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Respiratory Therapy a Tertiary NICU
Brandon Kuehne, MBA, RRT-NPS, RPFT Director- Neonatal Respiratory Services
Why do we do what we do? Kuehne 2011
Disclosures
Purpose: To enhance staff’s knowledge of the various types of respiratory therapy equipment that are unique to the neonatal intensive care environment.
Objectives: Discuss the indications and clinical implications for various types of Respiratory Therapy Related Devices commonly used in the Neonatal Intensive Care Unit Describe various disease process related to common to CPAP/Bi-level devices
The Planning Committee and Faculty of this activity have no disclosed conflicts of interest related to this content.
Completion Criteria: In order to receive Continuing Education (CE) credit, you must attend 80% of the program.
No commercial support was received for this program
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Why do we do what we do?
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Amillia Sonja Taylor
Neo RT History
Miami 2007 Birth Weight Length Gestational Age Hospital LOS Oxygen Req. Home w/o deficit
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283 grams 10 inches 22 weeks
“3,000 Years and Going Strong”
4 months Low PRICELESS
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Old Testament, Elijah, I Kings 17:17 And he went up, and lay upon the child and, put his mouth upon his mouth, and his eyes upon his eyes, and his hands upon his hands; and he stretched himself upon the child and the flesh waxed warm NRP done OLD School
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Slide courtesy of Robert DiBlassi RRT
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Technological Advancements in Ventilators- Now
The Future is now* SNIPPV TR mode
Rapid response times Active expiratory valves Accuracy of delivered volumes Volume targeted ventilation Proximal flow sensing Volume, triggering at ET tube, graphics Pulmonary graphics Identify various problems of the patient-ventilator system
Closed loop FiO2 SPO2:
85-90%
NAVA- Neurally Adjusted
Ventilatory Assist
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Slide courtesy of Robert DiBlassi RRT
Slide courtesy of Robert DiBlassi RRT
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*Availability of these modes are FDA dependent as they are already available overseas and in Canada
Introduction Multiple modes ventilation
With all that’s out thereWhat is the Right or Best approach?
Volume v. Pressure
Conventional vs. High Frequency
Bubble vs. Infant Flow vs. HFNC
Many
different settings
Oscillator
vs. Jet
Some confusion about how we arrive at
the “right” settings for each patient Kuehne 2011
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If humans were identical in every way, like specially bred laboratory mice, everything in their environment could be controlled, and we’d get the same great results in humans.
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Once again…….. What is the Right or Best approach?
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3. Early Extubation/ Leads to a decreased incidence of BPD….getting to nCPAP remains an ongoing challenge
Universal Rules What we know 1. Whatever form of ventilation you use, know how to use it well. 2. Limiting the variability of treatment modalities will lead to better outcomes! 3. Early Extubation/ Leads to a decreased incidence of BPD! Kuehne 2011
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Key Point:
Basic Ventilation Strategy
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Comes down to an basic understanding physiology differences between neonate and pediatric/adult pulmonary systems
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The Definitions Pulmonary function – how well is the
respiratory system working?
Two key components of pulmonary mechanics Compliance
And a little bit of…. Math
– how easy it is to inflate lungs
(Premature Neonates generally have big problem with this) Resistance – opposition to airflow caused by forces of friction ie. obstruction to airflow (generally associated with adult physiological/ pulmonary problems asthma- COPD, similar to BPD in infant populations)
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Math
Math cont.
Compliance CL = ∆V/∆P (getting lungs to
Time constant – the rate at which lung
open up-getting air in) CL
fills or empties
= ml/cmH2O
Resistance (getting air out)
Time constant = R x C Time constant = (cmH20/ml/s)x(ml/cmH2O) Time constant = seconds
R = Directly proportional to length R= Inversely proportional to r4 R
= cmH20/ml/s
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Time Constant
Surfactant Therapy
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(Multi-Access Catheter)
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Pressure- Volume Graphical Analysis of RDS
Graphical Analysis of RDS
Nice football shape @ 45°angle Six Hours Post Survanta Kuehne 2011
Pre Survanta
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2011-2012 A Pharmacoeconomic Comparison of beractant and poractant alfa in the presence of a Rapid Extubation Protocol in a NICU
Surfactant Research at NCH
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What?
