dr. ashok deorari - non invasive ventilation way forward for india
TRANSCRIPT
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Non invasive ventilationNon invasive ventilationWay forward for IndiaWay forward for India
Dr. Ashok K. Deorari MD FAMSProfessor, Department of Pediatrics,Division of NeonatologyWHO Collaborating Centre for Training and Research in
Newborn Care, AIIMS, New Delhi
Conflict of interest -None
OverviewOverview
Physiological basis for NIPPV
Evidence supporting its use
Complications and concerns
Way forward for SE Asia
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Non invasive ventilationNon invasive ventilation CPAP*
NIPPV Synchronized vs non synchronized
*Kandiraju H ..Neonatology 2012 Early vs Late rescue ST
Non invasive ventilationNon invasive ventilation
25- 50 % CPAP fails
Mechanical ventilation life saving but oftenits a risk factor for morbidities
Pulmonary, Infections, Cost
Ind Ped 2009, Bangalore ; Ind Ped 2010 Hyderabad;J Trop Ped 2010 Delhi
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Open the lungs and keep lungs openOpen the lungs and keep lungs open Low volume also induces lung injury
Adequate recruitment of lungs to FRC important
LowFRC
Compliantchest
Surfactantdeficiency
Easy fatigue ofrespiratory
muscles
Lachmann et al Int Care Med 1992
Physiological basisPhysiological basis--NIPPVNIPPV Increases pharyngeal dilation
Induces Heads paradoxical reflex
Increasing MAP allowing recruitment of alveoli
Increased FRC
NIPPV Possible advantages over CPAP
Increased MAP / VTBetter Recruitment- Respiratory drive
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Respiratory Function
Improves
Gas exchange
Lower TCO2Higher SpO2
Work of breathing
Reduced WOB
Reduced AB-T synchrony
Moretti et al , Early hum dev 1999
VLBW infants
Abdomino- Thoracic Synchrony
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Clinical uses of
NIPPV
Post
Extubation
Apnea of
Prematurity
Primary
modality
RDS
PostPost ExtubationExtubation
Three trials (n=159), VLBW infants
All synchronised form of NIPPV (Infant Star ventilator)
2 studies- Short Bi Nasal , one used- NP prongs
80% reduction in extubation failure, NNT 3 (95% CI 2, 5). Trend towards CLD reduction in NIPPV
RR 0.73 (95% CI 0.49, 1.07),
Lemyre , Davis et al, 2009
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Apnea of PrematurityApnea of Prematurity
NIPPVNIPPV vsvs NCPAPNCPAP
No reduction in need for intubation
No reduction in rate of apnea
One study- reduction in apnea
2 trials(n=54)
Preterm < 37 weeks with apnea
NIPPV might augment the beneficial effects of NCPAP
Appears to reduce the frequency of apneas moreeffectively than NCPAP.
Lemyre , Davis et al, 2009
Apnea on CPAP a trial of NIPPV may be given before
IMV
Primary treatment of RDSAuthor Year Population
Design
Intervention Findings
Meneses et al2011
RCT,26-336/7
N=100 in each arm
ns NIPPVvsB-CPAPBinasalSurf used rescue
Need for intubation first 72 hrs NS
55% reduced need for IMV
Benefit seen in > 1000 g
Overall 30% failed on non invasive
No difference in Duration of MV/BPD
Sai SunilKishore2009
RCT28-34 wksBwt > 750 g
ns NIPPV (n-37)VsNCPAP(n-39)NP delivery
Lesser intubation with NIPPV(48hrs)
13.5% vs 35% ( RR=0.38; 0.15, 0.89)
Failure rate in first week also lesser
No difference in airleak, duration ofventilation, BPD rates, NEC etc
Increased abd girth in NIPPV
Kugelman2007
RCT24-34wks
NIMV (n=43)vsNCPAP(n=41)
NIMV lesser intubation 25% vs 49%Reduced BPD rates in NIMV( 2% vs17%)
Bhandari etal RCT rapid extubation to NIPPV vs MV Reduction of CLD / Death 52% v25% p=0.03 at 22 months longterm no difference J of Perinatology 2007
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Should NIPPV replace early CPAP ?Should NIPPV replace early CPAP ?What is the practice implicationsWhat is the practice implications
In preterm babies esp. 28-34 weeks and > 1000g Reduced need for Intubation
A subset of infants with high index of CPAP
failureNeed for PPV in DR
Higher A-Ado2 (>180)
No ANS exposure
Higher FiO2 ( 40-50%)CXR- Severe RDS
Downe score > 7
CPAP pressure x FiO2 1.28
Consider
early NIPPV
SynchronizedSynchronized vsvs Non synchronizedNon synchronized
Synchronization- mechanical inflation commencing within 100 ms
of the onset of inspiration
SIMV has outdone IMV
sNIPPV- delivered higher tidal volume
Non synchronized - increase work of breathing/ air leaks No definite consensus
Non-synchronized NIPPV increasingly used
No definite adv effect reported
Difficulty in synchronization- need customized equipments
Non synchronized seems to be effective and safe
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Long term beneficial outcomes ..Long term beneficial outcomes ..Evidence is encouragingEvidence is encouraging
NIV for RDS (RCT)
Preterm < 35 wks
Kugelman 2007
Might reduce BPD
33% vs 5%
Bi PAPBi PAPIs it synonymous with CPAP !Is it synonymous with CPAP !
Two alternating levels of CDP
Also called Bi-level-NCPAP
Phasic change in delivered pressure
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NIPPVNIPPV --advantages over CPAPadvantages over CPAP
FRC switch- better recruitment
Higher Tidal volume -- phasic change in pressure
Reduced work of breathing
Nasal Bi PAP for RDSNasal Bi PAP for RDSmight be superior to NCPAPmight be superior to NCPAP
RCT( N=40); 28-34wks with RDS
No difference in serum cytokine markers
( No increased lung injury)
CPAP group
Longer length of hospital stay
Longer duration O2 dependency
Longer respiratory support
No difference- BPD, ROP, intubation ratesLista et a,l ADCFN 2009
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Latest in press.. But the answerLatest in press.. But the answer
has to come from Indiahas to come from India
BPD NIPPV vs CPAP
Multisite only patients; POOR DESIGN
Key MessagesKey Messages
NIPPV seems to safe promising better
alternative modality of Non invasive ventilation
Tested Indications
RDS, AOP and Post Extubation
Subset of infants severe RDS and babies with clinical predictors of
CPAP failure or recurrent apnea seems best suited
Reduction in BPD is encouraging
Safety/ Efficacy in < 28 weeks, Long term
benefits/ outcomes - yet to be established
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