Transcript of Non-Invasive Positive Pressure Ventilation – evidence base in preterm infants.
- Slide 1
- Non-Invasive Positive Pressure Ventilation evidence base in
preterm infants
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- And he went and lay upon the child.. Put his mouth upon his
mouth.. And the flesh of the child waxed warm Kings 4:32 Lord
Leighton Elisha reviving the Shunammite child Methods used to avoid
tracheal intubation
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- OUTLINE 1. Why does non-invasive support matter? endotracheal
intubation damages airway mucosa from top to bottom Long term
adverse effects of BPD 2. Some relevant physiology 3. Methods to
avoid intubation NIPPV Evidence from randomized trials
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- Sato K Ann Otol Rhinol Laryngol. 2006 115:816 Grossmann G, Eur
J Pediatr 1986 145:361 Necrotizing TracheoBronchitis Kirpalani H
CCM1985 Reyburn M. Am J Respir Crit Care Med. 2008 Control
Ventilation no SFTVentilation + SFT
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- (n=910) Baseline Risk Probability of a poor outcome at 18
months Number of Morbidities at 36 weeks: BPD, ROP, Brain
Injury
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- Objectives 1. Why does non-invasive support matter? BPD and
endotracheal intubation Long term effects of BPD 2. Physiology 3.
Methods to avoid intubation CPAP, NIPPV Evidence from randomized
trials
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- Historical Surgical Therapy for HMD: Sternal traction Warley
& Gairdner Arch Dis Child 1962; 37: 464
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- Newborn chest wall and lung pressure-volume curves Agostino E
and Mead J 1964; Handbook of Physiology Chest Wall Adult Newborn
Pressure Lung
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- 90 135 Normal or abnormal chest wall-abdominal movements 45 Ped
Pulmonol 1998; 25; 175
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- Synchronized Effects of Synchronization During Nasal
Ventilation Hung-Yang Ang C Pediatr Res 69: 84, 2011 Non -
Synchronized Synchronization did not affect tidal volumes; phase
angles; apnea spells; hypoxemic spells
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- Moretti C: Comparing nasal synchronized intermittent positive
pressure ventilation (nSIPPV) and nCPAP) after extubation in VLBW.
Early Hum Dev. 1999;56:167
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- Objectives 1. Why does non-invasive support matter? BPD and
endotracheal intubation Long term effects of BPD 2. Physiology of
NIPPV 3. Methods to avoid intubation CPAP, NIPPV Evidence from
randomized trials
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- Repetitive themes in ventilation Spiral philosophy: The
progress.. raises to each next stage of determination the whole
content, and enriches and concentrates itself... G.F.Hegel Science
of Logic; The Absolute Idea; 812; Circular philosophy: The thing
that hath been, it is that which shall be; and that which is done
is that which shall be done: and there is no new thing under the
sun Ch 1, v9 Ecclesiastes
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- 1889 ALEXANDER GRAHAM BELL: Presented results to a meeting of
the American Association for the Advancement of Science at Montreal
his invention met with little enthusiasm. Stern L: Symposium on
Artificial Ventilation Paris 1969; Biol. Neonate 16: 2429
(1970)
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- Drinker P, Shaw LA. J Clin Invest. 1929 Jun;7(2):229-47. 1890s
Wilhelm Schwake: Pneumatic Chamber
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- Simple device for producing continuous negative pressure in
infants with IRDS. Bancalari E, Gerhardt T, Monkus E. Pediatrics.
1973;52:128
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- NEGATIVE PRESSURE ISOLETTE NPV: RCTs (i)Silverman WA Pediatrics
1967 Sequential RCT: NPV vs IPPV in >1000 g BW; Stopped early
for no benefit after 27 pairs. (ii)Fanaroff AA J Pediatr 1973
Sequential analysis RCT: NPV vs IPPV; benefit in oxygenation
(iii)Alexander G: AJDC:1979 RCT n=36; NPV vs CPAP: equivalent
HEAD
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- Treatment of RDS CPAP Gregory GA: N Engl J Med. 1971;
284:1333
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- P :In infants VLBW or ELBW in DR I : does randomization to
nCPAP C :compared to intubation IMV O :increase survival without
BPD T :at 36 weeks PMA? PICOT CPAP
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- N Engl J Med 2008;358:700
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- Wright CL, Kirpalani H 2011: 128: 111 0.91 (0.83, 1.00 )
Primary Outcome Death or BPD 36 weeks
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- Mortality similar Nevertheless we encountered complications
stomach distension... Oedema of the face RCT of ventilation using
oro-nasal mask Llewellyn MA, Tilak KS, Swyer PR: 1970; Arch Dis
Child 45:453
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- Garland JS: Increased risk of GI perforations in neonates
mechanically ventilated with either face mask or nasal prongs.
