Download RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
KARNATAKA, BANGALORE.
ANNEXURE-2
PROFORMA FOR REGISTRATION OF TOPIC FOR DISSERTATION
1.
Name of the
candidate
DR VENKATESH MURTHY D V
Address
DOOR NO 971,2 nd ‘F’ CROSS,3 rd MAIN ,3 rd
STAGE,BASAVESHWARANAGAR,
BANGALORE-560079
2.
Name of the
Institution
INDIRA GANDHI INSTITUTE OF CHILD
HEALTH,BANGALORE
3.
Course of study
M.D - PAEDIATRICS
4.
Date of admission to
the course
01-06-2013
5.
Title of the topic
HIGH FREQUENCY VENTILATION –RESCUE
TREATMENT FOR NEONATES WITH SEVERE
RESPIRATORY FAILURE
Brief resume of the intended work:
6.
6.1 Need for the study:
Respiratory failure in neonates, defined as retention of carbon dioxide with a resultant
decrease in the arterial blood pH and accompanied by hypoxemia, has multiple
etiologies. Respiratory failure is a result of impaired pulmonary gas exchange
mechanisms, such as can be seen with surfactant deficiency, atelectasis, or obstructive
airway disease. Less common causes of respiratory failure may be a result of airway,
musculature, or central nervous system abnormalities.
Conventional mechanical ventilation (CMV) has been used for many years but may
lead to lung injury, High frequency oscillatory ventilation (HFOV) is a new mode of
ventilation using lung protective strategy and the safer use of mean airway pressure
that is higher than that generally used during CMV.
INTRODUCTION
The key features of HFOV that are thought to be responsible for decreasing the
incidence and severity of VILI when compared with CV are explained below.
1. Smaller tidal volumes – This helps prevent volutrauma caused by alveolar overdistension.
2. Higher mean airway pressure (MAWP) – The continuously high distending pressure
provides improved oxygenation via improved alveolar recruitment.
3. Smaller differences between inspiratory and expiratory pressures – This helps
prevent atelectotrauma associated with cyclical alveolar collapse and distension that
can be a feature of CV.
4. Lower peak pressures – This helps reduce barotraumas.
Gas transport on HFOV is thought to occur via 5 mechanisms, as suggested by
Weavind and Wenker in 2000. The individual contribution of each mechanism to
overall gas exchange remains debated:
1. Bulk flow. This is the predominant mechanism of gas transport seen in CV and it
plays a part in HFOV, providing gas delivery to proximal alveoli with low regional
dead space volumes.
2. Pendelluft. This refers to inter-regional gas mixing between alveolar units whereby
there is transient movement of gas out of some alveoli and into others when flow stops
at the end of inspiration and in the opposite direction at the end of expiration. This
occurs where regions of the lung differ in compliance or airway resistance so that their
time constants of filling in response to changes in trans-pulmonary pressure are not the
same.
3. Taylor dispersion. This leads to mixing of fresh and residual gases along the front of
a flow of gas through a tube, due to the interaction of the axial velocity profile and
radial concentration gradient.
4. Coaxial flow. This occurs when gas in the centre flows inward and the gas on the
periphery flows outward. It is attributed to the asymmetry between inspiratory and
expiratory velocity profiles.
5. Augmented molecular diffusion. This occurs at the alveolar level as a result of the
added kinetic energy supplied by the oscillations.
Oxygenation on HFOV is similar to conventional ventilation (CV). It is dependent on
two set variables; FiO2 and MAWP. CO2 clearance on HFOV differs . During
conventional ventilation CO2 removal is dependent on minute volume, the product of
tidal volume (Vt) and respiratory rate. An increase in minute volume leads to an
increase in CO2 clearance. CO2 clearance on HFOV is also dependent on the
frequency of oscillations and tidal volume (Vt). However, decrease in frequency on
HFOV leads to larger tidal volumes and subsequent increased CO2 clearance. This is
the opposite of CV. Cycle volume is analogous to tidal volume and is a function of
amplitude of oscillation.
6.2 Review of literature:
High frequency oscillatory ventilation (HFOV) is an alternative form of mechanical
ventilation that can be delivered on critical care units. HFOV utilises much higher
frequencies than CV (120 – 600 breaths per minute versus up to 40 breaths per minute
for CV).1 This allows the use of tidal volumes that with conventional ventilation would
lead to rising CO2 levels.
