Nasal Cannula Intermittent Nasal Cannula Intermittent Mandatory VentilationMandatory Ventilation

(NC-IMV)(NC-IMV)

IntroductionIntroduction With increased survival of very low birth weight (VLBW) With increased survival of very low birth weight (VLBW)

infants, the number of infants who require prolonged infants, the number of infants who require prolonged mechanical ventilation (MV) has increasedmechanical ventilation (MV) has increased

The pulmonary management of these infants is directed The pulmonary management of these infants is directed at minimizing the need for prolonged MV to reduce at minimizing the need for prolonged MV to reduce ventilator-induced trauma and oxygen toxicityventilator-induced trauma and oxygen toxicity

Early extubation often presents difficulties because of Early extubation often presents difficulties because of upper-airway instability, poor respiratory drive, alveolar upper-airway instability, poor respiratory drive, alveolar atelectasis, and residual lung damageatelectasis, and residual lung damage

Khalaf et al Khalaf et al PediatricsPediatrics 2001; 108:13-17 2001; 108:13-17

BackgroundBackground Use of Nasal respiratory support (NARES) Use of Nasal respiratory support (NARES)

is on the rise to decrease post-extubation is on the rise to decrease post-extubation failures, bronchopulmonary dysplasia failures, bronchopulmonary dysplasia (BPD), and for the treatment of apnea of (BPD), and for the treatment of apnea of prematurityprematurity

CPAP, by various means, commonly is CPAP, by various means, commonly is used to wean premature infants from used to wean premature infants from mechanical ventilationmechanical ventilation

NCPAP Failure RatesNCPAP Failure Rates

NCPAP use is associated with failure rates NCPAP use is associated with failure rates of 20 to 80% in preterm infantsof 20 to 80% in preterm infants

Reasons for failure include recurrent Reasons for failure include recurrent apnea/ bradycardia/desaturations or apnea/ bradycardia/desaturations or respiratory acidosis requiring intubation or respiratory acidosis requiring intubation or re-intubationre-intubation

RamanathanRamanathan et al et al J PerinatolJ Perinatol October 2010; 30:S67-S72 October 2010; 30:S67-S72

BackgroundBackground The addition of a back-up rate by using The addition of a back-up rate by using

NIPPV not only adds intermittent NIPPV not only adds intermittent distending pressure above PEEP but also distending pressure above PEEP but also increases flow delivery in the upper airwayincreases flow delivery in the upper airway

Friedlich et al J PerinatolJ Perinatol 1999; 19:413-418 1999; 19:413-418Barrington et al Barrington et al PediatricsPediatrics 2001; 107:638-641 2001; 107:638-641

NCPAP vs. NIPPV for NARESNCPAP vs. NIPPV for NARES

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

BackgroundBackground Typical nasal interfaces used:Typical nasal interfaces used:

Short bi-nasal prongs Short bi-nasal prongs Inca prongs or Argyle ProngsInca prongs or Argyle Prongs

Nasopharyngeal prongs Nasopharyngeal prongs Nasal mask with SiPAP machineNasal mask with SiPAP machine Variable flow devicesVariable flow devices

Infant Flow Drivers with nasal prongs or nasal mask. Infant Flow Drivers with nasal prongs or nasal mask. Problems with these nasal interfacesProblems with these nasal interfaces

CumbersomeCumbersome Mucosal irritation, bleeding, nasal traumaMucosal irritation, bleeding, nasal trauma Obstruction due to secretions in the nose or nasopharynxObstruction due to secretions in the nose or nasopharynx

BackgroundBackground High flow nasal cannula systems are High flow nasal cannula systems are

increasingly adopted because of the ease of use increasingly adopted because of the ease of use Vapotherm, Fisher Paykel HFNCVapotherm, Fisher Paykel HFNC

