Non -invasive Ventilation -...

AW Flemmer Krakau 2013

NonNon --invasiveinvasive VentilationVentilation

Krakau 2013Krakau 2013

A.W. Flemmer

Div. Div. NeonatologyNeonatology , , ChildrenChildren ‘‘s Hospital and Perinatal Center,s Hospital and Perinatal Center,LMLM--University Munich, GermanyUniversity Munich, Germany

AW Flemmer Krakau 2013

• Increased and stabilized lung volume

• Stabilized „soft“ thorax of the neonate→→→→ reduced work of breathing

• ….

• Decreased airway resistance

• Surfactant „restitution“

• Reduced left-right shunting across patent ductus botalli

Physiological effects of CPAP - potential benefits

AW Flemmer Krakau 2013

Rees et al. J Rees et al. J NeuropathNeuropath and and ExpExp NeurolNeurol , June 2009, June 2009

Extubation to nCPAPafter 24 hrs

Extubation to nCPAPafter 5 days

nCPAP & Surfactant:„beyond the lung“

AW Flemmer Krakau 2013

• CPAP-induced overdistention of the lung, inverted diaphragm →→→→ impaired exspiration

• Airleak / pneumothorax

• ET tube and airway- obstruktion

• Overdistention →→→→ reduced venous return→→→→ reduced cardiac output

• ....

Physiological effects of CPAP - potential harms

AW Flemmer Krakau 2013

CPAP CPAP systems

nasal ET tubenasal prongsnasal cannula

.....

Flow-generator:•Ventilator

• cont. flow• demand flow

•Bubble-CPAP•Medijet•Infant-flow•...

Pressure-generator:expir.-valvesurge chamber...

Interface:Hudson prongsArgyle prongsBuenavistaFluid flip device...

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nCPAP - Failure

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NIV -- NIPPV

nIMV sNIMVsNIPPV

n-HFOV

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n-HFOV

Mukerji et al. Neonatology 2013

AW Flemmer Krakau 2013Meneses et al. Pediatrics 2011

NN--IPPV vs. NIPPV vs. N --CPAPCPAP

Prim Outcome: Use of ETT

N.S.All sec. Outcomes:(Surv. With no BPD, ROP, NEC, IVH, PDA)

2.89 (0.30-27.2)1.90 (0.49-7.4)

7.27.2

1.23.7

BPD moderatesevere

0.90 (0.72-1.13)5864Need for MV

1.19 (0.55-2.53)0.56 (0.32-0.98)

2922

2439

Failure of NIV <1000g>1000g

RR (95%CI)NIPPV (%)(n=100)

NCPAP (%)(n=100)

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Non-synchronized NIV

Owen L et al.Arch Dis Child 2011

AW Flemmer Krakau 2013O‘Brien et al. BMJ Ped 2012

NN--IPPV vs. NIPPV vs. N --CPAPCPAP

Prevent Extubation Failure

sNIPPV

NFSIPPV

NP-SIMV

nSIMV

BL-NCPAP

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Positive Effectsof Synchronization

� ↑↑↑↑ Tidalvolume (Bernstein 1994, Hummler 1996, Rosas 1992)

� ↑↑↑↑ Oxygenation (Cleary 1995)

� ↓↓↓↓ Blood pressure fluctuations (Amitay 1993, Hummler 1996)

� ↓↓↓↓ IVH ? (Perlman 1985)

� ↓↓↓↓ Work of breathing (Jarreau 1996)

� ↓↓↓↓ Active exspiration (Heldt & Bernstein 1994, Greenough 1985)

� ↓↓↓↓ Air leaks (Greenough 1983, 1984)

� ↓↓↓↓ Sedation / Paralysis (Henry 1979)

� ↓↓↓↓ Stress (Epinephrinlevel) (Quinn 1998)

� Earlier weaning (Donn 1994)

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Does SynchronizationMatter?

Prim Outcome RR (95% CI) # Studies Pt enrolled

Death 1.19 (0.95-1.49) 5 1729

Air Leaks 1.03 (0.80-1.34) 6 1769

Ext. Failure 0.93 (0.68-1.28) 4 1056

Severe IVH 1.03 (0.74-1.43) 5 1729

BPD@28d 0.91 (0.75-1.12) 4 805

BPD@36wk 0.90 (0.75-1.08) 2 1310

Days vent (h) -35 (-62;-7) 4 1402

Greenough A. et al. 2008 Cochrane Database AW Flemmer Krakau 2013

nCPAP vs. sNIPPV

BPD or death

Neurodevelopmental Impairment or Death

Bahndari et al. Pediatrics 2009Retrospective Data with Graseby & Infant Star & Star Synch

