Titration and monitoring of CPAP in infants
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1 Titration and monitoring of CPAP in infants Brigitte Fauroux, MD PhD Pediatric Noninvasive Ventilation and Sleep Unit Necker University Hospital & Inserm U 955 Paris, France Inserm Institut national de la santé et de la recherche médicale
2 Conflict of interest Period Industry (ventilators and interfaces) Home care providers Sleep equipment Study coordinator SOFT Baby nasal mask (Air Liquide Medical Systems Trigger system of the ELISEE ventilator (Resmed) Consultant Congress support Invited speaker IP Santé (home care provider), Philips ADEP Assistance, IP Santé Respironics, IP Santé, ADEP Assistance Equipment for research Research staff SenTec, Respironics, Radiometer, Covidien, Cidelec ADEP Assistance, ASV Sante, IP Santé The material presented in this lecture has no relationship with any of these potential conflicts
3 Titration and monitoring of CPAP in infants CPAP in infants How to titrate CPAP in infants? How to monitor CPAP in infants
4 15 year experience of a pediatric centre (Vancouver) McDougall et al. Arch Dis Childh 2013;98:660
5 97 children started on NIV or CPAP over a 18 months period Ramirez et al. Intensive Care Med 2012;38:655
6
7 Titration and monitoring of CPAP in infants CPAP in infants How to titrate CPAP in infants? How to monitor CPAP in infants
8 CPAP titration in children < 12 yrs (AASM 2012) Disappearance of all obstructive respiratory events apneas, hypopeas, respiratory-effort related arousals (RERAs), snoring If presence of one AO or one hypopnea or 3 RERAs: k CPAP (also if snoring > 1 min) Minimal CPAP level 4 cmh 2 O (max 15 cmh 2 O) k by 1 cmh 2 O levels 5 minutes Bilevel if patient uncomfortable during CPAP
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10 In practice Attended poly(somno)graphy for CPAP titration not always available Necker CPAP titration protocol minimal CPAP 6 cmh 2 O, ramp 5 min, initial CPAP -2 cmh 2 O below target (constant) CPAP increase progressively to maximal tolerated CPAP level adjust on clinical tolerance (sleep, comfort) nocturnal gas exchange (with PtcCO 2 ) memory cards (leaks, flow, pressure, desaturation)
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12 Comparison of a clinical and physiological CPAP setting Spontaneous breathing Clinical CPAP Physiological CPAP Physiological CPAP Poes (cmh 2 O) Pgas (cmh 2 O) Paw (cmh 2 O) Pdi (cmh 2 O) Khirani et al. Crit Care 2013;17:R Time (sec) Time (sec) Time (sec) Time (sec)
13 Comparison of a clinical and physiological CPAP setting Swing Poes (cmh 2 O) UAO BPD Swing Expiratory Pgas (cmh 2 O) UAO BPD SB CPAP clin CPAP PhysioCPAP Physio SB CPAP clin CPAP Physio CPAP Physio + 1 Khirani et al. Crit Care 2013;17:R167
14 Comparison of a clinical and physiological CPAP setting UAO BPD CPAP level (cmh 2 O) CPAP Clin CPAP Physio Khirani et al. Crit Care 2013;17:R167
15 Titration and monitoring of CPAP in infants CPAP in infants How to titrate CPAP in infants? How to monitor CPAP in infants? tolerance of the interface objective compliance gas exchange and persistent respiratory events CPAP withdrawal
16 Nasal interfaces for infants
17 Unintentional leaks: memory card analysis Decrease of unintentional leaks as compared with a custom made mask
18
19 Retromaxilla Facial flattening
20 Titration and monitoring of CPAP in infants CPAP in infants How to titrate CPAP in infants? How to monitor CPAP in infants? tolerance of the interface objective compliance gas exchange and persistent respiratory events CPAP withdrawal
21 Audrey, 2 yrs, choanal atresia with OSA CPAP initiation
22 Audrey, 2 yrs, choanal atresia with OSA
23 Alexis, 3 months, 5,5 kg, severe laryngomalacia, CPAP initiation Discrepancy between software data
24
25 NIV and CPAP adherence according to the interface NIV and CPAP duration < 3 months 3-12 months > 12 months Ramirez et al. Sleep Med 2013;14:1290
26 Titration and monitoring of CPAP in infants CPAP in infants How to titrate CPAP in infants? How to monitor CPAP in infants? tolerance of the interface objective compliance gas exchange and persistent respiratory events CPAP withdrawal
27
28
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30 Number of respiratory events/polygraphy
31 Consequences of the respiratory events
32 Titration and monitoring of CPAP in infants CPAP in infants How to titrate CPAP in infants? How to monitor CPAP in infants? tolerance of the interface objective compliance gas exchange and persistent respiratory events CPAP withdrawal
33 CPAP withdrawal No validated criteria Normal nocturnal gas exchange + poly(somno)graphy + no symptoms Continuation of surveillance underlying pathology recurrence of OSAS (growth)
34 Fauroux et al. Ped Crit Care Med 2010;11:31
35 Conclusion CPAP titration in infants underestimation of the optimal CPAP level: target the highest tolerated level CPAP monitoring inaccuracy of the memory card data of most CPAP devices in infants PtcCO 2 monitoring is mandatory long term surveillance is recommended after CPAP withdrawal
36
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