CPAP e ventila o n o invasiva Continuous positive pressure and noninvasive ventilation

1. CPAP e ventila��o n�o invasiva(Continuous positive pressure and noninvasive ventilation)

2. Qual a melhor maneira de tratar um RN que requer suporte ventilat�rio? Como minimizar os danos do tratamento na via a�rea e pulm�es?

3. Patrick Kennedy, nasceu em 1963 com 34 semanas, mais de 2000gramas...e faleceu de DMH! As primeiras tentativas de ventila��o em prematuros foram desajeitadas, a falta de equipamentos adequados dificultava muito. Equipamentos de adultos eram adaptados... Para se fornecer PEEP, se submergia a mangueira exalat�ria do aparelho de adultos em um recipiente com �gua.

4. Nem imaginavam que d�cadas mais tarde Gregory postularia o CPAP com selo de �gua. O grupo de Gregory n�o criou este sistema achando que fosse melhor, simplesmente naquele tempo n�o havia outra maneira de se gerar CPAP t�o facilmente em rec�m-nascidos (RN).

5. N�o era f�cil oferecer CPAP sem intubar. Foram tentadas m�scaras fixadas com el�stico ao redor do cr�nio, mas precisavam ficar muito apertadas para selar bem e acabavam por lesar o RN. Kattwinkel propus em 1973 o uso de prongas nasais. Quase simultaneamente apareceram ventiladores neonatais de v�rias marcas e modelos.

6. Os neonatologistas ficaram fascinados com esses novos � brinquedos� pois de fato esses ventiladores salvaram muitas vidas... Contudo, negligenciaram o CPAP. Depois, surgiram d�vidas a respeito de qual era o melhor manuseio dos prematuros em ventila��o. Aparecera �n�meros m�gicos� Intubar todos os menores de x gramas N�o extubar abaixo de y gramas N�o usar PEEP maior que z...

7. O aparecimento de ventiladores de alta frequencia na d�cada de 80 adicionou mais complexidade � ventila��o neonatal e mais novas m�quinas para o nosso �arsenal�. UTINS constru�das h� 15 ou 20 anos mal conseguem acomodar os aparelhos necess�rios para cada leito.

8. A era da VM (ventila��o mec�nica) invasiva como melhor e �nica resposta para o RN com problemas respirat�rios chega ao fim. Conhecimentos a respeito da fragilidade pulmonar, a cascata ativada com o volutrauma, barotrauma, atelectrauma e biotrauma... Aparelhos modernos permitem sincronizar a respira��o e medir o volume corrente... Ao mesmo tempo h� renovado interesse em m�todos que possibilitem a n�o intuba��o como medida protetora do pulm�o.

9. Usado quando o alv�olo tende ao colapso ou est� cheio de l�quido. DMH, TTRN, SAM,ICC, hemorragia pulmonar, ?complac�ncia tor�cica, etc. Usado na apn�ia da prematuridade, laringomal�cia e traqueomal�cia.

10. Existem muitos m�todos de se aplicar CPAP e isso dificulta as compara��es. Fluxo cont�nuo No ventilador No selo de �gua Fluxo vari�vel ? tipos de prongas. Simples Bi-nasais Curtas ou compridas TOT posicionado na faringe

11. Metan�lise da Cochrane de 2003 e 2005 n�o acharam evidencias suficientes para o uso profil�tico de CPAP nasal. Por outro lado, os estudos anteriores a 1990, sem cortic�ide antenatal e sem surfactante n�o se aplicam � atual popula��o de prematuros. Os crit�rios de intuba��o, de extuba��o e de necessidade de surfactante varia de centro para centro. Isso dificulta os trabalhos com CPAP nasal.

