non -invasive ventilation -...

6
AW Flemmer Krakau 2013 Non Non- invasive invasive Ventilation Ventilation Krakau 2013 Krakau 2013 A.W. Flemmer Div. Div. Neonatology Neonatology, , Children Children‘s Hospital and Perinatal Center, s Hospital and Perinatal Center, LM LM-University Munich, Germany University Munich, Germany AW Flemmer Krakau 2013 Increased and stabilized lung volume Stabilized „soft“ thorax of the neonate reduced work of breathing …. Decreased airway resistance Surfactant „restitution“ Reduced left-right shunting across patent ductus botalli Physiological effects of CPAP - potential benefits AW Flemmer Krakau 2013 Rees et al. J Rees et al. J Neuropath Neuropath and and Exp Exp Neurol Neurol, June 2009 , June 2009 Extubation to nCPAP after 24 hrs Extubation to nCPAP after 5 days nCPAP & Surfactant: „beyond the lung“ AW Flemmer Krakau 2013 CPAP-induced overdistention of the lung, inverted diaphragm impaired exspiration Airleak / pneumothorax ET tube and airway- obstruktion Overdistention reduced venous return reduced cardiac output .... Physiological effects of CPAP - potential harms AW Flemmer Krakau 2013 CPAP CPAP systems nasal ET tube nasal prongs nasal cannula ..... Flow-generator: •Ventilator cont. flow demand flow •Bubble-CPAP •Medijet •Infant-flow •... Pressure-generator: expir.-valve surge chamber ... Interface: Hudson prongs Argyle prongs Buenavista Fluid flip device ... AW Flemmer Krakau 2013 nCPAP - Failure

Upload: trinhcong

Post on 08-Aug-2019

224 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Non -invasive Ventilation - ipokrates.infoipokrates.info/wp-content/uploads/AW-Flemmer-non-invasive-ventilation.pdf · AW Flemmer Krakau 2013 Non -invasive Ventilation Krakau 2013

AW Flemmer Krakau 2013

NonNon --invasiveinvasive VentilationVentilation

Krakau 2013Krakau 2013

A.W. Flemmer

Div. Div. NeonatologyNeonatology , , ChildrenChildren ‘‘s Hospital and Perinatal Center,s Hospital and Perinatal Center,LMLM--University Munich, GermanyUniversity Munich, Germany

AW Flemmer Krakau 2013

• Increased and stabilized lung volume

• Stabilized „soft“ thorax of the neonate→→→→ reduced work of breathing

• ….

• Decreased airway resistance

• Surfactant „restitution“

• Reduced left-right shunting across patent ductus botalli

Physiological effects of CPAP - potential benefits

AW Flemmer Krakau 2013

Rees et al. J Rees et al. J NeuropathNeuropath and and ExpExp NeurolNeurol , June 2009, June 2009

Extubation to nCPAPafter 24 hrs

Extubation to nCPAPafter 5 days

nCPAP & Surfactant:„beyond the lung“

AW Flemmer Krakau 2013

• CPAP-induced overdistention of the lung, inverted diaphragm →→→→ impaired exspiration

• Airleak / pneumothorax

• ET tube and airway- obstruktion

• Overdistention →→→→ reduced venous return→→→→ reduced cardiac output

• ....

Physiological effects of CPAP - potential harms

AW Flemmer Krakau 2013

CPAP CPAP systems

nasal ET tubenasal prongsnasal cannula

.....

Flow-generator:•Ventilator

• cont. flow• demand flow

•Bubble-CPAP•Medijet•Infant-flow•...

Pressure-generator:expir.-valvesurge chamber...

Interface:Hudson prongsArgyle prongsBuenavistaFluid flip device...

AW Flemmer Krakau 2013

nCPAP - Failure

Page 2: Non -invasive Ventilation - ipokrates.infoipokrates.info/wp-content/uploads/AW-Flemmer-non-invasive-ventilation.pdf · AW Flemmer Krakau 2013 Non -invasive Ventilation Krakau 2013

AW Flemmer Krakau 2013

NIV -- NIPPV

nIMV sNIMVsNIPPV

n-HFOV

AW Flemmer Krakau 2013

n-HFOV

Mukerji et al. Neonatology 2013

AW Flemmer Krakau 2013Meneses et al. Pediatrics 2011

NN--IPPV vs. NIPPV vs. N --CPAPCPAP

Prim Outcome: Use of ETT

N.S.All sec. Outcomes:(Surv. With no BPD, ROP, NEC, IVH, PDA)

