Nonivasive Respiratory Support - NIV

High Frequency Ventilation - HFV

Iwona Maroszyńska

Department of Neonatal Intensive Care and Congenital Malformations

Memorial Institute of Polish Mother‟s Health Center

Київ 2013

Nonivasive Respiratory Support

High Frequency Ventilation HFV

Lung protective strategy

• High chest compliance

– Bone underdevelopment

– Intercostal muscles

– Sleep REM

• Muscles tone

• Ineffective respiratory effort

• Low lung compliance

– Surfactant insufficiency

– Fewer terminal airspaces

– More stroma

• Newborn‟s chest

– More cylindrical

– Shorter intercostal muscles

– Diaphragm horizontal position

VT ↓; f↑; grunting

• Elastic recoil (compliance/elastance)

– The tendency of stretched object to return to their original shape

• Inspiratory muscles relaxation during exhalation

• Chest wall

• Diaphragm recoil

• Lungs

– Surfactant, bone development

• Viscous resistance

– Fewer terminal airspaces

– More stroma

lung-chest wall system = pressure-volume characteristic (lung + chest wall)

FRC - outward recoil force of the chest wall = inward elastic forces of the lung

(resting state of the respiratory system)

• Closing volume

– < FRC

– = RV

• Neonate

– Closing volume ↑ FRC

Crit Care Med 2005 Vol. 33, No. 3 (Suppl.)

Pulmonary vascular resistance

Modified from West JB: Respiratory Physiology:

The Essentials, 2nd ed. Baltimore, Williams & Wilkins, 1979, p. 39

.

Pulmonary vascular resistance

Pa Palv Pv

*** * **

III

Pa Palv Pv

*** ** *

II

Pa Palv Pv

** *** * I

FRC

PTV

Hakim TS, Michel RP, Chang HK (1982) Effect of lung inflation on pulmonary vascular

resistance by arterial and venous occlusion. J Appl Physiol 53(5):1110–1115

Pa Palv Pv

** *** * I

LV preload ↓

shunt

Pulmonary vascular resistance

- Good conditions for the contact of blood and endothelial cells

- High blood flow

- Well developed microcirculation

- Low perfusion pressure

- Highly represented macrophage system

- Direct contact with the external environment - colonization

Disadvantages of Ventilation via ETT

• Cardiovascular and cerebrovascular instability during ventilation

• Complication of ETT

– Subglotic stenosis

– Tracheal lesions

• Acute and chronic lung damage

– Volutrauma

– Barotrauma

– Shear

• Infection

• If you do not ventilate en infant, it‟s hard to cause BPD

Compensatory mechanisms

• f↑ VT ↓

• Grunting

• Mechanical Ventilation

– Open lung strategy

• CPAP

– Lung protective strategy

• Low VT

• PEEP

• PIP < 25 – 30

• Synchronized

Noninvasive ventilation

High frequency ventilation

• Open Lung Strategy

– Alveolar collapse

– Alveolar overdistention

• Benefits from open lung strategy

– Decreased intrapulmonary shunt

– Improved oxygenation

– Reduced PVR

• Optimal recruitment

– Reduced intrapulmonary shunt < 10%

– Adequate oxygenation without supplemental oxygen

• Practical optimal recruitment

– FiO2 ≤ 0,3

Lung Recruitment Maneuver

0

4

8

12

16

20

24

A

FiO2 0,8

B

FiO2 0,3

A

FiO2 0,6

D

FiO2 0,3

C

Target fraction of FiO2

• Retrospective study

– To retrospectively evaluate if HVS is associated with better oucome

– FiO2 ≤ 0,25

– FiO2 > 0,25

• No - 28 vs 23

• GA < 26,1 vs 25,9 hbd

• Birth weight 603 vs 703

J Matern Fetal Neonatal Med. 2011 in press

Tana M et all

Unexpected effect of recruitment procedure on lung volume measured by respiratory inductive plethysmography (RIP) during high frequency oscillatory ventilation (HFOV) in preterm neonates with respiratory distress syndrome

(RDS).

