The document describes a case of a preterm infant born at 33 weeks gestation with low birth weight and respiratory distress. It then provides information on assessing and managing respiratory distress in newborns, including different scoring systems, delivery room management for preterm infants, and various modalities of non-invasive respiratory support such as nasal prongs, nasal CPAP, and high-flow nasal cannula. Key points discussed include initiating CPAP early for signs of respiratory distress and adjusting settings based on patient response and blood gas values.
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
Surfactant replacement therapy : RDS & beyondDr-Hasen Mia
This presentation is about Surfactant, its use in Respiratory Distress Syndrome & some other conditions of surfactant deficiency due to inactivation like meconium aspiration syndrome & others
Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: resuscitation at birth, assessing infant size and gestational age, routine care and feeding of both normal and high-risk infants, the prevention, diagnosis and management of hypothermia, hypoglycaemia, jaundice, respiratory distress, infection, trauma, bleeding and congenital abnormalities, communication with parents
This is a detailed presentation on Non-Invasive Ventilation in Neonates. it includes modes of NIV, Evidence related to CPAP vs NIV, use of NIV/CPAP and detailed description of CPAP and its use, complications associated with NIV and related management
Surfactant replacement therapy : RDS & beyondDr-Hasen Mia
This presentation is about Surfactant, its use in Respiratory Distress Syndrome & some other conditions of surfactant deficiency due to inactivation like meconium aspiration syndrome & others
Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: resuscitation at birth, assessing infant size and gestational age, routine care and feeding of both normal and high-risk infants, the prevention, diagnosis and management of hypothermia, hypoglycaemia, jaundice, respiratory distress, infection, trauma, bleeding and congenital abnormalities, communication with parents
This is a detailed presentation on Non-Invasive Ventilation in Neonates. it includes modes of NIV, Evidence related to CPAP vs NIV, use of NIV/CPAP and detailed description of CPAP and its use, complications associated with NIV and related management
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.
How to resuscitate, management in meconium aspirated baby, thin and thick meconium, ratio of ventilation and perfusion in new born, latest change in guidelines for resuscitation
Seminar on critical Congenital heart disease Dr Habibur Rahim | Dr Faria YasminDr. Habibur Rahim
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Duct-dependent systemic circulations
Critical aortic stenosis
Coarctation of the aorta
Interruption of aortic arch
Hypoplastic left heart syndrome
Duct-dependent pulmonary circulations
Pulmonary atresia Critical pulmonary stenosis
Tricuspid atresia
Tetralogy of Fallot
Ebstein’s anomaly
Parallel non-mixing circulation
Transposition of great arteries
Other
Total anomalous pulmonary venous connection (TAPVC)
Double outlet right ventricle
Single ventricle
Truncus arteriosus
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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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.
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.
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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.
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Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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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
1. Case scenario
D/O Zakia, inborn, got admitted in NICU at 15 min of
her age due to prematurity (33weeks), LBW(1600g) and
respiratory distress soon after birth. Premature delivery
was done due to PET. Baby cried immediately after
birth & APGAR was good. Mother got single dose of
antenatal corticosteroid. On arrival baby was
normothermic, euglycemic, reflex & activities were
good, but having respiratory distress in the form of
tachypnea, nasal flaring, chest retraction & grunting.
5. Content
• Definition of respiratory distress
• Respiratory distress scoring system
• Delivery room management of respiratory distress
• Different modalities of respiratory support
• Supplemental O2 delivery apparatus
• Different types of non invasive respiratory support
• O2 toxicities
• O2 monitoring device
6. Suzanne Reuter et al. Respiratory Distress in the
Newborn. Pediatrics in Review. 2014;35(10):417 - 29
Respiratory distress in the newborn is defined as
one or more signs of increased work of breathing,
such as
- tachypnea,
- nasal flaring,
- chest retractions or
- grunting.
9. Downes’ scoring system
0 1 2
Cyanosis none In room air In 40% Fio2
Retractions none Mild Severe
Grunting none Audible with
stethoscope
Audible without
stethoscope
Air entry Clear Decreased or
delayed
Barely audible
Respiratory rate <60 60-80 >80 or apnea
10. • Term newborn infant reach stable arterial
oxygen saturation values around 85% to 90%
by arterial oxygen saturation within 5 minutes.
