g.lista, md phd nicu v.buzzi children’s hospital...

Respiratory function monitoring in the delivery room

G.Lista, MD PhD

NICU – “V.Buzzi”-Children’s Hospital Milan-Italy

Dr Lista has received honoraria for lectures from Chiesi, Draeger and Vyaire Company. None of these Companies had any input into the content of this presentation

Conflict of interest statement:

Flow sensor in the

RFM (in DR) and

on the ventilator ( in DR and NICU)

RFM : measures and continuously displays

respiratory parameters and can help to

adjust the assisted ventilation to meet the

newborn‘s requirements :

• Flow/Pressure

• SpO2

• FiO2

• Vt

Videorecording

Leaks No leaks Leaks

Correction of mask position

Respiratory Inductance Plethysmography (RIP)

Respiratory Function Monitor (RFM)

Volumetric CO2 monitor

T-piece resuscitator

Monitoring lung aeration

3

1

2

4

4 3 2 1

Hooper S, gentle concession, partly modified

At the end of 1° SI

Breathing infants during SI

(11 out of 15)

Apneic infants during SI

(4 out of 15)

SBs (average) n° 4(3) 0

Vte (range) ml/Kg 5.9 (2.4-8.2) 5.2 (0.2-6.0) p<0.005

ECO2 (range) mmHg 16.0 ( 10-30) 5.0 (2.0-15.0) p<0.01

At the end of 2° SI

Breathing infants during SI

(4 out of 5)

Apneic infants during SI

(1 out of 5)

SBs (average) n° 2(1) 0

Vte (range) ml/Kg 5.2 (0.2-6.0) 4.6 p=NS

ECO2 (range) mmHg 16.0 ( 4-25) 4.0 p=NS

Spontaneuos breathing appears to play an important part in the success

of ventilation given at birth

Manual Ventilation with a Few Large Breaths at Birth Compromises the Therapeutic Effect of Subsequent Surfactant

Replacement in Immature Lambs Lars J Björklund, Jonas Ingimarsson, Tore Curstedt, Joseph John,

Bengt Robertson, Olof Werner and Carsten T Pediatric Research (1997) 42, 348–355

Respiratory Function Monitor (RFM)

2012

Do we really understand the efficacy of spontaneous breathing only supported by n-CPAP in the DR ? When we can decide that mask ventilation is not adequate and decide

to intubate the newborn in DR?

Spontaneous breathing during SI

Spontaneous breathing with adequate Vte in NCPAP

In course of PPV: at first adequate Vte then Vte too much higher after increasing of PIP

level

In course of spontaneous breathing only suported by NCPAP, low Vte at first, then adequate. Significative

reduction of mask leaks

PIP 25 cmH2O

Inadequate Vte

Low SpO2 and <100 for 3‘

Have we….. to intubate the infant ?

PIP 31 cmH2O

Vte 6-8 ml/kg

Reduced Leaks

HR>120 bpm, SpO2 100%

We begin to reduce FiO2

Using RFM, we can check in «real time» the Vte generated and so adjust PIP level and decide if the infants really needs ………to be

intubated or not in the DR

Effects of mask PPV on HR and SpO2 during DR stabilization of

bradycardic preterm infants: an RFM analysis

Francesco Cavigioli MD and Gianluca Lista MD PhD

V.Buzzi Children’s Hospital San Francisco May 11th 2017

METHODS

• Retrospective observational study approved by local IRB

• Recordings were reviewed on a breath by breath analysis including Pressure, Flow, Vte, HR, SpO2 and FiO2 signals

• Three different moments of the stabilization process were identified and 10 leaks free ventilations in each period were studied :

• T0 : First 10 ventilations at PPV start

• T1: 10 ventilations around the moment of HR raise over 100 bpm

• T2: Last period of PPV before moving to CPAP or before stopping recording (max

10 minutes, could be mask ventilation or ET- ventilation in intubated infants)

T0 T1 T2

Elegibility criteria

• Preterm infants <30 wks’ GA born between jan 2014 and jan 2017 in Milan at “V.Buzzi Children’s Hospital” who were recorded with an RFM during early stabilization with T-piece and mask in the first minutes of life.

• Showing HR < 100 bpm when first oxymetry signal appeared

70 infants <30 wks

10 excluded

-4 major leaks -6 device failure

3 only CPAP From birth

10 had HR >100 at time of Oxymeter

signal

47 infants were analysed

at T0, T1 and T2

N GA

median (IQR) Birth Weight median (IQR)

Cesarean section (%)

Twins (%) Prenatal steroids (%)

47 27 (25+4-28+1) wks 789 (699-1025) g 39/47 (82%) 17/47 (36%) 44/47 (93%)

Objective

• To analyze correlations between:

• ROSC (return of spontaneous circulation intended as Pulse-oxymetry HR and SpO2 data) in the first minutes of life and

• Ventilation data (pressures and tidal volumes delivered in course of PPV, lung dynamic compliance).

Main results

Parameter Median IQR

Oximetry signal (sec) 58.5 (44 – 76)

Initial HR (bpm) 67 (54 – 84)

Initial SpO2 (%) 29.5 (15 – 44.5)

Time of PPV start (sec) 64 (46-111)

HR > 100 bpm (sec) 166 (116-236)

SpO2 > 75 % (sec) 272 (229 – 323)

DR intubation 9/47 (19%)

CPAP in DR 36/47 (76,5%)

Time of CPAP start (sec) 288 (238-432)

VM < 72 h 15/47 ( 42%)

Surfactant given NICU 32/47 (68%)

Mortality 11/47 (23%)

T0

T1

T2

Unpublished data

P=0,005

P<0,001

P=0,007

P<0,001

T PIP (median IQR) cmH2O

T0 25 (22.7 - 26)

T1 26 (24.7 - 29)

T2 25 (22.5 - 26)

T MAP (median IQR) cmH2O

T0 16.2 (13.7 – 17.7)

T1 17.5 (14.5 – 19.8)

T2 14.9 (12.4 – 17.2)

P<0,001

P = ns

P<0,001

P=0,03

T Vte/kg (median IQR) ml

T0 2.7 (1.9 - 4.7)

T1 6.4 (4.4 - 7.4)

T2 6.6 (5.3 - 8.2)

T Cdyn (median IQR) ml/cmH2O/Kg

T0 0.16 (0.11 – 0.23)

T1 0.32 (0.20 – 0.37)

T2 0.37 (0.29 – 0.45)

Or Check

Vte values by RFM???

Neonatal resuscitation algorithm. Wyckoff MH et al Circulation 2015; 132:S543-S560

Conclusions

1. Adequate ventilation of the lung and initial recruitment seems to be the key point for ROSC

2. Initial assessment with an RFM when delivering PPV with a face mask could help the resuscitating team in their decisions ….to maintain the baby in CPAP or intubate and start MV .

RFM: practice points

• RFM+ videorecording could be used during mannequin based neonatal training program or as “audit” with the resuscitation team to teach

• 1) correct mask hold to reduce leak,

• 2) assessment of PIP/PEEP and

• 3) appropriate Vt

• RFM during resuscitation can provide continuous information in “real time” about:

• 1) Vte

• 2) mask or EET leak

• 3) airway or EET obstruction,

• 4) the spontaneous breathing patterns, Vte and interaction with inflations like exhaled CO2 amount (…….decision for intubation ?)

• Limitations : RFM only displays the waves and data and not interpretation of the signals or a diagnosis. Neonatologists need to be trained in its using. At beginning it is not easy to use by alone during resuscitation (learning curve)

Respiratory Function Monitoring in the DR…is feasible, but this technology

merits further investigations.