2.89 (0.30-27.2)1.90 (0.49-7.4)

7.27.2

1.23.7

BPD moderatesevere

0.90 (0.72-1.13)5864Need for MV

1.19 (0.55-2.53)0.56 (0.32-0.98)

2922

2439

Failure of NIV <1000g>1000g

RR (95%CI)NIPPV (%)(n=100)

NCPAP (%)(n=100)

AW Flemmer Krakau 2013

Non-synchronized NIV

Owen L et al.Arch Dis Child 2011

AW Flemmer Krakau 2013O‘Brien et al. BMJ Ped 2012

NN--IPPV vs. NIPPV vs. N --CPAPCPAP

Prevent Extubation Failure

sNIPPV

NFSIPPV

NP-SIMV

nSIMV

BL-NCPAP

AW Flemmer Krakau 2013

Positive Effectsof Synchronization

� ↑↑↑↑ Tidalvolume (Bernstein 1994, Hummler 1996, Rosas 1992)

� ↑↑↑↑ Oxygenation (Cleary 1995)

� ↓↓↓↓ Blood pressure fluctuations (Amitay 1993, Hummler 1996)

� ↓↓↓↓ IVH ? (Perlman 1985)

� ↓↓↓↓ Work of breathing (Jarreau 1996)

� ↓↓↓↓ Active exspiration (Heldt & Bernstein 1994, Greenough 1985)

� ↓↓↓↓ Air leaks (Greenough 1983, 1984)

� ↓↓↓↓ Sedation / Paralysis (Henry 1979)

� ↓↓↓↓ Stress (Epinephrinlevel) (Quinn 1998)

� Earlier weaning (Donn 1994)

Page 3: Non -invasive Ventilation - ipokrates.infoipokrates.info/wp-content/uploads/AW-Flemmer-non-invasive-ventilation.pdf · AW Flemmer Krakau 2013 Non -invasive Ventilation Krakau 2013

AW Flemmer Krakau 2013

Does SynchronizationMatter?

Prim Outcome RR (95% CI) # Studies Pt enrolled

Death 1.19 (0.95-1.49) 5 1729

Air Leaks 1.03 (0.80-1.34) 6 1769

Ext. Failure 0.93 (0.68-1.28) 4 1056

Severe IVH 1.03 (0.74-1.43) 5 1729

BPD@28d 0.91 (0.75-1.12) 4 805

BPD@36wk 0.90 (0.75-1.08) 2 1310

Days vent (h) -35 (-62;-7) 4 1402

Greenough A. et al. 2008 Cochrane Database AW Flemmer Krakau 2013

nCPAP vs. sNIPPV

BPD or death

Neurodevelopmental Impairment or Death

Bahndari et al. Pediatrics 2009Retrospective Data with Graseby & Infant Star & Star Synch

AW Flemmer Krakau 2013 Dumpa et al. et al. J Perinat 2011

OR 95% CI

BPD or death NIPPV (238) sNIPPV (172) 0.74 0.42 – 1.30

Retrospective Data with Graseby & Infant Star & Star Synch

NIPPV vs. sNIPPV

AW Flemmer Krakau 2013

CV vs. sNIPPV

Bahndari et al. J Perinat 2007

Outcome Conv. Ventilation

(n=21)

sNIPPV

(=20)

p

BPD or deathn (%)

11 (52) 4 (20) 0.03

BPD n (%) 7 (33) 2 (10) 0.04

death n (%) 4 (19) 2 (10) 0.66

Initial RDS-Treatment (RCT)

RCT 2 Centers 2000-2005 with Graseby & Infant Star & Star Synch

AW Flemmer Krakau 2013

ExternalSignals

Internal Signals

Graseby Capsule Flow

RespiratoryInductionPlethysmography: RIP-Bands

NAVA

Piezo Sensor ∆P oesophageal

Potential Respiratory Signals forsynchronized NIPPV

Best Triggerfor sNIPPV?

AW Flemmer Krakau 2013

Best signal for synchronisation of NIPPV

� Onset of signal and � Quality of signal

Best way to provide sNIPPV?

