Review
Current methods of non-invasive ventilatory support for neonates

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Summary

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.

Introduction

The transition from dependence on placental gas in utero to breathing of air after birth is a critical event, and several processes occur in utero to ensure an effective switch. However, full respiratory adaptation to breathing of air takes several weeks. Soon after birth, the newborn may suffer from incomplete transition because of prematurity, respiratory distress syndrome (RDS), asphyxia, persistent pulmonary hypertension, infection, or acute respiratory problems.1 Despite technological and clinical progress in neonatal care, pulmonary disorders remain the most common cause of neonatal mortality, are associated with morbidities that have severe long-term consequences,2 and are responsible for 20% of neonatal deaths.3

In previous decades, it was common to initiate endotracheal intubation and mechanical ventilation in neonates with moderate or severe respiratory distress. However, it is now known that such actions may have adverse effects on the respiratory system. Moreover, it is accepted that the application of positive pressure ventilation for an extended duration increases the likelihood of bronchopulmonary dysplasia (BPD).4 Despite the increased use of antenatal steroids; surfactant replacement therapy, and modern ventilation techniques, including patient-triggered ventilation, volume target ventilation, and high-frequency oscillation,5, 6 the incidence of BPD in very low birth weight (VLBW) infants has not changed significantly over the last decade.7 Furthermore, once a tube is in the trachea, this can serve as a bridge between the sterile lower respiratory system and the outside world.8 In 80% of intubated infants, bacterial colonization of the trachea occurs within a few days.9 These bacteria initiate inflammation, which can lead to lung injury and BPD. Furthermore, as recently shown, VLBW infants have the highest incidence of endotracheal tube leaks, which also impair mechanical ventilation.10

BPD primarily affects premature infants, and improved survival of very immature infants has increased the number of babies with this disorder. This has placed a heavy burden on healthcare resources, because these infants frequently require re-admission in the first 2 years after birth.11 The overall concepts of ventilator-induced lung injuries (VILIs) are: Volu/barotrauma, injury related to lung over-distension or stretching of the pulmonary structures; atelectrauma, injury caused by alveolar collapse; biotrauma, injury caused by hyperactive inflammatory responses secondary to bacterial airway colonization; and endotrauma, injury to the airway.8, 12

In recent years, there has been an increase in clinical attempts to reduce the incidence of BPD. Such efforts begin with resuscitation of preterm infants in delivery rooms. As shown by te Pas et al.13 VLBW infants who did not stabilise following early nasal continuous positive airway pressure (nCPAP) in the delivery room and who were mechanically ventilated during the first 3 days of life had less BPD than did VLBW infants who were initially given mechanical ventilation. Furthermore, it has been shown that survival rate and incidence of BPD in some medical centres improved when early nCPAP therapy was administered.14, 15, 16

Improvements in the measurement of volume and flow in modern neonatal ventilators have led to a variety of alternative non-invasive ventilation (NIV) procedures, in addition to the well-known nCPAP (Figure 1). NIV refers to any technique that uses constant or variable pressure to provide ventilatory support, but without tracheal intubation e.g. nasal intermittent positive pressure ventilation (nIPPV) combines nCPAP with superimposed ventilator breaths which may be synchronized (nSIPPV) with patient breathing movements. Currently, NIV is widely used in neonatal intensive care units (NICUs),17 however, its place in neonatal respiratory support is not yet fully defined. The aim of this overview is to describe the basic principles of NIV techniques and to review recent reports on the application of NIV techniques in NICUs.

Section snippets

Continuous positive airway pressure (CPAP)

The use of CPAP for the treatment of newborns with respiratory distress was first described by Gregory et al. in 1971.18 However, the basic principle of CPAP in newborns had by then already been developed by Benveniste and Pedersen in 1968.19 Gregory's first description has paved the way for the use of CPAP as the primary treatment for preterm infants with respiratory distress. Since that time, many prospective studies have shown an improved survival of premature infants treated with early CPAP.

Humidified high-flow nasal cannula

Low-flow nasal cannulas (LFNC) have been used for several years to deliver air or an air/oxygen mix to neonates, at low flow rates (< 0.5 L/min). This technique has been particularly useful in weaning infants off nCPAP. Caregivers often prefer this method because it is easy to use and because they can look after infants without limiting the interactions of the baby with the environment. More recently, it has been demonstrated that if the flow is increased to more than 2 L/min using a high-flow

Nasal intermittent positive pressure ventilation (nIPPV)

Nasal intermittent positive pressure ventilation (nIPPV) is a recent development in non-invasive ventilatory support. This procedure combines nCPAP with superimposed ventilator breathing at a set peak pressure.73 It has been reported that about 46-60% of premature infants with RDS who initially failed nCPAP therapy ultimately required mechanical support.15, 74 Furthermore, about 25-40% of LBW infants failed extubation to nCPAP and required re-intubation and mechanical ventilation.75 Efforts to

Nasal Bilevel positive airway pressure (nBiPAP)

Nasal Bilevel positive airway pressure (nBiPAP) is a non-invasive ventilation mode of respiratory support in which air and oxygen are sent to the upper respiratory tract via a face mask or nasal prongs. nBiPAP is a form of pressure-controlled ventilation, affording freedom of respiration and spontaneous breathing on two CPAP levels, with pressure support on inspiration and expiration. In contrast to CPAP therapy, in which the pressure is constant during inspiration and expiration, nBiPAP

Nasal or nasopharyngeal high-frequency ventilation (nHFV)

Both physiological theory and clinical data support the notion that high-frequency oscillation delivered to the nasopharynx may improve CO2 elimination in infants.104 Bubble CPAP is the oldest form of NIV support, and has been embraced with renewed interest because the bubbling may create gas pressure variations in the circuit. Such variations may be transferred to the infant's airway42 and may help in CO2 elimination. Moreover, a potential advantage of nHFV over nSIPPV and nBiPAP is that

Summary

nCPAP clearly has beneficial effects. Re-intubation can be avoided and the therapy is effective in treating apnoea of prematurity. Also, nCPAP and HFNC appear to be suitable primary alternatives to endotracheal intubation in infants with RDS, provided the infants display sufficient breathing efforts. However, different types of CPAP devices are available, and success with nCPAP may be device-specific. Further, it is not yet clear which CPAP device interface is least likely to cause nasal

Acknowledgments

The authors thank Dr. Scott Butler of English Manager Science Editing, Sydney, Australia, for linguistic correction.

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      Citation Excerpt :

      The NIV provides ventilatory support through a noninvasive (external) interface, replacing the invasive mechanical ventilation and their deleterious effects [1, 2, 3]. The NIV has interfaces with the NB skin, such as facial masks, nasal masks, nasopharyngeal prong, and short binasal prong [4]. The most common interface used in NB is the short binasal prong [5] which can cause nasal injuries due to the rubbing with the skin [6], causing from simple hyperemia to necrosis that destroys the columella and nasal septum [7].

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