12. So & Col: estudo aleat�rio com 50 RN <1500 gr. HOOD vs CPAP p�s extuba��o: o grupo CPAP teve maior sucesso na extuba��o. Higgins & col confirmaram estes resultados para RN <1000 gr. Robertson & Hamilton compararam IFD com HOOD em 58 RN de � 1000 gr � n�o acharam diferen�a no sucesso da extuba��o. Contudo 100% tinha recebido surfactante

13. Davis & col compararam 92 RN entre 600-1250 gr para CPAP vs HOOD: 66% de sucesso no CPAP contra 40% no grupo HOOD. A revis�o da Cochrane 2003 concluiu que o CPAP � ferramenta �til na preven��o do insucesso na extuba��o.

14. Os aparelhos de fluxo intermitente n�o mostraram ser melhores ou piores que os de fluxo cont�nuo. Mazzella demonstrou menor necessidade de o2 no IFD vs CPAP de selo de �gua mas o grupo era pequeno e o CPAP fornecido com pronga hipo faringea simples. Davis & col compararam as prongas simples com as bi-nasais em 87 RN <1000gr. Sucesso na extuba��o: 43% vs 76%. O CPAP com selo de �gua � utilizado no centro com menor DBP!

15. Os benef�cios - preju�zos do selo de �gua s�o discut�veis.

16. qualquer m�todo que forne�a press�o positiva em todo o ciclo respirat�rio sem a presen�a de TET (tubo endotraqueal) NV (ventila��o nasal), NIMV e (SNIMV (ventila��o nasal sincronizada mandat�ria intermitente), NPSIMV ( ventila��o nasofaringeana sincronizada mandat�ria intermitente), NPPV (ventila��o por press�o positiva n�o invasiva) e Bi Level CPAP (BiPAP). Estes termos s�o confusos e quase que sin�nimos. Todos indicam ventila��o n�o invasiva via nasal. Tem as vantagens do CPAP (*) e mais o beneficio de ciclos de press�o positiva. Propicia volumes correntes maiores, ?o trabalho respirat�rio e provavelmente ? a PCO2.

17. O ? da press�o transpulmonar durante os picos inspirat�rios pode recrutar �reas atelect�sicas terminais. A PEEP mant�m a VA patente e os ciclos de PI ? as dessatura��es e a bradicardia. A VNI n�o sincronizada pode ser realizada com qualquer aparelho a ? da sincronizada. Os sensores podem ser de superf�cie corporal ou de fluxo de ar. Ambos apresentam dificuldades.

18. O conceito de Bi Level CPAP � confuso. Pode ser usado com o plateau > 1 segundo e PI menor que as habituais. S�o necess�rios mais estudos para avaliar os benef�cios do Bipap. Parece que a VNI sincronizada � mais eficiente que o CPAP convencional no sucesso de extuba��o (3 trabalhos). Ainda n�o est� claro se a VNI � mais eficiente que o CPAP convencional na preven��o das apn�ias.

19. Inicia com PEEP 6 cm H2O; PI 16 cm H2O; TI 0,4 seg; FR 15pm Alguns casos individuais podem requerer PEEP maiores (7-8 cmH2O) Os casos de apn�ia da prematuridade sem les�o pulmonar requerem PI menores (10-12 cm H2O) e PEEP entre 4-6 cm H2O. Contudo alguns prematuros precisam de PEEP maiores para prevenir o colabamento da via a�rea que leva a apn�ias.

20. Contudo, vale a pena lembrar que o �nico beneficio comprovado da VNI sincronizada � o sucesso na extuba��o de rec�m-nascido de muito baixo peso As complica��es da VNI parecem ser apenas as do CPAP nasal.

