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Invasive Neonatal Invasive Neonatal VentilationVentilation
Dr Badr ChabanDr Badr Chaban
280109280109
Invasive Neonatal VentilationInvasive Neonatal Ventilation
Conventional Mechanical Ventilation CMVConventional Mechanical Ventilation CMV Intermittent Mandatory Ventilation IMVIntermittent Mandatory Ventilation IMV Synchronized Intermittent Mandatory Synchronized Intermittent Mandatory
Ventilation SIMVVentilation SIMV AssistControl Ventilation IPPV ACAssistControl Ventilation IPPV AC Pressure-Support Ventilation PSVPressure-Support Ventilation PSV Patient-Triggered Ventilation SPatient-Triggered Ventilation S
Ventilatory TechniquesVentilatory Techniques
Pressure-Limited VentilationPressure-Limited Ventilation Pressure-Controlled VentilationPressure-Controlled Ventilation Volume VentilationVolume Ventilation Volume GuaranteeVolume Guarantee Pressure-Regulated Volume ControlPressure-Regulated Volume Control Volume-Assured Pressure SupportVolume-Assured Pressure Support Proportional Assist VentilationProportional Assist Ventilation
Ventilatory StylesVentilatory Styles
Conservative or ldquoGentlerdquo VentilationConservative or ldquoGentlerdquo Ventilation Nasopharyngeal SynchronizedNasopharyngeal Synchronized Intermittent Mandatory VentilationIntermittent Mandatory Ventilation
Goals of Mechanical VentilationGoals of Mechanical Ventilation
(1) adequate pulmonary gas ex-change (1) adequate pulmonary gas ex-change (2) (2) darrdarr risk of lung injury risk of lung injury (3) (3) darrdarr (WOB) (WOB) (4) optimize patient comfort (4) optimize patient comfort
Ideal Mode of VentilationIdeal Mode of Ventilation
Delivers a breath thatDelivers a breath that 1048707 1048707 Synchronizes with the patientrsquosSynchronizes with the patientrsquos spontaneous respiratory effortspontaneous respiratory effort 1048707 1048707 Maintains adequate and consistent tidalMaintains adequate and consistent tidal volume and minute ventilation at lowvolume and minute ventilation at low airway pressuresairway pressures 1048707 1048707 Responds to rapid changes in pulmonaryResponds to rapid changes in pulmonary mechanics or patient demandmechanics or patient demand 1048707 1048707 Provides the lowest possible WOBProvides the lowest possible WOB
Ideal Ventilator DesignIdeal Ventilator Design
1048707 1048707 Achieves all the important goals ofAchieves all the important goals of mechanical ventilationmechanical ventilation 1048707 1048707 Provides a variety of modes that canProvides a variety of modes that can ventilate even the most challengingventilate even the most challenging pulmonary diseasespulmonary diseases 1048707 1048707 Has monitoring capabilities to adequatelyHas monitoring capabilities to adequately assess ventilator and patient performanceassess ventilator and patient performance 1048707 1048707 Has safety features and alarms that offerHas safety features and alarms that offer lung protective strategieslung protective strategies
Carbon Dioxide (CO2) EliminationCarbon Dioxide (CO2) Elimination
alveolar minute ventilation =alveolar minute ventilation =
(tidal volume - dead space) x frequency (tidal volume - dead space) x frequency
Copyright copy1999 American Academy of Pediatrics
Carlo W A et al Pediatrics in Review 199920117-126e
Relationships among various ventilator-controlled (shaded circles) and
Copyright copy1999 American Academy of Pediatrics
Carlo W A et al Pediatrics in Review 199920117-126e
Determinants of oxygenation during pressure-limited
MAP = K (PIP - PEEP) (TITI + TE) + MAP = K (PIP - PEEP) (TITI + TE) + PEEP PEEP
K is a constant determined by the flow rate K is a constant determined by the flow rate and the rate of rise of the airway pressure and the rate of rise of the airway pressure curvecurve
COMPLIANCECOMPLIANCE
Compliance describes the elasticity or Compliance describes the elasticity or distensibility (eg lungs chest wall distensibility (eg lungs chest wall respiratory system) respiratory system)
compliance = volume pressure compliance = volume pressure
in neonates who have normal lungs in neonates who have normal lungs ranges from 0003 to 0006 Lcm H2O ranges from 0003 to 0006 Lcm H2O compared with compliance in neonates compared with compliance in neonates who have RDS which may be as low as who have RDS which may be as low as 00005 to 0001 Lcm H2O 00005 to 0001 Lcm H2O
RESISTANCERESISTANCEResistance describes the inherent Resistance describes the inherent capacity of the air conducting system (eg capacity of the air conducting system (eg airways endotracheal tube) and tissues to airways endotracheal tube) and tissues to oppose airflow and is expressed as the oppose airflow and is expressed as the change in pressure per unit change in change in pressure per unit change in flow flow
resistance = pressure flow resistance = pressure flow
Airway resistance depends onAirway resistance depends on
1)1) radii of the airways (total cross-sectional radii of the airways (total cross-sectional area) area)
2)2) length of airways length of airways
3)3) flow rate flow rate
4)4) density and viscosity of gas breathed density and viscosity of gas breathed
Resistance
Δ Pressure (cm H2O)
Δ Flow (Lsec)
Normal lungs 20-40 cm H2OLsec
RDS 20-40 cm H2OLsec
Intubated infant 50-150 cm H2OLsec
The time constant of the respiratory system is a measure of the time necessary The time constant of the respiratory system is a measure of the time necessary
for the alveolar pressure to reach 63 of the change in airway pressurefor the alveolar pressure to reach 63 of the change in airway pressure time constant = resistance x compliance time constant = resistance x compliance
For example the lungs of a healthy For example the lungs of a healthy neonate with a compliance of 0004 Lcm neonate with a compliance of 0004 Lcm H2O and a resistance of 30 cm H2OLs H2O and a resistance of 30 cm H2OLs have a time constant of 012 seconds have a time constant of 012 seconds
Carlo W A et al Pediatrics in Review 199920117-126e
CMVCMV
IMVIMV
SIMVSIMV
SIMV+VGSIMV+VG
IPPVIPPV
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Invasive Neonatal VentilationInvasive Neonatal Ventilation
Conventional Mechanical Ventilation CMVConventional Mechanical Ventilation CMV Intermittent Mandatory Ventilation IMVIntermittent Mandatory Ventilation IMV Synchronized Intermittent Mandatory Synchronized Intermittent Mandatory
Ventilation SIMVVentilation SIMV AssistControl Ventilation IPPV ACAssistControl Ventilation IPPV AC Pressure-Support Ventilation PSVPressure-Support Ventilation PSV Patient-Triggered Ventilation SPatient-Triggered Ventilation S
Ventilatory TechniquesVentilatory Techniques
Pressure-Limited VentilationPressure-Limited Ventilation Pressure-Controlled VentilationPressure-Controlled Ventilation Volume VentilationVolume Ventilation Volume GuaranteeVolume Guarantee Pressure-Regulated Volume ControlPressure-Regulated Volume Control Volume-Assured Pressure SupportVolume-Assured Pressure Support Proportional Assist VentilationProportional Assist Ventilation
Ventilatory StylesVentilatory Styles
Conservative or ldquoGentlerdquo VentilationConservative or ldquoGentlerdquo Ventilation Nasopharyngeal SynchronizedNasopharyngeal Synchronized Intermittent Mandatory VentilationIntermittent Mandatory Ventilation
Goals of Mechanical VentilationGoals of Mechanical Ventilation
(1) adequate pulmonary gas ex-change (1) adequate pulmonary gas ex-change (2) (2) darrdarr risk of lung injury risk of lung injury (3) (3) darrdarr (WOB) (WOB) (4) optimize patient comfort (4) optimize patient comfort
Ideal Mode of VentilationIdeal Mode of Ventilation
Delivers a breath thatDelivers a breath that 1048707 1048707 Synchronizes with the patientrsquosSynchronizes with the patientrsquos spontaneous respiratory effortspontaneous respiratory effort 1048707 1048707 Maintains adequate and consistent tidalMaintains adequate and consistent tidal volume and minute ventilation at lowvolume and minute ventilation at low airway pressuresairway pressures 1048707 1048707 Responds to rapid changes in pulmonaryResponds to rapid changes in pulmonary mechanics or patient demandmechanics or patient demand 1048707 1048707 Provides the lowest possible WOBProvides the lowest possible WOB
Ideal Ventilator DesignIdeal Ventilator Design
1048707 1048707 Achieves all the important goals ofAchieves all the important goals of mechanical ventilationmechanical ventilation 1048707 1048707 Provides a variety of modes that canProvides a variety of modes that can ventilate even the most challengingventilate even the most challenging pulmonary diseasespulmonary diseases 1048707 1048707 Has monitoring capabilities to adequatelyHas monitoring capabilities to adequately assess ventilator and patient performanceassess ventilator and patient performance 1048707 1048707 Has safety features and alarms that offerHas safety features and alarms that offer lung protective strategieslung protective strategies
