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05/14/2012
1
Respiratory Therapy a Tertiary NICU
Why do we do what we do?
Kuehne 2011
Brandon Kuehne, MBA, RRT-NPS, RPFT
Director- Neonatal Respiratory Services
Kuehne 2011
Disclosures
� Purpose: To enhance staff’s knowledge of the various types of respiratory therapy equipment that are unique to the neonatal intensive care environment.
� Objectives:
� Discuss the indications and clinical implications for various types of Respiratory Therapy Related Devices commonly used in the Neonatal Intensive Care Unit
� Describe various disease process related to common to CPAP/Bi-level devices
� The Planning Committee and Faculty of this activity have no disclosed conflicts of interest related to this content.
� Completion Criteria: In order to receive Continuing Education (CE) credit, you must attend 80% of the program.
� No commercial support was received for this program
Kuehne 2011
Why do we do what we do?
Kuehne 2011
Amillia Sonja TaylorMiami 2007
Birth Weight 283 grams
Length 10 inches
Gestational Age 22 weeks
Hospital LOS 4 months
Oxygen Req. Low
Home w/o deficit PRICELESS
Kuehne 2011
Neo RT History
“3,000 Years and Going Strong”
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And he went up, and lay upon the child
and, put his mouth upon his mouth,
and his eyes upon his eyes, and his
hands upon his hands; and he
stretched himself upon the child and
the flesh waxed warm
Old Testament, Elijah, I
Kings 17:17
NRP done OLD School
Slide courtesy of Robert DiBlassi RRTKuehne 2011
Kuehne 2011
Technological Advancements in Ventilators- Now
� Rapid response times � Active expiratory valves
� Accuracy of delivered volumes � Volume targeted ventilation
� Proximal flow sensing� Volume, triggering at ET tube,
graphics
� Pulmonary graphics� Identify various problems of
the patient-ventilator system
� NAVA- Neurally Adjusted Ventilatory Assist
Slide courtesy of Robert DiBlassi RRTKuehne 2011
The Future is now*
SPO2:
85-90%
Closed loop FiO2
SNIPPV TR mode
*Availability of these modes are FDA dependent as they are
already available overseas and in Canada
Slide courtesy of Robert DiBlassi RRT
Kuehne 2011
With all that’s out there-
What is the Right or Best approach?
Kuehne 2011
Introduction
� Multiple modes ventilation
� Volume v. Pressure
� Many different settings
� Conventional vs. High Frequency
� Oscillator vs. Jet
� Bubble vs. Infant Flow vs. HFNC
� Some confusion about how we arrive at the “right” settings for each patient
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If humans were identical in every way, like
specially bred laboratory mice, everything in
their environment could be controlled, and
we’d get the same great results in humans.
Kuehne 2011
Once again……..
What is the Right or Best approach?
Kuehne 2011
1. Whatever form of ventilation you use, know how to use it well.
2. Limiting the variability of treatment modalities will lead to better outcomes!
3. Early Extubation/ Leads to a decreased incidence of BPD!
Universal Rules
What we know
Kuehne 2011
3. Early Extubation/ Leads to a decreased incidence of BPD….getting to nCPAP remains an ongoing challenge
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Basic Ventilation Strategy
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Key Point:
Comes down to an basic understanding physiology differences between neonate and pediatric/adult pulmonary systems
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The Definitions
� Pulmonary function – how well is the respiratory system working?
� Two key components of pulmonary
mechanics
� Compliance – how easy it is to inflate lungs
(Premature Neonates generally have big problem with this)
� Resistance – opposition to airflow caused by forces of friction ie. obstruction to airflow
(generally associated with adult physiological/ pulmonary problems asthma- COPD, similar to BPD in infant populations)
And a little bit of…. Math
Kuehne 2011
Kuehne 2011
Math
� Compliance CL = ∆V/∆P (getting lungs to open up-getting air in)
� CL = ml/cmH2O
� Resistance (getting air out)
� R = Directly proportional to length
� R= Inversely proportional to r4
� R = cmH20/ml/s
Kuehne 2011
Math cont.
� Time constant – the rate at which lung fills or empties
� Time constant = R x C
� Time constant = (cmH20/ml/s)x(ml/cmH2O)
� Time constant = seconds
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Time Constant
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Surfactant Therapy
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(Multi-Access Catheter)
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Graphical Analysis of RDS
Pre Survanta Kuehne 2011
Pressure- Volume Graphical Analysis
of RDS
Six Hours Post Survanta
Nice football shape @ 45°angle
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Surfactant Research at NCH
Kuehne 2011
A Pharmacoeconomic Comparison of beractant and
poractant alfa in the presence of a
Rapid Extubation Protocol in a NICU
2011-2012
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What?