Target fraction of FiO2

• Results

– MAP – 12,8 vs 11,2

– FiO2 - 0,25 vs > 0,25

– Extubation – 3,5d vs 9 d (p=0,005)

– Oxygen - 488 d vs 1109 d (p=0,02)

– Mechanical ventilation 187 vs 525 (p=0,03)

– Surfactant > 1 dose 1 vs 6 (p=0,04)

– BPD - NS

J Matern Fetal Neonatal Med. 2011

Tana M et all

Unexpected effect of recruitment procedure on lung volume measured by respiratory inductive

plethysmography (RIP) during high frequency oscillatory ventilation (HFOV) in preterm neonates with

respiratory distress syndrome (RDS).

What is the HFV ?

• HFV

– Complex process of mixing gases

– Normal human lung > 170/min

• Small tidal volume

– VT < anatomic dead space 1-3ml/kg

• Very rapid ventilator rates

– > 4 x physiological respiratory rate

– 2 - 20 Hz = 120 – 1200 breaths/min.

• MAP

– HFV > CMV

Back to the physiology…

• Alveolar ventilation

– VA = VT – VD

• HFV

– VT ≤ VD → VT – VD ≤ 0

– VA ≤ 0

HFV vs CMV

• VT

– Const. f ≤ 25 -30/min. > 30/min. VT ↓

• Valv = (VT – VD) x f

– F > 75/min. ↓ → VA = VT2f

– f > 75/min. - VT determined by Ti

Using conventional infant ventilators at unconventional rates

Pediatrics. 1984 Oct;74(4):487-92.

Boros SJ, Bing DR, Mammel MC, Hagen E, Gordon M • Flow

• VT

• Amplitude ↑

• PIP – PEEP

• f↑ → VT↓

• MAP • PIP ; PEEP

Why HFV?

• VT < VD 1-3ml/kg

• Possibility of independent management of the oxygenation and

ventilation

• Preservation of normal lung architecture even when using high MAP

• Optimal lung inflation

– The lung volume at which the recruitable lung is open but not

overinflated

Boros SJ, Bing DR, Mammel MC, et al: Pediatrics 74:487, 1984

Mammel MC, Bing DR: Clin Chest Med 17:603, 1996

PIP – 25 cmH2O

PEEP – 5 cmH2O

I : E – 1 : 2 > 75/min 1 :1

F = 10 L/min

PIP – 25 cmH2O

PEEP – 5 cmH2O

I : E – 1 : 2

Consepts of gas transport….

• Convection ventilation or bulk flow

• Taylor dispersion and molecular diffusion

– A high velocity of gas travels down the center of a tube, leaving

the molecules on the periphery unmoved

– High flow facilitates diffusion

• Pendelluft effect

– Regional differences in time constants for inflation and deflation

cause gas to recirculate among lung

– Open lung allows to gas recirculate between alveoli

• Cardiogenic mixing

Crit Care Med 2005 Vol. 33, No. 3 (Suppl.)

Is the HFV more effective than CMV?

Study Year Study disign Results

Observational: Sjostrand V

Acta Anesthesiol Scand 1977

60 – 150 breaths/min

2000 adults and children

and 32 neonates with

RDS

HFPPV adequate

respiratory support

Observational: Bland RD

Crit Care Med 1980

24 neonates with RDS

60 – 110 breaths/min,

volume preset vent.

Improved outcome

HiFi study 1989 673/346 preterms

750-2000g

BPD ND, IVH↑, PVL↑,

Air leak↑

M-RCT (OCTAVE) Oxford Region Controlled Trial of Artificial

Ventilation study group

Arch Dis Child

1991

346 neonates

HFPPV vs CMV

60 vs 20 - 40

HFPPV ↓ air leak

Pardou A

Int Care Med 1993

22 neonates, HFFI

rescue therapy

CMV trend ↓ BPD w

28 dobie i 36 tyg.

