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Nonivasive Respiratory Support - NIV, High Frequency Ventilation - HFV

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International conference «Actual approaches to the extremely preterm babies» (Kyiv, Ukraine, March 5-6, 2013)

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Nonivasive Respiratory Support - NIV, High Frequency Ventilation - HFV

  1. 1. Nonivasive Respiratory Support - NIV High Frequency Ventilation - HFV Iwona MaroszyńskaDepartment of Neonatal Intensive Care and Congenital Malformations Memorial Institute of Polish Mother‟s Health Center Київ 2013
  2. 2. Lung protective strategyNonivasive Respiratory SupportHigh Frequency Ventilation HFV
  3. 3. • High chest compliance • Newborn‟s chest – Bone underdevelopment – More cylindrical – Intercostal muscles – Shorter intercostal muscles – Sleep REM – Diaphragm horizontal position • Muscles tone • Ineffective respiratory effort• Low lung compliance – Surfactant insufficiency – Fewer terminal airspaces – More stroma VT ↓; f↑; grunting
  4. 4. • Elastic recoil (compliance/elastance) – The tendency of stretched object to return to their original shape • Inspiratory muscles relaxation during exhalation • Chest wall • Diaphragm recoil • Lungs – Surfactant, bone development• Viscous resistance – Fewer terminal airspaces – More stroma
  5. 5. lung-chest wall system = pressure-volume characteristic (lung + chest wall)FRC - outward recoil force of the chest wall = inward elastic forces of the lung (resting state of the respiratory system)
  6. 6. • Closing volume – < FRC – = RV • Neonate – Closing volume ↑ FRCCrit Care Med 2005 Vol. 33, No. 3 (Suppl.)
  7. 7. Pulmonary vascular resistance
  8. 8. Pulmonary vascular resistance Pa Palv Pv *** * ** Pa Palv Pv *** ** * Pa Palv PvIII ** *** * I II Modified from West JB: Respiratory Physiology: The Essentials, 2nd ed. Baltimore, Williams & Wilkins, 1979, p. 39 .
  9. 9. Pulmonary vascular resistance LV preload ↓shunt I Pa Palv Pv ** *** * PTV FRC Hakim TS, Michel RP, Chang HK (1982) Effect of lung inflation on pulmonary vascular resistance by arterial and venous occlusion. J Appl Physiol 53(5):1110–1115
  10. 10. - Good conditions for the contact of blood and endothelial cells - High blood flow - Well developed microcirculation - Low perfusion pressure - Highly represented macrophage system - Direct contact with the external environment - colonization
  11. 11. Disadvantages of Ventilation via ETT• Cardiovascular and cerebrovascular instability during ventilation• Complication of ETT – Subglotic stenosis – Tracheal lesions• Acute and chronic lung damage – Volutrauma – Barotrauma – Shear• Infection• If you do not ventilate en infant, it‟s hard to cause BPD
  12. 12. Compensatory mechanisms• f↑ VT ↓• Grunting• Mechanical Ventilation – Open lung strategy • CPAP – Lung protective strategy • Low VT • PEEP • PIP < 25 – 30 • Synchronized
  13. 13. Noninvasive ventilation High frequency ventilation• Open Lung Strategy – Alveolar collapse – Alveolar overdistention• Benefits from open lung strategy – Decreased intrapulmonary shunt – Improved oxygenation – Reduced PVR• Optimal recruitment – Reduced intrapulmonary shunt < 10% – Adequate oxygenation without supplemental oxygen• Practical optimal recruitment – FiO2 ≤ 0,3
  14. 14. Lung Recruitment Maneuver24 B20 FiO2 0,3 C1612 D A FiO2 0,38 FiO2 0,6 A4 FiO2 0,80
  15. 15. Target fraction of FiO2• Retrospective study – To retrospectively evaluate if HVS is associated with better oucome – FiO2 ≤ 0,25 – FiO2 > 0,25• No - 28 vs 23• GA < 26,1 vs 25,9 hbd• Birth weight 603 vs 703 J Matern Fetal Neonatal Med. 2011 in press Tana M et all Unexpected effect of recruitment procedure on lung volume measured by respiratory inductive plethysmography (RIP) during high frequency oscillatory ventilation (HFOV) in preterm neonates with respiratory distress syndrome (RDS).