• Preterm infants, especially extremely preterm
infants need almost 10 minutes to reach
preductal Sp02 of around 85%.
Delivery room management
11. Recommendation for pre term
• In spontaneously breathing babies
stabilise with CPAP of at least 6 cm H2O
• Intubation should be reserved for babies not
responding to positive pressure ventilation.
• Surfactant who require intubation for stabilisation.
Respiratory support in Delivery room
12. • T – piece resuscitator for resuscitation
in delivery room.
• Use an initial FiO2 of
- 0.30 for < 28 weeks of gestation
- 0.21–0.30 for 28–31 weeks
- 0.21 for 32 weeks of gestation
and above.
(European Consensus Guidelines on the Management of Respiratory
Distress Syndrome – 2019 )
Respiratory support in Delivery room
13. Rescue or therapeutic surfactant: Preterm who are -
o Suspected of having surfactant deficiency
o Required endotracheal intubation & MV
o Required an FiO2 > 0.40
o Clinical and radiographic evidence of neonatal RDS
AARC Clinical Practice Guideline.
Surfactant Replacement Therapy: 2013
14. • Using CPAP immediately after birth with
subsequent selective surfactant
administration considered as an alternative to
routine intubation with prophylactic or early
surfactant administration in preterm infants.
Respiratory support in Delivery room
15. CHIRUVOLU et al. Delivery room management of meconium-
stained newborns and respiratory support. PEDIATRICS. 2018;
142(6): 1 – 7
• The recent NRP guideline change in the delivery
room management of newborns who are
nonvigorous and born through MSAF avoided a large
number of intubations in the delivery room and was
not associated with an increased incidence of MAS.
• This change was associated with a higher incidence
of NICU respiratory admissions and increased needs
for mechanical ventilation, oxygen, and surfactant
therapy.
17. Nasal prongs
• Nasal prongs are a
disposable plastic device
that ends in two short
tapered tubes (about 1
cm in length) designed to
lie just within the nostrils.
They are also called nasal
cannula.
• Standard flow rates
through nasal prongs are
0.5–1 L/min for neonates
18. Nasal prongs
Advantages
• No risk of gastric
distension
• Humidification is not
required with standard
oxygen flow rates
19. Disadvantages
• Airway will become
obstructed by mucus
• Unable to use with nasal
obstruction
• Can dislodge from nares
easily
• Causes skin irritation or
breakdown over ears or
at nares
Nasal prongs
20. Nasal catheter
• A nasal catheter is a
thin, flexible tube that is
passed into the nose
and ends with its tip in
the nasal cavity.
• In neonates and
infants, 8-French (F) size
catheters should be
used.
• The maximum flow rate
should be set at 0.5–1
L/min for neonates and
1–2 L/min for infant.
21. • Catheter passed for a
distance equal to the
distance from the side
of the nostril to the
inner margin of the
eyebrow usually
reaches the posterior
part of the nasal cavity.
• The tip of the catheter
should not be visible
below the uvula.
22. Advantage:
The oxygen does not
have to be humidified
because the tip of the
catheter lies in the nasal
cavity.
Disadvantage:
Catheters can become
blocked with mucus,
which can cause upper
airway obstruction
There is little risk of
displacement into the
oesophagus, with a
consequent risk of
gastric distension
Nasal catheter
23. Nasopharyngeal catheters
• Nasopharyngeal catheters are inserted into the nose
to a depth 1 cm less than the distance from the side
of the nose to the front of the ear (tragus).
• In neonates and infants, 8-F catheters should be
used.
• Maximum flow rate 0.5 L/min for neonates
24.
25. Nasopharyngeal catheters
Disadvantage
• Higher flow rates without
effective humidification
may cause drying of the
nasal mucosa, with
associated bleeding and
airway obstruction.
• Can be displaced
downwards into the
oesophagus and cause
gagging, vomiting and
gastric distension.
Advantages:
• Oxygen delivery is most
economical of all the
methods described
here.
• Better oxygenation is
achieved with a lower
oxygen flow than with
nasal prongs
26. • An oxygen hood (cube)
is a plastic enclosure
that surrounds the head
of the neonate, to
which a continuous flow
of humidified oxygen is
supplied
• Gas flow rate 3 – 10
L/min.
Head box
27. Head box
Advantages
No increased risk for
airway obstruction or
gastric distension
Humidification is not
necessary.
