemical Stockpile Emergency Preparedness Program. The report discusses problems the program is having in helping to . In 1988, the Army established the Chemical Stockpile Emergency Preparedness Program (CSEPP) to help local communities near such sites prepare to respond to such .
The Strategic National Stockpile, or SNS, includes large quantities of medicine, vaccine, and medical supplies intended to protect the American people when a public health emergency is severe enough to cause state and local supplies to run out. The SNS is managed by the Division of Strategic National Stockpile, or DSNS, which is part
