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Avoiding Mechanical Ventilation: (AMV mode)
The growing options in non invasive respiratory supportMichael Finelli RRT
Neonatal Respiratory Care Practitioner Sickkids, Toronto
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1993
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Objectives1. Identify some of the risks with
intubation and mechanical ventilation of the newborn lung, relating specifically to VILI and BPD.
2. List 3 possible methods of providing non invasive support to infants.
3. Reflect on past bedside experiences whereby nCPAP has not worked and consider the possibility of other non invasive ventilation support options in the future
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Reasons to Avoid Mechanical Ventilation
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Why Worry?• Mechanical ventilation is the #1 contributor to CLD and neonatal morbidity
• Ventilator Induced Lung Injury (V.I.L.I) is an unfortunate reality for so many of the patients we care for. It is our job to continually look for opportunities to minimize/eliminate this risk.
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V.I.L.I General Concepts
Excessive tidal volumes/PPV damages lungs: epithelial injury/shear stress protein leak & surfactant inhibition increased micro‐vascular permeability/pulmonary edema Air leak syndrome Remember: Volutrauma not Barotrauma is the culprit
PEEP Phobia‐ Low lung volume is just as bad as excessive lung volume (Atelectrauma)
Exposure to high FiO2 is toxic to the developing lung, giving rise to high levels of oxygen free radicals in the absence of developed antioxidant defense mechanisms (Oxytrauma)
Hypocapnea is very dangerous to the developing brain and steps should be taken to avoid CO2 swings in newborns. Excessive alkalosis has been linked to auditory impairment and neurodevelopmental delays
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Avoiding Intubation
• Decrease imposed respiratory work if allowing the infant to breath through there natural structures vs. an ETT
• PROTECT the lungs by decreasing VILI when attached to a mechanical ventilator and administering oxygen
• Decrease tracheal Colonization / VAP• Eliminating the so called routine “cares”
(more like tortures) that go along with ETTS i.e. taping ,suctioning etc
• Negate cricoid injury due to the ETT• Access to nasopharyngeal airway natural
humidification system
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How are we doing in the USA and Canada with respect to BPD rates of infants <28 weeks?
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Trends in Neonatal RDS management (2003‐2007)20 NRN Centers, Jan 2003 to Jan 2007 Survived >12 hours after birth
GA, wks 22 23 24 25 26 27 28 ALLn 62 496 1223 1426 1530 1811 1967 8515
BW. Mean g 511 581 651 744 854 960 1082 836
BPD@36wks
85 73 69 55 44 34 23 42Mild BPD % 15 26 26 37 35 28 16 27
ModBPD %
30 35 34 29 26 20 15 23
Severe BPD %
56 39 37 26 17 13 8 18
Physiological BPD %
89 70 68 55 44 31 22 40N(S)IMV % @24hrs
0 1 2 3 3 3 2 3 (0‐14)
NCPAP % @24hrs
0 3 8 18 30 36 38 26(8‐46)
Stoll B et al. NICHD‐NRN Paediatrics 126:443‐456Sept 2010
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Outcomes <27 weeks – Canada2009‐2010CNN Data
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NIV
NIPPVNCPAPBubble CPAPConventional VentilatorCPAP (NPT)IFS/SiPAP
Conventional VentilatorSiPAP: Biphasic, Trig
HI FLOW not included
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BUBBLE CPAP easy breezy and cheap!!!