Disadvantage
Carbon dioxide toxicity
can occur if the flow of
oxygen is inadequate. A
gas flow of 2–3 L/kg per
min is necessary to
avoid rebreathing of
carbon dioxide in a
head box .
• Head boxes interfere
with feeding.
28. Face mask
• Simple mask is made of
clear, flexible,plastic or
rubber that can be
molded to fit the face
• Not use in neonates
29. Supplemental Oxygen via the Incubator
Is the most common
method of low-level
supplemental O2 delivery
in Europe
These incubators have
respiratory gas connection
ports, a microprocessor,
and an oxygen sensor that
control O2 content
30. Advantages:
• Servo controlled
incubators provides
steady oxygen
• Avoid the skin
breakdown
• Noise is low
Disadvantages:
Infant must be
maintained in an
incubator
Supplemental Oxygen via the Incubator
31. O2 Administration By Holding O2 Source Near The
Infant’s Face
This kind of oxygen
administration is widely
used for short periods-
- after extubation
- during breast feeding who
is on headbox O2
32. Oxygen Delivery Devices and Flow Limit
• Nasal prongs : 1-2L /min
• Nasal cannula: 1-2 L/min
• Nasal catheter : 1-2L /min
• Nasopharyngeal catheter : 1-2L /min
• Head Box : 3-10L /min
• CPAP : 3-10 L /min
• HFNC: 3 – 8 L/min
• Ventilator : As much as
33. Non invasive respiratory support(NIRS)
NIRS
Typical
Non Typical
eg. HHHFNC
CPAP NIMV/NIPPV NHFV NIV-NAVA
34. Choice of respiratory support
• CPAP should be initiated at the earliest or subtle signs of
respiratory distress in neonates at risk for RDS.
• Some arbitrary criteria can be Silverman score of ≥ 4 or
FiO2 requirement ≥ 0.3.
• For preterm baby especially in extremely low birth
weight baby
as tachypnea is the earliest sign of respiratory distress.
Tachypnea = CPAP
35. A. B. Hedstrom et al. Performance of the Silverman Andersen Respiratory
Severity Score in predicting PCO2 and respiratory support in newborns.
Journal of Perinatology. February 2018.
38. Most widely used CPAP is Bubble CPAP
Indications: Presence of good respiratory drive is pre
requisite of CPAP support.
- Respiratory disorder (RDS, MAS, Pneumonia, PPHN)
- Apnea of prematurity
- Disorder causing excessive lung fluid (TTN, PDA, CCF,
Hydrops fetalis ect.)
- Laryngo/tracheo/broncho malacia
- After extubation
39. Contraindications of CPAP
• Poor respiratory drive that is not improved by CPAP
• Cleft palate
• Choanal atresia
• Tracheoesophageal fistula
• Unrepaired CDH
• Severe cardiovascular instability (Hypotension)
• Severe apneic episode
• Severe ventilatory impairment (PH < 7.25, PCO2>60)
40. How CPAP work?
• Increase FRC
• Improve lung compliance
• Aid in the stabilization of highly complaint
infant chest wall
• Decrease thoracoabdominal asynchrony
• Decrease intrapulmonary shunting
• Reduce tachypnea
• Decrease labored breathing
41. Time of application of CPAP
• Prophylactic CPAP in delivery room
• Early : within 2 hours of distress
• Late : after FiO2 requirement > 0.40
CPAP does not work as expected if it is started after
atelectasis have been already occurred.
Early CPAP is beneficial. It enhance
- surfactant conservation
- lower PEEP
- reduce the need for MV
42. Devices used for interface
• Nasal prong
• Nasopharyngeal prong
• Nasal mask
• Face mask
Widely used nasal prong.
No published data concerning the safety and efficacy
of nasal mask.
43. Bipin.Is nasal mask better than nasal prongs for delivering nasal
continuous positive airway pressure in preterm infants with
respiratory distress syndrome? 2018
CONCLUSION
Nasal Continuous positive airway pressure (NCPAP)
with mask interface is equally effective as nasal
continuous positive airway pressure (NCPAP) with
prongs interface. Incidence of stage II nasal trauma
was significantly lower in mask group than in the
prongs group.
44. Setting of PEEP, FiO2 & Flow
• Set up is disease specific.
