NON INVASIVE VENTILATION IN NEONATE

DR.ANSHUMAN PARIAPOST DOCTORAL TRAINEE

DEPARTMENT OF NEONATOLOGYSSKM HOSPITAL1

NON INVASIVE VENTILATION

Non invasive ventilation: TOPICS

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1. NIV: What?why?How?

2. Indications of NIV3. Evidence Based Physiology4. Evidence Based Decisions:

NIV vs CMVNIV vs CPAPNIV vs SNIPPV

5. Synchronization: why and How?

6. NIV: GUIDELINES primary mode secondary mode reintubation criteria weaning criteria

7. Long term follow-up8. Newer directions:

N-BIPAPNIV-NAVAN-HFV

Non invasive ventilation: WHY INTEREST IN NIV??

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In the United Kingdom, 48% of 91 use NIPPV(2009) in Ireland 61% of 28units surveyed reported using NIPPV(2011)in Brazil 98.7% of 81 units used NIPPV(2012) No such data are available from the United States

Non invasive ventilation: WHY & WHAT?

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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).

In an effort to support ventilation and avoid need for invasive support the use of intermittent positive pressure ventilation via nasal devices has been proposed (positive pressure cycle delivered on top of continuous distending pressure by nasal route)

No inflation5 inflations of

32 ml/kg

Bjorklund LJ, et al: Acta Anaesthesiol Scand 45:986, 2001

Non invasive ventilation: WHY INTEREST IN NIV??

Non invasive ventilation: WHY?

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Non invasive ventilation: CLASSIFICATION OF NIV IN NEONATES:

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Non invasive ventilation: HOW?-machines delivering SNIPPV

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Infant Star ventilator (CareFusion, Yorba Linda, CA) with the Star- Sync module (CareFusion, Yorba Linda, CA) for synchronization

Sechrist IV-200 SAVI ventilator (Sechrist Industries, Anaheim, CA)Nasal-flow synchronized ventilator (Giulia; Ginevri, Rome, Italy) Servo-i ventilator (Maquet Medical Systems, Wayne, NJ) with neurally

adjusted ventilator assist(NAVA)Infant Flow SiPAP Comprehensive (CareFusion, San Diego, CA)

ventilator (available in Europe and Canada, but not in the United States)- a bilevel device providing higher and lower pressures with much longer inspiratory times compared with SNIPPV mode. The PIPs generated by the SiPAP device are between 9 to 11 cm H2O.

phased out, most of the S N I P P V studies have used it. Recently N I P P V studies have emerged as INFANT STAR was phased out

NIV-NAVA, an extra module ,added to Servo-i for synchronization was used in a small study of five low-birth-weight infants

Non invasive ventilation: HOW? machines delivering NIPPV

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SLE 2000 (Specialized Laboratory Equipment, South Croydon, UK)VIP Bird -R Sterling (Viasys Health Care, Conshohocken, PA)Drager Babylog 8000 (Drager Medicals, Lubeck, Germany) Inter Neo (Intermed,Sao Paulo, Brazil)Avea ventilator (CareFusion, San Diego, CA)Bear Cub 750 PSVServo-i ventilator (Maquet Medical Systems, Wayne, NJ)

Non invasive ventilation: CLINICAL INDICATIONS:

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APNEA OF PREMATURITY

RESPIRATORY DISTRESS SYNDROME POST EXTUBATION

Non invasive ventilation: HOW? Physiological effects of NIV

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1. Apnea: Nasal IPPV may improve patency of the upper airway by

creating intermittently elevated pharyngeal pressures. This intermittent inflation of the pharynx may activate respiratory drive, by Head’s paradoxical reflex, where lung inflation provokes an augmented inspiratory reflex. This results in resumption of breathing in infants with apnea following cycling of the ventilator.

2. Work of breathing has also been shown to be decreased with the use of SNIPPV compared to nasal CPAP (Kiciman NM Pediatr Pulmonol 1998; 25: 175–81)

Non invasive ventilation: HOW? Physiological effects of NIV

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3. Chest wall distortion: The negative pressure generated during spontaneous inspiration often produces an inward motion of the chest wall weakening the inspiratory effort and delaying lung expansion. N-SIMV at 10 breaths per minute reduced thoraco-abdominal asynchrony in preterm infants compared to N-CPAP immediately after extubation.

