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Nasal intermittent positive pressure ventilation in the newborn: review of literature and evidence-based guidelines

A Corrigendum to this article was published on 29 November 2010

Abstract

Various modes of nasal continuous positive airway pressure have been well established as a means of providing non-invasive respiratory support in the neonate. Recent reports suggest that nasal intermittent positive pressure ventilation may offer a better alternative, as a mode of non-invasive ventilation. This article will critically review the literature and provide some practical guidelines of the use of this technique in neonates.

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References

  1. Millar D, Kirpalani H . Benefits of non invasive ventilation. Indian Pediatr 2004; 41: 1008–1017.

    CAS  PubMed  Google Scholar 

  2. Halliday HL . What interventions facilitate weaning from the ventilator? A review of the evidence from systematic reviews. Paediatr Respir Rev 2004; 5 (Suppl A): S347–S352.

    Article  Google Scholar 

  3. Kumar P, Kiran PS . Changing trends in the management of respiratory distress syndrome (RDS). Indian J Pediatr 2004; 71: 49–54.

    Article  Google Scholar 

  4. Latini G, De Felice C, Presta G, Rosati E, Vacca P . Minimal handling and bronchopulmonary dysplasia in extremely low-birth-weight infants. Eur J Pediatr 2003; 162: 227–229.

    CAS  PubMed  Google Scholar 

  5. Davis PG, Morley CJ, Owen LS . Non-invasive respiratory support of preterm neonates with respiratory distress: continuous positive airway pressure and nasal intermittent positive pressure ventilation. Semin Fetal Neonatal Med 2009; 14: 14–20.

    Article  Google Scholar 

  6. Owen LS, Morley CJ, Davis PG . Neonatal nasal intermittent positive pressure ventilation: a survey of practice in England. Arch Dis Child Fetal Neonatal Ed 2008; 93: F148–F150.

    Article  CAS  Google Scholar 

  7. Kiciman NM, Andreasson B, Bernstein G, Mannino FL, Rich W, Henderson C et al. Thoracoabdominal motion in newborns during ventilation delivered by endotracheal tube or nasal prongs. Pediatr Pulmonol 1998; 25: 175–181.

    Article  CAS  Google Scholar 

  8. Friedlich P, Lecart C, Posen R, Ramicone E, Chan L, Ramanathan R . A randomized trial of nasopharyngeal-synchronized intermittent mandatory ventilation versus nasopharyngeal continuous positive airway pressure in very low birth weight infants after extubation. J Perinatol 1999; 19: 413–418.

    Article  CAS  Google Scholar 

  9. Moretti C, Gizzi C, Papoff P, Lampariello S, Capoferri M, Calcagnini G et al. Comparing the effects of nasal synchronized intermittent positive pressure ventilation (nSIPPV) and nasal continuous positive airway pressure (nCPAP) after extubation in very low birth weight infants. Early Hum Dev 1999; 56: 167–177.

    Article  CAS  Google Scholar 

  10. Aghai ZH, Saslow JG, Nakhla T, Milcarek B, Hart J, Lawrysh-Plunkett R et al. 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 (NCPAP). Pediatr Pulmonol 2006; 41: 875–881.

    Article  Google Scholar 

  11. Khalaf MN, Brodsky N, Hurley J, Bhandari V . A prospective randomized, controlled trial comparing synchronized nasal intermittent positive pressure ventilation versus nasal continuous positive airway pressure as modes of extubation. Pediatrics 2001; 108: 13–17.

    Article  CAS  Google Scholar 

  12. Barrington KJ, Bull D, Finer NN . Randomized trial of nasal synchronized intermittent mandatory ventilation compared with continuous positive airway pressure after extubation of very low birth weight infants. Pediatrics 2001; 107: 638–641.

    Article  CAS  Google Scholar 

  13. Bhandari V, Gavino RG, Nedrelow JH, Pallela P, Salvador A, Ehrenkranz RA et al. A randomized controlled trial of synchronized nasal intermittent positive pressure ventilation in RDS. J Perinatol 2007; 27: 697–703.

    Article  CAS  Google Scholar 

  14. Kugelman A, Feferkorn I, Riskin A, Chistyakov I, Kaufman B, Bader D . Nasal intermittent mandatory ventilation versus nasal continuous positive airway pressure for respiratory distress syndrome: a randomized, controlled, prospective study. J Pediatr 2007; 150: 521–526.

    Article  Google Scholar 

  15. Santin R, Brodsky N, Bhandari V . 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 2004; 24: 487–493.

    Article  Google Scholar 

  16. Kulkarni A, Ehrenkranz RA, Bhandari V . 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 2006; 23: 233–240.

    Article  Google Scholar 

  17. Moretti C, Giannini L, Fassi C, Gizzi C, Papoff P, Colarizi P . Nasal flow-synchronized intermittent positive pressure ventilation to facilitate weaning in very low-birthweight infants: unmasked randomized controlled trial. Pediatr Int 2008; 50: 85–91.