63% vs 80%; 25% vs

40%

Thome U (RCT) 1999

284 neonates

24-29hbd < 1000g

HFV Inf Star

Infant Star ↑ air leak

BPD

28 days; 36 weeks PMA

Trial Study group/

HFV 28 – 30 d 36 PMA HLVS Surfaktant

RCT CO

Clark RH

1992

83 ≤ 1750

HFOF SM/CV – 27

HFOV SM – 30

P=0,008

P=0,013

RMCT (Provo)

Gerstmann

DR

1996

125 < 35 weeks

(1500;30,9)

HFOF SM – 64

P < 0,05 P < 0,05 36 PMA 100%

redosing

RMCT

Courtney

2002

499

< 1200g

HFOV SM - 244

P = 0,046 all 100% (4)

redosing

• N=273

• GA – 24 -29

• Birth weight < 1000g

• Randomization

– 142 min - 145 min

• HFOV

– Reduction of surfactant doses - 30% vs 64%

– Higher incidence IVH 24% vs 14%

Moriette G et al. Pediatrics 2001,107:363-72.

Prospective randomized multicenter comparison of high-frequency oscillatory ventilation and conventional

ventilation in preterm infants of less than 30 weeks with respiratory distress syndrome

Meata-

analysis Trials 28 – 30 d 36 PMA HLVS Surfaktant

Cools F

1999 16 trials ND

RR – 0,5

CI: 0,32, 0,78

RR – 0,44

CI: 0,16, 0,73

Hendreson-

Smart DJ

2000

Cochrane:

CD000104

6 trials

Rand. – 12h

Trend toward

decreasing

in HFV

or death

trend toward

decreasing

in HFV

28-30 days

RR – 0,5

CI: 0,36, 0,76

Death or BPD

Similar to

HLVS

Hendreson-

Smart DJ

2003

Cochrane:

CD000104

10 trials

NNT 17

Or death

NNT - 20

Results the

same

Results

the same

Hendreson-

Smart DJ

2007

Cochrane:

CD000104

15 trials

3585

neonates

ND ND borderline

significance

36 PMA

3652 neonates

Mortality at 28 -30 days

BPD – 36 PMA

• HVLS in HFV - ND

• HFOV

• Not used LPS in CV

• Randomization 2 – 6 hours

• I : E – 1 : 2

• Air leaks – more frequently in HFOV

• Secondary end points

– Gross pulmonary air leaks

• pneumothorax, pneumomediastinum, pneumopericardium

– Any pulmonary air leaks ↑*

• Gross pulmonary air leaks + PIE

– PDA – surgical ligation ↓

– ROP > 2 ↓*

– Final extubation HFOV < CV

• Ventilator type ND

– Sensormedics vs others vs „flow interrupter”

– HVLS

• Trials with HLVS

– Lower target of FiO2

• Time of randomization

– Death or BPD or neurological event

•1 – 4 h vs after 4h: HFOV (p=0,01)

• Outcome measures

– Death

– BPD at 36 weeks PMA

• Other variables

– Type of ventilator

• 11 – HFOV

– 7 – Sensormedics

• 2 – HFJV

• 2 - HFFI

– Ventilation strategies applied in the HFV and CV treatment groups

– Time on mechanical ventilation before randomization

No of trials – 15

HVLS i LPS

Neurological outcome

IVH, PVL

Trial Study group/

HFV

IVH

Grades: 3,4 PVL

RMCT

HiFi

1989

No – 673/327

750g – 2000g

26 vs 18

P = 0,02

12 vs 7

P = 0,05

Cools F

1999 16 trials

ND (HiFi)

RR 1.31, Fixed:

95% CI: 1.04, 1.66

Random: RR 1.34,

(95%

CI: 1.05, 1.70

ND

Longterm neurological outcome

Trial Study group/

HFV

No

followed up

Pulmonary

function

Neurodevelopmental

outocome

RMCT

HiFi

1989

673/327

750 – 2000g

Surv. - 524

432 (82%) ND

(No 223-43%)

386 (77%) 16 – 24 m.

