April 30, BronchoPulmonary Dysplasia. Respiratory Distress Syndrome. Multifactorial Etiology of BPD. Clinical O 2 Use Comparison

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1 Lunch & Learn March 26, 2014 Kevin Coughlin MD Brooke Read RRT Donna Pletsch RN Respiratory Distress Syndrome Disease of prematurity Significant decrease in incidence and severity of RDS Antenatal Corticosteroids Post Natal Surfactant Better Ventilatory Management BronchoPulmonary Dysplasia Disease in survivors of prematurity No significant change in incidence of BPD Change in the pattern of presentation Clinical O 2 Use Comparison Multifactorial Etiology of BPD Avery s Diseases of the Newborn 8 th ed, 2005

2 Multifactorial Approach to BPD Antenatal steroids Decrease RDS 50% Post natal surfactant Improved ventilation strategies Improved ventilators Judicious use of O 2 Fluid management Better nutrition Rationale/ Background Management of RDS / prevention of BPD was identified as an area of practice that could be improved at the NICU at LHSC Prior to 2012 LHSC did not utilize any specific criteria/guideline for RDS management- inconsistent practice Quality Improvement (QI) initiative was needed to target this area of practice Literature review conducted Identified the INSURE method and early use of noninvasive as key practices to be adopted INSURE Method Intubate, SURfactant, Extubate Involves intubating spontaneously breathing preterm infants with evidence of RDS early in the post-natal period to facilitate surfactant administration followed by immediate extubation to Biphasic/NCPAP Aims to avoid routine mechanical ventilation following surfactant delivery Most infants with a good spontaneous drive and good response to surfactant can be successfully extubated following surfactant delivery Evidence Sandri et al, 2010 Large RCT (208 infants, weeks gestation) Compared prophylactic INSURE to NCPAP with early, selective INSURE Dunn et al, 2011 Large RCT (648 infants, 26 o weeks gestation) Compared NCPAP with selective surfactant vs. INSURE vs. Surfactant and Mechanical Ventilation SUPPORT Study, 2010 Large RCT (1319 infants, weeks gestation) Compared NCPAP and selective surfactant to prophylactic surfactant and mechanical ventilation COIN Study, 2008 Large RCT (610 infants weeks gestation) Compared NCPAP and selective surfactant to prophylactic surfactant and mechanical ventilation Findings No significant differences in the outcome of BPD Fewer infants required mechanical ventilation in the NCPAP and INSURE group Fewer infants in the NCPAP group required treatment with surfactant These studies have not shown any higher risk of IVH, NEC,PDA or any other adverse outcomes when compared to prolonged MV INSURE method and NCPAP alone are safe alternatives to prophylactic surfactant and ongoing mechanical ventilation in even the most preterm infants

3 Development of a Practice Guideline for RDS Management Synthesize the evidence Assist healthcare professionals in making decisions regarding the most appropriate course of treatment for that patient (evidence-based decision making tool) Facilitate a consistent approach to medical management Severity of RDS varies (mild to very severe) It is difficult to predict which preterm infants will require surfactant therapy and the level of respiratory support needed to manage RDS A comprehensive, yet individualized approach to RDS management is needed Establish a fine balance between avoiding unnecessary intubations with facilitating early surfactant delivery to those infants who need it The Practice Guideline for RDS Management in Preterm Infants Target population: Preterm infants born between weeks gestation (high risk for RDS) Provides delivery room and ongoing post-natal management strategies for RDS Employs a graded response to management by utilizing specific criteria to determine whether respiratory support and/ or surfactant therapy is required Incorporates 4 different RDS management strategies No respiratory support required (no evidence of RDS) Non-invasive respiratory support only (NCPAP or NIPPV) INSURE (Intubate, Surfactant, Extubate) Surfactant and ongoing mechanical ventilation Utilizes a flowchart to guide decision making Goal is to target the least invasive approach needed to safely manage RDS How to Utilize the Guideline At birth all infants will be initially resuscitated according to NRP guidelines Early intubation should be reserved for infants who DO NOT respond to PPV Once infant stabilized, the flowchart is utilized to determine the most appropriate respiratory management strategy No Respiratory Support Non-Invasive Respiratory Support If infant does not require any supplemental oxygen or show any signs of increased work of breathing (tachypnea, intercostal retractions, nasal flaring, or grunting) post resuscitation the infant will not be placed on any respiratory support If the infant shows signs of increased work of breathing (tachypnea, intercostal retractions, nasal flaring, or grunting) and/ or requires supplemental oxygen post resuscitation the infant will be given CPAP via the Neopuff The infant should then be transitioned to a consistent form of CPAP (e.g. Infant Flow)