• Pressure ranges 4 – 7 cmH2O
• FiO2 0.21 – 0.60
• Flow rate 2 – 8 L/min
General rules of initial setup is rules of “5”.
- Pressure: 5 cmH2O
- FiO2: 0.50
- Flow: 5 L/min
Always insert orogastric tube while baby on CPAP and keep
open & above the level of stomach
45. How to assess optimum CPAP
• Baby is comfortable in CPAP
• Minimal or no retraction
• No grunt
• Normal CRT & BP
• Maintain SpO2 within 90 – 95%
• CXR: Presence of 8 posterior ICS above diaphragm.
• Achieve expected blood gas level in high set up
(PH > 7.25, PCO2 < 60 & PO2 > 50)
46. Adjustment of PEEP, FiO2 & Flow
• ↑ PEEP by 1 cmH20 in every 15 to 20 min to maintain
SpO2 between 90 – 95%
• Adjust PEEP by seeing the chest retraction. Increase
PEEP upto 8 cmH2O
• Do not raise FiO2 before pressure.
• ↑ FiO2 upto 0.60 to maintain SpO2
• No bubbling inadequate flow to generate pressure
or may be leak in circuit.
• Excess bubbling wastage of gases or turbulence in
flow.
47. CPAP & FiO2 proportionality
CPAP 4 FiO2 25 – 40%
CPAP 5 FiO2 50%
CPAP 6 FiO2 60%
CPAP 7 FiO2 70%
If there is any discrepancy between CPAP and pressure & FiO2
think about
- PPHN
- CHD
- Metabolic acidosis
- Over distended lungs
48. Weaning of CPAP
• The process of weaning should be slow and steady.
• Every 1 cmH2O decrease in CPAP aims to decrease
FiO2 10%.
• When baby comes down to PEEP 5 & FiO2 50% then
first decrease FiO2 upto 30% and then decrease
pressure from 5 to 4 cmH2O.
• When pressure 4 and FiO2 < 30% with normal SpO2
and minimal retraction, CPAP may be weaned to air
or head hood.
49. CPAP Failure
• Presence of retraction/grunt despite giving optimum
CPAP
• Recurrent or severe apnea (significant apnea means
3 apnea/ hour or that requiring bag & mask
ventilation)
• Significant bradycardia
• PO2 < 50 in FiO2 >0.60
• PCO2 > 60 or PH < 7.25
Most common cause for CPAP failure is delayed in
initiation after birth.
50. Complications of CPAP
• Pulmonary air leak syndrome
• Decreased cardiac out put due to reduction in
venous return
• Impedance of pulmonary blood flow with increased
pulmonary vascular resistance
• Gastric distension & CPAP belly syndrome
• Nasal irritation, damage to the septal mucosa, skin
damage and necrosis from fixing devices.
51. Other CPAP devices
Infant Flow Driver:
This device generate CPAP at the airway proximal to
infants nose.
Principles:
- Bernoullis effect (maintain constant pressure)
- Venturi effect (flow variation acc. to baby needs)
- Coanda effect (causes fluidic flip & hence ↓ WOB)
52. Sigh Intermittent Positive Airway Pressure (SiPAP)
• It is newer mode of NIV which provides bilevel CPAP
• SiPAP is not a nasal IMV
• Small (2-3 cmH2O), slow, intermittent increase in
CPAP pressure for duration up to 3 sec →sigh breath.
• SiPAP setting:
- Baseline CPAP level
- Frequency (usually 6)
- Pressure rise (2-3 cm H2O)
- Duration of pressure rise (1-2 sec)
53. Advantages of different types of NCPAP
• Bubble CPAP → continuous bubbling & pressure
oscillates in the circuit → facilitates gas exchange by
facilitated diffusion.
• Sea-PAP → more oscillation by bending at an angle of
135 degree in expiratory tube.
• IFD → more uniform pressure.
• SiPAP → more alveoli recruitment, stimulate resp center.
There are no definite data to support or refute using one
NCPAP system to another.
