Non-invasive respiratory support of preterm neonates with respiratory distress: Continuous positive airway pressure and nasal intermittent positive pressure ventilation

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Summary

Non-invasive techniques of respiratory support were developed in order to reduce the adverse effects associated with ventilation via an endotracheal tube. Short bi-nasal prongs provide the most effective nasal interface for delivery of nasal continuous positive airway pressure (nCPAP). Devices used to generate CPAP include conventional ventilators, the ‘bubbly bottle’ system and the infant flow driver. NCPAP improves the rate of successful extubation. It is useful for preterm infants with respiratory distress syndrome, reducing time spent on an endotracheal tube and oxygen requirement at 28 d. However, nCPAP is associated with an increased rate of pneumothorax. Nasal intermittent positive pressure ventilation (NIPPV) is useful for augmenting the effectiveness of nCPAP. It further improves rates of successful extubation and shows promise as an initial method of respiratory support. Further research is required to determine the optimal settings for both nCPAP and NIPPV.

Introduction

Application of intermittent positive pressure ventilation to preterm infants using an endotracheal tube began in the 1960s. High mortality rates were reported and the high rates of air leak dampened initial enthusiasm. George Gregory first described the use of continuous positive airway pressure (CPAP) in 1971 for the early treatment of respiratory distress syndrome (RDS).1 Initially this was delivered via an endotracheal tube but subsequently other, more efficient, interfaces were developed.

Attitudes to the relative merits of intubation and ventilation and non-invasive ventilation [CPAP and nasal intermittent positive pressure ventilation (NIPPV)] have evolved since Gregory's study. Advocates of non-invasive ventilation cite the reduced risk of trauma to the larynx and trachea, infection and acute and chronic lung disease with this form of support. Although there is little evidence to support these assertions, there is general acceptance of the view that endotracheal intubation when required should be as brief as possible.

Section snippets

Source material for this review

Where possible the evidence quoted in this review comes from individual randomised controlled trials (RCTs) or meta-analyses of these trials. Most meta-analyses come from systematic reviews conducted for the Cochrane Library. Results are expressed in a similar format to that used in the Library, i.e. pooled analyses are provided as typical relative risk (RR) and risk difference (RD). The number needed to treat (NNT) or harm (NNH) is the inverse of the RD. Point estimates and their 95%

How does CPAP work?

CPAP supports the breathing of premature infants in a number of ways. The upper airway of the preterm infant is very compliant and therefore prone to collapse. CPAP splints the upper airway and therefore reduces obstruction and apnoea.2 Preterm infants struggle to establish and maintain lung volumes due to surfactant deficiency, muscle hypotonia, slow clearance of lung fluid and a compliant chest wall. CPAP assists expansion of the lungs and prevents alveolar collapse. In doing so it reduces

CPAP interfaces

CPAP may be delivered through a variety of interfaces. The use of an endotracheal tube is no longer recommended because it increases the infant's work of breathing. Gregory invented a head chamber with a tight seal and a pressure release valve.1 Alternative devices included a face chamber3 and a face mask.4 These systems were hampered by difficulties achieving a good seal in order to generate adequate pressure and they fell into disuse. Interfaces using nasal prongs (nCPAP) have the advantage

Leak at the nose and mouth

The aim of nCPAP is to pressurise the infant's nasopharynx and lungs. One of the problems is that the nasal prongs rarely fit tightly into the nostrils. This means that gas can leak down the pressure gradient from inside the nose to the outside. Gas can also leak from the mouth. This leak means that the set CPAP level is rarely maintained in the pharynx.9, 21 The best way to reduce nose leak is to ensure that the prongs are of sufficient size to snugly fit the nostrils without making them

Post-extubation

Preterm infants are frequently intubated and ventilated in the days following birth. In order to minimise the risks of ventilation, most clinicians attempt to wean support and remove the endotracheal tube as soon as possible. Atelectasis and apnoea often follow extubation to air or headbox oxygen and nCPAP is used in an attempt to reduce the need to reventilate infants.

A systematic review updated in 2007 identified nine trials published between 1982 and 2005 which addressed the question of

Nasal intermittent positive pressure ventilation (NIPPV)

NIPPV is a form of respiratory support in which ventilator inflations augment nCPAP. End expiratory pressure (PEEP), peak pressure (PIP), inflation rate (IR) and time (Ti) can all be manipulated.

Terminology used to describe NIPPV is not standardised and may be confusing. Terms include synchronised nasal intermittent positive pressure ventilation (SNIPPV),42, 43 nasopharyngeal synchronised intermittent mandatory ventilation (NP-SIMV),44 nasal synchronised intermittent mandatory ventilation

Devices to generate NIPPV

Although most ventilators can be adapted to deliver non-synchronised NIPPV, with the demise of the Infant Star ventilator (Infrasonics, San Diego, CA, USA), the availability of synchronised NIPPV has decreased. The only specialised devices which attempt to provide synchronised NIPPV are the Infant Flow SiPAP and Infant Flow Advance – IFDa (Viasys Healthcare, Conshohocken, PA, USA).

Nasal interface

NIPPV may be delivered by nasal prongs, which can be short or long, single or bi-nasal or by nasal mask. In our UK

Treatment of apnoea

Two RCTs compared non-synchronised NIPPV with nCPAP for the treatment of apnoea61, 66 in premature infants. Pooled analysis showed no advantage of NIPPV over nCPAP.70

Post-extubation

Three RCTs compared SNIPPV with nCPAP following extubation.44, 68, 69 All three studies showed that more SNIPPV-treated infants remained extubated at either 48 or 72 h. Pooled analysis showed a significant reduction in extubation failure [RR 0.21 (0.10, 0.45), RD −0.32 (−0.45, −0.20), NNT 3 (2, 5)] using NIPPV.71

Initial treatment of respiratory disease

Bhandari et al.