Inefficient ventilation and waste of work

(the non-coincident motion of the rib cage and abdomen during breathing)

the rib cage is sucked in or retracted as abdominal excursions occur (e.g., in upper airway obstruction), or the abdomen is retracted as the rib cage expands (e.g., diaphragmatic paralysis)

Prisk GK Pediatric Pulmonology 2002; 34:462–472

Non invasive ventilation: physiology:Thoraco-abdominal Asynchrony

25 weeks: Abdominal (red) & Chest Wall (green) Movements Synchronized NIPPV: Better ventilation

NCPAP NIPPV

Courtesy of Simon Bignall

Thoraco-abdominal Asynchrony Synchrony

Non invasive ventilation: physiology

Non invasive ventilation: Primary Mode VS Secondary Mode

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NIPPV in the primary mode refers to its use soon after birth with or without a short period ( 2 hours) of intubation for surfactant delivery, followed by extubation.

The secondary mode refers to its use after a longer period (>2 hours to days to weeks) of intubation.

NON INVASIVE VENTILATION

Evidence Based Decisions

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Non invasive ventilation: Evidence Based DecisionsNIPPV STUDIES IN NEONATE

17Adopted from: Noninvasive Respiratory Support in the P r e term Infant, Bhandari.V. Clin Perinatol 39 (2012) 497–511

Non invasive ventilation: Evidence Based Decisions SNIPPV STUDIES IN NEONATE(primary mode)


Non invasive ventilation: Evidence Based Decisions SNIPPV STUDIES IN NEONATE(secondary mode)


META-ANALYSIS?

NIV : Evidence Based Decisions:

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META-ANALYSIS?

The meta-analysis demonstrates a statistically and clinically significant reduction in the risk of meeting extubation failure criteria [typical RR 0.21 (95% CI 0.10, 0.45), NNT 3 (95% CI 2, 5)]

NIPPV may be a useful method of augmenting the beneficial effects of NCPAP in preterm infants with apnea that is frequent or severe. Its use appears to reduce the frequency of apneas more effectively than NCPAP. Additional safety and efficacydata are required before recommending NIPPV as standard therapy for apnea.

Non invasive ventilation: Evidence Based Decisions : NIPPV VS NCPAP

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EXTUBATION FAILURE RATE:NIPPV VS NCPAP

Nasal Intermittent Positive Pressure Ventilation versus Nasal Continuos Positive Airway Pressure in Neonates: A Systematic Review and Meta-analysis: Tang et al, Indian pediatrics,2012

Five papers reported the rate of extubation failure of NIPPV versus nCPAP following ETT and mechanical ventilation. Meta-analysis showed that the rate of extubation failure of NIPPV was significantly lower than that of nCPAP [OR=0.15 (95% CI: 0.08 0.31)]; P<0.001.


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FAILURE RATE as a primary mode in RDS :NIPPV VS NCPAP


Six papers reported the failure rate of NIPPV versus nCPAP as a primary respiratory mode, which was indicated by whether or not requiring ETT and mechanical ventilation.

Metaanalysis showed that the failure rate in NIPPV group was significantly lower than that in nCPAP group as a primary respiratory mode [OR=0.44 (95% CI: 0.31-0.63); P<0.0001)


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META-ANALYSIS OF SECONDARY OUTCOMES BETWEEN NIPPV AND NCPAP GROUPS


• FINAL OUTCOME (DEATH AND/OR BPD): NIPPV was significantly better than that of nCPAP as a primary respiratory mode [OR=0.57 (95% CI: 0.37-0.88); P=0.01]

• APNEA OF PREMATURITY: NIPPV showed a statistically lower rate of apnea (episodes per hour) as compared with nCPAP group [WMD=-0.48 (95%CI:-0.58-0.37; P<0.001]

• DURATION OF HOSPITALIZATION : (primary respiratory mode /extubation mode) : No significant difference in duration of hospitalization between NIPPV and nCPAP group [WMD=-0.51 (95%CI:-5.62-4.61;

• INCIDENCE OF BPD : NIPPV led to a marginally significant reduction in the incidence of BPD as compared with nCPAP. [OR(95%CI)=0.39-1.00,P=0.05]

• incidence of IVH, PVL, ROP, PDA, Pneumothorax or air leak, abdominal distention, necrotizing enterocolitis : no significant differences

Non invasive ventilation: SNIPPV VERSUS NIPPV “does synchronization matter?”

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There is only one retrospective study [from YALE NEW HAVEN NICU](Dumpa V, Katz K, Northrup V, et al. SNIPPV vs NIPPV: does synchronization matter? J Perinatol 2012;32(6):438–42).