  16. 16. Target fraction of FiO2• Results – MAP – 12,8 vs 11,2 – FiO2 - 0,25 vs > 0,25 – Extubation – 3,5d vs 9 d (p=0,005) – Oxygen - 488 d vs 1109 d (p=0,02) – Mechanical ventilation 187 vs 525 (p=0,03) – Surfactant > 1 dose 1 vs 6 (p=0,04) – BPD - NS J Matern Fetal Neonatal Med. 2011 Tana M et all Unexpected effect of recruitment procedure on lung volume measured by respiratory inductive plethysmography (RIP) during high frequency oscillatory ventilation (HFOV) in preterm neonates with respiratory distress syndrome (RDS).
  17. 17. What is the HFV ?• HFV – Complex process of mixing gases – Normal human lung > 170/min• Small tidal volume – VT < anatomic dead space 1-3ml/kg• Very rapid ventilator rates – > 4 x physiological respiratory rate – 2 - 20 Hz = 120 – 1200 breaths/min.• MAP – HFV > CMV
  18. 18. Back to the physiology…• Alveolar ventilation – VA = VT – VD• HFV – VT ≤ VD → VT – VD ≤ 0 – VA ≤ 0
  19. 19. HFV vs CMV• VT – Const. f ≤ 25 -30/min. > 30/min. VT ↓• Valv = (VT – VD) x f – F > 75/min. ↓ → VA = VT2f – f > 75/min. - VT determined by Ti Using conventional infant ventilators at unconventional rates Pediatrics. 1984 Oct;74(4):487-92. • Flow Boros SJ, Bing DR, Mammel MC, Hagen E, Gordon M • VT • Amplitude ↑ • PIP – PEEP • f↑ → VT↓ • MAP • PIP ; PEEP
  20. 20. Why HFV?• VT < VD 1-3ml/kg• Possibility of independent management of the oxygenation and ventilation• Preservation of normal lung architecture even when using high MAP• Optimal lung inflation – The lung volume at which the recruitable lung is open but not overinflated
  21. 21. PIP – 25 cmH2O PEEP – 5 cmH2O I : E – 1 : 2 > 75/min 1 :1 F = 10 L/minBoros SJ, Bing DR, Mammel MC, et al: Pediatrics 74:487, 1984 PIP – 25 cmH2O PEEP – 5 cmH2O I:E–1:2Mammel MC, Bing DR: Clin Chest Med 17:603, 1996
  22. 22. Consepts of gas transport….• Convection ventilation or bulk flow• Taylor dispersion and molecular diffusion – A high velocity of gas travels down the center of a tube, leaving the molecules on the periphery unmoved – High flow facilitates diffusion• Pendelluft effect – Regional differences in time constants for inflation and deflation cause gas to recirculate among lung – Open lung allows to gas recirculate between alveoli• Cardiogenic mixing
  23. 23. Crit Care Med 2005 Vol. 33, No. 3 (Suppl.)
  24. 24. Is the HFV more effective than CMV?