Carbon Dioxide (CO2) EliminationCarbon Dioxide (CO2) Elimination
alveolar minute ventilation =alveolar minute ventilation =
(tidal volume - dead space) x frequency (tidal volume - dead space) x frequency
Copyright copy1999 American Academy of Pediatrics
Carlo W A et al Pediatrics in Review 199920117-126e
Relationships among various ventilator-controlled (shaded circles) and
Copyright copy1999 American Academy of Pediatrics
Carlo W A et al Pediatrics in Review 199920117-126e
Determinants of oxygenation during pressure-limited
MAP = K (PIP - PEEP) (TITI + TE) + MAP = K (PIP - PEEP) (TITI + TE) + PEEP PEEP
K is a constant determined by the flow rate K is a constant determined by the flow rate and the rate of rise of the airway pressure and the rate of rise of the airway pressure curvecurve
COMPLIANCECOMPLIANCE
Compliance describes the elasticity or Compliance describes the elasticity or distensibility (eg lungs chest wall distensibility (eg lungs chest wall respiratory system) respiratory system)
compliance = volume pressure compliance = volume pressure
in neonates who have normal lungs in neonates who have normal lungs ranges from 0003 to 0006 Lcm H2O ranges from 0003 to 0006 Lcm H2O compared with compliance in neonates compared with compliance in neonates who have RDS which may be as low as who have RDS which may be as low as 00005 to 0001 Lcm H2O 00005 to 0001 Lcm H2O
RESISTANCERESISTANCEResistance describes the inherent Resistance describes the inherent capacity of the air conducting system (eg capacity of the air conducting system (eg airways endotracheal tube) and tissues to airways endotracheal tube) and tissues to oppose airflow and is expressed as the oppose airflow and is expressed as the change in pressure per unit change in change in pressure per unit change in flow flow
resistance = pressure flow resistance = pressure flow
Airway resistance depends onAirway resistance depends on
1)1) radii of the airways (total cross-sectional radii of the airways (total cross-sectional area) area)
2)2) length of airways length of airways
3)3) flow rate flow rate
4)4) density and viscosity of gas breathed density and viscosity of gas breathed
Resistance
Δ Pressure (cm H2O)
Δ Flow (Lsec)
Normal lungs 20-40 cm H2OLsec
RDS 20-40 cm H2OLsec
Intubated infant 50-150 cm H2OLsec
The time constant of the respiratory system is a measure of the time necessary The time constant of the respiratory system is a measure of the time necessary
for the alveolar pressure to reach 63 of the change in airway pressurefor the alveolar pressure to reach 63 of the change in airway pressure time constant = resistance x compliance time constant = resistance x compliance
For example the lungs of a healthy For example the lungs of a healthy neonate with a compliance of 0004 Lcm neonate with a compliance of 0004 Lcm H2O and a resistance of 30 cm H2OLs H2O and a resistance of 30 cm H2OLs have a time constant of 012 seconds have a time constant of 012 seconds
Carlo W A et al Pediatrics in Review 199920117-126e
CMVCMV
IMVIMV
SIMVSIMV
SIMV+VGSIMV+VG
IPPVIPPV
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Ventilatory TechniquesVentilatory Techniques
Pressure-Limited VentilationPressure-Limited Ventilation Pressure-Controlled VentilationPressure-Controlled Ventilation Volume VentilationVolume Ventilation Volume GuaranteeVolume Guarantee Pressure-Regulated Volume ControlPressure-Regulated Volume Control Volume-Assured Pressure SupportVolume-Assured Pressure Support Proportional Assist VentilationProportional Assist Ventilation
Ventilatory StylesVentilatory Styles
Conservative or ldquoGentlerdquo VentilationConservative or ldquoGentlerdquo Ventilation Nasopharyngeal SynchronizedNasopharyngeal Synchronized Intermittent Mandatory VentilationIntermittent Mandatory Ventilation
Goals of Mechanical VentilationGoals of Mechanical Ventilation
(1) adequate pulmonary gas ex-change (1) adequate pulmonary gas ex-change (2) (2) darrdarr risk of lung injury risk of lung injury (3) (3) darrdarr (WOB) (WOB) (4) optimize patient comfort (4) optimize patient comfort
Ideal Mode of VentilationIdeal Mode of Ventilation
Delivers a breath thatDelivers a breath that 1048707 1048707 Synchronizes with the patientrsquosSynchronizes with the patientrsquos spontaneous respiratory effortspontaneous respiratory effort 1048707 1048707 Maintains adequate and consistent tidalMaintains adequate and consistent tidal volume and minute ventilation at lowvolume and minute ventilation at low airway pressuresairway pressures 1048707 1048707 Responds to rapid changes in pulmonaryResponds to rapid changes in pulmonary mechanics or patient demandmechanics or patient demand 1048707 1048707 Provides the lowest possible WOBProvides the lowest possible WOB
Ideal Ventilator DesignIdeal Ventilator Design
1048707 1048707 Achieves all the important goals ofAchieves all the important goals of mechanical ventilationmechanical ventilation 1048707 1048707 Provides a variety of modes that canProvides a variety of modes that can ventilate even the most challengingventilate even the most challenging pulmonary diseasespulmonary diseases 1048707 1048707 Has monitoring capabilities to adequatelyHas monitoring capabilities to adequately assess ventilator and patient performanceassess ventilator and patient performance 1048707 1048707 Has safety features and alarms that offerHas safety features and alarms that offer lung protective strategieslung protective strategies
Carbon Dioxide (CO2) EliminationCarbon Dioxide (CO2) Elimination
alveolar minute ventilation =alveolar minute ventilation =
(tidal volume - dead space) x frequency (tidal volume - dead space) x frequency
Copyright copy1999 American Academy of Pediatrics
Carlo W A et al Pediatrics in Review 199920117-126e
Relationships among various ventilator-controlled (shaded circles) and
Copyright copy1999 American Academy of Pediatrics
Carlo W A et al Pediatrics in Review 199920117-126e
Determinants of oxygenation during pressure-limited
MAP = K (PIP - PEEP) (TITI + TE) + MAP = K (PIP - PEEP) (TITI + TE) + PEEP PEEP
K is a constant determined by the flow rate K is a constant determined by the flow rate and the rate of rise of the airway pressure and the rate of rise of the airway pressure curvecurve
COMPLIANCECOMPLIANCE
Compliance describes the elasticity or Compliance describes the elasticity or distensibility (eg lungs chest wall distensibility (eg lungs chest wall respiratory system) respiratory system)
compliance = volume pressure compliance = volume pressure
in neonates who have normal lungs in neonates who have normal lungs ranges from 0003 to 0006 Lcm H2O ranges from 0003 to 0006 Lcm H2O compared with compliance in neonates compared with compliance in neonates who have RDS which may be as low as who have RDS which may be as low as 00005 to 0001 Lcm H2O 00005 to 0001 Lcm H2O
RESISTANCERESISTANCEResistance describes the inherent Resistance describes the inherent capacity of the air conducting system (eg capacity of the air conducting system (eg airways endotracheal tube) and tissues to airways endotracheal tube) and tissues to oppose airflow and is expressed as the oppose airflow and is expressed as the change in pressure per unit change in change in pressure per unit change in flow flow
resistance = pressure flow resistance = pressure flow
Airway resistance depends onAirway resistance depends on
1)1) radii of the airways (total cross-sectional radii of the airways (total cross-sectional area) area)
2)2) length of airways length of airways
3)3) flow rate flow rate
4)4) density and viscosity of gas breathed density and viscosity of gas breathed
Resistance
Δ Pressure (cm H2O)
Δ Flow (Lsec)
Normal lungs 20-40 cm H2OLsec
RDS 20-40 cm H2OLsec
Intubated infant 50-150 cm H2OLsec
The time constant of the respiratory system is a measure of the time necessary The time constant of the respiratory system is a measure of the time necessary
for the alveolar pressure to reach 63 of the change in airway pressurefor the alveolar pressure to reach 63 of the change in airway pressure time constant = resistance x compliance time constant = resistance x compliance
For example the lungs of a healthy For example the lungs of a healthy neonate with a compliance of 0004 Lcm neonate with a compliance of 0004 Lcm H2O and a resistance of 30 cm H2OLs H2O and a resistance of 30 cm H2OLs have a time constant of 012 seconds have a time constant of 012 seconds
Carlo W A et al Pediatrics in Review 199920117-126e
CMVCMV
IMVIMV
SIMVSIMV
SIMV+VGSIMV+VG
IPPVIPPV
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Ventilatory StylesVentilatory Styles