At Yale, before 2007, NIPPV was delivered through a ventilator, which synchronized breaths with infant’s respiratory efforts (SNIPPV), using the Infant Star ventilator with StarSync and synchronization with infant’s respiratory efforts was achieved utilizing the Graseby capsule. NIPPV replaced SNIPPV, as the Infant Star ventilator was phased out of production in the United States. From 2007, NIPPV has been utilized using the Bear Cub 750 psv ventilator.

Retrospectively they compared the clinical outcomes of the two eras (SNIPPV=2004-2006) and (NIPPV=2007-2009).


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Study groups: There was no significant difference in the mean gestational

age and birth weight in the two groups: SNIPPV (n = 172; 27w; 1016 g) and NIPPV (n = 238; 27.7w; 1117 g).

There were no significant differences in maternal demographics, use of

antenatal steroids, gender, multiple births, small for gestational age or Apgar scores in the two groups. More infants in the NIPPV(63%) group were given resuscitation in the delivery room as compared to SNIPPV(44%). Use of surfactant (84.4 vs 70.2%; P<0.001) was significantly higher in the SNIPPV group.


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Results: After adjusting for significant confounding variables, use of NIPPV versus SNIPPV (odds ratio, 0.74; 95% confidence interval, 0.42–1.30) was not associated with BPD/death or other common neonatal morbidities.

Conclusion: These data suggest that use of SNIPPV vs NIPPV is not significantly associated with a differential impact on clinical outcomes

Non invasive ventilation: NIPPV VS SNIPPV (PHYSIOLOGY)

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There have been two reports, comparing SNIPPV with NIPPV, evaluating short-term effects.

1) Chang et al. studied the effects of synchronization during nasal ventilation comparing NIPPV,SNIPPV,NCPAP in a randomized manner, each for 1 h. They concluded that SNIPPV reduced breathing effort and resulted in better infant –ventilator interaction than NSIPPV.

2) Owen et al effects of NIPPV on spontaneous breathing and proposed that synchronization of NIPPV pressure peaks with spontaneous inspirations may increase the benefits of NIPPV

Non invasive ventilation: flow synchronized nasal ventilation newer alternative?

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Gizzi et al (Flow-Synchronized Nasal Intermittent Positive Pressure Ventilation for Infants <32 Weeks’

Gestation with Respiratory Distress Syndrome, Crit care res and prac, 2012) retrospectively evaluated whether SNIPPV(“Giulia” Neonatal Nasal Ventilator-Ginevri Medical Technologies, Rome, Italy) used after the INSURE procedure can reduce mechanical ventilation (MV) need in preterm infants<32wks with RDS more effectively than NCPAP and also compared the clinical course and the incidence of short-term outcomes of infants managed with SNIPPV or NCPAP.

INSURE failure was defined as FiO2 need >0.4, respiratory acidosis, or intractable apnea that occurred within 72 hours of surfactant administration.

Non invasive ventilation: Evidence Based Decisions flow synchronized nasal ventilation-newer alternative?

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Results:

35.5% infants in the NCPAP group and 6.1%infants in the SNIPPV group failed the INSURE approach and underwent MV (P < 0.004).

Fewer infants in the INSURE/SNIPPV group needed a second dose of surfactant, a high caffeine maintenance dose, and pharmacological treatment for PDA. Differences in O2 dependency at 28 days and 36 weeks of postmenstrual age were at the limit of significance in favor of SNIPPV treated infants.

Conclusions. Flow Synchronized Nasal Ventilation use after INSURE technique reduced MV need and favorably affected short-term morbidities of premature infants

Non invasive ventilation: GUIDELINES: (S)NIPPV (primary mode)

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1. Settings: Frequency = 40 per minute PIP 4 cm H2O > PIP required during manual ventilation (adjust PIP for effective aeration per auscultation) PEEP 4–6 cm H2O Ti = 0.45 s FiO2 adjusted to maintain SpO2 of 85–93% Flow 8–10 lpm

2. Caffeine loading → maintenance3. Hematocrit 35%4. Monitor SpO2, HR and respirations5. Obtain blood gas in 15–30 min6. Adjust ventilator settings to maintain blood gas parameters within normal limits7. Suction mouth and pharynx and insert clean airway Q4, as necessary8. Maximal support recommendations:

1000 g MAP 14 cm H2O>1000 g MAP 16 cm H2O

Adopted from: Noninvasive Respiratory Support in the P r e term Infant, Bhandari.V. Clin Perinatol 39 (2012) 497–511