21. CPAP na sala de parto: faz maior sentido. CPAP e surfactante: qual primeiro? � necess�rio mesmo sincronizar a VNI? VNI como suporte inicial na doen�a da membrana hialina VNI na apn�ia da prematuridade: perspectiva interessante

23. Refer�ncias do artigo: [1]� Gregory G.A.,�Kitterman J.A.,�Phibbs R.H.,�et al:� Treatment of the idiopathic respiratory-distress syndrome with continuous positive airway pressure. �N Engl J Med�284.�(24): 1333-1340.1971;� Citation [2]� Kattwinkel J.,�Fleming D.,�Cha C.C.,�et al:� A device for administration of continuous positive airway pressure by the nasal route. �Pediatrics�52.�131-134.1973;� Citation [3]� Miller M.J.,�DiFiore J.M.,�Strohl K.P.,�et al:� Effects of nasal CPAP on supraglottic and total pulmonary resistance in preterm infants. �J Appl Physiol�68.�(1): 141-146.1990;� Abstract [4]� Benveniste D.,�Berg O.,�Pedersen J.E.P.:� A technique for delivery of continuous positive airway pressure to the neonate. �J Pediatr�88.�(6): 1015-1019.1976;� Citation [5]� Moa G.,�Nilsson K.,�Zetterstrom H.,�et al:� A new device for administration of nasal continuous positive airway pressure in the newborn: an experimental study. �Crit Care Med�16.�1238-1242.1988;� Abstract [6]� Klausner J.F.,�Lee A.Y.,�Hutchison A.A.:� Decreased imposed work with a new nasal continuous positive airway pressure device. �Pediatr Pulmonol�22.�188-194.1996;� Abstract [7]� DePaoli A.G.,�Davis P.G.,�Faber B.,�et al:� Devices and pressure sources for administration of nasal continuous positive airway pressure (NCPAP) in preterm neonates. �Cochrane Database Syst Rev�3.�2002;CD002977�[8]� Subramaniam P.,�Henderson-Smart D.J.,�Davis P.G.:� Prophylactic nasal continuous positive airways pressure for preventing morbidity and mortality in very preterm infants. �Cochrane Database Syst Rev�3.�2005;CD001243�[9]� O'Donnell C.,�Davis P.,�Morley C.:� Positive end-expiratory pressure for resuscitation of newborn infants at birth. �Cochrane Database Syst Rev�3.�2003;CD004341�[10]� Ho J.J.,�Subramaniam P.,�Henderson-Smart D.J.,�et al:� Continuous distending pressure for respiratory distress syndrome in preterm infants. �Cochrane Database Syst Rev�2.�2002;CD002271�

24. [11]� Ho J.J.,�Henderson-Smart D.J.,�Davis P.G.:� Early versus delayed initiation of continuous distending pressure for respiratory distress syndrome in preterm infants. �Cochrane Database Syst Rev�2.�2002;CD002975�[12]� Krouskop R.W.,�Brown E.G.,�Sweet A.Y.:� The early use of continuous positive airway pressure in the treatment of idiopathic respiratory distress syndrome. �J Pediatr�87.�(2): 263-267.1975;� Abstract [13]� Han V.K.M.,�Beverley D.W.,�Clarson C.,�et al:� Randomized controlled trial of very early continuous distending pressure in the management of preterm infants. �Early Hum Dev�15.�21-32.1987;� Abstract [14]� Verder H.,�Robertson B.,�Greisen G.,�et al:� Surfactant therapy and nasal continuous positive airway pressure for newborns with respiratory distress syndrome. �N Engl J Med�331.�1051-1055.1994;� Abstract [15]� Sandri F.,�Ancora G.,�Lanzoni A.,�et al:� Prophylactic nasal continuous positive airways pressure in newborns of 28-31 weeks gestation: multicentre randomized controlled clinical trial. �Arch Dis Child Fetal Neonatal Ed�89.�F394-F398.2004;� Abstract [16]� Jonsson B.,�Katz-Salamon M.,�Faxelius G.:� Neonatal care of very-low-birth weight infants in special-care units and neonatal intensive-care units in Stockholm. Early nasal continuous positive airway pressure versus mechanical ventilation: gains and losses. �Acta Paediatr Suppl�419.�4-10.1997;� Abstract [17]� Lindner W.,�Vofsbeck S.,�Hummler H.,�et al:� Delivery room management of extremely low birth weight infants: spontaneous breathing or intubation?. �Pediatrics�103.�(5): 961-967.1999;� Abstract [18]� Gitterman M.K.,�Fusch C.,�Gitterman A.R.:� Early nasal continuous positive airway pressure treatment reduces the need for intubation in very low birth weight infants. �Eur J Pediatr�156.�384-388.1997;� Abstract [19]� Annibale D.J.,�Hulsey T.C.,�Engstrom P.C.,�et al:� Randomized, controlled trial of nasopharyngeal continuous positive airway pressure in the extubation of very low birth weight infants. �J�Pediatr�124.�455-460.1994;�[20]� So B.H.,�Tamura M.,�Mishina J.,�et al:� Application of nasal continuous positive airway pressure to early extubation in very low birthweight infants. �Arch Dis Child Fetal Neonatal Ed�72.�F191-F193.1995;� Abstract 

