Continuous Positive Airway Pressure and Noninvasive Ventilation
Section snippets
Noninvasive ventilation
What is the best way to treat an infant requiring ventilatory support? How can we minimize damage to the lungs and airways while treating the underlying disorder? We do not yet have all the answers to these important questions. Respiratory support without endotracheal intubation is an attractive option. In this article the authors review the different methods of providing continuous positive airway pressure (CPAP) and more complex forms of noninvasive ventilation (NIV), such as bilevel CPAP and
Back to the future
In the 1960s and early 1970s intubation and ventilation of infants, especially premature infants, was largely experimental. The authors recall the death of President Kennedy's son Patrick, born at 34 weeks' gestation in 1963 at a weight of more than 2 kg, from respiratory distress syndrome (RDS). More than 40 years later, death of such an infant is nearly inconceivable. Early attempts at ventilation were cumbersome, hampered by lack of appropriate equipment, and could be likened to hanging a
Continuous positive airway pressure
CPAP is used predominantly for maintaining lung expansion in conditions in which the alveoli tend to collapse or fill with fluid. These conditions include RDS, postextubation and postoperative respiratory management, meconium and other aspiration syndromes, transient tachypnea of the newborn, pulmonary edema, congestive heart failure, pneumonia, resuscitation in the delivery room, high chest wall compliance (such as with extreme prematurity), and pulmonary hemorrhage. CPAP is also used to treat
Noninvasive ventilation
There has recently been substantial interest in the use of noninvasive methods of providing assisted ventilation. We define such methods as any mode of assisted ventilation that delivers positive pressure throughout the respiratory cycle with additional phasic increases in airway pressure, without the presence of an endotracheal tube. These additional phasic increases in airway pressure can be either synchronized to the infant's respiratory effort or nonsynchronized depending on the delivery
Using noninvasive ventilation
The settings chosen depend on the indication for assisted ventilation. Our postextubation study commenced with a PEEP of 6 cm H2O and a peak inspiratory pressure to a maximum of 16 cm H2O [48]. At these settings we did not see an increase in abdominal distension or feeding intolerance compared with CPAP alone. Individual patients may require higher PEEP (up to 7–8 cm H2O on occasion). We generally start with a respiratory rate of 15 and an inspiratory time of 0.4 seconds.
The settings we choose
Continuous positive airway pressure in the delivery room
Use of positive pressure in the delivery room makes theoretic sense. Establishing functional residual capacity quickly, thereby diminishing the potential lung damage from atelectrauma, is supported by animal data [52], [53], [54] and by human data outside of the delivery room as already discussed. Given that CPAP is used routinely in the NICU for infants who have mild or moderate respiratory distress, its use in the delivery room for the same infants is reasonable. Using CPAP in very immature
Summary
CPAP and forms of noninvasive mechanical ventilation are important tools for the neonatologist today. CPAP can recruit the lung and prevent or decrease apnea, thereby preventing or decreasing the need for intubation. Noninvasive positive pressure breaths seem to further extend the applicability of CPAP. Many questions remain as to which, if any, CPAP and NIV system is better and under what circumstances. We must diligently seek the answers to these questions and not assume we know what is best
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Cited by (66)
Non-invasive ventilatory support in neonates: An evidence-based update
2022, Paediatric Respiratory ReviewsCitation Excerpt :Nasal (synchronized) intermittent positive pressure ventilation (s)NIPPV is defined as any mode of assisted ventilation that delivers pressure throughout the respiratory cycle without endotracheal intubation; with or without synchronization of neonatal breathing. NIPPV therefore augments nCPAP with superimposed inflations to a set PIP [55]. High nCPAP failure rates have prompted neonatologists to seek other more effective NIV modalities [4].
Noninvasive respiratory support
2022, Goldsmith's Assisted Ventilation of the Neonate: An Evidence-Based Approach to Newborn Respiratory Care, Seventh EditionNasal Intermittent Mandatory Ventilation Versus Nasal Continuous Positive Airway Pressure Before and After Invasive Ventilatory Support
2019, Clinics in PerinatologyCitation Excerpt :Of the 6 studies investigating carbon dioxide clearance between NIPPV and CPAP, only 2 reported lower carbon dioxide during NIPPV.50,56 NIPPV may also induce the Head paradoxic reflex and be of benefit in apnea of prematurity management.20 Again, the evidence is conflicting on its effect on apnea.52,57
Non-invasive Respiratory Support
2017, Assisted Ventilation of the Neonate: An Evidence-Based Approach to Newborn Respiratory Care: Sixth Edition