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Surfactant Comparison while
using a Rapid Extubation Protocol
in the NICU
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Purpose of Study
The overall objective is to determine if Poractant alfa (Curosurf®) reduces costs of care as compared to beractant (Survanta®) when utilized in the presence of a unit based rapid extubation protocol in the treatment of respiratory distress syndrome (RDS). Several outcome variables will be monitored and observed in a sequential, open label non-randomized format to determine if costs associated with the use of poractant alfa for treatment therapy are reduced as compared to beractant. A secondary objective will be to determine if patients demonstrate better tolerance of the surfactant administration process with poractant alfa as compared to beractant due to lower dose volumes and pharmacodynamic properties
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What?
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Vs.
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Collection of Data to Establish Baseline Response
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nCPAP
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Why use CPAP?
� Recruitment
� Atelectasis
� Maintenance of FRC
� Post extubation
� Apnea of prematurity
� RDS
� Structural
� Tracheal malacia
� Chest wall stability
� To treat an ↑’d WOB
� Poor gas exchange
� Alternative to intubation
� ↓ CLD (VON)
� ↓ VAP
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??? Bubble CPAP ???
� Successfully used by Dr. Wung in 1970’s
� 30+ years
� Extremely low incidence of BPD/CLD from his facility (Columbian Presbyterian Medical Center, NY)
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Devices� Bubble CPAP
� Requirements
� Air/O2 proportioner (Blender)
� Water column
� Modified ventilator circuit (Factory setup available)
� Benefits
� Potential for:
� Gas exchange due to bubbling
�Not easily reproduced
Kuehne 2011
F & P Bubble CPAP System
Now commercially available in USA
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NIPPV
Non-Invasive Positive Pressure Ventilation
or
Nasal Intermittent Positive Pressure Ventilation
� Two levels of pressure delivered via ventilator
using short bi-nasal prongs or nasopharyngeal prongs.
� Can be achieved with either:
�PS/CPAP
�Set rate, PIP and PEEP
Kuehne 2011
NIPPV
� Potential Benefits
� Reduction in apnea frequency
� ↑ CO2 removal
� Lung recruitment
� Synchrony may ↓ WOB
� Use of current facility equipment
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NIPPV Ventilators
� FDA 510K NCPAP approved devices:
� Viasys AVEA
� PB-840
� Servo I
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VF-NCPAP
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� Variable Flow (Infant Flow nCPAP) Generator
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What is SiPAP?
� SiPAP is a CPAP/Bi-Level device.
� That is, it is capable of functioning as a
straight forward VF-NCPAP machine. It
can also function as a Bi-Level device
providing two separate pressures to the
patient.
� Very similar to low span APRV or IMV-
Pressure control
Kuehne 2011
Complications common to all
nCPAP
� Septal Breakdown
� Labor intensive (Sicker patients now on CPAP)
� Dry mucosa
� CPAP Belly
� Atelectasis due to pressure loss
� Dilated nares
� Developmental delays due to mobility
� Positioning difficulties
Kuehne 2011
Non Invasive Monitoring
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Apnea monitor with Built-in
Pulse Oximeter
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Saturation Study
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Radiometer TCM –Analog
Electrode
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SenTec Digital TCM
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Stow-Severinghaus Digital
Electrode
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TCM Disposables
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Proofing Sample TCM
SenTec y = 0.872x + 5.3413
R2 = 0.9402
05
10152025
30354045505560657075
80859095
100
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 10
0
CBG
TCM
0
10
20
30
40
50
60
70
80
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
TCM
CBG
Invasive Monitoring
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i-STAT Portable Clinical Analyser
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High Frequency Ventilation
High Frequency Ventilation
Key Characteristics of high frequency ventilation:
1. Constant lung volume
2. Tidal volumes that approximate(often less than) the
anatomical dead-space.
3. Rates = or >180 breaths/minute.
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High Frequency Ventilation
Definition:
Mechanical ventilation using supraphysiologic rates with tidal
volumes that less than the anatomical dead space of the
airways.
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Mechanisms of Gas Exchange:
� Bulk Convection
� Pendeluft
� Asymmetric Velocity Profiles
� Taylor Dispersion
� Molecular Diffusion
� Cardiogenic Mixing
High Frequency Ventilation
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High Frequency Ventilators
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High Frequency VentilatorsSensorMedics Oscillator
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High Frequency Ventilators:
Bunnell Jet Ventilator
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Specialized Gases
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Sub-ambient FIO2 Nitrogen Gas Delivery
When room air is not good enough!