  25. 25. Study Year Study disign Results 60 – 150 breaths/minObservational: Sjostrand V 2000 adults and children HFPPV adequate 1977Acta Anesthesiol Scand and 32 neonates with respiratory support RDS 24 neonates with RDSObservational: Bland RD 1980 60 – 110 breaths/min, Improved outcomeCrit Care Med volume preset vent. 673/346 preterms BPD ND, IVH↑, PVL↑,HiFi study 1989 750-2000g Air leak↑M-RCT (OCTAVE) 346 neonatesOxford Region Controlled Trial of Artificial 1991 HFPPV vs CMV HFPPV ↓ air leakVentilation study groupArch Dis Child 60 vs 20 - 40 CMV trend ↓ BPD wPardou A 22 neonates, HFFI 28 dobie i 36 tyg. 1993Int Care Med rescue therapy 63% vs 80%; 25% vs 40% 284 neonatesThome U (RCT) 1999 24-29hbd < 1000g Infant Star ↑ air leak HFV Inf Star
  26. 26. BPD 28 days; 36 weeks PMA Study group/ Trial 28 – 30 d 36 PMA HLVS Surfaktant HFV RCT CO 83 ≤ 1750 Clark RH HFOF SM/CV – 27 1992 HFOV SM – 30 P=0,008 P=0,013RMCT (Provo) 125 < 35 weeks Gerstmann 100% (1500;30,9) P < 0,05 P < 0,05 36 PMA DR redosing HFOF SM – 64 1996 RMCT 499 100% (4) Courtney < 1200g P = 0,046 all redosing 2002 HFOV SM - 244
  27. 27. • N=273• GA – 24 -29• Birth weight < 1000g• Randomization – 142 min - 145 min• HFOV – Reduction of surfactant doses - 30% vs 64% – Higher incidence IVH 24% vs 14% Moriette G et al. Pediatrics 2001,107:363-72. Prospective randomized multicenter comparison of high-frequency oscillatory ventilation and conventional ventilation in preterm infants of less than 30 weeks with respiratory distress syndrome
  28. 28. Meata- Trials 28 – 30 d 36 PMA HLVS Surfaktant analysis Cools F RR – 0,5 RR – 0,44 16 trials ND 1999 CI: 0,32, 0,78 CI: 0,16, 0,73Hendreson- or death 28-30 days Smart DJ Trend toward 6 trials trend toward RR – 0,5 Similar to 2000 decreasing Rand. – 12h decreasing CI: 0,36, 0,76 HLVSCochrane: in HFV in HFV Death or BPDCD000104Hendreson- Smart DJ NNT 17 Results the Results 2003 10 trials Or death same the sameCochrane: NNT - 20CD000104Hendreson- Smart DJ 15 trials ND borderline 36 PMA 2007 3585 ND significanceCochrane: neonatesCD000104
  29. 29. 3652 neonatesMortality at 28 -30 days BPD – 36 PMA
  30. 30. • HVLS in HFV - ND• HFOV• Not used LPS in CV• Randomization 2 – 6 hours• I:E–1:2• Air leaks – more frequently in HFOV
  31. 31. • Secondary end points – Gross pulmonary air leaks • pneumothorax, pneumomediastinum, pneumopericardium – Any pulmonary air leaks ↑* • Gross pulmonary air leaks + PIE – PDA – surgical ligation ↓ – ROP > 2 ↓* – Final extubation HFOV < CV
  32. 32. • Ventilator type ND – Sensormedics vs others vs „flow interrupter” – HVLS• Trials with HLVS – Lower target of FiO2• Time of randomization – Death or BPD or neurological event •1 – 4 h vs after 4h: HFOV (p=0,01)
  33. 33. No of trials – 15• Outcome measures – Death – BPD at 36 weeks PMA• Other variables – Type of ventilator • 11 – HFOV – 7 – Sensormedics • 2 – HFJV • 2 - HFFI – Ventilation strategies applied in the HFV and CV treatment groups – Time on mechanical ventilation before randomization
  34. 34. HVLS i LPS
  35. 35. Neurological outcome IVH, PVL Study group/ IVH Trial PVL HFV Grades: 3,4RMCT HiFi No – 673/327 26 vs 18 12 vs 71989 750g – 2000g P = 0,02 P = 0,05 ND (HiFi) RR 1.31, Fixed:Cools F 95% CI: 1.04, 1.66 16 trials Random: RR 1.34, ND 1999 (95% CI: 1.05, 1.70
