3/10/2017 Mechanical Ventilation of Disclosures Infants with Severe BPD: • Steven Abman, MD, has no direct conflicts of An Interdisciplinary Approach interest but receives some funding for laboratory research from: Steven H. Abman, MD - Shire Pharmaceuticals Professor, Department of Pediatrics Director, Pediatric Heart Lung Center - United Therapeutics and The Children ’ ’ ’ s Hospital, ’ University of Colorado School of Medicine • Dr. Abman has also received funding for sponsoring educational activities from Aurora, CO Malinckrodt (for the Young Investigator’s Forum ) and has served as a scientific advisor for GlaxoSmithKline. Learning Objectives • To review physiologic differences in lung disease during the progression from acute to chronic respiratory failure in severe BPD; • To understand the goals and strategies of long-term mechanical ventilator support in severe BPD; • To appreciate the need for interdisciplinary teams to enhance late outcomes of infants with severe BPD. 1
3/10/2017 Case Study: Lessons Learned • Surprising resilience of the developing lung; • Progressive stages of clinical respiratory course requiring different goals and strategies: acute , transitional , and long-term care; • Need for better insights into “life span” issues (e.g., more relevant clinical endpoints beyond “36 weeks PMA on oxygen therapy”); • Need for more interdisciplinary collaborations (neonatology, pulmonary medicine, others) to better understand and enhance long-term outcomes Re-Admissions of Preterm Infants to Pediatric ICUs During Early Childhood Relationship of Gestational Age (* n = 296 patients) to BPD Severity 350 Subjects readmitted to a (58%) hospital 300 Subjects readmitted to an ICU 250 Subjects readmitted with MV Number of Subjects 200 150 (20%) 100 (12%) 50 (Stoll B et al. JAMA, 2015) (Stoll B et al. Pediatrics, 2010) 0 To 1 y of age 1 to 2 y of age 2 to 3 y of age 3 to 4.5 y of age Total 2
3/10/2017 Severe Bronchopulmonary Dysplasia Impact of Early Impairment of Age 6 months Age 14 months Age 23 months Lung Growth on COPD (McGeachie et al. NEJM 2016) (Rob Castile) Point Prevalence Study from the BPD Collaborative : Severe BPD* BPD Severity: NIH Workshop * * Jobe A, Bancalari E. AJRCCM , 2001; Ehrenkranz RA et al. Pediatrics , 2005; (Cuevas Guaman M, Gien J, Baker C et al. Am J Perinatology, 2015) Abman SH et al. J Pediatrics, 2017, (* denominator: infants with GA < 32 weeks; presence of any BPD, range: 20 – 77%) 3
3/10/2017 Changing Care Issues During Point Prevalence Study: the Progression of BPD Respiratory Support in sBPD Early Evolving Established Prevention Modulation Treatment • Maternal Factors • Ventilation • Ventilation - Prenatal care • Oxygen Use • Oxygen use - Preterm birth Rx • Fluids, PDA tx • Bronchodilators - Environmental • Nutrition • Diuretics • Prenatal Steroids • Steroids • Steroids • Delivery room • Vit A practice • Caffeine • Surfactant delivery • nCPAP ? HFV? (Cuevas Guaman M, Gien J, Baker C et al. Am J Perinataology, 2015) • Birth 7 - 10 days > 2 - 3 weeks the “ Baby Lung ” Adult ARDS: Ventilating Severe BPD Small tidal volumes Increased PEEP Prone positioning “ “ “ “ A TWO COMPARTMENT MODEL ” ” ” ” 4
