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AW Flemmer Krakau 2013
NonNon --invasiveinvasive VentilationVentilation
Krakau 2013Krakau 2013
A.W. Flemmer
Div. Div. NeonatologyNeonatology , , ChildrenChildren ‘‘s Hospital and Perinatal Center,s Hospital and Perinatal Center,LMLM--University Munich, GermanyUniversity Munich, Germany
AW Flemmer Krakau 2013
• Increased and stabilized lung volume
• Stabilized „soft“ thorax of the neonate→→→→ reduced work of breathing
• ….
• Decreased airway resistance
• Surfactant „restitution“
• Reduced left-right shunting across patent ductus botalli
Physiological effects of CPAP - potential benefits
AW Flemmer Krakau 2013
Rees et al. J Rees et al. J NeuropathNeuropath and and ExpExp NeurolNeurol , June 2009, June 2009
Extubation to nCPAPafter 24 hrs
Extubation to nCPAPafter 5 days
nCPAP & Surfactant:„beyond the lung“
AW Flemmer Krakau 2013
• CPAP-induced overdistention of the lung, inverted diaphragm →→→→ impaired exspiration
• Airleak / pneumothorax
• ET tube and airway- obstruktion
• Overdistention →→→→ reduced venous return→→→→ reduced cardiac output
• ....
Physiological effects of CPAP - potential harms
AW Flemmer Krakau 2013
CPAP CPAP systems
nasal ET tubenasal prongsnasal cannula
.....
Flow-generator:•Ventilator
• cont. flow• demand flow
•Bubble-CPAP•Medijet•Infant-flow•...
Pressure-generator:expir.-valvesurge chamber...
Interface:Hudson prongsArgyle prongsBuenavistaFluid flip device...
AW Flemmer Krakau 2013
nCPAP - Failure
AW Flemmer Krakau 2013
NIV -- NIPPV
nIMV sNIMVsNIPPV
n-HFOV
AW Flemmer Krakau 2013
n-HFOV
Mukerji et al. Neonatology 2013
AW Flemmer Krakau 2013Meneses et al. Pediatrics 2011
NN--IPPV vs. NIPPV vs. N --CPAPCPAP
Prim Outcome: Use of ETT
N.S.All sec. Outcomes:(Surv. With no BPD, ROP, NEC, IVH, PDA)
2.89 (0.30-27.2)1.90 (0.49-7.4)
7.27.2
1.23.7
BPD moderatesevere
0.90 (0.72-1.13)5864Need for MV
1.19 (0.55-2.53)0.56 (0.32-0.98)
2922
2439
Failure of NIV <1000g>1000g
RR (95%CI)NIPPV (%)(n=100)
NCPAP (%)(n=100)
AW Flemmer Krakau 2013
Non-synchronized NIV
Owen L et al.Arch Dis Child 2011
AW Flemmer Krakau 2013O‘Brien et al. BMJ Ped 2012
NN--IPPV vs. NIPPV vs. N --CPAPCPAP
Prevent Extubation Failure
sNIPPV
NFSIPPV
NP-SIMV
nSIMV
BL-NCPAP
AW Flemmer Krakau 2013
Positive Effectsof Synchronization
� ↑↑↑↑ Tidalvolume (Bernstein 1994, Hummler 1996, Rosas 1992)
� ↑↑↑↑ Oxygenation (Cleary 1995)
� ↓↓↓↓ Blood pressure fluctuations (Amitay 1993, Hummler 1996)
� ↓↓↓↓ IVH ? (Perlman 1985)
� ↓↓↓↓ Work of breathing (Jarreau 1996)
� ↓↓↓↓ Active exspiration (Heldt & Bernstein 1994, Greenough 1985)
� ↓↓↓↓ Air leaks (Greenough 1983, 1984)
� ↓↓↓↓ Sedation / Paralysis (Henry 1979)
� ↓↓↓↓ Stress (Epinephrinlevel) (Quinn 1998)
� Earlier weaning (Donn 1994)
AW Flemmer Krakau 2013
Does SynchronizationMatter?
Prim Outcome RR (95% CI) # Studies Pt enrolled
Death 1.19 (0.95-1.49) 5 1729
Air Leaks 1.03 (0.80-1.34) 6 1769
Ext. Failure 0.93 (0.68-1.28) 4 1056
Severe IVH 1.03 (0.74-1.43) 5 1729
BPD@28d 0.91 (0.75-1.12) 4 805
BPD@36wk 0.90 (0.75-1.08) 2 1310
Days vent (h) -35 (-62;-7) 4 1402
Greenough A. et al. 2008 Cochrane Database AW Flemmer Krakau 2013
nCPAP vs. sNIPPV
BPD or death
Neurodevelopmental Impairment or Death
Bahndari et al. Pediatrics 2009Retrospective Data with Graseby & Infant Star & Star Synch
AW Flemmer Krakau 2013 Dumpa et al. et al. J Perinat 2011
OR 95% CI
BPD or death NIPPV (238) sNIPPV (172) 0.74 0.42 – 1.30
Retrospective Data with Graseby & Infant Star & Star Synch
NIPPV vs. sNIPPV
AW Flemmer Krakau 2013
CV vs. sNIPPV
Bahndari et al. J Perinat 2007
Outcome Conv. Ventilation
(n=21)
sNIPPV
(=20)
p
BPD or deathn (%)
11 (52) 4 (20) 0.03
BPD n (%) 7 (33) 2 (10) 0.04
death n (%) 4 (19) 2 (10) 0.66
Initial RDS-Treatment (RCT)
RCT 2 Centers 2000-2005 with Graseby & Infant Star & Star Synch
AW Flemmer Krakau 2013
ExternalSignals
Internal Signals
Graseby Capsule Flow
RespiratoryInductionPlethysmography: RIP-Bands
NAVA
Piezo Sensor ∆P oesophageal
Potential Respiratory Signals forsynchronized NIPPV
Best Triggerfor sNIPPV?
