Respiratory support during neonatal resuscitation · Neonatal Resuscitation • Heart and Stroke...
Transcript of Respiratory support during neonatal resuscitation · Neonatal Resuscitation • Heart and Stroke...
Respiratory support during neonatal resuscitation
Georg M Schmölzer
Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Canada; Dept. of Pediatrics, University of Alberta, Edmonton, Canada
GM Schmölzer is supported by: • Heart and Stroke Foundation Alberta Professorship of
Neonatal Resuscitation • Heart and Stroke Foundation Canada - New Investigator
Award Funding • Canadian Institute of Health Research • Heart and Stroke Foundation Canada • Neonatal Resuscitation Program, AAP & CP
• Member of ILCOR since 2015
Disclosure
• Fetal to neonatal Transition
• How much oxygen should we use?
• Respiratory support - What to do?
• What ventilation device and interface?
• What about PEEP?
• SI or just PPV at birth?
Objectives
• Fetal to neonatal Transition
• How much oxygen should we use?
• Respiratory support - What to do?
• What ventilation device and interface?
• What about PEEP?
• SI or just PPV at birth?
Objectives
• Majority of infants do not need help
• With lower gestational age an increasing number of infants do need help • ~80% of infants breathe and cry at birth1 • Different expiratory breathing patterns2 • Lungs after birth partially liquid-filled
• Clear lung liquid • Establish functional residual capacity • Initiate spontaneous breathing • Facilitate gas exchange
Neonatal Transition
1O’Donnell CPF et al JPeds 20112te Pas AB et al Ped Res 2008
Lung liquid clearance
Lung liquid clearance
CO2
CO2
CO2CO2CO2CO2
CO2
CO2
• When infants fail to breathe after birth - Need to support breathing (CPAP/PEEP and/or PPV and/or SI)
• The goals of PPV are:
• Clear lung liquid
• Establish functional residual capacity • Deliver adequate VT
• Facilitate gas exchange
• Stimulate breathing
• While minimizing lung injury
Fetal to Neonatal Transition
• Fetal to neonatal Transition
• How much oxygen should we use?
• Respiratory support - What to do?
• What ventilation device and interface?
• What about PEEP?
• SI or just PPV at birth?
Objectives
• Newborns >35 weeks’ begins with 21% O2
• Newborns <35 weeks’ begins with 21% to 30% O2
• Use a Blender to adjust oxygen concentration as needed to achieve SpO2 target
How much oxygen should we use?
Perlman et al. Circulation 2015
Reference ranges of SpO2
Dawson JA et al, Pediatrics 2010
How much oxygen should we use?
Oei JL et al, Acta Pædiatrica 2016
• Using <1.0 FiO2 to initiate DR resuscitation is a relatively new practice
• Lack of evidence for preterm-specific SpO2 targets
• During the first 10 min after birth of life
• Neurodevelopmental outcomes
How much oxygen should we use?
• The TO2RPIDO compared babies <32 weeks resuscitated with either FiO2 0.21 or 1.0
• Study was closed early after recruiting only 292 patients
• Post hoc analysis
• Significantly increased hospital mortality in infants <29 (28+6) resuscitated with FiO2 0.21 (10/46 (22%) vs. 1.0 (3/54 (6%), OR, 95% CIs 0.2 (0.05 to 0.8, p=0.03)
How much oxygen should we use?
Oei JL et al, ADC FN 2016
• Data from 17 NICUs included 2326 infants
• 1244 in the OXtitrate group and 1082 in the OX100 group.
• The AOR for the primary outcome of severe neurologic injury or death was higher in the OXtitrate group compared with the OX100 group (AOR 1.36; 95% CI 1.11, 1.66)
• A similar increase was also noted when comparing infants initially resuscitated with room air to the OX100 group (AOR 1.33; 95% CI 1.04, 1.69)
• In Canadian NICUs, we observed a higher risk of severe neurologic injury or death among preterm infants of ≤27 weeks
How much oxygen should we use?
Rabi Y et al, Resuscitation 2015
• Use current recommendations until new evidence is available
• Well-designed and adequately powered RCTs are needed
• PRESOX closed 2017 - lack of recruitment
• PROMOTION-Collaboration
• HILO-trial
• Torpido 2
Implications for practice
• Fetal to neonatal Transition
• How much oxygen should we use?
• Respiratory support - What to do?
• What ventilation device and interface?
• What about PEEP?
• SI or just PPV at birth?