3/10/2017 Severe Bronchopulmonary Dysplasia Management of Ventilator- (GA 25 weeks, BW 698 g, oligohydramnious; CT at 6 months) Dependent Infants with Severe BPD • Heterogeneity of lung disease: - marked variability in regional time constants decreased surface area ( “ hypoplasia ” ), edema, - mixed airways and parenchymal disease, with atelectasis; • Tracheomalacia, diffuse bronchomalacia • Airway Secretions • Aspiration • Pulmonary Hypertension (Robert Castile, Columbus Children ’ s Hospital) Heterogeneity of Lung Disease in Established Heterogeneity of Lung Disease in Established BPD: Role of Variable Time Constants BPD: Role of Variable Time Constants Low Tidal Volume Higher Tidal Volume (T = Resistance x Compliance) Short Insp Times Longer Insp Time Normal C Normal C Adverse Effects: Benefits: Normal R Normal R • Worse distribution of gas • Improved Gas Distribution • Lower Vd/Vt • Increased dead space ventilation • Higher PCO 2 • Lower PCO 2 • Higher FiO 2 Low C Low C • Lower FiO 2 • Progressive atelectasis High R High R • Less atelectasis • Regional overdistension High C High C Low R Low R Normal C Normal C High R High R 5
3/10/2017 Acute PEEP Study in Severe BPD Dynamic Hyperinflation High PEEP, 25 cm H 2 O No PEEP, 0 cm H 2 O in Severe BPD (Rob Castile, Columbus Children ’ s Hospital) Interim Summary: Basic Questions for Invasive Chronic Ventilator Strategies in BPD Respiratory Care for Infants with BPD Early (Preventive): Late (Established BPD) Due to Regional Heterogeneity: • Low tidal volumes (4 - 6 ml/kg) • • When to transition strategies from lung • What is “ stable ” disease? • Short inspiratory times - Larger tidal volumes (10 - 12 ml/kg) protective to chronic support? • Increase PEEP as needed for - Longer inspiratory times (> 0.6 sec) Airway Obstruction lung recruitment without over- • distension (as reflected by high - Slower rates (better emptying) peak airway pressures) - Complex role for PEEP (due to • Achieve lower FiO 2 • When stable, what to wean? dynamic airway collapse) Goals for Gas Exchange: • • When to commit to chronic ventilation and – Adjust FiO2 to target lower O 2 saturations (88 - 92%) place a tracheostomy for supportive care? – Permissive hypercapnea 6
3/10/2017 Problems with the Care of Ventilator-Dependent BPD Infants - Severe, acute illness takes precedence over chronic patients in ICU settings; - Differences in pace of illness, response to therapy - High staff turnover leads to inconsistencies in care - Consistent communication between attendings, nurses, RTs, consultants, other providers and family is complex - Need for interdisciplinary approaches What is “ stable ” in ventilated BPD Successful Treatment of BPD is infants? Synonymous With Good Supportive Care – Tolerance of therapies, cares and handling with minimal episodes of desaturation and Minimal Impact Respiratory Support distress – Less reliance on blood gas tensions (pCO2) – Demonstrating consistent growth including � Prevention of Infection � Prevention of Right Heart Failure weight and length � Excellent Nutrition for Growth and Repair – When stable, initially wean FiO2 and not � Developmental Assistance tidal volume or pressures (Stephen Welty, Baylor University) 7
3/10/2017 (Pediatric s, 2015) ( Am J Perinatol , 2016) Chronic Mechanical Ventilation: Conclusions Road Map to Home Discharge • Factors that contribute to the development of severe BPD and modulate long-term outcomes are incompletely understood; • Ventilator goals and strategies for chronic care of ventilator-dependent children are strikingly different than current approach to acute respiratory failure; • Improvements in long-term outcomes require greater and earlier integration of interdisciplinary teams that link inpatient with ambulatory care. 8
3/10/2017 The “BPD Collaborative” • Leif Nelin, Nationwide Children’s Hospital • Stephen Welty, Texas Children’s Hospital • Haresh Karpalani, CHOP • Martin Keszler/Barbara Stonestreet, Brown • Paul Moore, Vanderbilt • Mike Collaco, Hopkins • Jason Gien/Chris Baker, Colorado • Bill Truog, Children’s Mercy, Kansas City 9
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