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Niet-Invasieve Respiratoire
Ondersteuning
Doel:
Verbeteren van zuurstofsaturatie
Verminderen van ademhalingsarbeid
Voorkomen van beademing
Preventie van CLD (BPD)
Verminderen post-extubatie falen
Behandelen van apneu’s (AoP)
Ligdagduur & -prijs verminderen
Werking:
Levert zuurstof
Vermindert ademhalingsarbeid
Recruteert alveoli (verbetering FRC)
Verbetert ‘closing volume’
Optimaliseert longcapaciteit
Begeleidt ventilatie, minder oxygenatie
Minder risico VAP
Niet-Invasieve Respiratoire
Ondersteuning
Niet-Invasieve Respiratoire
Ondersteuning
Indicatie:
Zuurstofnood
Respiratoir Distress Syndroom (RDS)
Transiënte Tachypneu van de Neonaat (TTN)
Apneu van de Prematuur (AoP)
Post-extubatie
Chronisch Longlijden (CLD/BPD)
Ondersteuning tijdens de transitie-fase
Niet-Invasieve Respiratoire
Ondersteuning
Contra-indicatie:
Weinig observatie van ervaren personeel
Geen spontane ademhaling of uitputtingsverschijnselen
Geen vrije BLW (bijv. epistaxis, choanale atresie, …)
Ernstige acidose
Multi-orgaan falen (en/of hemodynamische instabiliteit)
Pneumothorax
Agitatie
Niet-Invasieve Respiratoire
Ondersteuning
Soorten:
Observatie
O2 (bijv. in couveuse)
Low flow neusbril
High flow neusbril
CPAP
BiPAP
NIPPV
Zuurstof
Low Flow Neusbril
FiO2 1.0 met
variabele zeer lage
flow
FiO2 variabel met
lage flow (<2 Lmin-1)
Low Flow Neusbril (NC)
Geleverde zuurstof is niet de ingestelde
x kg lichaamsgewicht
y Lmin-1 flow (y(z-21)/x)+21
z % zuurstof
2,1 kg; 0,2 Lmin-1; 65% effectief 25,2 % zuurstof
Koude & droge gassen (meer indien hogere
flow)
Warme, vochtige lucht & RDS
Humidified-Heated High Flow
Neusbril
FiO2 variabel
Hoge flow (>2 Lmin-1)
Warme, bevochtigde lucht
High Flow Neusbril (HHHFNC)
Geleverde zuurstof is gekend
Geleverde warmte en bevochtiging is gekend
Beter voor de ontwikkeling ?
Minder schade thv mond & neus
Stiller dan de meeste andere methoden
Gemakkelijker voor verzorging
Gemakkelijker voor ouders (kangoeroeën, BV)
Betere interactie tussen patiënt en hun omgeving
Veroorzaakt minder energieverbruik tijdens ademen
High Flow Neusbril (HHHFNC)
Werking is niet duidelijk Reduceert nasopharyngeale dode ruimte
Reduceert Rins (nasopharynx)
Verbetert conductie (bronchi) ademhalingsarbeid
Verbetert compliantie bij verhoging flow
Verbetert ventilatie en oxigenatie
Positieve druk long ‘recruitment’ & voorkomt alveolaire collaps
‘Flush’ effect
prongs <50% neusgatdiameter lek mogelijk belangrijk tijdens uitademing van CO2
High Flow Neusbril (HHHFNC)
Continue positieve distentie druk is afhankelijk van:
Grootte baby
Grootte van interface (de neusbril)
Ademhalingspatroon
Ingestelde flow
Druk is evenwel niet gekend
Baro- & volutraumata
Adequate druk vereist gesloten mond
High Flow Neusbril (HHHFNC)
Andere bezorgdheden
Zuurstofintoxicatie
Mechanische of thermotraumata
Teveel lucht in abdomen
Teveel water in luchtweg
Infectierisico
Subcutane scalp emphyseem & pneumo-orbitus
Thoraxwand vervorming
Continue Positieve Luchtweg Druk
FiO2 variabel
Druk continu
Warme, bevochtigde lucht
Negatieve druk genereert een intrekkende
beweging van de thoraxwand bij spontane
ademhaling
Verzwakt inspiratie kracht en capaciteit
Vertraagt longexpansie
Inefficiënte ventilatie en arbeidsverspilling
Thoraxwand vervorming
Continue Positieve Luchtweg Druk
(CPAP)
Best gekende Niet-Invasieve Respiratoire
Ondersteuning (NIRO)
Initieel ontwikkeld als secundair device
Inmiddels ook primaire methode voor
ondersteuning
Interface
Endotracheale tube
Prongs
Unilateraal
Kort (tot in neuscaviteit)
Lang (tot in nasopharynx)
Bilateraal
Kort (tot in neuscaviteit)
Lang (tot in nasopharynx)
Masker (neus)
Continue Positieve Luchtweg Druk
(CPAP)
Geleverde zuurstof is gekend
Geleverde warmte en bevochtiging is gekend
Beter voor de ontwikkeling ?