4 Non-Invasive Respiratory Support Infant flow CPAP facilitates the delivery of consistent CPAP with a lower WOB than the Neopuff CPAP Provides a more accurate assessment of the infants FiO2 requirements After a minimum of 10 minutes of effective CPAP the FiO 2 requirements of the infants are assessed to determine whether or not surfactant is indicated FiO 2 < 30 %, infants will not receive surfactant and will be maintained on non-invasive INSURE Method Infants requiring a FiO 2.30 on CPAP in the resuscitation room will be electively intubated in the resuscitation room to facilitate surfactant administration Following surfactant administration all infants will be assessed for immediate extubation back to noninvasive To meet criteria to be extubated the infants must have spontaneous respiratory drive and FiO 2 <.30 following surfactant administration Delayed INSURE Method Infants who are initially meet criteria to receive noninvasive respiratory support should be considered for the INSURE method if FiO 2 requirements progress to >0.40 for a minimum of 30 minutes despite optimizing CPAP (increase pressure to 6-7cmH20, ensure patency of airway, proper fit of CPAP device) Surfactant and Ongoing MV The use of ongoing mechanical ventilation following surfactant delivery should be reserved for infants with: No spontaneous drive Poor response to surfactant (FiO2 >.30) If respiratory drive improves and FiO 2 drops to <.30 after to admission to NICU, patient should be considered for extubation to non-invasive Indications for Intubation/ Re-Intubation Any of the following should indicate the need for intubation/ reintubation: FIO 2 > 0.40 for at least 30 minutes (give Surfactant if <48 hours old) ph <7.20 and CO 2 >60 (capillary gases should not routinely be drawn before 4 hours of age) Frequent Apnea requiring stimulation (>4/Hr.) Requirement for Bag Mask Ventilation (>1/Hr.) Note: These indications are valid only if the delivery of non-invasive has been assessed as adequate Surfactant Delivery Confirm placement of ETT 6 cm + weight in kg for oral 7cm + weight in kg for nasal Ensure proper size ETT for patient weight Obtain CXR if necessary to confirm placement Suction prior to surfactant delivery Closed system (Multi-access catheter or Neolink adaptor) 1 aliquot bolus administration

5 Outcomes Conducted an observational 1- year before and after study following guideline implementation in infants born between weeks gestation (272 infants) Found a 47% reduction in the use of ongoing mechanical ventilation and a 34 % reduction in the incidence of BPD following implementation of the guideline Of the preterm infants treated with the guideline (143 infants) 50% required surfactant and only 26% required ongoing mechanical ventilation in the first week of life Treatment failure rates remained low 21% Non-invasive respiratory support 16% INSURE Method Outcomes Late preterm ( weeks gestation) 87 infants Initial Respiratory Management Strategy No respiratory support required: 33% Non-invasive only: 51% INSURE: 8% Surf and MV: 8% Overall only 24% of infants required surfactant and 16% required ongoing mechanical ventilation in the first week of life Take Home Message Most late preterm infants (>30 weeks) can be managed with CPAP alone If surfactant required, use INSURE Only use ongoing mechanical ventilation if indicated (poor respiratory drive, poor response to surfactant) Interpret early blood gas values with caution (usually acidotic) should wait at least 4 hours after delivery Continuous Positive Airway Pressure CPAP Care Guidelines CPAP Care Goals 1. Maintaining therapeutic and safe delivery of CPAP (distending alveolar recruitment) 2. Preventing nasal skin complications 3 parts to any nasal CPAP system 1. Circuit for continuous flow of inspired gases (warmed and humidified) 2. Driving force or method of generating positive pressure in the circuit 3. Nasal interface component * Shared role between RRTs and RNs in NICU Options: CPAP machines (Infant Flow Systems: VIASYS Healthcare Inc., ARABELLA [Aladdin] Hamilton Medical Inc., etc.) Bubble CPAP