However, these HFNC systems have no ability However, these HFNC systems have no ability to measure or limit the pressure delivered to the to measure or limit the pressure delivered to the babybaby There are no pop-off valves in these systemsThere are no pop-off valves in these systems Only pop-off is at 20 PSI to protect the device and not Only pop-off is at 20 PSI to protect the device and not

to protect the baby to protect the baby Can generate significant amount of distending Can generate significant amount of distending

pressures at the nasal interfacepressures at the nasal interface Air leaks have been reported Air leaks have been reported

IndicationsIndications To facilitate extubation of mechanically To facilitate extubation of mechanically

ventilated neonatesventilated neonates As a primary mode of support for neonates As a primary mode of support for neonates

with respiratory distresswith respiratory distress Infants with moderate-to-severe apneaInfants with moderate-to-severe apnea

MaterialsMaterials We use a time-cycled pressure and flow We use a time-cycled pressure and flow

limited (TCPFL) intermittent mandatory limited (TCPFL) intermittent mandatory ventilation via nasal cannula (NC-IMV) ventilation via nasal cannula (NC-IMV)

This system gives us the ability to control This system gives us the ability to control pressure and flow rate with the use of pressure and flow rate with the use of nasal cannula while safely delivering rate, nasal cannula while safely delivering rate, PIP, PEEP and limit the flow rate to 6 or 7 PIP, PEEP and limit the flow rate to 6 or 7 LPMLPM

MaterialsMaterials Nasal cannula-short tubingNasal cannula-short tubing Connected to larger adapterConnected to larger adapter Larger circuitLarger circuit Same humidity, but heating at 40°CSame humidity, but heating at 40°C

MaterialsMaterials

NC-IMV Set-UpNC-IMV Set-Up Set up: Conventional Ventilator (Viasys)Set up: Conventional Ventilator (Viasys) Mode: Time Cycled Pressure Limited SIMV mode Mode: Time Cycled Pressure Limited SIMV mode

(TCPL-SIMV) (TCPL-SIMV) Reason: To allow us to be able to control the flow rate. Reason: To allow us to be able to control the flow rate.

Flow Rate: Flow Rate: 6 LPM if using Neonatal size Nasal cannula6 LPM if using Neonatal size Nasal cannula 7 LPM if using Infant size Nasal cannula7 LPM if using Infant size Nasal cannula

IMV rate: started at a maximum of 40 bpmIMV rate: started at a maximum of 40 bpm PIP: Same as the most recent Conventional Ventilator PIP: Same as the most recent Conventional Ventilator

PIP (max 30 CmsH2O)PIP (max 30 CmsH2O) PEEP: 5 cmsH2OPEEP: 5 cmsH2O Insp. Time: 0.5 seconds Insp. Time: 0.5 seconds

NC-IMV Set-UpNC-IMV Set-Up Select appropriate Nasal cannula Select appropriate Nasal cannula

according to patient’s sizeaccording to patient’s size Babies <1KgBabies <1Kg

Premie NeoTech RAM Nasal Cannula (2.0mm Premie NeoTech RAM Nasal Cannula (2.0mm ID)ID)

Babies 1-2.5KgBabies 1-2.5Kg Newborn NeoTech RAM Nasal Cannula (2.5mm Newborn NeoTech RAM Nasal Cannula (2.5mm

ID)ID) Babies >2.5KgBabies >2.5Kg

Infant NeoTech RAM Nasal Cannula (3.0mm ID)Infant NeoTech RAM Nasal Cannula (3.0mm ID)

Weaning ProtocolWeaning Protocol Wean PIP first Wean PIP first

Once PIP was around 10, rate was decreased Once PIP was around 10, rate was decreased to 10to 10

If infant remained stable, switched to NC-If infant remained stable, switched to NC-CPAPCPAP

If infant was stable for 12-24 hours on NC-If infant was stable for 12-24 hours on NC-CPAP, switched to low flow nasal cannula CPAP, switched to low flow nasal cannula (<2 LPM)(<2 LPM)