1.Clarke et al studied use of HFOV as a rescue therapy for severe respiratory failure
or persistent pulmonary hypertension.2,3 Infants of at least 34 gestational weeks were
randomized for either to HFOV or CMV. Those who failed the initial treatment were
switched to the alternative ventilator modality. The proportion of infants who failed
their initial treatment assignment was comparable between the two groups. However of
those who failed CMV, 63% responded to HFOV, which was significantly higher than
the 23% who responded to CMV after failing HFOV. No significant differences were
observed with regard to mortality or morbidity such as CLD, air leak and intracranial
hemorrhage.3
2.Johan S Clarissa et al studied the efficacy of HFOV as a rescue mode of therapy in
newborn infants with severe respiratory failure poorly responsive or unresponsive to
conventional ventilation and supportive management.4 Conventional support failed in
34 consecutive infants; they were transferred to HFOV at a mean postnatal age of 30
hours. Their respiratory diagnoses included respiratory distress syndrome (RDS) (N =
19), neonatal 'adult respiratory distress syndrome' (ARDS) (N = 3) and meconium
aspiration syndrome (MAS) (N = 12). After starting HFOV the AaO2 gradient, had
significantly improved (P < 0.05) by 6 hours in the RDS group and by 12 hours in the
infants with MAS. This improvement was sustained throughout the first 48 hours of
HFOV. Twenty six (76%) of the infants ultimately survived Air leaks occurred on
HFOV in 6 infants. 3 each in the MAS and RDS groups. Bronchopulmonary dysplasia
was diagnosed in 6 (40%) of the 15 RDS infants and in 2 (18%) of the 11 infants with
MAS. Eight infants died, 3 following nosocomial sepsis (Pseudomonas sp.), 3 due to
extensive air leaks, 1 due to irreversible shock (unproven).
3.5 Preetham K P et al studied efficacy of rescue HFOV in improving the
oxygenation and ventilation in neonates with acute respiratory failure after failing
CMV.6,7 675 babies were ventilated and of them received HFOV. HFOV significantly
improved oxygenation index, alveolararterial oxygen gradient, pH, PCO2, PO2 and
caused better lung recruitment within 2 hours. Fifty seven babies (58.77%) survived
and the mortality was more in <28 weeks, babies with pulmonary hemorrhage, sepsis
and CDH.
4.Kyung lee,Yun sil chang,Wan soon park et al did retrospective analysis of medical
records who were admitted due to severe respiratory failure,they had arterioalveolar
O2 tension below 0.25 despite of CMV.22 neonates were evaluated HFOV treatment
was initiated at 4 days after birth in survivor group and 5 days after birth in non
survivor group.pulmonary haemorrhage and air leak syndrome was the common
indication of HFOV. They noticed O2 index and arterioalveolar o2 gradient after 6
hours of HFOV significantly improved.
6.3 OBJECTIVES OF THE STUDY
1.To study the role of high frequency oscillatory ventilation in tertiary nicu as rescue
mode in neonates with severe respiratory failure.
7.
MATERIALS AND METHODS:
7.1 Source of data:
This comprises of neonates admitted in NICU with severe respiratory failure
requiring ventilatory support failing conventional mode of ventilation at Indira Gandhi
institute of Child Health
7.2 Method of collection of data:
A sample size of neonates presenting with respiratory failure requiring HFOV will
be included in the study as per inclusion and exclusion criteria.
Inclusion Criteria:
1. All neonates with gestational age more than 34 weeks and weight more than
1000gms presenting with severe respiratory failure requiring hfov after failed
conventional mode for 6hrs
a) PaO2 partial oxygen tension below 50 mm hg
b)PaCo2 partial carbon dioxide tension above 60 mmhg PaCo2 despite fractional
inspired O2 of 1.0
c) MAP of more than 14cm H20 in neonates in weight more than 1000gms.
2) pulmonary interstitial emphysema or pulmonary pneumothorax,
3) persistent pulmonary hypertension of the neonate.8
Exclusion Criteria:
1. infants with lethal congenital malformations.
METHODOLOGY:
A Prospective study of neonates admitted in NICU with respiratory failire
failing conventional mode of Ventillatory support will be included in the study.
Written informed consent will be taken from the parents for participation in the study.
Detailed history including demographic data, primary complaints for admission , birth
history, immediate antenatal history ,family history, thorough physical and systemic
examination will be done
Each baby with impending respiratory failure will be ventilated conventionally for
minimum of six hours and if the baby does not improve and deteriorates the following
measures will be done. Recruitment of the lung will be prioritized by increasing the
PEEP to a higher level of 7, followed by arterial blood gas (ABG) and a chest X-ray. If
the X-ray shows under-inflation, then PEEP will be increased to higher levels.All the
other causes like tube displacement,obstruction,equipment failure will be ruled out
before shifting over to hfov.
On HFOV, babies will be initially started on a MAP of 2 cm higher than the MAP on
conventional ventilator and MAP increased until a saturation of >95% is achieved
(after which priority was given to wean off FiO2).
The amplitude will be adjusted based on the chest wriggle; frequency started at 12Hz
for the preterm babies and at 10 Hz for term babies and adjusted later based on ABG
analysis.
OUTCOME MEASURES AND STATISTICAL ANALYSIS
The ventilatory settings, ABG analysis , Oxygenation index (OI), Alveolar-arterial
Oxygen Gradient (AaDO2), duration of ventilation, and complications of ventilation
shall be recorded during CMV and subsequently when shifted over to HFOV. Primary
outcome in terms of short term oxygenation, lung recruitment, ventilation, and
secondary outcome of survival will be evaluated.
7.3 DOES THE STUDY REQUIRES ANY INVESTIGATIONS OR
INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS
OR ANIMALS?
YES
7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR
INSTITUTION IN CASE?