Conservative or ldquoGentlerdquo VentilationConservative or ldquoGentlerdquo Ventilation Nasopharyngeal SynchronizedNasopharyngeal Synchronized Intermittent Mandatory VentilationIntermittent Mandatory Ventilation
Goals of Mechanical VentilationGoals of Mechanical Ventilation
(1) adequate pulmonary gas ex-change (1) adequate pulmonary gas ex-change (2) (2) darrdarr risk of lung injury risk of lung injury (3) (3) darrdarr (WOB) (WOB) (4) optimize patient comfort (4) optimize patient comfort
Ideal Mode of VentilationIdeal Mode of Ventilation
Delivers a breath thatDelivers a breath that 1048707 1048707 Synchronizes with the patientrsquosSynchronizes with the patientrsquos spontaneous respiratory effortspontaneous respiratory effort 1048707 1048707 Maintains adequate and consistent tidalMaintains adequate and consistent tidal volume and minute ventilation at lowvolume and minute ventilation at low airway pressuresairway pressures 1048707 1048707 Responds to rapid changes in pulmonaryResponds to rapid changes in pulmonary mechanics or patient demandmechanics or patient demand 1048707 1048707 Provides the lowest possible WOBProvides the lowest possible WOB
Ideal Ventilator DesignIdeal Ventilator Design
1048707 1048707 Achieves all the important goals ofAchieves all the important goals of mechanical ventilationmechanical ventilation 1048707 1048707 Provides a variety of modes that canProvides a variety of modes that can ventilate even the most challengingventilate even the most challenging pulmonary diseasespulmonary diseases 1048707 1048707 Has monitoring capabilities to adequatelyHas monitoring capabilities to adequately assess ventilator and patient performanceassess ventilator and patient performance 1048707 1048707 Has safety features and alarms that offerHas safety features and alarms that offer lung protective strategieslung protective strategies
Carbon Dioxide (CO2) EliminationCarbon Dioxide (CO2) Elimination
alveolar minute ventilation =alveolar minute ventilation =
(tidal volume - dead space) x frequency (tidal volume - dead space) x frequency
Copyright copy1999 American Academy of Pediatrics
Carlo W A et al Pediatrics in Review 199920117-126e
Relationships among various ventilator-controlled (shaded circles) and
Copyright copy1999 American Academy of Pediatrics
Carlo W A et al Pediatrics in Review 199920117-126e
Determinants of oxygenation during pressure-limited
MAP = K (PIP - PEEP) (TITI + TE) + MAP = K (PIP - PEEP) (TITI + TE) + PEEP PEEP
K is a constant determined by the flow rate K is a constant determined by the flow rate and the rate of rise of the airway pressure and the rate of rise of the airway pressure curvecurve
COMPLIANCECOMPLIANCE
Compliance describes the elasticity or Compliance describes the elasticity or distensibility (eg lungs chest wall distensibility (eg lungs chest wall respiratory system) respiratory system)
compliance = volume pressure compliance = volume pressure
in neonates who have normal lungs in neonates who have normal lungs ranges from 0003 to 0006 Lcm H2O ranges from 0003 to 0006 Lcm H2O compared with compliance in neonates compared with compliance in neonates who have RDS which may be as low as who have RDS which may be as low as 00005 to 0001 Lcm H2O 00005 to 0001 Lcm H2O
RESISTANCERESISTANCEResistance describes the inherent Resistance describes the inherent capacity of the air conducting system (eg capacity of the air conducting system (eg airways endotracheal tube) and tissues to airways endotracheal tube) and tissues to oppose airflow and is expressed as the oppose airflow and is expressed as the change in pressure per unit change in change in pressure per unit change in flow flow
resistance = pressure flow resistance = pressure flow
Airway resistance depends onAirway resistance depends on
1)1) radii of the airways (total cross-sectional radii of the airways (total cross-sectional area) area)
2)2) length of airways length of airways
3)3) flow rate flow rate
4)4) density and viscosity of gas breathed density and viscosity of gas breathed
Resistance
Δ Pressure (cm H2O)
Δ Flow (Lsec)
Normal lungs 20-40 cm H2OLsec
RDS 20-40 cm H2OLsec
Intubated infant 50-150 cm H2OLsec
The time constant of the respiratory system is a measure of the time necessary The time constant of the respiratory system is a measure of the time necessary
for the alveolar pressure to reach 63 of the change in airway pressurefor the alveolar pressure to reach 63 of the change in airway pressure time constant = resistance x compliance time constant = resistance x compliance
For example the lungs of a healthy For example the lungs of a healthy neonate with a compliance of 0004 Lcm neonate with a compliance of 0004 Lcm H2O and a resistance of 30 cm H2OLs H2O and a resistance of 30 cm H2OLs have a time constant of 012 seconds have a time constant of 012 seconds
Carlo W A et al Pediatrics in Review 199920117-126e
CMVCMV
IMVIMV
SIMVSIMV
SIMV+VGSIMV+VG
IPPVIPPV
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Goals of Mechanical VentilationGoals of Mechanical Ventilation
(1) adequate pulmonary gas ex-change (1) adequate pulmonary gas ex-change (2) (2) darrdarr risk of lung injury risk of lung injury (3) (3) darrdarr (WOB) (WOB) (4) optimize patient comfort (4) optimize patient comfort
Ideal Mode of VentilationIdeal Mode of Ventilation
Delivers a breath thatDelivers a breath that 1048707 1048707 Synchronizes with the patientrsquosSynchronizes with the patientrsquos spontaneous respiratory effortspontaneous respiratory effort 1048707 1048707 Maintains adequate and consistent tidalMaintains adequate and consistent tidal volume and minute ventilation at lowvolume and minute ventilation at low airway pressuresairway pressures 1048707 1048707 Responds to rapid changes in pulmonaryResponds to rapid changes in pulmonary mechanics or patient demandmechanics or patient demand 1048707 1048707 Provides the lowest possible WOBProvides the lowest possible WOB
Ideal Ventilator DesignIdeal Ventilator Design
1048707 1048707 Achieves all the important goals ofAchieves all the important goals of mechanical ventilationmechanical ventilation 1048707 1048707 Provides a variety of modes that canProvides a variety of modes that can ventilate even the most challengingventilate even the most challenging pulmonary diseasespulmonary diseases 1048707 1048707 Has monitoring capabilities to adequatelyHas monitoring capabilities to adequately assess ventilator and patient performanceassess ventilator and patient performance 1048707 1048707 Has safety features and alarms that offerHas safety features and alarms that offer lung protective strategieslung protective strategies
Carbon Dioxide (CO2) EliminationCarbon Dioxide (CO2) Elimination
alveolar minute ventilation =alveolar minute ventilation =
(tidal volume - dead space) x frequency (tidal volume - dead space) x frequency
Copyright copy1999 American Academy of Pediatrics
Carlo W A et al Pediatrics in Review 199920117-126e
Relationships among various ventilator-controlled (shaded circles) and
Copyright copy1999 American Academy of Pediatrics
Carlo W A et al Pediatrics in Review 199920117-126e
Determinants of oxygenation during pressure-limited
MAP = K (PIP - PEEP) (TITI + TE) + MAP = K (PIP - PEEP) (TITI + TE) + PEEP PEEP
K is a constant determined by the flow rate K is a constant determined by the flow rate and the rate of rise of the airway pressure and the rate of rise of the airway pressure curvecurve
COMPLIANCECOMPLIANCE
Compliance describes the elasticity or Compliance describes the elasticity or distensibility (eg lungs chest wall distensibility (eg lungs chest wall respiratory system) respiratory system)
compliance = volume pressure compliance = volume pressure
in neonates who have normal lungs in neonates who have normal lungs ranges from 0003 to 0006 Lcm H2O ranges from 0003 to 0006 Lcm H2O compared with compliance in neonates compared with compliance in neonates who have RDS which may be as low as who have RDS which may be as low as 00005 to 0001 Lcm H2O 00005 to 0001 Lcm H2O
RESISTANCERESISTANCEResistance describes the inherent Resistance describes the inherent capacity of the air conducting system (eg capacity of the air conducting system (eg airways endotracheal tube) and tissues to airways endotracheal tube) and tissues to oppose airflow and is expressed as the oppose airflow and is expressed as the change in pressure per unit change in change in pressure per unit change in flow flow
resistance = pressure flow resistance = pressure flow
Airway resistance depends onAirway resistance depends on
1)1) radii of the airways (total cross-sectional radii of the airways (total cross-sectional area) area)
2)2) length of airways length of airways
3)3) flow rate flow rate
4)4) density and viscosity of gas breathed density and viscosity of gas breathed
Resistance
Δ Pressure (cm H2O)