  36. 36. Longterm neurological outcome Study group/ No Pulmonary Neurodevelopmental Trial HFV followed up function outocome 386 (77%) 16 – 24 m. RMCT 673/327 ND Bayley score > 83 HiFi 750 – 2000g 432 (82%) (No 223-43%) no major defect 1989 Surv. - 524 CV ↓ (54% vs 65%) 1 year RMCT 92/46 BPD in chest x Developmenta delay – Ogawa 91 (100%) 750 - 2000 –ray 9% in both groups 1993 2% vs 4% ND RMCT 125 < 35 (Provo) Available 79Gerstmann 69 (87%) ND ND (1500;30,9) DR HFOF SM – 64 1996 MRCT 428 – 73% 797/400 22-28 month UKOS 373 – In 9% sever Surv. 592 40%Marlow N „window” 38% other disabilities 23 – 28 PMA ND 2006 (211vs217)
  37. 37. HFOV – indications• Air leak syndromes – Pulmonary interstitial emphysema ( PIE) – bronchopleural or tracheoesophageal fistula• Until at least 24 hours after the air leak resolved
  38. 38. HFOV - indications• Severe uniform lung disease – Respiratory distress syndrome – Pneumonia – ARDS
  39. 39. HFOV - indications• Severe nonuniform disease such – MAS - meconium aspiration syndrome – Others aspiration syndromes• Complication – air - trapping
  40. 40. HFOV - indications• Parenchymal lung disease and require inhaled nitric oxide therapy Kinsela JP wsp – Randomised, multicenter trial of iNO and HFOV in severe PPHN. J Pediatr 1997;131: 55-62• Pulmonary hypoplasia – CDH – Oligohydramnios sequence• Severe chest wall restriction or upward pressure on the diaphragm – Gastroschisis – Omphalocoele – NEC
  41. 41. HFOV - indications• Severe respiratory failure meeting the criteria for ECMO
  42. 42. HFOV strategy Optimal lung volume strategy MAPMAP 2-3 cmH2O in 1-2 cmH2O steps Frequency - 10 Hzabove the CMV until oxygenation improves Aim: to maximise recruitment of alveoli
  43. 43. HFOV strategy Low volume strategy Adjust amplitudeMAP equal to the to get an adequate Frequency - 10 Hz CMV chest wall vibration. Aim: to minimise lung trauma
  44. 44. HFOV strategy• Obtain an early blood gas and adjust settings as appropriate• Obtain chest radiograph to assess inflation – Initial at 1-2 hrs • baseline lung volume on HFOV (aim for 8 ribs). – A follow-up in 4-6 hours • to assess the expansion – Repeat chest radiography with acute changes in patient condition• Reduce MAP – chest radiograph shows evidence of over-inflation (> 9 ribs)
  45. 45. Poor Over Under OverOxygenation Oxygenation Ventilation VentilationIncrease FiO2 Decrease FiO2 Increase Amplitude Decrease Amplitude Decrease Frequency Increase Frequency Decrease MAPIncrease MAP (1-2Hz) (1-2Hz) (1-2cmH2O) if Amplitude Maximal if Amplitude Minimal
  46. 46. Weaning• Reduce FiO2 to < 40% before weaning MAP (except overinflation)• Reduce MAP in 1-2cm H2O increments to 8-10 cm H2O• Air leak syndromes (low volume strategy) – Reducing MAP takes priority over weaning the FiO2• Wean the amplitude• Do not wean the frequency• Discontinue weaning when MAP 8-10 cm H2O and Amplitude 20-25• Infant is stable, oxygenating well and blood gases are satisfactory – extubation to CPAP or switched to conventional ventilation
  47. 47. Suctioning• Indications – diminished chest wall movement (chest wobble) – elevated CO2 and/or worsening oxygenation – visible/audible secretions in the airway• Avoid in the first 24 hours of HFOV, unless clinically indicated.• In-line suctioning must be used• Press the STOP button briefly while quickly inserting and withdrawing suction catheter (PEEP is maintained)
  48. 48. 2006 OPEN FORUM AbstractsOPEN VERSUS CLOSED SUCTION DELIVERY DURING HIGH FREQUENCYOSCILLATORY VENTILATION (HFOV)Dennis Gaudet, RRT; Matthew P. Branconnier, RRT, EMT; Dean R. Hess, PhD,RRT, FAARC. Massachusetts General Hospital and Harvard Medical School,Boston MA.
