Non-Ventilation of the Neonate

Lynn MacIsaac
BC Children’s Hospital
Thompson River’s University
 Introduction
• Why non- invasive ventilation?
• Difference options for non-invasive ventilators
• Evidence for clinical uses
• Controversies
• Guidelines for use
• Conclusions
 Rationale
• Why do we need alternatives to mechanical ventilation?
 Rationale
• Why do we need non-invasive ventilation?
– Decrease the need for intubation
– Decrease the days or initiation of mechanical ventilation
– Reduce the incidence of bronchopulmonary
dysplasia(BPD)
 Option for non-invaive ventilation
• SiPAP: CPAP, BiPhaic, or BiPhaic Trigger
• Bubble CPAP
• High flow
• Opti Jr.
 • Heated circuit
Bubble CPAP • With expiratory limb attached
to the under water seal
• The flow will enter the
humidifier to the patient
• Then on expiration the patient
will meet a resistance.
• The resistance is what you set
on the stick that is in the
underwater seal
• This is your CPAP
Bubble CPAP
 The Drive for CPAP; Columbia
vs Boston
• Comparative outcomes in 452 newborns born
between 1991-1993
• Columbia Babies Hospital vs Beth Israel and
Brigham and Women’s Hospitals
• Demonstrated significant differences in CLD (4% vs
22%)
• Adjusting for baseline risks, an increased risk was
associated with higher use of mechanical ventilation
in Boston vs CPAP at Columbia
VanMarter Pediatrics 2000
 SiPAP
Driver

Circuit / Generator

Interface
 SiPAP The Driver
• Air/Oxygen Mixer
• O2 Analyzer
• 2 Flow Controls
• LCD Touch Screen
• Alarm Safety Systems
– High/Low Pressure
– FiO2 high/low
– 11 cmH2O Pressure Limit Valve(15cmH2O in Biphasic Tr)
– Gas Supply Pressures
– Battery
– Low Breath Rate/Apnea
 Criteria for Successful CPAP
• Stable and CONSTANT Positive Pressure
• Normalization of FRC
• Improvement in Compliance
• Reduction in Added Work of Breathing
• Easily Maintains Prongs in Place Without Causing Injury
• Does Not Interfere with Patient Care
 Lung Volume Recruitment in CPAP
Do Devices Make a Difference?
• RCT of VLBW infants Change in Lung Volume (VL)
(1092 g)
• Bubble CPAP vs Fluidic 14
Bubble

CPAP
12
VF
10

• Trend towards better

VL (ml/kg)
8

lung volume 6

recruitment with fluidic

4

CPAP 0

8 6 4 0
NCPAP (cmH2O)
Courtney SPR 2003
 The Generator
• Infant controlled demand
flow system situated
directly at the airway with
no moving parts.
• Maintains a very stable
CPAP Pressure
• Reduces the work of
breathing
 GENERATOR
The Generator is a fluidic
Pressure Measurement device that delivers
Insp. Flow
nasal CPAP using a
constant flow
delivered by the
Driver.

Breathing Channels
Fluidic Flip
 CPAP Pressure Stability
The fluidic CPAP produces
a very stable CPAP
pressure compared to
conventional CPAP

Moa & Nilsson 1988

 BiPhasic (two levels of CPAP)
• Two levels of CPAP one low one high
• The baby will breath at the low then bumped up
the breath at the high level
SiPAP™ , what potential benefits does it have?

