care of the preterm infant: non-invasive ventilation and other related important stuff se courtney,...
TRANSCRIPT
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Care of the Preterm Infant:Non-invasive Ventilation and Other Related
Important Stuff
SE Courtney, MD MSProfessor of PediatricsStony Brook University Medical Center
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Opening the Lung
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Congratulations! Baby is at OPTIMAL MEAN AIRWAY PRESSURE
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Pressure
Benefit
Optimal Mean Airway Pressure
AtelectasisOverdistension
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CPAP/PEEP: DR and beyond
• CPAP/PEEP should be used from the beginning
• If a self-inflating bag must be used, equip it with a PEEP valve
• Consider T-piece resuscitator
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Finer NN et al, Resuscitation 2001
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Use of oxygen
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Oxygen Toxicity
• Retinopathy of prematurity• Increased days on ventilator• Increased days on oxygen• Increased incidence/severity of BPD
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Finer N and Leone T. Oxygen saturation monitoring for the preterm infant: The evidence basis for current practice. Pediatr Res 2009;65:375-380
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Oxygen in the Delivery Room
• A blender and pulse oximeter should be used• Start with 30 or 40% oxygen in the preterm
infant• Saturations of around 80% at 5 minutes are
normal
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Oxygen in the NICU
• Saturations of 85-93% appear to be safe
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Temperature control
Admission temperature <36 degrees centigrade is an independent risk factor for mortality in the preterm infant.
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CPAP and Non-invasive Ventilation
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Goal of Mechanical Ventilation
To get the patient OFF mechanical ventilation!
• Airway trauma• Infection• Decreased mucus clearance• Over-ventilation• Air leak• Contribution to BPD
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NCPAP is probably a good thing
• CPAP Reduces mortality and respiratory failure in RDS
• Early CPAP reduces need for mechanical ventilation
• CPAP post-extubation can prevent extubation failure
• NO STUDY has shown reduction in BPD with use of CPAP under any conditions (testimonials don’t count)
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NCPAP/NIV
• Constant-flow– conventional– bubble
• Variable-flow– Infant Flow– Bi-level
• NIPPV
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Not all CPAP is created equal:Know your equipment
• Variable-flow NCPAP recruits lung volume well and decreases work of breathing. Care must be taken to avoid nasal trauma.
• Bubble NCPAP: pressures must be monitored; they will be higher than the depth of the underwater expiratory tube.
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CPAP by Conventional Ventilator
• Constant flow of air/oxygen.
• CPAP provided by changing orifice size at expiratory port of the ventilator, thus providing back-pressure.
• Variety of prongs, usually bi-nasal.
• Convenient, easily available, inexpensive.
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“Bubble” NCPAP
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“Bubble” NCPAP – Do We Know What We’re Doing?
Bias Flow (Liters/min)
4 6 8 10 12
Me
an
(+
/- S
D)
Pre
ss
ure
(c
mH 2O
)
2
4
6
8
10
12
No Leak
(set
NC
PA
P)8
4
Ventilator: open symbolsBubble: solid symbols
Kahn DJ et al, Pediatric Research 2007;62:343.
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Kahn et al, Pediatrics, 2007
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3 5 7 4 2135
140
145
150
3 5 7 4 291
92
93
94
95
96
97
Set NCPAP (cmH2O)
Set NCPAP (cmH2O)
B-NCPAP
V-NCPAP
B-NCPAP
V-NCPAP
He
art
Ra
te
(m
in-1
)S
aO
2
(%)
3 5 7 4 2
Tc
O2
(m
mH
g)
50
55
60
65
70
3 5 7 4 2
Tc
CO
2
(mm
Hg
)
46
48
50
52
54
56
Set NCPAP (cmH2O)
Set NCPAP (cmH2O)
B-NCPAP
V-NCPAP
B-NCPAP
V-NCPAP
Courtney et al, Bubble vs ventilator NCPAP, J Perinatol 2010
Pp=0.01
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Variable-Flow (Infant Flow) CPAP• Flow is varied to deliver the required CPAP pressure.
• The direction of flow depends on the pressures generated by the patient.
• On inspiration, the CPAP flow is towards the nasal cavity, assisting in inspiration
• On exhalation, the flow is down the expiratory branch of the CPAP tubing.
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Childs, Neonatal Intensive Care, 2000
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What Do We Know AboutVariable-Flow NCPAP?
• Provides a very stable mean airway pressure
• Decreases work of breathing
• Increases lung volume recruitment
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Adapted from Moa G and Nilsson K. Acta Paediatr 1993;82:210.
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C = Cannula
A = Aladdin (Infant Flow)
I = Inca Prongs (Conventional Ventilator)
Courtney SE, Pyon KH, Saslow JG et al. Pediatrics 2001;107:304-308
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Pandit PB, Courtney SE, Pyon KH et al. Pediatrics 2001;108: 682-685
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38.1 38.5
0
20
40
60
80
100
Conventional Infant Flow
Fa
ilu
re (
%)
Stefanescu et al, Pediatrics 2003;112:1031
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Secondary Outcomes
Conv IF P
Days on O2 77.2 65.7 0.03
Length of Stay 86.3 73.7 0.02
Stefanescu et al, Pediatrics 2003;112:1031
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Stefanescu et al, Pediatrics 2003;112:1031
58%
16%
15%
3%
8%
Apnea / bradycardia
FiO2>0.5, CPAP>8 cm
PaCO2>65, pH<7.25
Surgery
Other
Apnea Hypoxia
Hypercarbia
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NCPAP with a Rate:(NIMV, NIPPV)
NIMV for reducing apnea and extubation failure
• Synchronized (?)NIMV reduces the incidence of extubation failure and possibly apnea more effectively than NCPAP.
• “Synchrony” done with Graesby capsule and Infant Star ventilator
• No information is available on non-synchronized NIMV.
• Current studies ongoing
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Owen LS, Morley CJ, Davis PG. PAS 2009
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SiPAP
What is SiPAP?– A small (2-3 cmH2O), slow,
intermittent increase in CPAP pressure for a duration up to 3 seconds to produce a “Sigh”
– Enables the infant to spontaneously breathe throughout the cycle
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0
2
4
6
8
10
12
14
0 2 4 6 8 10
CPAP Pressure
Volu
me
Chan
ge (m
l/kg)
5.5 ml/kg
Small increases in IF CPAPpressure can change lungvolume by 4-6 ml/kg.
Unlike NIPPV, SiPAP pressure riseis only 2-3 cmH2O
Adapted from Pandit PB, Courtney SE, Pyon KH et al. Pediatrics 2001;108: 682-685
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SiPAP can therefore potentially:
• Recruit lung volume
• Decrease work of breathing
• Stimulate the respiratory center
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Patients who may benefit from SiPAP:
• Infants weaning from mechanical ventilation
• Premature infants that don’t require aggressive support
• Infants with apnea
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Nasal Bilevel vs Continuous Positive Airway Pressure in Preterm Infants. Migliori C et al, Pediatr Pulmonol
2005;40:426.
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Nasal CPAP vs Bi-level nasal CPAP in preterm infants with RDS: a randomized control study. Lista G et al, Arch Dis Child Fetal Neonatal Ed. 2009
40 infants enrolled, mean GA 30wks, BW 1400g.
IF-CPAP SiPAP P
Respiratory support (d) 6.2 ± 2 3.8 ± 10 0.025
O2 dependency (d) 13.8±8 6.5 ± 4 0.027
GA at discharge (wk) 36.7± 2.5 35.6±1.2 0.02
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SiPAP vs NCPAPWork of Breathing and Respiratory Parameters
S. Courtney, M. Weisner, V. Boyar, R. Habib
• 17 infants <1200gms birth weight, on NCPAP for mild respiratory distress
• Each infant own control; order of application randomized and data collected in two periods for a minimum of one hour, with 15 min on each device in each period (ie, CPAP/SiPAP, CPAP/SiPAP
• Data collected using calibrated respiratory inductance plethysmography; esophageal balloon for estimation of pleural pressure
• Continuous monitoring of saturation, pulse, transcutaneous oxygen and carbon dioxide
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Minute Ventilation
Minute Ventilation
Period I Period II
MV
(m
l/kg
/min
)
22
02
40
26
02
80
30
03
20
CPAP SiPAP CPAP SiPAP
n=13 P=0.037
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Synchronized Non-invasive ventilation
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Shortcut to Graph.PNG.lnk
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Conclusions about SiPAP
• Appears to be at least as effective as NCPAP
• May improve gas exchange and decrease minute ventilation (?decrease WOB)
• Synchrony may be useful
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NCPAP by Nasal Cannula
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NCPAP by Cannula
• Uncontrolled positive pressure may be generated with nasal cannula
• Amount of positive pressure generated will depend on cannula size, flow rate, and shape of nasal passages.
• High humidity, high flow cannulas also may pose an infection risk.
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Nasal Cannula Use
Current literature would support that gas delivered by nasal cannula:
• be heated and humidified
• not exceed 1 L/min in infants <1500gm
• not exceed 2 L/min in infants >1500gm
If CPAP is desired, a CPAP device should be used.
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Non-invasive Ventilation is not appropriate when…
• Infant cannot maintain oxygenation (FiO2 > 0.5-0.6)
• PCO2 >60• pH < 7.25• Increased work of breathing• Apnea
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Questions…………….• Over the long term, is any one form of NCPAP more advantageous than any other?
• Is non-invasive ventilation combined with NCPAP advantageous? Is S-NIPPV better?
• When should NCPAP be initiated?
• When and how should surfactant be given for babies on NCPAP only?
• What levels of pH and PCO2 are “safe” for babies on NCPAP?
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Keep an open mind and something useful may fall into it.