This document provides an overview of non-invasive ventilation in neonates. It begins by explaining the objectives and need for non-invasive ventilation, as respiratory problems are a major complication for preterm neonates. The document then contrasts invasive ventilation with non-invasive ventilation (NIV), noting that NIV avoids ventilator-induced lung injuries seen with invasive ventilation. Continuous positive airway pressure (CPAP) is discussed as a form of NIV. Evidence is presented that supports NIV and CPAP for indications like respiratory distress syndrome, apnea of prematurity, and post-extubation support. Finally, the document covers nasal devices, ventilators, and care considerations for neonates receiving NIV.
This gives a brief idea about the:
Techniques, Response To NIV, Clinical indications, Contraindications and Evidence Based Decisions on the use of noninvasive ventilation with neonates
This gives a brief idea about the:
Techniques, Response To NIV, Clinical indications, Contraindications and Evidence Based Decisions on the use of noninvasive ventilation with neonates
CLINICAL TEACHING ON BUBBLE CPAP: Introduction, Definition, History of development, Physiology of Bubble CPAP, Principle, Patient interface, equipments for bubble CPAP, indication and contraindication for bubble CPAP, essential of CPAP, CPAP machine, bubble cpap machine application, setting pressure, FiO2, oxygen flow, Monitoring adequacy and complications of bubble CPAP, Monitoring infant condition, weaning for Bubble CPAP, CPAP Failure, complications related to CPAP, Preventing complications, Nursing Care.
Basic concepts in neonatal ventilation - Safe ventilation of neonatemohamed osama hussein
Lecture by by dr Muhammad Ezzat Abdel-Shafy MB.BCh, M.Sc Pediatrics Neonatology Sp. , Benha Children Hospital, provided during our Doctors neonatology workshop, 20th of January 2017
This presentation deals with the basic physics of human ventillation. I have made an effort to clarify most of the venti lingo , so as to make way for further discussions on ventilator use. Hope it turns out to be helpful for you. Thank you.
CLINICAL TEACHING ON BUBBLE CPAP: Introduction, Definition, History of development, Physiology of Bubble CPAP, Principle, Patient interface, equipments for bubble CPAP, indication and contraindication for bubble CPAP, essential of CPAP, CPAP machine, bubble cpap machine application, setting pressure, FiO2, oxygen flow, Monitoring adequacy and complications of bubble CPAP, Monitoring infant condition, weaning for Bubble CPAP, CPAP Failure, complications related to CPAP, Preventing complications, Nursing Care.
Basic concepts in neonatal ventilation - Safe ventilation of neonatemohamed osama hussein
Lecture by by dr Muhammad Ezzat Abdel-Shafy MB.BCh, M.Sc Pediatrics Neonatology Sp. , Benha Children Hospital, provided during our Doctors neonatology workshop, 20th of January 2017
This presentation deals with the basic physics of human ventillation. I have made an effort to clarify most of the venti lingo , so as to make way for further discussions on ventilator use. Hope it turns out to be helpful for you. Thank you.
Final newer modes and facts niv chandanChandan Sheet
THIS IS THE BASIC POINTS REGARDING NIV, THIS IS COMPILED AND ARRANGED FROM DIFFERENT BOOKS, JOURNALS AND PPTs.
The author is grateful to the teachers and authors of pulmonology and critical care.
It is an updated presentation(2019) which covers the basic concept of mechanical ventilation, Modes, Settings, Troubleshoots, Complications, New modes, and Preventive care. The presentation will be useful for emergency doctors
Non-invasive ventilation (NIV) is the use of breathing support administered through a face mask or nasal mask. Learn more about NIV in this presentation by Dr Somnath Longani, consultant Anaesthesiologist & Intensivist, Midland Healthcare & Research Center, lucknow
https://midlandhealthcare.org/
this is compiled & created to discuss the basic modes and initiation of NIV
the author is thankful to the previous authors,teachers who helped to conceptualize the NIV .