Bayley score > 83

no major defect

CV ↓ (54% vs 65%)

RMCT

Ogawa

1993

92/46

750 - 2000 91 (100%)

1 year

BPD in chest x

–ray

2% vs 4% ND

Developmenta delay –

9% in both groups

RMCT

(Provo)

Gerstmann

DR

1996

125 < 35

Available 79

(1500;30,9)

HFOF SM – 64

69 (87%) ND ND

MRCT

UKOS

Marlow N

2006

797/400

Surv. 592

23 – 28 PMA

428 – 73%

373 – In

„window”

(211vs217)

22-28 month

40%

ND

9% sever

38% other disabilities

HFOV – indications

• Air leak syndromes

– Pulmonary interstitial emphysema ( PIE)

– bronchopleural or tracheoesophageal fistula

• Until at least 24 hours after the air leak resolved

• Severe uniform lung disease

– Respiratory distress syndrome

– Pneumonia

– ARDS

HFOV - indications

HFOV - indications

• Severe nonuniform disease such

– MAS - meconium aspiration syndrome

– Others aspiration syndromes

• Complication – air - trapping

HFOV - indications

• Parenchymal lung disease and require inhaled nitric

oxide therapy

Kinsela JP wsp – Randomised, multicenter trial of iNO and HFOV in severe PPHN. J Pediatr 1997;131: 55-62

• Pulmonary hypoplasia

– CDH

– Oligohydramnios sequence

• Severe chest wall restriction or upward pressure on the

diaphragm

– Gastroschisis

– Omphalocoele

– NEC

HFOV - indications

• Severe respiratory failure meeting the criteria for ECMO

Optimal

lung volume strategy

MAP 2-3 cmH2O

above the CMV

MAP

in 1-2 cmH2O steps

until

oxygenation improves

Frequency - 10 Hz

Aim: to maximise recruitment of alveoli

HFOV strategy

Low

volume strategy

MAP equal to the

CMV

Adjust amplitude

to get an adequate

chest wall vibration.

Frequency - 10 Hz

Aim: to minimise lung trauma

HFOV strategy

HFOV strategy

• Obtain an early blood gas and adjust settings as appropriate

• Obtain chest radiograph to assess inflation

– Initial at 1-2 hrs

• baseline lung volume on HFOV (aim for 8 ribs).

– A follow-up in 4-6 hours

• to assess the expansion

– Repeat chest radiography with acute changes in patient condition

• Reduce MAP

– chest radiograph shows evidence of over-inflation (> 9 ribs)

Poor

Oxygenation

Over

Oxygenation

Under

Ventilation

Over

Ventilation

Increase FiO2 Decrease FiO2 Increase Amplitude Decrease Amplitude

Increase MAP Decrease MAP

(1-2cmH2O)

Decrease Frequency

(1-2Hz)

if Amplitude Maximal

Increase Frequency

(1-2Hz)

if Amplitude Minimal

Weaning

• Reduce FiO2 to < 40% before weaning MAP (except overinflation)

• Reduce MAP in 1-2cm H2O increments to 8-10 cm H2O

• Air leak syndromes (low volume strategy)

– Reducing MAP takes priority over weaning the FiO2

• Wean the amplitude

• Do not wean the frequency

• Discontinue weaning when MAP 8-10 cm H2O and Amplitude 20-25

• Infant is stable, oxygenating well and blood gases are satisfactory

– extubation to CPAP or switched to conventional ventilation

Suctioning

• Indications

– diminished chest wall movement (chest wobble)

– elevated CO2 and/or worsening oxygenation

– visible/audible secretions in the airway

• Avoid in the first 24 hours of HFOV, unless clinically

indicated.

• In-line suctioning must be used

• Press the STOP button briefly while quickly inserting and

withdrawing suction catheter (PEEP is maintained)

2006 OPEN FORUM Abstracts

OPEN VERSUS CLOSED SUCTION DELIVERY DURING HIGH FREQUENCY

OSCILLATORY VENTILATION (HFOV)

Dennis Gaudet, RRT; Matthew P. Branconnier, RRT, EMT; Dean R. Hess, PhD,

RRT, FAARC. Massachusetts General Hospital and Harvard Medical School,

Boston MA.

Summary.…

• HFV is an effective treatment modality in a variety of clinical

situations

• The most important contribution of HFOV is that it helped clinicians

overcome the fear of using adequate distending airway pressure

• The most important is to achieve optimal lung volume, I:E – 1:2

• When used in appropriately selected patients with the optimal

volume recruitment strategy and careful attention to avoide

hypocapnia, HFOV is capable of reducing the incidence of CLD

• Recent meta-analyses have suggested that surfactant, antenatal

steroids, and improvements in conventional mechanical ventilation

with the use of lung-protective strategies have eliminated any

advantages of HFV as a primary mode of ventilation

Nasal Ventilation: How does it work?

