XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung...
Transcript of XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung...
![Page 1: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/1.jpg)
Non-invasive ventilation in the delivery
room of the extreme preterm infant.
Máximo Vento MD PhD Director Neonatal Research Unit
Division of Neonatology & Health Research Institute
University and Polytechnic Hospital La Fe
(Valencia; Spain)
XIX International Symposium in Neonatology
![Page 2: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/2.jpg)
Scheme of the presentation…
• Introduction. – Lung development
– Physiology of ventilation after birth
• Ventilation in the Delivery Room. – Traumas to the lung with positive pressure ventilation
– Non invasive ventilation in the DR : RCT’s
– Sustained inflations? Basic concepts and experimental and clinical experience.
• Take home message
SAO PAOLO 2013 2
![Page 3: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/3.jpg)
INTRODUCTION (I)
Lung development
SAO PAOLO 2013 3
![Page 4: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/4.jpg)
Modified from the Course in Embryology. Univ. Lausanne (Switzerland)
Antioxidant system
4 SAO PAOLO 2013
![Page 5: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/5.jpg)
SAO PAOLO 2013 5
Canalicular phase (16th -24th week)
1. Neumocytes type I 2. Neumocytes type 2 3. Capillary vessels
Lung development
![Page 6: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/6.jpg)
SAO PAOLO 2013 6
Saccular phase (24th -36th week)
1. Neumocytes type I 2. Pseudoalveolar spacer 3. Neumocytes type 2 4. Elastic fibers 5. Mesoderm 6. Vascular endothelium
Lung development
![Page 7: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/7.jpg)
SAO PAOLO 2013 7
Saccular phase: formation of the alveolar lining fluid
Surfactant is detected
▲ non-enzymatic antioxidants’ synthesis rate
▲ enzymatic antioxidants’ expression
![Page 8: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/8.jpg)
*
** IU
/g H
gb
IU
/g H
gb
*
**
0,00
0,50
1,00
1,50
2,00
2,50
3,00
3,50
Umbilical cord Day 1
SOD activity (IU/g Hgb)
CTRL ELBW
0,00
50,00
100,00
150,00
200,00
250,00
300,00
Umbilical cord Day 1
CAT activity (IU/mg Hgb)
CTRL ELBW
Vento M et al Antioxid Redox Signal 2009
Antioxidant enzyme activity
8 SAO PAOLO 2013
![Page 9: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/9.jpg)
**
**
0
10
20
30
40
50
60
Umbilical cord Day 1
GS
H/G
SS
G X
10
0
CTRL ELBW
Vento M et al Antioxid Redox Signal 2009
Reduced to Oxidized Glutathione ratio
9 SAO PAOLO 2013
![Page 10: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/10.jpg)
INTRODUCTION (II)
Physiology of ventilation after birth
SAO PAOLO 2013 10
![Page 11: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/11.jpg)
Surfactant
Fetal lung Onset of breathing Established breathing
PIP (30-40 cmH2O)
Glotis
Negative thoracic pressure
PIP (20-25 cmH2O)
4-5 cm H2O
PEEP
FROM LIQUID TO AIR BREATHING
(-52 cmH2O)
SAO PAOLO 2013 11
![Page 12: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/12.jpg)
Initiation of ventilation
• Clear lung fluid
• Recruit alveolar spaces
• Establish Functional Residual Capacity (FRC)
• Avoid expiratory collapse
SAO PAOLO 2013 12
![Page 13: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/13.jpg)
Clear lung fluid
SAO PAOLO 2013 13
PIP 35-40 cmH2O
PIP 15-20 cmH2O PEEP 2-3 cmH2O
First breath
Successive breaths
![Page 14: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/14.jpg)
Clear lung fluid
SAO PAOLO 2013 14
Mechanical forces imposed on the fetus during labor.
Activation of epithelial Na+ channels (ENaCs)
Adrenaline Vasopressin
Na+
Am
ilori
de
-sen
siti
ve
ENaC
s
Cl-
H2O + Na+ +
-
![Page 15: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/15.jpg)
Clear lung fluid
SAO PAOLO 2013 15
Aquaporins
Relative gene expression of aquaporins in chorial vellosity and placenta. mRNA fold
expression was determined by the ct method. The mRNA of AQP2 and AQP6 were not
amplified neither in chorial villus nor in placenta. ** p<0,01 & * p<0,05 vs placenta.
