Continuous Positive Airway Pressure and Noninvasive Ventilation

https://doi.org/10.1016/j.clp.2006.12.008Get rights and content

Continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV) hold much promise as means to protect the lungs of newborn infants who have respiratory distress from many causes. A wide variety of options are available to the clinician, including CPAP, bilevel CPAP, and both synchronized and unsynchronized noninvasive mechanical breaths. Limited data are available regarding the best ways to use CPAP and NIV in today's NICU environment. This article reviews current information on these modalities, including available options, possible risks, and unanswered questions.

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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