Avoiding Mechanical Ventilation: (AMV mode) The growing options in non invasive respiratory support

Transcription

1 Avoiding Mechanical Ventilation: (AMV mode) The growing options in non invasive respiratory support Michael Finelli RRT Neonatal Respiratory Care Practitioner Sickkids, Toronto

2 1993

3 Objectives 1. Identify some of the risks with intubation and mechanical ventilation of the newborn lung, relating specifically to VILI and BPD. 2. List 3 possible methods of providing non invasive support to infants. 3. Reflect on past bedside experiences whereby ncpap has not worked and consider the possibility of other non invasive ventilation support options in the future

4 Reasons to Avoid Mechanical Ventilation

5 Why Worry? Mechanical ventilation is the #1 contributor to CLD and neonatal morbidity Ventilator Induced Lung Injury (V.I.L.I) is an unfortunate reality for so many of the patients we care for. It is our job to continually look for opportunities to minimize/eliminate this risk.

6 V.I.L.I General Concepts Excessive tidal volumes/ppv damages lungs: epithelial injury/shear stress protein leak & surfactant inhibition increased micro vascular permeability/pulmonary edema Air leak syndrome Remember: Volutrauma not Barotrauma is the culprit PEEP Phobia Low lung volume is just as bad as excessive lung volume (Atelectrauma) Exposure to high FiO 2 is toxic to the developing lung, giving rise to high levels of oxygen free radicals in the absence of developed antioxidant defense mechanisms (Oxytrauma) Hypocapnea is very dangerous to the developing brain and steps should be taken to avoid CO 2 swings in newborns. Excessive alkalosis has been linked to auditory impairment and neurodevelopmental delays

7 Avoiding Intubation Decrease imposed respiratory work if allowing the infant to breath through there natural structures vs. an ETT PROTECT the lungs by decreasing VILI when attached to a mechanical ventilator and administering oxygen Decrease tracheal Colonization / VAP Eliminating the so called routine cares (more like tortures) that go along with ETTS i.e. taping,suctioning etc Negate cricoid injury due to the ETT Access to nasopharyngeal airway natural humidification system

8 How are we doing in the USA and Canada with respect to BPD rates of infants <28 weeks?

9 Trends in Neonatal RDS management ( ) 20 NRN Centers, Jan 2003 to Jan 2007 Survived >12 hours after birth GA, wks ALL n BW. Mean g BPD@ 36wks Mild BPD % Mod BPD % Severe BPD % Physiological BPD % N(S)IMV NCPAP (0 14) (8 46) 40 Stoll B et al. NICHD NRN Paediatrics 126: Sept 2010

10 Outcomes <27 weeks Canada CNN Data

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13 NIV HI FLOW not included NCPAP NIPPV Bubble CPAP Conventional Ventilator CPAP (NPT) IFS/SiPAP Conventional Ventilator SiPAP: Biphasic, Trig

14 BUBBLE CPAP easy breezy and cheap!!!

15 Fluidic Flip CPAP (IFS) or variable flow

16 The many (inter) faces of CPAP

17 What is at the NOSE Nasal prongs (various shapes and sizes) Nasal mask (various shapes and sizes) Long prongs (spaghetti prongs) Short prongs NPT Inca prongs Cannula PAP

18 Bi nasal vs single prong Bi Nasal Prongs(n41) Single prong (n46) P BW, grams mean 790 (140) 816 (125) NS (SD) GA 26 (1.9) 26 (1.9) NS extubation 3 (1 9) 3 (1 6) NS days, median Extubation Failures 24% 57% Intubated <800g 24% 88% <0.001 Reintubation in <800g 18% 63% Bi Nasal Prongs are significantly better at preventing extubation failure Davis P et al Melbourne Arch Dis Child 85: F82 85;2001

19 NCPAP vs Surfactant: SUPPORT TRIAL weeks GA (n=1316) CPAP (n=663) Surfactant (n=653) P BW, g NS GA, wks NS GA 24 0r 25/ wks 43%/57% 43%/57% NS Antenatal Steroids, Any 97% 96% NS Antenatal Steroids, 74% 70% NS Complete Male 52% 57% 0.05 Intubated in the delivery room or NICU for Surf Rx BPD or death by 36 weeks 67% 99% < % 51% 0.3 SUPPORT: Surfactant, Positive Pressure and Pulse Oximetry Randomized Trial Finer et al NEJM. 2010; 362;

20 NCPAP Failure (over a 10 year period) Binasal vs single IFD vs, VCPAP

21 Conventional CPAP vs. Infant Flow CPAP for Extubation: Reasons for Extubation Failures Stefanescu BM et al (Winston Salem, NC) Pediatrics 112:1031 8;2003

22 What to do if CPAP fails? Currently practiced PLAN Bs : Re intubate? Higher CPAP levels ADD A BACK UP RATE Biphasic / SiPAP (2 CPAP levels: Lo and Hi) NIMV NSIMV?NIHFOV

23 Why might enhanced Non Invasive support work? Helps preserve Surfactant Maintains lung volume FRC/Alveolar recruitment Promotes release of surfactant from type 2 cells Pharyngeal dilation decreasing upper airway resistance Induces head s paradoxical reflex Increases VT and MV Reduced Chest wall distortion Augmenting Spontaneous efforts Decrease WOB

24 Controls in Non Invasive Ventilation Time at High at least (0.5 sec or longer) increases volume delivery significantly with no increases in CPAP high and CPAP low Time at Low CPAP high CPAP low # of Cycles higher rates helps unload respiratory work