6 Nasal Interface Component Successful CPAP delivery is facilitated by: 1. Proper fitting hat/head device and nasal prongs/mask Initial application using measurement guides and ongoing assessment 2. Applying and examining the interface set-up (systematic approach) 3. Maintaining patent airway Place gastric feeding tubes orally Suction prn 4. Maintaining consistent CPAP delivery 5. Assessing skin integrity Using skin protective barriers, adhesives correctly 6. Educating and supporting caregivers proficiency at trouble-shooting Proper fitting of mask/ nasal prongs Tools provided by manufacturer with directions for measuring infant nares for proper sizing, including head circumference (hat/bonnet) Nasal prongs should gently fill the nare without causing blanching of external skin Do not force entire prong into the nare With gas flow, silicone prongs will flare at ends creating a seal A small space should be present between nare and prong base Head circumference and proper hat sizing (Color-coding) Template -nare size measurement Applying and examining the interface Hat should sit just above the eyebrows Back of hat extending to the base of neck Ears should be completely covered by the hat (make sure ears are not folded) Lateral straps secured at prong base should provide equal tension (do not over tighten) Tubing secured with hat ties or velcro decreases interface movement (reduce potential air leaks) Exhalation tubing distal end should not be occluded Ongoing assessment of interface Every 3-4 hours and prn Observe hat placement Sliding off head pulling nose superior? Examine prongs/mask placement Are prongs placed in the nares? Moved? Is the mask pressing up against the nares and occluding them? Is there blanching of skin around the nares? Is size appropriate? Good fit? Straps Do the straps fit snug, but not too tight? Is the interface component twisted because of tension on the tubing?

7 Maintaining a patent airway Gently suction each nostril with a soft catheter in external nare prn (repeated routine suctioning may cause irritation, trauma, inflammation and edema) Place gastric tubes orally to reduce airway resistance (2º nasal tube placement) vent gastric tubes to air between feeds to decompress gastric distension Position infant optimal airway and comfort Assessing skin for pressure areas Nasal prongs Nasal wall and septal redness, breakdown Mask Pressure noted on septum on the base of the philtrum High on the bridge of the nose Apply skin barrier protection carefully Cannulaide Alternate between mask and nasal prongs Maintaining consistent CPAP Maintain CPAP to avoid decruitment first hours following RDS protocol (based on clinical condition) Later on with stable infant...take off prongs/mask, providing supplemental free flow oxygen prn during skin assessment/care Auscultate chest sounds off CPAP Note tolerance off CPAP and document any oxygen desaturation, WOB, apnea/ bradycardia episodes Replace nasal CPAP carefully, ensuring correct placement Patient Care Monitoring Achieving desired CPAP pressures FiO2 requirements (stable/reducing?) Auscultation: chest sounds Vital signs monitoring SpO2 (colour) Respiratory assessment: WOB (retractions), RR, symmetrical chest movement, abdominal movement in comparison to chest Tolerance and comfort Discontinuing CPAP Stability Criteria Discontinuing CPAP should be considered when: CPAP < 6 cmh20 FiO2 consistently at 0.21 Respiratory rate consistently < 60 breaths/min No significant chest retractions Less than 4 episodes of self-resolving apneas and/or desaturations within 12 hour time period The infant can be successfully transitioned off CPAP to room air If the infant requires supplemental oxygen when taken off CPAP, restarting CPAP should be considered

8 References As listed within presentation Images taken from Google, Bing Images websites LHSC Respiratory Policies, Guidelines McCoskey, L. Nursing care guidelines for prevention of nasal breakdown in neonates receiving nasal CPAP. Advances in Neonatal Care. 2008;8(2): Squires, AJ, Hyndman, M. Prevention of nasal injuries secondary to ncpap applications in the ELBW infant. Neonatal Network. 2009;28(1):13-27.