non invasive ventilation in neonates-part 1
TRANSCRIPT
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Non invasive ventilation
Neonates -1 Dr. ADHI ARYA
SENIOR RESIDENT –GMCH -32 CHANDIGARH
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WHATWHYWHEN
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•VENTILATION VIA NON INVASIVE AIRWAY
i.e without an endotraceal tube
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Non Invasive Negative Pressure Ventilation (NNPV) (IRON LUNGS)
Non Invasive Positive Pressure Ventilation (NPPV)
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WHY• Intubation is single major preventable factor contributing to BPD
• Even a single positive pressure breath can initiate biotrauma /baro/volutrauma
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• CPAP does not consistently improve ventilation and does not work in infants with poor respiratory effort
• 46-60% of babies with RDS may fail CPAP and 25-40% of intubated LBW babies fail extubation to CPAP)
• Invasive ventilation causes baro/volutrauma, atelecto-trauma along with bio-trauma resulting in ventilator induced lung injury( VILI).
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• In an effort to support ventilation and avoid need for invasive support the use of intermittent positive pressure ventilation via nasal devices is being done .
•positive pressure cycle delivered on top of continuous distending pressure by nasal route
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CPAP• DEFINITION • HISTORY• PHYSIOLOGY/MECHANISM • INDICATIONS • CONTRAINDICATIONS • SETUP• INITIAL SETTINGS• WEANING• FAILURE
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CPAP
• COMPARISON OF DEVICES• TROUBLE SHOOTING • COMPLICATIONS• EVIDENCE
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DEFINITION
POSITIVE PRESSURE SPONTANEOUSLY BREATHING INFANT THROUGH OUT RESPIRATORY CYCLE.
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HISTORY• GREGORY• KATTWINKEL• AVERY/ COLUMBIA UNIVERSITY
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MECHANISM
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INDICATIONS • AOP• RD(RDS/PNEUM/MAS/TTNB)• POST EXTUBATION• AIRWAY MALACIAS• Pulmonary insufficiency of prematurity• DR CPAP
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CONTRAINDICATIONS• Poor resp drive• Cong malformations( CDH/CA/TEF/Cleft palate)• Cardiovasc instability• Progressive Type 2 resp failure• Pulm air leaks
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SET UP• PRESSURE GENERATOR: Positive pressure in the circuit Continous / variable flow
• GAS SOURCE: continuous supply of warm humidified/ blended gases
• PATIENT INTERFACE/DELIVERY SYSTEM
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Pressure generator• Ventilator -exp flow valve, OR cont airflow in opp direction to exp
limb
• Bubble CPAP - due to stochastic resonance
• IFD( variable flow devices)- by adjusting flow
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BASED ON FLOWCF• Vary press by mechanism other
than flow variation • Expiratory limb not open to
atmosphere
VF (IFD)• Desired pressure by varying flow• Open( by venturi effect can
entrain additional flow)
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PATIENT INTERFACE (PI)• Nasal prongs• Nasoph prongs• Mask• Nasal canula
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PI-NASAL PRONGS• HUDSON • F&P• ARGYLE
• Selection of size important • Small/loose-leak• Tight-pressure necrosis• Bridge of prongs should not abutt columella/ there should be no blanching
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PI- NASOPHARYNGEAL PRONG• NASOP ET Tube• NASOP prongs -Vygon
• ADV- easier to fix,• DIS- inc resistance, leak, diffic nursing care
Cochrane 2008 - Better oxyg, waening in bi-nasal short prongs compared to single prong nasop CPAP
Devices and pressure sources for administration of nasal continuous positive airway pressure (NCPAP) in preterm neonates. Cochrane Database Syst Rev. 2008
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MASK
ARGYLE PRONGS
VYGON NP PRONGS
FISCHER PAYKEL HUDSON
CANNULAIDE ( for preventing trauma)
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• b/w Argyle and hudson - equal in pressure gen
• But argyle difficult to maintain & nasal hyperemia more
• Hudson prongs easily avail and widely used in our set up.
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HUDSON PRONG SIZE
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GAS SOURCE • Pressurized gases • Air o2 blender • Flow meter• Humidifier( 37/ 100%)
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INITIAL SETTINGS• Depend on condition for which started• For respiratory distress scores can be useful
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Initial pressures for RDS• 7 vs 5• No diff in need for MV in first week
• Acta Paediatr. 2016 Aug;105(8):Initiating nasal continuous positive airway pressure in preterm neonates at 5 cm as against 7 cm did not decrease the need for mechanical ventilation.
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• When to increase-grunting /retrac/<6 spaces• When to decrease-> 8 spaces/flat diaph
To increase/dec pressure• Bubble CPAP –Inc or Dec depth of expiratory limb in bubble chamber• Indigenous- increasing /dec water level
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Before considering failure ensure • Airway patency( secretions /neck flexed)• Surf given for RDS• Correct size prongs in position • Baby is not fighting
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WEANING
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CPAP MACHINES COMAPRISON
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TROUBLE SHOOTING • No Bubbles
• Prongs wont stay in place
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NO BUBBLES ?
• Circuit problem or baby problem
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• Bubble generation depends on flow, leaks in circuit/airway • Should be seen both during insp and exp
Seal the end of prongs No bubbling ---circuit problem – check from wall to end Present- look for leak(mouth) suspect air leaks
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IS CHIN STRAP OR PACIFIER NEEDED
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PRONGS WONT STAY IN PLACE
• Correct size
• Hat snugly fit or not – loose hat allows movement of head to dislodge prongs
• Tubings at correct angles to keep prongs in place
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COMPLICATIONS
• Air -Leaks• CPAP Belly• Sepsis• Nasal obstr• Nasl septum erosion/necrosis
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Nursing care• Vitals • Airway patency• Nasal care/ prevention of injury • OG in situ ( 90/30)
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RECENT EVIDENCE• J Perinatol. 2016 May;36 Suppl 1:S21-8. doi: 10.1038/jp.2016.29.• Efficacy and safety of CPAP in low- and middle-income countries.
50% reduction in the need for mechanical ventilation following the introduction of bubble CPAP failed CPAP and required mechanical ventilation varied from 20 to 40% (eight studies). The incidence of air leaks varied from 0 to 7.2% .
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EVIDENCE FOR PRETERMS/ RDS• COIN • IFDAS• SUPPORT • Cochrane 2015
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COIN TRIAL( CPAP OR INTUBATION)
• no statistical difference – death or bronchopulmonary dysplasia at 36 weeks' gestational age between infants who were assigned to receive early nasal CPAP and those who were assigned to receive intubation.
• lower risk of the combined outcome of death or the need for oxygen therapy at 28 days and
• fewer days of assisted ventilation. (3 VS 4)• increase in the number of pneumothoraxes. (9 % VS 3%) WITHOUT effect on overall
mortality, G3/4 IVH, PVL BPD
• Overall, starting early CPAP treatment in very preterm infants was not detrimental.
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IFDAS• Hypot –early surf use – CPAP or CPAP alone dec need for subseq
ventilat in PT
• CONCLUDED THAT BOTH cpap alone and with surf decreased need for MV
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SUPPORT(SUrfactant Positive pressure Pulse Oximetry RCT) hypoth--nasal CPAP started immediately after birth is an effective and safe alternative to prophylactic or early surfactant administration and may be superior.
CPAP and the limited-ventilation strategy, rather than intubation and surfactant, resulted in less respiratory morbidity by 18 to 22 months’ corrected age
A follow-up study at 18 to 22 months’ corrected age showed that death or neurodevelopmental impairment occurred in 28% of the infants in the CPAP group compared with 30% of those in the surfactant/ventilation group (RR: 0.93; 95% CI: 0.78–1.10; P = .38).NOT SIG CLINICALLY
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AAP• Respiratory Support in Preterm Infants at BirthCOMMITTEE ON FETUS AND NEWBORN 2014
• early CPAP with subsequent selective surfactant I extreme PT- lower rates BPD/death compared with treatment with prophylactic or early surfactant therapy (Level of Evidence: 1).
• treated with early CPAP alone -not at increased risk of adverse outcomes if treatment with surfactant is delayed or not given
• Early initiation of CPAP may lead to a reduction in duration of mechanical ventilation and postnatal corticosteroid therapy
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Cochrane 2015
• In preterm infants with respiratory distress, the application of CDP as CPAP or CNP is associated with reduced respiratory failure and mortality and an increased rate of pneumothorax.
• Cochrane Database Syst Rev. 2015 Jul 4;(7):CD00227
• Continuous distending pressure for respiratory distress in preterm infants.
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• NIV -2 • Will discuss NIPPV/HHFNC