NONCONVENTIONAL MODES OF LIFE SUPPORT

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NONCONVENTIONAL MODES OF LIFE SUPPORT

• Lynn Chlebanowski RCP, RRT, NPS
• Clinical Educator, Respiratory Care
• Childrens Memorial Hospital

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Background

• 1960s Death from RDS estimated at 80 to 100
• Intubation and ventilation largely experimental
• President Kennedys son
• Early attempts at ventilation
• Water column CPAP
• 1970s infant ventilators began being used

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Hazards of Mechanical Intubation and Ventilation

• Subglottic stenosis
• Ventilator induced lung injury
• Increased risk of chronic lung disease
• VAP

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Why Non-Invasive?

• Looking for best way to support ventilation while
  minimizing damage to the lungs and airways
• Looking to the past for answers in the present
• Increase in knowledge and technology means
  invasive mechanical ventilation is not the best
  or only answer

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Nasal CPAP

• Potential for low lung volumes
• Oxygen delivery
• Minimize airway collapse

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Physiological Effects

• Maintains alveolar volumes
• Prevents airway collapse
• Decreases barotrauma and volutrauma
• May preserve surfactant
• Improves oxygenation
• Produces more regular pattern of breathing
• Does not impair secretion clearance

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Indications

• Clinical states that require increased FRC
• Clinical states that require positive pressure to
  maintain patency of hypotonic airways

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Clinical Conditions

• Respiratory Distress Syndrome
• Atelectasis
• Apnea of Prematurity
• Transient tachypnea of the newborn
• Recent extubation
• Tracheal malacia
• Transient tachypnea of the newborn
• Pulmonary edema

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Respiratory Distress Syndrome and NCPAP

• RDS and chronic lung disease
• Ventilator vs. disease process
• RDS on the rise
• CPAP thought to lower risk of chronic lung
  disease
• Ideally started early in disease course

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Apnea of Prematurity

• Definition of apnea in the premature infant
• pauses in respiration last gt20 sec.
• Pathologic conditions that may contribute
• hypoglycemia
• hypocalcemia
• sepsis
• intracranial hemorrhage
• gastroesophageal reflux

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Types of Apnea

• Periodic breathing
• apnea gt 20 seconds
• hypoxemia/bradycardia may result
• Central Apnea
• lack of sufficient neural impulses

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Types of Apnea (continued)

• Upper airway obstruction (obstructive apnea)
• cessation of respiratory airflow
• chest wall movement present
• Mixed apnea
• combination of both types of apnea

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Treatment

• Respiratory stimulants
• CPAP
• moderate to severe apnea
• gt8 episodes in a 12 hour period
• 2 episodes in 24 hours requiring bag/mask
  ventilation

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Other Uses of CPAP

• Heart defects
• Airway collapse
• Can be used for infants with less severe
  restrictive lung disease
• diffuse atelectasis
• lung edema
• Hypoxema

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Contraindications

• Upper airway abnormalities
• choanal atresia
• cleft palate
• T-E fistula
• Cardiovascular instability
• untreated tension pneumothorax
• unstable respiratory drive
• ventilatory failure (PaCO2 gt55 mmHg)

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Components of Nasal CPAP

• Circuit
• Interface to airway
• Device generating positive pressure

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Airway Interface

• Endotrachael Tube
• Binasal Devices

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Types of Nasal CPAP Delivery

• Constant flow CPAP
• uses nasal prongs
• conventional ventilator circuit
• neonatal ventilator
• associated with increased WOB
• Variable flow CPAP
• uses nasal prongs
• specialized circuit
• associated with decrease WOB

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Bubble CPAP

• Uses water column
• Produces small vibrations in chest
• May facilitate gas exchange
• Decrease RR and MV
• May result in less chronic lung disease

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Bubble CPAP
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Complications/Side Effects

• Abdominal distention
• Feeding disturbances
• Nasal irritation

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Set-up

• Continuous Flow NCPAP
• INCA nasal prongs or bipharyngeal long prongs
• ventilator with standard circuit
• place in CPAP mode
• adjust flow
• dial in PEEP

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Set-up (continued)

• INCA Prongs
• select size based on
• age
• weight
• largest prongs to fit without blanching nare
  tissue
• secured to cap

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INCA Set-Up
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Set-up (continued)

• Bipharyngeal nasal prong
• diameter largest that can easily pass both nares
• length measured from tragus of ear to nare
• secure with tape

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Bipharyngeal Prongs
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Set-up (continued)

• Variable Flow NCPAP
• Headgear and prongs also sized for patient based
  on age/weight
• Requires circuit specially manufactured for
  machine

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Variable Flow Nasal CPAP
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Management of CPAP

• CPAP levels generally between 4-6 cwp
• Observe changes in SaO2
• Increase CPAP if hypoxemia and respiratory
  distress persist
• Increase in small increments (1-2 cwp)
• Worsening hypoxemia, hypercapnia or active
  abdominal muscle use with excessive CPAP

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Management of CPAP (continued)

• Suctioning
• Adequate humidity
• Monitor patient
• ABG/TCM
• SaO2
• WOB
• BS

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Failed CPAP

• CO2 gt55 mmHg
• Frequent apnea with bradycardia

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Orders

• CPAP
• FiO2

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Complications/Troubleshooting

• Gastric distention
• Tissue necrosis
• Barotrauma
• Decreased cardiac output
• Increased nasal secretions
• Risk of nasal infection

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Complications/Troubleshooting

• Nasal prong obstruction
• Dislodged nasal prongs
• Water in circuit
• Changes in flow

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When to Wean CPAP

• No apnea present
• Vital signs stable
• CXR ok
• Oxygenation improved
• Resolution of underlying disorder

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How to Wean

• Decrease FiO2 to less than .50
• Decrease CPAP level
• Minimum CPAP level is 2 cwp

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Age/Developmental Level Considerations

• Most beneficial for infants
• obligate nose breathers

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Disadvantages

• Difficult to maintain a good fit.
• CPAP levels vary if patient leaks through mouth

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High Flow Nasal Cannula

• Warming and humidifying gas allows for higher
  flows
• Higher flows guarantee FiO2
• Well tolerated
• Prevents airway water loss/cooling
• Helps thin secretions
• Less irritation and bleeding

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HFNC NCPAP?