54. Trouble Shoot in CPAP
SpO2 Retraction Air entry Bubbling Diagnosis
Low +++ Poor Yes Lung disease
Low +/nil Good Yes PPHN/CHD
Normal +++ Good Yes Metabolic acidosis
Low +++ Poor Yes Obstruction
Low +++ Poor Nil Leaks
55. Colin et al. Nasal CPAP or Intubation at Birth for Very Preterm
Infants. n engl j med.2008; 358(7). COIN trial
Conclusion:
Infants who were born at 25-28 weeks’ gestation and
were breathing spontaneously were treated with
CPAP shortly after birth. Half were subsequently
intubated.
Infants in the CPAP group had a better outcome at 28
days.
Two groups had a similar outcome at 36 weeks’
gestational age, but there was an increased incidence
of pneumothorax in the CPAP group.
56. Early CPAP versus Surfactant in Extremely Preterm Infants. n engl
j med. 2010; 362(21). SUPPORT trial
Conclusion:
No significant difference in the primary outcome of
death or bronchopulmonary dysplasia between two
groups.
CPAP results lower rate of intubation, reduced rate of
postnatal corticosteroid use, shorter duration of
ventilation without an increased risk of any adverse
neonatal outcome.
Data supports CPAP as an alternative to routine
intubation and surfactant administration in preterm
infants.
57. SANDRI et a. Prophylactic or Early Selective Surfactant Combined
With nCPAP in Very Preterm Infants. PEDIATRICS.2010;125(6).
CURPAP trial.
CONCLUSIONS:
• Prophylactic surfactant was not superior to nCPAP.
• Early selective surfactant decreases the need for MV
in the first 5 days of life and the incidence of main
morbidities of prematurity in spontaneously
breathing very preterm infants on nCPAP.
58. DUNN et a. Randomized Trial Comparing 3 Approaches to the Initial
Respiratory Management of Preterm Neonates. PEDIATRICS.
2011;128(5). VON DRM trail
CONCLUSIONS:
Preterm neonates were initially managed with either
nCPAP or PS with rapid extubation to nCPAP had
similar clinical outcomes to those treated with PS
followed by a period of mechanical ventilation.
An approach that uses early nCPAP leads to a
reduction in the number of infants who are
intubated and given surfactant.
59.
60. Humidified High Flow Nasal Cannula(HHFNC)
• Same as CPAP but
without having in-
build PEEP.
• Here PEEP is created
by high flow (3-8
L/mi) which is
dynamic pressure.
61. HHFNC cont…
Mechanism by which it works:
Flushing the upper airway dead space of CO2,
allowing for better alveolar gas exchange.
Providing a flow adequate to support inspiration,
thereby reducing inspiratory WOB.
Improving lung & airway mechanics by eliminating
the effect of drying/cooling.
Reducing or eliminating the metabolic cost of gas
conditioning.
Provide end distending pressure.
62. Indications of HHFNC
• In post extubation setting
• Weaning from nCPAP
• As primary mode of support in respiratory
distress though enough evidence for safety
and efficacy lacking.
63. Protocol for initiating set up of HHFNC
• First appropriate size nasal cannula is attached to
circuit tube.
• Set FiO2 at same or 5-10% higher from previous
mode of support in post extubation cases. Start with
FiO2 0.40 in case of primary support.
• A rule of thumb for initial flow rate setting, use 1-2-3,
2-3-4, 3-4-5 formula
1 to 2 kg = 3 L/min
2 to 3 kg = 4 L/min
> 3 kg = 5 L/min
64. Maintain & weaning of HHFNC
• ↑flow rate 1 L/min if FiO2 increases > 10% and PCO2
increases > 10 mmHg above baseline.
• Titrate flow & FiO2 to keep SpO2 between 90-95%.
• First decrease FiO2 during weaning upto 40% then
decrease flow rate slowly by 1 L/min upto 3L/min.
• Then further decrease FiO2.
• Then wean to air or headhood.
65. Non Invasive Ventilation (NIV)
NIV or NIPPV is used for patient failing NCPAP or
following extubation from MV.
Synchronized & nonsynchronized NIMV with a
conventional ventilation is the most common form.
NIV avoid complications of prolonged invasive
ventilator (volutrauma, infection & subglottic
stenosis.)
One study showed that NPSIMV may be less injurious
to lungs & provide better ventilation with less need
for support than invasive SIMV.
66. NIPPV cont…
• Short binasal prongs are the most commonly used
interface for NIPPV.
• Nasal mask & nasopharyngeal prongs can be used.
