Non invasive ventilation

Neonates -1 Dr. ADHI ARYA

SENIOR RESIDENT –GMCH -32 CHANDIGARH

WHATWHYWHEN

•VENTILATION VIA NON INVASIVE AIRWAY

i.e without an endotraceal tube

Non Invasive Negative Pressure Ventilation (NNPV) (IRON LUNGS)

Non Invasive Positive Pressure Ventilation (NPPV)

WHY• Intubation is single major preventable factor contributing to BPD

• Even a single positive pressure breath can initiate biotrauma /baro/volutrauma

• 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 is being done .

•positive pressure cycle delivered on top of continuous distending pressure by nasal route

CPAP• DEFINITION • HISTORY• PHYSIOLOGY/MECHANISM • INDICATIONS • CONTRAINDICATIONS • SETUP• INITIAL SETTINGS• WEANING• FAILURE

CPAP

• COMPARISON OF DEVICES• TROUBLE SHOOTING • COMPLICATIONS• EVIDENCE

DEFINITION

POSITIVE PRESSURE SPONTANEOUSLY BREATHING INFANT THROUGH OUT RESPIRATORY CYCLE.

HISTORY• GREGORY• KATTWINKEL• AVERY/ COLUMBIA UNIVERSITY

MECHANISM

INDICATIONS • AOP• RD(RDS/PNEUM/MAS/TTNB)• POST EXTUBATION• AIRWAY MALACIAS• Pulmonary insufficiency of prematurity• DR CPAP

CONTRAINDICATIONS• Poor resp drive• Cong malformations( CDH/CA/TEF/Cleft palate)• Cardiovasc instability• Progressive Type 2 resp failure• Pulm air leaks

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

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

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)

PATIENT INTERFACE (PI)• Nasal prongs• Nasoph prongs• Mask• Nasal canula

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

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

MASK

ARGYLE PRONGS

VYGON NP PRONGS

FISCHER PAYKEL HUDSON

CANNULAIDE ( for preventing trauma)

• 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.

HUDSON PRONG SIZE

GAS SOURCE • Pressurized gases • Air o2 blender • Flow meter• Humidifier( 37/ 100%)

INITIAL SETTINGS• Depend on condition for which started• For respiratory distress scores can be useful

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.

• 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

Before considering failure ensure • Airway patency( secretions /neck flexed)• Surf given for RDS• Correct size prongs in position • Baby is not fighting

WEANING

CPAP MACHINES COMAPRISON

TROUBLE SHOOTING • No Bubbles

• Prongs wont stay in place

NO BUBBLES ?

• Circuit problem or baby problem

• 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

IS CHIN STRAP OR PACIFIER NEEDED

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

COMPLICATIONS

• Air -Leaks• CPAP Belly• Sepsis• Nasal obstr• Nasl septum erosion/necrosis

Nursing care• Vitals • Airway patency• Nasal care/ prevention of injury • OG in situ ( 90/30)

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% .

EVIDENCE FOR PRETERMS/ RDS• COIN • IFDAS• SUPPORT • Cochrane 2015

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.

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

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

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

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.

• NIV -2 • Will discuss NIPPV/HHFNC