25. [21]� Higgins R.D.,�Richter S.E.,�Davis J.M.:� Nasal continuous positive airway pressure facilitates extubation of very low birth weight neonates. �Pediatrics�88.�(5): 999-1003.1991;� Abstract [22]� Robertson N.J.,�Hamilton P.A.:� Randomised trial of elective continuous positive airway pressure (CPAP) compared with rescue CPAP after extubation. �Arch Dis Child Fetal Neonatal Ed�79.�F58-F60.1998;� Abstract [23]� Davis P.,�Jankov R.,�Doyle L.,�et al:� Randomised, controlled trial of nasal continuous positive airway pressure in the extubation of infants weighing 600-1250g. �Arch Dis Child Fetal Neonatal Ed�79.�F54-F57.1998;� Abstract [24]� Davis P.G.,�Henderson-Smart D.J.:� Nasal continuous positive airway pressure immediately after extubation for preventing morbidity in preterm infants. �Cochrane Database Syst Rev�2.�2003;CD000143�[25]� Courtney S.E.,�Aghai Z.H.,�Saslow J.G.,�et al:� Changes in lung volume and work of breathing: a comparison of two variable-flow nasal continuous positive airway pressure devices in very low birth weight infants. �Pediatr Pulmonol�36.�248-252.2003;� Abstract [26]� Pandit P.B.,�Courtney S.E.,�Pyon K.H.,�et al:� Work of breathing during constant- and variable-flow nasal continuous positive airway pressure in preterm neonates. �Pediatrics�108.�(3): 682-685.2001;� Abstract [27]� Courtney S.E.,�Pyon K.H.,�Saslow J.G.,�et al:� Lung recruitment and breathing pattern during variable versus continuous flow nasal continuous positive airway pressure in premature infants: an evaluation of three devices. �Pediatrics�107.�(2): 304-308.2001;� Abstract [28]� Stefanescu B.M.,�Murphy W.P.,�Hansell B.J.,�et al:� A randomized, controlled trial comparing two different continuous positive airway pressure systems for the successful extubation of extremely low birth weight infants. �Pediatrics�112.�(5): 1031-1038.2003;� Abstract [29]� Mazzella M.,�Bellini C.,�Calevo M.G.,�et al:� A randomized control study comparing the Infant Flow Driver with nasal continuous positive airway pressure in preterm infants. �Arch Dis Child Fetal Neonatal Ed�85.�F86-F90.2001;� Abstract [30]� Davis P.,�Davies M.,�Faber B.:� A randomized controlled trial of two methods of delivering nasal continuous positive airway pressure after extubation to infants weighing less than 1000 g: binasal (Hudson) versus single nasal prongs. �Arch Dis Child Fetal Neonatal Ed�85.�(2): F82-F85.2001;� Abstract 

