Negative Pressure Ventilation - Hilary Klonin

The power of the negativeHilary Klonin

The Beggars LitanyThere is a Proverbe, and a prayer withall,That we may not to these strange placesfall,From Hull, from Halifax, from Hell, ‘tisthus,From all these three, Good Lord deliverus.John Taylor 1612

In or out?

The new face masks were on trial and it was hoped they would savethe day“You must try not to worry. The doctor is doing everything humanly possible.” ref and appologies tonoo yorkah

This is a patient – free zoneLazner et al, Peds Pulmonol, 2012

• Things you didn’t know about negativepressure ventilation

Giant Left Atrium Needed NegativePressure Ventilation• Erez Kachel, MDa,*, Hartzell V. Schaff, MDb, FuadMoussa, MDc, Sergey Preisman, MDd, Ehud Ranani,MDa, Leonid Sternik, MDa a Department of CardiacSurgery, Sheba Medical Center, Ramat Gan, Israelb Division of Thoracic and Cardiovascular Surgery, MayoClinic College of Medicine, Rochester, Minnesotac Division of Cardiovascular Surgery Sunnybrook HealthSciences Center, Toronto, Ontario, Canadad Department of Anesthesia, Sheba Medical Center,Ramat Gan, Israel• Accepted for publication March 18, 2009.• * Address correspondence to Dr Kachel, Department ofCardiac Surgery, Sheba Medical Center, Ramat Gan,52621, Israel• Ann Thorac Surg 2010;89:269-271.doi:10.1016/j.athoracsur.2009.03.102

Journal of Critical Care, Vol 19, No 1 (March), 2004:

Mechanism - Inspirationg1• Sub-atmospheric pressure to thorax• Thoracic expansion• Decrease alveolar pressure• Pressure gradient / air/gas movement in

Slide 15g1 Gelbu Lama, 2007/01/14

Mechanism - Expiration• Return to atmospheric pressure• Return to smaller negative pressure• Pressure gradient• Air/gas out from alveoli

Bronchiolitis• Retrospective review 2 PICU databases and casenotes• 2 similarly sized and staffed PICUs• One offered NPV• Both offered CPAP/Caffeine• All patients admitted with bronchiolitis relatedapnoeaAl-balkia et al, ADC 2005

Outcome• Invasive ventilation• LOS PICU

Results• 22 patients to control centre• No significant difference;• Age, weight, prematurity, PMHx apnoea, daysill prior to admission, RSV status, preadmissionoxygen requirement, retrieval fromoutside• 31 patients to NPV centre

Further respiratory support• NPV centre• 8 PPV• 23 NPV• Control centre• 18 PPV• 1 CPAP• Intubation rate p

Duration of stay• NPV centre• 2 days• Control centre• 7 days

A natural experiment• Non NPV centre stopped offering NPV in the 2years after this data period• Intubation rate increased to 14/17- 82%• Median PIC stay of 7.5 days

Conclusion• NPV was associated with less intubation andshorter stay

Negative pressure ventilation• Utilising external cuirass• Allows development of a negative mean intrathoracic pressure• Peak negative inspiratory pressure• Small positive expiratory pressure• Chest enclosure

Physiology textbook used by Zamir Hayek (1948-2005) in Saskatoon , USA

Right and left ventricular stroke volume

Those real life stories• 4 month old ex-premature male• History of BPD• Post – ARDS• Mild bulbar palsy• Recent extubation• Already on CPAP• Increased work of breathing

Treatment• Continuous negative pressure at negative24 to 30mcs H 2 O• Secretion clearance for 45 minutes, every2-3 hours

Modes• Continuous negative pressure• Trigger inspiration, set I time• Trigger inspiration/expiration• High frequency• Secretion clearance• Mandatory ventilation• ECG triggered

Indications• Apnoea / hypoventilation• Neuro-muscular disease• Immuno-compromised patients• Air trapping, Small airways disease• Post operative cardiac disease• Disease associated with pulmonary hypertension• Cystic Fibrosis• De-recruited lung• Acute respiratory failure• Acute admissions and home care

Mixed modes“Bundles of care”• Cardiac patients, Shekerdamian, various• IPPV plus cuirass, CNEP, improved oxygenation, Sholz 1997• IMV, neonates, CNEP started as rescue therapy, 37/50improved oxygenation, (Cvetnik)• IMV with CNEP/PEEP, Randomised crossover, 30 infants, RDS,MAS, PHT, fullfilled ECMO criteria, Highly significantimprovement in pA 02, only 3 to ECMO, Sepsis, 5 Deaths (83%survival). Failure due to septic shock, asphyxia (Cvetnik)• ALI patients ECWO plus PS, increased cardiac index, improvedP/F ratio, improved CO2, Tadeka 1997 Klonin 2000• PHT infants, Cventnic , 1997

Advantages• Avoids mask / ET tube• Supports blood pressure• Decreased ventilator associated pneumonia• Easy to take off• Easy to wean• Patient comfort !• Non invasive monitoring• Works with other modalities• Outcome data is good (Telford studies)

Disadvantages• Cuirass may mark skin• May not work for patients with severe skeletaldeformities• Does not support upper airway• Pneumothorax in older studies

Monitoring• HR, RR,• Arcane rituals; Patientcomfort and WoB,• Pulse oximetry and oxygenrequirement• Transcutaneous carbondioxide• Possibly invasive blood gas,2 -4 hours

Weaning• Nurse led• Either wean pressure• Or wean time on• Usually off every six hours for skin check• Remember normal disease convalescence,take time

Indications, longer term• Apnoea / hypoventilation ( approx 1200 days)• Neuro-muscular disease• Immuno-compromised patients• Air trapping ( 76 days)• Small airways disease• Post operative cardiac disease (75 days CDH)• Cystic Fibrosis• De-recruited lung• Nearing end of life situations

Why not universal use• I never tried it so I don’t likeit• Other things seem moreexciting or easier• Transient population ofcarers/staff• People feel comfortablewith trouble shooting PPV• All respiratory techniquesrequire patience, skill andsupport from carersNurse-driven programme more likely to workSubhash Daga, J.J. hospital Mumbai (1978 – 1992)

Overall• Helpful technique• Literature supports its use in a variety ofsituations• Some barriers to implementation

Suddenly a heated exchange blew upbetween the King and the Moat contractorAny questions?

• PEDIATRIC AND NEONATAL, NIV MEETING• aulapediatria@hsjdbcn.org

Its good to talkProtocols, guidelines, friendship, maybemore…..