0,0
0,5
1,0
1,5
2,0
0,0
1,0
2,0
3,0
4,0
5,0
6,0
mRN
A fo
ld e
xpre
ssio
n (v
s 18S
)
AQPs in chorial vellosity
Placenta
Chorial Vellosity
0,0
1,0
2,0
3,0
4,0
5,0
6,0
mRN
A fo
ld e
xpre
ssio
n (v
s 18S
)
AQPs in chorial vellosity
Placenta
Chorial Vellosity
Placenta
Chorial Villosity
**
p=0.08
*
**
AQUAPORIN GENES EXPRESSION IN CHORIAL VILLOSITY AND PLACENTA
First vs. third trimester AQP’s expression
Escobar JJ et al EAPS 2011
**
![Page 16: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/16.jpg)
Establishment of FRC
SAO PAOLO 2013 16
![Page 17: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/17.jpg)
O2
Avoid expiratory collapse
SAO PAOLO 2013 17
CO2
Inspiratory phase Expiratory phase
Alveolar lining fluid (Surfactant)
Mature lung Expiratory
Braking Maneuvers
![Page 18: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/18.jpg)
Establishment of FRC
SAO PAOLO 2013 18
Hooper SB et al Clin Exp Pharm Physiol 2009
Spontaneously breating
![Page 19: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/19.jpg)
O2
Avoid expiratory collapse
SAO PAOLO 2013 19
CO2
Inspiratory phase Expiratory phase
Alveolar lining fluid lacking (Surfactant)
Immature lung
Muscle weakness Compliant chest wall Elastic resistance
![Page 20: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/20.jpg)
SAO PAOLO 2013 20
Pressure
Volume
FRC 4-5 cmH2O
Pressure/Volume curve in term vs. preterm
(PIP) 30-35 cmH2O
![Page 21: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/21.jpg)
Establishment of FRC
SAO PAOLO 2013 21
Hooper SB et al Clin Exp Pharm Physiol 2009
Mechanically ventilated preterm rabbits
Without PEEP
With PEEP
![Page 22: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/22.jpg)
Compliance
Probyn ME et al Pediatr Res 2004
arterio-venous O2
PEEP during resuscitation of premature lambs
SAO PAOLO 2013 22
0 PEEP
4 cm H2O
8 cm H2O
12 cm H2O
![Page 23: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/23.jpg)
0 PEEP
4 cm H2O
8 cm H2O
12 cm H2O
Oxygen saturation and PEEP
Probyn ME et al Pediatr Res 2004
FiO2 needed and PEEP
PEEP during resuscitation of premature lambs
SAO PAOLO 2013 23
![Page 24: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/24.jpg)
SAO PAOLO 2013 24
Pressure
Volume
FRC 4-5 cmH2O
Pressure/Volume curve in preterm with/without PEEP
(PEEP) 4-5 cmH2O
![Page 25: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/25.jpg)
Establishment of FRC
SAO PAOLO 2013 25
Without PEEP With PEEP
Hooper SB et al Clin Exp Pharm Physiol 2009
![Page 26: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/26.jpg)
SAO PAOLO 2013 26
Initial breathing difficulties associated to prematurity
• Low lung compliance • Compliant chest wall • Surfactant deficiency • Immature antioxidant defenses • Impaired liquid clearance • Muscular weakness • Inefficient grunting • Double-walled interstitium • Incompletely developed capillary bed • Incipient septation (low exchange surface)
Vento M et al Neonatology 2009
![Page 27: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/27.jpg)
501 – 749 g
(n: 4046)
750 – 999 g
(n: 4266)
Respiratory Distress Syndrome 71 (51-98) 55 (39-75)
Oxygen at 28 d 66 (39-90) 37 (15-70)
Bronchopulmonary dysplasia 46 (25-81) 33 (11-62)
Pneumothorax 13 (1-19) 6 (3-10)
MORBIDITY % (RANGE)
Respiratory morbidity in ELGAN’s
Fanaroff AA et al AJOG 2007
SAO PAOLO 2013 27
![Page 28: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/28.jpg)
VENTILATION in the DR (I)
Positive pressure ventilation: traumas to the lung
SAO PAOLO 2013 28
![Page 29: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/29.jpg)
Fanaroff AA et al AJOG 2007 SAO PAOLO 2013
29
![Page 30: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/30.jpg)
Volutrauma
SAO PAOLO 2013 30
![Page 31: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/31.jpg)
Björklund LJ Pediatr Res 1997
Pressure – volume curves in lambs bagged 6 x with high tidal volumes
SAO PAOLO 2013 31
![Page 32: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/32.jpg)
Lung histological findings after bagging with high tidal volume and unsatisfactory response to surfactant.