26. [31]� De Paoli A.G.,�Morley C.J.,�Davis P.G.:� In vitro comparison of nasal continuous positive airway pressure devices for neonates. �Arch Dis Child Fetal Neonatal Ed�86.�F42-F45.2002;� Abstract [32]� Avery M.E.,�Tooley W.H.,�Keller J.B.,�et al:� Is chronic lung disease in low-birth-weight infants preventable? A survey of eight centers. �Pediatrics�79.�26-30.1987;� Abstract [33]� Christensen E.F.,�Jensen R.H.,�Schonemann N.K.,�et al:� Flow-dependent properties of positive expiratory pressure devices. �Monaldi Arch Chest Dis�50.�(2): 150-153.1995;� Abstract [34]� Pillow J.J.,�Travadi J.N.,�Bubble C.P.A.P.:� Is the noise important? An in vitro study. �Pediatr Res�57.�826-830.2005;� Abstract [35]� Morley C.J.,�Lau R.,�De Paoli A.,�et al:� Nasal continuous positive airway pressure: does bubbling improve gas exchange?. �Arch Dis Child Fetal Neonatal Ed�90.�F343-F344.2005;� Abstract [36]� Liptsen E.,�Aghai Z.H.,�Pyon K.H.,�et al:� Work of breathing during nasal continuous positive airway pressure in preterm infants: a comparison of bubble vs variable-flow devices. �J Perinatol�25.�453-458.2005;�[37]� Locke R.C.,�Wolfson M.R.,�Shaffer T.H.:� Inadvertent administration of positive end-distending pressure during nasal cannula flow. �Pediatrics�91.�(1): 135-138.1993;� Abstract [38]� Sreenan C.,�Lemke R.P.,�Hudson-Mason A.,�et al:� High-flow nasal cannulae in the management of apnea of prematurity: a comparison with conventional nasal continuous positive airway pressure. �Pediatrics�107.�(5): 1081-1083.2001;� Abstract [39]� Finer N.N.:� Nasal cannula use in the preterm infant: oxygen or pressure?. �Pediatrics�116.�(5): 1216-1217.2005;� Citation [40]� Chang G.Y.,�Cox C.C.,�Shaffer T.H.:� Nasal cannula, CPAP and vapotherm: effect of flow on temperature, humidity, pressure and resistance. �PAS�57.�1231.2005

27. [41]� American Association of Respiratory Care :� AARC clinical practice guideline: selection of an oxygen delivery device for neonatal and pediatric patients � 2002 revision & update. �Respir Care�47.�707-716.2002;� Citation [42]� Migliori C.,�Motta M.,�Angeli A.,�et al:� Nasal bilevel vs. continuous positive airway pressure in preterm infants. �Pediatr Pulmonol�40.�426-430.2005;� Abstract [43]� Moretti C.,�Gizzi C.,�Papoff P.,�et al:� Comparing the effects of nasal synchronized intermittent positive pressure ventilation (nSIPPV) and nasal continuous positive airway pressure (nCPAP) after extubation in very low birth weight infants. �Early Hum Dev�56.�167-177.1999;� Abstract [44]� Kiciman N.M.,�Andreasson B.,�Bernstein G.,�et al:� Thoracoabdominal motion in newborns during ventilation delivered by endotracheal tube or nasal prongs. �Pediatr Pulmonol�25.�175-181.1998;� Abstract [45]� Pape K.E.,�Armstrong D.L.,�Fitzhardinge P.M.:� Central nervous system pathology associated with mask ventilation in the very low birth weight infant: a new etiology for intracerebellar hemorrhages. �Pediatrics�58.�473-483.1976;� Abstract [46]� Padman R.,�Lawless S.T.,�Kettrick R.G.:� Noninvasive ventilation via bilevel positive airway pressure support in pediatric practice. �Crit Care Med�26.�169-173.1998;� Full Text [47]� Migliori C.,�Cavazza A.,�Motta M.,�et al:� Early use of nasal-BiPAP in two infants with congenital central hypoventilation syndrome. �Acta Paediatr�92.�823-826.2003;� Abstract [48]� Barrington K.J.,�Bull D.,�Finer N.N.:� Randomized trial of nasal synchronized intermittent mandatory ventilation compared with continuous positive airway pressure after extubation of very low birth weight infants. �Pediatrics�107.�638-641.2001;� Abstract [49]� Davis P.G.,�Lemyre B.,�de Paoli A.G.:� Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for preterm neonates after extubation. �Cochrane Database Syst Rev�3.�2001;CD003212�[50]� Ryan C.A.,�Finer N.N.,�Peters K.L.:� Nasal intermittent positive-pressure ventilation offers no advantages over nasal continuous positive airway pressure in apnea of prematurity. �Am J Dis Child�143.�(10): 1196-1198.1989;� Abstract 