Pediatrics,1985, 76:406 Retrospective Matched Case control study (1
case: 4 controls)
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- Post- Extubation BPD Death Un-intubated BPD Death Updated:
Trials of NIPPV vs nCPAP Outcome NIPPV nCPAP Relative Risk n/N n/N
(95% CI) 0.2 0.5 1 2 5 Favours NIPPV Favours nCPAP 26/93 3/56 3/80
5/79 38/88 3/55 10/80 9/85 0.2 (0.05, 0.87) 0.59 (0.22, 1.59) 0.97
(0.21, 4.44) 0.64 (0.44, 0.95) Lemyre B, DePaoli A, Kirpalani H,
Davis P; and Salter S, Laughon M, Lemyre B, Bose C; Cochrane
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- V Rajadurai B Urlesberger P Maton G Dempsey D Millar E Boyle J
Frank K Sankaran J Cairnie B Lemyre K Abubakar F Reiterer A
Chaudhary M Roy R van Lingen S Rahman P Srinivasan E Asztalos P
McNamara C ODonnell T Ibrahim W Marion M Finelli S Godambe B Simma
W Stelzl B Jonsson P Gerhard R Roberts R Kim L Costantini I Herlihy
P Dijk I Frantz I Hand M Hyndman J Miletin S Ranu A OSullivan L
Legnevall R Whyte N Rashid C Thiel J Zupancic H Kirpalani NIPPV:
The Nasal Intermittent Positive Ventilation for Prematures
Trial
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- N Engl J Med. 2013 Aug 15;369(7):611-20
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- P : In infants
- Primary Outcome Prior death or survival with BPD at 36 weeks
PMA Definition of BPD: On respiratory support (IMV, nCPAP, NIPPV)
or > 30% supplemental oxygen; or < 30% supplemental oxygen,
and failed Oxygen Reduction test (ORT) ( J Perinatol 2003)
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- 1009 infants randomized 504 NIPPV503 nCPAP Primary outcome
BPD-ORT 497 98% 490 97% 2 withdrew consent Ascertainment of primary
outcome
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- Mother NIPPV nCPAP Race White 56%57% Age Years 30.3 6.330.5 6.1
Antenatal Steroids92%91% Baseline Characteristics
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- Infant NIPPV nCPAP BW - g 802 131805 126 GA - wks 26.1 1.526.2
1.5 Male53%46% Multiples23%24% SNAP II 30.6 13.630.4 13.4 Baseline
Characteristics
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- Primary Outcome: Death or BPD by ORT at 36 weeks NIPPV nCPAP
180 of 490 37% OR=1.1 95% CI 0.8 to 1.4 p=0.6 191 of 497 38%
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- sNIPPV nCPAP p = 0.6 108 of 279 39% NIPPV 36 of 101 36% 180 of
490 37% Sub-Group effects: Synchronization NIPPV adjusted Death or
ORT-BPD
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- Number of post-randomization failures of respiratory support,
requiring re-intubation and subsequent extubation by group NIPPV
Median (IQR) 1 (0,1) nCPAP Median (IQR) 1 (0,1)
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- Death Cochrane: Greenough A 2008: Synchronised ventilation
newborns Favours Synchronized Favours Control RR 1.19
(0.95,1.49)
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- Peak Trans-Diaphragm Electrical Potential
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- Brigitte Lemyre, Peter G Davis, Antonio G De Paoli, Haresh
Kirpalani Nasal intermittent positive pressure ventilation (NIPPV)
versus nasal continuous positive airway pressure (NCPAP) for
preterm neonates after extubation Cochrane; 4 SEP 2014
CD003212.pub2
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- Some current barriers to sNIPPV 1. Available flow triggers
rendered dependent on minimal- no leak nose and mouth 2. Devices
for abdominal wall movement synchrisation no longer available
(Graseby capsule) 3. Limited data on NAVA Needed now 1.Moderate to
large scale trials with synchronizing devices, with a relevant
primary outcome 2. Improved patient-device-interfaces C.T.Roberts,
P.G.Davis, LS.Owen Neonatology 2013; 104:203 Bancalari E, Claure C
Arch Dis Child (F&N): 2013: 98; F98
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- Leonardo Da Vinci (1452-1519) Notebook Conclusions:
Non-invasive support using CPAP does reduce BPD Superior methods
still needed Simple non-synchronized NIPPV does not improve BPD
Synchronization for NIPPV needs further trials HFNVpromising trials
needed
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- Diego Rivera (1886-1957) Hospital Mural Medicine for the People
Technology marches on but is too often untested