Björklund LJ Pediatr Res 1997
Bagged Non-bagged
SAO PAOLO 2013 32
![Page 33: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/33.jpg)
HIGH TIDAL VOLUME AND LUNG INJURY
Hillman NH et al AJRCCM 2007
(IL: interleukin; MCP: monocyte chemotactic protein)
SAO PAOLO 2013 33
![Page 34: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/34.jpg)
HIGH TIDAL VOLUME AND LUNG INJURY
Hillman NH et al AJRCCM 2007
(SAA: serum amyloid A)
SAO PAOLO 2013 34
![Page 35: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/35.jpg)
Stretch-induce damage
SAO PAOLO 2013 35
![Page 36: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/36.jpg)
Interstitial edema
TNFα
Protein leakage p55
Wilson MR et al AJP LCMP 2007
p75 Neutrophil recruitment
Oxidative stress
SAO PAOLO 2013 36
Stretch
![Page 37: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/37.jpg)
Wilson MR et al AJP LCMP 2007
Pulmonary edema formation
SAO PAOLO 2013 37
![Page 38: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/38.jpg)
SAO PAOLO 2013
Bland R et al Am J Physiol 2008
Secondary alveolar septation
38
Formation of secondary septae Blunting of secondary septae formation by PPV.
![Page 39: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/39.jpg)
We conclude…
● A brief period of high tidal volume (VT) ventilation (e.g.: resuscitation) may injure the fetal lung.
● Mechanical ventilation, thereafter, selectively amplifies injury markers.
● The brief initial ventilation period also triggers a systemic response in the preterm modulated by temperature and endogenous surfactant, and not by NFkB, IL1 or IL8.
SAO PAOLO 2013 39
![Page 40: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/40.jpg)
VENTILATION in the DR (II)
Is non-invasive ventilation protective?
SAO PAOLO 2013 40
![Page 41: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/41.jpg)
CPAP applied to the airway (+)
● Improves lung expansion & increases lung volume, FRC and compliance.
● Improves ventilation/perfusion matching & oxygenation
● Decreases pulmonary vascular resistance & atelectasis
● Enhances release and conservation of surfactant
● Reduces inspiratory resistance by dilating the airways
● Improves work of breathing and reduces CO2 retention
Halamek LP & Morley Clin Perinatol 2006
SAO PAOLO 2013 41
![Page 42: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/42.jpg)
CPAP applied to the airway (-)
● Exact pressure applied is unknown due to leakage (if lungs are compliant over distension may occur)
● Associated with air leaks (e.g.: pneumothorax)
● Local tissue injury
● Does not allow to instillate surfactant
Halamek LP & Morley Clin Perinatol 2006
SAO PAOLO 2013 42
![Page 43: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/43.jpg)
Non-invasive ventilation in the delivery room
SAO PAOLO 2013 43
![Page 44: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/44.jpg)
Finer NN et al Pediatrics 2004
Delivery Room – CPAP/PEEP in ELBW infants: feasibility trial.
SAO PAOLO 2013 44
![Page 45: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/45.jpg)
ENCPAP implementation and BPD
% use CPAP
incidence of BPD
Aly H et al Pediatrics 2005
SAO PAOLO 2013 45
![Page 46: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/46.jpg)
Morley CJ et al NEJM 2008 SAO PAOLO 2013
46
![Page 47: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/47.jpg)
Morley CJ et al NEJM 2008
SAO PAOLO 2013 47
![Page 48: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/48.jpg)
Morley CJ et al NEJM 2008 SAO PAOLO 2013
0
1
2
3
4
5
6
7
8
9
10
Pneumothorax Death BPD - 28 d O2 BPD - 36 wksO2CPAP INTUBATION
*
*
COIN Trial – 36 weeks outcomes
x 10
x 10
48
![Page 49: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/49.jpg)
Comments
● Only patients breathing spontaneously at 5 min were randomized (“good vs. bad”)
● High CPAP pressure (8 cm H2O) caused significant increase in pneumothorax after resuscitation.
