Dr. Ashok Deorari - Non Invasive Ventilation Way Forward for India

8/12/2019 Dr. Ashok Deorari - Non Invasive Ventilation Way Forward for India

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Non invasive ventilationNon invasive ventilationWay forward for IndiaWay forward for India

Dr. Ashok K. Deorari MD FAMSProfessor, Department of Pediatrics,Division of NeonatologyWHO Collaborating Centre for Training and Research in

Newborn Care, AIIMS, New Delhi

Conflict of interest -None

OverviewOverview

Physiological basis for NIPPV

Evidence supporting its use

Complications and concerns

Way forward for SE Asia


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Non invasive ventilationNon invasive ventilation CPAP*

NIPPV Synchronized vs non synchronized

*Kandiraju H ..Neonatology 2012 Early vs Late rescue ST

Non invasive ventilationNon invasive ventilation

25- 50 % CPAP fails

Mechanical ventilation life saving but oftenits a risk factor for morbidities

Pulmonary, Infections, Cost

Ind Ped 2009, Bangalore ; Ind Ped 2010 Hyderabad;J Trop Ped 2010 Delhi


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Open the lungs and keep lungs openOpen the lungs and keep lungs open Low volume also induces lung injury

Adequate recruitment of lungs to FRC important

LowFRC

Compliantchest

Surfactantdeficiency

Easy fatigue ofrespiratory

muscles

Lachmann et al Int Care Med 1992

Physiological basisPhysiological basis--NIPPVNIPPV Increases pharyngeal dilation

Induces Heads paradoxical reflex

Increasing MAP allowing recruitment of alveoli

Increased FRC

NIPPV Possible advantages over CPAP

Increased MAP / VTBetter Recruitment- Respiratory drive


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Respiratory Function

Improves

Gas exchange

Lower TCO2Higher SpO2

Work of breathing

Reduced WOB

Reduced AB-T synchrony

Moretti et al , Early hum dev 1999

VLBW infants

Abdomino- Thoracic Synchrony


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Clinical uses of

NIPPV

Post

Extubation

Apnea of

Prematurity

Primary

modality

RDS

PostPost ExtubationExtubation

Three trials (n=159), VLBW infants

All synchronised form of NIPPV (Infant Star ventilator)

2 studies- Short Bi Nasal , one used- NP prongs

80% reduction in extubation failure, NNT 3 (95% CI 2, 5). Trend towards CLD reduction in NIPPV

RR 0.73 (95% CI 0.49, 1.07),

Lemyre , Davis et al, 2009


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Apnea of PrematurityApnea of Prematurity

NIPPVNIPPV vsvs NCPAPNCPAP

No reduction in need for intubation

No reduction in rate of apnea

One study- reduction in apnea

2 trials(n=54)

Preterm < 37 weeks with apnea

NIPPV might augment the beneficial effects of NCPAP

Appears to reduce the frequency of apneas moreeffectively than NCPAP.

Lemyre , Davis et al, 2009

Apnea on CPAP a trial of NIPPV may be given before

IMV

Primary treatment of RDSAuthor Year Population

Design

Intervention Findings

Meneses et al2011

RCT,26-336/7

N=100 in each arm

ns NIPPVvsB-CPAPBinasalSurf used rescue

Need for intubation first 72 hrs NS

55% reduced need for IMV

Benefit seen in > 1000 g

Overall 30% failed on non invasive

No difference in Duration of MV/BPD

Sai SunilKishore2009

RCT28-34 wksBwt > 750 g

ns NIPPV (n-37)VsNCPAP(n-39)NP delivery

Lesser intubation with NIPPV(48hrs)

13.5% vs 35% ( RR=0.38; 0.15, 0.89)

Failure rate in first week also lesser

No difference in airleak, duration ofventilation, BPD rates, NEC etc

Increased abd girth in NIPPV

Kugelman2007

RCT24-34wks

NIMV (n=43)vsNCPAP(n=41)

NIMV lesser intubation 25% vs 49%Reduced BPD rates in NIMV( 2% vs17%)

Bhandari etal RCT rapid extubation to NIPPV vs MV Reduction of CLD / Death 52% v25% p=0.03 at 22 months longterm no difference J of Perinatology 2007


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Should NIPPV replace early CPAP ?Should NIPPV replace early CPAP ?What is the practice implicationsWhat is the practice implications

In preterm babies esp. 28-34 weeks and > 1000g Reduced need for Intubation

A subset of infants with high index of CPAP

failureNeed for PPV in DR

Higher A-Ado2 (>180)

No ANS exposure

Higher FiO2 ( 40-50%)CXR- Severe RDS

Downe score > 7

CPAP pressure x FiO2 1.28

Consider

early NIPPV

SynchronizedSynchronized vsvs Non synchronizedNon synchronized

Synchronization- mechanical inflation commencing within 100 ms

of the onset of inspiration

SIMV has outdone IMV

sNIPPV- delivered higher tidal volume

Non synchronized - increase work of breathing/ air leaks No definite consensus

Non-synchronized NIPPV increasingly used

No definite adv effect reported

Difficulty in synchronization- need customized equipments

Non synchronized seems to be effective and safe


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Long term beneficial outcomes ..Long term beneficial outcomes ..Evidence is encouragingEvidence is encouraging

NIV for RDS (RCT)

Preterm < 35 wks

Kugelman 2007

Might reduce BPD

33% vs 5%

Bi PAPBi PAPIs it synonymous with CPAP !Is it synonymous with CPAP !

Two alternating levels of CDP

Also called Bi-level-NCPAP

Phasic change in delivered pressure


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NIPPVNIPPV --advantages over CPAPadvantages over CPAP

FRC switch- better recruitment

Higher Tidal volume -- phasic change in pressure

Reduced work of breathing

Nasal Bi PAP for RDSNasal Bi PAP for RDSmight be superior to NCPAPmight be superior to NCPAP

RCT( N=40); 28-34wks with RDS

No difference in serum cytokine markers

( No increased lung injury)

CPAP group

Longer length of hospital stay

Longer duration O2 dependency

Longer respiratory support

No difference- BPD, ROP, intubation ratesLista et a,l ADCFN 2009

18


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Latest in press.. But the answerLatest in press.. But the answer

has to come from Indiahas to come from India

BPD NIPPV vs CPAP

Multisite only patients; POOR DESIGN

Key MessagesKey Messages

NIPPV seems to safe promising better

alternative modality of Non invasive ventilation

Tested Indications

RDS, AOP and Post Extubation

Subset of infants severe RDS and babies with clinical predictors of

CPAP failure or recurrent apnea seems best suited

Reduction in BPD is encouraging

Safety/ Efficacy in < 28 weeks, Long term

benefits/ outcomes - yet to be established


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Dr. Ashok Deorari - Non Invasive Ventilation Way Forward for India

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