• Set up:
Short inflation times (0.3–0.5 s),
Variable inflation rates of 10–60/min and
Peak pressures and positive end expiratory pressure
similar to those used with endotracheal ventilation.
67. Neurally Adjusted Ventilatory Assist (NAVA)
• NAVA is new & unique form of assisted ventilation.
• It can be used in both intubated & non intubated
patients.
• It controls the ventilator by using the electrical
activity of the diaphragm (EAdi).
• EAdi signal is obtained by nine miniaturized
electrodes embedded on a conventional naso/oro
gastric tube, positioned in the lower esophagus.
68.
69. NAVA cont…
• EAdi signal will not be present during apnea,
oversedation or severe brain injury.
• NIV-NAVA is possible only when the infant has a
reasonably stable respiratory drive.
• A RCT of 15 infants of <32 weeks compared NIV-
NAVA with NIV-Pressure Support and found better
patient ventilator synchrony with NAVA.
70. Nasal High Frequency Ventilation (NHFV)
• NHFV breath can be delivered by nasopharyngeal or
nasal prongs.
• NHFV with Drager VN500 ventilator showed nearly
threefold more efficient CO2 clearance than NIMV.
• Potential advantage of NHFV over NIMV is that
synchronization is not necessary, because of
relatively high frequencies.
73. The aim : was to assess the clinical effectiveness and
safety of HFNC compared to CPAP as a noninvasive
respiratory support for the initial respiratory
management of respiratory distress in preterm infants.
Conclusion : There is no evidence to support the non
inferiority of HFNC compared to CPAP as an initial
management of respiratory distress in premature infants
at between 30 and 35 weeks gestational age. The
difference in failure rate is not significant without an
increase in the incidence of complications.
HFNC Vs CPAP cont…
74. Sarah et al.Safety and Efficacy of High-Flow Nasal Cannula
Therapy in Preterm Infants: A Meta-analysis.PEDIATRICS Volume
136, number 3, September 2015
RESULTS:
High-flow therapy was similar in efficacy to other
modes of NIV in preterm infants when used as
primary support (odds ratio of failure of therapy, 1.02)
as well as after extubation (1.09).
There were no significant differences in odds of death
(0.48) between the groups. Preterm infants supported
on high flow had significantly lower odds of nasal
trauma (0.13)
75.
76.
77.
78.
79. HFNC
CPAP
More trials is required to find out
optimum non invasive ventilation
NIPPV
Answer is
Which non invasive modality is the best?
80. Oxygen is Life Saving, but….
• Oxygen is the energy source of cellular life.
• It is the biomedical double –edged sword.
• It is mandatory to avoid hypoxia, but prolonged
hyperoxia leads to oxidative stress and cellular
injury.
81. Complications of Oxygen Therapy
• Skin irritation
• Drying of nasal and pharyngeal mucosa
• Induced hypoventilation
• Absorption atelectasis
• Adverse effect on retina
• Adverse effect on lung eg CLD
82. Noninvasive monitoring of Gas Exchange?
Pulse oximetry: by which SpO2 is measured.
Transcutaneous oxygen monitoring (TcPO2)
Capnography & End – Tidal CO2 monitoring
- Mainstream capnography
- Sidestream devices
Transcutaneous CO2 monitoring
Tissue oxygen saturation monitoring using Near
Infrared Spectroscopy (NIRS)
83. Target Range of Saturation spo2
• Preterm : 88-92%
• The optimal SpO 2
target of ELBW
infants is not known
• Term : 93-97%
84. Take home message
• Stabilization in the delivery room should be
done with 30% O2 in gestation ≤ 32 weeks.
• CPAP immediately after birth with
subsequent selective surfactant
administration is an alternative to routine
intubation with prophylactic or early
surfactant administration in preterm.
• Noninvasive ventilator (NIV) support is
preferred in comparison to invasive
supports.
85. References
• Rennie & Roberton’s textbook of neonatolog. 5th edition
• Neonatolog. management, procedure, no-call problems, and
drugs. 7th editiom
• Manual of neonatal care. 8th edition
• Avery’s diseases of the newborn. 7th edition
• Nelson textbook of pediatrics. 20th edition
• Assisted ventilation of the neonate. 5th edition
• CPAP bedside application in the newborn. 2nd edition
• Workshop on CPAP. Science, evidence & practice. 4th edition
• Online journal