05/14/2012

1

Respiratory Therapy a Tertiary NICU

Why do we do what we do?

Kuehne 2011

Brandon Kuehne, MBA, RRT-NPS, RPFT

Director- Neonatal Respiratory Services

Kuehne 2011

Disclosures

� Purpose: To enhance staff’s knowledge of the various types of respiratory therapy equipment that are unique to the neonatal intensive care environment.

� Objectives:

� Discuss the indications and clinical implications for various types of Respiratory Therapy Related Devices commonly used in the Neonatal Intensive Care Unit

� Describe various disease process related to common to CPAP/Bi-level devices

� The Planning Committee and Faculty of this activity have no disclosed conflicts of interest related to this content.

� Completion Criteria: In order to receive Continuing Education (CE) credit, you must attend 80% of the program.

� No commercial support was received for this program

Kuehne 2011

Why do we do what we do?

Kuehne 2011

Amillia Sonja TaylorMiami 2007

Birth Weight 283 grams

Length 10 inches

Gestational Age 22 weeks

Hospital LOS 4 months

Oxygen Req. Low

Home w/o deficit PRICELESS

Kuehne 2011

Neo RT History

“3,000 Years and Going Strong”

05/14/2012

2

Kuehne 2011

And he went up, and lay upon the child

and, put his mouth upon his mouth,

and his eyes upon his eyes, and his

hands upon his hands; and he

stretched himself upon the child and

the flesh waxed warm

Old Testament, Elijah, I

Kings 17:17

NRP done OLD School

Slide courtesy of Robert DiBlassi RRTKuehne 2011

Kuehne 2011

Technological Advancements in Ventilators- Now

� Rapid response times � Active expiratory valves

� Accuracy of delivered volumes � Volume targeted ventilation

� Proximal flow sensing� Volume, triggering at ET tube,

graphics

� Pulmonary graphics� Identify various problems of

the patient-ventilator system

� NAVA- Neurally Adjusted Ventilatory Assist

Slide courtesy of Robert DiBlassi RRTKuehne 2011

The Future is now*

SPO2:

85-90%

Closed loop FiO2

SNIPPV TR mode

*Availability of these modes are FDA dependent as they are

already available overseas and in Canada

Slide courtesy of Robert DiBlassi RRT

Kuehne 2011

With all that’s out there-

What is the Right or Best approach?

Kuehne 2011

Introduction

� Multiple modes ventilation

� Volume v. Pressure

� Many different settings

� Conventional vs. High Frequency

� Oscillator vs. Jet

� Bubble vs. Infant Flow vs. HFNC

� Some confusion about how we arrive at the “right” settings for each patient

05/14/2012

3

Kuehne 2011

If humans were identical in every way, like

specially bred laboratory mice, everything in

their environment could be controlled, and

we’d get the same great results in humans.

Kuehne 2011

Once again……..

What is the Right or Best approach?

Kuehne 2011

1. Whatever form of ventilation you use, know how to use it well.

2. Limiting the variability of treatment modalities will lead to better outcomes!

3. Early Extubation/ Leads to a decreased incidence of BPD!

Universal Rules

What we know

Kuehne 2011

3. Early Extubation/ Leads to a decreased incidence of BPD….getting to nCPAP remains an ongoing challenge

Kuehne 2011

Basic Ventilation Strategy

Kuehne 2011

Key Point:

Comes down to an basic understanding physiology differences between neonate and pediatric/adult pulmonary systems

05/14/2012

4

Kuehne 2011

The Definitions

� Pulmonary function – how well is the respiratory system working?

� Two key components of pulmonary

mechanics

� Compliance – how easy it is to inflate lungs

(Premature Neonates generally have big problem with this)

� Resistance – opposition to airflow caused by forces of friction ie. obstruction to airflow

(generally associated with adult physiological/ pulmonary problems asthma- COPD, similar to BPD in infant populations)

And a little bit of…. Math

Kuehne 2011

Kuehne 2011

Math

� Compliance CL = ∆V/∆P (getting lungs to open up-getting air in)

� CL = ml/cmH2O

� Resistance (getting air out)

� R = Directly proportional to length

� R= Inversely proportional to r4

� R = cmH20/ml/s

Kuehne 2011

Math cont.

� Time constant – the rate at which lung fills or empties

� Time constant = R x C

� Time constant = (cmH20/ml/s)x(ml/cmH2O)

� Time constant = seconds

Kuehne 2011

Time Constant

Kuehne 2011

Surfactant Therapy

05/14/2012

5

Kuehne 2011 Kuehne 2011

(Multi-Access Catheter)

Kuehne 2011

Graphical Analysis of RDS

Pre Survanta Kuehne 2011

Pressure- Volume Graphical Analysis

of RDS

Six Hours Post Survanta

Nice football shape @ 45°angle

Kuehne 2011

Surfactant Research at NCH

Kuehne 2011

A Pharmacoeconomic Comparison of beractant and

poractant alfa in the presence of a

Rapid Extubation Protocol in a NICU

2011-2012

05/14/2012

6

Kuehne 2011

What?

Kuehne 2011

Surfactant Comparison while

using a Rapid Extubation Protocol

in the NICU

Kuehne 2011

Purpose of Study

The overall objective is to determine if Poractant alfa (Curosurf®) reduces costs of care as compared to beractant (Survanta®) when utilized in the presence of a unit based rapid extubation protocol in the treatment of respiratory distress syndrome (RDS). Several outcome variables will be monitored and observed in a sequential, open label non-randomized format to determine if costs associated with the use of poractant alfa for treatment therapy are reduced as compared to beractant. A secondary objective will be to determine if patients demonstrate better tolerance of the surfactant administration process with poractant alfa as compared to beractant due to lower dose volumes and pharmacodynamic properties

Kuehne 2011

What?

Kuehne 2011

Vs.

Kuehne 2011

Collection of Data to Establish Baseline Response

05/14/2012

7

Kuehne 2011 Kuehne 2011

nCPAP

Kuehne 2011

Why use CPAP?

� Recruitment

� Atelectasis

� Maintenance of FRC

� Post extubation

� Apnea of prematurity

� RDS

� Structural

� Tracheal malacia

� Chest wall stability

� To treat an ↑’d WOB

� Poor gas exchange

� Alternative to intubation

� ↓ CLD (VON)

� ↓ VAP

Kuehne 2011

??? Bubble CPAP ???

� Successfully used by Dr. Wung in 1970’s

� 30+ years

� Extremely low incidence of BPD/CLD from his facility (Columbian Presbyterian Medical Center, NY)

Kuehne 2011

Devices� Bubble CPAP

� Requirements

� Air/O2 proportioner (Blender)

� Water column

� Modified ventilator circuit (Factory setup available)

� Benefits

� Potential for:

� Gas exchange due to bubbling

�Not easily reproduced

Kuehne 2011

F & P Bubble CPAP System

Now commercially available in USA

05/14/2012

8

Kuehne 2011 Kuehne 2011

Kuehne 2011 Kuehne 2011

Kuehne 2011

NIPPV

Non-Invasive Positive Pressure Ventilation

or

Nasal Intermittent Positive Pressure Ventilation

� Two levels of pressure delivered via ventilator

using short bi-nasal prongs or nasopharyngeal prongs.

� Can be achieved with either:

�PS/CPAP

�Set rate, PIP and PEEP

Kuehne 2011

NIPPV

� Potential Benefits

� Reduction in apnea frequency

� ↑ CO2 removal

� Lung recruitment

� Synchrony may ↓ WOB

� Use of current facility equipment

05/14/2012

9

Kuehne 2011

NIPPV Ventilators

� FDA 510K NCPAP approved devices:

� Viasys AVEA

� PB-840

� Servo I

Kuehne 2011

VF-NCPAP

Kuehne 2011

� Variable Flow (Infant Flow nCPAP) Generator

Kuehne 2011

What is SiPAP?