25 snippv vs. NCPAP as modes of Extubation in Preterm Infants RCT (n 54) snippv (n=27) NCPAP (n=27) P BW (g) NS GA (wks) NS Surfactant Doses NS NS Extubation, d NS Apnea/24 hr, after <0.05 extubation Failed Extubation 15 % 44 % <0.05 BPD 44 % 56 % NS Infant Star with abdominal sensor Hudson Prongs PIP 16 PEEP 5 and Rate 12 Barrington KJ et al UCSD, Pediatrics 2001:

26 NIMV vs. NCPAP as a Primary Mode of Rx in PT infants <35 weeks with RDS: RCT (n=84) NIMV (n=43) NCPAP (n=41) p BW (g) NS GA (weeks) NS Baseline FiO NS Support, min 17 (3 2940) 4 (3 3240) NS Failed nasal Support 25% 49% 0.04 Duration of MV, days NS BPD 2% 17% 0.03 LOS, days NS SLE INCA prongs Kngelman A et al J. Pediatrics 2007; 150:

27 NFsIPPV vs. NCPAP in VLBW infants <1251 g at primary Extubation: RCT 9n=63) NFsIPPV NCPAP p BW (g) NS GA (weeks) NS Poractant Alfa (SURF) 81 % 84 % NS Extubation, hrs 4 (1 14) 6 (1 14) NS Failed Extubation 6 % 39% <0.01 Duration of MV, days 6 (1 20) 10 (1 66) BPD 6 % 22 % 0.08 LOS, days NS Moretti C et al. Pediatrics International 2008; 50: 85 91

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29 NCPAP vs. NIPPV post Surfactant Rx in PT infants <30 wks with RDS: RCT Respiratory Outcomes / Extubation Failures % Ramanathan R, Sekar K. Rasmussen R, Bhatia J, Soll R. PAS A3212.6, May 2009

30 Conclusion The authors concluded that use of NIPPV resulted in reduced need for MVET at 7 days, duration of MVET and incidence of clinical as well as clinical or physiological BPD

31 NIPPV vs. NCPAP in PT infants wks: RCT (n=40) NIPPV (n=20) NCPAP (n=20) P BW (g) NS GA (weeks) NS Poractant Alfa 25% 25% NS (INSURE) Re Intubated 10% 15% NS Pneumothorax 0% 5% NS Oxygen dependency <days Length of Resp Support, days GA at discharge Randomized at 1 hour of age; Bipasic 8/4.5; Rate 30, I time sec; NCPAP using IFD; no difference in BPD, Serum Cytokine levels IL-6, IL-8 TNF alpha Lista G et al (Milan) Arch Dis Child 95:F85-F89;2010

32 BiPhasic after INSURE failure n=60 Historical Control (n=22) Biphasic (n=38) P BW (g) median NS GA (weeks) median (range) 30 (24 34) 30 (24 36) NS INSURE Failure 6/22 (27%) 14/38 (37%) NS Need for Mechanical Ventilation 27% 0% Retrospective Study; ; GA,32 wks; Biphasic 8/5 Rates Ti sec INSURE Failure = Respiratory Acidosis, Fi02>0.40 or intractable apnea within 1 week of surfactant Biphasic reduced the need for MV after INSURE failure Ancor G et at (bologna) ACTA Pediatrica 99: ; 2010

33 NCPAP vs. NIPPV: Extubation Failures (9RCT) out of 9 trails reached statistical significance

34 Nasal Injuries reported 20 60% Fischer C et al (Switzerland) Arch Dis Child: 95 F447-F451; 2010

35 NIV Guideline Highlights SickKids Initial Parameter Selection: Rate of bpm. Inspiratory time (I time) of 0.5secs 1.0 secs (oropharyngeal equilibration time, therefore longer I time needed than with invasive ventilation). PEEP of 5 8cmH20 (may need to go higher). PIP 10 15cmH20 higher than PEEP level.(max PIP 30 35) Weaning: Wean NIV CMV every 6 12hrs as tolerated. Wean PIP first if PIP is greater than 10cm H20 above PEEP Wean rate if indicated or consider changing to CPAP once delta P is minimized. Consider switching to a ncpap level <to the MAP on the NIPPV settings Wean CPAP level to 5 6cmH20. Only If clinically indicated, consider weaning to heated high flow nasal cannula, after patient has been stable on CPAP for 6 12hrs.

36 What may the future hold? Practical and improved non invasive options?synchronization Less CPAP fear = More optimal CPAP timing / usage and levels titrated to patients requirement not just an arbitrary number New Ways of administering surfactant when needed without using an endotracheal tube (ETT) MIST NIHFOV rescue?

37 So all in all, Perhaps there is something to be said for the old phrase less is more Andrea del Sarto "The Faultless Painter a poem by Robert Browning And practicing AMV mode may just be the way of the future Thank you for all the amazing work you do each and everyday! michael.finelli@sickkids.ca

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39 Flow diagram

40 Need for MV

41 Need for MV among those who received surfactant

42 Incidence of BPD

43 Flow-Synchronized Nasal Intermittent Positive Pressure Ventilation for Infants <32 Weeks' Gestation with Respiratory Distress Syndrome C. Gizzi, et al Critical Care Research and Practice 2012

44 Critical Care Research and Practice 2012

45 Critical Care Research and Practice 2012

46 Critical Care Research and Practice 2012