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Care of the Preterm Infant: Non-invasive Ventilation and Other R elated I mportant Stuff

Care of the Preterm Infant: Non-invasive Ventilation and Other R elated I mportant Stuff. SE Courtney, MD MS Professor of Pediatrics Stony Brook University Medical Center. Opening the Lung. Congratulations! Baby is at OPTIMAL MEAN AIRWAY PRESSURE. Optimal Mean Airway Pressure. Benefit.

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Care of the Preterm Infant: Non-invasive Ventilation and Other R elated I mportant Stuff

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  1. Care of the Preterm Infant:Non-invasive Ventilation and Other Related Important Stuff SE Courtney, MD MS Professor of Pediatrics Stony Brook University Medical Center

  2. Opening the Lung

  3. Congratulations! Baby is at OPTIMAL MEAN AIRWAY PRESSURE

  4. Optimal Mean Airway Pressure Benefit Overdistension Atelectasis Pressure

  5. CPAP/PEEP: DR and beyond • CPAP/PEEP should be used from the beginning • If a self-inflating bag must be used, equip it with a PEEP valve • Consider T-piece resuscitator

  6. Finer NN et al, Resuscitation 2001

  7. Use of oxygen

  8. Oxygen Toxicity • Retinopathy of prematurity • Increased days on ventilator • Increased days on oxygen • Increased incidence/severity of BPD

  9. Finer N and Leone T. Oxygen saturation monitoring for the preterm infant: The evidence basis for current practice. Pediatr Res 2009;65:375-380

  10. Oxygen in the Delivery Room • A blender and pulse oximeter should be used • Start with 30 or 40% oxygen in the preterm infant • Saturations of around 80% at 5 minutes are normal

  11. Oxygen in the NICU • Saturations of 85-93% appear to be safe

  12. Temperature control Admission temperature <36 degrees centigrade is an independent risk factor for mortality in the preterm infant.

  13. CPAP and Non-invasive Ventilation

  14. Goal of Mechanical Ventilation To get the patient OFF mechanical ventilation! • Airway trauma • Infection • Decreased mucus clearance • Over-ventilation • Air leak • Contribution to BPD

  15. NCPAP is probably a good thing • CPAP Reduces mortality and respiratory failure in RDS • Early CPAP reduces need for mechanical ventilation • CPAP post-extubation can prevent extubation failure • NO STUDY has shown reduction in BPD with use of CPAP under any conditions (testimonials don’t count)

  16. NCPAP/NIV • Constant-flow • conventional • bubble • Variable-flow • Infant Flow • Bi-level • NIPPV

  17. Not all CPAP is created equal:Know your equipment • Variable-flow NCPAP recruits lung volume well and decreases work of breathing. Care must be taken to avoid nasal trauma. • Bubble NCPAP: pressures must be monitored; they will be higher than the depth of the underwater expiratory tube.

  18. CPAP by Conventional Ventilator • Constant flow of air/oxygen. • CPAP provided by changing orifice size at expiratory port of the ventilator, thus providing back-pressure. • Variety of prongs, usually bi-nasal. • Convenient, easily available, inexpensive.

  19. “Bubble” NCPAP

  20. “Bubble” NCPAP – Do We Know What We’re Doing? Kahn DJ et al, Pediatric Research 2007;62:343.

  21. Kahn et al, Pediatrics, 2007

  22. Pp=0.01 Courtney et al, Bubble vs ventilator NCPAP, J Perinatol 2010

  23. Variable-Flow (Infant Flow) CPAP • Flow is varied to deliver the required CPAP pressure. • The direction of flow depends on the pressures generated by the patient. • On inspiration, the CPAP flow is towards the nasal cavity, assisting in inspiration • On exhalation, the flow is down the expiratory branch of the CPAP tubing.

  24. Childs, Neonatal Intensive Care, 2000

  25. What Do We Know AboutVariable-Flow NCPAP? • Provides a very stable mean airway pressure • Decreases work of breathing • Increases lung volume recruitment

  26. Adapted from Moa G and Nilsson K. Acta Paediatr 1993;82:210.

  27. C = Cannula A = Aladdin (Infant Flow) I = Inca Prongs (Conventional Ventilator) Courtney SE, Pyon KH, Saslow JG et al. Pediatrics 2001;107:304-308

  28. Pandit PB, Courtney SE, Pyon KH et al. Pediatrics 2001;108: 682-685

  29. Stefanescu et al, Pediatrics 2003;112:1031

  30. Secondary Outcomes Conv IF P Days on O2 77.2 65.7 0.03 Length of Stay 86.3 73.7 0.02 Stefanescu et al, Pediatrics 2003;112:1031

  31. Apnea Hypoxia Hypercarbia Stefanescu et al, Pediatrics 2003;112:1031

  32. NCPAP with a Rate:(NIMV, NIPPV) • NIMV for reducing apnea and extubation failure • Synchronized (?)NIMV reduces the incidence of extubation failure and possibly apnea more effectively than NCPAP. • “Synchrony” done with Graesby capsule and Infant Star ventilator • No information is available on non-synchronized NIMV. • Current studies ongoing

  33. Owen LS, Morley CJ, Davis PG. PAS 2009

  34. SiPAP What is SiPAP? • A small (2-3 cmH2O), slow, intermittent increase in CPAP pressure for a duration up to 3 seconds to produce a “Sigh” • Enables the infant to spontaneously breathe throughout the cycle

  35. Small increases in IF CPAP pressure can change lung volume by 4-6 ml/kg. Unlike NIPPV, SiPAP pressure rise is only 2-3 cmH2O 5.5 ml/kg Adapted from Pandit PB, Courtney SE, Pyon KH et al. Pediatrics 2001;108: 682-685

  36. SiPAP can therefore potentially: • Recruit lung volume • Decrease work of breathing • Stimulate the respiratory center

  37. Patients who may benefit from SiPAP: • Infants weaning from mechanical ventilation • Premature infants that don’t require aggressive support • Infants with apnea

  38. Nasal Bilevel vs Continuous Positive Airway Pressure in Preterm Infants. Migliori C et al, Pediatr Pulmonol 2005;40:426.

  39. Nasal CPAP vs Bi-level nasal CPAP in preterm infants with RDS: a randomized control study. Lista G et al, Arch Dis Child Fetal Neonatal Ed. 2009 40 infants enrolled, mean GA 30wks, BW 1400g. IF-CPAP SiPAP P Respiratory support (d) 6.2 ± 2 3.8 ± 10 0.025 O2 dependency (d) 13.8±8 6.5 ± 4 0.027 GA at discharge (wk) 36.7± 2.5 35.6±1.2 0.02

  40. SiPAP vs NCPAPWork of Breathing and Respiratory ParametersS. Courtney, M. Weisner, V. Boyar, R. Habib • 17 infants <1200gms birth weight, on NCPAP for mild respiratory distress • Each infant own control; order of application randomized and data collected in two periods for a minimum of one hour, with 15 min on each device in each period (ie, CPAP/SiPAP, CPAP/SiPAP • Data collected using calibrated respiratory inductance plethysmography; esophageal balloon for estimation of pleural pressure • Continuous monitoring of saturation, pulse, transcutaneous oxygen and carbon dioxide

  41. Minute Ventilation n=13 P=0.037

  42. Synchronized Non-invasive ventilation

  43. Conclusions about SiPAP • Appears to be at least as effective as NCPAP • May improve gas exchange and decrease minute ventilation (?decrease WOB) • Synchrony may be useful

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