Non Invasive Ventilation In Preterm Infants. Manuel Sanchez Luna Hospital General Universitario Gregorio Marañón Complutense University Madrid

Transcription

1 Non Invasive Ventilation In Preterm Infants Manuel Sanchez Luna Hospital General Universitario Gregorio Marañón Complutense University Madrid

2 Summary Noninvasive ventilation begings in the delivery room Nasal CPAP CPAP failure SNIPPV 19/07/2017 M Sanchez Luna 2

3 19/07/2017 M Sanchez Luna 3

4 Pulmonary Function Monitoring during resuscitation Airway Obstruction 14/ 56 (26%) 27/ 56 (51%) Air Leaks 19/07/2017 M Sanchez Luna Schmölzer GM Arch Dis Child Fetal Neonatal Ed

5 PFM in the delivery room RCT Recordings of 64 preterm infants < 32 week s gestation were analyzed 32 infants RFM visible 32 masked. G Zeballos 2017, unpublished data 19/07/2017 M Sanchez Luna 5

6 PFM Masked PFM Median, (SD) Un-Masked PFM Median, (SD) P Expired volume tidal (VTe) 5.85 ml/kg (2.54) 4.95 ml/kg (1,97) 0.3 Respiratory Rate 40 (11,2) 33 (8,5) 0.02 Minute Ventilation 220 (0.15) ml/kg/min 0.15 (0,07) ml/kg/min 0.09 EtCO mmHg (8) 41.83mmHg (13,9) G Zeballos 2017, unpublished data 19/07/2017 M Sanchez Luna 6

7 PFM Events Number of breaths analyzed Adverse Events Mask Repositioni ng CPAP Masked PFM CPAP Un-Masked PFM P NIPPV Masked PFM NIPPV Un-Masked PFM (10.74%) 69/492 (14%) 2 (16.74%) < (29.9%) 119/202 (59%) <0.01 7/125 (5.6%) P 21 (17.9%) /21 (66%) <0.001 G Zeballos 2017, unpublished data 19/07/2017 M Sanchez Luna 7

8 PFM Observational study of infants <32 week s gestation between October 2014-June 2016 Single tertiary center receiving mask NIPPV in the delivery-room. The RFM display was Masked to the resuscitator. PFM data and videos were recorded during the first 10 min of stabilization with mask respiratory support G Zeballos 2017, unpublished data 19/07/2017 M Sanchez Luna 8

9 PFM 4885 inflations N= 32 babies Gestational Age (weeks) Mean (SD) Weight (gr) Mean (SD) < 28weeks, n=14 28weeks, n= [1.22] 30+4 [1.68] [140] [384] G Zeballos 2017, unpublished data 19/07/2017 M Sanchez Luna 9

10 PFM Masked Monitoring < 28weeks, n=14 28weeks, n=18 CPAP 944 breaths NIPPV 528 breaths p CPAP 3008 breaths NIPPV 405 breaths p Expired tidal volumes (ml /kg) Mean (SD) 4.87 (0.4) 9.96 (2.11) < (2.2) 6.5 (2.5) 0.18 G Zeballos 2017, unpublished data 19/07/2017 M Sanchez Luna 10

11 Monitoring lung in preterm infants at birth N= 51, < 37 week s gestation Mean GA (SD): 28 (3) NM3 Philips-Respironics PFMonitor Kang LJ, et al PLoS One 2014; 9 (7): e /07/2017 M Sanchez Luna 11

12 ECO2 CPAP ECO2 PPV VT PPV VT CPAP Kang LJ, et al PLoS One 2014; 9 (7): e /07/2017 M Sanchez Luna 12

13 Mask CPAP at delivery Courtesy from Zeballos G 7/19/2017 M Sanchez Luna 13

14 Noninvasive PPIV at delivery Courtesy from Zeballos G 7/19/2017 M Sanchez Luna 14

15 Non invasive Hand Bag Ventilation in the DR Courtesy from Zeballos G 7/19/2017 M Sanchez Luna 15

16 Non invasive T-Tube Ventilation in the DR Courtesy from Zeballos G 7/19/2017 M Sanchez Luna 16

17 PFM 7/19/2017 M Sanchez Luna 17

18 PFM 7/19/2017 M Sanchez Luna 18

19 ncpap failure Retrospective Bubble CPAP U Columbia, NY Ammari A, et al J Pediatr 2005;147: /07/2017 M Sanchez Luna 19