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Nitrogen Therapy
Ventilator Hood
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Purpose:
To keep PDA open
� Used in conjunction with prostoglandens
� FIO2 levels driven down to approximately 17% using Nitrogen.
� Used mainly for Hypoplastic Left Heart syndrome
Kuehne 2011
Calculating Flow via Nitrogen Tank
[(flow RA flow meter) x 0.21] + [(flow N flow meter) x 0]
FiO2 = Total Flow (or flow RA+ flow N)
Ex: If 17% FiO2 desired:
8 lpm x .21
.17
Gives total flow of: 9.8 lpm
To get Nitrogen flow
9.8 lpm total flow – 8 lpm air = 1.8 lpm of Nitrogen
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Nitric Oxide
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The Basics
� Nitric Oxide was first discovered by Joesph Priestly in
1772 during his research and discovery of the Oxygen molecule
� It is formed from superheated Nitrogen in the presence of
Oxygen (aka combustion of fossil fuels).
� Nitric Oxide is a Free Radical thus making it very reactive
and unstable.
Kuehne 2011
Normal NO function
� NO relaxes the smooth muscle in the walls of the arterioles. At each systole, the endothelial cells that line the blood vessels
release a puff of NO. This diffuses into the underlying smooth muscle cells causing them to relax and thus permit the surge of
blood to pass through easily
� During diastole, the myocyte has consumed the provided NO,
the dilatation ceases. Venous blood flow is encouraged.
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Open Label Use
� Inclusion Criteria
� Newborns > 34 weeks gestational age
� Hypoxic Respiratory failure
� Clinical or echocardiographic (ideal)
evidence of PPHN
� Oxygen Index (OI) > 20
� ECMO eligible
Kuehne 2011
Why we use it
PPHNPersistent Pulmonary Hypertension
� Newborns > 34 weeks gestational age� Hypoxic Respiratory failure
� Clinical or echocardiographic (ideal) evidence of PPHN
� Oxygen Index (OI) > 20� ECMO eligible
And
� Because I am asked to …
Kuehne 2011
Off Label Use
� < 34 weeks gestational age
� > 10-14 days of mechanical ventilation
� Irreversible lung disease
� Significant congenital heart disease
� Significant IVH
� Severe asphyxia or poor neurological prognosis
� Lethal congenital or chromosomal anomaly
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INOmax DSIR
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iNO Weaning Algorhythm, developed at NCH
Kuehne 2011
Aerosol Delivery
Research
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Radio-Aerogen In Vitro Study
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Laurie Gibson, RT(R) injects 3ml of TC 99mTC DTDA aerosol
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Fig. 2 CPAP with aerogen placed 18 inches from patientFig. 1 CPAP with aerogen placed at
humidifier
PILOT RANDOMIZED CLINICAL TRIAL OF INHALED PGE1 IN
NEONATES WITH SUB-OPTIMAL RESPONSE TO INHALED NITRIC OXIDE
Design/Methods
Inclusion Criteria:� GA ≥ 34 weeks
� Postnatal age ≤ 7 d
� Diagnosis of NHRF
� MV, INO, OI ≥ 15 x 2
� Indwelling arterial line
� Parental consent
Exclusion Criteria:
� Lethal conditions
� CDH
� CHD
� Thrombocytopenia
� Conflicting clinical trial
Trial Design: Multi-center, pilot RCT
IPGE1 Setup: Conventional & Jet Vent
Study Medications will be delivered
to the mini-nebs via syringe pumps
Study Drug
Normal Saline
T- Connector inInspiratory Line
Flow sensor remains inline
iNO sample line
0.3ml Tubing
Mini-Neb
Tri-flowconnector
Study Drug
Normal Saline
Screening & Enrolling Patients in the IPGE1 RCT Pilot
Kuehne 2011
Improving BPD Patient
Outcomes
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Successfully Extubating the BPD Infant to nCPAPComprehensive Center for Bronchopulmonary Dysplasia
Kuehne 2011
Background
� February 2007 through September 2010 total of 94 extubation attempts of 62
BPD infants
� Success rate 66%
� Of the 62 patients
� 4 patients received trachs
� 4 deceased
� 54 successfully extubated and discharged
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Successful Extubation
� Defined: 72 hrs without out needing reintubation.