Objectives
• Positive Pressure Ventilation (PPV) in preterm infants:
• Adjust the flowmeter to 10 L/min
• Initial peak inflating pressure (PIP) 20 to 25 cm H2O
• Use an initial PEEP of 5 cm H2O
• If PPV is required for resuscitation of a preterm newborn, it is preferable to use a device that can provide PEEP.
• Using PEEP helps the baby’s lungs remain inflated between positive pressure inflations
Recommendations
Perlman J et al. Circulation 2015
• Self-inflating bags, flow-inflating bags or T-piece devices may all be used for mask ventilation1
T-Piece preferred ventilation device2: • 31% in Ireland • 45% in Spain • 80% in Austrian • 41% in German • 20% in Swiss
Ventilation devices
1Perlman J et al. Circulation 2015 2Hawkes CP et al. Resuscitation 2012
Morley C et al. Journal of Paediatrics and Child Health 2010
The effect of a PEEP valve on a Laerdal neonatal self-inflating resuscitation bag
• Self-inflating • Does not provide PEEP or CPAP • An attached PEEP-valve provides inconsistent PEEP
and cannot deliver CPAP • Flow-inflating bag
• Variable and operator dependent PEEP • T-piece device
• Consistent, predetermined level of PEEP and PIP • Most accurate device for delivering SI
Implications for practice
O’Shea J et al, ADC FN 2016
• Face Masks
• Round silicone mask most common
• Nasal Prongs
• Shortened endotracheal tube
• Large leaks from mouth or contralateral nostril
Interface
• Reduces delivered VT • Varies between resuscitators1
• Mask leak >75% in 50% of analyzed resuscitations2
Enemy of Mask Ventilation
1Schmölzer GM et al ACD FN 20102Schmölzer GM et al ADC FN 2010
Schmölzer GM et al ACD F&N 2009
Airway obstruction during PPV is common1
• 75% of infants had obstructed inflations
• Pedi-Cap during PPV to identify airway obstruction
• 25% of infants had severe airway obstruction2
Airway Obstruction
1Finer NN et al Pediatrics 20092Schmölzer GM et al ADC FN 2010
Mask ventilation with two different face masks in the delivery room for preterm infants: a randomized controlled trial
Cheung D et al. Journal of Perinatology 2015
Mask ventilation with two different face masks in the delivery room for preterm infants: a randomized controlled trial
Cheung D et al. Journal of Perinatology 2015
Nasal Prong or Face Mask for Respiratory Support for Preterm Newborns
Schmölzer, unpublished data
Intubation
Chronic lung disease
• Different face mask have similar leaks • Both interfaces can be used during respiratory
support at birth • Staff needs to be trained with the device used in
their hospital
Implications for practice
• Fetal to neonatal Transition
• How much oxygen should we use?
• Respiratory support - What to do?
• What ventilation device and interface?
• What about PEEP?
• SI or just PPV at birth?
Objectives
• Helps establish and maintain the FRC • Decreases airway resistance • Improves lung compliance • Regularizes & slows respiratory rate • Reduces apnoea • Improves oxygenation • Conserves surfactant • Reduces lung injury and inflammation • Reduces the need for ventilation
CPAP or PEEP during resuscitation
• PPV without PEEP
• repeated collapse and reopening of alveoli
• PPV with PEEP
• PEEP of 8 cm H2O increased oxygenation1,2
• compared to PEEP of 0 or 4 cm H2O
• Better oxygenation compared to surfactant3
Optimal PEEP at birth
1Probyn ME et al. Acta Paediatr 2005 2Probyn ME et al. Ped Res. 2004 3Crossley KJ et al. Ped Res. 2007
Siew M et al 2009
Courtesy of Stuart Hooper
Courtesy of Stuart Hooper
Dawson J et al. JPeds 2011
T-Piece versus SIB for Ventilation of Extremely Preterm Infants at Birth
Dawson J et al. JPeds 2011
T-Piece versus SIB for Ventilation of Extremely Preterm Infants at Birth
Comparison of Devices for Newborn Ventilation in the Delivery Room
Szyld et al. JPeds 2014
Comparison of Devices for Newborn Ventilation in the Delivery Room
Szyld et al. JPeds 2014
PEEP vs. NO PEEP during Stabilization in the Delivery Room
Schmölzer, unpublished data
Chronic lung disease
• During stabilization of preterm infants use an interface which can provide PEEP
• Use at least 5cm H2O to support lung aeration
Implications for practice
• In observational studies CPAP was associated with lower rate of BPD
• Comparison of centres - BPD rates 22% vs. 4%, associated with more use of mechanical ventilation
• 261 preterm infants intubation and ventilation with nasal CPAP reported lower mortality and lower rates of administered surfactant, BPD, and IVH
• 14 tertiary level neonatal intensive care units in northern Italy - BPD rates Centres with high delivery room intubation rates had higher rates of ventilation and BPD
Intubate immediately or stabilize on CPAP?
Schmölzer GM et al. BMJ 2013
Death
Non-invasive versus invasive respiratory support in preterm infants at birth: systematic review and meta-analysis
BPD
Non-invasive versus invasive respiratory support in preterm infants at birth: systematic review and meta-analysis
Death
Schmölzer GM et al. BMJ 2013
Death / BPD
Non-invasive versus invasive respiratory support in preterm infants at birth: systematic review and meta-analysis
Schmölzer GM et al. BMJ 2013
Pooled analysis showed a significant benefit for the combined outcome of death and/or BPD at 36 weeks corrected gestation for babies treated with nCPAP
(RR 0.91 [0.84, 0.99], risk difference -0.04 [-0.07, 0.00], NNT of 25)
• Use CPAP before intubation
• Try to avoid intubation in the Delivery Room
• One additional infant could survive to 36 weeks without BPD for every 25 babies treated with nasal CPAP in the delivery room rather than being intubated.
Implications for practice
• What is the optimal PEEP/CPAP? • Difference in outcomes of 21-30% O2 vs. 100% O2? • Does DCC or cord milking compared to earlier cord
clamping affects outcomes? • Should we use a PEEP recruitment maneuver to establish
FRC?
Open questions PEEP/CPAP
• Fetal to neonatal Transition
• How much oxygen should we use?
• Respiratory support - What to do?
• What ventilation device and interface?
• What about PEEP?
• SI or just PPV at birth?
Objectives
Courtesy of Stuart Hooper
Foglia EE et a. Clin Perinatol 2016
Klingenberg et al. Neonatology 2011
Delivery of Sustained Inflation
T-Piece FIB SIB
• Experimental non-breathing rabbit model:
• SI 20” + with PEEP rapid increase in FRC
• as did PEEP alone compared to
• PPV with or without PEEP
SI or just PPV at birth?
te Pas A et a. Ped Research 2009
Fuchs H et al Ped Res 2011
Successful vs. unsuccessful SI
• Two meta-analyses of SI trials have been published • 2 trials (352 infants)
• No significant difference in death during hospitalization or BPD
• 4 trials (611 preterm infants) • SI - less mechanical ventilation within 72 hours after birth (RR 0.87, 95% CI 0.77–0.97) • The absolute risk reduction was 0.10 (95% CI 0.17 to 0.03), giving a number needed
to treat of 10 • There were no significant differences in the outcomes of BPD, death
• Both analyses found an increased rate of medical or surgical treatment for PDA (RR 1.27, 95% CI 1.05– 1.54)
• Neither meta-analysis demonstrated a significant difference in air leaks, severe IVH, or other measured neonatal outcomes.
SI or just PPV at birth?
O’Donnell CPF et al Cochrane Rev FN 2015 Schmölzer GM et al, ADC FN 2015
Mechanical Ventilation <72 hours
Death / BPD
SI or just PPV at birth?
Schmölzer GM et al, ADC FN 2015
PDA
SI or just PPV at birth?
Schmölzer GM et al, ADC FN 2015
Using exhaled CO2 to guide initial respiratory support at birth: a randomised controlled trial
Ngan A et al, ADC FN 2017
Ngan A et al, ADC FN 2017
• The optimal method to safely and effectively aerate the preterm lung is unknown
• Sustained inflation is a promising alternative strategy to intermittent PPV with PEEP
• There are insufficient data to recommend sustained inflation for routine clinical use at this point
Implications for practice
• What is the optimal inflation time? • What inflation pressure(s) are required to establish an
effective FRC? • Does DCC or cord milking compared to earlier cord
clamping affects outcomes in the presence or absence of SI?
• Ongoing randomized trials • Kirpalani et al will include long-term outcomes - SAIL
Open questions SI
• Use PEEP/CPAP
• Intubate only when needed
• People struggle with mask ventilation
• Get the lung open
• Only then think about oxygen
Summary
http://www.research4babies.org
https://twitter.com/Research4Babies
YouTube: Centre - Studies of Asphyxia and Resuscitation
Respiratory support during neonatal resuscitation
Respiratory support in the DR : What is new?
Georg M Schmölzer
Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Canada; Dept. of Pediatrics, University of Alberta, Edmonton, Canada