Just Say No To Mechanical Ventilation! Bubble CPAP, IMV CPAP and Other Strategies to Avoid Mechanical Ventilation. Anna Marie Cosgrove RNC MS NNP Anna Marie Cosgrove RNC, MS, NNP Morgan Stanley Children’s Hospital of New York Columbia
Is Chronic Lung Disease in Low Birth Weight Infants P Preventable? A Survey of Eight Centers t bl ? A S f Ei ht C t Avery ME et al Pediatrics 1987; 79; 26‐30
The Columbia Difference: The Columbia Difference: • Instituted CPAP at 5 cm H2O pressure with nasal prongs after birth in all weight groups for signs and prongs after birth in all weight groups for signs and symptoms of respiratory distress applied in delivery room • Hyperventilation was avoided and PaCO2 value was allowed to go as high as 60 mm Hg before endotracheal intubation • Muscle relaxants were not used. Minimal but adequate ventilator settings with mechanical ventilation il i ih h i l il i • Jen‐ Tien Wung MD supervised ventilatory care full time
Do Clinical Markers of Barotrauma and Oxygen Toxicity Explain Interhospital Variations in Rates of Chronic Lung Explain Interhospital Variations in Rates of Chronic Lung Disease? VanMarter L J, et al Pediatrics 2000; 105;1194‐2001
Do Clinical Markers of Barotrauma and Oxygen Toxicity Explain Interhospital Variations in Rates of Chronic Lung Explain Interhospital Variations in Rates of Chronic Lung Disease? VanMarter L J, et al Pediatrics 2000; 105;1194‐2001
Do Clinical Markers of Barotrauma and Oxygen Toxicity Explain Interhospital Variations in Rates of Chronic Lung Disease? VanMarter L J, et al Pediatrics 2000; 105;1194‐2001
Permissive / Therapeutic Hypercapnia Permissive / Therapeutic Hypercapnia • Intentional Intentional hypoventilation to avoid hypoventilation to avoid volutrauma and diminish lung injury either by avoiding ventilation or employing low‐tidal‐ avoiding ventilation or employing low tidal volume ventilation. • Limited controlled data in infants to support Limited controlled data in infants to support its efficacy & safety. • Is there a role for therapeutic hypercapnia? I h l f h i h i ?
Permissive Hypercapnia: Adverse Effects Permissive Hypercapnia: Adverse Effects • Increased Increased pulmonary vascular resistance pulmonary vascular resistance (hypoxemia) • Alterations in cerebral blood flow (IVH) Alterations in cerebral blood flow (IVH) • Opening blood‐brain barrier (kernicterus) • Increased intrapulmonary shunt (hypoxemia) • Impaired myocardial contractility p y y
MSCHONY VS VON 2008 MSCHONY VS VON 2008
MSCHONY VS VON 2008 MSCHONY VS VON 2008
MSCHONY VS VON 2008 MSCHONY VS VON 2008
NYPH Columbia Campus NYPH Columbia Campus
Nasal Prong Continuous Positive Airway Pressure
Nasal Prong CPAP Nasal Prong CPAP • • • • • • •
Oxygen blender Oxygen blender Flow meter Heated humidifier Heated humidifier Thermometer Inspiratory tubing Nasal cannula Velcro and tegaderm Velcro and tegaderm
Nasal Prong CPAP Nasal Prong CPAP • Manometer (optional) ( p ) • Expiratory tubing • Bottle containing 0.25% acetic acid and filled to a i id d fill d depth of 7cm • Expiratory tubing with its Expiratory tubing with its end submerged to a depth of 5 cm or +5cm H2O pressure H2O pressure • Safety Pins and rubber bands
