Weaning Approaches in Neonatal Ventilatory Care - PowerPoint PPT Presentation

Loading...

PPT – Weaning Approaches in Neonatal Ventilatory Care PowerPoint presentation | free to view - id: 7ddfe-YWVkY



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Weaning Approaches in Neonatal Ventilatory Care

Description:

Discussion of Goals and Concerns of Ventilation in the Newborn. Discussion of Criteria for intubation and IPPV ... Semin Neonatology 2002 Sinha. Literature review ... – PowerPoint PPT presentation

Number of Views:1106
Avg rating:3.0/5.0
Slides: 67
Provided by: DanM
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Weaning Approaches in Neonatal Ventilatory Care


1
Weaning Approaches in Neonatal Ventilatory Care
  • D.T. Murai

2
Objectives
  • Discussion of Goals and Concerns of Ventilation
    in the Newborn
  • Discussion of Criteria for intubation and IPPV
  • Discussion of Elements to consider in preparation
    of extubation
  • Review of Literature

3
Weaning
  • Also known as
  • LIBERATION
  • DISCONTINUATION

4
Goals of IPPV
  • Provide supplemental oxygen
  • Provide distending pressures
  • Provide ventilation

5
Goals of IPPV
  • Provide supplemental oxygen
  • Use hoods, nasal cannula
  • Provide distending pressures
  • Use nasal CPAP, BIPAP
  • Provide ventilation
  • Provide mask bag ventilation
  • Apneic ventilation

6
Apnea
  • Treated with methylxanthines and CPAP and IPPV
  • Stability essential for Normal organ function and
    development
  • Brain
  • Cardiovascular system
  • Gut - nutrition

7
Concerns of IPPV in Newborn
  • Intubation associated soft tissue trauma
  • Intubation associated cerebral hypertension and
    intraventricular hemorrhage
  • ETT assoc airway trauma, strictures
  • Loss of glottal braking, atelectasis
  • Excessive volume, airleak syndromes

8
Concerns of IPPV in Newborn
  • 6. Loss of normal ciliary function, retention of
    secretions, need for suctioning
  • Loss of cough, retention of secretions
  • Postural changes inhibited, atelectasis
  • Ventilator associated Pneumonia
  • Pain and distress

9
Concerns of IPPV in Newborn
  • Secondary concerns malnutrition
  • Malnutrition related
  • Infection
  • Laryngotracheomalacia
  • Delayed lung repair and growth
  • Short
  • Developmental Delays, Learning disabilities

10
Long Term Consequences of IPPV in Newborn
  • Chronic Lung Disease
  • Bronchopulmonary Dysplasia
  • BPD

11
Concerns associated with BPD in Newborn
  • BPD related chronic ventilation
  • Diuretics, Fluid restriction - Growth delays
  • Dexamethasone therapy - developmental delays,
    cerebral palsy, MR
  • Tracheostomy

12
What should we do?
  • Avoid intubation if possible- non invasive
    ventilatory support
  • Early extubation when possible
  • Avoid reintubation which affects brain, gums,
    teeth, throat, trachea

13
Criteria for Intubation
  • Baby who is Extremely Small
  • Baby who is Depressed
  • Baby with Congenital anomalies
  • Baby with Meconium in Amniotic fluid
  • Baby with Need for immediate CPR
  • Baby who has Apnea
  • Baby with Hypercapnia

14
What do we know?
15
Weaning in the Adult
  • Readiness Testing
  • Respiratory failure has resolved (at least part)
  • Respiratory muscle function has recovered
  • Ready for trial of spontaneous breathing

16
Weaning in the Adult
  • Readiness testing
  • Subjective
  • Objective - guidelines vs rigid rules - 30
  • Between 65-85 of patients will pass trial of
    spontaneous breathing if satisfy readiness

17
Weaning in the AdultReadiness Criteria
18
Weaning in the AdultReadiness Criteria
  • Required (use by all researchers)
  • PaO2/FiO2 gt151
  • SaO2 gt91 in lt41Peep lt6 cmH20
  • Hemodynamic stability (no or low meds)
  • No active cardiac ischemia

19
Weaning in the AdultReadiness Criteria
  • Optional (used by some researchers)
  • Rate lt36 bpm
  • Spont Vt gt5ml/kg
  • Neg inspir force lt -20 to - 25 cmH20
  • f/Vt lt105 b/L min
  • Hemoglobin gt8-10
  • Core temp lt38.5
  • Normal electrolytes
  • CNS awake alert, arousable

20
Weaning in the AdultSpontaneous Breathing Trial
21
Other Weaning Predictors
  • Measurement of O2 and gas exchange
  • Simple meas of respiratory load and muscle
    capacity
  • Meas integrating multiple factors
  • Complex meas requiring special equipment

22
Weaning Predictors
  • Measurement of O2 and gas exchange
  • PaO2/FiO2
  • PaO2/PAO2
  • Dead space / Vd/Vt

23
Weaning Predictors
  • Simple meas of respiratory load and muscle
    capacity
  • Negative inspiratory force
  • Resp system compliance
  • Resp system resistance
  • Minute ventilation
  • Resp frequency
  • Tidal volume
  • Maximum voluntary ventilation
  • Vital capacity

24
Weaning Predictors
  • Measure integrating multiple factors
  • f/Vt
  • CROP

25
Weaning Predictors
  • Complex measurements requiring special equipment
  • Airway occlusion pressure
  • P0.1/max insp presure
  • Work of breathing
  • Oxygen cost of breathing
  • Gastric intramucosal pH

26
Weaning Predictors
  • Negative inspiratory force
  • Maximal inspiratory pressure
  • Minute ventilation
  • Airway occlusion pressure/max Pinsp
  • CROP index
  • Compliance, Rate, Oxygen, Pressure

27
Weaning in the AdultIf Fails Readiness Criteria
28
Weaning in the AdultReadiness Criteria
29
Spontaneous Breathing Trial
  • PSV lt7 cm H20
  • CPAP
  • Unassisted on T- piece
  • 30 to 120 minutes or more
  • 40 failure if extubated after readiness
    criterial alone

30
Criteria of Success of SBT
  • SaO2 gt90 or PaO2 gt60 on FiO2 lt.50 or Pa/FiO2
    gt150
  • Increase of PCO2 lt10 torr, pH lt 0.1
  • RR lt35 bpm
  • HR lt140 bpm or increase lt20
  • BP gt90 sys lt160 mmHg or lt20 baseline
  • Absence of signs of increased work
  • Absence of signs of distress

31
Failure of SBT
  • 30 may require more time
  • Hypoxemia - unusual
  • Depressed central drive - occasionally
  • More often signs of increased drive
  • Tachypnea
  • Shallow breathing
  • Muscle fatigue
  • Cardiac dysfunction
  • Psychologic

32
Weaning in the AdultIf Fails SBT
33
Weaning in the Adult
Failure
34
Weaning in the Newborn
Failure
35
Elements to Consider Prior to Extubation in
Newborn
  • Mechanics
  • Airway patent
  • Lungs more compliant than chest wall
  • Diaphragm function adequate
  • Drugs
  • Nutrition
  • Mechanical disadvantage
  • Central Drive Adequate
  • Apnea
  • Need for pain relief

36
Literature review
  • What should be the rate, PIP,PEEP, TV before we
    are ready to extubate?
  • How long from SBT?

37
Weaning in the NewbornsReadiness Criteria
  • Not Uniform
  • Rate lt6, lt15-25 bpm
  • PIP lt12 -16
  • PEEP lt 2 -5
  • FiO2 lt.3- .35
  • CNS No apnea

38
LiteratureNeed for SBT
  • Direct extubation rather than SBT
  • Usually from low rates lt10 bpm
  • J Perinatology 1989 Kim

39
Protocols?
40
Literature review
  • Literature fails to provide uniform view
  • Semin Neonatology 2002 Sinha

41
Literature review
  • Automated protocols vs physician adjustment of
    pressure support
  • No difference 76 v 85 v no protocols 73
  • All weaned lt2 days
  • Need for sedation lt 24h predicted failure
  • JAMA 2002, Randolph, Ped Acute Lung Injury
    Network

42
Literature review
  • Minute Ventilation Test vs Clinical Assess
  • Shorter time to trial of extubation 8 vs 36h
  • Extubation failure rate similar
  • J Perinatol 2003, Gillespie

43
Literature review
  • Test Respiratory muscle strength, respiratory
    load
  • Airway occlusion method
  • 30 failed, lower GA, Low max inspiratory
    pressures
  • Unable to Predict - Similar with all groups
  • Low GA, older PNA, better than max press
  • Arch Dis Childhood Fetal Neonatal Edition 2002
    Dimitrious

44
Literature reviewPFT
  • lt1000g infants
  • Spontaneous expiratory minute ventilation
    lt125ml/min/kg during 2 hr of ETT CPAP
  • 27 failed extubation, no diff in C or R,
  • Lower rates 43 v 53, MV 240 v 309
  • More time lt125 predictions better than Sats,
    TCCO2
  • J Mat Fetal Neonatal Medicine 2004 Vento, et,al.

