Non-Invasive Ventilation Neonatal Best Evidence & BIDMC Applications Beth Israel Hospital Boston...

Non-Invasive Ventilation NeonatalBest Evidence & BIDMC Applications

Beth Israel Hospital Boston Respiratory Care

Non-Invasive Ventilation Neonatal – Outline of Points

•Indications & Incentives for Use•Background Definitions•Devices•Interfaces•Use outside of BI•Unanswered questions•Controversies•Recommendations for BI use

•Current use•How should use to improve care

Non-Invasive Ventilation Neonatal - Indications & Incentives

Indications & Incentives

•Reduced BPD (time independent)•Reduce volu-trauma•Reduce hyper & hypoxia

•Reduce work of breathing•Increase thoracic abdominal synchrony•Increase spontaneous tidal volume

•Reduce VAP with shorter intubation

•Reduce discomfort

•Improve interaction with mother and environs

Non-Invasive Ventilation Neonatal

Eur J Pediatr. 2010 July; 169(7): 777–782.Published online 2010 February 24. doi: 10.1007/s00431-010-1159-xCopyright/LicenseRequest permission to reuseTable 2. Beneficial effects of noninvasive ventilation in newborns

•Important practical conclusions for applying NIV in newborns with respiratory distress:•A physiological background is needed to understand NIV•NIV can be used to avoid mechanical ventilation•Adjustable and measured PEEP should be used immediately after birth•PEEP levels should remain around +5 cm H2O or higher•nCPAP appears to be a satisfactory alternative to endotracheal intubation•Without available scientific evidence, it seems potentially harmful to use HHFNC in newborns

Eur J Pediatr. 2010 July; 169(7): 777–782.Published online 2010 February 24. doi: 10.1007/s00431-010-1159-xCopyright/LicenseRequest permission to reuseTable 2. Beneficial effects of noninvasive ventilation in newborns

Improved respiratory mechanics Increased lung volume

Increased compliance

Decreased resistance

Improved respiratory timing Decreased thoracoabdominal asynchrony

Decreased obstructive and mixed apnoea

Improved respiratory timing

Improved oxygenation Decreased pulmonary vascular resistance

Decreased intrapulmonary shunting

Increased alveolar volume and less collapse

Non-Invasive Ventilation Neonatal - Indications & Incentives

Concerns

•Complicated devices and techniques must learned

•Gastric distention & perf. (Garland Pediatrics 1985; 76:406-410)

•Contraindicated with upper airway anomalies (choanal atresia, cleft palate, te fistula or severe cardiovascular instability

•Tissue breakdown around interface device

•Feeding intolerance

Setup of NIPPV

* V Bhandari JOP 2010 30, 505-512•O2 to optimize saturation per policy, •Caffeine •Hct. > 35

CLD Working Group

rate Ti PIP PEEP rise time flow LPMPressure

Ramanathan

40 max 50

0.5to1

PEEP plus

10-155-8 0.1-0.2 10-15 PIP 30

V Bhandari *

~40 ~0.45PIPvent

4-6Not

specified8-10

MAP 14 < 1000g16 > 1000 g

Chronic LungDisease NIPPV

Overview

15-200.3to

PIPvent plus2-4

specifiedNot

specified

Transition of Support

• Remove NIPPV– Rate 15-25– PIP < 17– PEEP <6– FiO2 <35

V Bhandari JOP 2010 30, 505-512

• Intubate– pH < 7.25 PaCO2 > 60– Apnea requiring bagging– Frequent As & Bs– Frequent desaturations

“…can use blood gases to help wean, but not typically needed—can wean or increase settings based on clinical appearance” CLD Working Group

Non-Invasive Ventilation Neonatal – Interfaces

•Interfaces for Non-Invasive

•High-Flow Cannula

•NP Tube

•Prongs•Long prong•Bi-Nasal Prongs

•Nasal Mask

•RAM Cannula

Case report Oral continuous positive airway pressure (CPAP) following nasal injury in a preterm infant, H R Carlisle, C O F Kamlin, L S Owen, P G Davis, C J Morley; Arch Dis Child Fetal Neonatal Ed 2010;95:F142F143 doi:10.1136/adc.2009.170084

Non-Invasive Ventilation Neonatal – Modes and Devices

•Modes of Non-Invasive Ventilation•Devices for Non-invasive Ventilation

•High-Flow Nasal Cannula•Bubble CPAP•Hansen Ventilator•Conventional•Conventional with NAVA•Hi-Fi

Non-Invasive Ventilation Neonatal – Device – Arabella CPAP & Vapotherm

Non-Invasive Ventilation Neonatal – Device - Hansen Ventilator

Non-Invasive Ventilation Neonatal – Device – Viasys BiPAP

BWH uses rarely.

NAVANon-Invasive Ventilation Neonatal

Beth Israel Hospital Boston Respiratory CareINSURE (intubatio-surfactant-extubation)

Non-Invasive Ventilation Neonatal – Indications & Incentives

Non-Invasive Ventilation Neonatal –Indication & Incentive

Non-Invasive Ventilation Neonatal – Indications & Incentives

Non-Invasive Ventilation Neonatal – High Flow Cannula

Long versus short inspiratory times in neonates receiving mechanical ventilation

Kamlin COF, Davis PG• http://www.nichd.nih.gov/cochrane/Kamlin/KAMLIN.HTM

• Reviewers' conclusions• Implications for practice• Long inspiratory times when used in acute HMD in a population not

exposed to antenatal steroids and postnatal surfactant are associated with higher rates of mortality and morbidity. Stiff lungs with HMD have very short time constants. Mechanically ventilated infants with HMD and especially those treated in institutions where these adjunctive therapies are not available should be ventilated using a short IT.

• The use of a long IT where time constants are longer than acute HMD such as premature infants with BPD, meconium aspiration syndrome and newborns in cardiac failure may be appropriate and is yet to be investigated.

Non-Invasive Ventilation Neonatal Best Evidence & BIDMC Applications Beth Israel Hospital Boston...

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