Non-Invasive Ventilation Neonatal Best Evidence & BIDMC Applications Beth Israel Hospital Boston Respiratory Care

Non-Invasive Ventilation Neonatal – Outline of Points •

Indications & Incentives for Use

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Background Definitions

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Devices

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Interfaces

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Use outside of BI

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Unanswered questions

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Controversies

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Recommendations for BI use

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Current use

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How should use to improve care

Beth Israel Hospital Boston Respiratory Care

Non-Invasive Ventilation Neonatal - Indications & Incentives

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 Beth Israel Hospital Boston Respiratory Care

Non-Invasive Ventilation Neonatal Eur J Pediatr. 2010 July; 169(7): 777 – 782.

Published online 2010 February 24. doi: 10.1007/s00431-010-1159-x Copyright/LicenseRequest permission to reuse

Table 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 Beth Israel Hospital Boston Respiratory Care

Non-Invasive Ventilation Neonatal Eur J Pediatr. 2010 July; 169(7): 777 – 782.

Published online 2010 February 24. doi: 10.1007/s00431-010-1159-x Copyright/LicenseRequest permission to reuse

Table 2.

Beneficial effects of noninvasive ventilation in newborns Improved respiratory mechanics Improved respiratory timing Improved oxygenation Increased lung volume Increased compliance Decreased resistance Decreased thoracoabdominal asynchrony Decreased obstructive and mixed apnoea Improved respiratory timing Decreased pulmonary vascular resistance Decreased intrapulmonary shunting Increased alveolar volume and less collapse Beth Israel Hospital Boston Respiratory Care

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

Non-Invasive Ventilation Neonatal CLD Working Group

Setup of NIPPV

rate Ti PIP PEEP rise time flow LPM Pressure MAX Ramanathan 40 max 50 0.5

to 1 ~40 ~0.45

PEEP plus 10-15 PIPvent plus 4 V Bhandari * Chronic Lung Disease NIPPV Overview 15-20 0.3

to 0.5

PIPvent plus 2-4 * V Bhandari JOP 2010 30, 505-512 •O2 to optimize saturation per policy, •Caffeine •Hct. > 35 5-8 * 5 0.1-0.2

4-6 Not specified 10-15 PIP 30 8-10 MAP 14 < 1000g 16 > 1000 g Not specified Not specified Not specified Beth Israel Hospital Boston Respiratory Care

Non-Invasive Ventilation Neonatal

Transition of Support

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Remove NIPPV

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Rate 15-25

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PIP < 17

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PEEP <6

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FiO2 <35

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Intubate

– pH < 7.25 PaCO2 > 60 – Apnea requiring bagging – Frequent As & Bs – Frequent desaturations “…can use blood gases to help wean, but not typically needed —can wean or increase settings based on clinical appearance” CLD Working Group V Bhandari JOP 2010 30, 505-512 Beth Israel Hospital Boston Respiratory Care

Non-Invasive Ventilation Neonatal – Interfaces •

Interfaces for Non-Invasive

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High-Flow Cannula

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NP Tube

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Prongs

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Long prong

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Bi-Nasal Prongs

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Nasal Mask

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RAM Cannula

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

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

Beth Israel Hospital Boston Respiratory Care

Non-Invasive Ventilation Neonatal – Modes and Devices •

Modes of Non-Invasive Ventilation

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Devices for Non-invasive Ventilation

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High-Flow Nasal Cannula

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Bubble CPAP

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Hansen Ventilator

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Conventional

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Conventional with NAVA

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Hi-Fi

Beth Israel Hospital Boston Respiratory Care

Non-Invasive Ventilation Neonatal – Device – Arabella CPAP & Vapotherm Beth Israel Hospital Boston Respiratory Care

Non-Invasive Ventilation Neonatal Beth Israel Hospital Boston Respiratory Care

Non-Invasive Ventilation Neonatal – Device - Hansen Ventilator Beth Israel Hospital Boston Respiratory Care

Non-Invasive Ventilation Neonatal – Device – Viasys BiPAP BWH uses rarely.

Beth Israel Hospital Boston Respiratory Care

Non-Invasive Ventilation Neonatal

NAVA

Beth Israel Hospital Boston Respiratory Care

Non-Invasive Ventilation Neonatal Beth Israel Hospital Boston Respiratory Care

Non-Invasive Ventilation Neonatal INSURE (intubatio-surfactant-extubation) 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 – 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

Non-Invasive Ventilation Neonatal – High Flow Cannula 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

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. Beth Israel Hospital Boston Respiratory Care