● Median ventilatory days for both were low!
SAO PAOLO 2013 49
![Page 50: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/50.jpg)
Support Trial
• Infants between 24+0 and 27 + 6 weeks gestation.
• Randomized “prior” to delivery.
• Protocol limited ventilation strategy.
• Primary outcome: death and/or BPD
SAO PAOLO 2013 Support Trial NEJM 2010
50
![Page 51: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/51.jpg)
SAO PAOLO 2013 Support Trial NEJM 2010
Support Trial
51
![Page 52: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/52.jpg)
Comments
• Infants recruited before delivery includes both good and bad postnatal adapted.
• Results seem to favor CPAP.
SAO PAOLO 2013 52
Jobe AH Lisbon 2011
![Page 53: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/53.jpg)
VENTILATION in the DR (III)
Sustained inflations?
SAO PAOLO 2013 53
![Page 54: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/54.jpg)
SAO PAOLO 2013
Brief inflation Sustained inflation 54
![Page 55: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/55.jpg)
SAO PAOLO 2013 55
![Page 56: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/56.jpg)
SAO PAOLO 2013
without SI
with SI
Te Pas AB et al Pediatr Res 2009
56
![Page 57: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/57.jpg)
Without SI
SI for 5 sec
SI for 10 sec
SI for 20 sec
SAO PAOLO 2013
Te Pas AB et al Pediatr Res 2009
57
![Page 58: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/58.jpg)
SAO PAOLO 2013 58
Effect of 20 sec SI on achievement of tidal volume & FRC
Hooper SB et al Neoreviews 2010
![Page 59: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/59.jpg)
Effectiveness of SI
• Maturity of the lung
• Amount of fluid present in the lung
• Total cross-sectional area of the small distal airways
• Duration of SI
• Pressure applied to the airways
• Combination of SI + PEEP was the best approach in the experimental setting.
SAO PAOLO 2013 59
Hooper SB et al Neoreviews 2010
![Page 60: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/60.jpg)
Early functional residual capacity (EFURCI) – UH Leiden (Netherlands)
• To determine whether early nasal continuous positive airway pressure (ENCPAP) preceded by a sustained inflation is more effective and less injurious than conventional mask ventilation followed by CPAP in babies ≤ 29 weeks gestation.
SAO PAOLO 2013
Te Pas AB et al Pediatrics 2007
60
![Page 61: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/61.jpg)
SAO PAOLO 2013
Conventional mask CPAP
PIP
PEEP
EFURCI + ENCPAP
PPIP
Te Pas AB et al Pediatrics 2007
PEEP
61
![Page 62: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/62.jpg)
SAO PAOLO 2013
Total recruited
207
Conventional
103
EFURCI
104
Intubation
52 (50.5%)
Intubation
38 (36.5%)**
Te Pas AB et al Pediatrics 2007
62
![Page 63: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/63.jpg)
SAO PAOLO 2013 Te Pas AB et al Pediatrics 2007
Intubation in the DR and < 72 hrs
63
![Page 64: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/64.jpg)
SAO PAOLO 2013
Secondary outcomes EFURCI CONVENTIONAL Univariate analysis
OR
Surfactant >1 dose, n(%) 10/103 (10%)
22/104 (21%)
0.02 0.39 (0.18-0.88)
BPD TOTAL, n(%) 22 (22a ) 34 (34) 0.05
BPD MODERATE – SEVERE n (%)
21 (20) 16 (16) 0.04 0.41 (0.18-0.96)
Mortality, n (%) 2 (2) 4 (4) 0.4
Te Pas AB et al Pediatrics 2007
Secondary outcomes
64
![Page 65: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/65.jpg)
SLI V Buzzi Hospital (Milan) trial: Objectives
• To verify if the application of SI applied at birth in preterm infants may reduce the need for mechanical ventilation and improve respiratory outcome.
