Non-invasive ventilation of the preterm infant

doi:10.1016/j.earlhumdev.2008.09.010

Early Human Development

Volume 84, Issue 12, December 2008, Pages 815-819

https://doi.org/10.1016/j.earlhumdev.2008.09.010 Get rights and content

Abstract

Non-invasive ventilation (NIV) is increasingly being used in preterm infants with the purpose of reducing the risk of adverse pulmonary outcome associated with invasive mechanical ventilation. This review analyzes the evidence from physiologic and clinical studies on the use of NIV in the preterm infant.

Physiologic data indicate advantages of NIV with regard to ventilation, gas exchange, breathing effort and thoraco-abdominal distortion. Data from clinical trials have consistently shown facilitation of weaning from mechanical ventilation and potential benefits in infants with RDS and apnoea. Long term improvements in respiratory outcome have also been reported but need to be confirmed in larger trials.

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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Comparing the effects of nasal synchronized intermittent positive pressure ventilation (nSIPPV) and nasal continuous positive airway pressure (N-CPAP) after extubation in very low birth weight infants
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M.A. Llewellyn et al.
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Neonatal nasal intermittent positive pressure ventilation: a survey of practice in England
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Effect of introduction of synchronized nasal intermittent positive-pressure ventilation in a neonatal intensive care unit on bronchopulmonary dysplasia and growth in preterm infants
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A prospective observational pilot study of synchronized nasal intermittent positive pressure ventilation (SNIPPV) as a primary mode of ventilation in infants > or = 28 weeks with respiratory distress syndrome (RDS)
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Nasal intermittent positive-pressure ventilation offers no advantages over nasal continuous positive airway pressure in apnea of prematurity
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A comparison of nasal intermittent versus continuous positive pressure delivery for the treatment of moderate respiratory syndrome in preterm infants
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Synchronized nasal intermittent positive pressure ventilation (SNIPPV) decreases work of breathing (WOB) in premature infants with respiratory distress syndrome (RDS) compared to nasal continuous positive airway pressure (N-CPAP)
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Effects of non-invasive pressure support ventilation (NI-PSV) on ventilation and respiratory effort in very low birth weight infants

Pediatr Pulmonol

(2007)

C. Migliori et al.

Nasal bilevel vs. continuous positive airway pressure in preterm infants

Pediatr Pulmonol

(2005)

M. van der Hoeven et al.

Nasal high frequency ventilation in neonates with moderate respiratory insufficiency

Arch Dis Child Fetal Neonatal Ed

(1998)