20 ncpap Failure Ammari A, et al J Pediatr 2005;147: /07/2017 M Sanchez Luna 20

21 CPAP failure What else can we do? Nasal ventilation? 19/07/2017 M Sanchez Luna 21

22 Noninvasive Mechanical Ventilation NIPPV, conventional ventilation, Unsynchronized Nasal Bipap SNIPPV The positive pressure ventilator breath is delivered only after initiation of respiratory effort, when the glottis is likely to be open, or after an apneic interval. 19/07/2017 M Sanchez Luna 22

23 Does BiPaP increase ventilation? NIPPV/SNIPPV NIPPV commonly uses a ventilator to provide intermittent breaths at peak pressures (10 25 cm H 2 O), rates (20 60/min) and inflation times ( sec) similar to those used for mechanical ventilation Bi-level CPAP (BiPAP/SiPAP) BiPAP systems provide sigh breaths with small differences between high and low NCPAP pressure (< 4-5 cm H 2 O), longer inflation times ( sec) and lower cycle rates (10 30 per minute) 19/07/2017 M Sanchez Luna 23

24 Bi-level CPAP does not improve gas exchange when compared with conventional CPAP for the treatment of neonates recovering from respiratory distress syndrome. - Comparison between NCPAP and Bi-level CPAP, in a randomised crossover study in twenty low-birthweight infants (weight at study entry 1310 g ) requiring oxygen therapy and recovering from RDS PIP: 8 cm H 2 O PEEP: 6 cm H 2 O - BiPAP, administered at the same MAP as NCPAP, confers no benefit in augmenting ventilation and does not significantly impact oxygenation, apnoea, bradycardia or desaturation events Lampland AL et al, Arch Dis Child Fetal Neonatal Ed 2015; 100 (1): F /07/2017 M Sanchez Luna 24

25 A comparison of bilevel and ventilator-delivered non-invasive respiratory support. non-randomised comparison of infants randomised to the NIPPV arm of the NIPPV trial - There is an increase in mortality in infants who received BiPAP - BiPAP and NIPPV may not be equivalent Millar D et al Arch Dis Child Fetal Neonatal Ed 2016; 101 (1): F /07/2017 M Sanchez Luna 25

26 Noninvasive MV and BPD prevention 3 trials were included n=360. Need for invasive ventilation (risk ratio, 0.60; 95% CI, ). BPD effect (risk ratio, 0.56; 95% CI, ). Jucille Meneses, Arch Pediatr Adolesc Med /07/2017 M Sanchez Luna 26

27 - 10 preterm infants - GA 25.3 w - BW 800 g - 24 d old - Rate PIP + 20/25 cm H 2 O - PEEP + 6/7 cm H 2 O only when pressure peaks occurred during spontaneous inspiration tidal volume increased (p=0.01) RIP: respiratory inductance plethysmography 19/07/2017 M Sanchez Luna 27

28 - 16 stable preterm infants - GA BW d old - PIP + 15 cm H 2 O - PEEP + 5 cm H 2 O - most of them on 0.21 FiO 2 Less inspiratory effort Reduction of the inspiratory efforts during synchronized nasal ventilation Chang et al Pediatr Res 2011; 69 (1): /07/2017 M Sanchez Luna 28

29 Forced expiration Alteration of spontaneous rhythm of breathing Chang et al Pediatr Res 2011; 69 (1): Increased positive pressure deflection in P ES during exhalation and prolongation of the expiration with asynchronous nasal ventilation (20 cycles/min) 19/07/2017 M Sanchez Luna 29