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Fluidic Flip CPAP (IFS) or variable flow
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The many (inter) faces of CPAP
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What is at the NOSE
• Nasal prongs (various shapes and sizes)• Nasal mask (various shapes and sizes)• Long prongs (spaghetti prongs)• Short prongs • NPT• Inca prongs• Cannula “PAP”
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Bi‐nasal vs single prongBi‐Nasal Prongs(n41) Single prong (n46) P
BW, grams mean (SD)
790 (140) 816 (125) NS
GA 26 (1.9) 26 (1.9) NS
Age @ extubation days, median
3 (1‐9) 3 (1‐6) NS
Extubation Failures 24% 57% 0.005
Intubated <800g 24% 88% <0.001
Reintubation in <800g
18% 63% 0.023
Bi Nasal Prongs are significantly better at preventing extubation failure
Davis P et al Melbourne Arch Dis Child 85: F82‐85;2001
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NCPAP vs Surfactant: SUPPORT TRIAL24+0‐27+6 weeks GA (n=1316)
CPAP (n=663) Surfactant (n=653) P
BW, g 835 +188 826 + 198 NS
GA, wks 26.2 + 1 26.2 + 1 NS
GA 24 0r 25/ 26‐27 wks 43%/57% 43%/57% NS
Antenatal Steroids, Any 97% 96% NS
Antenatal Steroids, Complete
74% 70% NS
Male 52% 57% 0.05
Intubated in the delivery room or NICU for Surf Rx
67% 99% <0.001
BPD or death by 36 weeks
48% 51% 0.3
SUPPORT: Surfactant, Positive Pressure and Pulse Oximetry Randomized TrialFiner et al NEJM. 2010; 362; 1970‐9
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NCPAP Failure (over a 10 year period)
Binasal vs single
IFD vs, VCPAP
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Conventional CPAP vs. Infant Flow CPAP for Extubation: Reasons for Extubation Failures
Stefanescu BM et al (Winston ‐Salem, NC) Pediatrics 112:1031‐8;2003
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What to do if CPAP fails?
Currently practiced “PLAN Bs”:• Re intubate?• Higher CPAP levelsADD A BACK UP RATE• Biphasic / SiPAP (2 CPAP levels: Lo and Hi)• NIMV• NSIMV• ?NIHFOV
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Why might enhanced Non Invasive support work?
• Helps preserve Surfactant• Maintains lung volume FRC/Alveolar recruitment • Promotes release of surfactant from type 2 cells• Pharyngeal dilation decreasing upper airway resistance• Induces head’s paradoxical reflex • Increases VT and MV• Reduced Chest wall distortion• Augmenting Spontaneous efforts• Decrease WOB
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Controls in Non Invasive Ventilation
• Time at High at least (0.5 sec or longer) increases volume delivery significantly with no increases in CPAP high and CPAP low
• Time at Low• CPAP high• CPAP low• # of Cycles higher rates helps unload respiratory work
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sNIPPV vs. NCPAP as modes of Extubation in Preterm Infants RCT (n‐54)
sNIPPV (n=27) NCPAP (n=27) P
BW (g) 816 + 241 864 + 167 NS
GA (wks) 26.1 + 1.7 26.1 + 1.4 NS
Surfactant Doses 1.3 + 0.2 1.1 + 0.2 NS
FiO2 @Extubation 0.23 + 0.14 0.26 + 0.1 NS
Age @ Extubation, d 6.8 + 7.2 7.9 + 6.7 NS
Apnea/24 hr, after extubation
5.1 + 4.4 8.2 +12 <0.05
Failed Extubation 15 % 44 % <0.05
BPD 44 % 56 % NS
Infant Star with abdominal sensor Hudson Prongs PIP 16 PEEP 5 and Rate 12Barrington KJ et al UCSD , Pediatrics 2001: 107638‐641
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NIMV vs. NCPAP as a Primary Mode of Rx in PT infants <35 weeks with RDS: RCT (n=84)
NIMV (n=43) NCPAP (n=41) p
BW (g) 1616 + 494 1533 + 603 NS
GA (weeks) 31.1 + 2.3 30.6 + 3.0 NS
Baseline FiO2 0.32 + 0.14 0.37 + 0.17 NS
Age @nasal Support, min 17 (3‐2940) 4 (3‐3240) NS
Failed nasal Support 25% 49% 0.04
Duration of MV , days 10.2 + 23.8 13.2 + 15.8 NS
BPD 2% 17% 0.03
LOS, days 39 + 26 53 + 39 NS
SLE 2000 + INCA prongs
Kngelman A et al J. Pediatrics 2007; 150: 521‐526
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NFsIPPV vs. NCPAP in VLBW infants <1251 g at primary Extubation: RCT 9n=63)
NFsIPPV NCPAP p
BW (g) 908 +192 957 + 213 NS
GA (weeks) 26.9 + 1.7 27.1 + 2.6 NS
Poractant Alfa (SURF) 81 % 84 % NS
Age @ Extubation, hrs 4 (1‐14) 6 (1‐14) NS
Failed Extubation 6 % 39% <0.01
Duration of MV, days 6 (1‐20) 10 (1‐66) 0.058
BPD 6 % 22 % 0.08
LOS, days 62 + 6 58 + 6 NS
Moretti C et al . Pediatrics International 2008; 50: 85‐91
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NCPAP vs. NIPPV post Surfactant Rx in PT infants <30 wks with RDS: RCT
Respiratory Outcomes / Extubation Failures
Ramanathan R, Sekar K. Rasmussen R, Bhatia J, Soll R. PAS A3212.6, May 2009
%
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Conclusion
• The authors concluded that use of NIPPV resulted in reduced need for MVET at 7 days, duration of MVET and incidence of clinical as well as clinical or physiological BPD
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NIPPV vs. NCPAP in PT infants 28‐34 wks: RCT (n=40)NIPPV (n=20) NCPAP (n=20) P
BW (g) 1411 + 560 1429 + 545 NS
GA (weeks) 30.2 + 2 30.3 + 2 NS
Poractant Alfa (INSURE)
25% 25% NS
Re‐Intubated 10% 15% NS
Pneumothorax 0% 5% NS
Oxygen dependency <days
6.5 + 4 13.8 + 8 0.027
Length of Resp. Support, days
3.8 + 1 6.2 + 2 0.025
GA at discharge 35.6 + 1.2 36.7 + 2.5 0.02
Randomized at 1 hour of age; Bipasic 8/4.5; Rate 30, I time 0.5-0.7 sec; NCPAP using IFD; no difference in BPD, Serum Cytokine levels IL-6, IL-8 TNF alphaLista G et al (Milan) Arch Dis Child 95:F85-F89;2010
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BiPhasic after INSURE failure n=60Historical Control (n=22)
Biphasic(n=38)
P
BW (g) median 1323 1236 NS
GA (weeks) median (range) 30 (24‐34) 30 (24‐36) NS
INSURE Failure 6/22 (27%) 14/38 (37%) NS
Need for Mechanical Ventilation
27% 0% 0.001
Retrospective Study; 2002-2008; GA ,32 wks; Biphasic 8/5 Rates 10-30 Ti 0.5-0.6 secINSURE Failure = Respiratory Acidosis, Fi02>0.40 or intractable apnea within 1 week of surfactantBiphasic reduced the need for MV after INSURE failure
Ancor G et at (bologna) ACTA Pediatrica 99: 1807-1811; 2010
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NCPAP vs. NIPPV: Extubation Failures (9RCT) 1999‐2011
7out of 9 trails reached statistical significance
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Nasal Injuries reported 20‐60%
Fischer C et al (Switzerland) Arch Dis Child: 95 F447-F451; 2010
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NIV Guideline Highlights SickKidsInitial Parameter Selection:• Rate of 30 – 40 bpm.• Inspiratory time (I time) of 0.5secs – 1.0 secs (oropharyngeal equilibration
time, therefore longer I time needed than with invasive ventilation).• PEEP of 5 – 8cmH20 (may need to go higher).• PIP 10‐15cmH20 higher than PEEP level.(max PIP 30‐35)
Weaning:Wean NIV CMV every 6 ‐12hrs as tolerated.• Wean PIP first if PIP is greater than 10cm H20 above PEEP• Wean rate if indicated or consider changing to CPAP once delta P is
minimized.• Consider switching to a nCPAP level < to the MAP on the NIPPV settings• Wean CPAP level to 5‐6cmH20.• Only If clinically indicated, consider weaning to heated high flow nasal
cannula, after patient has been stable on CPAP for 6‐12hrs .
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What may the future hold?
• Practical and improved non invasive options ?synchronization
• Less CPAP fear = More optimal CPAP timing / usage and levels titrated to patients requirement not just an arbitrary number
• New Ways of administering surfactant when needed without using an endotracheal tube (ETT) “MIST”
• NIHFOV rescue?
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So all in all, Perhaps there is something to be said for the old phrase “less is more”Andrea del Sarto "The Faultless Painter” a poem by Robert Browning
And practicing AMV mode may just be the way of the future…
Thank you for all the amazing work you do each and everyday!
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Flow diagram
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Need for MV
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Need for MV among those who received surfactant
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Incidence of BPD
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Flow-Synchronized Nasal Intermittent Positive Pressure Ventilation for Infants <32 Weeks' Gestation with Respiratory Distress Syndrome
C. Gizzi, et al
Critical Care Research and Practice 2012
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Critical Care Research and Practice 2012
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Critical Care Research and Practice 2012
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Critical Care Research and Practice 2012