neonatal ventilation ventilation: l...
TRANSCRIPT
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NEONATAL VENTILATION: LATEST UPDATE
Dr Robin Saggers
NEONATAL VENTILATION: LATEST UPDATES
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CONFLICT OF INTEREST
• No affiliation to any respiratory care companies
• Neonatal Fellow – I am no expert!
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OUTLINE
• History
• Goals and safety
• Indications and common conditions
• Types of ventilation & settings
• Synchronization (SIMV, A/C)
• Modes (Pressure vs volume)
• Meta analysis 2016
• Meta analysis 2017
• Recommendations and best practice
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HIS
TO
RY
0
10
20
30
40
50
60
70
Averag
e N
eo
nata
l M
orta
lity
Rate
Year
NMR 1953 - 2018
4th gen. ventilators
Steroids
Surfactant
1st gen. ventilators
1940s and 1950sPositive pressureOnly volume controlNo PEEP
2nd gen. ventilators
1970sPEEP introducedIMVBasic alarms1972Antepartum steroid use1980Surfactant used as treatment for RDS
MicroprocessorsMany modes availableAll the bells and whistles
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TYPES OF VENTILATION
• Non-invasive ventilation (NCPAP, HFNC, NIPPV)
• Conventional mechanical ventilation (CMV/IPPV)• Intermittent exchange of bulk volumes of gas
• High frequency ventilation (HFV)• Small volumes of respiratory gas
• At extremely rapid rate
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INDICATIONS
• Respiratory failure• Type 1 – failure of oxygenation
• PaO2 <50mmHg despite oxygen supplementation
• Or when FiO2 exceeds 40 % on nCPAP
• Type 2 – failure of ventilation (pH <7.2 and PaCO2 >60 – 65 mmHg)
• Recurrent apnoeas
• To relieve work of breathing
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COMMON CONDITIONS
Respiratory distress syndrome
Apnoea due to prematurity or perinatal depression
Infection – Sepsis and/or pneumonia
Postoperative recovery
Persistent pulmonary hypertension
Meconium aspiration syndrome
Congenital pulmonary and cardiac abnormalities
Hypoxic-ischaemic encephalopathy
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VENTILATOR INDUCED LUNG INJURY
• Atelectrauma• Volutrauma• Biotrauma
• Cystic PVL• IVH
Van Kaam AH, Rimensberger PC: Lung-protective ventilation strategies in neonatology: What do we know – What do we need to know? Crit Care Med 2007; 35:925-931
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OPEN LUNG APPROACH
• Searches for optimal lung volume
• More even distribution of the applied tidal volume
• Reducing the risk of local alveolar overdistension
• Limiting tidal volume
• Applying PEEP
• Combined with a recruitment manoevre to reopen already collapsed alveoli
Van Kaam AH, Rimensberger PC: Lung-protective ventilation strategies in neonatology: What do we know – What do we need to know? Crit Care Med 2007; 35:925-931
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LUNG PROTECTIVE VENTILATION
• Optimizing lung volume
• Limiting excessive lung expansion
• Appropriate PEEP
• Using shorter IT (0,35 – 0,5 secs)
• Smaller tidal volume (4 – 6 mL/kg)
• Permissive hypercapnia
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SETTINGS
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SYNCHRONIZED VENTILATION
• Patient-triggered
• May improve patient comfort
• Reported to lower MAP and reduce need for sedatives (Bernstein 1996)
• Some benefit over non-synchronized ventilation in neonates• Fewer periods of low oxygen saturation
• Less variability in exhaled tidal volume (Firme 2005, Donn 1994, Baumer 2000, Beresford 2000, Cleary 1995)
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PRESSURE-TARGETED VENTILATION
• PC-A/C
• PC-SIMV
• PC-PSV
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VOLUME-TARGETED VENTILATION
• VC-A/C
• VC-SIMV
• VG
• PRVC
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PRESSURE-REGULATED VOLUME