Non invasive ventilation: GUIDELINES: (S)NIPPV (secondary mode)

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1. Extubation criteria while on CV: Frequency =15–25 per minute PIP 16 cm H2O PEEP 5 cm H2O FiO2 0.35 Caffeine loading →maintenance Hematocrit 35%

2. Place on (S)NIPPV Frequency =15–25 per minute PIP 2–4 > CV settings; adjust PIP for effective aeration per auscultation PEEP 5 cm H2O FiO2 adjusted to maintain SpO2 of 85–93% Flow 8–10 lpm

3. Suction mouth and pharynx and insert clean airway Q4, as necessary4. Maximal support recommendations:

1000 g MAP 14 cm H2O>1000 g MAP 16 cm H2OAdopted from: Noninvasive Respiratory Support in the P r e term Infant, Bhandari.V. Clin Perinatol 39 (2012) 497–511

Non invasive ventilation: GUIDELINES:

REINTUBATION CRITERIA

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1. pH <7.25; PaCO2 >60 mm Hg2. Episode of apnea requiring bag and mask ventilation3. Frequent (>2–3 episodes per hour) apnea/bradycardia (cessation of respiration

for>20 s associated with a heart rate <100 per minute) not responding to caffeine therapy

4. Frequent desaturation (<85%)=3 episodes per hour not responding to increased ventilator settings


Non invasive ventilation: GUIDELINES:

(S)NIPPV WEANING to oxy hood/nasal cannula

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1. Minimal (S)NIPPV settings Frequency 20 per minute PIP 14 cm H2O PEEP 4 cm H2O FiO2 0.3 Flow 8–10 lpm Blood gases within normal limits

2. Wean to: Oxy hood adjust FiO2 to keep SpO2 85–93% NC adjust flow (1–2 l m–1) and FiO2 to keep SpO2 85–93%


Non invasive ventilation: in which preterms do we choose NIPPV?

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MORE SUCCESSFUL IN 28-34 WKS & >1000 GM

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Non invasive ventilation: SIPAP

Two alternating levels of CDP Also called Bi-level-NCPAP Phasic change in delivered pressure

TI RATE PRESSURE

NIV SIMULATES IMV,WITHOUT ET 0.3-0.5 30-60 MAP=14 ATLEAST

SIPAP 2 LEVELS OF CDP, OVER WHICH BABY BREATHES SPONTANEOUSLY

0.5-1 10-30 11 AND 4 ABOVE IT

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better recruitmentHigher Tidal volume Reduced work of breathing

Non invasive ventilation: NASAL BIPAP vs CPAP

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Lista etal,Arch Dis Child Fetal Neonatal Ed. 2010 Mar;95(2)

http://www.ncbi.nlm.nih.gov/pubmed/19948523

Non invasive ventilation: NASAL BIPAP vs SNIPPV

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28.6+/-1.8 WKS…78 NEWBORNS…RETROSPECTIVE

Ricotti Etal

Non invasive ventilation: NASAL HIGH FREQUENCY VENTILATION

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In a small study by Colaizy (Acta Paediatr 2008;97:1518–1522) ,14 very low-birth-weight infants, who were stable on NCPAP, were placed on NHFV (using the Infant Star) for 2 h. The investigators noted that NHFV was effective in decreasing pCO2.

These results are similar to an earlier report(Van der hooven 1998)

A significant amount of additional research needs to be done to determine the clinical utility of this technique, if any, in the prevention and/or treatment of BPD.

Non invasive ventilation: NAVA

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NAVA/Neurally adjusted ventilator assist is a mode of synchronisation which uses diaphragmatic electromyography to synchronise not only the time of breath according to patients initiation of inspiration ,but also it gives breath proportionate to electrical activity of diaphragm.

Non invasive ventilation: Evidence Based Decisions :follow up: BPD

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Bhandari(2007) compared invasive with non invasive in terms of long term outcome and opined that those with early extubation to SNIPPV had 20% chance of BPD/DEATH as compared to 52% among those who were cont on MV.

Non invasive ventilation: Evidence Based Decisions :follow up:BPD

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secondary

Non invasive ventilation: Evidence Based Decisions :follow up:BPD

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Biggest RCT till date….all babies<1000 gm …all babies<30 wks…500 in each arm

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Non invasive ventilation: SUMMING IT UP!

BANCALARI ,2013

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THANK YOU

NON INVASIVE VENTILATION IN NEONATE

Health & Medicine

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