is there an optimal ventilatory mode for - antadir › uploads › editor ›...
TRANSCRIPT
![Page 1: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/1.jpg)
Is there an optimal ventilatory mode for
neuromuscular children ?Brigitte Fauroux & Alessandro Amaddeo
Pediatric noninvasive ventilation and sleep unitResearch unit INSERM U 955
Necker university Hospital, Paris, France
InsermInstitut nationalde la santé et de la recherche médicale
![Page 2: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/2.jpg)
Is there an optimal ventilatorymode for neuromuscular children ?
• Introduction• Ventilatory modes• In practice• Conclusion
![Page 3: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/3.jpg)
![Page 4: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/4.jpg)
Heterogeneity of neuromuscular
disorders in children
Motoneuron- SMA
Peripheral nerve- Metabolic- Hereditary
Neuromuscularjunction- Myasthenia
Muscle- DMD, myotonic D.- Cong. myopathies
![Page 5: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/5.jpg)
Ramirez et al. Intensive Care Med 2012;38:655
97 children over an 18 months period
36%
![Page 6: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/6.jpg)
McDougall et al. Arch Dis Childh 2013;98:660
![Page 7: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/7.jpg)
NIV for children with NMD in Rome
Pavone et al. Early Human Development 2013;89:S25
34%
![Page 8: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/8.jpg)
Is there an optimal ventilatorymode for neuromuscular children ?
• Introduction• Ventilatory modes
– principles– efficacy
• In practice• Conclusion
![Page 9: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/9.jpg)
Volume targetedventilation
Pressure targetedventilation
Target volumewith variable
pressure supportTidalvolume
stable variable « guaranteed »
Pressure variable stable variable (withintargets)
Flow
Avantages known tidal volume known IPAPleakcompensation
control of IPAPleak compensation« guantanteed »tidal volume
Limitations no leakcompensationno control of IPAP
variable tidalvolume
possibility to guarantee tidal volume……
![Page 10: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/10.jpg)
![Page 11: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/11.jpg)
AVAPSIVAPS
Target volume pressure support
![Page 12: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/12.jpg)
Target volume with variable pressure support
Entire night
1 minute
![Page 13: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/13.jpg)
Target volume with variable pressure support and back up rate
Entire night
1 minute
![Page 14: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/14.jpg)
Is there an optimal ventilatorymode for neuromuscular children ?
• Introduction• Ventilatory modes
– principles– efficacy
• In practice• Conclusion
![Page 15: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/15.jpg)
![Page 16: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/16.jpg)
![Page 17: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/17.jpg)
Evolution of IPAP and VT during mouth leaks
![Page 18: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/18.jpg)
![Page 19: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/19.jpg)
![Page 20: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/20.jpg)
Difference in leaks calculated on the bench and given by the in-built software
O IPAP 15 cmH2OX IPAP 25 cmH2O
![Page 21: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/21.jpg)
O IPAP 15 cmH2OX IPAP 25 cmH2O
Difference in tidal volume calculated on the bench and given by the in-built software
![Page 22: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/22.jpg)
13 adults with NMD requiring NIV, 3 modes in a random order, duration 25 min
![Page 23: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/23.jpg)
![Page 24: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/24.jpg)
7/18 patients NM
No difference on PSG and nocturnal gas exchange
![Page 25: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/25.jpg)
![Page 26: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/26.jpg)
![Page 27: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/27.jpg)
Daytime PaCO2
Patients with nocturnal PtcCO2 < 50 mmHg
n=29 (%)
Patients with nocturnal PtcCO2 > 50 mmHg
n=21 (%)
PaCO2 < 45 mmHg 29 (48%) 18 (36%)
PaCO2 ≥ 45 mmHg 0 (0%) 3 (6%)
Paiva et al. Intensive Care Med 2009:35:1068
Normal daytime blood gases and normal nocturnal SpO2 do not exclude nocturnal hypercapnia
![Page 28: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/28.jpg)
![Page 29: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/29.jpg)
No effect of ventilatory mode
Detection of alveolarhypoventilation by SpO2 or withPtcCO2:• SpO2 ≤ 88% > 5min• Mean SpO2 < 90% or SpO2
< 90% ≥ 10% recording time• Mean SpO2 < 92% or SpO2
< 90% ≥ 10% recording time• PtcCO2 max ≥ 49mmHg
![Page 30: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/30.jpg)
![Page 31: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/31.jpg)
PtcCO2 > 49 mmHg > 10% total recording time peak PtcCO2 > 55 Hg
Cumulative incidence of respiratoryevents requiring ICU admission
![Page 32: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/32.jpg)
PtcCO2 > 49 mmHg > 10% total recording time peak PtcCO2 > 55 Hg
Event free survival:time to ICU admission or death
![Page 33: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/33.jpg)
Which ventilatory mode for childrenwith neuromuscular diseases ?
• Aim of NIV: guarantee an adequat(physiological) tidal volume with an optimal comfort
• NM patients are « easy » to ventilate: NIV replaces the respiratory muscles– adequat inspiratory trigger (sensitive) or back up rate
= physiological breathing rate– expiratory pressure = 0 ou minimal
• No ventilatory mode has proven its superiority• In practice: S/T + volume guarantee + back up
rate
![Page 34: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/34.jpg)
![Page 35: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/35.jpg)
Non intentional leaks are associated with autonomic arousals
![Page 36: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/36.jpg)
Conclusion• Outbreak of « new » ventilatory modes
– lack of harmonisation of definitions ++– none has proven its superiority
• Primary aim– guarantee a physiological tidal volume with
maximal comfort• Priorities > ventilatory mode
– for the patient• interface and headgear ++• ergonomy of the ventilator: weight, encumbrance,
humidification• possibility of different modes (mouthpiece ventilation)
– for the medical staff• easiness and accuracy of in-built software• integrated SpO2 monitoring (PtcCO2?)
![Page 37: Is there an optimal ventilatory mode for - ANTADIR › uploads › editor › ...ventilatory-mode.pdf · Is there an optimal ventilatory mode for neuromuscular children ? • Introduction](https://reader034.vdocuments.net/reader034/viewer/2022042402/5f126ab9dd672b5b3d1a8233/html5/thumbnails/37.jpg)
Acknowledgements