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Surfactant Comparison while using a Rapid Extubation Protocol in the NICU
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Purpose of Study The overall objective is to determine if Poractant alfa (Curosurf®) reduces costs of care as compared to beractant (Survanta®) when utilized in the presence of a unit based rapid extubation protocol in the treatment of respiratory distress syndrome (RDS). Several outcome variables will be monitored and observed in a sequential, open label non-randomized format to determine if costs associated with the use of poractant alfa for treatment therapy are reduced as compared to beractant. A secondary objective will be to determine if patients demonstrate better tolerance of the surfactant administration process with poractant alfa as compared to beractant due to lower dose volumes and pharmacodynamic properties Kuehne 2011
What?
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Collection of Data to Establish Baseline Response
Vs.
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nCPAP
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Why use CPAP? Recruitment
To treat an ↑’d WOB
Atelectasis Maintenance of FRC
Apnea of prematurity RDS
↓ CLD (VON) ↓ VAP
Structural
Successfully used by Dr. Wung in 1970’s
Poor gas exchange Alternative to intubation
Post extubation
??? Bubble CPAP ???
30+ years Extremely low incidence of BPD/CLD from his facility (Columbian Presbyterian Medical Center, NY)
Tracheal malacia
Chest wall stability
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F & P Bubble CPAP System
Devices Bubble CPAP
Requirements Air/O2 proportioner (Blender) Water column Modified ventilator circuit (Factory setup available)
Benefits Potential for:
Gas exchange due to bubbling Not easily reproduced Now commercially available in USA
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NIPPV
NIPPV
Non-Invasive Positive Pressure Ventilation or Nasal Intermittent Positive Pressure Ventilation
Potential Benefits
Two levels of pressure delivered via ventilator using short bi-nasal prongs or nasopharyngeal prongs. Can be achieved with either:
Reduction in apnea frequency ↑ CO2 removal Lung recruitment Synchrony may ↓ WOB Use of current facility equipment
PS/CPAP Set
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rate, PIP and PEEP Kuehne 2011
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NIPPV Ventilators
VF-NCPAP
FDA 510K NCPAP approved devices:
Viasys AVEA PB-840 Servo I
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What is SiPAP? Variable Flow (Infant Flow nCPAP) Generator
SiPAP is a CPAP/Bi-Level device.
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That is, it is capable of functioning as a straight forward VF-NCPAP machine. It can also function as a Bi-Level device providing two separate pressures to the patient. Very similar to low span APRV or IMVPressure control
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Complications common to all nCPAP Septal Breakdown Labor intensive (Sicker patients now on
CPAP)
Non Invasive Monitoring
Dry mucosa CPAP Belly Atelectasis due to pressure loss Dilated nares Developmental delays due to mobility Positioning difficulties Kuehne 2011
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Apnea monitor with Built-in Pulse Oximeter
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Saturation Study
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Radiometer TCM –Analog Electrode
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SenTec Digital TCM
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Stow-Severinghaus Digital Electrode
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TCM Disposables
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Proofing Sample TCM SenTec
Invasive Monitoring
y = 0.872x + 5.3413 R2 = 0.9402
100 95 90 85 80 75 70 65 60 55 TCM 50 45 40 35 30 25 20 15 10 5 0
80 70 60 50 40
TCM CBG
30 20 10 0 0 0
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5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 10 0 CBG
i-STAT Portable Clinical Analyser Kuehne 2011
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High Frequency Ventilation High Frequency Ventilation
Key Characteristics of high frequency ventilation: 1. Constant lung volume 2. Tidal volumes that approximate(often less than) the anatomical dead-space. 3. Rates = or >180 breaths/minute.
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High Frequency Ventilation Definition: Mechanical ventilation using supraphysiologic rates with tidal volumes that less than the anatomical dead space of the airways.
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High Frequency Ventilation Mechanisms of Gas Exchange: Bulk Convection Pendeluft Asymmetric Velocity Profiles Taylor Dispersion Molecular Diffusion Cardiogenic Mixing
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High Frequency Ventilators SensorMedics Oscillator
High Frequency Ventilators
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High Frequency Ventilators: Bunnell Jet Ventilator
Specialized Gases
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Sub-ambient FIO2
Nitrogen Gas Delivery When room air is not good enough!
