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Non Invasive Respiratory


Support in Newborn
Infants

20 March, 2018

Vladimiras Chijenas, MD
Consultant neonatologist,
Vilnius Maternity Hospital,
Lithuania
 1973 Jens Camper et al.  Caliumi-Pellegrini
G., et al.
CPAP by the Nasal Route
Arch Dis Child 1974;
49: 228–30.
Fleming, Fanaroff,
 Twin nasal cannula
Klaus, et al. A Device for administration of
continuous positive
for Administr ation of
airway pressure to
CPAP by the Nasal
newborn infants
Route
Pediatrics 1973; 52:131
In 1970-1980 some centers stopped using CPAP
after the development of infant ventilators.

 MV has many adverse effects on the lungs strongly


associated with adverse neurologic outcomes - each
week of additional MV is associated with a
significant increase in neurodevelopmental
impairment
(Neonatal Research Network) .
VENTILATOR INDUCED LUNG INJURY – VILI
Source: Paediatric Respiratory Reviews 2011; 12:196-205
(DOI:10.1016/j.prrv.2010.12.001

 VOLUME/BAROTRAUMA (↑PPV-PIP/↑VT)
 ATELECTOTRAUMA(OPENING AND CLOSING LUNG UNITS)
 RHEOTRAUMA
 ENDOTRAUMA
 BIOTRAUMA

4
Respiratory rate Minute ventilation

Outcome: lung function in survivors


before discharge

Compliance

Work of breathing

Roehr C et al. Arch Dis Child 2011


the incidence of BPD:
(Fanaroff AA, Am J Obstet Gynecol. 2007)

42% (BW 501–750 g),

25% (BW 751–1000 g),

11% (BW 1001–1250 g),

5% (BW 1251–1500 g).

Concerns about ventilator-induced


lung injury and the continued high
incidence of chronic lung disease led
to a CPAP comeback.
Non-Invasive Respiratory Support can be defined as any
form of respiratory support that is not delivered via an
endotracheal tube or tracheostomy.

Source: Paediatric Respiratory Reviews 2011; 12:196-205


(DOI:10.1016/j.prrv.2010.12.001 )
NRS effective in treatment of:

 RDS,
 AOP - obstructive/mixed apnea of
prematurity,
 Weaning from MV, ensuring successful
extubation,
 DR stabilisation,
 Atelectasis, tracheomalacia, others types of
upper airway obstructions.
Limitations of NRS:

 Nasal irritation or injury,


 Obstruction of the nasal device by
secretions,
 Gastric distention,
 Risk of pulmonary air leak.
Contraindications to NRS

o Ventilatory failure,
o Cardiovascular instability,
o Upper airways abnormalities (choanal
atresia, tracheo-esophageal fistula,
diaphragmatic hernia),
o Unrelenting apneas.
 Sankaran K. Neonatal CPAP ventilation, PERINATOLOGY, Vol.12, No.4, 2012
INTERFACES OF NON INVASIVE/NASAL
RESPIRATORY SUPPORT ( NRS)

binasal short prongs


nasal masks
nasopharyngeal tubes
facial mask.

The choice of the interface should balance two goals:


 achieving a satisfactory comfort and
 reducing dampening and pressure loss.
 It is a form of continuous distending pressure coupled with
positive end expiratory pressure (PEEP) in spontaneously
breathing infants throughout the respiratory cycle, preventing the Definition - C PAP
collapse of alveoli and terminal airways during expiration.
The acronym CPAP reflects a
Continuous Positive Airway Pressure
– sustained inflation of lungs – PEEP
applied to a spontaneously breathing
baby.

Variable flow systems intra alveoli pressure


cm H2O
 The variable flow systems use jet
entrainment, i.e. use of a fast moving jet
of compressed gas to accelerate an air
6
mass. The CPAP pressure is built at the
5 E E
nasal orifices via a jet stream passing
4
through an opening in the nosepiece. I I
3

Constant flow systems 2

1
 Constant flow systems are either
ventilator derived or use the classic
Zeitachse
underwater bubble CPAP system
Initial stabilization CPAP/PEEP
Strong evidence

 The delivery room use of CPAP or PEEP of at least 5 –6 cm H2O


during initial stabilization of preterm infants is likely to be beneficial
and should be used if suitable equipment is available.
CPAP vs MV

 COIN, SUPPORT and VON (n=2358 preterm <30 weeks)

 Starting CPAP resulted in:

 decreased rate of intubation in the delivery room,

 decreased duration of mechanical ventilation,

 potential benefit of reduction of death and/or BPD.


NCPAP failure
 But… use of nCPAP may fail in extremely low birth
weight infants, with 34 to 83% of such infants requiring
subsequent intubation.
 post extubation support with nCPAP in these infants is
associated with a 16-40% failure rate.

Unrelenting apnea:
pH<7.25 PaCO2>60 – 65 mmHg FiO2>60
(Sankaran K. Neonatal CPAP ventilation, PERINATOLOGY, Vol.12, No.4,
2012)
CPAP failed:

Efforts to reduce these failure rates have prompted the


use of “superior” forms of NCPAP:

 Nasal Bilevel positive airway pressure (nBiPAP),


 Nasal intermittent positive pressure ventilation
NIPPV or synchronized NIPPV (SNIPPV) and
 nHFOV

as a „path“ from nCPAP to avoid mechanical ventilation.


