1. Advances in Mechanical Ventilation & Respiratory Therapy

2. Your Host for this Lecture
Chad J. Pezzano MA, RT, RRT-NPS
Pediatric/Neonatal Clinical Instructor
Cardio-Respiratory Services
Albany Medical Center

3. I will be discussing new innovations in surfactant therapy
Disclosure
I have interest in
LMA North America - provided supplies for study
Ony (Infasurf) - provided educational grant for study
“Randomized Controlled Trial of Surfactant Delivery via Laryngeal Mask Airway (LMA) Versus Endotracheal Tube”
I will be discussing new innovations in surfactant therapy

4. Goals & Objectives
Provide both useful and useless information during this lecture.
Discuss new innovations in respiratory technology.
Learn about the vast changes occurring with mechanical ventilation.
Discuss why invasive mechanical mechanical ventilation may soon be a thing of the past.
Enjoy this lecture and have fun!

6. Liquid Ventilation (LV) History
Perfluorocarbons first synthesized during the development of the atomic bomb (Manhattan Project)
Kylstra 1962 – early mice experiments with oxygenated saline
Clark 1966 – PFC’s experiment with mice
1989 Preterm neonatal studies conducted
Leach 1996 multi-center preterm infant study

7. Liquid Ventilation History Cont.
Bartlett et al 1997 conducted randomized controlled adult trial of PLV.
Kacmarek et al 2006 larger adult study of patients who had ARDS.

8. What are Perfluorocarbons?
Chemically and biologically inert
Clear and odorless
Undergo no metabolism in kidneys or liver
Oxygen carrying capacity can be three times more than blood.
Toxicity has been shown in some studies.

9. What are the advantages of LV?
Improves oxygenation
Improved lung compliance
Anti-inflammatory effects
Alveolar and endobronchial lavage

10. Types of LV Total liquid ventilation (TLV)
Lungs filled with PFC to a volume which is equivalent to the patients functional residual capacity (approximately 30 ml/kg).
A liquid ventilator is used to generate tidal breathing.
A respiratory rate of 4 – 5 bpm is used for optimal CO2 clearance.
Tidal volumes range from 15 – 20 ml/kg.
Partial liquid ventilation (PLV)
Tracheal instillation of PFC’s in combination with gas ventilation.
Continuous mechanical ventilation and rotating dose will decrease oxygenation index after 15 ml/kg of perflubron.

14. Liquid Ventilators

15. Disadvantages to LV Pneumothorax Circulatory impairment
Lactic acidosis
Blockage of ETT
Carbon dioxide elimination
Toxicity
X-ray interference
Limited data to use as a standard of care
Cost

16. Future of LV? Brain cooling Drug delivery Gene transfer
Lung protection during CV bypass
Antineoplastic drug delivery
Deep ocean diving
Naval rescue
Space travel

17. Surfactant Replacement Therapy

18. Surfactants Current indications (on-label uses):
Treatment and Prevention for RDS in Neonates (Infasurf and Survanta).
Treatment for RDS in Neonates (Curosurf and Surfaxin KL4).

19. Surfactant Traditionally used in neonates for RDS
Delivery method involves the patient being intubated and surfactant delivered intratracheally.
Investigations have been conducted over the past 15 years on Pediatric and Adult Patients.
Theoretically there is an implication for adult patients.
ARDS
Direct
Indirect

20. Pediatric/Adult Surfactant Administration
Calfactant for Direct Acute Respiratory Distress Syndrome (CARDS Study); Wilson et al 2008 – 2012.
Multicenter RCT involving hospitals in North America, South Korea, Australia, Canada, Israel, and New Zealand
Compared Calfactant vs Placebo
Primary outcome- mortality rate
Secondary outcome – ventilator free days
Inclusion Criteria: Respiratory failure due to diffuse infectious pneumonia, aspiration, near drowning, smoke inhalation or industrial gas
Study terminated recently.

21. Current Surfactant Studies
Current studies for alternative delivery methods:
Delivery via LMA
Albany Medical Center
University of Minnesota
Potential future studies
Nebulized delivery

22. Future of Surfactant Research
If you would understand anything, observe its beginning and its development - Aristotle

24. Non-Invasive Ventilation Nasal CPAP/BiPAP

25. Issues with Non-Invasive Ventilation
Tissue Necrosis
Skin integrity issues
Mask/Prong positioning
Adherence to therapy
Lot’s of work in acute care settings

26. New Methods of CPAP/BiPAP Delivery

27. Helmet CPAP

28. Helmet CPAP /BiPAP

29. Other forms of Non-Invasive Ventilation

30. Reference: http://historical.hsl.virginia.edu/ironlung/
Drinker Respirator (1929)
Reference:

31. Emerson Iron Lung & Dräger Iron Lung (1931)
Reference: &

32. Chest Cuirass

33. Hayek RTX

35. Neurally Adjusted Ventilatory Assist (NAVA)
Mode of ventilation exclusively on the Servo i Ventilator.
NAVA gives the user access to information concerning both the patient’s ability to breathe and the status of the central nervous system.
NAVA delivers assist in proportion to and in synchrony with the patient’s respiratory efforts, as reflected by the Edi signal.

36. Ideal Technology vs. Current Technology
Central nervous system
Phrenic nerve
Ventilator
Diaphragm excitation
Diaphragm contraction
Chest wall, lung and esophageal response
Airway flow, pressure and volume changes
Current Technology
Bedside feedback for the RT

37. Poor Timing: Asynchrony during SIMV (Infants)37

38. Ineffective triggering predicts increased duration of mechanical ventilation*
Marjolein de Wit, MD, MS; Kristin B. Miller, MD; David A. Green, MD; Henry E. Ostman, MD;
Chris Gennings, PhD; Scott K. Epstein, MD
Conclusions: Ineffective triggering is a common problem early
in the course of MV and is associated with increased morbidity,
including longer MV duration, shorter VFS, longer length of stay,
and lower likelihood of home discharge.
(Crit Care Med 2009; 37: 000–000)

39. Missed Triggers Volume Control

40. Ineffective Triggers PCV

41. Even in PSV

42. NAVA Ideal Technology vs. Current Technology Ideal Technology
Central nervous system
Phrenic nerve
NAVA
Ventilator
Diaphragm excitation
Bedside feedback for the RT
Diaphragm contraction
Chest wall, lung and esophageal response
Airway flow, pressure and volume changes
Current Technology
Bedside feedback for the RT

44. Catheter Positioning

45. Diaphragm Signal
Edi Signals from NAVA Catheter

46. SIMV/PSV NAVA Total synchrony 1 Pneumatic Breaths
3 Diaphragmatic Breaths

48. Parts Needed for NAVA 1. NAVA software 2. Edi Module 3. Edi Cable
4. Edi Catheter
5. Servo I ventilator

49. What we know so far about NAVA:
Improves patient ventilator interaction
Provides efficient respiratory muscle unloading even at high levels of assist
May provide protective ventilation based on reflexes
Adapts to altered respiratory drive and reflexes
May prevent disuse atrophy
Allows on-line monitoring of respiratory drive 49

50. Reference: Critical Care Medicine 2010 Vol
Reference: Critical Care Medicine 2010 Vol. 38, No 10 (Supplement) S555 – S558

55. Conclusions Sci-Fi is not always too far off.
Older respiratory modalities are coming back as new technology.
It takes a long time for new technology to reach most people.

56. Thank You