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Nitrogen Therapy Ventilator
Purpose: Hood
To keep PDA open Used in conjunction with prostoglandens FIO2 levels driven down to approximately 17% using Nitrogen. Used mainly for Hypoplastic Left Heart syndrome
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Calculating Flow via Nitrogen Tank [(flow RA flow meter) x 0.21] + [(flow N flow meter) x 0]
FiO2 =
Total Flow (or flow RA+ flow N)
Nitric Oxide
Ex: If 17% FiO2 desired: 8 lpm x .21 .17 Gives total flow of: 9.8 lpm To get Nitrogen flow 9.8 lpm total flow – 8 lpm air = 1.8 lpm of Nitrogen
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The Basics
Normal NO function
Nitric Oxide was first discovered by Joesph Priestly in
NO relaxes the smooth muscle in the walls of the arterioles. At
each systole, the endothelial cells that line the blood vessels release a puff of NO. This diffuses into the underlying smooth muscle cells causing them to relax and thus permit the surge of blood to pass through easily
1772 during his research and discovery of the Oxygen molecule It is formed from superheated Nitrogen in the presence of
Oxygen (aka combustion of fossil fuels).
During diastole, the myocyte has consumed the provided NO,
the dilatation ceases. Venous blood flow is encouraged. Nitric Oxide is a Free Radical thus making it very reactive
and unstable.
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Open Label Use
Why we use it
PPHN
Inclusion Criteria
Persistent Pulmonary Hypertension
Newborns > 34 weeks gestational age Hypoxic Respiratory failure Clinical or echocardiographic (ideal) evidence of PPHN Oxygen Index (OI) > 20 ECMO eligible
Newborns > 34 weeks gestational age Hypoxic Respiratory failure Clinical or echocardiographic (ideal) evidence of PPHN Oxygen Index (OI) > 20 ECMO eligible
And
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Because I am asked to …
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INOmax DSIR
Off Label Use < 34 weeks gestational age > 10-14 days of mechanical ventilation Irreversible lung disease Significant congenital heart disease Significant IVH Severe asphyxia or poor neurological prognosis Lethal congenital or chromosomal anomaly
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Aerosol Delivery Research
iNO Weaning Algorhythm, developed at NCH Kuehne 2011
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Radio-Aerogen In Vitro Study
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Laurie Gibson, RT(R) injects 3ml of TC 99mTC DTDA aerosol
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PILOT RANDOMIZED CLINICAL TRIAL OF INHALED PGE1 IN NEONATES WITH SUB-OPTIMAL RESPONSE TO INHALED NITRIC OXIDE Fig. 1 CPAP with aerogen placed at humidifier
Fig. 2 CPAP with aerogen placed 18 inches from patient
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IPGE1 Setup: Conventional & Jet Vent
Design/Methods
T- Connector in Inspiratory Line
Trial Design: Multi-center, pilot RCT Inclusion Criteria:
Exclusion Criteria:
GA ≥ 34 weeks
Lethal conditions
Postnatal age ≤ 7 d
CDH
Diagnosis of NHRF
CHD
MV, INO, OI ≥ 15 x 2 Indwelling arterial line Parental consent
Study Medications will be delivered to the mini-nebs via syringe pumps Study Drug
Tri-flow connector
Flow sensor remains inline
iNO sample line Study Drug
Thrombocytopenia Conflicting clinical trial
Normal Saline
0.3ml Tubing Mini-Neb Normal Saline
Screening & Enrolling Patients in the IPGE1 RCT Pilot
Improving BPD Patient Outcomes
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Background
Successfully Extubating the BPD Infant to nCPAP
February 2007 through September 2010
Comprehensive Center for Bronchopulmonary Dysplasia
total of 94 extubation attempts of 62 BPD infants
Success rate 66% Of the 62 patients 4
patients received trachs deceased 54 successfully extubated and discharged 4
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Successful Extubation
Extubation Checklist
Defined: 72 hrs without out needing
No Airway Anomaly Fi02 ≤ 40% No elevation in respiratory management within past
reintubation.