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
1. Non Invasive Ventilation in
Neonates
Mrs. Geetanjli
Clinical Instructor
National Institute of Nursing Education
PGIMER, Chandigarh
Geetanjli NINE, PGIMER
copyright@
2. OBJECTIVES
At the end of the class the participants will be
able to
Explain NIV and its need
Explain modes of NIV
Provide care to baby on CPAP
Explain benefits of NIV over invasive ventilation and
CPAP
Describe physiological basis for NIPPV
Indications and Evidence supporting its use
Identify complications and contraindications of NIV
Provide nursing care to babies on NIV effectively
Geetanjli NINE, PGIMER
3. Why??? NEED
Respiratory problem is one of the major
among all complications of preterm
NEONATES
Causes include lack of
Inadequate lung development and surfactant,
and inadequate surface area for gas exchange.
further it is complicated by
apnea and inability to maintain the high work of
breathing
Geetanjli NINE, PGIMER
4. NIV
Non invasive ventilation means the delivery of
ventilatory support without the use of an
invasive artificial airway to babies
having poor respiratory efforts
And are not spontaneously breathing
Geetanjli NINE, PGIMER
5. Invasive vs NIV
Invasive ventilation causes
Ventilator induced lung injury VILI
Volutrauma
Barotrauma
Atelectrauma
Biotrauma
De Paoli AG, Davis PG, Faber B, Morley CJ.
Geetanjli NINE, PGIMER
6. Invasive vs NIV contd…..
Other complications include
bronchopulmonary dysplasia (BPD).
Airway injury
Increase risk of infection
Air leak
Decreased cardiac output.
Geetanjli NINE, PGIMER
7. Invasive vs NIV contd…..
In addition to that certain tube complication
like
Dislodgement
Obstruction
Malposition
Geetanjli NINE, PGIMER
10. What is CPAP?
Application of positive pressure to the airway of
a spontaneously breathing infant through out
the respiratory cycle (inspiration & expiration)
Geetanjli NINE, PGIMER
11. How it works?
Prevents collapse of alveoli at the end of
expiration
Fluid lined alveoli tend to collapse!Fluid lined alveoli tend to collapse!Geetanjli NINE, PGIMER
34. Procedure- CPAP
Select CPAP machine- eg Bubble, machine
Aseptic precautions
Prepare circuit
Choose prongs- appropriate size
Connect prongs to Circuit- check connections
Keep gas flow 4-6 l/min
Adjust CPAP pressures to desired level – acc. to disease
Stabilize head of baby and insert prongs
Titrate according to needs of the baby
Don’t forget to put
oro-gastric tube
Geetanjli NINE, PGIMER
35. How to initiate CPAP
Starting CPAP pressure levels 5 cm H2O can
increase upto 8 cm H2O
Apnea: 5cm H2O
RDS: 5 cm H2O
Starting FiO2:
30 Titrate to maintain SpO2 Target- 87-93/91-95%
(depending upon institution policy)
Depends on indication
Flow of gases- 2-6 L/minGeetanjli NINE, PGIMER
36. How to stabilize on CPAP
How to titrate CPAP
Pressure levels
According to the work of breathing
FiO2 requirement
Increase to maintain 6-8 posterior rib spaces
FiO2 21-60% ideal
Flow-2-6 L/min
PaO2 - >50mmhg
Geetanjli NINE, PGIMER
38. Adequacy of CPAP
Baby is stable and comfortable with minimal
chest retractions on clinical monitoring
Normal CFT AND BP
SpO2 Target- 87-93%
Blood gases targets
PaO2-50-80 mm Hg
PCO2-35-45 mm Hg/40-60mm Hg
• Ph- 7.35-7.45
Geetanjli NINE, PGIMER
39. Weaning
• When to Wean
• Natural history of disease
• Depends upon indication
– RDS- No Respiratory distress/ ↓ FiO2 requirement
– Apnea- 24 -48 hr apnea free
• How to Wean
• In steps of
– First wean off oxygen to 21% in steps
– Than wean form PEEP to 4 cm H2O in step of 1 cm
H2O
Geetanjli NINE, PGIMER
40. Remove
• PEEP -4 cm H2O AND
• FiO2 – 21 %
• Baby maintain normal saturation and minimal
retraction is there.
