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7_+SNIPPV+Rimensberger

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					Non-invasive positive pressure
  ventilation in the neonate




          Peter C. Rimensberger
        Pediatric and Neonatal ICU
       University Hospital of Geneva
                Switzerland
                        COIN-trial
   610 infants, 25-to-28-weeks’ gestation, randomized to
           CPAP ßà intubation + ventilation
                   at 5 minutes after birth




In the year 2008: BPD incidence = 35% < 29 wks
COIN-trial, NEJM 2008
                        Elastic work of breathing

                                                     Thorax
                                                     Lungs
Work = P * V          Volume                         Chest wall
                      (%VC)
                                            Adult




                      Volume
                      (%VC)                 Infant


ACB: Move the
chest wall from the
resting position      Volume                Infant
                      (%VC)                 (Reduced Compliance)
AXC: Overcome
resistive forces
                                       Pressure
  Inward distortion of the rib cage on the
   volume displaced by the diaphragma
à Innefficient ventilation and waist of work
       Thoraco-abdominal Asynchrony
(the noncoincident motion of the rib cage and abdomen during breathing)


If the rib cage is sucked in
or retracted as abdominal
excursions occur (e.g., in
upper airway obstruction),
or the abdomen is retracted
as the rib cage expands
(e.g., diaphragmatic
paralysis)




                                    Prisk GK Pediatric Pulmonology 2002; 34:462–472
  Thoracoabdominal Asynchrony à Synchrony

        NCPAP                            NIPPV




25 weeks: Abdominal (red) & Chest Wall (green) Movements
Synchronized NIPPV: Better ventilation

                                    Courtesy of Simon Bignall
SNIPPV
1) To avoid the need for endotracheal intubation in preterm infants with
   respiratory failure
  Barrington KJ Pediatrics 2001; 107: 638–41 (RCT)
  De Paoli AG Acta Paediatrica 2003; 92: 70–5 (review and meta-analysis)
  Khalaf MN Pediatrics 2001; 108: 13–7 (RCT)
  Santin R Perinatol 2004; 24: 487–93 (prospective observational study)
  Friedlich P Perinat 1999; 19: 413 (RCT)

2) It has been shown to be particularly effective in decreasing
  reintubation when compared with nasal CPAP as an extubation mode
  Barrington KJ Pediatrics 2001; 107: 638–41 (RCT)
  Khalaf MN Pediatrics 2001; 108: 13–7 (RCT)
  Friedlich P Perinat 1999; 19: 413 (RCT)

3) SNIPPV has been used as an alternative to continued endotracheal
  mechanical ventilation after surfactant therapy in 28- to 34-week
  gestation infants with respiratory distress syndrome
  Santin R Perinatol 2004; 24: 487–93 (prospective observational study)

4) Work of breathing has also been shown to be decreased with the use of
  SNIPPV compared to nasal CPAP
  Kiciman NM Pediatr Pulmonol 1998; 25: 175–81
Reintubation after extubation:
A prospective RCT comparing SNIPPV vs NCPAP
                             (Khalaf MN, et al. Pediatrics 2001;108:13-17)


Criteria for extubation:            After extubation:
  1. MAP = 4-6 cm H2O                 1. SNIPPV: PIP +4, same IMV-PEEP
  2. IMV £ 25/minute                  2. NCPAP: 4- 6
  3. PIP £ 16 cm H2O                  3. FiO2: O2 saturations 90-96%
  4. PEEP £ 5 cm H2O
  5. FiO2 £ 0.35                    Criteria for re-intubation:
  6. Aminophylline level ³ 8 mg/L     1. pH < 7.25
  7. Hematocrit ³ 40%                 2. PaCO2 > 60 mmHg
                                      3. PaO2 < 50 mmHg despite a FiO2 of 0.7
                                      4. A single episode of apnea requiring bag
                                         and mask resuscitation
                                      5. Frequent (³ 3/hr) apnea/bradycardia
                                          spells
                                      6. Multiple (³ 3/hr) desaturation episodes
                                         despite a FiO2 of 1.0
Reintubation after extubation:
                     (Khalaf MN, et al. Pediatrics 2001;108:13-17)