Veroorzaakt minder energieverbruik tijdens ademen
Minder obstructieve apneu’s
Continue Positieve Luchtweg Druk
(CPAP)
Werking is niet volledig duidelijk Reduceert nasopharyngeale dode ruimte
Reduceert Rins (nasopharynx)
Verbetert conductie (bronchi) ademhalingsarbeid
Verbetert compliantie bij verhoging flow
Verbetert ventilatie en oxigenatie
Positieve druk long ‘recruitment’ & voorkomt alveolaire collaps
Stabiliseert thoraxwand
Vermindert obstructieve apneu’s
Minimaliseert longoedeem (low-level nCPAP)
Continue Positieve Luchtweg Druk
(CPAP)
Continue positieve distentie druk is afhankelijk van:
Ademhalingspatroon
Ingestelde druk
Adequate druk vereist gesloten mond en juiste aansluiting interface
Neusseptum schade, neus irritatie
Impressie letsels (aangezicht & hoofd)
Continue Positieve Luchtweg Druk
(CPAP)
Andere bezorgdheden
Zuurstofintoxicatie
Baro- & volutraumata
Mechanische of thermotraumata
Teveel lucht in abdomen
Teveel water in luchtweg
Infectierisico
Veneuze retour van hart gecompromitteerd
Continue Positieve Luchtweg Druk
(CPAP)
Apneu van de Prematuur
Bilevel Positieve Luchtweg Druk
FiO2 variabel
Druk wisselend
Frequentie ingesteld
Synchroon
Asynchroon
Warme, bevochtigde lucht
Voor- en nadelen van CPAP
Verbetering van patente bovenste luchtweg
door (intermittente) gestegen pharyngeale
drukken
Intermittente inflatie van de pharynx activeert
mogelijk de respiratoire ‘drive’
Bilevel Positieve Luchtweg Druk
(BiPAP)
Synchronisatie
Abdominaal device
Pneumotachograaf Flow-trigger
Druk-trigger
Respiratoir ‘inductance’ plethysmografie
‘Neurally Adjusted Ventilator Assist (NAVA)
sBiPAP versus nsBiPAP geen verschil qua apneu’s
Bilevel Positieve Luchtweg Druk
(BiPAP)
Falen
BiPAP/CPAP/HHHFNC/LFNC
Afgevlakt diaphragma & horizontale ribben
limiteren inspiratoire reserve volume sneller
ademen om minuut volume te verbeteren
eerder uitgeput
Thoraxwand deformatie diaphragma moet dit
compenseren
Weinig type 1 oxidatieve spiervezels in
diaphragma & intercostale spieren eerder
uitgeput
Falen
BiPAP/CPAP/HHHFNC/LFNC
Primaire surfactant deficiëntie Atelectase
Onevenwicht tussen compliante thoraxwand
en non-compliante long met immature
elastische vezels luchtwegcollaps
inflammatie secundaire surfactant
deficiëntie
Centrale & obstructieve apneu’s
compromiteren ademhaling
Falen
BiPAP/CPAP/HHHFNC/LFNC
pH<7.25; PaCO2 > 60 mmHg
Apneu waarvoor T-piece met masker nodig
>3 apneu of bradycardie/uur (bij caffeine
onderhoud)
> 3 saturatiedalingen (<85%)/uur die niet
reageren op verhoogde respiratoire
ondersteuning instellingen
BiPAP versus CPAP
Primair support
Secundair support
Mech. Vent. na InSurE
Ademhalingsfrequenti
e
Primair support
Secundair support
Mech. Vent. na InSurE
Ademhalingsfrequenti
e
BiPAP CPAP
BiPAP versus CPAP
Oxygenatie
Ventilatie
Pro-inflam. Cytokines
CLD/BPD
Oxygenatie
Ventilatie
Pro-inflam. Cytokines
CLD/BPD
BiPAP CPAP
BiPAP versus CPAP
Centrale apneu’s
Obstructieve apneu’s
Mortaliteit
Hospitalisatieduur
Centrale apneu’s
Obstructieve apneu’s
Mortaliteit
Hospitalisatieduur
BiPAP CPAP
CPAP versus HHHFNC
Ervaring
Primair support
Secundair support
Ademhalingsarbeid
Ervaring
Primair support
Secundair support
Ademhalingsarbeid
CPAP HHHFNC
CPAP versus HHHFNC
Comfort
Duur zuurstoftherapie
Weaning
Duur tot volledig PO
Comfort
Duur zuurstoftherapie
Weaning
Duur tot volledig PO
CPAP HHHFNC
CPAP versus HHHFNC
RDS
Pneumothorax
Neustraumata
ELBW Mortaliteit
RDS
Pneumothorax
Neustraumata
ELBW Mortaliteit
CPAP HHHFNC
CPAP versus HHHFNC
CLD/BPD
