donald m. null, jr., md medical director – nicu primary ... director – nicu primary children’s...

Donald M. Null, Jr., MDMedical Director – NICU

Primary Children’s Medical Center

Donald M. Null, Jr., MD

Speaker of this CME activity has financial relationships with

commercial entities to disclose:*Draeger consultant*Ikaria Speakers Bureau

I do not intend to discuss an unapproved/ investigative use of a commercial product or device in my presentation.

Noninvasive Respiratory Support Why, How and When

Terminology

NCPAP– Nasal Continuous Positive

Airway PressureHFNC

– High Flow Nasal Cannula

TerminologyNIMV

– Nasal CPAP with IntermittentPositive Pressure Breath

HFNCPAP/HFNV– Nasal CPAP with high Frequency

pulsations added/HighFrequency Nasal Ventilation

A. Functional Residual Capacity

I. Physiology of CPAP

1. Early 2. Late

Physiology of CPAP

B. Compliance

1. Early 2. Late

Physiology of CPAP

C. Resistance

D. Work of Breathing

Physiology of CPAP

E. Blood Gases 1. Early 2. Late

II. Delivery of CPAP

A. Nasal Cannula

B. Face Mask

Delivery of CPAP C. Nasal Prongs

1. Short 2. Long

A. Small B. Large C. RAM Cannula

Delivery of CPAP

D. ETT

E. Advantages

F. Disadvantages

III. Timing of CPAP

IV. Maximal Pressure Consideration

V. Adjunctive Therapy with CPAP

VI. CPAP for Ventilator Weaning

A. Early Physiology

B. Late Physiology

A. Too Little

B. Too Much

C. Too Late

Options for Assisted Respiratory Support besides Intubation

CPAPNIPPVHFNCHFNCPAP

CPAPMaintains lung volumeImproves complianceDecreases airway resistance

CPAPDoes not recruit lungDoes not ventilate patientVulnerable to de‐recruitment

NIPPVMaintains lung volumeImproves complianceCan recruit lung with breathsCan help ventilate patientLess vulnerable to de‐recruitment

HFNCMaintains lung volume with appropriate flowImproves complianceDecreases airway resistance

HFNCDoes not recruit lungVulnerable to de‐recruitmentMay help to ventilate some

HFNCPAPMaintains lung volumeImproves complianceDecreases airway resistance

HFNCPAPEnables lung recruitmentNot vulnerable to de‐recruitmentVentilates patient

1. Pulmonary pathophysiology

2. Cardiac pathophysiology

3. Central nervous system pathophysiology

4. GI pathophysiology

D. Patient Considerations

Pulmonary Pathophysiology

Altitude (feet)Sea level

5,0008,00010,00020,000

Relative Gas Volume1.001.201.351.452.20

Cardiac Pathophysiology

• PPHN• Transposition• RV Dysfunction• LV Dysfunction

Central Nervous System Pathophysiology

• IVH• HIE• Apnea

GI Pathophysiology

• Bowel Obstruction• NEC

A. Conventional

1. Why

2. How Much

A. Flow RangeB. Pressure Delivered

1. Cath Size2. Patient Size 3. Flow

C. Potential Benefits1. Patient2. Staff

D. Potential Risks1. Patient2. Staff

X. High Frequency Nasal CPAP in Preterm Lambs

Reason for HFNCPAP/HFNV

Preterm Lambs at 72 HoursCV HFNCPAP

Physiologic Parameters HFNCPAP vs CV for 72 hours

Parameters able to be keptwithin acceptable range

CV (n=1)HFNCPAP (n=1)

0

2 0 0

4 0 0

6 0 0

8 0 0

0 1 0 2 0 3 0 4 0

V o lu m e(m l)

P re s s u r e (m m H g )

HFNCPAP vs CV– Histology

– Molecular markers of apoptosis glucocorticoid processing and angiogenesis

CLD in Preterm Lambs- Alveolar Simplification -

CLD, 21d Term, 1d old

TRU TRU

CV NCPAP

Preterm Lamb Lungs at 72 Hours- Alveolar Septation -

TRUTRU

Preterm Lambs at 72 Hours- Alveolar Septation (Mean ± SD; n=6) -

3 ± 115 ± 4* Secondary Crest Volume Density (%)

2 ± 16 ± 2*Radial Alveolar Count (#)

CVNCPAPGroupVariable

mRNA Expression at 72 Hours

500

100

0p53

300

FASreceptor

Bax VEGF Flk-1(VEGF-R2)

Apoptosis Angiogenesis

Percentageof CV

mRNA Expression at 21 Days

200200

00p53p53

100100

FASFASreceptorreceptor

BaxBax

Percentageof CV

VEGF Flk-1(VEGF-R2)

Apoptosis Angiogenesis

Conclusion

• NCPAP enhanced alveolar secondary septation and capillary growth, in part by upregulating expression of signaling molecules for thinning of mesenchyme and capillary growth

DiscussionThese results are important because

NCPAP permits appropriate structural formation of alveoli

Nasal CPAP also effectively supports the preterm lambs based on physiological parameters

(PaO2, PaCO2, pH, OI, A-a gradient, P/V curves)

1. Improve PaCO2


1. Poor Patient Effort 2. VQ Mismatch 3. Decrease in Lung Compliance 4. Apnea

2. Improve PaO2


1. Low Lung Compliance 2. VQ Mismatch 3. Apnea 4. Patient Effort

3. Earlier Extubation/Non-Intubation


1. Transport Intubation

Case Study


• 4 month old 26 wk SGA 405 gramsHad plication of R diaphragm 1-3Never off ventilator

Case Study


• FiO2: 29–38% PIP: 14-21 Rate: 32 SIMV wt: 1775 TV: 4.2 cc/kg Sat: 86-94 CBG: 7.42 PCO2: 42 PO2: 34

Case Study


• Placed on HFNCPAP: 1-10 DOL: 121 Rate: 440 PEEP: 7 Rate: 16 FiO2: 32% Sat: 93

Case Study


• FiO2: 30-40% Sat: 91-93CBC: 7.37 PaCO2: 46 PaO2: 54 HcO3: 265

Case Study


• On 1-14-11 - DOL: 125 Weaned to HFNC at 5LFiO2: 30-38% Sat: 85-93

Improve gas exchange Decreases work of breathing Adjustable rate and amplitude Bubble CPAP provides high

frequency amplitude but is not adjustable


Works for patients who have:1. Poor Respiratory Effort

2. Apnea

3. Lung Instability


SUMMARY

donald m. null, jr., md medical director – nicu primary ... director – nicu primary children’s...

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