Nasal Bilevel positive airway pressure
(nBiPAP)
 In contrast to CPAP, where the pressure is
constant during inspiration and expiration,
nBiPAP is a non-invasive form of pressure-
controlled ventilation, provides a higher
pressure during inhalation and lower pressure
during exhalation
.
Biphasic is a timed
bilevel pressure rise
above baseline CPAP
Nasal intermittent positive pressure ventilation
(nIPPV) combines nCPAP with superimposed
ventilator breathing at a set peak pressure.

18
BiPAP/NIPPV
 The major differences of BiPaP compared with NIPPV modes are:
 the limited ability to deliver PIP (~10-12 cm H2O),
 lower delta pressures (PIP-PEEP: ~3-4 cmH2O) and
 use of longer inspiratory times (~ 0.5 to 2 sec.).

NIPPV mode usually provides shorter inspiratory time (0.3-0.5 sec), but
higher (16-25 cm H2O) peak inspiratory pressure.
NIPPV (expected advantages)

 reduces the dead space,


 stabilizes the functional residual capacity,
 promotes reexpansion of areas with
microatelectasis and
 improves pulmonary function
(Davis P.G. et al., 2003).
 Ramanathan et al. reported that only 17% of
infants born at 26-29 weeks’ gestation needed
endotracheal ventilation at 7 days of age in the
NIPPV group.
SNIPPV
 Synchronized nasal intermittent positive pressure
ventilation (SNIPPV) is a variation of NIPPV which
combines CPAP with triggered inflations of the
respirator.

 In 1999, after a paper by Friedlich, who successfully used


SNIPPV for weaning from MV (22 VLBW neonates), this
technic became interesting to neonatologists.

 IManzar et el 2004, indicates 81% success with


(S)NIPPV therapy.
Synchronization (mechanical inflations are timed with
spontaneous inspiration efforts, when the glottis is
open):

 reduces the breathing effort of the patient


and results in better infant-ventilator interaction
than non-synchronized nasal ventilation,
o Improves the stability of the chest wall and
pulmonary mechanics,
o Use of a PIP above the PEEP activate the
resp. drive, Vt increases.
SNIPPV

Upper airways of infants treated with


this technic require extra care:
 properly positioned,
 avoidance of rain out in the circuit
and
 regularly checked the nasal cavity to
keep it clear of secretions.
Triggering

 When performing SNIPPV in neonates,


special attention should be paid to the
selection of the triggering system.
 SNIPPV is possible, but challenging,
because of air leaking around the
interface (prongs or nasal mask) and
from the mouth.
The main trigger systems and the principles of their operation as well as disadvantages are
presented
Trigger systems for performing the noninvasive APV in neonates,
Trigger type Principle of operation Disadvantage
Abdominal pneumatic capsule Detects the outward movements of the abdomen due 1.Mistakes in positioning, especially in case of
(Graseby) to the contraction of the diaphragm abdominal distention may produce artifacts and
mimic respiratory efforts - asynchrony,
2. Bench top data suggest that at higher breath
rates may not respond to all detected breaths
with a pressure peak.

Flow adjusted trigger Flow sensors interposed between the Y piece and the 1.Difficult to analyze the flow signals because
nasal cannula and connected to a time-cycled, of the leaks, increase of the dead volume,
pressure-limited neonatal ventilator (Moretti device). 2.Weight of the flow-sensor – risk of nasal
damage

Pressure-adjusted trigger Pressure sensor detects the pressure differences in 1.Difficult to analyze the signals because of the
the reservoir of the generator (connected to the leaks
patient’s airways) while inhaling and exhaling

NAVA The sensor detects the phrenic nerve impulses - 1.Invasive,


(Neurally Adjusted Ventilatory diaphragmatic EMG 2.Costly,
Assist) 3.There is little data on clinical outcomes; NIV
use has been tested in rabbits and adults, but
not described in neonatal NIV

© Modern Concepts of Noninvasive Respiratory Support in Neonatology, Vladimiras Chijenas et al., Deutscher Wissenschafts-
Verlag (DWV), 2015.

SNIPPV vs. NIPPV and CPAP

 No reports of GI perforations when the


simulated breaths or back up rate is
synchronized with the patient’s breaths,
 Using SNIPPV, less NEC and nasal
injuries than using NIPPV,
 Using CPAP, pneumothorax is more
often than using SNIPPV.
Haresh Kirpalani et al. “A trial comparing noninvasive ventilation strategies in Preterm
Infants”, NEJM, August 15, 2013
Does it work?
High flow nasal cannula (HFNC)
Heated, humidified high-flow nasal cannula (HHHFNC)

By definition HFNC delivers flow rates that exceed patient


inspiratory flow rates at various minute volumes.
High flows
 can enhance respiratory efficiency by flushing out carbon dioxide
from the nasopharyngeal anatomical dead space.
Gas conditioning: warming and humidification of the
conducting airways by delivery of warm, humid gas is associated
with improved conductance and pulmonary compliance.

may reduce the need for CPAP or intubation in some clinical


situations.
M O D E R N C O M P O N E N T S O F N E O N ATA L N O N I N VA S I V E
R E S P I R ATO R Y S U P P O R T ( S T E R O I D S , D C C , R S B C C ,
C A F F E I N E , L I S A / M I ST, E TC . )

SUSTAINED
INFLATION

NIPPV/
HFNC NCPAP
SNIPPV

HFNOV

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