SAO PAOLO 2013 65
Lista G et al Neonatology 2011
![Page 66: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/66.jpg)
SLI trial: Design
SAO PAOLO 2013 66
Control group (n: 119)
GA: 28.1±2.0
(2004-6)
SLI group (n: 89)
GA: 28.12.2
(2007-9)
Bag & mask
PEEP 5%
FiO2 for Sat 80-85%
Bag & mask
PIP 25 cmH2O x 15 sec
Repeated if HR<100 bpm or SpO2<<
PEEP 5%
FiO2 for Sat 80-85%
AAP GUIDELINES
Lista G et al Neonatology 2011
![Page 67: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/67.jpg)
SLI trial: Results without statistical significance
Outcome SLI GROUP CONTROL P
Pneumothorax 8 (9%) 10 (8%) NS
PDA 24 (27%) 29 (24%) NS
Grade 3-4 IVH 1 (1%) 5 (4%) NS
PVL 4 (4%) 11 (9%) NS
ROP > grade 3 10 (11%) 7 (6%) NS
NEC 4 (4%) 0 NS
Hospital stay (days) 54±29 55±32 NS
MORTALITY 8 (9%) 17 (14%) NS
SAO PAOLO 2013 67
![Page 68: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/68.jpg)
SLI trial: Results with statistical significance
Outcome SLI GROUP CONTROL P
INSURE 14(16%) 3 (3%) 0.001
MV (days) 5±11 11±19 0.008
Exclusive NCPAP 44 (49%) 29 (24%) 0.0001
Surfactant 40 (45%) 73 (61%) 0.029
Oxygen therapy (days) 21±27 31±31 0.016
BPD (O2 at 36 wks) 6 (7%) 25 (25%) 0.004
Postnatal steroids 9 (10%) 30 (25%) 0.01
SAO PAOLO 2013 68
![Page 69: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/69.jpg)
SLI trial: Conclusions
• Sustained inflations at birth in preterm infants with respiratory distress may decrease the need for mechanical ventilation without inducing adverse effects.
SAO PAOLO 2013 69
Lista G et al Neonatology 2011
![Page 70: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/70.jpg)
SLI : unanswered questions
• Duration and intensity of inflations
• Hemodynamic consequences of increased thoracic pressure
• Short-lasting beneficial effect
• Individually adjustment of SI
• Titration of oxygen during SI
SAO PAOLO 2013 70
![Page 71: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/71.jpg)
SLI: comparison of 3 devices UN Norway & U Melbourne
• Objective: Provide SI 10 sec & 30 cmH2O to a leak free manikin with SIB, FIB and T-piece.
SAO PAOLO 2013 71
Klingenberg C et al Neonatology 2011
![Page 72: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/72.jpg)
SLI: comparison of 3 devices UN Norway & U Melbourne
• Conclusions
– T-piece provided consistent PIP during a single 10 s sustained inflation with less variation in pressure compared to the flow-inflating bag.
– SI > 3 s were difficult to achieve with the self-inflating bag.
SAO PAOLO 2013 72
Klingenberg C et al Neonatology 2011
![Page 73: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/73.jpg)
Home take message
SAO PAOLO 2013 73
![Page 74: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/74.jpg)
SAO PAOLO 2013
■ CPAP is comparable to (or even a bit better) than intubation +/- surfactant for initial stabilization in DR. ■ Perhaps 50% of ELBW infants do not have RDS (“good responders”). ■ Some infants will not respond to our interventions because of immaturity or unknown factors (“bad responders”). ■ Death or BPD are outcomes with casualties not necessarily related to the interventions.
Conclusions from RCT’s
adapted from Dr AH Jobe ( International Neonatal Meeting; Lisbon 2011)
74
![Page 75: XIX International Symposium in Neonatology...Scheme of the presentation… •Introduction. –Lung development –Physiology of ventilation after birth •Ventilation in the Delivery](https://reader035.fdocuments.in/reader035/viewer/2022071104/5fdd872e63fa664e070c72f6/html5/thumbnails/75.jpg)
Postnatal interventions
• If the baby is spontaneously breathing initiate non-invasive ventilation – Mask or ENCPAP applied with T-piece if possible (or bag with EV)
– Apply PEEP 4-6 cmH2O
– Flow 4-8 l/min
– Sustained inflation of 30 cmH2O for 15 sec if you are confident with the technique and repeat 2nd time if no response seem to be beneficial (National Guidelines Holland; Norway; ERC)
– Titrate oxygen according to SpO2 and HR.
• If the baby is not spontaneously breathing and does not respond to non-invasive ventilation proceed to intubate and ventilate with PIP+PEEP.
SAO PAOLO 2013 75