Kuehne 2011
Extubation Checklist
� No Airway Anomaly� Fi02 ≤ 40%
� No elevation in respiratory management within past 72 hrs
� Weight Trend: +/- ______ g/d� Full enteral feeds
� No surgery planned with in next 72 hrs
� No ROP exam scheduled for day of extubation
� No active infections� Medications for extubation ordered
� Team consensus
� Previous extubation failure????
Kuehne 2011
Extubation Timeline
2hours prior to extubation
-Evaluation by Extubation Team-patient confirmed by group as ready for extubation-feeds are stopped
1 hour prior to extubation
-Sipap machine set-up at bedside and plugged into air/oxygen wall inlets-Additional supplies placed at bedside
-intubation box-chin strap-shoulder rolls-sucrose-Chloral Hydrate
-Appropriate prong and hat size selected using package insert and head circumference
45 minutes prior to extubation
-RN and RT at bedside to deep suction nares of patient with 8 Fr suction catheter-ET-Tube suctioned-NCPAP interface placed on patient with ET-Tube remaining in place
30 minutes prior to extubation
-Diaper change/pt care needs met-OG separated from ET-Tube and re-secured to patient-Sipap machine and heater turned on.-Minimal flow initiated on Sipap machine-At this time, patient should be allowed to rest until extubation
Kuehne 2011
Interventions� Mild Respiratory Distress
� Mechanical Intervention
� Reposition� Suction� Chin Strap (if not already in place)� Assure proper size of hat and prongs� Assure appropriate humidity� Assure adequate CPAP is being achieved� Assure adequate O2
� Non Pharmacologic Interventions/Comfort Measures
� Swaddling� Prone positioning� Hand containment� Holding by mom� Pacifier� Change diaper, feed?
� Pharmacologic Interventions
� Moderate Respiratory Distress
� Mechanical Interventions as above� Non Pharmacologic Interventions/Comfort Measures as above
� Pharmacologic Interventions
� Chloral Hydrate (25-50 mg/kg), may repeat after discussion with attending� Lasix (give oral dose early, consider IM)� Steroids for airway edema or if evidence of wheezing, consider starting systemic steroid course� Consider benzodiazepam� Consider bronchodilators if wheezing is predominant finding
� Severe Respiratory Distress
� Reevaluate mechanical � Discuss with attending
� Apnea
� Consider reloading with Caffeine
� Assure adequately suctioned nares� Discuss with attending
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Post Extubation ScoreWOB – Retractions, flaring and head bobbing
*Score infant 1 2 or 3 depending on how many symptoms they have*
Respirations – Scoring • 40 – 60 auscultated breaths per minute = 0• 61 – 80 auscultated breaths per minute = 1• 81 – 100 auscultated breaths per minute = 2• > 101 auscultated breaths per minute = 3
Apnea= 4
CNSSleeps between cares =0Irritable consolable =1
Irritable inconsolable=3Lethargic (does not wake for cares) =4
Color – Scoring• Pink = 0• Pale = 1• Dusky = 2
• Cyanosis = 3
Heart Rate – Scoring• Baseline = 0
• 180 – 200 bpm = 1• > 201 bpm =2
• Bradycardia =3
FiO2 – Scoring• Baseline + 10 % = 0• Baseline + 20 % = 1• Baseline + 30 % = 2• Baseline + 40 % = 3
Saturations - Scoring• 95 – 100 % = 0
• 90 – 94 % = 1• < 89 % = 2
Temperature – Scoring• < 100 .0 F = 0• > 100 .0 F = 1
* This scoring with be implemented at extubation, 15 min x 4, 30 min x 2, and q 1 hr for 22 hours
ECMO
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System Overview
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ECMOExtracorporeal membrane Oxygenation
� Extracorporeal
membrane oxygenation is the use of prolonged
cardiopulmonary bypass
for infants with hypoxic respiratory or cardiac
failure who fail to respond
to maximal medical management and less-
invasive therapies.
Kuehne 2011
Neonatal Diseases Treated by
ECMO
� MAS – Meconium Aspiration Syndrome
� PPHN – Persistent Pulmonary Hypertension of the Newborn
� CDH – Congenital Diaphragmatic Hernia
� Sepsis/pneumonia
� RDS – Respiratory Distress Syndrome
� Airleak syndrome
� Recent, novel uses include hydrops fetalis, viral pneumonia and cardiomyopathy
Kuehne 2011
ECMO
Extracorporeal Membrane
Oxygenation
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Questions?