What do we still need to learn about neonatal NIPPV?

There is strong evidence that NIPPV after extubation of very premature infants reduces the reintubation rate. The technique may be used as a primary mode of support to reduce the need for intubation and may reduce the rate of BPD. It is not clear if NIPPV has a role in treating apnoea and this requires further investigation.

We have limited understanding of how NIPPV works and there is no evidence regarding the best device, interface or settings to use, nor whether SNIPPV is advantageous when

Conclusions

Non-invasive ventilation is increasingly used both as a primary method of respiratory support for preterm infants and to facilitate early extubation if an endotracheal tube is used. Bi-nasal interfaces have the lowest resistance and are the most clinically effective. Nasal trauma and leak around the prongs are commonly seen, therefore careful selection of prong size and monitoring of position are important. CPAP is an effective alternative to endotracheal intubation when managing RDS. Some

References (75)

  • H. Ahlstrom et al.

    Continuous postive airways pressure treatment by a face chamber in idiopathic respiratory distress syndrome

    Arch Dis Child

    (1976)
  • L.P. Allen et al.

    Continuous positive airway pressure and mechanical ventilation by facemask in newborn infants

    Br Med J

    (1975)
  • A.G. De Paoli et al.

    In vitro comparison of nasal continuous positive airway pressure devices for neonates

    Arch Dis Child Fetal Neonatal Ed

    (2002)
  • S.C. Yong et al.

    Incidence of nasal trauma associated with nasal prong versus nasal mask during continuous positive airway pressure treatment in very low birthweight infants: a randomised control study

    Arch Dis Child Fetal Neonatal Ed

    (2005)
  • A. De Paoli et al.

    Devices and pressure sources for administration of nasal continuous positive airway pressure (NCPAP) in preterm neonates

    Cochrane Database Syst Rev

    (2008)
  • K.S. Lee et al.

    A comparison of underwater bubble continuous positive airway pressure with ventilator-derived continuous positive airway pressure in premature neonates ready for extubation

    Biol Neonate

    (1998)
  • D.J. Kahn et al.

    Unpredictability of delivered bubble nasal continuous positive airway pressure: role of bias flow magnitude and nares-prong air leaks

    Pediatr Res

    (2007)
  • J.J. Pillow et al.

    Bubble continuous positive airway pressure enhances lung volume and gas exchange in preterm lambs

    Am J Respir Crit Care Med

    (2007)
  • C.J. Morley et al.

    Nasal continuous positive airway pressure: does bubbling improve gas exchange?

    Arch Dis Child Fetal Neonatal Ed

    (2005)
  • G. Moa et al.

    A new device for administration of nasal continuous positive airway pressure in the newborn: an experimental study

    Crit Care Med

    (1988)
  • J.S. Ahluwalia et al.

    Infant flow driver or single prong nasal continuous positive airway pressure: short-term physiological effects

    Acta Paediatr

    (1998)
  • M. Mazzella et al.

    A randomised control study comparing the infant flow driver with nasal continuous positive airway pressure in preterm infants

    Arch Dis Child Fetal Neonatal Ed

    (2001)
  • S.E. Courtney et al.

    Lung recruitment and breathing pattern during variable versus continuous flow nasal continuous positive airway pressure in premature infants: an evaluation of three devices

    Pediatrics

    (2001)
  • B.M. Stefanescu et al.

    A randomized, controlled trial comparing two different continuous positive airway pressure systems for the successful extubation of extremely low birth weight infants

    Pediatrics

    (2003)
  • H. Boumecid et al.

    Influence of three nasal continuous positive airway pressure devices on breathing pattern in preterm infants

    Arch Dis Child Fetal Neonatal Ed

    (2007)
  • M.T. Shoemaker et al.

    High flow nasal cannula versus nasal CPAP for neonatal respiratory disease: a retrospective study

    J Perinatol

    (2007)
  • D.M. Campbell et al.

    Nasal continuous positive airway pressure from high flow cannula versus infant flow for preterm infants

    J Perinatol

    (2006)
  • N.N. Finer

    Nasal cannula use in the preterm infant: oxygen or pressure?

    Pediatrics

    (2005)
  • A.G. De Paoli et al.

    Pharyngeal pressure in preterm infants receiving nasal continuous positive airway pressure

    Arch Dis Child Fetal Neonatal Ed

    (2005)
  • B.H. So et al.

    Clinical experience in using a new type of nasal prong for administration of N-CPAP

    Acta Paediatr Jpn

    (1992)
  • A. Ronnestad et al.

    Septicemia in the first week of life in a Norwegian national cohort of extremely premature infants

    Pediatrics

    (2005)
  • P.G. Davis et al.

    Nasal continuous positive airways pressure immediately after extubation for preventing morbidity in preterm infants

    Cochrane Database Syst Rev

    (2003)
  • F. Sandri et al.

    Prophylactic nasal continuous positive airways pressure in newborns of 28–31 weeks gestation: multicentre randomised controlled clinical trial

    Arch Dis Child Fetal Neonatal Ed

    (2004)
  • P. Subramaniam et al.

    Prophylactic nasal continuous positive airways pressure for preventing morbidity and mortality in very preterm infants

    Cochrane Database Syst Rev

    (2000)
  • J.J. Ho et al.

    Continuous distending pressure for respiratory distress syndrome in preterm infants

    Cochrane Database Syst Rev

    (2002)
  • A.G. Buckmaster et al.

    CPAP use in babies with respiratory distress in Australian special care nurseries

    J Paediatr Child Health

    (2007)
  • M.E. Avery et al.

    Is chronic lung disease in low birthweight infants preventable? A survey of 8 centres

    Pediatrics

    (1987)
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