  49. 49. Summary.…• HFV is an effective treatment modality in a variety of clinical situations• The most important contribution of HFOV is that it helped clinicians overcome the fear of using adequate distending airway pressure• The most important is to achieve optimal lung volume, I:E – 1:2• When used in appropriately selected patients with the optimal volume recruitment strategy and careful attention to avoide hypocapnia, HFOV is capable of reducing the incidence of CLD• Recent meta-analyses have suggested that surfactant, antenatal steroids, and improvements in conventional mechanical ventilation with the use of lung-protective strategies have eliminated any advantages of HFV as a primary mode of ventilation
  50. 50. Nasal Ventilation: How does it work?• Increase in FRC – Alveolar recruitment due to higher MAP – Decrease in intrapulmonary shunt – Protection of surfactant – Increases alveolar surface area for gas exchange• Improves oxygenation• Increase in VT and minute volume
  51. 51. NIV - History• August Ritter von Reus 1914 – Bubble CPAP• 1940s – High altitude flying• 1967 – PEEP was added to MV• 1960s – Neonates PEEP=0
  52. 52. NIV - History• Harrison (1968) – Grunting was producing positive end expiratory pressure (PEEP)• Gregory (1971) – Clinical use of CPAP in premature neonates with hyaline membrane disease (RDS)• Avery (1987) – The lowest incidence of BPD, at Columbia where they used much more CPAP• Nasal Continuous positive airway pressure (NCPAP) – By far the most commonly used form of NIV in neonates today
  53. 53. When is NIV used ? After birth After extubation To treat apnea
  54. 54. Nasal CPAP Delivering Devices• Components – Circuit for continuous or variable flow of inspired gases • Continuous flow – gas flow generated and directed against the resistance of the expiratory limb – Nasal interface • single or bi-nasal prongs (Argyle & Hudson), mask, NP tube – Device to generate positive airway pressure
  55. 55. Know Your CPAP• Continuous flow: flow constant irrespective of phase of respiration – Ventilator generated CPAP (conventional CPAP) – Bubble: CPAP varied by immersion of expiratory tubing • Flow varies with immersion depth and affects CPAP• Variable flow: CPAP varied by varying the flow rate – Infant flow, Arabella, Aladdin – Bi-level (“SiPAP”) Courtnay SE et al; Pediatr Pulmonol; 36; 2003 Lipsten F et al; J Perinatol; 2005 Boumecid H et al; Arch Dis Chid Fetal Neonatal; 2007
  56. 56. Conventional Ventilator CPAP vs. Infant Flow CPAP for Extubation (n=162) Extubation Failure Rate: Conv. CPAP= 38.1% IF-CPAP= 38.5%Infant Flow CPAP is as effective as conventional CPAP Stefanescu BM et al. (Winston-Salem, NC) Pediatrics 2003
  57. 57. Infant Flow Driver CPAPPressure is generated by Varying the Flow Rate • Reduced work of breathing • Maintains uniform pressure Fluidic Flip or Coanda Effect
  58. 58. CPAP Interfaces Argyle Prongs Hudson Prongs Nasopharyngeal Catheter Nasal mask Nasal CannulaInca Prongs R ~ F L / r4
  59. 59. Bi-Nasal vs Single Prong CPAP in ELBWI Bi-Nasal Prongs Single Prong p (n=41) (n=46) BW, g mean (SD) 790 (140) 816 (125) NS GA 26 (1.9) 26 (1.9) NS Age at extubation, days, 3 (1-9) 3 (1-6) NS Median, IQ range Extubation Failures 24 % 57 % 0.005 In < 800 g 24 % 88 % <0.001 Reintubation in < 800 g 18 % 63 % 0.023Bi-Nasal Prongs are more effective than Single Prong Davis P et al. (Melbourne) Arch Dis Child 2001
  60. 60. Single-prong vs double-prong NCPAP ventilation: effect on extubation failure De Paoli A: Cochrane Database Rev; 2008; CD002977
  61. 61. NCPAP at birth• Intubation in the delivery room was reduced from 84% to 40% » Linder W et al.; Pediatrics; 1999;• Intubation in the delivery room was reduced from 89% to 33% » Aly H et al.; Pediatrics; 2004;• Lack of RCT – „…the dramatic effect of CPAP (was) observed after a brief period of treatment in all patients.” » Novogroder et al.; J Pediatrics: 1973• „…Although one or two such (RCT) studies of CPAP would be welcome, many more „would be foolish.”