YES
8.
List of references:
1. Pillow JJ. High Frequency Oscillatory ventilation: mechanisms of gas exchange and
lung mechanics. Crit care Med 2005;S135-S141
2. Clark RH,Yoder BA, Sell MS. Prospective randomised comparison of high
frequency oscillation and conventional ventilation in candidates for extracorporeal
membrane oxygenation. J Pediatr 1994;124:447-454
3. Clark RH, Gerstmann DR, Null Jr DM, et al. Prospective randomised comparison of
high frequency oscillatory and conventional ventilation in respiratory distress
syndrome. Paediatr 1992;89:5-12
4. Smith J, Clarissa H P, Gert F K, David M, Jaenette V Z, Marie L P. High frequency
oscillatory ventilation – rescue treatment for infants with severe respiratory failure.
SAMJ 1998;88(4):484-9
5. Lee E N, Chang Y S, Park W S. High frequency oscillatory ventilation as a rescue
therapy of severe neonatal respiratory failure. J Korean Pediatr Soc 1998;41:456-65
6.Preetham KP,Dinesh KC, Kapil S, Farhan A,et al. Rescue high frequency Oscillation
in neonates with Acute respiratory failure. Ind Ped 2011;48:467-9
7. Courtney SE, Durand DJ, Asselin JM,et al. High Frequency oscillatory ventilation
versus conventional mechanical ventilation for very low birth weight infants. N Engl J
Med 2002;347:643-52
8. Johnson MH, Peacock JL, Greenough A, et al. High frequency oscillatory
ventilation for the prevention of chronic lung disease of prematurity. N Engl J Med
2002;347:633-42
9. Gerstmann DR, Minton SD, Stoddard RA, et al. The provo multicenter early high
frequency oscillatory ventilation trial: improved pulmonary and clinical outcome in
respiratory distress syndrome. Paediatr 1996;98:1044-57
10. Jeng M J, Soong W J, Lee Y S, Tsao P C. High Frequency Oscillartory Ventillation
in neonates with Acute Pulmonary dysfunction. J Pediatr Resp Dis 2011;7:98-105
9.
Signature of the candidate:
Name of the Candidate:
10.
Dr. VENKATESH MURTHY D V
RESEARCH FACULTY
INFORMATION:
10.1 GUIDE
DR NAVEEN BENAKAPPA
Professor and Unit Head,
Department of Paediatrics
Indira Gandhi Institute Of Child Health
SIGNATURE
10.3 Head of the Department and
Director of the institute
PROFESSOR DR. PREMALATHA
MD (paed),
DIRECTOR &
HEAD OF THE DEPARTMENT
INDIRA GANDHI INSTITUTE OF CHILD
HEALTH, BANGALORE.
10.4 Signature
11.
Remarks of the GUIDE
.
12.1 Remarks of the Director and
Head of the Department
It is a new mode of ventilation , used for rescue
therapy after conventional ventilation fails. No
data available in India. So this study can be given
for thesis topic.
12.2 Signature
PROFORMA
Name:
Patient No:
Male/ Female:
Date of admission:
Address:
Phone No: Mobile:................................./ Landline...........................................
Referred hospital:
Age at Admission:
Date and Time of Birth:
Gestational age:
Temperature at Admission
GRBS at Admission:
MATERNAL HISTORY:
Mode of Transport:
Consanguinity.........................................................Gravida..................Para...............................
Pedigree:
Mother’s Blood group:
Anemia:
Hypertension:
Diabetes:
Drugs:
Ultrasound Findings:
Antenatal steroid Administered:
Cause of Preterm
NATAL HISTORY
Mode of Delivery:
Normal Vaginal/ Instrumental.................................../ Vaccum
LSCS...............................................Indication.......................................................................
Birth history:
APGAR
At 1min..............................3 min...........................................5 min.......................................
Modified Ballard Score:
ANTHROPOMETRY:
Weight:
AGA
SGA
LGA
Head Circumference:
Respiratory Rate:
Heart Rate:
Spo2:
Blood pressure:
RESPIRATORY SYSTEM
CARDIOVASCULAR SYSTEM:
PER ABDOMEN:
Height:
CENTRAL NERVOUS SYSTEM:
ADMISSION DIAGNOSIS:
PROBLEMS IDENTIFIED:
INFECTION:
HYPERBILIRUBINEMIA
FEED INTOLERANCE:
CVS:
RS:
CNS:
METABOLIC:
TEMPERATURE INSTABILITY:
OTHERS:
FINAL DIAGNOSIS:
INTERVENTION DONE:
Inotropes:
Oxygen:
CPAP:
NO OF DAYS
Surfactant:
Antibiotics:
HMF/SIMYL MCT:
VENTILATION:
Initial Ventilatory settings:
Conventional mode
Fio2
PIP
PEEP
MAP
VT
Ti
Rate
Post HFOV:
Fio2
MAP
Amplitude
Duration of Days on HFOV:
Any Complications if noticed:
INVESTIGATIONS:
Complete Hemogram
Blood culture:
FINAL OUTCOME:
Baby’s Blood group:............
Others: