Non-Invasive Ventilation NeonatalBest Evidence & BIDMC Applications
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal – Outline of Points
Beth Israel Hospital Boston Respiratory Care
•Indications & Incentives for Use•Background Definitions•Devices•Interfaces•Use outside of BI•Unanswered questions•Controversies•Recommendations for BI use
•Current use•How should use to improve care
Non-Invasive Ventilation Neonatal - Indications & Incentives
Beth Israel Hospital Boston Respiratory Care
Indications & Incentives
•Reduced BPD (time independent)•Reduce volu-trauma•Reduce hyper & hypoxia
•Reduce work of breathing•Increase thoracic abdominal synchrony•Increase spontaneous tidal volume
•Reduce VAP with shorter intubation
•Reduce discomfort
•Improve interaction with mother and environs
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
Eur J Pediatr. 2010 July; 169(7): 777–782.Published online 2010 February 24. doi: 10.1007/s00431-010-1159-xCopyright/LicenseRequest permission to reuseTable 2. Beneficial effects of noninvasive ventilation in newborns
•Important practical conclusions for applying NIV in newborns with respiratory distress:•A physiological background is needed to understand NIV•NIV can be used to avoid mechanical ventilation•Adjustable and measured PEEP should be used immediately after birth•PEEP levels should remain around +5 cm H2O or higher•nCPAP appears to be a satisfactory alternative to endotracheal intubation•Without available scientific evidence, it seems potentially harmful to use HHFNC in newborns
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
Eur J Pediatr. 2010 July; 169(7): 777–782.Published online 2010 February 24. doi: 10.1007/s00431-010-1159-xCopyright/LicenseRequest permission to reuseTable 2. Beneficial effects of noninvasive ventilation in newborns
Improved respiratory mechanics Increased lung volume
Increased compliance
Decreased resistance
Improved respiratory timing Decreased thoracoabdominal asynchrony
Decreased obstructive and mixed apnoea
Improved respiratory timing
Improved oxygenation Decreased pulmonary vascular resistance
Decreased intrapulmonary shunting
Increased alveolar volume and less collapse
Non-Invasive Ventilation Neonatal - Indications & Incentives
Concerns
•Complicated devices and techniques must learned
•Gastric distention & perf. (Garland Pediatrics 1985; 76:406-410)
•Contraindicated with upper airway anomalies (choanal atresia, cleft palate, te fistula or severe cardiovascular instability
•Tissue breakdown around interface device
•Feeding intolerance
Setup of NIPPV
* V Bhandari JOP 2010 30, 505-512•O2 to optimize saturation per policy, •Caffeine •Hct. > 35
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
CLD Working Group
rate Ti PIP PEEP rise time flow LPMPressure
MAX
Ramanathan
40 max 50
0.5to1
PEEP plus
10-155-8 0.1-0.2 10-15 PIP 30
V Bhandari *
~40 ~0.45PIPvent
plus4
4-6Not
specified8-10
MAP 14 < 1000g16 > 1000 g
Chronic LungDisease NIPPV
Overview
15-200.3to
0.5
PIPvent plus2-4
5Not
specifiedNot
specifiedNot
specified
*
Transition of Support
• Remove NIPPV– Rate 15-25– PIP < 17– PEEP <6– FiO2 <35
V Bhandari JOP 2010 30, 505-512
• Intubate– pH < 7.25 PaCO2 > 60– Apnea requiring bagging– Frequent As & Bs– Frequent desaturations
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
“…can use blood gases to help wean, but not typically needed—can wean or increase settings based on clinical appearance” CLD Working Group
Non-Invasive Ventilation Neonatal – Interfaces
Beth Israel Hospital Boston Respiratory Care
•Interfaces for Non-Invasive
•High-Flow Cannula
•NP Tube
•Prongs•Long prong•Bi-Nasal Prongs
•Nasal Mask
•RAM Cannula
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
Case report Oral continuous positive airway pressure (CPAP) following nasal injury in a preterm infant, H R Carlisle, C O F Kamlin, L S Owen, P G Davis, C J Morley; Arch Dis Child Fetal Neonatal Ed 2010;95:F142F143 doi:10.1136/adc.2009.170084
Non-Invasive Ventilation Neonatal – Modes and Devices
Beth Israel Hospital Boston Respiratory Care
•Modes of Non-Invasive Ventilation•Devices for Non-invasive Ventilation
•High-Flow Nasal Cannula•Bubble CPAP•Hansen Ventilator•Conventional•Conventional with NAVA•Hi-Fi
Non-Invasive Ventilation Neonatal – Device – Arabella CPAP & Vapotherm
Beth Israel Hospital Boston Respiratory Care
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal
Non-Invasive Ventilation Neonatal – Device - Hansen Ventilator
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal – Device – Viasys BiPAP
Beth Israel Hospital Boston Respiratory Care
BWH uses rarely.
NAVANon-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory CareINSURE (intubatio-surfactant-extubation)
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal – Indications & Incentives
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal –Indication & Incentive
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal – Indications & Incentives
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal – High Flow Cannula
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal – High Flow Cannula
Beth Israel Hospital Boston Respiratory Care
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal – High Flow Cannula
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care
Long versus short inspiratory times in neonates receiving mechanical ventilation
Kamlin COF, Davis PG• http://www.nichd.nih.gov/cochrane/Kamlin/KAMLIN.HTM
• Reviewers' conclusions• Implications for practice• Long inspiratory times when used in acute HMD in a population not
exposed to antenatal steroids and postnatal surfactant are associated with higher rates of mortality and morbidity. Stiff lungs with HMD have very short time constants. Mechanically ventilated infants with HMD and especially those treated in institutions where these adjunctive therapies are not available should be ventilated using a short IT.
• The use of a long IT where time constants are longer than acute HMD such as premature infants with BPD, meconium aspiration syndrome and newborns in cardiac failure may be appropriate and is yet to be investigated.
Non-Invasive Ventilation Neonatal
Beth Israel Hospital Boston Respiratory Care