NON INVASIVE VENTILATION IN NEONATES- modes with CPAP in detail

1. Non invasive ventilation
Neonates -1
Dr. ADHI ARYA
SENIOR RESIDENT –GMCH -32 CHANDIGARH

2. WHAT
WHY
WHEN

3. •VENTILATION VIA NON INVASIVE
AIRWAY
i.e without an endotraceal tube

4. Non Invasive Negative Pressure Ventilation
(NNPV) (IRON LUNGS)
Non Invasive Positive Pressure Ventilation
(NPPV)

6. WHY
• Intubation is single major preventable factor contributing to BPD
• Even a single positive pressure breath can initiate biotrauma
/baro/volutrauma

7. • CPAP does not consistently improve ventilation and
does not work in infants with poor respiratory effort
• 46-60% of babies with RDS may fail CPAP and
25-40% of intubated LBW babies fail extubation to
CPAP)
• Invasive ventilation causes baro/volutrauma, atelecto-
trauma along with bio-trauma resulting in ventilator
induced lung injury( VILI).

8. • In an effort to support ventilation and avoid need for
invasive support the use of intermittent positive
pressure ventilation via nasal devices is being done .
•positive pressure cycle delivered on top of
continuous distending pressure by nasal route

9. CPAP
• DEFINITION
• HISTORY
• PHYSIOLOGY/MECHANISM
• INDICATIONS
• CONTRAINDICATIONS
• SETUP
• INITIAL SETTINGS
• WEANING
• FAILURE

10. CPAP
• COMPARISON OF DEVICES
• TROUBLE SHOOTING
• COMPLICATIONS
• EVIDENCE

11. DEFINITION
POSITIVE PRESSURE
SPONTANEOUSLY BREATHING INFANT
THROUGH OUT RESPIRATORY CYCLE.

12. HISTORY
• GREGORY
• KATTWINKEL
• AVERY/ COLUMBIA UNIVERSITY

13. MECHANISM

14. INDICATIONS
• AOP
• RD(RDS/PNEUM/MAS/TTNB)
• POST EXTUBATION
• AIRWAY MALACIAS
• Pulmonary insufficiency of prematurity
• DR CPAP

15. CONTRAINDICATIONS
• Poor resp drive
• Cong malformations( CDH/CA/TEF/Cleft palate)
• Cardiovasc instability
• Progressive Type 2 resp failure
• Pulm air leaks

16. SET UP
• PRESSURE GENERATOR: Positive pressure in the circuit
Continous / variable flow
• GAS SOURCE: continuous supply of warm humidified/ blended gases
• PATIENT INTERFACE/DELIVERY SYSTEM

17. Pressure generator
• Ventilator -exp flow valve, OR cont airflow in opp direction to exp
limb
• Bubble CPAP - due to stochastic resonance
• IFD( variable flow devices)- by adjusting flow

18. BASED ON FLOW
CF
• Vary press by mechanism other
than flow variation
• Expiratory limb not open to
atmosphere
VF (IFD)
• Desired pressure by varying flow
• Open( by venturi effect can
entrain additional flow)

19. PATIENT INTERFACE (PI)
• Nasal prongs
• Nasoph prongs
• Mask
• Nasal canula

20. PI-NASAL PRONGS
• HUDSON
• F&P
• ARGYLE
• Selection of size important
• Small/loose-leak
• Tight-pressure necrosis
• Bridge of prongs should not abutt columella/ there should be no blanching

21. PI- NASOPHARYNGEAL PRONG
• NASOP ET Tube
• NASOP prongs -Vygon
• ADV- easier to fix,
• DIS- inc resistance, leak, diffic nursing care
Cochrane 2008 - Better oxyg, waening in bi-nasal short prongs
compared to single prong nasop CPAP
Devices and pressure sources for administration of nasal continuous positive airway
pressure (NCPAP) in preterm neonates. Cochrane Database Syst Rev. 2008

22. MASK
ARGYLE PRONGS
VYGON NP PRONGS
FISCHER PAYKEL HUDSON
CANNULAIDE ( for preventing trauma)

23. • b/w Argyle and hudson - equal in pressure gen
• But argyle difficult to maintain & nasal hyperemia more
• Hudson prongs easily avail and widely used in our set up.

24. HUDSON PRONG SIZE

27. GAS SOURCE
• Pressurized gases
• Air o2 blender
• Flow meter
• Humidifier( 37/ 100%)

29. INITIAL SETTINGS
• Depend on condition for which started
• For respiratory distress scores can be useful

30. Initial pressures for RDS
• 7 vs 5
• No diff in need for MV in first week
• Acta Paediatr. 2016 Aug;105(8):Initiating nasal continuous positive
airway pressure in preterm neonates at 5 cm as against 7 cm did not
decrease the need for mechanical ventilation.

