1. Respiratory Current  Trends in the Neonatal ICU SE Courtney, MD MS CL SD NMP ML DATMQBIGTSPMTAMLOT Schneider Children’s Hospital North Shore Long Island Jewish Health System

2. CPAP and Related Stuff Plus ça change, plus c’est la m ê me chose.

5. Pediatrics 1973;52:131

6. CPAP fell out of favor in some centers after the development of infant ventilators. Concerns about ventilator-induced lung injury and the continued high incidence of chronic lung disease, coupled with the high profile given to CPAP by Columbia (in NY, not South America) have led to a CPAP comeback.

7. You’ve Seen This Before

8. If insufficient CPAP is used, the lung is not “open” and is subject to mechanical stress and inflammatory response just like with mechanical ventilation. CPAP on high FiO 2 (indicating atelectasis) may be worse than intubation, surfactant administration and lung protective ventilation

10. Bubble, Bubble, Boil and Trouble

13. Bubble data: The world’s literature on bubble CPAP consists of 3 small studies

18. What is Variable-Flow NCPAP? A child with a very disturbed family life.

19. Stay tuned for the sequel…………..

21. Moa G, Nilsson K, Zetterstrom H, Jonsson L. Critical Care Medicine 1988;16:1238

22. Who is this kid, anyway? Childs, Neonatal Intensive Care, 2000

26. Is All NCPAP Created Equal? Controlled clinical trials: Clinical data Stefanescu B, Murphy P, Hansell B, Fuloria M, Morgan, T, Aschner J: Pediatrics 2003;112:1031 162 infants < 1000gm randomized at extubation

27. Extubation Failure Stefanescu et al, Pediatrics 2003;112:1031

28. Kaplan – Meier curve depicting the time course of extubation failure within the first 7 days (168 hours) Stefanescu et al, Pediatrics 2003;112:1031

30. Reasons for Extubation Failure Stefanescu et al, Pediatrics 2003;112:1031

31. Cochrane Review, 2002 Devices and pressure sources for administration of NCPAP in preterm infants Conclusions: “ Short binasal prong devices are more effective than single prongs in reducing the rate of re-intubation. Although the Infant Flow Driver appears more effective than the Medicorp prongs the most effective short binasal prong device remains to be determined. The improvement in respiratory parameters with short binasal prongs suggests they are more effective than nasopharyngeal CPAP in the treatment of early RDS. Further studies incorporating longer-term outcomes are required. Studies are also needed to determine the optimal pressure source for the delivery of NCPAP.”

33. … .VF Family Court: THE SEQUEL The Godfather, Viasys, intervenes. EME and SM get back together (sob!!) and merge (oh my!) And a little sister is born, SiPAP!!

36. World Literature on SiPAP Long JA, Courtney SE: Bilevel Continuous Positive Airway Pressure (SiPAP) in Extremely Low Birth Weight Infants: An Observational Study of a New Device. Pediatr Res 2005: 3410A 9 infants 5 extubated successfully to SiPAP 3 reintubated for severe apnea 1 developed a pneumothorax while on SiPAP*****

37. SiPAP: Hot off the press Migliori et al, Pediatric Pulmonology Sept 2005: Nasal bilevel vs. continuous positive airway pressure in preterm infants 20 babies, mean study weight 1kg, received 2 cycles of CPAP alternated with 2 cycles of bilevel CPAP, each phase lasted one hour. Oxygen saturation and tcO 2 increased, and tcCO 2 and respiratory rate decreased during the bilevel CPAP periods.

38. “In my experience……” “… .a phrase that usually introduces a statement of rank prejudice or bias. The information that follows it cannot be checked, nor has it been subjected to any analysis other than some vague tally in the speaker’s memory.” -Dr. Michael Crichton

39. SiPAP Observations/Recommendations More data are needed Seems to work in some very little babies For extubation, seems to work better if you start at a higher sigh rate and work down rather than a low sigh rate and work up SiPAP is NOT nasal IMV. Use the term “sigh” not “breath” Keep sigh time at one second. Make sure you’re not overdistending on xray We are starting a work of breathing study soon. Did I say that more data are needed?

40. Nasal IMV Available literature predominantly done with synchronized IMV on the old Infant Star. Cochrane reviews of these data suggest decreased apnea and need for reintubation; work of breathing appears to be decreased. BUT – most NIMV today is not synchronized, because few people have the old Stars anymore. AND – there is little data on non-synchronized NIMV. Nasal IMV is popular despite limited data. PS – SiPAP is NOT nasal IMV!!!!

41. Vapotherm More popular than McDonald’s Data, data, where are the data?

42. World’s Literature on Vapotherm: 4 abstracts at SPR 2005 Chang GY, Cox CC, Shaffer TH: Nasal cannula, CPAP, and Vapotherm: Effect of flow on temperature, humidity, pressure and resistance Bench study Temperature/humidity were very close with Vapotherm and IF NCPAP. Pressure/resistance at cannula with Vapotherm VERY high.

44. Vapotherm World Lit (cont) Saslow et al : Work of breathing during Vapotherm vs NCPAP for the treatment of RDS Conventional NCPAP at 4 cmH 2 O vs Vapotherm at 3-5 lpm. No differences Ramanathan A et al : High flow nasal cannula use in preterm and term newborns admitted to NICU: A prospective, observational study Vapotherm used in 64 infants, max 6 lpm, babies did well. Nair G, Karma P : Comparison of the effects of vapotherm and NCPAP in respiratory distress in preterm infants. 28 infants, ?CPAP level, ?Vapo flows. No differences

45. Thoughts on Vapotherm More data urgently needed PROBABLY ok up to about 6 lpm, likely providing about 5cmH 2 O NCPAP at that level Should not be used at higher flows until more data on WOB and NCPAP provided are available.

48. Great unknown of the universe: Why do neonatologists continue to do stuff without data even though they know better?

50. Transcutaneous Monitoring - Back to the Future

54. Why We Need to Resurrect Tc Monitoring – Especially for CO 2 New data raises concerns about brain damage from HYPERCARBIA “ Permissive hypercarbia” has never defined, and has never been shown to be safe in the newborn.

60. Fun New Stuff You May Be Hearing About

61. Use of iNO in Preterm Infants

62. Additional Surfactant to Prevent/Lessen BPD

63. Jet Ventilation to Lessen BPD Severity

64. When in doubt, let the kid make his own damn vent changes!!