  62. 62. Davis PG: 2003;Cochrane Database RevCD000143
  63. 63. NCPAP - 8 Studies; 2001-2009 Extubation failures - 20-80%90 Bi-Nasal vs. 8080 Single Prongs70 NCPAP vs.60 57 Surf + IFD vs. V-CPAP 46 NCPAP*50 IFD vs. 38,5 38,1 B-CPAP 3940 33 33 2930 24 26 19,720100 Davis-01 Stefanescu- Finer-04 Booth-06 Morley-08 Gupta-09 Sandri-09 Rojas-09 03 Ramanathan R. J Perinatol 2010; 30: S67-72
  64. 64. What to do when NCPAP fails? when should the neonate be intubated ?• NCPAP – Faillure rate -20 -80%• Definition of CPAP faillure – FiO2 > 0,6 → 0,75 – FiO2 > 0,35 – 0,4 – COIN trial • FiO2 > 0,6; pH < 7,25; PaCO2 > 60mm • Apneic episodes > 6/6hour requiring stimulation or >1 requiring PPV
  65. 65. NIPPV• Added positive pressure inflation to a background of NCPAP• How NIPPV improve clinical outcomes – PIP results in only a slight increase in VT when delivered during spontaneous breathing – Occasionally lead to chest inflation when delivered during apneic period » Owen LS et al.; Arcg Dis Child Fetal Neonatal Ed; 2011
  66. 66. sNIPPV in Preterm Infants with RDS sNIPPV -242; nCPAP - 227; NCPAP sNIPPV P (n=227) (n=242) Birth Weight, g 964  183 863  198 < 0.001Gestational Age, wks 27.9  2.4 26.4  1.7 < 0.001Antenatal Steroids, % 92 94 0.274 Surfactant Rx, % 68 85 < 0.001BPD, Total population 25 % 35 % 0.028 BPD in 500-750 g 67 % 43 % 0.031 BPD in 751-1000 g 23 % 35 % 0.097BPD in 1001-1250 g 14 % 21 % 0.277 sNIPPV when compared to NCPAP was associated with decreased BPD, BPD/Death, NDI, and NDI/Death Bhandari V et al. Pediatrics 2009
  67. 67. NCPAP vs. NIPPV: 9 RCT; 1999 - 2011 Extubation Failures 60 Extubation Failures 5-25% 49 50 44 42 41 40 39 40 37 34 30 25 25 18,9 20 17 15 15 10 10 5 6 6 0 Friedlich-99 Barrinton-01 Khalaf-01 Kugelman-07 Moretti-08 Ramanathan- Kishore 09 Lista-10 Meneses-11 (Ramanathan) 09* P <0.05 Modified from Ramanathan R. J Perinatol 2010
  68. 68. NCPAP vs. NIPPV: 8 RCT; 1999 – 2011 BPD60 56 5350 44 3940 35 3330 2526,5 22 2120 17 1010 6 7,7 2 2,7 0 Barrinton-01 Khalaf-01 Kugelman-07 Bhandari-07 Moretti-08 Ramanathan-09 Kishore-09 Meneses-11
  69. 69. •NIPPV • Lower risk of respiratory faillure • Apnea • Respiratory acidosis • Increased oxygen requirements To prevent reintubationDavis PG; Cachrane Database Rev. 2001; CD003212
  70. 70. S-NIPPV and NS-NIPPV• NCPAP vs S-NIPPV vs NS-NIPPV (20-40/min) – VT, minute ventilation, gas exchange – ND – S-NIPPV • Less inspiratory effort • Better infant – ventilator interaction – NS-NIPPV – no advantage over NCPAP » Chang HY et al; Pediatr Res; 2011
  71. 71. Neurally Adjusted Ventilatory Assist (NAVA)• Electrical activity of the diaphragm (Edi) is used for controlling ventilation in Neurally Adjusted Ventilatory Assist• NAVA ventilation mode may be used both as invasive and non-invasive ventilation• Timing and amount of delivered pressure is controlled by patient• One condition must be met – spontaneous breathing
  72. 72. • Edi catheter (6 Fr) is introduced through nostril and placed according to the formula• Edi catheter positioning was adjusted by means of ECG display• After appropriate placement sufficient Edi signal could be detected
  73. 73. From NAVA to NIV - NAVA
  74. 74. NAVA NAVA level - set on ha base of Peak Inspiratory Pressure applied in the previous ventilation mode
  75. 75. NIV - NAVA
  76. 76. HFNC – high flow nasal cannulae• Flow rates exceeding 1L/min – Initial support for early respiratory distress – Postextubation support – Step-down therapy from NCPAP• HFNC interfaces – Vapotherm – Optiflow (pressure- relief valve in circuit)• Open systems with leak at the nose and mouth• Heated and humidified gas, blending and oxygen and air
  77. 77. HFNC – high flow nasal cannulae• Pressure generated – unpredictable – 0,3 cm outer diameter, flow rate 2L/min • Mean esophageal pressure – 9,8 cm H2O » Locke RG; pediatrics, 1993 – Recent studies • Pressure ≤ NCPAP » Kubica ZJ et al; Pediatrics 2008 » Spence KL et al.; J Perinatol; 2008 » Wilkinson DJ et al.; J Perinatol: 2008
  78. 78. How to use NIV ?