Δ Flow (Lsec)
Normal lungs 20-40 cm H2OLsec
RDS 20-40 cm H2OLsec
Intubated infant 50-150 cm H2OLsec
The time constant of the respiratory system is a measure of the time necessary The time constant of the respiratory system is a measure of the time necessary
for the alveolar pressure to reach 63 of the change in airway pressurefor the alveolar pressure to reach 63 of the change in airway pressure time constant = resistance x compliance time constant = resistance x compliance
For example the lungs of a healthy For example the lungs of a healthy neonate with a compliance of 0004 Lcm neonate with a compliance of 0004 Lcm H2O and a resistance of 30 cm H2OLs H2O and a resistance of 30 cm H2OLs have a time constant of 012 seconds have a time constant of 012 seconds
Carlo W A et al Pediatrics in Review 199920117-126e
CMVCMV
IMVIMV
SIMVSIMV
SIMV+VGSIMV+VG
IPPVIPPV
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Ideal Mode of VentilationIdeal Mode of Ventilation
Delivers a breath thatDelivers a breath that 1048707 1048707 Synchronizes with the patientrsquosSynchronizes with the patientrsquos spontaneous respiratory effortspontaneous respiratory effort 1048707 1048707 Maintains adequate and consistent tidalMaintains adequate and consistent tidal volume and minute ventilation at lowvolume and minute ventilation at low airway pressuresairway pressures 1048707 1048707 Responds to rapid changes in pulmonaryResponds to rapid changes in pulmonary mechanics or patient demandmechanics or patient demand 1048707 1048707 Provides the lowest possible WOBProvides the lowest possible WOB
Ideal Ventilator DesignIdeal Ventilator Design
1048707 1048707 Achieves all the important goals ofAchieves all the important goals of mechanical ventilationmechanical ventilation 1048707 1048707 Provides a variety of modes that canProvides a variety of modes that can ventilate even the most challengingventilate even the most challenging pulmonary diseasespulmonary diseases 1048707 1048707 Has monitoring capabilities to adequatelyHas monitoring capabilities to adequately assess ventilator and patient performanceassess ventilator and patient performance 1048707 1048707 Has safety features and alarms that offerHas safety features and alarms that offer lung protective strategieslung protective strategies
Carbon Dioxide (CO2) EliminationCarbon Dioxide (CO2) Elimination
alveolar minute ventilation =alveolar minute ventilation =
(tidal volume - dead space) x frequency (tidal volume - dead space) x frequency
Copyright copy1999 American Academy of Pediatrics
Carlo W A et al Pediatrics in Review 199920117-126e
Relationships among various ventilator-controlled (shaded circles) and
Copyright copy1999 American Academy of Pediatrics
Carlo W A et al Pediatrics in Review 199920117-126e
Determinants of oxygenation during pressure-limited
MAP = K (PIP - PEEP) (TITI + TE) + MAP = K (PIP - PEEP) (TITI + TE) + PEEP PEEP
K is a constant determined by the flow rate K is a constant determined by the flow rate and the rate of rise of the airway pressure and the rate of rise of the airway pressure curvecurve
COMPLIANCECOMPLIANCE
Compliance describes the elasticity or Compliance describes the elasticity or distensibility (eg lungs chest wall distensibility (eg lungs chest wall respiratory system) respiratory system)
compliance = volume pressure compliance = volume pressure
in neonates who have normal lungs in neonates who have normal lungs ranges from 0003 to 0006 Lcm H2O ranges from 0003 to 0006 Lcm H2O compared with compliance in neonates compared with compliance in neonates who have RDS which may be as low as who have RDS which may be as low as 00005 to 0001 Lcm H2O 00005 to 0001 Lcm H2O
RESISTANCERESISTANCEResistance describes the inherent Resistance describes the inherent capacity of the air conducting system (eg capacity of the air conducting system (eg airways endotracheal tube) and tissues to airways endotracheal tube) and tissues to oppose airflow and is expressed as the oppose airflow and is expressed as the change in pressure per unit change in change in pressure per unit change in flow flow
resistance = pressure flow resistance = pressure flow
Airway resistance depends onAirway resistance depends on
1)1) radii of the airways (total cross-sectional radii of the airways (total cross-sectional area) area)
2)2) length of airways length of airways
3)3) flow rate flow rate
4)4) density and viscosity of gas breathed density and viscosity of gas breathed
Resistance
Δ Pressure (cm H2O)
Δ Flow (Lsec)
Normal lungs 20-40 cm H2OLsec
RDS 20-40 cm H2OLsec
Intubated infant 50-150 cm H2OLsec
The time constant of the respiratory system is a measure of the time necessary The time constant of the respiratory system is a measure of the time necessary
for the alveolar pressure to reach 63 of the change in airway pressurefor the alveolar pressure to reach 63 of the change in airway pressure time constant = resistance x compliance time constant = resistance x compliance
For example the lungs of a healthy For example the lungs of a healthy neonate with a compliance of 0004 Lcm neonate with a compliance of 0004 Lcm H2O and a resistance of 30 cm H2OLs H2O and a resistance of 30 cm H2OLs have a time constant of 012 seconds have a time constant of 012 seconds
Carlo W A et al Pediatrics in Review 199920117-126e
CMVCMV
IMVIMV
SIMVSIMV
SIMV+VGSIMV+VG
IPPVIPPV
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Ideal Ventilator DesignIdeal Ventilator Design
1048707 1048707 Achieves all the important goals ofAchieves all the important goals of mechanical ventilationmechanical ventilation 1048707 1048707 Provides a variety of modes that canProvides a variety of modes that can ventilate even the most challengingventilate even the most challenging pulmonary diseasespulmonary diseases 1048707 1048707 Has monitoring capabilities to adequatelyHas monitoring capabilities to adequately assess ventilator and patient performanceassess ventilator and patient performance 1048707 1048707 Has safety features and alarms that offerHas safety features and alarms that offer lung protective strategieslung protective strategies
Carbon Dioxide (CO2) EliminationCarbon Dioxide (CO2) Elimination
alveolar minute ventilation =alveolar minute ventilation =
(tidal volume - dead space) x frequency (tidal volume - dead space) x frequency
Copyright copy1999 American Academy of Pediatrics
Carlo W A et al Pediatrics in Review 199920117-126e
Relationships among various ventilator-controlled (shaded circles) and
Copyright copy1999 American Academy of Pediatrics
Carlo W A et al Pediatrics in Review 199920117-126e
Determinants of oxygenation during pressure-limited
MAP = K (PIP - PEEP) (TITI + TE) + MAP = K (PIP - PEEP) (TITI + TE) + PEEP PEEP
K is a constant determined by the flow rate K is a constant determined by the flow rate and the rate of rise of the airway pressure and the rate of rise of the airway pressure curvecurve
COMPLIANCECOMPLIANCE
Compliance describes the elasticity or Compliance describes the elasticity or distensibility (eg lungs chest wall distensibility (eg lungs chest wall respiratory system) respiratory system)
compliance = volume pressure compliance = volume pressure
in neonates who have normal lungs in neonates who have normal lungs ranges from 0003 to 0006 Lcm H2O ranges from 0003 to 0006 Lcm H2O compared with compliance in neonates compared with compliance in neonates who have RDS which may be as low as who have RDS which may be as low as 00005 to 0001 Lcm H2O 00005 to 0001 Lcm H2O
RESISTANCERESISTANCEResistance describes the inherent Resistance describes the inherent capacity of the air conducting system (eg capacity of the air conducting system (eg airways endotracheal tube) and tissues to airways endotracheal tube) and tissues to oppose airflow and is expressed as the oppose airflow and is expressed as the change in pressure per unit change in change in pressure per unit change in flow flow
resistance = pressure flow resistance = pressure flow
Airway resistance depends onAirway resistance depends on
1)1) radii of the airways (total cross-sectional radii of the airways (total cross-sectional area) area)
2)2) length of airways length of airways
3)3) flow rate flow rate
4)4) density and viscosity of gas breathed density and viscosity of gas breathed
Resistance
Δ Pressure (cm H2O)
Δ Flow (Lsec)
Normal lungs 20-40 cm H2OLsec
RDS 20-40 cm H2OLsec
Intubated infant 50-150 cm H2OLsec
The time constant of the respiratory system is a measure of the time necessary The time constant of the respiratory system is a measure of the time necessary
for the alveolar pressure to reach 63 of the change in airway pressurefor the alveolar pressure to reach 63 of the change in airway pressure time constant = resistance x compliance time constant = resistance x compliance
For example the lungs of a healthy For example the lungs of a healthy neonate with a compliance of 0004 Lcm neonate with a compliance of 0004 Lcm H2O and a resistance of 30 cm H2OLs H2O and a resistance of 30 cm H2OLs have a time constant of 012 seconds have a time constant of 012 seconds
Carlo W A et al Pediatrics in Review 199920117-126e
CMVCMV
IMVIMV
SIMVSIMV
SIMV+VGSIMV+VG
IPPVIPPV
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Carbon Dioxide (CO2) EliminationCarbon Dioxide (CO2) Elimination
alveolar minute ventilation =alveolar minute ventilation =
(tidal volume - dead space) x frequency (tidal volume - dead space) x frequency
Copyright copy1999 American Academy of Pediatrics
Carlo W A et al Pediatrics in Review 199920117-126e
Relationships among various ventilator-controlled (shaded circles) and
Copyright copy1999 American Academy of Pediatrics
Carlo W A et al Pediatrics in Review 199920117-126e
Determinants of oxygenation during pressure-limited
MAP = K (PIP - PEEP) (TITI + TE) + MAP = K (PIP - PEEP) (TITI + TE) + PEEP PEEP
K is a constant determined by the flow rate K is a constant determined by the flow rate and the rate of rise of the airway pressure and the rate of rise of the airway pressure curvecurve
COMPLIANCECOMPLIANCE
Compliance describes the elasticity or Compliance describes the elasticity or distensibility (eg lungs chest wall distensibility (eg lungs chest wall respiratory system) respiratory system)
compliance = volume pressure compliance = volume pressure
in neonates who have normal lungs in neonates who have normal lungs ranges from 0003 to 0006 Lcm H2O ranges from 0003 to 0006 Lcm H2O compared with compliance in neonates compared with compliance in neonates who have RDS which may be as low as who have RDS which may be as low as 00005 to 0001 Lcm H2O 00005 to 0001 Lcm H2O
RESISTANCERESISTANCEResistance describes the inherent Resistance describes the inherent capacity of the air conducting system (eg capacity of the air conducting system (eg airways endotracheal tube) and tissues to airways endotracheal tube) and tissues to oppose airflow and is expressed as the oppose airflow and is expressed as the change in pressure per unit change in change in pressure per unit change in flow flow
resistance = pressure flow resistance = pressure flow
Airway resistance depends onAirway resistance depends on
1)1) radii of the airways (total cross-sectional radii of the airways (total cross-sectional area) area)
2)2) length of airways length of airways
3)3) flow rate flow rate
4)4) density and viscosity of gas breathed density and viscosity of gas breathed
Resistance
Δ Pressure (cm H2O)
Δ Flow (Lsec)
Normal lungs 20-40 cm H2OLsec
RDS 20-40 cm H2OLsec
Intubated infant 50-150 cm H2OLsec
The time constant of the respiratory system is a measure of the time necessary The time constant of the respiratory system is a measure of the time necessary
for the alveolar pressure to reach 63 of the change in airway pressurefor the alveolar pressure to reach 63 of the change in airway pressure time constant = resistance x compliance time constant = resistance x compliance
For example the lungs of a healthy For example the lungs of a healthy neonate with a compliance of 0004 Lcm neonate with a compliance of 0004 Lcm H2O and a resistance of 30 cm H2OLs H2O and a resistance of 30 cm H2OLs have a time constant of 012 seconds have a time constant of 012 seconds
Carlo W A et al Pediatrics in Review 199920117-126e
CMVCMV
IMVIMV
SIMVSIMV
SIMV+VGSIMV+VG
IPPVIPPV
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Copyright copy1999 American Academy of Pediatrics
Carlo W A et al Pediatrics in Review 199920117-126e
Relationships among various ventilator-controlled (shaded circles) and
Copyright copy1999 American Academy of Pediatrics
Carlo W A et al Pediatrics in Review 199920117-126e
Determinants of oxygenation during pressure-limited
MAP = K (PIP - PEEP) (TITI + TE) + MAP = K (PIP - PEEP) (TITI + TE) + PEEP PEEP
K is a constant determined by the flow rate K is a constant determined by the flow rate and the rate of rise of the airway pressure and the rate of rise of the airway pressure curvecurve
COMPLIANCECOMPLIANCE
Compliance describes the elasticity or Compliance describes the elasticity or distensibility (eg lungs chest wall distensibility (eg lungs chest wall respiratory system) respiratory system)
compliance = volume pressure compliance = volume pressure
in neonates who have normal lungs in neonates who have normal lungs ranges from 0003 to 0006 Lcm H2O ranges from 0003 to 0006 Lcm H2O compared with compliance in neonates compared with compliance in neonates who have RDS which may be as low as who have RDS which may be as low as 00005 to 0001 Lcm H2O 00005 to 0001 Lcm H2O
RESISTANCERESISTANCEResistance describes the inherent Resistance describes the inherent capacity of the air conducting system (eg capacity of the air conducting system (eg airways endotracheal tube) and tissues to airways endotracheal tube) and tissues to oppose airflow and is expressed as the oppose airflow and is expressed as the change in pressure per unit change in change in pressure per unit change in flow flow
resistance = pressure flow resistance = pressure flow
Airway resistance depends onAirway resistance depends on
1)1) radii of the airways (total cross-sectional radii of the airways (total cross-sectional area) area)
2)2) length of airways length of airways
3)3) flow rate flow rate
4)4) density and viscosity of gas breathed density and viscosity of gas breathed
Resistance
Δ Pressure (cm H2O)
Δ Flow (Lsec)
Normal lungs 20-40 cm H2OLsec
RDS 20-40 cm H2OLsec
Intubated infant 50-150 cm H2OLsec
The time constant of the respiratory system is a measure of the time necessary The time constant of the respiratory system is a measure of the time necessary
for the alveolar pressure to reach 63 of the change in airway pressurefor the alveolar pressure to reach 63 of the change in airway pressure time constant = resistance x compliance time constant = resistance x compliance
For example the lungs of a healthy For example the lungs of a healthy neonate with a compliance of 0004 Lcm neonate with a compliance of 0004 Lcm H2O and a resistance of 30 cm H2OLs H2O and a resistance of 30 cm H2OLs have a time constant of 012 seconds have a time constant of 012 seconds
Carlo W A et al Pediatrics in Review 199920117-126e
CMVCMV
IMVIMV
SIMVSIMV
SIMV+VGSIMV+VG
IPPVIPPV
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Copyright copy1999 American Academy of Pediatrics
Carlo W A et al Pediatrics in Review 199920117-126e
Determinants of oxygenation during pressure-limited
MAP = K (PIP - PEEP) (TITI + TE) + MAP = K (PIP - PEEP) (TITI + TE) + PEEP PEEP
K is a constant determined by the flow rate K is a constant determined by the flow rate and the rate of rise of the airway pressure and the rate of rise of the airway pressure curvecurve
COMPLIANCECOMPLIANCE
Compliance describes the elasticity or Compliance describes the elasticity or distensibility (eg lungs chest wall distensibility (eg lungs chest wall respiratory system) respiratory system)
compliance = volume pressure compliance = volume pressure
in neonates who have normal lungs in neonates who have normal lungs ranges from 0003 to 0006 Lcm H2O ranges from 0003 to 0006 Lcm H2O compared with compliance in neonates compared with compliance in neonates who have RDS which may be as low as who have RDS which may be as low as 00005 to 0001 Lcm H2O 00005 to 0001 Lcm H2O
RESISTANCERESISTANCEResistance describes the inherent Resistance describes the inherent capacity of the air conducting system (eg capacity of the air conducting system (eg airways endotracheal tube) and tissues to airways endotracheal tube) and tissues to oppose airflow and is expressed as the oppose airflow and is expressed as the change in pressure per unit change in change in pressure per unit change in flow flow
resistance = pressure flow resistance = pressure flow
Airway resistance depends onAirway resistance depends on
1)1) radii of the airways (total cross-sectional radii of the airways (total cross-sectional area) area)
2)2) length of airways length of airways
3)3) flow rate flow rate
4)4) density and viscosity of gas breathed density and viscosity of gas breathed
Resistance
Δ Pressure (cm H2O)
Δ Flow (Lsec)
Normal lungs 20-40 cm H2OLsec
RDS 20-40 cm H2OLsec
Intubated infant 50-150 cm H2OLsec
The time constant of the respiratory system is a measure of the time necessary The time constant of the respiratory system is a measure of the time necessary
for the alveolar pressure to reach 63 of the change in airway pressurefor the alveolar pressure to reach 63 of the change in airway pressure time constant = resistance x compliance time constant = resistance x compliance