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 Pediatrie
Citation 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.
There is inadequate evidence regarding which noninvasive ventilation (NIV) is superior for initial respiratory support of preterm infants with respiratory distress syndrome.
To compare the failure of noninvasive ventilation (NIV) and neonatal outcomes between nasal continuous positive airway pressure (NCPAP), bi-level positive airway pressure (BiPAP), and nasal intermittent positive pressure ventilation (NIPPV) as the initial respiratory support with less invasive surfactant administration (LISA) in very low birth weight (VLBW) infants.
Medical records of 419 VLBW infants born at 26–30 weeks’ gestation who did not require intubation in the delivery room and were initially supported with either NCPAP (n = 221), BiPAP (n = 101), or NIPPV (n = 97) were retrospectively reviewed. The LISA approach was preferred in cases of surfactant requirement. The primary outcome was the failure of NIV within the first 72 h of life. Failure of NIV was defined as the persistence or recurrence of one or more of the following: hypoxemia, respiratory acidosis, more than one episode of apnea requiring bag and mask ventilation or more than six episodes of apnea requiring stimulation over a 6-h period. Data were analyzed using univariate and multivariate logistic regression analysis.
Failure of NIV within the first 72 h of life was significantly higher in the NCPAP group (29.4%) compared with the BiPAP (12.9%) or NIPPV (12.4%) group (P < 0.001). However, the BiPAP and NIPPV groups were not different in terms of NIV failure (P = 0.91). Multivariable logistic regression analysis showed that antenatal steroid administration (OR: 0.49, 95% CI: 0.27–0.90; P = 0.02) and gestational age ˂ 28 weeks (OR: 2.03, 95% CI: 1.18–3.49; P = 0.01) were independent factors that influence failure of NIV within the first 72 h of life.
Compared with NCPAP, the use of NIPPV/BiPAP strategies for initial respiratory support can reduce the need for invasive ventilation in infants born at 26–30 weeks’ gestation.
Disorders of Foals
2018, Equine Internal Medicine: Fourth Edition
An Integrative Review of Skin Breakdown in the Preterm Infant Associated with Nasal Continuous Positive Airway Pressure
2013, JOGNN - Journal of Obstetric, Gynecologic, and Neonatal Nursing
Citation 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.
To identify factors associated with skin injury during nasal continuous positive airway pressure (NCPAP) and describe differences in frequency, severity, and type of skin injuries when comparing nasal interfaces used during NCPAP in the preterm infant.
Scientific databases were searched using provided key terms and yielded 113 articles.
Forty‐six articles were included in this integrative review: six case studies, 22 with identified aim of examining skin and nasal injury during NCPAP; 18 included skin care considerations during NCPAP.
Studies were categorized into four themes: types of nasal injuries; associated risk factors that increase incidence of injury; differences between NCPAP devices and/or nasal interface and corresponding rate and severity of nasal injury; and recommended prevention strategies to reduce iatrogenic cutaneous injury.
Skin injury was a common theme during neonatal NCPAP with skin breakdown rates of 20% to 60%. Increased skin injury risk was associated with smaller infant size, gestational age, and duration of therapy. Nursing care strategies to improve skin integrity during NCPAP had little supportive evidence. Nursing practice is varied with reportedly little standardized care during NCPAP therapy. Recommendations for specific care strategies to reduce skin injury during NCPAP were supported by limited experimental studies.
Risk factors during NCPAP include nasal injury and trauma secondary to tight‐fitting nasal interfaces necessary to provide continuous distending pressure for respiratory stability. Identifying strategies to reduce skin breakdown will support noninvasive treatment success, reduce reintubation rates, reduce sepsis, reduce patient discomfort, and improve developmental outcomes during NCPAP use.
Current methods of non-invasive ventilatory support for neonates
2011, Paediatric Respiratory Reviews
Citation 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
Non-invasive ventilatory support can reduce the adverse effects associated with intubation and mechanical ventilation, such as bronchopulmonary dysplasia, sepsis, and trauma to the upper airways. In the last 4 decades, nasal continuous positive airway pressure (CPAP) has been used to wean preterm infants off mechanical ventilation and, more recently, as a primary mode of respiratory support for preterm infants with respiratory insufficiency. Moreover, new methods of respiratory support have been developed, and the devices used to provide non-invasive ventilation (NIV) have improved technically. Use of NIV is increasing, and a variety of equipment is available in different clinical settings. There is evidence that NIV improves gas exchange and reduces extubation failure after mechanical ventilation in infants. However, more research is needed to identify the most suitable devices for particular conditions; the NIV settings that should be used; and whether to employ synchronized or non-synchronized NIV. Furthermore, the optimal treatment strategy and the best time for initiation of NIV remain to be identified. This article provides an overview of the use of non-invasive ventilation (NIV) in newborn infants, and the clinical applications of NIV.
Aerosol Delivery of Lung Surfactant and Nasal CPAP in the Treatment of Neonatal Respiratory Distress Syndrome
2022, Frontiers in Pediatrics
Randomized trial of mask or prongs for nasal intermittent mandatory ventilation in term infants with transient tachypnea of the newborn
2020, Pediatrics International

View all citing articles on Scopus

^☆: Supported by the University of Miami Project NewBorn and Bank of America Charitable Foundation.

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Non-invasive ventilation of the preterm infant☆

Abstract

Section snippets

Introduction/rationale

Modalities and strategies of non-invasive ventilation

Physiologic effects of non-invasive ventilation

Role of synchronization in non-invasive ventilation

Animal data on lung injury

Non-invasive ventilation for RDS

Non-invasive ventilation for weaning

Possible complications and drawbacks

Conclusions and future directions

Early Hum Dev

A controlled trial of assisted ventilation using an oro-nasal mask

Arch Dis Child

Neonatal nasal intermittent positive pressure ventilation: a survey of practice in England

Arch Dis Child Fetal Neonatal Ed

Effect of introduction of synchronized nasal intermittent positive-pressure ventilation in a neonatal intensive care unit on bronchopulmonary dysplasia and growth in preterm infants

Am J Perinatol

A prospective observational pilot study of synchronized nasal intermittent positive pressure ventilation (SNIPPV) as a primary mode of ventilation in infants > or = 28 weeks with respiratory distress syndrome (RDS)

J Perinatol

Increased risk of gastrointestinal perforations in neonates mechanically ventilated with either face mask or nasal prongs

Pediatrics

Nasal intermittent positive-pressure ventilation offers no advantages over nasal continuous positive airway pressure in apnea of prematurity

Am J Dis Child

Efficacy of nasal intermittent positive pressure ventilation in treating apnea of prematurity

Pediatr Pulmonol

A comparison of nasal intermittent versus continuous positive pressure delivery for the treatment of moderate respiratory syndrome in preterm infants

Minerva Pediatr

Synchronized nasal intermittent positive pressure ventilation (SNIPPV) decreases work of breathing (WOB) in premature infants with respiratory distress syndrome (RDS) compared to nasal continuous positive airway pressure (N-CPAP)

Pediatr Pulmonol

Effects of non-invasive pressure support ventilation (NI-PSV) on ventilation and respiratory effort in very low birth weight infants

Pediatr Pulmonol

Nasal bilevel vs. continuous positive airway pressure in preterm infants

Pediatr Pulmonol

Nasal high frequency ventilation in neonates with moderate respiratory insufficiency

Arch Dis Child Fetal Neonatal Ed