32. • When to increase-grunting /retrac/<6 spaces
• When to decrease-> 8 spaces/flat diaph
To increase/dec pressure
• Bubble CPAP –Inc or Dec depth of expiratory limb in bubble chamber
• Indigenous- increasing /dec water level

33. Before considering failure ensure
• Airway patency( secretions /neck flexed)
• Surf given for RDS
• Correct size prongs in position
• Baby is not fighting

34. WEANING

36. CPAP MACHINES COMAPRISON

39. TROUBLE SHOOTING
• No Bubbles
• Prongs wont stay in place

40. NO BUBBLES ?
• Circuit problem or baby problem

41. • Bubble generation depends on flow, leaks in circuit/airway
• Should be seen both during insp and exp
Seal the end of prongs
No bubbling ---circuit problem – check from wall to end
Present- look for leak(mouth)
suspect air leaks

42. IS CHIN STRAP OR PACIFIER NEEDED

43. PRONGS WONT STAY IN PLACE
• Correct size
• Hat snugly fit or not – loose hat allows movement of head to dislodge
prongs
• Tubings at correct angles to keep prongs in place

44. COMPLICATIONS
• Air -Leaks
• CPAP Belly
• Sepsis
• Nasal obstr
• Nasl septum erosion/necrosis

45. Nursing care
• Vitals
• Airway patency
• Nasal care/ prevention of injury
• OG in situ ( 90/30)

46. RECENT EVIDENCE
• J Perinatol. 2016 May;36 Suppl 1:S21-8. doi: 10.1038/jp.2016.29.
• Efficacy and safety of CPAP in low- and middle-income countries.
50% reduction in the need for mechanical ventilation following the
introduction of bubble CPAP
failed CPAP and required mechanical ventilation varied from 20 to 40%
(eight studies).
The incidence of air leaks varied from 0 to 7.2% .

47. EVIDENCE FOR PRETERMS/ RDS
• COIN
• IFDAS
• SUPPORT
• Cochrane 2015

48. COIN TRIAL( CPAP OR INTUBATION)
• no statistical difference – death or bronchopulmonary dysplasia at 36 weeks'
gestational age between infants who were assigned to receive early nasal CPAP
and those who were assigned to receive intubation.
• lower risk of the combined outcome of death or the need for oxygen therapy at
28 days and
• fewer days of assisted ventilation. (3 VS 4)
• increase in the number of pneumothoraxes. (9 % VS 3%) WITHOUT effect on
overall mortality, G3/4 IVH, PVL BPD
• Overall, starting early CPAP treatment in very preterm infants was not
detrimental.

50. IFDAS
• Hypot –early surf use – CPAP or CPAP alone dec need for subseq
ventilat in PT
• CONCLUDED THAT BOTH cpap alone and with surf decreased need
for MV

51. SUPPORT(SUrfactant Positive pressure Pulse
Oximetry RCT)
hypoth--nasal CPAP started immediately after birth is an effective and safe
alternative to prophylactic or early surfactant administration and may be
superior.
CPAP and the limited-ventilation strategy, rather than intubation and
surfactant, resulted in less respiratory morbidity by 18 to 22 months’
corrected age
A follow-up study at 18 to 22 months’ corrected age showed that death or
neurodevelopmental impairment occurred in 28% of the infants in the CPAP
group compared with 30% of those in the surfactant/ventilation group (RR:
0.93; 95% CI: 0.78–1.10; P = .38).NOT SIG CLINICALLY

52. AAP
• Respiratory Support in Preterm Infants at Birth
COMMITTEE ON FETUS AND NEWBORN 2014
• early CPAP with subsequent selective surfactant I extreme PT- lower rates
BPD/death compared with treatment with prophylactic or early surfactant
therapy (Level of Evidence: 1).
• treated with early CPAP alone -not at increased risk of adverse outcomes if
treatment with surfactant is delayed or not given
• Early initiation of CPAP may lead to a reduction in duration of mechanical
ventilation and postnatal corticosteroid therapy

53. Cochrane 2015
• In preterm infants with respiratory distress, the application of CDP as
CPAP or CNP is associated with reduced respiratory failure and
mortality and an increased rate of pneumothorax.
• Cochrane Database Syst Rev. 2015 Jul 4;(7):CD00227
• Continuous distending pressure for respiratory distress in preterm infants.

54. • NIV -2
• Will discuss NIPPV/HHFNC