– Recruit Lung Volume

• Lung protective strategy
• Shifts unstable alveoli to the deflation limb of the PV curve

– Off-Load Respiratory Work

• 3-6 ml/kg shifts in FRC improves gas exchange

– May Stimulate the Respiratory Center

• may decrease the incidence of re/intubation for apnea
 SiPAP rapid increase in pressure
• NIPPV is still
conventional ventilation
with the potential for
conventional ventilation
induced lung injury
 SiPAP
Gentle Lung Recruitment

• Lung Recruitment by
Time
– Lower pressures sustained
for longer time periods can
recruit as effectively as
higher pressures for shorter
periods and with less
induced injury
Opti jr
Vapor therm
 Approx. Max. Quantit
rt No. Description
Weight Flow y
OPT31 Premature size nasal
<2 kg 8 L/min 20/box
2 cannula
OPT31 Neonatal size nasal
1-8 kg 8 L/min 20/box
4 cannula
OPT31
Infant size nasal cannula 3-15 kg 20 L/min 20/box
6
OPT31 Pediatric size nasal
12-22 kg 25 L/min 20/box
8 cannula
Opti flow jr
 Opi Flow
• Washout of nasopharyngeal deadspace
The most common reasons for needing to switch to invasive
ventilation are hypercapnia and apnoea secondary to
hypercapnia. Therefore, if deadspace in the nasopharyngeal
cavity (and overall deadspace) is reduced, alveolar
ventilation will be a greater fraction of minute ventilation.
NHF oxygen therapy has been shown to have an immediate
effect on ventilation rates and to improve oxygenation,
indicating that deadspace is reduced. In addition, the results
of animal studies of tracheal gas insufflation (TGI) support
the notion that deadspace washout is a lung protective
strategy for acute lung injury
 ENEFITS OF OPTIFLOW WITH
OPTIMAL HUMIDTY
• Clinician More comfortable and tolerable than other respiratory
therapies may reduce the requirement for CPAP Receives a more
accurate level of oxygen. May reduce the need for intubation
Reduces the work of breathing easy to set up and maintain Can
enjoy greater interaction with parents and clinicians (assisting
development care)More control and flexibility with delivery of a
fraction of inspired oxygen (FiO2)More likely to receive an
uninterrupted oxygen flow Easier holding of the infant less risk of
upper airway trauma sedation may be reduced due to a more
comfortable infant easier feeding may reduce length of stay
 Reduced work of breathing
(WOB):
The nasopharyngeal surface area, distensibility of the nasopharynx and
gas volume all contribute resistance to gas flow. NHF oxygen therapy
provides nasopharyngeal gas flows that are equal to, or greater than, a
patient’s peak inspiratory flow thereby decreasing resistance which in
turn translates into a reduction in resistive WOB. The effects of NHF
oxygen therapy on expiration are not as well understood.
 Improved mechanics:

Improved respiratory compliance has been documented

in infants receiving NHF oxygen therapy for respiratory
support. These results indicate that, by reducing
distending pressure and therefore also functional residual
volume, adequate conditioning of inspired gases during
NHF oxygen therapy affects physiological responses in
the lung.
 Reduced metabolic cost of gas
conditioning
There is an energy cost associated with conditioning of
inspired gases by the upper airway. This cost is higher
when gas is cooler and drier. Use of a NHF oxygen
therapy system that warms and humidifies inspired gas
presumably reduces the energy required for gas
conditioning.
Provision of distending pressure:
Ventilatory mechanics can be improved by providing
distending pressure to the lungs which then improves lung
compliance and gas exchange. There is the potential for
continuous positive airway pressure (CPAP) to be generated
during NHF oxygen therapy. This is dependent on the
relationship between the size of nasal prongs and the nose,
and requires the mouth to be closed. One clinical study in
infants receiving NHF oxygen therapy showed that
pharyngeal pressure was correlated with flow and inversely
correlated with infant size.
 KEY POINTS:
• The five proposed mechanisms for the efficacy of NHF
oxygen therapy are: washout of nasopharyngeal
deadspace; reduced WOB, improved mechanics; reduced
metabolic cost of gas conditioning; and provision of
distending pressure.
• HFT can be regarded as a viable device for gas
conditioning.
• Numerous studies have established the safety and efficacy
of NHF in acute care.
• There are some studies which demonstrated the application
of NHF beyond conventional oxygen therapy.
Family time.....Questions?
Invasive ventilation
 The patient
• 31 year old female delivered a 26 + 3 days week
old female 750 grams. The baby was born by c-
section for fetal distress. Apgars 6, 6, and 8 baby
required IPPV, intubated and given surfactant
xray
• Started on CPAP +7 and
30 % oxygen
• Capillary gas pH 7.27,
pCO2 60, pO2 27, HCO3
23, BE 0.6
• Over the next 4 hr oxygen
increased to 55%
• Increases work of
breathing....baby intubated
 Intubated
• FiO2 .4, RR 40, I time .3 (I:E 1:3),
tidal volume set at 4 ml/kg, PIP
19, PEEP 6
• Capillary gas:
• pH 7.23, pCO2 69, pO2 27 , HCO3
23, BE –o.3
• Over the next 4 hours the baby
oxygen increased to 60% .
• Patient changed to HVO to avoid
lung damage.
 Why Oscillation ventilation?
1. Hypothesis of lung protection due to avoidance
of alveolar stretching and shearing forces
2. Animal studies suggest that HFOV improves
oxygenation
3. Successes in neonates and pediatrics
4. Reports of HFOV improving oxygenation with
few adverse effects
 Conventional vs. HFOV
Conventional:
• Larger tidal volumes and lower respiratory rates
• MV = RR x Vt
• Ventilate above a PEEP
• Active inspiration and passive exhalation
 Conventional vs. HFOV
HFO:
• Piston driven
• Small Vt’s (less than deadspace?)
• High RR’s (>150)
• Ventilate around a mean airway pressure
• MV = RR x Vt2
• Active inspiration and exhalation
 Goals
1. Avoid overdistention
2. Avoid underinflation
3. Keep the lung inflated (maintain optimal FRC)
4. Reduce FiO2 (P/F ratio improves)
5. Improve lung function (V/Q matching)
 Settings
Flow
Paw
Power (delta P)
Ti %
Hz
Alarms (MAP)
FiO2 (blender)
 Flow
• Continuous through inspiration and expiration
• Flow setting is determined by the amount of
desired Paw:
– Neonates = 10-20 Lpm
– Pediatrics = 15-30 Lpm
– Adults = 25-40 Lpm
• Determines the level of Paw that can be achieved
*may need to set higher if there is a leak
 Paw
• Primarily used to control oxygenation
• Constant Paw – decreases sheering injury from
opening and closing of the alveoli
• Paw can be weaned if FiO2 < 0.60
• Oscillator Paw > 5cmH2O higher than
conventional Paw
– Why?
 Power
• Determines the delta P - ‘Think of it like a Vt
setting’
• Do not change power for desired delta P
– delta P increases = worse compliance
– delta P decreases = improved compliance
• Influences Vt (small changes to Vt)
• Attenuation…
 Ti %
• Default to 33%
I : E ratio = 1:2
• May be increased but be cautious of auto-trapping
(1:1)
 Hertz
• 1 Hz = 60 cycles / min
– Neonates = 10 – 15 Hz
– Pediatrics = 6 – 12 Hz
– Adults = 3 – 8 Hz
• Decreasing Hz = increase MV = improving CO2
removal
• Increasing Hz = decrease MV = worsening CO2
removal
 Humidification
• The use of a low compressible volume humidifier
chamber is preferred
• Water consumption is higher, due to constant
flow
• Condensation in the circuit is good
• There is no evidence to support HME use with
HFOV
 Suctioning
• In-line suctioning is preferred (maintain FRC and
minimize derecruitment)
• Pause oscillator
• Recruitment prior to re-starting

There is evidence to support suctioning the patient prior to initiation of HFOV and then
avoid suctioning for at least 12 hours or when clinically indicated (this will enable
maximum alveolar recruitment).
 Recruitment Maneuvers
• more and more mounting evidence that
recruitment maneuvers are more beneficial
• ensure that you have better volume in the lung
when you restart oscillation
 Choking Points
• importance of the ‘sub
ambient pressure’ and how it
could be troublesome to your
patient
• phenomenon called “choking
points” on an oscillator and it
is caused by the negative
pressure generated on active
exhalation.
Choke point