Nasal Cannula Intermittent Mandatory Ventilation (NC-IMV)

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Nasal Cannula Intermittent Mandatory
Ventilation(NC-IMV)
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Introduction

• With increased survival of very low birth weight
  (VLBW) infants, the number of infants who require
  prolonged mechanical ventilation (MV) has
  increased
• The pulmonary management of these infants is
  directed at minimizing the need for prolonged MV
  to reduce ventilator-induced trauma and oxygen
  toxicity
• Early extubation often presents difficulties
  because of upper-airway instability, poor
  respiratory drive, alveolar atelectasis, and
  residual lung damage

Khalaf et al Pediatrics 2001 10813-17
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Background

• Use of Nasal respiratory support (NARES) is on
  the rise to decrease post-extubation failures,
  bronchopulmonary dysplasia (BPD), and for the
  treatment of apnea of prematurity
• CPAP, by various means, commonly is used to wean
  premature infants from mechanical ventilation

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NCPAP Failure Rates

• NCPAP use is associated with failure rates of 20
  to 80 in preterm infants
• Reasons for failure include recurrent apnea/
  bradycardia/desaturations or respiratory acidosis
  requiring intubation or re-intubation

Ramanathan et al J Perinatol October 2010
30S67-S72
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Background

• The addition of a back-up rate by using NIPPV not
  only adds intermittent distending pressure above
  PEEP but also increases flow delivery in the
  upper airway

Friedlich et al J Perinatol 1999
19413-418 Barrington et al Pediatrics 2001
107638-641
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NCPAP vs. NIPPV for NARES

• Additionally, NIPPV has been shown to decrease
  NCPAP failure rates to 5 -20

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Background

• Typical nasal interfaces used
• Short bi-nasal prongs
• Inca prongs or Argyle Prongs
• Nasopharyngeal prongs
• Nasal mask with SiPAP machine
• Variable flow devices
• Infant Flow Drivers with nasal prongs or nasal
  mask.
• Problems with these nasal interfaces
• Cumbersome
• Mucosal irritation, bleeding, nasal trauma
• Obstruction due to secretions in the nose or
  nasopharynx

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Background

• High flow nasal cannula systems are increasingly
  adopted because of the ease of use
• Vapotherm, Fisher Paykel HFNC
• However, these HFNC systems have no ability to
  measure or limit the pressure delivered to the
  baby
• There are no pop-off valves in these systems
• Only pop-off is at 20 PSI to protect the device
  and not to protect the baby
• Can generate significant amount of distending
  pressures at the nasal interface
• Air leaks have been reported

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Indications

• To facilitate extubation of mechanically
  ventilated neonates
• As a primary mode of support for neonates with
  respiratory distress
• Infants with moderate-to-severe apnea

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Materials

• We use a time-cycled pressure and flow limited
  (TCPFL) intermittent mandatory ventilation via
  nasal cannula (NC-IMV)
• This system gives us the ability to control
  pressure and flow rate with the use of nasal
  cannula while safely delivering rate, PIP, PEEP
  and limit the flow rate to 6 or 7 LPM

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Materials

• Nasal cannula-short tubing
• Connected to larger adapter
• Larger circuit
• Same humidity, but heating at 40C

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Materials
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NC-IMV Set-Up

• Set up Conventional Ventilator (Viasys)
• Mode Time Cycled Pressure Limited SIMV mode
  (TCPL-SIMV)
• Reason To allow us to be able to control the
  flow rate.
• Flow Rate
• 6 LPM if using Neonatal size Nasal cannula
• 7 LPM if using Infant size Nasal cannula
• IMV rate started at a maximum of 40 bpm
• PIP Same as the most recent Conventional
  Ventilator PIP (max 30 CmsH2O)
• PEEP 5 cmsH2O
• Insp. Time 0.5 seconds

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NC-IMV Set-Up

• Select appropriate Nasal cannula according to
  patients size
• Babies lt1Kg
• Premie NeoTech RAM Nasal Cannula (2.0mm ID)
• Babies 1-2.5Kg
• Newborn NeoTech RAM Nasal Cannula (2.5mm ID)
• Babies gt2.5Kg
• Infant NeoTech RAM Nasal Cannula (3.0mm ID)

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Weaning Protocol

• Wean PIP first
• Once PIP was around 10, rate was decreased to 10
• If infant remained stable, switched to NC-CPAP
• If infant was stable for 12-24 hours on NC-CPAP,
  switched to low flow nasal cannula (lt2 LPM)