AW Flemmer Krakau 2013
Best signal for synchronisation of NIPPV
� Onset of signal and � Quality of signal
Best way to provide sNIPPV?
AW Flemmer Krakau 2013
(n=5813) Signal Onset vs. RIP-Abd
SD
∆∆∆∆t Pes + 52 ms ± 160 ms
∆∆∆∆t RIP-Chest + 157 ms ± 154 ms
∆∆∆∆t Graseby + 61 ms ± 98 ms
∆∆∆∆t Piezo + 118 ms ± 1375 ms
ΘΘΘΘ RIP Chest – RIP Abd
49 ° ± 118 °
80.4 ±±±± 10 % valid Signals for RIP Abd & Graseby
VLBWSpont breathing
AW Flemmer Krakau 2013
VLBW CPAP
(n=5813) Signal Onset vs. RIP-Abd
SD
∆∆∆∆t Pes - 45 ms ± 95 ms
∆∆∆∆t RIP-Chest + 167 ms ± 105 ms
∆∆∆∆t Graseby + 44 ms ± 66 ms
∆∆∆∆t Piezo + 35 ms ± 88 ms
AW Flemmer Krakau 2013Moretti Corrado et al. 2008 Pediatrics Int
Nasal Flow sNIPPV
NCPAP nfsNIPPV p
Extubation -Failure n/n (%) 2/32 (6%) 12/31 (39%) p<0.005
Special ventilator „Gulia“ with sNI-algorythm
AW Flemmer Krakau 2013
Neurally adjusted ventilatory assist (NAVA)
Moerer et al. Anaesthetist 2008
AW Flemmer Krakau 2013
Adult Pt Camarota et al. ICM 2012
n-i NAVA
AW Flemmer Krakau 2013
1) RIP – Abdominal Band2) Graseby Capsule3) Flow sensor with special algorythm
4) NAVA
Valid Triggers
AW Flemmer Krakau 2013
�So far no comperative studies lookinginto differences of triggers
AW Flemmer Krakau 2013
Best way to provide sNIPPV?
Supported Frequency
���� synchronised intermittent NV?
���� synchronised assist control NV?
AW Flemmer Krakau 2013
Observational with Graseby & Infant Star + Star Synch
nCPAP ni-MV @20/min
s-ni-MV@ 20/min
ni-MV @40/min
s-ni-MV@ 40/min
Vt (AU) 10.6(8.0–13.9)
11.6(7.8–19.6)
10.2(7.8–14.6)
10.4(6.2–14.1)
10.1(8.7–13.5)
MV (AU) 508 (369 – 857)
681 (321–1051)
535(342–783)
546 (330 –746)
581 (399 – 811)
RR (/min)
54 (43–59) 54 (44 – 60) 51 (44 – 60) 50 (45– 61) 52 (45– 61)
tcpCO 255.2 ±±±±10.4 55.1 ±±±± 10.7 54.9 ±±±± 10.7 56.3 ±±±± 11.1 55.8 ±±±± 12.3
SPO292.5 ±±±± 1.9 92.9 ±±±± 2.6 92.5 ±±±± 2.9 92.9 ±±±± 2.7 92.2 ±±±± 2.8
ni-MV vs. s-ni-MV
Chang H. & Bancalari E. et al. 2011 Ped Res AW Flemmer Krakau 2013
Chang H. & Bancalari E. et al. 2011 Ped Res
SIMV-NIPPV @ 40/ min
IMV-NIPPV @ 20/ min
BUT ���� no comparison of SIMNV vs. AC-NV
AW Flemmer Krakau 2013
Triggering Expiration in PSV
Reyes et al. Pediatrics 2006AW Flemmer Krakau 2013
� Loss of FRC� Prolonged Desaturations � Bradycardia
Apnoea & Periodic Breathing
AW Flemmer Krakau 2013
Summary
� sIM-NIV 40/min seems more effective than IM-NIV 20/min
� Triggering expiration during sNIPPV is possibleand available
� Apnoea-detection and adaptive backupventilation during sNIPPV may be achieved witha Graseby sensor
� Moving artefacts are a major backdraw of sNIPPV
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