• Several studies indicate nasal cannula CPAP may
  be possible
• Cannula 0.3 cm with flows 1-2 lpm provide
  positive pressures
• Cannula 0.2 cm with flow up to 3 lpm provided no
  positive pressure
• Positive distending pressures depend on
  flow/cannula size

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Concerns

• No way to measure pressure
• Depending up system no pop-off valve
• Possibility of lung overdistension and trauma
• Gastric distension

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NFNC Has Its Place

• Useful to provide high flow oxygen
• Less NCPAP
• Better tolerated explain why patients do better
  vs existance of positive distending pressure

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Vapotherm
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Vapotherm

• Allows for delivery of heated humidity at higher
  flows
• Two size cartridges
• Infant 1-8 lpm
• Peds/Adult 5-40 lpm

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Vapotherm

• Delivery tube
• Shorter cannula
• Control over temperature

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Vapotherm Delivery Tube
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Shorter Cannula
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VAPOTHERM
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Fischer-Paykel HFNC

• Easy to set up
• Equipment readily in most neo/peds units
• Incorporates a pop-off valve

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Fischer-Paykel HFNC
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Circuit
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Pop-Off Valve
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BIPAP

• Introduction
• Ventilation
• Gold standard in managing acute respiratory
  failure
• Complications can result from intubation and
  ventilation
• Increased risk for nosocomial infections
• Often requires analgesia and sedation
• Complications may prolong recovery

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BiPAP Benefits

• Noninvasive
• Eliminates side effects of intubation and
  ventilation
• Reduces length of stay

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Physiologic Effects

• Provides positive airway pressure at two
  different levels
• inspiratory
• expiratory
• Can provide bi-level positive airway pressure or
  CPAP

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Physiologic Effects (continued)

• Noninvasive
• Used for patients requiring non-life support
  ventilation
• Creates pressure gradients
• inspiration results in assist in tidal volume
• expiration maintains baseline pressure

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Pressures

• IPAP
• augments alveolar ventilation
• relieves sense of dyspnea
• reduces use of accessory muscles of ventilation
• eliminates stridor (if present)

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Pressures (continued)

• EPAP
• increases FRC
• improves oxygenation
• prevents airway collapse
• improves gas distribution in lungs

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Indications

• Acute respiratory insufficiency
• Chronic respiratory failure
• Neuromuscular disease
• SMA
• Muscular Dystrophy
• CF

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Indications (continued)

• Anatomic airway obstruction
• tracheal or laryngeal malacia
• Sleep related disorders
• nocturnal hypoventilation
• sleep apnea syndrome
• Post-extubation

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Acute and Chronic Respiratory Failure

• Patients breath spontaneously but cannot meet
  total respiratory requirements
• Improves oxygenation
• Improves patient comfort

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Anatomic Airway Obstruction (Tracheal or
Laryngeal Malacia)

• Tracheomalacia
• Useful for patients requiring non-upper airway
  surgery
• May avoid the need for intubation
• Positive pressure can stent open airways

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Anatomic Airway Obstruction (continued)

• Laryngotracheal reconstruction
• Require ventilation immediately postop
• Irritation and edema may complicate extubation
• Reintubation poses risk of further injury
• BiPAP may help avoid reintubation while pulmonary
  dysfunction/edema resolve

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Neuromuscular Disease

• Helps patients meet respiratory requirements
  through noninvasive means
• Represents alternative to mechanical ventilation
  in the short term

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Contraindications

• Patients incapable of maintaining life sustaining
  ventilation
• Caution must be used when patient at risk for
  aspiration
• Patients with history of allergy/hypersensitivity
  to mask material

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Delivery

• Nasal mask
• nasal pillows
• full face mask
• head-strap vs soft-cap

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Delivery (continued)

• Appropriate mask size essential
• corneal abrasions
• skin breakdown
• Circuit
• do not block bleed hole
• Humidity
• Aerosol delivery

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Modes

• Spontaneous
• Spontaneous/Timed (ST)
• Timed
• Continuous Positive Airway (CPAP)

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Settings

• Pressure
• IPAP - 10 cwp
• EPAP - 5 cwp
• Rate
• IPAP
• O2
• Leak

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Neonatal NIPPV

• Growing interest in non-invasive assisted
  ventilation
• Can improve blood gases, respiratory effort,
  respiratory rates, Vt
• May reduce need for reintubation

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NIPPV

• Delivered by nasal prongs
• No studies have investigated optimal PIP
• Some studies suggest PIP 2-4 cwp higher than
  pre-extubation PIP
• Others suggest enough PIP to provide good chest
  rise
• Can set rate

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NIPPV Benefits

• May reduce need for reintubation
• May be beneficial in treatment of apnea

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NIPPV Complications

• Gastric distension
• Middle ear infection
• Hearing impairment
• Chronic mucosal inflammation

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NIPPV Research Needed

• No evidence about best device
• Settings
• Synchronized vs Non-synchronized

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SIPAP
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Drager Babylog
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Assessment

• Blood gas
• TCM
• SaO2
• WOB
• Mask fit/tolerance