• After removal frequent observation till 24
hours for apnea, tachypnea, retractions
bradycardia.
Geetanjli NINE, PGIMER
41. CPAP failure criteria
• Increased WOB
– CPAP- 7 cm H2O
– FiO2- 80%
• ABG
– PaO2 <50 mmHg on FiO2 80%
– PaCO2 >60 mmHg or >55 mmHg if pH <7.2
• Recurrent Apnea
Ensure before declaring CPAP Failure
1.Interface correctly fitting
2.Equipment working properly
3.Oxygen source connected
4.No obstruction to flow of gases
5.Airways clear
6.Baby not fighting
Geetanjli NINE, PGIMER
42. Failure criteria
– PaO2>50mmhg AND PaCO2>60mmhg ON
– FiO2 >60 %
– PEEP >7 cm H2O AND
– not maintaining Spo2 > 85%
• Baby
– have severe retraction and
– apnea,
Geetanjli NINE, PGIMER
AT THIS TIME BABY REQUIRES MECHANICAL VENTILATION
49. NIV vs CPAP
• CPAP ????
• Neonates having poor respiratory efforts
CPAP does not sufficiently off-load the burden
of high WOB, nor is capable of providing
effective alveolar ventilation.
Geetanjli NINE, PGIMER
50. “Open the lungs and keep lungs
open”
• Low volume also induces lung injury
• Adequate recruitment of lungs to FRC important
Lachmann et al Int Care Med 1992
Geetanjli NINE, PGIMER
52. Clinical uses of
NIV
Post Extubation
3 trials (n=159), VLBW
NIPPV 80% reduction in
extubation, no
gastrointestinal
perforation , less
CLD
Lemyre , Davis et al, 2009
Apnea of
Prematurity
2 trials(n=54)
One study-
reduction in
apnea
Primary
modality
RDS
13/2/14 Geetanjli NINE, PGIMER
53. Post Extubation
• Three trials (n=159), VLBW infants
• All synchronised form of NIPPV (Infant Star ventilator)
• 2 studies- Short Bi Nasal , one used- NP prongs
• 80% reduction in extubation failure, NNT 3 (95% CI 2, 5).
• No reports of gastrointestinal perforation
• Trend towards CLD reduction in NIPPV
– RR 0.73 (95% CI 0.49, 1.07),
Lemyre , Davis et al, 2009
13/2/14 Geetanjli NINE, PGIMER
54. Apnea of Prematurity
NIPPV vs NCPAP
• No reduction in need for intubation
• No reduction in rate of apnea
• One study- reduction in apnea
• 2 trials(n=54)
• Preterm < 37 weeks with apnea
NIPPV might augment the beneficial effects of NCPAP
Appears to reduce the frequency of apneas more
effectively than NCPAP.