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72 hrs Weight Trend: +/- ______ g/d Full enteral feeds No surgery planned with in next 72 hrs No ROP exam scheduled for day of extubation No active infections Medications for extubation ordered Team consensus Previous extubation failure????
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Interventions
Extubation Timeline
Mild Respiratory Distress Mechanical Intervention
2hours prior to extubation
-Evaluation by Extubation Team -patient confirmed by group as ready for extubation -feeds are stopped
1 hour prior to extubation
Non Pharmacologic Interventions/Comfort Measures
-Sipap machine set-up at bedside and plugged into air/oxygen wall inlets -Additional supplies placed at bedside -intubation box -chin strap -shoulder rolls -sucrose -Chloral Hydrate -Appropriate prong and hat size selected using package insert and head circumference
45 minutes prior to extubation
30 minutes prior to extubation -Diaper change/pt care needs met -OG separated from ET-Tube and re-secured to patient -Sipap machine and heater turned on. -Minimal flow initiated on Sipap machine -At this time, patient should be allowed to rest until extubation
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Swaddling Prone positioning Hand containment Holding by mom Pacifier Change diaper, feed?
Pharmacologic Interventions Moderate Respiratory Distress Mechanical Interventions as above Non Pharmacologic Interventions/Comfort Measures as above Pharmacologic Interventions
-RN and RT at bedside to deep suction nares of patient with 8 Fr suction catheter -ET-Tube suctioned -NCPAP interface placed on patient with ET-Tube remaining in place
Reposition Suction Chin Strap (if not already in place) Assure proper size of hat and prongs Assure appropriate humidity Assure adequate CPAP is being achieved Assure adequate O2
Chloral Hydrate (25-50 mg/kg), may repeat after discussion with attending Lasix (give oral dose early, consider IM) Steroids for airway edema or if evidence of wheezing, consider starting systemic steroid course Consider benzodiazepam Consider bronchodilators if wheezing is predominant finding
Severe Respiratory Distress Reevaluate mechanical Discuss with attending Apnea Consider reloading with Caffeine Assure adequately suctioned nares Discuss with attending
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Post Extubation Score
WOB – Retractions, flaring and head bobbing *Score infant 1 2 or 3 depending on how many symptoms they have* • • • •
Respirations – Scoring 40 – 60 auscultated breaths per minute = 0 61 – 80 auscultated breaths per minute = 1 81 – 100 auscultated breaths per minute = 2 > 101 auscultated breaths per minute = 3 Apnea= 4 CNS Sleeps between cares =0 Irritable consolable =1 Irritable inconsolable=3 Lethargic (does not wake for cares) =4 Color – Scoring • Pink = 0 • Pale = 1 • Dusky = 2 • Cyanosis = 3
•
• • • • •
Heart Rate – Scoring • Baseline = 0 180 – 200 bpm = 1 • > 201 bpm =2 • Bradycardia =3 FiO2 – Scoring Baseline + 10 % = 0 Baseline + 20 % = 1 Baseline + 30 % = 2 Baseline + 40 % = 3 Saturations - Scoring 95 – 100 % = 0 • 90 – 94 % = 1 • < 89 % = 2
ECMO
Temperature – Scoring • < 100 .0 F = 0 • > 100 .0 F = 1 * This scoring with be implemented at extubation, 15 min x 4, 30 min x 2, and q 1 hr for 22 hours
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ECMO Extracorporeal membrane Oxygenation
System Overview
Extracorporeal
membrane oxygenation is the use of prolonged cardiopulmonary bypass for infants with hypoxic respiratory or cardiac failure who fail to respond to maximal medical management and lessinvasive therapies.
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ECMO Extracorporeal Membrane Oxygenation
Neonatal Diseases Treated by ECMO MAS – Meconium Aspiration Syndrome PPHN – Persistent Pulmonary Hypertension of
the Newborn CDH – Congenital Diaphragmatic Hernia Sepsis/pneumonia RDS – Respiratory Distress Syndrome Airleak syndrome Recent, novel uses include hydrops fetalis, viral
pneumonia and cardiomyopathy Kuehne 2011
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Questions?
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