Professional Documents
Culture Documents
Respiratory Support:
Overview and Challenges
Jeffrey S. Gerdes, MD, MBA
Associate Chair, Department of Pediatrics
Children’s Hospital of Philadelphia
Associate Professor, Perelman School of Medicine
• Mechanisms of Action
• Physiologic Rationale
• Challenges for Clinical
Research
Question
of the day
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Nasal CPAP: Physiologic Rationale
• Distending pressure recruits lung volume
• Increases and stabilizes FRC
• Splints upper airways and compliant chest wall
• Improves lung Compliance
• Reduces airway Resistance
• Decreases Work of Breathing
• Improves gas exchange
• Reduces apnea
NCPAP: Mechanisms of Delivery
• Constant flow: flow • Patient expiratory flow
opposition (conventional opposes system flow and an
vent) expiratory resistor valve
RAM (micro-preemie )
RAM (preemie)
at 6 L/min
RAM (Newborn)
0 2 4 6 8 21
Pressure drop (cmH2O)
Modified from: De Paoli, Morley, Davis et al. Arch Dis Child Neonatal Ed 2002
Effect of mouth leak
8
7
Pharyngeal pressure
5
(cm H2O)
0
3 4 5 6 7 8
Set CPAP (cm H2O)
De Paoli, et al. Arch Dis Child Neonatal Ed 2005
Bubble CPAP vs. CPAP with Mech. Ventilator
Bubble CPAP pressure is flow dependent
Bubble CPAP
12 Ventilator
Mean Pressure (±SD)
10
(cm H2O)
8 8
Set
6
CPAP
4 4
2 No Leak
4 6 8 10 12
Bubble Bias Flow (L/min)
Kahn, Habib, Courtney, Pediatrics 2008
Clinical Correlations of different CPAP
Drivers and Interfaces
• Clinical studies often do not offer clear actionable
results
• Do mechanistic differences matter, or have they not
been discoverable with current studies?
• Babies have widely variable pathophysiology and
severity of illness
• Do the large pragmatic trials of NIRS strategies deliver
specific answers for relative efficacy when the “gold
standard” of CPAP is delivered with widely divergent
modalities?
NIPPV or SNIPPV:
Physiologic Rationale
• Benefits of NCPAP + additional tidal ventilation and/or lung
recruitment from higher MAP
• May reduce WOB relative to CPAP
(Aghai et al, Pediatr Pulmonol 2006; Chang et al, Ped Res 2011)
• Airway pressures actually delivered vary considerably from
settings (Owen et al, Arch Dis Child Fetal Neonat Ed. 2010 )
• Is variable pressure delivery favorable to lung function?
• Is apnea Improved through cyclic receptor stimulation?
• Synchronization may improve efficacy
• Unclear if NIPPV or bi-level CPAP is more efficacious
(Roberts et al, Pediatrics 2013)
• Are these modalities “Super CPAP”?
Heated and Humidified High Flow Nasal Cannula
HFNC: Mechanisms of Action
Flow Effects
Pressure Effects
HFNC: Mechanisms of Action
Gas Conditioning Effects
• Reduces patient’s metabolic workload needed
for Heating and Humidifying
(Waugh et al, Granger, RespCare 2004)
• Improves mechanics
-H&H Increases Compliance and Conductance
(Greenspan et al, J Peds 1991)
HFNC: Mechanisms of Action
Flow Effects
• Improves lung mechanics
- Reduced inspiratory resistance => Reduced resistive Work of
Breathing (Saslow et al, J Perinatol 2006)
- Expiration: possible “Coanda” effect (Dysart et al, Resp Med 2009)
to improved oxygenation
Schibler et al, Int Care Med 2011
Washout of
nasopharyngeal
Washout cavity
upper airway
• Avoids rebreathing of high- Courtesy of Walsh et al, Resp Care 2009
Prongs
O.D.
HFNC Pressure Delivery:
Effect of flow rate, % nares occlusion,
and mouth leak
Mouth Fully Closed Mouth Fully Open
F&P Neonatal Cannula (3.0mm prongs)
F&P Infant Cannula (3.7mm prongs)
25 2.5
Mean Airway Pressure (cmH 2O)
20 2.0 Percent
Occlusion
Flow 6 Lpm
Flow 4 Lpm
Flow 2 Lpm
1 minute
8 3.0 100% 8
7 7
6 6
3.5 78%
5 5
`
4 4
3 3
4.0 60%
2 2
4.5 48%
1 1
5.0 38%
0 0
4 5 6 7 8 4 5 6 7 8
Nasal CPAP setting (cmH2O) Nasal CPAP setting (cmH2O)
65
n=14 Infants
60
GA 27 (25-30) wks
55
BW 1.6 (1.1-2.9) kg
50
45
p = 0.011
40
35
30
2 hours NHFV
Initial pCO2 Final pCO2
Colaizy et al, Acta Paediatr. 200
HFNC NIV using
NCPAP RAM
Cannula
NIPPV
SiPap
NAVA
HFONC
• Mechanisms of Action
• Physiologic Rationale
• Challenges for Clinical
Research
Question
of the day
BUT
Are we reasonably able to study these differences,
And are these differences clinically important?
Extra-pulmonary Factors to Consider
When Evaluating NIRS Systems
• Minimizing nasal septal injury
• Ease of nursing and respiratory therapy care
• Comfort for baby and family
• Noise pollution
• Promotion of infant development
• Cost –interface and disposables, amortized cost of
the driver, RRT and RN time, and possible impacts on
length of stay or severity of illness
NIRS: Summary and Challenges for this conference
• NCPAP, NIPPV, and HFNC all have physiologic
rationales and feasible mechanisms of action
• All provide varying degrees of respiratory support
which improve physiologic parameters and gas
exchange in neonates
• Little is known about which devices may be better
for different patho-physiologies or different
severities of illness
• Do the clinical trials have sufficient numbers or
stratification of diagnoses and severity of illness to
differentiate the utility of these modalities? OR,
NIRS: Summary and Challenges for this conference