AW Flemmer Krakau 2013 Dumpa et al. et al. J Perinat 2011

OR 95% CI

BPD or death NIPPV (238) sNIPPV (172) 0.74 0.42 – 1.30

Retrospective Data with Graseby & Infant Star & Star Synch

NIPPV vs. sNIPPV

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CV vs. sNIPPV

Bahndari et al. J Perinat 2007

Outcome Conv. Ventilation

(n=21)

sNIPPV

(=20)

p

BPD or deathn (%)

11 (52) 4 (20) 0.03

BPD n (%) 7 (33) 2 (10) 0.04

death n (%) 4 (19) 2 (10) 0.66

Initial RDS-Treatment (RCT)

RCT 2 Centers 2000-2005 with Graseby & Infant Star & Star Synch

AW Flemmer Krakau 2013

ExternalSignals

Internal Signals

Graseby Capsule Flow

RespiratoryInductionPlethysmography: RIP-Bands

NAVA

Piezo Sensor ∆P oesophageal

Potential Respiratory Signals forsynchronized NIPPV

Best Triggerfor sNIPPV?

AW Flemmer Krakau 2013

Best signal for synchronisation of NIPPV

� Onset of signal and � Quality of signal

Best way to provide sNIPPV?

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(n=5813) Signal Onset vs. RIP-Abd

SD

∆∆∆∆t Pes + 52 ms ± 160 ms

∆∆∆∆t RIP-Chest + 157 ms ± 154 ms

∆∆∆∆t Graseby + 61 ms ± 98 ms

∆∆∆∆t Piezo + 118 ms ± 1375 ms

ΘΘΘΘ RIP Chest – RIP Abd

49 ° ± 118 °

80.4 ±±±± 10 % valid Signals for RIP Abd & Graseby

VLBWSpont breathing

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VLBW CPAP

(n=5813) Signal Onset vs. RIP-Abd

SD

∆∆∆∆t Pes - 45 ms ± 95 ms

∆∆∆∆t RIP-Chest + 167 ms ± 105 ms

∆∆∆∆t Graseby + 44 ms ± 66 ms

∆∆∆∆t Piezo + 35 ms ± 88 ms

AW Flemmer Krakau 2013Moretti Corrado et al. 2008 Pediatrics Int

Nasal Flow sNIPPV

NCPAP nfsNIPPV p

Extubation -Failure n/n (%) 2/32 (6%) 12/31 (39%) p<0.005

Special ventilator „Gulia“ with sNI-algorythm

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Neurally adjusted ventilatory assist (NAVA)

Moerer et al. Anaesthetist 2008

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Adult Pt Camarota et al. ICM 2012

n-i NAVA

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1) RIP – Abdominal Band2) Graseby Capsule3) Flow sensor with special algorythm

4) NAVA

Valid Triggers

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�So far no comperative studies lookinginto differences of triggers

AW Flemmer Krakau 2013

Best way to provide sNIPPV?

Supported Frequency

���� synchronised intermittent NV?

���� synchronised assist control NV?

AW Flemmer Krakau 2013

Observational with Graseby & Infant Star + Star Synch

nCPAP ni-MV @20/min

s-ni-MV@ 20/min

ni-MV @40/min

s-ni-MV@ 40/min

Vt (AU) 10.6(8.0–13.9)

11.6(7.8–19.6)

10.2(7.8–14.6)

10.4(6.2–14.1)

10.1(8.7–13.5)

MV (AU) 508 (369 – 857)

681 (321–1051)

535(342–783)

546 (330 –746)

581 (399 – 811)

RR (/min)

54 (43–59) 54 (44 – 60) 51 (44 – 60) 50 (45– 61) 52 (45– 61)

tcpCO 255.2 ±±±±10.4 55.1 ±±±± 10.7 54.9 ±±±± 10.7 56.3 ±±±± 11.1 55.8 ±±±± 12.3

SPO292.5 ±±±± 1.9 92.9 ±±±± 2.6 92.5 ±±±± 2.9 92.9 ±±±± 2.7 92.2 ±±±± 2.8

ni-MV vs. s-ni-MV

Chang H. & Bancalari E. et al. 2011 Ped Res AW Flemmer Krakau 2013

Chang H. & Bancalari E. et al. 2011 Ped Res

SIMV-NIPPV @ 40/ min

IMV-NIPPV @ 20/ min

BUT ���� no comparison of SIMNV vs. AC-NV

AW Flemmer Krakau 2013

Triggering Expiration in PSV

Reyes et al. Pediatrics 2006AW Flemmer Krakau 2013

� Loss of FRC� Prolonged Desaturations � Bradycardia

Apnoea & Periodic Breathing

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Summary

� sIM-NIV 40/min seems more effective than IM-NIV 20/min

� Triggering expiration during sNIPPV is possibleand available

� Apnoea-detection and adaptive backupventilation during sNIPPV may be achieved witha Graseby sensor

� Moving artefacts are a major backdraw of sNIPPV