  79. 79. How much supporting pressure should be used •NIPPV •PIP as on MV or slighty above •Respiratory rate – 20-40 Davis PG: 2003; Cochrane Database Rev; CD000143
  80. 80. Suggested Weaning Guidelines During Nasal Ventilation• Wean every 6–12 h• Wean PIP first• When PIP is at 10, then wean rate• When rate is at 10, wean to NCPAP• When patient is stable – NCPAP of ± 5 cm H2O for 6–12 h • wean to heated nasal cannula with flow rates of < 2 LPM.
  81. 81. Contraindication to NIV• Progressive respiratory faillure or with poor respiratory drive – High oxygen requirement – PCO2 > 60mmHg – pH < 7,25 – Apnea, bradycardia, desaturation do not responded to NCPAP• Congenital malformations – Choanal atresia – Cleft plate – Congenital diaphragmatic hernia – Tracheoesophageal fistula – Gastroschisis• Severe cardiovascular instability
  82. 82. NIPPV - Complications• Malpositioned nasal cannulae – Variable flow CPAP system – Airway obstruction by secretion• Inadvertent PEEP – air leaks – High ventilatory rate – Too short expiratory time – Minimal or no lung disease (high compliance)• Carbon dioxide retention – Alveolar overdistantion • Increase work of breathing, PVR↑, CO↓ • Decrease urine output – Too short expiratory time
  83. 83. NIPPV - Complications• Decreased gastrointestinal blood flow - „CPAP belly” – Abdominal distention • Placement of orogastric tube – NEC – not confirmed – Gastric perforation - not confirmed• Skin trauma Fischer C et al (Switzerland). Arch Dis Child 95: F447-F451; 2010
  84. 84. Summary• NCPAP reduces respiratory instability and the need for extra support after intubation• NCAP reduces the rate of apnea• NIPPV may augment the benefits of NCPAP• Binasal prongs are better than single nasal prongs• Used NCPAP after delivery may prevent or at least diminish respiratory distress
  85. 85. • It does not matter what ventilator we choose but …• How to provide respiratory support
  86. 86. • The art of medicine is to achieve optimal lung volume in neonates with respiratory disorders• CPAP is one method many clinicians believe best achieves optimal lung inflation with resultant good oxygenation and ventilation without the use of an endotracheal tube
  87. 87. ECMO – instead of ventilators?• Low volume of circuit• Possibility to provide without hyalinization and trough thin cannulas• Even then Optimal Lung Volume in neonates with surfactant insufficiency will be necessary
  88. 88. Thank you…
  89. 89. „Bubble” CPAP vs CPAP with Mechanical Ventilator (12 PT infants; <1500g) Mean (+/- SD) Pressure (cmH 2O) Ventilator: open symbols 12 Bubble: solid symbols 10 8 8 (set NCPAP) 6 4 4 2 No Leak 4 6 8 10 12 Bias Flow (Liters/min) Kahn et al, Pediatrics, 2007

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