Non-invasive ventilation of the preterm infant☆
Section snippets
Introduction/rationale
The use of mechanical ventilation in preterm infants although life saving in many instances, is frequently associated with serious acute complications and long term morbidity. For this reason, there has been a shift towards gentler and less invasive forms of respiratory support in an effort to avert adverse pulmonary outcome. The application of nasal continuous positive airway pressure (N-CPAP) is one of the strategies that has been used to reduce the need for invasive ventilation. This mode of
Modalities and strategies of non-invasive ventilation
Early individual center experience with NIV demonstrated beneficial effects [1] while one report suggested a higher risk of gastrointestinal perforation [5]. Initially, non-invasive ventilation was accomplished using conventional ventilators in IMV mode (N-IMV). As triggering devices became available they were introduced into non-invasive neonatal ventilation and enabled delivery of non-invasive assist/control (N-A/C) also known as non-invasive synchronized IPPV (N-SIPPV), pressure support
Physiologic effects of non-invasive ventilation
The following are the reported physiologic effects of NIV in preterm infants.
Role of synchronization in non-invasive ventilation
During conventional mechanical ventilation in the IMV mode mechanical breaths are delivered at fixed intervals and these positive pressure breaths have a fixed duration. Since preterm infants breathe at varying rates and their spontaneous inspiration varies over time, asynchrony between the ventilator and the infant is often observed. An IMV breath delivered at the end of spontaneous inspiration produces an inspiratory hold that can reduce spontaneous respiratory rate. When an IMV breath is
Animal data on lung injury
The use of NIV for a period of 6 h in a piglet model of surfactant deficiency revealed less evidence of interstitial inflammation on histological examination than that observed in animals that were ventilated invasively. However, biochemical markers of lung inflammation were similar in both groups [18].
More striking were the effects of high frequency nasal ventilation compared to conventional IMV for 3 days in a preterm lamb model. N-HFV improved oxygenation and better preserved alveolarization
Non-invasive ventilation for RDS
The use of NIV in the management of RDS is particularly appealing because of the possibility of reducing intubation rates and exposure to the potentially lung damaging effects of mechanical ventilation. N-CPAP has been used for this purpose early in the respiratory course, but a significant proportion of the smaller infants fail. As reported in the COIN trial 55% of infants born at 25–26 weeks gestation and 40% of 27–28 weeks failed N-CPAP during the first 5 days and required intubation [20].
Non-invasive ventilation for weaning
Maintenance of lung volume by continuous distending pressure with N-CPAP is important during weaning from invasive ventilation. However, N-CPAP may not be sufficient if the failure is due to reduced ventilation resulting from central apnea, a weak respiratory pump or disease-increased elastic or resistive loads.
Non-invasive ventilation has been proposed as a way to facilitate weaning and prevent extubation failure. Four randomized controlled trials using N-SIMV in the post-extubation period
Possible complications and drawbacks
Until now most of the results with non-invasive ventilation have been beneficial but there are potential problems with its clinical application that need to be addressed. One complication reported early was gastrointestinal distension and perforation due to the application of pressure in the nasopharynx [5]. As mentioned before, the risks are probably greater when the positive pressure is not synchronized with the spontaneous respiratory effort. Although there are no reports of increased
Conclusions and future directions
In conclusion, data from physiologic studies and clinical trials suggest important benefits of non-invasive nasal ventilation. Despite this evidence, nasal ventilation is not widely used which may be due to the fact that there are few devices available that are designed specifically to be used in this modality. More importantly, there is paucity of data on the use of early non-invasive ventilation in infants with RDS as a way of avoiding the use of invasive ventilation. This may become the most
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Cited by (29)
Comparison of three different noninvasive ventilation strategies as initial respiratory support in very low birth weight infants with respiratory distress syndrome: A retrospective study
2020, Archives de PediatrieCitation Excerpt :Our results were also consistent with those found in the retrospective study by Ricotti et al. [12], who showed no significant difference in NIV failure, postnatal steroid use, and other neonatal outcomes attributable to the type of NIV support (NIPPV and BiPAP) as a primary mode of treatment for RDS. The NIPPV and BiPAP strategies might be superior to NCPAP in the prevention of NIV failure because they were found to be more effective in stabilizing the airways, maintaining optimal functional residual capacity, reducing the work of breathing as well as stimulating spontaneous respiration, and preventing apnea and hypercapnia [26–28]. We suppose that these features could explain the impact of NIPPV and BiPAP on NIV failure and better respiratory outcomes observed in our study.
Disorders of Foals
2018, Equine Internal Medicine: Fourth EditionAn Integrative Review of Skin Breakdown in the Preterm Infant Associated with Nasal Continuous Positive Airway Pressure
2013, JOGNN - Journal of Obstetric, Gynecologic, and Neonatal NursingCitation Excerpt :In a meta‐analysis completed on the devices and pressure sources for the administration of NCPAP, implications for further research include determining which nasal interface device is the least traumatic to the neonatal nose, particularly the very LBW neonate (DePaoli et al.). A review of current noninvasive ventilation of the preterm infant describe NCPAP interfaces as “too rigid, oversized or too heavy for smaller infants” recommending manufacture development of physiologic appropriate devices (Bancalari & Claure, 2008). Additionally, a systematic review is needed of those noninvasive ventilatory strategies describing nasal prongs and nasal masks for use in the neonate.
Current methods of non-invasive ventilatory support for neonates
2011, Paediatric Respiratory ReviewsCitation Excerpt :However, an important aspect that limits not only nCPAP but also all forms of NIV in the preterm infant is the lack of an optimal interface. Currently available interfaces are often too rigid, too large, or too heavy for small infants and most require that the infant remains in a supine position, which increases fluctuations in oxygenation and may affect control of breathing.45 Nevertheless, short bi-nasal prongs (entering both nostrils) have been shown to be better than single-prong CPAP or use of a nasopharyngeal tube in treatment of RDS, with a reduction in the rate of re-intubation of preterm babies.46,47
Aerosol Delivery of Lung Surfactant and Nasal CPAP in the Treatment of Neonatal Respiratory Distress Syndrome
2022, Frontiers in Pediatrics
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Supported by the University of Miami Project NewBorn and Bank of America Charitable Foundation.