Results: (n=183)Results: (n=183)RangeRange

Birth weight (g)Birth weight (g) 385 – 4167385 – 4167Gestational Age (weeks)Gestational Age (weeks) 23 – 41 23 – 41 BW < 1500 g (n) (%)BW < 1500 g (n) (%) 109 (60 %)109 (60 %)Age @ NC-IMV start (days)Age @ NC-IMV start (days) 1 -124 1 -124 Duration of NC-IMV (days)Duration of NC-IMV (days) 1 - 491 - 49NC-IMV Failures, (%) NC-IMV Failures, (%) 15 (8 %)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 >300pts for >3,000 days of NC-IMV

Ramanathan R, Andaya S et al, SPR Meetings, Vancouver, May 2010Ramanathan R, Andaya S et al, SPR Meetings, Vancouver, May 2010

Previous StudiesPrevious Studies All infants tolerated NC-IMV All infants tolerated NC-IMV

All infants tolerated feeds during NC-IMVAll infants tolerated feeds during NC-IMV

No cases of nasal injury, or gastric perforation No cases of nasal injury, or gastric perforation were seen were seen

NC-IMV failure rate requiring intubation in our NC-IMV failure rate requiring intubation in our study population was 8%study population was 8%

ConclusionConclusion NC-IMV is feasible and well tolerated.NC-IMV is feasible and well tolerated. TCPFL NC-IMV allows clinicians to limit pressures and can be TCPFL NC-IMV allows clinicians to limit pressures and can be

delivered safely to neonatesdelivered safely to neonates Therefore, it appears that NC-IMV may be used in facilitating Therefore, it appears that NC-IMV may be used in facilitating

extubation of mechanically ventilated neonates, as a primary mode extubation of mechanically ventilated neonates, as a primary mode of support for neonates with respiratory distress, and for the of support for neonates with respiratory distress, and for the treatment of apnea of prematurity treatment of apnea of prematurity

While reducing obstacles such as mucosal irritation, bleeding, nasal While reducing obstacles such as mucosal irritation, bleeding, nasal trauma, or obstruction due to secretions in the nose or nasopharynx.trauma, or obstruction due to secretions in the nose or nasopharynx.

A NOVEL MEANS FOR DELIVERING NASAL A NOVEL MEANS FOR DELIVERING NASAL INTERMITTENT POSITIVE PRESURE VENTILATION INTERMITTENT POSITIVE PRESURE VENTILATION

IN INFANTS VIA THE NASAL CANNULA (NC): IN INFANTS VIA THE NASAL CANNULA (NC): MEASUREMENTS OF DELIVERED PARAMETERS IN A MEASUREMENTS OF DELIVERED PARAMETERS IN A

NASAL AIRWAY/LUNG MODELNASAL AIRWAY/LUNG MODEL

NC-IMVNC-IMV Nasal Cannula Intermittent Mandatory Ventilation (NC-Nasal Cannula Intermittent Mandatory Ventilation (NC-

IMV) is a novel means of delivering pressure controlled IMV) is a novel means of delivering pressure controlled NIPPV breaths noninvasively to neonates requiring NIPPV breaths noninvasively to neonates requiring respiratory support. respiratory support.

We have previously reported that NC-IMV is feasible and We have previously reported that NC-IMV is feasible and well tolerated in a large number of neonates. well tolerated in a large number of neonates.

However, pressures or volume delivered to the patient is However, pressures or volume delivered to the patient is not known. not known.

Ramanathan et al Ramanathan et al Pediatric Academic SocietyPediatric Academic Society, May 2010; Abstract 1472.217, May 2010; Abstract 1472.217

HypothesisHypothesis

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

ObjectiveObjective

To determine the magnitude of pressure and To determine the magnitude of pressure and volume delivered to an infant nasal airway/lung volume delivered to an infant nasal airway/lung model model Using different sized nasal cannula Using different sized nasal cannula At different peak inspiratory pressure (PIP) At different peak inspiratory pressure (PIP)

settings during constant flow, time-cycled, settings during constant flow, time-cycled, pressure-limited ventilation.pressure-limited ventilation.

MethodsMethods

We configured a neonatal test lung to We configured a neonatal test lung to simulate an apneic premature infant simulate an apneic premature infant (C(CLL:0.8 mL/cmH:0.8 mL/cmH220; R:75 cmH0; R:75 cmH220/L/sec).0/L/sec).

A realistic infant nasal airway model was A realistic infant nasal airway model was attached to the test lung.attached to the test lung.

MethodsMethods

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

MethodsMethods

Schematic of Experimental set-upSchematic of Experimental set-up

MethodsMethods Set up: Conventional Ventilator (Viasys)Set up: Conventional Ventilator (Viasys) Mode: Time Cycled Pressure Limited SIMV mode Mode: Time Cycled Pressure Limited SIMV mode

(TCPL-SIMV) (TCPL-SIMV) Flow Rate: 7-9 LPMFlow Rate: 7-9 LPM IMV rate: 40 bpmIMV rate: 40 bpm PEEP: 5 cmsHPEEP: 5 cmsH22OO Insp. Time: 0.5 secondsInsp. Time: 0.5 seconds The nasal airway was ventilated at PIP of 10, 15, 20, 25, The nasal airway was ventilated at PIP of 10, 15, 20, 25,

and 30 cmHand 30 cmH2200

MethodsMethods

Nasal cannulae usedNasal cannulae used Neonatal nasal cannula (Fisher Paykel, Neonatal nasal cannula (Fisher Paykel,

Auckland, NZ): Auckland, NZ): ID 1.5 mmID 1.5 mm Infant nasal cannula (Fisher Paykel, Infant nasal cannula (Fisher Paykel,

Auckland, NZ) : Auckland, NZ) : ID 1.8 mmID 1.8 mm New prototype nasal cannulaNew prototype nasal cannula (Neotech Ram (Neotech Ram

Nasal Cannula®) : Nasal Cannula®) : ID of 3 mmID of 3 mm

Results with ID 1.5 mmResults with ID 1.5 mmResults with ID 1.5 mmResults with ID 1.5 mm

Fisher Paykel Fisher Paykel Neonatal Nasal Neonatal Nasal

ProngsProngs

Results with ID 1.8 mmResults with ID 1.8 mm

Fisher Paykel Fisher Paykel Infant Nasal Infant Nasal

ProngsProngs

Results with ID 3 mmResults with ID 3 mmResults with ID 3 mmResults with ID 3 mm

Neotech Ram Neotech Ram Nasal Nasal

Cannula®Cannula®

ResultsResults

Under all testing conditions, there was Under all testing conditions, there was detectable Pdetectable PLUNGLUNG, V, VLUNGLUNG, and PEEP during , and PEEP during

NC-IMV. NC-IMV. There was a linear relationship between There was a linear relationship between

PIP applied by the ventilator and PIP applied by the ventilator and VVLUNGLUNG/P/PLUNGLUNG up to 30 cmH up to 30 cmH220.0.

ResultsResults

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

PoiseuillePoiseuille’’s Laws Law

ππrr44ΔΔPPQQ = ________ = ________ 88μμLL

Increased ID to 3mmIncreased ID to 3mm Increased ID of delivery tubing to 3 or 3.5mmIncreased ID of delivery tubing to 3 or 3.5mm Shortened length of delivery tubingShortened length of delivery tubing Changed shape of prongsChanged shape of prongs

Thank YouThank You

NCPAP: NCPAP: Extubation Failures ~20-Extubation Failures ~20-80% 80%

(8 Studies; 2001-2009)(8 Studies; 2001-2009)

24

38.5

80

33

46

2933

39

57

2619.7

38.1

0

10

20

30

40

50

60

70

80

90

Davis-01 Stefanescu-03

Finer-04 Booth-06 Morley-08 Gupta-09 Sandri-09 Rojas-09

%Bi-Nasal vs.

Single Prongs

IFD vs. B-

CPAP

NCPAP vs. Surf+NCPAP*

IFD vs. V-

CPAP

Ramanathan R. J Perinatol 30:S67-S72; October 2010