For example the lungs of a healthy For example the lungs of a healthy neonate with a compliance of 0004 Lcm neonate with a compliance of 0004 Lcm H2O and a resistance of 30 cm H2OLs H2O and a resistance of 30 cm H2OLs have a time constant of 012 seconds have a time constant of 012 seconds
Carlo W A et al Pediatrics in Review 199920117-126e
CMVCMV
IMVIMV
SIMVSIMV
SIMV+VGSIMV+VG
IPPVIPPV
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
MAP = K (PIP - PEEP) (TITI + TE) + MAP = K (PIP - PEEP) (TITI + TE) + PEEP PEEP
K is a constant determined by the flow rate K is a constant determined by the flow rate and the rate of rise of the airway pressure and the rate of rise of the airway pressure curvecurve
COMPLIANCECOMPLIANCE
Compliance describes the elasticity or Compliance describes the elasticity or distensibility (eg lungs chest wall distensibility (eg lungs chest wall respiratory system) respiratory system)
compliance = volume pressure compliance = volume pressure
in neonates who have normal lungs in neonates who have normal lungs ranges from 0003 to 0006 Lcm H2O ranges from 0003 to 0006 Lcm H2O compared with compliance in neonates compared with compliance in neonates who have RDS which may be as low as who have RDS which may be as low as 00005 to 0001 Lcm H2O 00005 to 0001 Lcm H2O
RESISTANCERESISTANCEResistance describes the inherent Resistance describes the inherent capacity of the air conducting system (eg capacity of the air conducting system (eg airways endotracheal tube) and tissues to airways endotracheal tube) and tissues to oppose airflow and is expressed as the oppose airflow and is expressed as the change in pressure per unit change in change in pressure per unit change in flow flow
resistance = pressure flow resistance = pressure flow
Airway resistance depends onAirway resistance depends on
1)1) radii of the airways (total cross-sectional radii of the airways (total cross-sectional area) area)
2)2) length of airways length of airways
3)3) flow rate flow rate
4)4) density and viscosity of gas breathed density and viscosity of gas breathed
Resistance
Δ Pressure (cm H2O)
Δ Flow (Lsec)
Normal lungs 20-40 cm H2OLsec
RDS 20-40 cm H2OLsec
Intubated infant 50-150 cm H2OLsec
The time constant of the respiratory system is a measure of the time necessary The time constant of the respiratory system is a measure of the time necessary
for the alveolar pressure to reach 63 of the change in airway pressurefor the alveolar pressure to reach 63 of the change in airway pressure time constant = resistance x compliance time constant = resistance x compliance
For example the lungs of a healthy For example the lungs of a healthy neonate with a compliance of 0004 Lcm neonate with a compliance of 0004 Lcm H2O and a resistance of 30 cm H2OLs H2O and a resistance of 30 cm H2OLs have a time constant of 012 seconds have a time constant of 012 seconds
Carlo W A et al Pediatrics in Review 199920117-126e
CMVCMV
IMVIMV
SIMVSIMV
SIMV+VGSIMV+VG
IPPVIPPV
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
COMPLIANCECOMPLIANCE
Compliance describes the elasticity or Compliance describes the elasticity or distensibility (eg lungs chest wall distensibility (eg lungs chest wall respiratory system) respiratory system)
compliance = volume pressure compliance = volume pressure
in neonates who have normal lungs in neonates who have normal lungs ranges from 0003 to 0006 Lcm H2O ranges from 0003 to 0006 Lcm H2O compared with compliance in neonates compared with compliance in neonates who have RDS which may be as low as who have RDS which may be as low as 00005 to 0001 Lcm H2O 00005 to 0001 Lcm H2O
RESISTANCERESISTANCEResistance describes the inherent Resistance describes the inherent capacity of the air conducting system (eg capacity of the air conducting system (eg airways endotracheal tube) and tissues to airways endotracheal tube) and tissues to oppose airflow and is expressed as the oppose airflow and is expressed as the change in pressure per unit change in change in pressure per unit change in flow flow
resistance = pressure flow resistance = pressure flow
Airway resistance depends onAirway resistance depends on
1)1) radii of the airways (total cross-sectional radii of the airways (total cross-sectional area) area)
2)2) length of airways length of airways
3)3) flow rate flow rate
4)4) density and viscosity of gas breathed density and viscosity of gas breathed
Resistance
Δ Pressure (cm H2O)
Δ Flow (Lsec)
Normal lungs 20-40 cm H2OLsec
RDS 20-40 cm H2OLsec
Intubated infant 50-150 cm H2OLsec
The time constant of the respiratory system is a measure of the time necessary The time constant of the respiratory system is a measure of the time necessary
for the alveolar pressure to reach 63 of the change in airway pressurefor the alveolar pressure to reach 63 of the change in airway pressure time constant = resistance x compliance time constant = resistance x compliance
For example the lungs of a healthy For example the lungs of a healthy neonate with a compliance of 0004 Lcm neonate with a compliance of 0004 Lcm H2O and a resistance of 30 cm H2OLs H2O and a resistance of 30 cm H2OLs have a time constant of 012 seconds have a time constant of 012 seconds
Carlo W A et al Pediatrics in Review 199920117-126e
CMVCMV
IMVIMV
SIMVSIMV
SIMV+VGSIMV+VG
IPPVIPPV
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
in neonates who have normal lungs in neonates who have normal lungs ranges from 0003 to 0006 Lcm H2O ranges from 0003 to 0006 Lcm H2O compared with compliance in neonates compared with compliance in neonates who have RDS which may be as low as who have RDS which may be as low as 00005 to 0001 Lcm H2O 00005 to 0001 Lcm H2O
RESISTANCERESISTANCEResistance describes the inherent Resistance describes the inherent capacity of the air conducting system (eg capacity of the air conducting system (eg airways endotracheal tube) and tissues to airways endotracheal tube) and tissues to oppose airflow and is expressed as the oppose airflow and is expressed as the change in pressure per unit change in change in pressure per unit change in flow flow
resistance = pressure flow resistance = pressure flow
Airway resistance depends onAirway resistance depends on
1)1) radii of the airways (total cross-sectional radii of the airways (total cross-sectional area) area)
2)2) length of airways length of airways
3)3) flow rate flow rate
4)4) density and viscosity of gas breathed density and viscosity of gas breathed
Resistance
Δ Pressure (cm H2O)
Δ Flow (Lsec)
Normal lungs 20-40 cm H2OLsec
RDS 20-40 cm H2OLsec
Intubated infant 50-150 cm H2OLsec
The time constant of the respiratory system is a measure of the time necessary The time constant of the respiratory system is a measure of the time necessary
for the alveolar pressure to reach 63 of the change in airway pressurefor the alveolar pressure to reach 63 of the change in airway pressure time constant = resistance x compliance time constant = resistance x compliance
For example the lungs of a healthy For example the lungs of a healthy neonate with a compliance of 0004 Lcm neonate with a compliance of 0004 Lcm H2O and a resistance of 30 cm H2OLs H2O and a resistance of 30 cm H2OLs have a time constant of 012 seconds have a time constant of 012 seconds
Carlo W A et al Pediatrics in Review 199920117-126e
CMVCMV
IMVIMV
SIMVSIMV
SIMV+VGSIMV+VG
IPPVIPPV
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
RESISTANCERESISTANCEResistance describes the inherent Resistance describes the inherent capacity of the air conducting system (eg capacity of the air conducting system (eg airways endotracheal tube) and tissues to airways endotracheal tube) and tissues to oppose airflow and is expressed as the oppose airflow and is expressed as the change in pressure per unit change in change in pressure per unit change in flow flow
resistance = pressure flow resistance = pressure flow
Airway resistance depends onAirway resistance depends on
1)1) radii of the airways (total cross-sectional radii of the airways (total cross-sectional area) area)
2)2) length of airways length of airways
3)3) flow rate flow rate
4)4) density and viscosity of gas breathed density and viscosity of gas breathed
Resistance
Δ Pressure (cm H2O)
Δ Flow (Lsec)
Normal lungs 20-40 cm H2OLsec
RDS 20-40 cm H2OLsec
Intubated infant 50-150 cm H2OLsec
The time constant of the respiratory system is a measure of the time necessary The time constant of the respiratory system is a measure of the time necessary
for the alveolar pressure to reach 63 of the change in airway pressurefor the alveolar pressure to reach 63 of the change in airway pressure time constant = resistance x compliance time constant = resistance x compliance