ELBW CLD/BPD
Hospitalisatieduur
ELBW
Hospitalisatieduur
CLD/BPD
ELBW CLD/BPD
Hospitalisatieduur
ELBW
Hospitalisatieduur
CPAP HHHFNC
HHHFNC versus LFNC
Ervaring
Oxygenatie
Ademhalingsarbeid
Neustraumata
Ervaring
Oxygenatie
Ademhalingsarbeid
Neustraumata
HHHFNC LFNC
Succes afhankelijk van:
Succesvolle transitie en extra-uteriene adaptatie Prematuriteit, Infectie, Persisterende pulmonale
hypertensie
Goede patiënt selectie
Juiste device met juiste interface
Ervaring zorgverleners
Adequate observatie
Zelfstandige ademhaling
Niet-Invasieve Respiratoire
Ondersteuning
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Ancora G, et al: Role of bilevel positive airway pressure in the management of preterm newborns who have received surfactant. Acta Paediatr 2010; 99: 1807-11.
Barrington KJ, Bull D, Finer NN: Randomized trial of nasal synchronized intermittent mandatory ventilation compared with continuous positive airway pressure after extubation of very low birth weight infants. Pediatrics 2001; 107: 638-41.
Beck J, et al: patient-ventilator interaction during neurally adjusted ventilatory assist in low birth weight infants. Pediatr Res 2009; 65: 663-8.
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Bisceglia M, et al: A comparison of nasal intermittent versus continuous positive pressure delivery for the treatment of moderate respiratory syndrome in preterm neonates. Minerva Pediatr 2007; 59: 91-5.
Chang HY, et al: Effects of synchronization during nasal ventilation in clinically stable preterm infants. Pediatr Res 2011; 69: 84-9.
Clarke P: Norfolk and Norwich University Hospitals Guideline .Nasal high flow therapy (Vapotherm) Use for non-invasive respiratory support in neonates. 2013.
Colaizy TT, et al: Nasal high-frequency ventilation for premature infants. Acta Paediatr 2008; 97: 1518-22.
Collins CL, Holberton JR and Konig K: Comparison of pharyngeal pressure provided by two heated, humidified high-flow nasal cannulae devices in premature infants. J Paediatr Child Health 2013; 49: 554-6
Courtney SE, Barrington KJ: Continuous positive airway pressure and noninvasive ventilation. Clin Perinatol 2007; 34: 73–92, vi.
Craft AP, Bhandari V, Finer NN: The sy-fi study: a randomized prospective trial of synchronized intermittent mandatory ventilation versus a high-frequency flow interrupter in infants less than 1000 g. J Perinatol 2003; 23: 14-9.
Dani C, Pratesi S, Migliori C et al: High flow nasal cannula therapy as respiratory in the preterm infant. Pediatr Pulmonol 2009; 44: 629-34.
Davis PG, Henderson-Smart DJ: Nasal continuous positive airways pressure immediately after extubation for preventing morbidity in preterm infants. Cochrane Database Syst Rev 2003. Issue 2.
Davis PG, Lemyre B, de Paoli AG: Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for preterm neonates after extubation. Cochrane Database Syst Rev 2001.
De Jongh BE, Locke R, Mackley A et al: Work of breathing indices in infants with respiratory insufficiency receiving high-flow nasal cannula and continuous positive airway pressure. J Perinatol 2014; 34: 27-32.
De Medeiros SK, Carvalho WB, Soriano CF: Practices of use of nasal intermittent positive pressure ventilation (NIPPV) in neonatology in northeastern Brazil. J Pediatr (Rio J) 2012; 88: 48-53.
De Paoli AG, Davis PG, Faber B, Morley CJ: Devices and pressure sources for administration of nasal continuous positive airway pressure (NNCPAP) in preterm neonates. Cochrane Database Syst Rev 2008. Issue 1.