• Increase in FRC

– Alveolar recruitment due to higher MAP

– Decrease in intrapulmonary shunt

– Protection of surfactant

– Increases alveolar surface area for gas exchange

• Improves oxygenation

• Increase in VT and minute volume

NIV - History

• August Ritter von Reus 1914

– Bubble CPAP

• 1940s

– High altitude flying

• 1967

– PEEP was added to MV

• 1960s

– Neonates PEEP=0

NIV - History

• Harrison (1968)

– Grunting was producing positive end expiratory pressure (PEEP)

• Gregory (1971)

– Clinical use of CPAP in premature neonates with hyaline membrane

disease (RDS)

• Avery (1987)

– The lowest incidence of BPD, at Columbia where they used much more

CPAP

• Nasal Continuous positive airway pressure (NCPAP)

– By far the most commonly used form of NIV in neonates today

When is NIV used ?

After birth

After extubation

To treat apnea

Nasal CPAP Delivering Devices

• Components

– Circuit for continuous or variable flow of inspired gases

• Continuous flow – gas flow generated and directed against the

resistance of the expiratory limb

– Nasal interface

• single or bi-nasal prongs (Argyle & Hudson), mask, NP tube

– Device to generate positive airway pressure

Know Your CPAP

• Continuous flow: flow constant irrespective of phase of

respiration

– Ventilator generated CPAP (conventional CPAP)

– Bubble: CPAP varied by immersion of expiratory tubing

• Flow varies with immersion depth and affects CPAP

• Variable flow: CPAP varied by varying the flow rate

– Infant flow, Arabella, Aladdin

– Bi-level (“SiPAP”)

Courtnay SE et al; Pediatr Pulmonol; 36; 2003

Lipsten F et al; J Perinatol; 2005

Boumecid H et al; Arch Dis Chid Fetal Neonatal; 2007

Conventional Ventilator CPAP vs. Infant Flow CPAP

for Extubation (n=162)

Stefanescu BM et al. (Winston-Salem, NC) Pediatrics 2003

Extubation Failure Rate:

Conv. CPAP= 38.1%

IF-CPAP= 38.5%

Infant Flow CPAP is as effective as conventional CPAP

Infant Flow Driver CPAP

Fluidic Flip or Coanda Effect

Pressure is generated by Varying the Flow Rate

• Reduced work of breathing

• Maintains uniform pressure

CPAP Interfaces

Argyle Prongs

Nasal mask

Hudson Prongs

Inca Prongs

Nasal Cannula

Nasopharyngeal

Catheter

R ~ F L / r4

Bi-Nasal vs Single Prong CPAP in ELBWI

Bi-Nasal Prongs

(n=41)

Single Prong

(n=46) p

BW, g mean (SD) 790 (140) 816 (125) NS

GA 26 (1.9) 26 (1.9) NS

Age at extubation, days,

Median, IQ range 3 (1-9) 3 (1-6) NS

Extubation Failures 24 % 57 % 0.005

In < 800 g 24 % 88 % <0.001

Reintubation in < 800 g 18 % 63 % 0.023

Bi-Nasal Prongs are more effective than Single Prong

Davis P et al. (Melbourne) Arch Dis Child 2001

Single-prong vs double-prong NCPAP ventilation: effect on

extubation failure

De Paoli A: Cochrane Database Rev; 2008; CD002977

NCPAP at birth

• Intubation in the delivery room was reduced from 84% to 40%

» Linder W et al.; Pediatrics; 1999;

• Intubation in the delivery room was reduced from 89% to 33%

» Aly H et al.; Pediatrics; 2004;

• Lack of RCT

– „…the dramatic effect of CPAP (was) observed after a brief period of treatment in

all patients.”

» Novogroder et al.; J Pediatrics: 1973

• „…Although one or two such (RCT) studies of CPAP would be

welcome, many more „would be foolish.”