Page 4: Non -invasive Ventilation - ipokrates.infoipokrates.info/wp-content/uploads/AW-Flemmer-non-invasive-ventilation.pdf · AW Flemmer Krakau 2013 Non -invasive Ventilation Krakau 2013

AW Flemmer Krakau 2013

(n=5813) Signal Onset vs. RIP-Abd

SD

∆∆∆∆t Pes + 52 ms ± 160 ms

∆∆∆∆t RIP-Chest + 157 ms ± 154 ms

∆∆∆∆t Graseby + 61 ms ± 98 ms

∆∆∆∆t Piezo + 118 ms ± 1375 ms

ΘΘΘΘ RIP Chest – RIP Abd

49 ° ± 118 °

80.4 ±±±± 10 % valid Signals for RIP Abd & Graseby

VLBWSpont breathing

AW Flemmer Krakau 2013

VLBW CPAP

(n=5813) Signal Onset vs. RIP-Abd

SD

∆∆∆∆t Pes - 45 ms ± 95 ms

∆∆∆∆t RIP-Chest + 167 ms ± 105 ms

∆∆∆∆t Graseby + 44 ms ± 66 ms

∆∆∆∆t Piezo + 35 ms ± 88 ms

AW Flemmer Krakau 2013Moretti Corrado et al. 2008 Pediatrics Int

Nasal Flow sNIPPV

NCPAP nfsNIPPV p

Extubation -Failure n/n (%) 2/32 (6%) 12/31 (39%) p<0.005

Special ventilator „Gulia“ with sNI-algorythm

AW Flemmer Krakau 2013

Neurally adjusted ventilatory assist (NAVA)

Moerer et al. Anaesthetist 2008

AW Flemmer Krakau 2013

Adult Pt Camarota et al. ICM 2012

n-i NAVA

AW Flemmer Krakau 2013

1) RIP – Abdominal Band2) Graseby Capsule3) Flow sensor with special algorythm

4) NAVA

Valid Triggers

Page 5: Non -invasive Ventilation - ipokrates.infoipokrates.info/wp-content/uploads/AW-Flemmer-non-invasive-ventilation.pdf · AW Flemmer Krakau 2013 Non -invasive Ventilation Krakau 2013

AW Flemmer Krakau 2013

�So far no comperative studies lookinginto differences of triggers

AW Flemmer Krakau 2013

Best way to provide sNIPPV?

Supported Frequency

���� synchronised intermittent NV?

���� synchronised assist control NV?

AW Flemmer Krakau 2013

Observational with Graseby & Infant Star + Star Synch

nCPAP ni-MV @20/min

s-ni-MV@ 20/min

ni-MV @40/min

s-ni-MV@ 40/min

Vt (AU) 10.6(8.0–13.9)

11.6(7.8–19.6)

10.2(7.8–14.6)

10.4(6.2–14.1)

10.1(8.7–13.5)

MV (AU) 508 (369 – 857)

681 (321–1051)

535(342–783)

546 (330 –746)

581 (399 – 811)

RR (/min)

54 (43–59) 54 (44 – 60) 51 (44 – 60) 50 (45– 61) 52 (45– 61)

tcpCO 255.2 ±±±±10.4 55.1 ±±±± 10.7 54.9 ±±±± 10.7 56.3 ±±±± 11.1 55.8 ±±±± 12.3

SPO292.5 ±±±± 1.9 92.9 ±±±± 2.6 92.5 ±±±± 2.9 92.9 ±±±± 2.7 92.2 ±±±± 2.8

ni-MV vs. s-ni-MV

Chang H. & Bancalari E. et al. 2011 Ped Res AW Flemmer Krakau 2013

Chang H. & Bancalari E. et al. 2011 Ped Res

SIMV-NIPPV @ 40/ min

IMV-NIPPV @ 20/ min

BUT ���� no comparison of SIMNV vs. AC-NV

AW Flemmer Krakau 2013

Triggering Expiration in PSV

Reyes et al. Pediatrics 2006AW Flemmer Krakau 2013

� Loss of FRC� Prolonged Desaturations � Bradycardia

Apnoea & Periodic Breathing

Page 6: Non -invasive Ventilation - ipokrates.infoipokrates.info/wp-content/uploads/AW-Flemmer-non-invasive-ventilation.pdf · AW Flemmer Krakau 2013 Non -invasive Ventilation Krakau 2013

AW Flemmer Krakau 2013

Summary

� sIM-NIV 40/min seems more effective than IM-NIV 20/min

� Triggering expiration during sNIPPV is possibleand available

� Apnoea-detection and adaptive backupventilation during sNIPPV may be achieved witha Graseby sensor

� Moving artefacts are a major backdraw of sNIPPV