Referenties
De Paoli AG, et al: In vitro comparison of nasal continuous positive airway pressure devices for neonates. Arch Dis Child Fetal Neonatal Ed 2002; 87:F42-5.
De Winter JP, de Vries MA, Zimmermann LJ: Clinical practice: noninvasive respiratory support in newborns. Eur J Pediatr 2010; 169: 777-82.
Dumas De La Roque E, et al: Nasal high frequency percussive ventilation versus nasal continuous positive airway pressure in transient tachypnea of the newborn: A pilot randomized controlled trial (NCT00556738). Pediatr Pulmonol 2011; 46: 218-23.
Dunn MS, Kaempf J, de Klerk A, et al: Randomized trial comparing 3 approaches to the initial respiratory management of preterm neonates. Pediatrics 2011; 128: e1069-76.
Dysart K, Miller TL, Wolfson MR et al: Research in high flow therapy: Mechanisms of action. Respir Med 2009; 103: 1400-5.
Dysart K: Physiologic Basis for Nasal Continuous Positive Airway Pressure, Heated and Humidified High-Flow Nasal Cannula, and Nasal Ventilation. Clin Perinatol 2016; 43: 621-31.
Finer NN, et al: Early CPAP versus surfactant in extremely preterm infants. N Engl J Med, 2010; 362: 1970-9.
Fischer HS, et al: Is volume and leak monitoring feasible during nasopharyngeal continuous positive airway pressure in neonates? Intensive Care Med 2009; 35: 1934-41.
Friedlich P, et al: A randomized trial of nasopharygeal-synchronized intermittent mandatory ventilation versus nasopharyngeal continuous positive airway pressure in very low birth weight infants after extubation. J Perinatol 1999; 19: 638-41.
Gizzi C, et al: Flow-synchronized nasal intermittent positive pressure ventilation for infants <32 weeks’ gestation with respiratory distress syndrome. Crit Care Res Pract 2012; 2012: 301818.
Glackin SJ, O'Sullivan A, George S, Semberova J, Miletin J: High flow nasal cannula versus NCPAP, duration to full oral feeds in preterm infants: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 2016; 0: F1-4.
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Jackson HD, et al: Mask versus prongs for CPAP delivery: Incidence of bradycardia, apnoea and desaturation (BAD) events. J Paediatr Child Health 2013; 49(suppl 2):21, abstr A072.
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Jaslin LR, Kern S, Thompson S: Subcutaneous scalp emphysema, pneumo-orbitus and pneumocephalus in a neonate on high humidity high flow nasal cannula. J Perinatol 2008; 28: 779-81.
Johnson AH, et al: High-frequency oscillatory ventilation for the prevention of chronic lung disease of prematurity. N Engl J Med 2002; 347: 633-42.
Khalaf MN, et al: A prospective randomized, controlled trial comparing synchronized nasal intermittent positive pressure ventilation versus nasal continuous positive airway pressure as modes of extubation. Pediatrics 2001; 108: 13-7.
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Kiciman NM, et al: Thoracoabdominal motion in newborns during ventilation delivered by endotracheal tube or nasal prongs. Pediatr Pulmonol 1998; 25: 175-81.
Referenties
Kieran EA, et al: Randomized trial of prongs or mask for nasal continuous positive airway pressure in preterm infants. Pediatrics 2012; 130:e1170-6.
Kieran EA, Walsh H, O’Donnell CP: Survey of nasal continuous positive airways pressure (NCPAP) and nasal intermittent positive pressure ventilation (NIPPV) use in Irish newborn nurseries. Arch Dis Child Fetal Neonatal Ed 2011; 96: F156.
Kirpalani H, et al: Nasal intermittent positive pressure ventilation (NIPPV) does not confer benefit above nasal CPAP (nCPAP) in extremely low birth weight (ELBW) infants <1000 g BW – The NIPPV International Randomised Controlled Trial. E-PAS 2012: 1675.1.
Klingerberg C, pettersen M, Hansen EA et al: Patient comfort during treatment with heated humidified high flow nasal cannulae versus nasal continuous positive airway pressure: a randomised cross-over trial. Arch Dis Child Fetal Neonatal Ed 2014; 99: F134-7.
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Referenties
Moretti C, et al: Nasal flow-synchronized intermittent positive pressure ventilation to facilitate weaning in very low-birth-weight infants: unmasked randomized controlled trial. Pediatr Int 2008; 50: 85-91.
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Referenties
Shah PS, et al: Outcomes of preterm infants <29 weeks gestation over 10-year period in Canada: a cause for concern? J Perinatol 2012; 32: 132-8.
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