1 / 81

by Eric Schultz, DO, MPH 07/2009 Children’s Hospital of Orange County

Nasal Continuous Positive Airway Pressure, Synchronized Nasal Intermittent Positive Pressure Ventilation, and Nasal Cannula. by Eric Schultz, DO, MPH 07/2009 Children’s Hospital of Orange County. Objectives.

karan
Download Presentation

by Eric Schultz, DO, MPH 07/2009 Children’s Hospital of Orange County

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Nasal Continuous Positive Airway Pressure, Synchronized Nasal Intermittent Positive Pressure Ventilation, and Nasal Cannula by Eric Schultz, DO, MPH 07/2009 Children’s Hospital of Orange County

  2. Objectives • Determine if Nasal Continuous Positive Airway Pressure (NCPAP) is superior to Intubation + Surfactant • Determine if bubble NCPAP is superior to Infant Flow Driver CPAP • Determine if Synchronized Nasal Intermittent Positive Pressure Ventilation (SNIPPV) improves neonatal outcomes compared to NCPAP • Determine if SNIPPV is superior to NCPAP in extubation of infants with RDS • Determine if Nasal Cannula is equivalent to NCPAP • Determine when Nasal Cannula should be used

  3. Rate of Prematurity (<36 weeks) 4.1M live births in U.S. in 2002

  4. COIN TrialNasal CPAP or Intubation at Birth for Very Preterm Infants Colin J. Morley, Lex Doyle, et al. NEJM Feb 2008

  5. Objective • Goal: NCPAP applied shortly after birth reduces rate of death or BPD in VLBW infants compared to intubation and ventilation

  6. Methods • RCT • Multi-center (Australia, Europe, Canada, US) • Total N = 610 (307 NCPAP, 303 Intubate) • 25 0/7 to 28 6/7 WGA • Randomized at 5 min of life • Pt had to have some resp effort, but needed resp support

  7. CPAP 8cm H2O initially, then adjusted • + criteria for intubation if in CPAP group • - criteria for extubation, surfactant administration, vent settings, reintubation (center dependent) • Primary Outcome: death or BPD (O2 need at 36 WGA)

  8. Conclusions • Early NCPAP did not reduce death or BPD • NCPAP had more PTX, but fewer received O2 at 28 days and had fewer ventilation days

  9. Objectives • Determine if Nasal Continuous Positive Airway Pressure (NCPAP) is superior to Intubation + Surfactant • Determine if bubble NCPAP is superior to Infant Flow Driver CPAP • Determine if Synchronized Nasal Intermittent Positive Pressure Ventilation (SNIPPV) improves neonatal outcomes compared to NCPAP • Determine if SNIPPV is superior to NCPAP in extubation of infants with RDS • Determine if HHHFN is equivalent to NCPAP • Determine when HHHFNC should be used

  10. A Randomized Controlled Trial of Post-Extubation Bubble CPAP Versus Infant Flow Driver CPAP in Preterm Infants with RDS Samir Gupta, et al. J Pediatrics, May 2009

  11. Objectives • Goal: compare the efficacy and safety of bubble CPAP and Infant Flow Driver CPAP for post-extubation management of preterm infants w/ RDS

  12. Methods • Prospective RCT • Single center • 24-29 WGA intubated for RDS • Stratified into <=14 days of ventilation vs. >14 days • Primary Outcome: successful extubation for >=72hrs • + criteria for extubation and reintubation

  13. CPAP 6 cm H2O – then weaned • Total N = 140 (IF 69, Bubble 71)

  14. * P value <0.05 # only 13 infants

  15. Conclusions • Bubble CPAP is as effective as IF CPAP for extubation of VLBW w/ RDS • Bubble CPAP had increased rate of successful extubation if infant ventilated <=14 days • Bubble CPAP associated w/ significantly reduced duration of CPAP support

  16. Early Bubble CPAP and Outcomes in ELBW Preterm Infants Vivek Narendran, Alan Jobe, et al. J Perinatology, Apr 2003

  17. Objectives • Goal: test whether early bubble CPAP results in improved respiratory outcomes in ELBW infants

  18. Methods • Retrospective cohort controlled • 401-1000 gm infants • Period 1 (1998-1999) Intubation + Surf • Period 2 (2000-2001) bubble CPAP in DR -> 5 cm H2O during entire study • + criteria for intubation • - criteria for extubation

  19. * P value <0.05

  20. Conclusions • Early bubble CPAP reduced DR intubations, days on vent, postnatal steroid use, and was associated w/ increased wt gain w/ no increased complications

  21. Objectives • Determine if Nasal Continuous Positive Airway Pressure (NCPAP) is superior to Intubation + Surfactant • Determine if bubble NCPAP is superior to Infant Flow Driver CPAP • Determine if Synchronized Nasal Intermittent Positive Pressure Ventilation (SNIPPV) improves neonatal outcomes compared to NCPAP • Determine if SNIPPV is superior to NCPAP in extubation of infants with RDS • Determine if HHHFN is equivalent to NCPAP • Determine when HHHFNC should be used

  22. Synchronized Nasal Intermittent Positive-Pressure Ventilation and Neonatal Outcomes Vineet Bhandari, Neil Finer, et al. PEDIATRICS, 2009

  23. Objectives • Goal: use of Synchronized Nasal Intermittent Positive Pressure Ventilation (SNIPPV) in patients with BW <=1250 grams is associated with lower incidence of BPD or death.