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Results (n183)
Range
Birth weight (g) 385 4167
Gestational Age (weeks) 23 41
BW lt 1500 g (n) () 109 (60 )
Age _at_ NC-IMV start (days) 1 -124
Duration of NC-IMV (days) 1 - 49
NC-IMV Failures, () 15 (8 )
No cases of nasal injury or gastric or ear drum
perforation were seen within the 1,168 days of
NC-IMV. One pt with pneumothorax. Now have
treated gt300pts for gt3,000 days of NC-IMV
Ramanathan R, Andaya S et al, SPR Meetings,
Vancouver, May 2010
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Previous Studies

• All infants tolerated NC-IMV
• All infants tolerated feeds during NC-IMV
• No cases of nasal injury, or gastric perforation
  were seen
• NC-IMV failure rate requiring intubation in our
  study population was 8

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Conclusion

• NC-IMV is feasible and well tolerated.
• TCPFL NC-IMV allows clinicians to limit pressures
  and can be delivered safely to neonates
• Therefore, it appears that NC-IMV may be used in
  facilitating extubation of mechanically
  ventilated neonates, as a primary mode of support
  for neonates with respiratory distress, and for
  the treatment of apnea of prematurity
• While reducing obstacles such as mucosal
  irritation, bleeding, nasal trauma, or
  obstruction due to secretions in the nose or
  nasopharynx.

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A NOVEL MEANS FOR DELIVERING NASAL INTERMITTENT
POSITIVE PRESURE VENTILATION IN INFANTS VIA THE
NASAL CANNULA (NC) MEASUREMENTS OF DELIVERED
PARAMETERS IN A NASAL AIRWAY/LUNG MODEL
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NC-IMV

• Nasal Cannula Intermittent Mandatory Ventilation
  (NC-IMV) is a novel means of delivering pressure
  controlled NIPPV breaths noninvasively to
  neonates requiring respiratory support.
• We have previously reported that NC-IMV is
  feasible and well tolerated in a large number of
  neonates.
• However, pressures or volume delivered to the
  patient is not known.

Ramanathan et al Pediatric Academic Society, May
2010 Abstract 1472.217
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Hypothesis

• NC-IMV is sufficient to provide measurable
  ventilation effects and pressure, using 3
  different cannula devices, in a lung model using
  a realistic "leaky neonatal airway model

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Objective

• To determine the magnitude of pressure and volume
  delivered to an infant nasal airway/lung model
• Using different sized nasal cannula
• At different peak inspiratory pressure (PIP)
  settings during constant flow, time-cycled,
  pressure-limited ventilation.

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Methods

• We configured a neonatal test lung to simulate an
  apneic premature infant (CL0.8 mL/cmH20 R75
  cmH20/L/sec).
• A realistic infant nasal airway model was
  attached to the test lung.

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Methods

• 28 week premature infant airway model that was
  reconstructed from a head CT scan and a rapid
  prototyping device

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Methods
Schematic of Experimental set-up
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Methods

• Set up Conventional Ventilator (Viasys)
• Mode Time Cycled Pressure Limited SIMV mode
  (TCPL-SIMV)
• Flow Rate 7-9 LPM
• IMV rate 40 bpm
• PEEP 5 cmsH2O
• Insp. Time 0.5 seconds
• The nasal airway was ventilated at PIP of 10, 15,
  20, 25, and 30 cmH20

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Methods

• Nasal cannulae used
• Neonatal nasal cannula (Fisher Paykel, Auckland,
  NZ) ID 1.5 mm
• Infant nasal cannula (Fisher Paykel, Auckland,
  NZ) ID 1.8 mm
• New prototype nasal cannula (Neotech Ram Nasal
  Cannula) ID of 3 mm

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Results with ID 1.5 mm
Results with ID 1.5 mm
Fisher Paykel Neonatal Nasal Prongs
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Results with ID 1.8 mm
Fisher Paykel Infant Nasal Prongs
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Results with ID 3 mm
Results with ID 3 mm
Neotech Ram Nasal Cannula
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Results

• Under all testing conditions, there was
  detectable PLUNG, VLUNG, and PEEP during NC-IMV.
  
• There was a linear relationship between PIP
  applied by the ventilator and VLUNG/PLUNG up to
  30 cmH20.

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Results

• The Neotech Ram Nasal Cannula provided greater
  PLUNG, VLUNG, and PEEP than the other infant
  nasal cannulae during NC-IMV.

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Poiseuilles Law

• pr4?P
• Q ________
• 8µL
• Increased ID to 3mm
• Increased ID of delivery tubing to 3 or 3.5mm
• Shortened length of delivery tubing
• Changed shape of prongs

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Thank You
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NCPAP Extubation Failures 20-80 (8 Studies
2001-2009)

Bi-Nasal vs. Single Prongs
IFD vs. V-CPAP
NCPAP vs. SurfNCPAP
IFD vs. B-CPAP
Ramanathan R. J Perinatol 30S67-S72 October
2010