For example the lungs of a healthy For example the lungs of a healthy neonate with a compliance of 0004 Lcm neonate with a compliance of 0004 Lcm H2O and a resistance of 30 cm H2OLs H2O and a resistance of 30 cm H2OLs have a time constant of 012 seconds have a time constant of 012 seconds
Carlo W A et al Pediatrics in Review 199920117-126e
CMVCMV
IMVIMV
SIMVSIMV
SIMV+VGSIMV+VG
IPPVIPPV
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Airway resistance depends onAirway resistance depends on
1)1) radii of the airways (total cross-sectional radii of the airways (total cross-sectional area) area)
2)2) length of airways length of airways
3)3) flow rate flow rate
4)4) density and viscosity of gas breathed density and viscosity of gas breathed
Resistance
Δ Pressure (cm H2O)
Δ Flow (Lsec)
Normal lungs 20-40 cm H2OLsec
RDS 20-40 cm H2OLsec
Intubated infant 50-150 cm H2OLsec
The time constant of the respiratory system is a measure of the time necessary The time constant of the respiratory system is a measure of the time necessary
for the alveolar pressure to reach 63 of the change in airway pressurefor the alveolar pressure to reach 63 of the change in airway pressure time constant = resistance x compliance time constant = resistance x compliance
For example the lungs of a healthy For example the lungs of a healthy neonate with a compliance of 0004 Lcm neonate with a compliance of 0004 Lcm H2O and a resistance of 30 cm H2OLs H2O and a resistance of 30 cm H2OLs have a time constant of 012 seconds have a time constant of 012 seconds
Carlo W A et al Pediatrics in Review 199920117-126e
CMVCMV
IMVIMV
SIMVSIMV
SIMV+VGSIMV+VG
IPPVIPPV
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Resistance
Δ Pressure (cm H2O)
Δ Flow (Lsec)
Normal lungs 20-40 cm H2OLsec
RDS 20-40 cm H2OLsec
Intubated infant 50-150 cm H2OLsec
The time constant of the respiratory system is a measure of the time necessary The time constant of the respiratory system is a measure of the time necessary
for the alveolar pressure to reach 63 of the change in airway pressurefor the alveolar pressure to reach 63 of the change in airway pressure time constant = resistance x compliance time constant = resistance x compliance
For example the lungs of a healthy For example the lungs of a healthy neonate with a compliance of 0004 Lcm neonate with a compliance of 0004 Lcm H2O and a resistance of 30 cm H2OLs H2O and a resistance of 30 cm H2OLs have a time constant of 012 seconds have a time constant of 012 seconds
Carlo W A et al Pediatrics in Review 199920117-126e
CMVCMV
IMVIMV
SIMVSIMV
SIMV+VGSIMV+VG
IPPVIPPV
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
The time constant of the respiratory system is a measure of the time necessary The time constant of the respiratory system is a measure of the time necessary
for the alveolar pressure to reach 63 of the change in airway pressurefor the alveolar pressure to reach 63 of the change in airway pressure time constant = resistance x compliance time constant = resistance x compliance
For example the lungs of a healthy For example the lungs of a healthy neonate with a compliance of 0004 Lcm neonate with a compliance of 0004 Lcm H2O and a resistance of 30 cm H2OLs H2O and a resistance of 30 cm H2OLs have a time constant of 012 seconds have a time constant of 012 seconds
Carlo W A et al Pediatrics in Review 199920117-126e
CMVCMV
IMVIMV
SIMVSIMV
SIMV+VGSIMV+VG
IPPVIPPV
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Carlo W A et al Pediatrics in Review 199920117-126e
CMVCMV
IMVIMV
SIMVSIMV
SIMV+VGSIMV+VG
IPPVIPPV
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
CMVCMV
IMVIMV
SIMVSIMV
SIMV+VGSIMV+VG
IPPVIPPV
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
IMVIMV
SIMVSIMV
SIMV+VGSIMV+VG
IPPVIPPV
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
SIMVSIMV
SIMV+VGSIMV+VG
IPPVIPPV
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
SIMV+VGSIMV+VG
IPPVIPPV
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
IPPVIPPV
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
SIPPV ACSIPPV AC
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
SIPPV+VGSIPPV+VG
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
PSVPSV
Pressure support ventilation (PSV) is Pressure support ventilation (PSV) is a mode where flow cycling is used to a mode where flow cycling is used to assist every spontaneous inspiratory assist every spontaneous inspiratory effort and terminate the mechanical effort and terminate the mechanical breath as the spontaneous breath as the spontaneous inspiration ends or inflation is inspiration ends or inflation is completedcompleted
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Synchronous breath termination gives the Synchronous breath termination gives the infant greater control over the frequency and infant greater control over the frequency and duration of inspirationduration of inspiration
while the support pressure compensates for while the support pressure compensates for instrumental and disease induced loadsinstrumental and disease induced loads
In the event of apnea back-up IMV ensures In the event of apnea back-up IMV ensures ventilationventilation
In some ventilators PSV can be combined In some ventilators PSV can be combined with a low SIMV ratewith a low SIMV rate
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
PROPORTIONAL ASSIST PROPORTIONAL ASSIST VENTILATIONVENTILATION
PAVPAV proportional assist ventilation matches the onset and proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support duration of both inspiratory and expiratory support Furthermore ventilatory support is in proportion to the Furthermore ventilatory support is in proportion to the volume and flow of the spontaneous breath Thus the volume and flow of the spontaneous breath Thus the ventilator can decrease the elastic or resistive work of ventilator can decrease the elastic or resistive work of breathing selectively The magnitude of the support can breathing selectively The magnitude of the support can be adjusted according to the patientrsquos needs When be adjusted according to the patientrsquos needs When compared with conventional and patient-triggered compared with conventional and patient-triggered ventilation proportional assist ventilation reduces ventilation proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas ventilatory pressures while maintaining or improving gas exchange exchange
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Ideal Monitoring FeaturesIdeal Monitoring Features
Proximal airway monitoringProximal airway monitoring real-time pulmonary graphicsreal-time pulmonary graphics 10487071048707WaveformsWaveforms 10487071048707LoopsLoops 10487071048707MechanicsMechanics 10487071048707TrendingTrending
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Volume GuaranteeVolume Guarantee Draumlger BabylogDraumlger Babylog 1048707 1048707 Pressure Regulated VolumePressure Regulated Volume Control and Volume SupportControl and Volume Support Siemens 300Siemens 300 1048707 1048707 Volume Assured Pressure SupportVolume Assured Pressure Support VIP BIRD GoldVIP BIRD Gold
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Neonatal VentilationNeonatal Ventilation
Dr Badr ChabanDr Badr Chaban
110209110209
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
High-Frequency Ventilation
HFV is a radical departure from standard conventional mechanical ventilation
There are several types of HFV devices including (HFJV) HFOV and hybrids
The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
MAP provides a constant distending MAP provides a constant distending pressure equivalent to CPAPpressure equivalent to CPAP
This inflates the lung to a constant and This inflates the lung to a constant and
optimal lung volume maximising the area optimal lung volume maximising the area for gas exchange and preventing alveolar for gas exchange and preventing alveolar collapse in the expiratory phase collapse in the expiratory phase
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Indications for high frequency Indications for high frequency ventilation includeventilation include
11Rescue following failure of Rescue following failure of conventional ventilation (conventional ventilation (PPHNPPHN MAS)MAS)
22Air leak syndromes (pneumothorax Air leak syndromes (pneumothorax pulmonary interstitial emphysema) pulmonary interstitial emphysema)
33To reduce barotrauma when To reduce barotrauma when conventional ventilator settings are conventional ventilator settings are highhigh
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
TerminologyTerminology
FrequencyFrequency High frequency ventilation rate (Hz High frequency ventilation rate (Hz
cycles per second) cycles per second)
MAPMAP Mean airway pressure (cmHMean airway pressure (cmH22O) O)
AmplitudeAmplitude delta P or power is the variation around delta P or power is the variation around
the MAP the MAP