    Article  Google Scholar 

  18. Owen LS, Morley CJ, Davis PG . Neonatal nasal intermittent positive pressure ventilation: what do we know in 2007? Arch Dis Child Fetal Neonatal Ed 2007; 92: F414–F418.

    Article  Google Scholar 

  19. Bhandari V . Non-invasive ventilation of the sick neonate: evidence-based recommendations. J Neonatol 2006; 20: 214–221.

    Google Scholar 

  20. Sai Sunil Kishore M, Dutta S, Kumar P . Early nasal intermittent positive pressure ventilation versus continuous positive airway pressure for respiratory distress syndrome. Acta Paediatr 2009; 98: 1412–1415.

    Article  CAS  Google Scholar 

  21. Manzar S, Nair AK, Pai MG, Paul J, Manikoth P, Georage M et al. Use of nasal intermittent positive pressure ventilation to avoid intubation in neonates. Saudi Med J 2004; 25: 1464–1467.

    PubMed  Google Scholar 

  22. Ramanathan R, Sekar KC, Rasmussen M, Bhatia J, Soll RF . Nasal intermittent positive pressure ventilation (NIPPV) versus synchronized intermittent mandatory ventilation (SIMV) after surfactant treatment for respiratory distress syndrome (RDS) in preterm infants <30 weeks gestation: multicenter, randomized, clinical trial. EPAS 2009; 3212: 3216. (abstract).

    Google Scholar 

  23. De Paoli AG, Davis PG, Lemyre B . Nasal continuous positive airway pressure versus nasal intermittent positive pressure ventilation for preterm neonates: a systematic review and meta-analysis. Acta Paediatr 2003; 92: 70–75.

    Article  CAS  Google Scholar 

  24. Jackson JK, Vellucci J, Johnson P, Kilbride HW . Evidence-based approach to change in clinical practice: introduction of expanded nasal continuous positive airway pressure use in an intensive care nursery. Pediatrics 2003; 111: e542–e547.

    PubMed  Google Scholar 

  25. Khorana M, Paradeevisut H, Sangtawesin V, Kanjanapatanakul W, Chotigeat U, Ayutthaya JK . A randomized trial of non-synchronized Nasopharyngeal Intermittent Mandatory Ventilation (nsNIMV) vs Nasal Continuous Positive Airway Pressure (NCPAP) in the prevention of extubation failure in pre-term < 1500 grams. J Med Assoc Thai 2008; 91 (Suppl 3): S136–S142.

    PubMed  Google Scholar 

  26. Garland JS, Nelson DB, Rice T, Neu J . Increased risk of gastrointestinal perforations in neonates mechanically ventilated with either face mask or nasal prongs. Pediatrics 1985; 76: 406–410.

    CAS  PubMed  Google Scholar 

  27. Bhandari V, Finer NN, Ehrenkranz RA, Saha S, Das A, Walsh MC et al. Synchronized nasal intermittent positive-pressure ventilation and neonatal outcomes. Pediatrics 2009; 124: 517–526.

    Article  Google Scholar 

  28. Davis PG, Lemyre B, de Paoli AG . Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for preterm neonates after extubation. Cochrane Database Syst Rev 2001; 3: CD003212.

    Google Scholar 

  29. Ryan CA, Finer NN, Peters KL . Nasal intermittent positive-pressure ventilation offers no advantages over nasal continuous positive airway pressure in apnea of prematurity. Am J Dis Child 1989; 143: 1196–1198.

    CAS  PubMed  Google Scholar 

  30. Lin CH, Wang ST, Lin YJ, Yeh TF . Efficacy of nasal intermittent positive pressure ventilation in treating apnea of prematurity. Pediatr Pulmonol 1998; 26: 349–353.

    Article  CAS  Google Scholar 

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Acknowledgements

I thank Richard Ehrenkranz, MD for his critical review of the paper.

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Correspondence to V Bhandari.

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The authors declare no conflict of interest.

Appendix

Appendix

Indications

(S)NIPPV is indicated as follows:

  1. 1

    A method of non-invasive ventilatory assistance in the spontaneously breathing infant with impending or existing ventilatory failure because of an increased work of breathing.

  2. 2

    A form of weaning from invasive conventional mechanical ventilation in the spontaneously breathing patient with an increased work of breathing.

Contraindications

  1. a

    Upper airway abnormalities

    1. 1

      Choanal atresia

    2. 2

      Cleft palate

    3. 3

      Tracheoesophageal fistula

  2. b

    Severe cardiovascular instability

Potential hazards/complications

  1. a

    Obstruction of prongs because of mucus plugging

  2. b

    Feeding intolerance

  3. c

    Abdominal distension

  4. d

    Abdominal perforation

  5. e

    Ventilator-induced lung injury

  6. f

    Hypoventilation

  7. g

    Infection

  8. h

    Nose bleed/nasal irritation

  9. i

    Skin irritation and pressure necrosis

Equipment and supplies

  1. a

    Infant Star 500/950 time cycled pressure limited infant ventilator*

  2. b

    Star Sync with abdominal probe*

  3. c

    V-SIL bi-nasal airway

    1. 1

      2.5 mm (4.0 cm length)

    2. 2

      3.0 mm (4.0 cm length) Or

  4. d

    Argyle CPAP nasal cannula kit

    1. 1

      X-small

    2. 2

      Small

  5. e

    Neobar endotracheal tube holder

    1. 1

      Ultra

    2. 2

      Micro

    3. 3

      Small

  6. f

    Tape

  7. g

    Surgical lube

  8. h

    Orogastric tube

  9. i

    Suction catheter

*This ventilator, which provides SNIPPV, has been phased out by the manufacturer. We are currently using the Bear Cub 750 psv (Bear Medical Systems, Palm Springs, CA, USA) in our unit to provide NIPPV, using the same guidelines.