Lemyre , Davis et al, 2009
Apnea on CPAP a trial of NIPPV may be given before IMV
13/2/14 Geetanjli NINE, PGIMER
55. Primary treatment of RDS
Author Year Population
Design
Intervention Findings
Meneses et al
2011
RCT,
26-336/7
N=100 in each arm
ns NIPPV
vs
B-CPAP
Binasal
Surf used rescue
•Need for intubation in first 72 hrs –
No difference
•55% reduced need for IMV
•Benefit seen in > 1000 g
•Overall 30% failed on non invasive
•No difference in Duration of MV/
BPD
Sai Sunil
Kishore
2009
RCT
28-34 wks
Bwt > 750 g
nsNIPPV (n-37)
Vs
NCPAP(n-39)
NP delivery
• Lesser intubation with NIPPV (48hrs)
•13.5% vs 35% ( RR=0.38; 0.15, 0.89)
•Failure rate in first week also lesser
•No difference in airleak, duration of
ventilation, BPD rates, NEC etc
•Increased abd girth in NIPPV
Kugelman
2007
RCT
24-34wks
NIMV (n=43)
vs NCPAP(n=41)
NIMV lesser intubation 25% vs 49%
Reduced BPD rates in NIMV( 2% vs
17%)
Bhandari etal RCT rapid extubation to NIPPV vs MV Reduction of CLD / Death 52% v
25% p=0.03 at 22 months longterm no difference J of Perinatology 2007
13/2/14 Geetanjli NINE, PGIMER
56. Nasal devices and evidence
• Devices previously used
• Currently used
Geetanjli NINE, PGIMER
59. Nasal devices
• NIV was earlier delivered by
• Nasal cannulae (measure from earlobe to tip
of the chin or nose) : now not used because it
causes nasal mucosa damage ×
• Face masks: minimal nasal trauma but
difficulty in obtaining tight seal. ×
• Nasopharyngeal tubes: using a cut endotracheal tube
×13/2/14 Geetanjli NINE, PGIMER
60. Binasal prong vs single nasal prong
• Bi-nasal prongs are more effective at
preventing reintubation than single nasal
prongs , preventing reintubation in as many as
1 out of every 5 babies in which they are used
[RR 0.59 (0.41, 0.85), NNT 5 (3, 14)].
De Paoli AG, Davis PG, Faber B, Morley CJ.
13/2/14 Geetanjli NINE, PGIMER
61. Nasal masks vs binasal prongs
13/2/14 Geetanjli NINE, PGIMER
62. Nasal masks vs binasal prongs
• Enrolled 120 preterm babies < 31 weeks
gestation
• to receive nasal CPAP or SiPAP through either
nasal mask or prongs,
• it was found that only 28% babies recruited
to nasal mask group required intubation at
<72 hours age against 52% infants in the nasal
prongs limb.
• Masks also cause less trauma
Kieran EA, Twomey A, Molloy EJ,Murphy JFA,
O’Donnell CPF
13/2/14 Geetanjli NINE, PGIMER
63. Hudson vs Argyle
• Both were equally effective
• But to keep argyle in place is bit difficult and
there more chances of having nasal
hyperemia
Rego MA, Martinez FE.
13/2/14 Geetanjli NINE, PGIMER
66. Currently used nasal devices
• Cannulaide and Ram’s cannuala
• Cannulaide
– Extremely soft and made of gentle hydrocolloid
material anatomically designed for a good fit on
the neonate.
– It helps in prevention of damage to the nasal
septum since the nCPAP seal is established on
contact with the cannulaide rather than the
infants nose.
Geetanjli NINE, PGIMER
70. Contraindications to NIV
• Respiratory failure defined as pH < 7.25, Pco2
> 60,
• Congenital malformations of the upper airway
– T-E fistula,
– choanal atresia,
– cleft palate
– Congenital diaphragmatic hernia,
– bowel obstruction, omphalocele, or gastroschisis,
– Severe cardiovascular instability, Poor respiratory
drive Geetanjli NINE, PGIMER
71. Weaning form NIV
• Taper the setting to FiO2 <30%, PEEP 5, PIP
14, Rate of 30 those having weight less <2kg
can be put on nCPAP for few hours
Geetanjli NINE, PGIMER
72. RDS
• Assess for
– RR: if (>60)
• Look for
– Chest retractions
• Listen for
– Expiratory grunt
• If any of the two present RDS +ve
• And the scoring of the same can be done by
– Downe’s score
– Silverman Geetanjli NINE, PGIMER
73. Downes’ Score is more comprehensive
and can be applied to any gestational
age and condition.
Geetanjli NINE, PGIMER
74. Silverman Anderson score (more
suited to preterm's with HMD)
A score of >failure.