45
Literature review
  • What should we do to enhance the likelihood of
    being successful after extubation?

46
Literature review
  • Caffeine
  • Non Invasive support

47
Literature reviewCaffeine
  • lt32 week infants
  • 3,15,30 mg/kg/d dose x 6 d
  • Did not significantly improve extubation success
  • Did reduce apnea at higher doses
  • J Paediatric Child Health 2003, Steer

48
Literature Review
  • Aminophylline
  • Vent settings 12/2 f12 FiO2 lt.3
  • Effective in lt 1000g lt 7days
  • 72 control vs 28 treated
  • Not effective gt1000g or lt1000g gt7 days no
    difference
  • Pediatrics 1987, Durand

49
Literature reviewMethyl xanthines
  • Reduced failure 53 lt1w
  • Absolute reduction of 27
  • NNT 13.7 but significant heterogenity in the 6
    RCT - control grp failures 20-100
  • Cochrane 2003 Henderson-Smart

50
Literature reviewMethyl xanthines
  • One RCT
  • Effective lt1000g , ltfirst week
  • Not effective lt1000g, gtfirst week
  • Not effective 1-1.25kg
  • Cochrane 2003 Henderson-Smart

51
Literature Review
  • Doxapram
  • Extubated from f 6
  • NCPAP
  • No difference from controls
  • Acta Paediatrica 1998 Barrington

52
Literature reviewNon invasive Pressure Support
  • Nasal CPAP
  • Any system acceptable and effective?

53
Literature reviewNCPAP
  • Infant Flow System vs long prongs
  • lt30weeks
  • Success rate 62 vs 62
  • Most common reason for failureapnea
  • Pediatrics 2003 Stefanescu

54
Literature reviewNCPAP
  • Hudson prongs vs single nasal prong
  • Hudson 24 v 57
  • Infants lt800g 24 v 88
  • Cochrane 2001 Davis

55
Literature reviewNCPAP
  • Reduces adverse clinical events after extubation
    by 40
  • apnea, resp acidosis, increased O2
  • NNT 1 6
  • Optimal level unknown
  • Cochrane 2003 Davis and Henderson Smart

56
Literature reviewNIPPV
  • NISIMV vs NCPAP lt34w
  • Extubated from 16/5 f15-25 FiO2 .35
  • Success NISIMV 94 v NCPAP 60
  • Ped 2001 Khalaf

57
Other Therapies
58
Literature review
  • Dexamethasone
  • Since 1985 Multiple RCT show increases success of
    Extubation
  • 1990s significant increase in Developmental
    Delay, Cerebral Palsy
  • Pediatrics 1985 Avery

59
Literature review
  • Dexamethasone
  • 7 days of 0.5 or 0.2 mg/kg/d
  • Similar changes to compliance, FiO2 need
  • Pediatrics 2002 Durand

60
Literature review
  • Aerosol Steroids vs IV Dexamethasone
  • Success is Extubation lt7d after start
  • 61 infants 761g, 25.7 w,
  • Dxm 7/15, hi 3/16, med 1/15, low 2/15
  • Inc BP, gluc, less wbc in T aspirates
  • Ped Pulm 2003 Rozycki etal, Richm VA

61
Literature review
  • gt3 weeks with BPD on Thiazides/Spirono
  • Improved Compliance
  • Reduced need for lasix.
  • Decreased risk of death,
  • Trend to decrease failure to extub in 8 w
  • No effect - vent support, LOS, long term outcome
  • Cochrane 2002 Brion

62
Literature Review
  • Nebulize racemic epinephrine
  • No evidence supporting or refuting the use
  • Cochrane 2002 Davies and Davis

63
Literature review
  • End tidal during mech and spont vent
  • 25 in icu capnography
  • Peak values of exhaled co2, rate of rise, area
    under curve
  • Ped Pulmonology 2001 Hsieh

64
Literature reviewNIPPV
  • Pulmonary function testing
  • Compliance gt0.5ml/kg/cm and Resistancelt70 cmH/l/s
  • 80 successful extubation
  • Pediatrics 2001 Khalaf
  • Ped 2001 Khalaf

65
Literature review
  • Ncpap
  • NINSIMV Vent12/6/f12 v NCPAP 6
  • lt35 lt18b/m extubated amniophylline
  • After 12 hours SIMV rate 12
  • Success lt70 CO2, lt.7 FiO2 no
    signs apnea x 3d
  • Extubation average 7.6days
  • 4/27 vs 12/27 most apnea, hyperCO2
  • Ped 2001 Barrington

66
Literature ReviewOne Article's Summary
  • NCPAP
  • NIPPV
  • Methylxanthines
  • IV Dexamethasone
  • Chest physiotherapy no effect on atelectasis,
    need q1-2h
  • Paediatric Resp Rev 2004 Halliday

67
Summary
  • Weaning or Liberation from Mechanical Ventilation
    is still part Science and a lot of Art
  • The differences in Adults and Neonates are due to
    differences in physiology, anatomy and degrees of
    consequences
  • When you are at KMCWC remember little a babies
    are not little adults
About PowerShow.com