28. (51)Lin C.H.,�Wang S.T.,�Lin Y.J.,�et al:� Efficacy of nasal intermittent positive pressure ventilation in treating apnea of prematurity. �Pediatr Pulmonol�26.�(5): 349-353.1998;� Abstract [52]� Naik A.S.,�Kallapur S.G.,�Bachurski C.J.,�et al:� Effects of ventilation with different positive end-expiratory pressures on cytokine expression in the preterm lamb lung. �Am J Respir Crit Care Med�164.�494-498.2001;� Abstract [53]� Mulrooney N.,�Champion Z.,�Moss T.J.M.,�et al:� Surfactant and physiologic responses of preterm lambs to continuous positive airway pressure. �Am J Respir Crit Care Med�171.�488-493.2005;� Abstract [54]� Thomson M.A.,�Yoder B.A.,�Winter V.T.,�et al:� Treatment of immature baboons for 28 days with early nasal continuous positive airway pressure. �Am J Respir Crit Care Med�169.�1054-1062.2004;� Abstract [55]� Finer N.N.,�Carlo W.A.,�Duara S.,�et al:� Delivery room continuous positive airway pressure/positive end-expiratory pressure in extremely low birth weight infants: a feasibility trial. �Pediatrics�114.�651-665.2004;� Abstract [56]� Aghai Z.H.,�Saslow J.G.,�Nakhla T.,�et al:� Synchronized nasal intermittent positive pressure ventilation (SNIPPV) decreases work of breathing (WOB) in premature infants with respiratory distress syndrome (RDS) compared to nasal continuous positive airway pressure (NCPAP). �Pediatr Pulmonol�41.�875-881.2006;� Abstract [57]� Santin R.,�Brodsky N.,�Bhandari V.A.:� A prospective observational pilot study of synchronized nasal intermittent positive airway pressure (SNIPPV) as a primary mode of ventilation in infants =28 weeks with respiratory distress syndrome (RDS). �J Perinatol�24.�487-493.2004;� Abstract [58]� Yong S.-C.,�Chen S.-J.,�Boo N.-Y.:� Incidence of nasal trauma associated with nasal prong versus nasal mask during continuous positive airway pressure treatment in very low birthweight infants: a randomised control study. �Arch Dis Child Fetal Neonatal Ed�90.�F480-F483.2005;� Abstract [59]� Garland J.S.,�Nelson D.B.,�Rice T.,�et al:� Increased risk of gastrointestinal perforations in neonates mechanically ventilated with either face mask or nasal prongs. �Pediatrics�76.�406-410.1985;� Abstract [60]� Kregenow D.A.,�Rubenfeld G.D.,�Hudson L.D.,�et al:� Hypercapnic acidosis and mortality in acute lung injury. �Crit Care Med�34.�1-7.2006;� Full Text [61]� Gressens P.,�Rogido M.,�Paindaveine B.,�et al:� The impact of neonatal intensive care practices on the developing brain. �J Pediatr�140.�646-653.2002;� Full Text [62]� Tin W.,�Wariyar U.:� Giving small babies oxygen: 50 years of uncertainty. �Semin Neonatol�7.�361-367.2002;� Abstract 

29. Consultem tamb�m: TESE DE MESTRADO (Universidade de Bras�lia): Avalia��o in vitro de dois aparelhos para CPAP nasal de uso neonatal Autor(es): Carlos Alberto Moreno Zaconeta

30. CPAP no ano de 2006: Indica��o e atualiza��o Autor(es): Nestor Vain (Argentina). Realizado por Carlos Zaconeta e Paulo R. Margotto