  24. Methods • Retrospective case control study • 2 center trial = Yale and UCSD • BW <=1250 gm (substratified: 500-750, 751-1000, 1001-1250) • + criteria for intubation • + criteria for extubation • + criteria for postnatal steroid use

  25. Methods • Infant Star w/ SIMV box = StarSync module for thoracoabdominal synchronization • Extubated to NCPAP (4-6cm H2O) or SNIPPV (same rate as CMV/SIMV, PIP increased by 2 to 4 cm H2O, PEEP <=6, flow 8-10 LPM) • Primary outcome: BPD or death

  26. Results

  27. Results NDI outcomes were not significantly different between the groups.

  28. Results: Logistic RegressionEffect of SNIPPV versus NCPAP

  29. Conclusions • SNIPPV improved BPD, BPD/death, NDI, and NDI/death for infants 500-750 gm versus NCPAP

  30. Study Limitations • Techniques for using SNIPPV not standardized between centers • Non-randomized study w/ selection bias • Retrospective versus prospective • Lacking BPD risk variables (eg: chorioamnionitis) • Equipment not commonly used anymore • Device application not similar (eg: no chin strap/pacifier used in all cases of NCPAP, but strict guidelines for SNIPPV)

  31. Objectives • Determine if Nasal Continuous Positive Airway Pressure (NCPAP) is superior to Intubation + Surfactant • Determine if bubble NCPAP is superior to Infant Flow Driver CPAP • Determine if Synchronized Nasal Intermittent Positive Pressure Ventilation (SNIPPV) improves neonatal outcomes compared to NCPAP • Determine if SNIPPV is superior to NCPAP in extubation of infants with RDS • Determine if HHHFN is equivalent to NCPAP • Determine when HHHFNC should be used

  32. A Prospective Randomized, Controlled Trial of SNIPPV versus NCPAP as Modes of Extubation Nabeel Khalaf, Vineet Bhandari, et al. PEDIATRICS, July 2001

  33. Objectives • Goal: to determine if SNIPPV would decrease extubation failure rates in preterm infants ventilated for RDS compared with NCPAP

  34. Methods • Randomized, controlled prospective trial • <=34 WGA intubated for RDS + survanta • Extubated to: Argyl NCPAP or Bear Cub versus Infant Star SNIPPV • + criteria for extubation (includes aminophylline level and Hct) • PFTs (dynamic lung compliance and expiratory airway resistance) prior to extubation – deemed accurate if air leak <20%

  35. Methods • Extubated to either: • NCPAP 4-6 cm H2O • SNIPPV: rate same as CMV/SIMV, PIP increased by 2-4, PEEP <=5, flow 8-10 LPM • Success if remained extubated <=72hrs • + intubation criteria

  36. Results No differences between groups for days on PPV, O2 days, neonatal sepsis, air leaks, PDA, postnatal steroids, IVH, PVL, NEC, ROP, CLD, and length of stay.

  37. Results • PFT: using Cdyn >=0.5 and RAW <=70 • Sensitivity = 86% • Specificity = 16% • PPV = 80% • NPV = 22% • In infants w/ poor lung function (Cdyn <0.5 and RAW >70), successful extubation in 27/29 (93%) SNIPPV and 15/25 (40%) NCPAP (p-value <0.01)

  38. Conclusions • SNIPPV is more effective than NCPAP in weaning infants w/ RDS from CMV. • PFTs may be used to aid in predicting successful extubation.

  39. Study Limitations • Single center • Equipment not serviced anymore? • Decreased apnea as reason for reintubation (even though low threshold in criteria) • Prongs or mask used for SNIPPV?

  40. Objectives • Determine if Nasal Continuous Positive Airway Pressure (NCPAP) is superior to Intubation + Surfactant • Determine if bubble NCPAP is superior to Infant Flow Driver CPAP • Determine if Synchronized Nasal Intermittent Positive Pressure Ventilation (SNIPPV) improves neonatal outcomes compared to NCPAP • Determine if SNIPPV is superior to NCPAP in extubation of infants with RDS • Determine if HHHFN is equivalent to NCPAP • Determine when HHHFNC should be used

  41. Case #1 29 week gestation age male, weight 1.2 kg Day of life 21, corrected 32 weeks Patient is having no A’s and B’s X 3 days CPAP 4 FiO2 = 0.21 Total Fluids=Feeds=150 ml/kg/day Should we put this patient on HHHFNC?

  42. Questions with use of HHHFNC • Using it as equivalent of NCPAP? • Using it as a “bridge” to room air trial? • Using it to deliver increased FiO2 to developing/diagnosed BPD patient? • Using it because of nasal/forehead breakdown from NCPAP? • Using it because infant >32 weeks and is nippling?

  43. HHHFNC Therapy: Yet Another Way to Deliver Continuous Positive Airway Pressure Kubicka et al. PEDIATRICS, 2008, 121:82-88

  44. Objective • Goal: estimate level of delivered positive airway pressure through oral cavity pressure in HHHFNC at 1-5L/min

  45. Methods • Center: Dartmouth • Jan 2005 to April 2006 • Apparatus: Vapotherm or Fisher & Paykel nasal cannula system • Outer diameter (OD)=0.2cm • Exclusion: neuromuscular d/o, congenital or chromosomal d/o, severe neurologic impairment (includes grades 3 or 4 IVH)

  46. Methods • Bench measurements w/ anesthesia bag (OD=0.2cm, and 3 opening sizes 3, 5, or 8mm) • No sedation, during quiet sleep • Supine • 8-F feeding catheter inserted ~3cm into oral cavity • Mouth closed during measurements • 3 measurements lasting 1-2 min each / infant • Comparison group on bubble CPAP

More Related