CONTROL / VOLUME GUARANTEE
• Clinician selects: • Expiratory tidal volume target• IT• Maximum inspiratory pressure limit (Pmax)
• Machine measures:• Inspired tidal volume • Expired tidal volume
• Inspiratory pressure (uses exhaled tidal volume reference) adjusted until the targeted tidal volume is achieved, using lowest possible pressure
• Lung compliance incr → inspiratory pressure decr
• Spontaneous respiratory effort incr → “self-weaning”
Modified pressure-targeted ventilatory mode
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MODES
PROS CONS
Pressure• Easy to use• Less costly
• Variation of tidal volume from breath to breath
Volume• More consistent tidal
volume• Less injury
• Expense• Experience
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COCHRANE REVIEW 2016
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• No difference in:• Overall outcome
• Mortality rate
• Incidence of BPD
• Synchronization may be useful in the subgroup of <28 weeks GA• shortens the period of
ventilation (patients more susceptible to VALI)
Ramanathan R: Optimal ventilatory strategies and surfactant to protect the preterm lungs.Neonatology. 2008;93(4):302-8
Claure N, Bancalari E: New modes of mechanical ventilation in the preterm newborn: evidence of benefit. Arch Dis Child Fetal Neonatal Ed. 2007 Nov;92(6):F508-12
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COCHRANE REVIEW 2017
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COCHRANE REVIEW
2017
BPD AND
DEATH
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COCHRANE REVIEW
2017
BPD ONLY
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PRIMARY OUTCOMES
VTV vs PLVRisk Ratio
NNTB
Death before discharge
No difference 0.75
Death or BPD at 36 weeks
VTV reduced risk
0.73 8
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SECONDARY OUTCOMES
VTV vs PLV Relative Risk NNTB
Mean days VTV reduced stay -1.35
Pneumothorax VTV reduced risk 0.52 20
Hypocarbia VTV reduced risk 0.49 3
Severe IVH or PVL VTV reduced risk 0.47 11
PVL VTV reduced risk 0.45
Severe IVH VTV reduced risk 0.53 11
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• VTV not associated with any increased adverse outcomes
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RECOMMENDATIONS
Eichenwald EC, Martin R, Kim MS. Mechanical ventilation in neonates. UpToDate 2019
Sweet DG, et al. European Consensus Guidelines on the Management of Respiratory Distress Syndrome – 2019 Update. Neonatology 2019
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RECOMMENDATIONS CONT.
Eichenwald EC, Martin R, Kim MS. Mechanical ventilation in neonates. UpToDate 2019
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RECOMMENDATIONS CONT.
Eichenwald EC, Martin R, Kim MS. Mechanical ventilation in neonates. UpToDate 2019
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PRACTICALLY SPEAKING
• Limited access to VG ventilation
• Limited comfort with VC ventilation
• Disappearing flow sensors
• Use the mode with which one is most comfortable
• Have a unit wide policy
• Ongoing education
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FUTURE
• Adaptive support ventilation / closed loop monitoring
• NAVA trigger mechanism
• nIPPV
• Optimal PEEP
• Recruitment manoeuvres in neonates
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THANK YOU!
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SLIDE SORTER
• Why
• Outline
• Goals
• History
• Indications
• Common conditions
• Types
• VILI
• Open lung
• Lung protection
• Settings
• P vs V graph
• Synchronization
• Pressure targeted
• Modes table comparison
• Volume targeted
• VG / PRVC
• VG pic
• Cochrane 2016
• Meta 2016 - 1
• Meta 2016 - 2
• Meta 2016 - 3
• Meta 2016 - 4 - pic
• Cochrane 2017
• Meta 2017 -1
• Meta 2017 - 2
• Meta 2017 -primary
• Meta 2017 -secondary
• Recommend 1
• Recommend 2
• Recommend 3
• Practical
• Future
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