Procedure

  1. a

    Using V-SIL bi-nasal airway

    1. 1

      Trim and apply neobar endotracheal tube holder to infant

    2. 2

      Estimate appropriate size airway for infant:  <1000 g 2.5 MM/OD  >1000 g 3.0 MM/OD

    3. 3

      Estimate depth of the airway in the nasopharynx by measuring from nose to posterior nasopharynx

    4. 4

      Lubricate airway with surgical lube

    5. 5

      Insert airway through nares to posterior nasopharynx

    6. 6

      Secure airway to tube holder with tape

    7. 7

      Insert orogastric tube, open to atmosphere

    8. 8

      Place on ventilator

  2. b

    Using Argyle CPAP nasal cannula

    1. 1

      Estimate appropriate size prongs for infant:newline <1000 g—x-small  >1000 g—small

    2. 2

      Position the prongs in the infant's nose; the prongs should fit fully inside the infants nostrils

    3. 3

      Slip the head cap behind the infant's head and secure to the prongs with the Velcro straps

    4. 4

      Insert orogastric tube open to atmosphere

    5. 5

      Place on ventilator

Clinical management

  1. a

    (S)NIPPV (primary mode)

    1. 1

      Settings:

      • Frequency ≈ 40 per minute

      • PIP 4 cm H2O > PIP required during manual ventilation (adjust PIP for effective aeration per auscultation)

      • PEEP 4–6 cm H2O

      • Ti ≈ 0.45 s

      • FiO2 adjusted to maintain SpO2 of 85–93%

      • Flow 8–10 l m–1

      • Caffeine 15–25 μgm ml or aminophylline level ⩾8 μg ml–1

      • Hematocrit ⩾35%

    2. 2

      Monitor SpO2, HR and respirations

    3. 3

      Obtain blood gas in 15–30 min

    4. 4

      Adjust ventilator settings to maintain blood gas parameters within normal limits

    5. 5

      Suction mouth and pharynx and insert clean airway Q4, as necessary

    6. 6

      Maximal support recommendations: ⩽1000 g MAP 14 cm H2O >1000 g MAP 16 cm H2O

  2. b

    (S)NIPPV (secondary mode)

    1. 1

      Extubation criteria while on CV:

      •  Frequency ≈15–25 per minute

      •  PIP ⩽16 cm H2O

      •  PEEP ⩽5 cm H2O

      •  FiO2 ⩽0.35

      •  Caffeine 15–25 μg ml–1 or aminophylline level ⩾8 μg ml–1

      •  Hematocrit ⩾35%

    2. 2

      Place on (S)NIPPV

      •  Frequency ≈15–25 per minute

      •  PIP 2–4 ↑> CV settings; adjust PIP for effective aeration per auscultation

      •  PEEP ⩽5 cm H2O

      •  FiO2 adjusted to maintain SpO2 of 85–93%

      •  Flow 8–10 l m–1

    3. 3

      Suction mouth and pharynx and insert clean airway Q4, as necessary

    4. 4

      Maximal support recommendations: ⩽1000 g MAP 14 cm H2O > 1000 g MAP 16 cm H2O

  3. c

    Considerations for re-intubation

    1. 1

      pH < 7.25; PaCO2 ⩾60 mm Hg

    2. 2

      Episode of apnea requiring bag and mask ventilation

    3. 3

      Frequent (>2–3 episodes per hour) apnea/bradycardia (cessation of respiration for >20 s associated with a heart rate <100 per minute) not responding to theophylline/caffeine therapy

    4. 4

      Frequent desaturation (< 85%) ⩾3 episodes per hour not responding to increased ventilatory settings

  4. d

    (S)NIPPV weaning to oxyhood/nasal cannula

    1. 1

      Minimal (S)NIPPV settings

      •  Frequency ⩽20 per minute

      •  PIP ⩽14 cm H2O

      •  PEEP ⩽4 cm H2O

      •  FiO2 ⩽0.3

      •  Flow 8–10 l m–1

      •  Blood gases within normal limits

    2. 2

      Wean to:

      •  Oxyhood adjust FiO2 to keep SpO2 85–93%

      •  NC adjust flow (1–2 l m–1) and FiO2 to keep SpO2 85–93%

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Bhandari, V. Nasal intermittent positive pressure ventilation in the newborn: review of literature and evidence-based guidelines. J Perinatol 30, 505–512 (2010). https://doi.org/10.1038/jp.2009.165

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