Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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: