Non invasive ventilation

Neonates -2 Dr. ADHI ARYA

SENIOR RESIDENT –GMCH -32 CHANDIGARH

nIPPV• intermittent positive pressure ventilation via nasal devices

positive pressure cycle delivered on top of continuous distending pressure by nasal route

Similar to CPAP, unassisted spontaneous breathing occurs at a pre-set PEEP level, but mandatory pressure control breaths are either patient-triggered (synchronized) or machine-triggered (non-synchronized).

How is synchronization done • Infant star—)• Phased out

• Servo –I ventilators ( for NAVA)

• Infant Flow SiPAP Comprehensive by pneumatic capsule grasby( detecting abd movements

Is synchronization required• In theory, patient-triggered nasal IMV is preferred because the

inflations are timed with the respiratory effort, and when the glottis is open, the inflations are more likely to be transmitted effectively to the lungs.

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Non invasive ventilation: Physiological effects of NIV

1. Apnea: Nasal IPPV may improve patency of the upper airway by creating

intermittently elevated pharyngeal pressures. This intermittent inflation of the pharynx may activate respiratory drive, by Head’s paradoxical reflex, where lung inflation provokes an augmented inspiratory reflex. This results in resumption of breathing in infants with apnea following cycling of the ventilator.

2. Work of breathing has also been shown to be decreased with the use of SNIPPV compared to nasal CPAP (Kiciman NM Pediatr Pulmonol 1998; 25: 175–81)

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Non invasive ventilation: Primary Mode VS Secondary Mode• NIPPV in the primary mode refers to its use soon after birth with or

without a short period ( 2 hours) of intubation for surfactant delivery, followed by extubation.

• The secondary mode refers to its use after a longer period (>2 hours to days to weeks) of intubation.

Non invasive ventilation: NIPPV STUDIES IN NEONATE

8Adopted from: Noninvasive Respiratory Support in the P r e term Infant, Bhandari.V. Clin Perinatol 39 (2012) 497–511

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Non invasive ventilation: Evidence Based Decisions

SNIPPV STUDIES IN NEONATE(primary mode)

Adopted from: Noninvasive Respiratory Support in the P r e term Infant, Bhandari.V. Clin Perinatol 39 (2012) 497–511

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Non invasive ventilation:SNIPPV STUDIES IN NEONATE(secondary mode)

Adopted from: Noninvasive Respiratory Support in the P r e term Infant, Bhandari.V. Clin Perinatol 39 (2012) 497–511

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Non invasive ventilation: Evidence Based Decisions : NIPPV VS NCPAP

EXTUBATION FAILURE RATE:NIPPV VS NCPAPNasal Intermittent Positive Pressure Ventilation versus Nasal Continuos Positive Airway Pressure in Neonates: A Systematic Review and Meta-analysis: Tang et al, Indian pediatrics,2012

Five papers reported the rate of extubation failure of NIPPV versus nCPAP following ETT and mechanical ventilation. Meta-analysis showed that the rate of extubation failure of NIPPV was significantly lower than that of nCPAP [OR=0.15 (95% CI: 0.08 0.31)]; P<0.001.

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Non invasive ventilation: Evidence Based Decisions : NIPPV VS NCPAP

FAILURE RATE as a primary mode in RDS :NIPPV VS NCPAP

Nasal Intermittent Positive Pressure Ventilation versus Nasal Continuos Positive Airway Pressure in Neonates: A Systematic Review and Meta-analysis: Tang et al, Indian pediatrics,2012

Six papers reported the failure rate of NIPPV versus nCPAP as a primary respiratory mode, which was indicated by whether or not requiring ETT and mechanical ventilation.

Metaanalysis showed that the failure rate in NIPPV group was significantly lower than that in nCPAP group as a primary respiratory mode [OR=0.44 (95% CI: 0.31-0.63); P<0.0001)

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Non invasive ventilation: Evidence Based Decisions : NIPPV VS NCPAP

META-ANALYSIS OF SECONDARY OUTCOMES BETWEEN NIPPV AND NCPAP GROUPS

Nasal Intermittent Positive Pressure Ventilation versus Nasal Continuos Positive Airway Pressure in Neonates: A Systematic Review and Meta-analysis: Tang et al, Indian pediatrics,2012

• FINAL OUTCOME (DEATH AND/OR BPD): NIPPV was significantly better than that of nCPAP as a primary respiratory mode [OR=0.57 (95% CI: 0.37-0.88); P=0.01]

• APNEA OF PREMATURITY: NIPPV showed a statistically lower rate of apnea (episodes per hour) as compared with nCPAP group [WMD=-0.48 (95%CI:-0.58-0.37; P<0.001]

• DURATION OF HOSPITALIZATION : (primary respiratory mode /extubation mode) : No significant difference in duration of hospitalization between NIPPV and nCPAP group [WMD=-0.51 (95%CI:-5.62-4.61;

• INCIDENCE OF BPD : NIPPV led to a marginally significant reduction in the incidence of BPD as compared with nCPAP. [OR(95%CI)=0.39-1.00,P=0.05]

• incidence of IVH, PVL, ROP, PDA, Pneumothorax or air leak, abdominal distention, necrotizing enterocolitis : no significant differences

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Non invasive ventilation: GUIDELINES: (S)NIPPV (primary mode)

1. Settings: Frequency = 40 per minute PIP 4 cm H2O > PIP required during manual ventilation (adjust PIP for effective aeration per auscultation) PEEP 4–6 cm H2O Ti = 0.45 s FiO2 adjusted to maintain SpO2 of 85–93% Flow 8–10 lpm

2. Caffeine loading → maintenance3. Hematocrit 35%4. Monitor SpO2, HR and respirations5. Obtain blood gas in 15–30 min6. Adjust ventilator settings to maintain blood gas parameters within normal limits7. Suction mouth and pharynx and insert clean airway Q4, as necessary8. Maximal support recommendations:

1000 g MAP 14 cm H2O>1000 g MAP 16 cm H2O

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Non invasive ventilation: GUIDELINES: (S)NIPPV (secondary mode)

1. Extubation criteria while on CV: Frequency =15–25 per minute PIP 16 cm H2O PEEP 5 cm H2O FiO2 0.35 Caffeine loading →maintenance Hematocrit 35%

2. Place on (S)NIPPV Frequency =15–25 per minute PIP 2–4 > CV settings; adjust PIP for effective aeration per auscultation PEEP 5 cm H2O FiO2 adjusted to maintain SpO2 of 85–93% Flow 8–10 lpm

3. Suction mouth and pharynx and insert clean airway Q4, as necessary4. Maximal support recommendations:

1000 g MAP 14 cm H2O>1000 g MAP 16 cm H2O

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Non invasive ventilation: GUIDELINES: REINTUBATION CRITERIA

1. pH <7.25; PaCO2 >60 mm Hg

2. Episode of apnea requiring bag and mask ventilation

3. Frequent (>2–3 episodes per hour) apnea/bradycardia (cessation of respiration for>20 s associated with a heart rate <100 per minute) not responding to caffeine therapy

4. Frequent desaturation (<85%)=3 episodes per hour not responding to increased ventilator settings

Adopted from: Noninvasive Respiratory Support in the P r e term Infant, Bhandari.V. Clin Perinatol 39 (2012) 497–511

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Non invasive ventilation-weaning

to oxy hood/nasal cannula1. Minimal (S)NIPPV settings

Frequency 20 per minute PIP 14 cm H2O PEEP 4 cm H2O FiO2 0.3 Flow 8–10 lpm Blood gases within normal limits

2. Wean to: Oxy hood adjust FiO2 to keep SpO2 85–93% NC adjust flow (1–2 l m–1) and FiO2 to keep SpO2 85–93%

Adopted from: Noninvasive Respiratory Support in the P r e term Infant, Bhandari.V. Clin Perinatol 39 (2012) 497–511

Bipap /Sipap

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Non invasive ventilation: NASAL BIPAP vs CPAP

Lista etal,Arch Dis Child Fetal Neonatal Ed. 2010 Mar;95(2)

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Non invasive ventilation: NASAL BIPAP vs SNIPPV

HHFNC

LOW FLOW V/S HIGH FLOW• HIGH FLOW--MORE THAN INPIRATORY FLOW • NO CONSENSUS • BUT IN NEONATES FLOWS >2L/MIN

MOA• warmed and humidified flow of air and/or air-oxygen.—DEC WOB

• some degree of end distending pressure – COMPARABLE TO nCPAP

• Reduced dead space- reduced co2 rebreathing

ADVANTAGES OVER CPAP• HHF may be better tolerated by infants becoming unsettled with

HCPAP.

• Less nasal injuries

• Sucking feeds and Kangaroo care are more easily attempted with HHF than HCPAP.

COMPARISON WITH CPAP• Yoder et al 2013

• Similar in efficacy in post extubation and as initial respiratory support

• No increased risk of air leaks

• No difference in different machines

COMPARISON WITH CPAP AND OTHER NIV MODES

High flow nasal cannula for respiratory support in preterm infants

Cochrane Neonatal Group FEB 2016DOI: 10.1002/14651858.CD006405

CONCLUSION

• similar rates of efficacy to other forms of non-invasive respiratory support in preterm infants for preventing treatment failure, death and CLD.

• Most evidence is available for the use of HFNC as post-extubation support. Following extubation, HFNC is associated with less nasal trauma, and may be associated with reduced pneumothorax compared with nasal CPAP.

• Further RCTs needed for comparing HFNC with other forms of primary non- invasive support after birth and for weaning from non-invasive support.

• also for evaluating the safety and efficacy of HFNC in extremely preterm and mildly preterm subgroups, and for comparing different HFNC devices.

DEVICES AVAILABLE • Optiflow System ( AIRVO- Fisher and Paykel,

• Precision Flow (VAPOTHERM), and

• Comfort-Flo®(Teleflex)

General considerations• Nasal cannula size is important

• Outer diameter of cannula should not be > 50% of internal diameter of nares

Flow rate is size dependent• 1000-1999 -- 3 –lpm• 2000-2999—4• >3000—5 Flow rate can increase in any slab by max of 3 Lpm

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Non invasive ventilation: NAVA

NAVA/Neurally adjusted ventilator assist is a mode of synchronisation which uses diaphragmatic electromyography to synchronise not only the time of breath according to patients initiation of inspiration ,but also it gives breath proportionate to electrical activity of diaphragm.