� SiPAP is a CPAP/Bi-Level device.

� That is, it is capable of functioning as a

straight forward VF-NCPAP machine. It

can also function as a Bi-Level device

providing two separate pressures to the

patient.

� Very similar to low span APRV or IMV-

Pressure control

Kuehne 2011

Complications common to all

nCPAP

� Septal Breakdown

� Labor intensive (Sicker patients now on CPAP)

� Dry mucosa

� CPAP Belly

� Atelectasis due to pressure loss

� Dilated nares

� Developmental delays due to mobility

� Positioning difficulties

Kuehne 2011

Non Invasive Monitoring

05/14/2012

10

Kuehne 2011

Apnea monitor with Built-in

Pulse Oximeter

Kuehne 2011

Saturation Study

Kuehne 2011

Radiometer TCM –Analog

Electrode

Kuehne 2011

SenTec Digital TCM

Kuehne 2011

Stow-Severinghaus Digital

Electrode

Kuehne 2011

TCM Disposables

05/14/2012

11

Kuehne 2011

Proofing Sample TCM

SenTec y = 0.872x + 5.3413

R2 = 0.9402

05

10152025

30354045505560657075

80859095

100

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 10

0

CBG

TCM

0

10

20

30

40

50

60

70

80

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

TCM

CBG

Invasive Monitoring

Kuehne 2011

i-STAT Portable Clinical Analyser

Kuehne 2011

High Frequency Ventilation

High Frequency Ventilation

Key Characteristics of high frequency ventilation:

1. Constant lung volume

2. Tidal volumes that approximate(often less than) the

anatomical dead-space.

3. Rates = or >180 breaths/minute.

Kuehne 2011

High Frequency Ventilation

Definition:

Mechanical ventilation using supraphysiologic rates with tidal

volumes that less than the anatomical dead space of the

airways.

Kuehne 2011

Mechanisms of Gas Exchange:

� Bulk Convection

� Pendeluft

� Asymmetric Velocity Profiles

� Taylor Dispersion

� Molecular Diffusion

� Cardiogenic Mixing

High Frequency Ventilation

05/14/2012

12

Kuehne 2011

High Frequency Ventilators

Kuehne 2011

High Frequency VentilatorsSensorMedics Oscillator

Kuehne 2011

High Frequency Ventilators:

Bunnell Jet Ventilator

Kuehne 2011

Specialized Gases

Kuehne 2011

Sub-ambient FIO2 Nitrogen Gas Delivery

When room air is not good enough!

05/14/2012

13

Kuehne 2011

Nitrogen Therapy

Ventilator Hood

Kuehne 2011

Purpose:

To keep PDA open

� Used in conjunction with prostoglandens

� FIO2 levels driven down to approximately 17% using Nitrogen.

� Used mainly for Hypoplastic Left Heart syndrome

Kuehne 2011

Calculating Flow via Nitrogen Tank

[(flow RA flow meter) x 0.21] + [(flow N flow meter) x 0]

FiO2 = Total Flow (or flow RA+ flow N)

Ex: If 17% FiO2 desired:

8 lpm x .21

.17

Gives total flow of: 9.8 lpm

To get Nitrogen flow

9.8 lpm total flow – 8 lpm air = 1.8 lpm of Nitrogen

Kuehne 2011

Nitric Oxide

Kuehne 2011

The Basics

� Nitric Oxide was first discovered by Joesph Priestly in

1772 during his research and discovery of the Oxygen molecule

� It is formed from superheated Nitrogen in the presence of

Oxygen (aka combustion of fossil fuels).

� Nitric Oxide is a Free Radical thus making it very reactive

and unstable.

Kuehne 2011

Normal NO function

� NO relaxes the smooth muscle in the walls of the arterioles. At each systole, the endothelial cells that line the blood vessels

release a puff of NO. This diffuses into the underlying smooth muscle cells causing them to relax and thus permit the surge of

blood to pass through easily

� During diastole, the myocyte has consumed the provided NO,

the dilatation ceases. Venous blood flow is encouraged.

05/14/2012

14

Kuehne 2011

Open Label Use

� Inclusion Criteria

� Newborns > 34 weeks gestational age

� Hypoxic Respiratory failure

� Clinical or echocardiographic (ideal)

evidence of PPHN

� Oxygen Index (OI) > 20

� ECMO eligible

Kuehne 2011

Why we use it

PPHNPersistent Pulmonary Hypertension

� Newborns > 34 weeks gestational age� Hypoxic Respiratory failure

� Clinical or echocardiographic (ideal) evidence of PPHN

� Oxygen Index (OI) > 20� ECMO eligible

And

� Because I am asked to …

Kuehne 2011

Off Label Use

� < 34 weeks gestational age

� > 10-14 days of mechanical ventilation

� Irreversible lung disease

� Significant congenital heart disease

� Significant IVH

� Severe asphyxia or poor neurological prognosis

� Lethal congenital or chromosomal anomaly

Kuehne 2011

INOmax DSIR

Kuehne 2011

iNO Weaning Algorhythm, developed at NCH

Kuehne 2011

Aerosol Delivery

Research

05/14/2012

15

Radio-Aerogen In Vitro Study

Kuehne 2011 Kuehne 2011

Kuehne 2011 Kuehne 2011

Laurie Gibson, RT(R) injects 3ml of TC 99mTC DTDA aerosol

Kuehne 2011 Kuehne 2011

05/14/2012

16

Kuehne 2011

Fig. 2 CPAP with aerogen placed 18 inches from patientFig. 1 CPAP with aerogen placed at

humidifier

PILOT RANDOMIZED CLINICAL TRIAL OF INHALED PGE1 IN

NEONATES WITH SUB-OPTIMAL RESPONSE TO INHALED NITRIC OXIDE

Design/Methods

Inclusion Criteria:� GA ≥ 34 weeks

� Postnatal age ≤ 7 d

� Diagnosis of NHRF

� MV, INO, OI ≥ 15 x 2

� Indwelling arterial line

� Parental consent

Exclusion Criteria:

� Lethal conditions

� CDH

� CHD

� Thrombocytopenia

� Conflicting clinical trial

Trial Design: Multi-center, pilot RCT

IPGE1 Setup: Conventional & Jet Vent

Study Medications will be delivered

to the mini-nebs via syringe pumps

Study Drug

Normal Saline

T- Connector inInspiratory Line

Flow sensor remains inline

iNO sample line

0.3ml Tubing

Mini-Neb

Tri-flowconnector

Study Drug

Normal Saline

Screening & Enrolling Patients in the IPGE1 RCT Pilot

Kuehne 2011

Improving BPD Patient

Outcomes

05/14/2012

17

Kuehne 2011

Successfully Extubating the BPD Infant to nCPAPComprehensive Center for Bronchopulmonary Dysplasia

Kuehne 2011

Background

� February 2007 through September 2010 total of 94 extubation attempts of 62

BPD infants

� Success rate 66%

� Of the 62 patients

� 4 patients received trachs

� 4 deceased

� 54 successfully extubated and discharged

Kuehne 2011

Successful Extubation

� Defined: 72 hrs without out needing reintubation.

Kuehne 2011

Extubation Checklist

� No Airway Anomaly� Fi02 ≤ 40%

� No elevation in respiratory management within past 72 hrs

� Weight Trend: +/- ______ g/d� Full enteral feeds

� No surgery planned with in next 72 hrs

� No ROP exam scheduled for day of extubation

� No active infections� Medications for extubation ordered

� Team consensus

� Previous extubation failure????

Kuehne 2011

Extubation Timeline

2hours prior to extubation

-Evaluation by Extubation Team-patient confirmed by group as ready for extubation-feeds are stopped

1 hour prior to extubation

-Sipap machine set-up at bedside and plugged into air/oxygen wall inlets-Additional supplies placed at bedside

-intubation box-chin strap-shoulder rolls-sucrose-Chloral Hydrate

-Appropriate prong and hat size selected using package insert and head circumference

45 minutes prior to extubation

-RN and RT at bedside to deep suction nares of patient with 8 Fr suction catheter-ET-Tube suctioned-NCPAP interface placed on patient with ET-Tube remaining in place

30 minutes prior to extubation

-Diaper change/pt care needs met-OG separated from ET-Tube and re-secured to patient-Sipap machine and heater turned on.-Minimal flow initiated on Sipap machine-At this time, patient should be allowed to rest until extubation

Kuehne 2011

Interventions� Mild Respiratory Distress

� Mechanical Intervention

� Reposition� Suction� Chin Strap (if not already in place)� Assure proper size of hat and prongs� Assure appropriate humidity� Assure adequate CPAP is being achieved� Assure adequate O2

� Non Pharmacologic Interventions/Comfort Measures

� Swaddling� Prone positioning� Hand containment� Holding by mom� Pacifier� Change diaper, feed?

� Pharmacologic Interventions

� Moderate Respiratory Distress

� Mechanical Interventions as above� Non Pharmacologic Interventions/Comfort Measures as above

� Pharmacologic Interventions

� Chloral Hydrate (25-50 mg/kg), may repeat after discussion with attending� Lasix (give oral dose early, consider IM)� Steroids for airway edema or if evidence of wheezing, consider starting systemic steroid course� Consider benzodiazepam� Consider bronchodilators if wheezing is predominant finding

� Severe Respiratory Distress

� Reevaluate mechanical � Discuss with attending

� Apnea

� Consider reloading with Caffeine

� Assure adequately suctioned nares� Discuss with attending

05/14/2012

18

Kuehne 2011

Post Extubation ScoreWOB – Retractions, flaring and head bobbing

*Score infant 1 2 or 3 depending on how many symptoms they have*

Respirations – Scoring • 40 – 60 auscultated breaths per minute = 0• 61 – 80 auscultated breaths per minute = 1• 81 – 100 auscultated breaths per minute = 2• > 101 auscultated breaths per minute = 3

Apnea= 4

CNSSleeps between cares =0Irritable consolable =1

Irritable inconsolable=3Lethargic (does not wake for cares) =4

Color – Scoring• Pink = 0• Pale = 1• Dusky = 2

• Cyanosis = 3

Heart Rate – Scoring• Baseline = 0

• 180 – 200 bpm = 1• > 201 bpm =2

• Bradycardia =3

FiO2 – Scoring• Baseline + 10 % = 0• Baseline + 20 % = 1• Baseline + 30 % = 2• Baseline + 40 % = 3

Saturations - Scoring• 95 – 100 % = 0

• 90 – 94 % = 1• < 89 % = 2

Temperature – Scoring• < 100 .0 F = 0• > 100 .0 F = 1

* This scoring with be implemented at extubation, 15 min x 4, 30 min x 2, and q 1 hr for 22 hours

ECMO

Kuehne 2011

System Overview

Kuehne 2011

ECMOExtracorporeal membrane Oxygenation

� Extracorporeal

membrane oxygenation is the use of prolonged

cardiopulmonary bypass

for infants with hypoxic respiratory or cardiac

failure who fail to respond

to maximal medical management and less-

invasive therapies.

Kuehne 2011

Neonatal Diseases Treated by

ECMO

� MAS – Meconium Aspiration Syndrome

� PPHN – Persistent Pulmonary Hypertension of the Newborn

� CDH – Congenital Diaphragmatic Hernia

� Sepsis/pneumonia

� RDS – Respiratory Distress Syndrome

� Airleak syndrome

� Recent, novel uses include hydrops fetalis, viral pneumonia and cardiomyopathy

Kuehne 2011

ECMO

Extracorporeal Membrane

Oxygenation

05/14/2012

19

Kuehne 2011 Kuehne 2011

Questions?