Oxygenation is dependent on MAP and FiOOxygenation is dependent on MAP and FiO22
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Ventilation is dependent on amplitude and Ventilation is dependent on amplitude and to lesser degree frequency to lesser degree frequency
Thus when using HFV CO2 elimination Thus when using HFV CO2 elimination and oxygenation are independent and oxygenation are independent
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Making adjustments once established on HFV
Poor Oxygenatio
n
Over Oxygenatio
n
Under Ventilation
Over Ventilation
Increase FiO2
Decrease FiO2
Increase Amplitude
Decrease Amplitude
Increase MAP
(1-2cmH2O)
Decrease MAP
(1-2cmH2O)
Decrease Frequency
(1-2Hz)if
Amplitude Maximal
Increase Frequency
(1-2Hz)if
Amplitude Minimal
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Continuous Positive Airway Pressure
Gregory et al in 1971 applied CPAP in RDS Although the first application of CPAP was
through the endotracheal tube It soon became apparent that it could also be
applied nasally since most newborns are obligate nasal breathers
At the same time the mouth acts as a pressure relief valve if the applied pressure is too high
Use of nasal CPAP also obviated face masks face chambers and head boxes
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Advantages of CPAPAdvantages of CPAP
regular pattern of breathing in preterm infants
This may be attributed to reducing thoracic distortion
and stabilizing the chest wall splinting the airway and
the diaphragm decreasing obstructive apnea and enhancing
surfactant release
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
CPAP delivery systems contain 3 major components
The first is a circuit to provide a continuous flow of inspired gas which must be warmed and humidified
The second is an interface to connect the circuit to the airwayBinasal tubes or prongs are the most commonly usedNewer devices use fluidics to reduce expiratory resistanceand decrease the WOB
The third component is a device togenerate positive pressure
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
COIN trialCOIN trial
Recent trials using nCPAP from birth in 25 Recent trials using nCPAP from birth in 25 to 28 week infants describe more to 28 week infants describe more customised strategies in the COIN trial customised strategies in the COIN trial 27-28 week infants breathing at birth 27-28 week infants breathing at birth benefit the most from nCPAP benefit the most from nCPAP
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Fewer infants received oxygen on day 28 Fewer infants received oxygen on day 28 they had fewer days of ventilation and no they had fewer days of ventilation and no increase in morbidities despite having increase in morbidities despite having more pneumothoracesmore pneumothoraces
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
REVE trialREVE trial
The suggests that intubation with early The suggests that intubation with early surfactant administration followed by surfactant administration followed by nCPAP mostly benefits to 25-26 week nCPAP mostly benefits to 25-26 week infants Thus nCPAP is feasible from infants Thus nCPAP is feasible from birth birth
The overall strategy should take into The overall strategy should take into account infants gestational age account infants gestational age maturation and behaviour in the delivery maturation and behaviour in the delivery roomroom
Hascoet et la Dec 2008Hascoet et la Dec 2008
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Complication Complication Nasal Septal
Erosion or Necrosis
bull This is preventable when using appropriate sized prongs that are correctly positioned
Pneumothoraxbull Usually occurs in acute phase bull It is uncommon (lt5) bull It usually results from the underlying disease
process rather than positive pressure alone bull It is not a contraindication to the use of CPAP
Abdominal Distension
from Swallowing Air
bull This is benign bull Easily reduced with gastric drainage or aspiration
Nasal obstruction bull From improper prong placement or inadequate
airway care
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
NIPPVNIPPV
Neonatal nasal intermittent positive pressure Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive ventilation (NIPPV) provides non-invasive respiratory support to premature infants respiratory support to premature infants who may otherwise require endotracheal who may otherwise require endotracheal intubation and ventilation intubation and ventilation
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
NIPPV is the augmentation of continuous NIPPV is the augmentation of continuous positive airway pressure (CPAP) with positive airway pressure (CPAP) with superimposed inflations to a set peak superimposed inflations to a set peak pressure pressure
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
HOW DOES NIPPV WORKHOW DOES NIPPV WORK the mechanism of action of NIPPV remains uncertain Hypotheses the mechanism of action of NIPPV remains uncertain Hypotheses
include include increasing pharyngeal dilationincreasing pharyngeal dilation
improving the respiratory driveimproving the respiratory drive
inducing Headrsquos paradoxical reflex inducing Headrsquos paradoxical reflex
increasing mean airway pressure allowing recruitment of alveoli increasing mean airway pressure allowing recruitment of alveoli
increasing functional residual capacity increasing functional residual capacity
increasing tidal and minute volume increasing tidal and minute volume
Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418 Arch Dis Child Fetal Neonatal Ed Sep 2007 92 F414 - F418
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
SNIPPVSNIPPV
Synchronisation defined as mechanical Synchronisation defined as mechanical inflation commencing within 100 ms of the inflation commencing within 100 ms of the onset of inspiration uses a capsule to onset of inspiration uses a capsule to detect abdominal movement at the start of detect abdominal movement at the start of inspiration inspiration
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
WHAT VENTILATOR SETTINGS SHOULD WE USE WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPVDURING NIPPV
PEEP 3-6 cm H2OPEEP 3-6 cm H2O
PIP 8-21 cm H2oPIP 8-21 cm H2o
R 10-30 mR 10-30 m
iT 04-06 siT 04-06 s
Flow 8-10 lm up to 15 lmFlow 8-10 lm up to 15 lm
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
NON-INVASIVE SYNCHRONISED MECHANICAL NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATIONVENTILATION
Synchronisation techniques enabled Synchronisation techniques enabled delivery of delivery of
(N-AC) (N-AC) (N-SIMV)(N-SIMV) N ACN AC N PSVN PSV N PASN PAS
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
In comparison to nasal continuous positive In comparison to nasal continuous positive airway pressure (NCPAP) N-SIMV airway pressure (NCPAP) N-SIMV reduced chest wall distortion in preterm reduced chest wall distortion in preterm infants following extubation while N-AC infants following extubation while N-AC reduced breathing effort and improved reduced breathing effort and improved ventilationventilation
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Three randomised trials have shown the consistent efficacy Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failurebetter respiratory evolution and lower extubation failure
These reports suggest that reduced apnea is responsible These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMVmechanics are likely to benefit more from N-SIMV
These data also showed a tendency towards reduced These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV oxygen dependency among infants extubated to N-SIMV
Eduardo Bancalari miamiEduardo Bancalari miami
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
In summaryIn summary
Data from physiological and clinical trials indicate Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has that non-invasive synchronised ventilation has important benefits important benefits
Despite this evidence the use of non-invasive Despite this evidence the use of non-invasive synchronised ventilation is uncommon perhaps synchronised ventilation is uncommon perhaps because few such ventilators are available because few such ventilators are available
More importantly there are few data on the use of More importantly there are few data on the use of non-invasive synchronised ventilation to avoid non-invasive synchronised ventilation to avoid earlier use of invasive ventilation earlier use of invasive ventilation
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
SNCPAP setting SNCPAP setting
PEEP 5PEEP 5
PIP up to 20PIP up to 20
10-4010-40
iT 025-1siT 025-1s
Flow depend on the leakFlow depend on the leak
Thank youThank you
Thank youThank you
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