Davis PG: 2003;

Cochrane Database Rev

CD000143

NCPAP - 8 Studies; 2001-2009

Extubation failures - 20-80%

24

38,5

80

33

46

2933

39

57

26

38,1

19,7

0

10

20

30

40

50

60

70

80

90

Davis-01 Stefanescu-

03

Finer-04 Booth-06 Morley-08 Gupta-09 Sandri-09 Rojas-09

Ramanathan R. J Perinatol 2010; 30: S67-72

Bi-Nasal vs.

Single Prongs

IFD vs.

B-CPAP

NCPAP vs.

Surf +

NCPAP* IFD vs.

V-CPAP

What to do when NCPAP fails?

when should the neonate be intubated ?

• NCPAP – Faillure rate -20 -80%

• Definition of CPAP faillure

– FiO2 > 0,6 → 0,75

– FiO2 > 0,35 – 0,4

– COIN trial

• FiO2 > 0,6; pH < 7,25; PaCO2 > 60mm

• Apneic episodes > 6/6hour requiring stimulation or >1 requiring PPV

NIPPV

• Added positive pressure inflation to a background of

NCPAP

• How NIPPV improve clinical outcomes

– PIP results in only a slight increase in VT when delivered during

spontaneous breathing

– Occasionally lead to chest inflation when delivered during apneic

period

» Owen LS et al.; Arcg Dis Child Fetal Neonatal Ed; 2011

sNIPPV in Preterm Infants with RDS

sNIPPV -242; nCPAP - 227;

NCPAP

(n=227)

sNIPPV

(n=242) P

Birth Weight, g 964 183 863 198 < 0.001

Gestational Age, wks 27.9 2.4 26.4 1.7 < 0.001

Antenatal Steroids, % 92 94 0.274

Surfactant Rx, % 68 85 < 0.001

BPD, Total population 25 % 35 % 0.028

BPD in 500-750 g 67 % 43 % 0.031

BPD in 751-1000 g 23 % 35 % 0.097

BPD in 1001-1250 g 14 % 21 % 0.277

sNIPPV when compared to NCPAP was associated with decreased

BPD, BPD/Death, NDI, and NDI/Death

Bhandari V et al. Pediatrics 2009

NCPAP vs. NIPPV: 9 RCT; 1999 - 2011

Extubation Failures

37

44

40

49

3942 41

15

34

5 6

25

6

1718,9

10

25

15

0

10

20

30

40

50

60

Friedlich-99

(Ramanathan)

Barrinton-01 Khalaf-01 Kugelman-07 Moretti-08 Ramanathan-

09

Kishore 09 Lista-10 Meneses-11

Modified from Ramanathan R. J Perinatol 2010 * P <0.05

Extubation Failures 5-25%

NCPAP vs. NIPPV: 8 RCT; 1999 – 2011

BPD

5653

17

33

22

39

7,7

25

44

2

106

21

2,7

26,5

35

0

10

20

30

40

50

60

Barrinton-01 Khalaf-01 Kugelman-07 Bhandari-07 Moretti-08 Ramanathan-09 Kishore-09 Meneses-11

Davis PG; Cachrane Database Rev. 2001; CD003212

•NIPPV

• Lower risk of respiratory faillure

• Apnea

• Respiratory acidosis

• Increased oxygen requirements

To prevent reintubation

S-NIPPV and NS-NIPPV

• NCPAP vs S-NIPPV vs NS-NIPPV (20-40/min)

– VT, minute ventilation, gas exchange – ND

– S-NIPPV

• Less inspiratory effort

• Better infant – ventilator interaction

– NS-NIPPV – no advantage over NCPAP

» Chang HY et al; Pediatr Res; 2011

Neurally Adjusted Ventilatory Assist (NAVA)

