Non-Invasive Ventilation Neonatal Best Evidence & BIDMC Applications Beth Israel Hospital Boston Respiratory Care

Non-Invasive Ventilation Neonatal – Outline of Points Indications & Incentives for Use Background Definitions Devices Interfaces Use outside of BI Unanswered questions Controversies Recommendations for BI use Current use How should use to improve care Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal - Indications & Incentives Reduced BPD (time independent) Reduce volu-trauma Reduce hyper & hypoxia Reduce work of breathing Increase thoracic abdominal synchrony Increase spontaneous tidal volume Reduce VAP with shorter intubation Reduce discomfort Improve interaction with mother and environs Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal Eur J Pediatr. 2010 July; 169(7): 777–782. Published online 2010 February 24. doi: 10.1007/s00431-010-1159-x Copyright/LicenseRequest permission to reuse Table 2. Beneficial effects of noninvasive ventilation in newborns Important practical conclusions for applying NIV in newborns with respiratory distress: A physiological background is needed to understand NIV NIV can be used to avoid mechanical ventilation Adjustable and measured PEEP should be used immediately after birth PEEP levels should remain around +5 cm H2O or higher nCPAP appears to be a satisfactory alternative to endotracheal intubation Without available scientific evidence, it seems potentially harmful to use HHFNC in newborns Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care 4

Non-Invasive Ventilation Neonatal Eur J Pediatr. 2010 July; 169(7): 777–782. Published online 2010 February 24. doi: 10.1007/s00431-010-1159-x Copyright/LicenseRequest permission to reuse Table 2. Beneficial effects of noninvasive ventilation in newborns Improved respiratory mechanics Increased lung volume Increased compliance Decreased resistance Improved respiratory timing Decreased thoracoabdominal asynchrony Decreased obstructive and mixed apnoea Improved oxygenation Decreased pulmonary vascular resistance Decreased intrapulmonary shunting Increased alveolar volume and less collapse Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care 5

Non-Invasive Ventilation Neonatal - Indications & Incentives Concerns Complicated devices and techniques must learned Gastric distention & perf. (Garland Pediatrics 1985; 76:406-410) Contraindicated with upper airway anomalies (choanal atresia, cleft palate, te fistula or severe cardiovascular instability Tissue breakdown around interface device Feeding intolerance

Setup of NIPPV Non-Invasive Ventilation Neonatal * CLD Working Group   rate Ti PIP PEEP rise time flow LPM Pressure MAX Ramanathan 40 max 50 0.5 to 1 plus 10-15 5-8 0.1-0.2 PIP 30 V Bhandari * ~40 ~0.45 PIPvent 4 4-6 Not specified 8-10 MAP 14 < 1000g 16 > 1000 g Chronic Lung Disease NIPPV Overview 15-20 0.3 2-4 5 * * V Bhandari JOP 2010 30, 505-512 O2 to optimize saturation per policy, Caffeine Hct. > 35 Beth Israel Hospital Boston Respiratory Care

Transition of Support Remove NIPPV Intubate Rate 15-25 PIP < 17 Non-Invasive Ventilation Neonatal Transition of Support Remove NIPPV Rate 15-25 PIP < 17 PEEP <6 FiO2 <35 Intubate pH < 7.25 PaCO2 > 60 Apnea requiring bagging Frequent As & Bs Frequent desaturations “…can use blood gases to help wean, but not typically needed—can wean or increase settings based on clinical appearance” CLD Working Group V Bhandari JOP 2010 30, 505-512 Beth Israel Hospital Boston Respiratory Care

Non-Invasive Ventilation Neonatal – Interfaces Interfaces for Non-Invasive High-Flow Cannula NP Tube Prongs Long prong Bi-Nasal Prongs Nasal Mask RAM Cannula Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal Case report Oral continuous positive airway pressure (CPAP) following nasal injury in a preterm infant, H R Carlisle, C O F Kamlin, L S Owen, P G Davis, C J Morley; Arch Dis Child Fetal Neonatal Ed 2010;95:F142F143 doi:10.1136/adc.2009.170084 Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal – Modes and Devices Modes of Non-Invasive Ventilation Devices for Non-invasive Ventilation High-Flow Nasal Cannula Bubble CPAP Hansen Ventilator Conventional Conventional with NAVA Hi-Fi Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal – Device – Arabella CPAP & Vapotherm Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal – Device - Hansen Ventilator Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal – Device – Viasys BiPAP BWH uses rarely. Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

NAVA Non-Invasive Ventilation Neonatal Beth Israel Hospital Boston Respiratory Care

Non-Invasive Ventilation Neonatal Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal INSURE (intubatio-surfactant-extubation) Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal – Indications & Incentives Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal –Indication & Incentive Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal – Indications & Incentives Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal – High Flow Cannula Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal – High Flow Cannula Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal – High Flow Cannula Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal Beth Israel Hospital Boston Respiratory Care Beth Israel Hospital Boston - Respiratory Care

Non-Invasive Ventilation Neonatal Long versus short inspiratory times in neonates receiving mechanical ventilation Kamlin COF, Davis PG http://www.nichd.nih.gov/cochrane/Kamlin/KAMLIN.HTM Reviewers' conclusions Implications for practice Long inspiratory times when used in acute HMD in a population not exposed to antenatal steroids and postnatal surfactant are associated with higher rates of mortality and morbidity. Stiff lungs with HMD have very short time constants. Mechanically ventilated infants with HMD and especially those treated in institutions where these adjunctive therapies are not available should be ventilated using a short IT. The use of a long IT where time constants are longer than acute HMD such as premature infants with BPD, meconium aspiration syndrome and newborns in cardiac failure may be appropriate and is yet to be investigated. Beth Israel Hospital Boston Respiratory Care