                     SNIPPV          NCPAP            p
                     (n =34)         (n =30)          value
Age at study (d)     4 (1 -83)       2.5 (1 -106)     0.95
Wt. at study (gm)    1110 + 55       1200 + 75        0.32
Pre -MAP (cm H2 O)   4.9 + 0.2       5.1 + 0.2        0.38
Pre -FiO2            0.30 + 0.02     0.30 + 0.01      0.84
AR (cm/H 2 O/L/s)    169 + 16        205 + 21         0.18
LC (ml/cmH 2 O)      0.74 + 0.02     0.8 + 0.1        0.57
Post -pH             7.36 + 0.03     7.34 + 0.02      0.14
Post -CO 2 (mmHg)    37 + 1.0        40 + 2.0         0.06
Apnea (n)            2.24 + 0.8      2.03 + 0.7       0.84
Success (n, %)       32 (94)         18 (60)          < 0.01
A Prospective Observational Pilot Study: SNIPPV as a
Primary Mode of Ventilation In Infants > or = 28 Weeks
with RDS
                       (Santin RS, et al. J Perinatol 2004;24:487-93)



                                      SNIPPV       CV (n=35)       P
                                        (n=24)                   value
Birth weight (grams) *                1582 ± 77    1511 ± 103    0.92

Gestational age (weeks) *             31.2 ± 0.5    31.0 ± 0.4   0.89

Gender (male, n, %)                     15 (63)      22(62)      0.88

Antenatal steroids (n, %)               18 (75)      24 (68)     0.90

Apgar at 5 minutes (median)               8             8        0.87

Age at surfactant instillation (h)*    3.1 ± 1.4    2.7 ± 0.49   0.49

Mean ± SEM
A Prospective Observational Pilot Study: SNIPPV as a
Primary Mode of Ventilation In Infants > or = 28 Weeks
with RDS
                          (Santin RS, et al. J Perinatol 2004;24:487-93)

                                                SNIPPV         CV           p
                                                                          value
                                                (n=24)       (n=35)
 OI pre-surfactant instillation (cm H2O)        6.0 ± 1.0    5.5 ± 0.6    0.67

 Duration of endotracheal intubation   (days)   0.3 ± 0.0    2.40 ± 0.4   0.001

 Duration of SNIPPV (days)                      2.8 ± 0.4    3.1 ± 0.7    0.68

 Duration of CPAP (days)                        0.3 ± 0.3    0.2 ± 0.1    0.71

 Duration of nasal cannula (days)               3.8 ± 1.5    5.1 ± 1.3     0.3

 Duration of supplemental O2 (days)             8.2 ± 3.3    15.0 ± 3.2   0.04

 Duration of parenteral nutrition (days)        8.4 ± 0.8    12.1 ± 1.6   0.02

 Length of stay (days)                          29.1 ± 3.3   37.5 ± 3.0   0.04

 OI: Oxygenation Index      Mean ± SEM
NIMV versus NCPAP for Respiratory Distress Syndrome:
A Randomized, Controlled, Prospective Study




                                     Kugelmann A   J Pediatr 2007;150:521-6
Infants treated initially with NIPPV
needed less ETT ventilation than
infants treated with NCPAP.
Infants treated with NIPPV had a
decreased incidence of BPD
compared with those treated with
NCPAP
Kugelmann A   J Pediatr 2007;150:521-6
A RANDOMIZED CONTROLLED TRIAL OF
SYNCHRONIZED NASAL INTERMITTENT POSITIVE
PRESSURE (SNIPPV) VENTILATION IN RDS
                    (Bhandari V, et al. J Perinatol 2007;27:697-703)




SURF-N-SAVE STUDY: HYPOTHESIS

Primary mode SNIPPV (defined as its use in the acute phase of
RDS, following the administration of the first dose of surfactant)
initiated shortly after birth would decrease the incidence of BPD
and/or death in smaller premature babies when compared to
conventional endotracheal mode of ventilation.
A RANDOMIZED CONTROLLED TRIAL OF SYNCHRONIZED NASAL INTERMITTENT
POSITIVE PRESSURE (SNIPPV) VENTILATION IN RDS
                                          (Bhandari V, et al. J Perinatol 2007;27:697-703)
INCLUSION CRITERIA
1.   <32 weeks gestational age.
2.   Birth weight 600-1250 grams
3.   RDS requiring intubation and surfactant therapy within one hour of birth.
     The need for intubation /surfactant was based on the following:
              a. Fi02 > 0.4 to maintain Sa02 > 90%.
              b. Chest radiograph consistent with RDS