• Electrical activity of the diaphragm (Edi) is used for

controlling ventilation in Neurally Adjusted Ventilatory

Assist

• NAVA ventilation mode may be used both as invasive

and non-invasive ventilation

• Timing and amount of delivered pressure is controlled by

patient

• One condition must be met – spontaneous breathing

• Edi catheter (6 Fr) is introduced through nostril and

placed according to the formula

• Edi catheter positioning was adjusted by means of ECG

display

• After appropriate placement sufficient Edi signal could be

detected

From NAVA to NIV - NAVA

NAVA

NAVA level - set on ha base of

Peak Inspiratory Pressure

applied in the previous ventilation mode

NIV - NAVA

HFNC – high flow nasal cannulae

• Flow rates exceeding 1L/min

– Initial support for early respiratory distress

– Postextubation support

– Step-down therapy from NCPAP

• HFNC interfaces

– Vapotherm

– Optiflow (pressure- relief valve in circuit)

• Open systems with leak at the nose and mouth

• Heated and humidified gas, blending and oxygen and air

HFNC – high flow nasal cannulae

• Pressure generated – unpredictable

– 0,3 cm outer diameter, flow rate 2L/min

• Mean esophageal pressure – 9,8 cm H2O

» Locke RG; pediatrics, 1993

– Recent studies

• Pressure ≤ NCPAP

» Kubica ZJ et al; Pediatrics 2008

» Spence KL et al.; J Perinatol; 2008

» Wilkinson DJ et al.; J Perinatol: 2008

How to use NIV ?

How much supporting pressure should be used

Davis PG: 2003; Cochrane Database Rev; CD000143

•NIPPV

•PIP as on MV or slighty

above

•Respiratory rate – 20-40

Suggested Weaning Guidelines During Nasal Ventilation

• Wean every 6–12 h

• Wean PIP first

• When PIP is at 10, then wean rate

• When rate is at 10, wean to NCPAP

• When patient is stable

– NCPAP of ± 5 cm H2O for 6–12 h

• wean to heated nasal cannula with flow rates of < 2 LPM.

Contraindication to NIV

• Progressive respiratory faillure or with poor respiratory drive

– High oxygen requirement

– PCO2 > 60mmHg

– pH < 7,25

– Apnea, bradycardia, desaturation do not responded to NCPAP

• Congenital malformations

– Choanal atresia

– Cleft plate

– Congenital diaphragmatic hernia

– Tracheoesophageal fistula

– Gastroschisis

• Severe cardiovascular instability

NIPPV - Complications

• Malpositioned nasal cannulae

– Variable flow CPAP system

– Airway obstruction by secretion

• Inadvertent PEEP – air leaks

– High ventilatory rate

– Too short expiratory time

– Minimal or no lung disease (high compliance)

• Carbon dioxide retention

– Alveolar overdistantion

• Increase work of breathing, PVR↑, CO↓

• Decrease urine output

– Too short expiratory time

NIPPV - Complications

• Decreased gastrointestinal blood flow - „CPAP belly”

– Abdominal distention

• Placement of orogastric tube

– NEC – not confirmed

– Gastric perforation - not confirmed

• Skin trauma Fischer C et al (Switzerland). Arch Dis Child 95: F447-F451; 2010

Summary

• NCPAP reduces respiratory instability and the need for

extra support after intubation

• NCAP reduces the rate of apnea

• NIPPV may augment the benefits of NCPAP

• Binasal prongs are better than single nasal prongs

• Used NCPAP after delivery may prevent or at least

diminish respiratory distress

• It does not matter what ventilator we choose but …

• How to provide respiratory support

• The art of medicine is to achieve optimal lung volume in

neonates with respiratory disorders

• CPAP is one method many clinicians believe best

achieves optimal lung inflation with resultant good

oxygenation and ventilation without the use of an

endotracheal tube

ECMO – instead of ventilators?

• Low volume of circuit

• Possibility to provide without hyalinization and trough

thin cannulas

• Even then Optimal Lung Volume in neonates with

surfactant insufficiency will be necessary

Thank you…

„Bubble” CPAP vs CPAP with Mechanical Ventilator

(12 PT infants; <1500g)

Kahn et al, Pediatrics, 2007

Bias Flow (Liters/min)

4 6 8 10 12

Me

an

(+

/- S

D)

Pre

ss

ure

(c

mH

2O

)

2

4

6

8

10

12

No Leak

(se

t N

CP

AP

)8

4

Ventilator: open symbolsBubble: solid symbols