A score of >6 is indicative of impending respiratory
failure. Geetanjli NINE, PGIMER
75. Clinical monitoring Electronic Monitoring
Vital signs : RR, HR , BP
Severity of RDS
Perfusion (Circulation)
•CFT, BP, PP, CP, UO
•Cyanosis
Abdominal girth
•Bowel sound
•Gastric aspirate to prevent
CPAP belly
Neurological status
•Tone, activity,
responsiveness
RR, HR, SPO2 (87-93%)
PEEP 4-8 CM H2O
Fio2 21-60%
Geetanjli NINE, PGIMER
78. Patient end monitoring
Time Distance
between
cannula and
interface
Nasal skin
blanched
Columella/ setal
excoriation
Oral/
nasal suction
OG in situ
and end
open
8am
10 am
Geetanjli NINE, PGIMER
84. Risk factor:
- Duration of CPAP
- Lower gestational age
- Low birth weight
- Type of CPAP patient interface
- Immature skin, mucous membranes and cartilage,
bone
Nasal InjuryNasal Injury
Geetanjli NINE, PGIMER
85. Causes:
• Difficulty keeping the device in place
• Misalignment or improper fixation of
nasal prongs.
• Hard to maintain an effective seal on the
infant’s nares
Geetanjli NINE, PGIMER
94. Assessing NoseAssessing Nose
– Note the size, shape, and position in relation to
the rest of the face
– Are the nares symmetrical, stretched out?
– Is there any blanching of skin at nares?
– Is there a skin breakdown?
– Septum position; is it straight or does it appear
crooked?
Advances in Neonatal Care.8,(2),116-124,2008Geetanjli NINE, PGIMER
95. Tip of Nose 0=Normal , 1= Red , 2= Red + indent
3=Red/indent/skin breakdown , 4=As above +tissue loss
Nasal Septum 0=Normal , 1= Red , 2= Red + indent
3=Red/indent/skin breakdown , 4=As above +tissue loss
Nostrils 0=Normal , 1= Enlarged , 2= Enlarged and prong shape
3=Red, bleeding , 4=As above + skin breakdown
Nose Shape 0= Normal , 1=Pushed up/back but normal , 2=Pushed up and
shortened., No normal orientation when prongs removed.
Scoring:
0= No injury
1-4= mild injury
5-6= moderate injury
>7= severe injury
Geetanjli NINE, PGIMER
96. Assessing the nasal interfaceAssessing the nasal interface
• Is the cap appropriately
placed?
• Is the nasal interface
component twisted?
• Is the nasal prong of
appropriate size?
• Compress the tip of the
noseGeetanjli NINE, PGIMER
97. Possible Solutions toPossible Solutions to
Prevent Nasal InjuriesPrevent Nasal Injuries
• Use correct prong size
• Use normal saline as a lubricant when
inserting the nasal prongs
• If blanching of the skin occurs, use smaller
prongs
• Massage the nasal septum
• Minimize points of contact
• Keep dry and clean
• Avoid topical applications – spirit x
Monitor/view the infant and the device every hourGeetanjli NINE, PGIMER
98. Maintain distance of 2-3 mm between bridge of
prongs and septum
Prevent the cap/tube to cause upward pull on
the nose
Do not allow weight of tubing to bear on face
Use Velcro mustache
Prevent excessive movement
– Interferes with a good seal
– Swaddling helps decrease movement
Possible Solutions toPossible Solutions to
Prevent Nasal InjuriesPrevent Nasal Injuries
Geetanjli NINE, PGIMER
99. Make sure there is no tension on the
tubing as this will put pressure on the
baby’s nares.
• Use skin friendly adhesive over the nose
and moustache
– Tegaderm
– Cannulaide (Beevers Manufacturing,
McMinnville, Oregon) is a tailored
hydrocolloid material with an adhesive
backing
Possible Solutions toPossible Solutions to
Prevent Nasal InjuriesPrevent Nasal Injuries
Geetanjli NINE, PGIMER
100. Other complications
• Pulmonary
– At high pressures, thoracic air leaks can
occur
• Cardiovascular
– Decrease Venous return and cardiac output
– Increase CVP
– Increased pulmonary resistance
Geetanjli NINE, PGIMER
101. • Gatro
– Abdominal distention
– Feeding disturbances because of the gas flow to
the stomach.
• CNS
– Increase intracranial pressure
– Decrease cerebral perfusion
Other complications contd…..
Geetanjli NINE, PGIMER
103. Prevention of complications contd…
• Check circuit for any leakage in circuit and
leakage from open mouth so that CPAP
pressure maintained
Ensure the bubble system &
humidification are always kept lower than
the baby to avoid condensation draining
into infants airway.
Geetanjli NINE, PGIMER
104. - Do not ignore alarms
- Look for the cause of desaturation rather
than just increasing Fio2
Prevention of complications contd…
Geetanjli NINE, PGIMER
105. Prevention of complications contd…
• Excessive movement
– Interferes with a good seal
– Swaddling helps decrease movement
Geetanjli NINE, PGIMER
106. Nursing care
• Ensure good seal
• Close assessment
• Manage the airway
• Close (hourly) clinical and electronic
monitoring
• Respiratory report
• Blood gases monitoring
• Prevent abdominal distension
• Monitoring and early reporting of
complications of NIV
Debbie Fraser Askin
Geetanjli NINE, PGIMER
108. Key Messages
• NIPPV seems to safe promising better
alternative modality of Non invasive ventilation
• Tested Indications
– RDS, AOP and Post Extubation
• Subset of infants
– severe RDS and babies with clinical predictors of
CPAP failure or recurrent apnea seems best suited
• Reduction in BPD is encouraging
• Safety/ Efficacy in < 28 weeks, Long term
benefits/ outcomes - yet to be established
Geetanjli NINE, PGIMER
109. References
• Ramanathan R, Sekar K, Rasmussen M, Bhatia J, Soll R. Nasal intermittent
positive pressure ventilation (nippv) versus synchronized intermittent
mandatory ventilation (simv) after surfactant treatment for respiratory
distress syndrome (rds) in preterm infants_30weeks’gestation:
multicenter, randomized, clinical trial. Available from URL:
http://www.pas-meeting.org/ 2009 baltimore/abstracts/lb%20pub
%20all_full%20text%2009.pdf.
• Sai Sunil Kishore M, Dutta S, Kumar P. Early nasal intermittent positive
pressure ventilation versus continuous positive airway pressure for
respiratory distress syndrome. Acta Paediatr 2009;98(9):1412-1415
• Robert M DiBlasi. Neonatal Noninvasive Ventilation Techniques: Do We
Really Need to Intubate?.Respiratory care. September 2011; 56 (9):1273-
1293
Geetanjli NINE, PGIMER
110. • Debbie Fraser Askin. Noninvasive Ventilation in the Neonate. J Perinat
Neonat Nurs 2007;21 (4) : 349–358
• De Paoli AG, Davis PG, Faber B, Morley CJ. Devices and pressure sources
for administration of nasal continuous positive airway pressure (NCPAP) in
preterm neonates. Cochrane Database Syst Rev 2008; (1): CD002977.
• Kieran EA, Twomey A, Molloy EJ,Murphy JFA, O’Donnell CPF. A
randomised controlled trial of prongs or mask for nasal continuous
positive airways pressure (NCPAP) in preterm infants: The POM trial. Arch
Dis Child 2011; 96 (Suppl 1): P5.
• C Aparna, Deorari A. Noninvasive Ventilation in Newborn. Workshop on
Advances Neonatal Ventialtion. In: K. Parveen etal, editors. Neonatal unit
Department of PGIMER, Chandigarh.
Geetanjli NINE, PGIMER
111. • Kieran EA, Twomey AR, Molloy EJ, Murphy JF, O'Donnell CP.
Randomized trial of prongs or mask for nasal continuous positive airway pressu
Pediatrics. 2012 Nov;130(5):e1170-6. doi: 10.1542/peds.2011-3548.