30 Synchronized nasal ventilation Synchronized NIMV is associated with: increased tidal volume and minute volume as compared with NCPAP. Moretti C et al, Early Hum Dev 1999 reduction in thoracoabdominal asynchrony, and thus stabilized the chest wall, and improved lung mechanics. Kiciman NM et al, Pediatr Pulmonol 1998 decrease the work of breathing. Lin CH et al, Pediatr Pulmonol /07/2017 M Sanchez Luna 30

31 a b c flow sensors prongs leak Pressure Vt 3-5 ml Ti 0.3 d test lung Flow response time activation volume ~ ~ 0, msec ml Simulated Neonatal Lung Model

32 Flow-Synchronized NPP <32 Weeks Gestation with RDS SNIPPV+INSURE vs ncpap+insure INSURE if: FiO 2 on ncpap (5-6 cm H 2 O) > 0.4 >30min, SpO 2 (85-93%) INSURE failure defined as: FiO 2 > 0.4 to maintain SpO % significant apnoea respiratory acidosis (pco 2 > 65mmHg) C Gizzi et al Critical Care Research and Practice /07/2017 M Sanchez Luna 32

33 N=64 Flow-Synchronized NPP <32 Weeks Gestation with RDS INSURE failure: CPAP SNIPPV p 11 (35.5%) 2 (6.1%) C Gizzi et al Critical Care Research and Practice /07/2017 M Sanchez Luna 33

34 SNIPPV HGUGM Prospective observational study of SNIPPV use in < 32weeks of gestation from January 2012 to December of 2015 Giulia Non Invasive flow-sensor Ventilator, GINEVRI Ramos Navarro C, Sanchez Luna M et al AJP Rep 2016; 6 (3): e /07/2017 M Sanchez Luna 34

35 SNIPPV HGUGM Indications of SNIPPV use ncpap failure: Electively For extubation: Preterm infants supported with ncpap that meet intubation criteria if they are in a stable situation Preterm infants in which ncpap extubation has previously failed. Prolonged mechanical ventilation (more than 15 days) with high respiratory parameters(pmap > 10 cmh2o and FiO2>35%). Ramos Navarro C, Sanchez Luna M et al AJP Rep 2016; 6 (3): e /07/2017 M Sanchez Luna 35

36 SNIPPV HGUGM Elective use (n=25) ncpap failure(n=53) p GA (median;iqr) 25+5; ; 2.6 0,001 Weight at birth (g) (median; IQR) Days of life (median; IQR) Prenatal corticosteroids Rate of intubation at delivery 680; ; 405 0,002 39; 43 11; ,022 76% (19) 84,9% (45) 0,517 72% (18) 43.4% (23) 0,061 Surfactant 88% (22) 86.8% (46) 0,356 Nasal injury 0 1.9%(1) 0,489 Neurological impairment 4%(1)1 7.5%(4)1 0,551 92% (23) 66%(35) 0,014 Success Previously ncpap extubation failure (n=12) Ventilator dependent patients (n=13) Apnea (n=23) Hipoxemia (n=15) Respiratory acidosis (n=15) 91.7%(11) 92.3%(12) 62.5%(15) 60%(9) 73.3%(11) 0,081 Ramos Navarro C, Sanchez Luna M et al AJP Rep 2016; 6 (3): e /07/2017 M Sanchez Luna 36

37 SNIPPV HGUGM SNIPPV use Rate of non-invasive failure 25% 27,70% 54,80% 45% 33% 27,20% 9,40% 0,80% "2012" "2013" "2014" "2015" Ramos Navarro C, Sanchez Luna M et al AJP Rep 2016; 6 (3): e /07/2017 M Sanchez Luna 37

38 Nasal ventilation of Apnoea of prematurity All infants were in stable conditions except for their apnoeic episodes 19/07/2017 M Sanchez Luna 38

39 The New Flow-Sensor 19/07/2017 M Sanchez Luna 39

40 Ester Sanz Elena Maderuelo Cristina Ramos Paz Chimenti Susana Zeballos Noelia González Gonzalo Zeballos 19/07/2017 M Sanchez Luna 40