EXCLUSION CRITERIA (any one)
1.    Nasopharyngeal pathology.
      a. Choanal atresia.
      b. Cleft lip or palate.
2.    Major congenital anomalies, especially thoracic or cardiac defects.
3.    Clinical parameters for exclusion ninety minutes after initial surfactant therapy
          (approximately 2½ hours after birth).
      a. Oxygenation index (OI=[(Fi02)(mean airway pressure)]/Pa02) > 9.
      b. No indwelling arterial line.
      c. More than two isotonic fluid boluses.
      d. Continuous medication infusion for blood pressure support.
      e. Fi02 > 0.8.
A RANDOMIZED CONTROLLED TRIAL OF SYNCHRONIZED NASAL INTERMITTENT
POSITIVE PRESSURE (SNIPPV) VENTILATION IN RDS
                                          (Bhandari V, et al. J Perinatol 2007;27:697-703)


Primary                                           CV            SNIPPV          P
Outcome:                                         (n=21)         (n=20)         value
                 Birth weight (grams)*          858 ± 27      915 ± 41          0.24
                 Gestational age (weeks)*       27.0 ± 0.4    26.9 ± 0.3        0.93

                 BPD or Deaths (n, %)            11 (52)         4 (20)         0.03
                 BPD (n, %)                      7 (33)          2 (10)         0.04
                 Deaths (n, %)                   4 (19)          2 (10)         0.66
                 Air leaks (n, %)                1 (5)           1 (5)          1.0
                 PDA (n, %)                      3 (14)          4 (20)         0.70
                 IVH (n, %)                      6 (29)          6 (30)         1.0
                 PVL (n, %)                      1 (5)           2 ( 10)        0.61


Longterm Outcome: Mental or Psychomotor Developmental Intex
There were no statistically significant differences in the MDI (mean ± SD; CV
(n=8) versus SNIPPV (n=7); 88.13 ± 10.32 versus 81.43 ± 17.54) or PDI (88.38±
11.87 versus 84.29 ± 19.47) scores in the infants, assessed at a median (25th –
75th centile) corrected GA of 22 (20.5-24) months.
                        COIN-trial
   610 infants, 25-to-28-weeks’ gestation, randomized to
           CPAP ßà intubation + ventilation
                   at 5 minutes after birth




In the year 2008: BPD incidence = 35% < 29 wks
COIN-trial, NEJM 2008
Strategizing SNIPPV

- As extubation mode
- To control apnea, avoiding extubation
- Primary mode (with or without surfactant use): more
    data needed
Synchronization Principles




               PSV
SNIPPV: Trigger systems for synchronization

Graseby Capsule
Infant Flow Advanced
Viasys “ SIPAP”


Flow sensor
Ginevri “ Giulia”
SLE 5000
Babylog 8000



NAVA-system
sensing of diaphragmatic electrical activity
Maquet “Servo-I”
  ?
      How to set Ti in a spontaneous breathing
       patient on a pressure support mode ?
                                             “Flow termination criteria”

                                                  Peak
                                                  Flow
                 0 flow             0 flow                       25%

Flow


           PIP
                           Tinsp.
                             Ti       Te                 PS above PEEP



Pressure
                    PEEP




           Pressure Control                  Pressure Support
Termination Sensitivity = Cycle-off Criteria

 Flow


                 Peak Flow (100%)




        TS 30%
                                             Leak
           TS 5%
                                                     Time



           Tinsp. (eff.)        Set maximal Tinsp.
           Neural breathing pattern in the preterm (room air, no vent)


                                                        Sleeping, 30 weeks, 1158 g


    1                                                   Sleeping, 30 weeks, 1158 g




                                                         Sleeping, 30 weeks, 1205 g


    2
                                                         Sleeping, 30 weeks, 1205 g




                                                         Feeding, baby moving
                                                           28 weeks, 1486g

    3
                                                         Baby awake, 28 weeks, 1486g
200 a.u.

                                                                    Beck et al, PAS 2006
             10 seconds
Non-invasive neurally adjusted
ventilatory assist (NAVA)
in rabbits with acute lung injury




Beck J et al. Intensive Care Med (2008) 34:316–323
Non-invasive neurally adjusted
ventilatory assist (NAVA)
in rabbits with acute lung injury




                                    Beck J et al. Intensive Care Med 2008; 34:316–323
baby 440 grams
1st experience




                 baby 440 grams
baby 440 grams
baby 440 grams
“NAVA can deliver assist in synchrony and proportionally to EAdi
after extubation, with a leaky non-invasive interface”
                                                         J.Beck ICM 2008
Conclusions
Meta-Analysis: “NIPPV is a useful method of
augmenting the beneficial effects of NCPAP in
preterm infants…..reassuring absence of the
gastrointestinal side-effects that were reported in
previous case series.” (Cochrane Collaboration)


Issues to be solved
Patient selection
Indications
Synchronization during NIPPV

				
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