Epub 2012 Oct 22. PubMed PMID: 23090339.
• Shaffer TH, Alapati D, Greenspan JS, Wolfson MR.
Neonatal non-invasive respiratory support: physiological implications.
Pediatr Pulmonol. 2012 Sep;47(9):837-47. doi: 10.1002/ppul.22610. Epub
2012 Jul 6. Review. PubMed PMID: 22777738.
• Deorari A, K. Parveen, M Srinivas, editors. Workbook on CPAP Science,
Evidence and Practice. Chetna. 2010.
• Lemyre B, Davis PG, de Paoli AG. Nasal intermittent positive pressure
ventilation (NIPPV) versus nasal continuous positive airway pressure
(NCPAP) for apnea of prematurity. Available from URL:
http://www.ncbi.nlm.nih.gov/pubmed/11869635
• Meneses J, Bhandari V, Alves JG, Herrmann D. Noninvasive ventilation for
respiratory distress syndrome. A randomized controlled trial. Pediatrics
2011; 127:300-307. Geetanjli NINE, PGIMER
CNET- Continous negative extrathoracic pressure ventilation- iron lung concept- now an outdated modality .
Mimics the grunt of a preterm infant with RDS
Heads paradoxical reflex---
Most effective treatments in Neonatology, avoiding or delay in deserving babies is inviting troubles for yourself !
Tachypnea (respiratory rate more than 60/min): Respiratory count
should be for a minute and should be rechecked if the child has
borderline of increased respiratory rates.
Presence of chest retractions: Specifically define whether the
retraction is suprasternal or infrasternal or intercostal. Suprasternal
recession more often suggests upper airway obstruction and may
be a pointer toward upper airway anomaly in neonates. Intercostal
retraction suggests alveolar involvement.
Grunting: This signifies the patients effort to maintain functional
residual capacity. The patient exhales against a partially closed
glottis thereby attempting to keep the alveoli open. This again
suggests presence of atelectasis.
Cyanosis: Presence of cyanosis indicates significant right to left
shunt resulting from widespread atelectasis. Objectivity for
assessment and monitoring for respiratory distress may be achieved
by using Silverman-Anderson scoring (Tables 3.1 and 3.2) or
Downe’s scoring (Table 3.3). It is recommended that clinicians make
regular use of any of these scoring systems to make management
decisions at the bedside.
In Silverman-Anderson score, inspection or auscultation of the
upper and lower chest and nares are scored on a scale of 0, 1 or 2
using this system are:
Chest movement: Synchronized vs minimal lag or sinking of the
upper chest as the abdomen rises. In the most extreme instances, a
seesaw-like movement of the chest and abdomen is observed and
would be given a score of 2.
Intercostal retractions: Retraction between the ribs is rated as none,
minimal or marked. This indicates loss of functional residual
capacity.
Xiphoid retractions: Similarly, retraction below the xiphoid process
are rated as none, minimal or marked.
Nasal flaring: Normally, there should be no nasal flaring. Minimal
flaring is scored 1 and marked flaring is scored 2.
Expiratory grunting: Grunting that is audible with a stethoscope is
scored 1, and grunting that is audible without using a stethoscope
is scored 2. The higher the score, the more severe the respiratory
distress. A score greater than 7 indicates that the baby is in
respiratory failure.
Downe score
Score: &gt; 4 = Clinical respiratory distress; monitor arterial blood gases
&gt; 8 = Impending respiratory failures
The author is of the opinion that this scoring system is very
practical and easy to use with good sensitivity and specificity in
preterm babies
A baby who appears unwell clinically, appears to be exhausted
or pale on any form of ventilatory assistance has to be evaluated for
the cause and appropriate action taken. The author opines that early
anticipatory action based on a protocolised approach is important
for a good neurological outcome.
Improvement in air entry is also a good measure of improvement
with CPAP especially in baby more than 1.5 kg