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.
This is a preview of subscription content, access via your institution
Access options
Subscribe to this journal
Receive 12 print issues and online access
$259.00 per year
only $21.58 per issue
Buy this article
- Purchase on Springer Link
- Instant access to full article PDF
Prices may be subject to local taxes which are calculated during checkout
References
Millar D, Kirpalani H . Benefits of non invasive ventilation. Indian Pediatr 2004; 41: 1008–1017.
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.
Kumar P, Kiran PS . Changing trends in the management of respiratory distress syndrome (RDS). Indian J Pediatr 2004; 71: 49–54.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Bhandari V . Non-invasive ventilation of the sick neonate: evidence-based recommendations. J Neonatol 2006; 20: 214–221.
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.
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.
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).
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.
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.
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.
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.
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.
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.
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.
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.
Acknowledgements
I thank Richard Ehrenkranz, MD for his critical review of the paper.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Competing interests
The authors declare no conflict of interest.
Appendix
Appendix
Indications
(S)NIPPV is indicated as follows:
-
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
A form of weaning from invasive conventional mechanical ventilation in the spontaneously breathing patient with an increased work of breathing.
Contraindications
-
a
Upper airway abnormalities
-
1
Choanal atresia
-
2
Cleft palate
-
3
Tracheoesophageal fistula
-
1
-
b
Severe cardiovascular instability
Potential hazards/complications
-
a
Obstruction of prongs because of mucus plugging
-
b
Feeding intolerance
-
c
Abdominal distension
-
d
Abdominal perforation
-
e
Ventilator-induced lung injury
-
f
Hypoventilation
-
g
Infection
-
h
Nose bleed/nasal irritation
-
i
Skin irritation and pressure necrosis
Equipment and supplies
-
a
Infant Star 500/950 time cycled pressure limited infant ventilator*
-
b
Star Sync with abdominal probe*
-
c
V-SIL bi-nasal airway
-
1
2.5 mm (4.0 cm length)
-
2
3.0 mm (4.0 cm length) Or
-
1
-
d
Argyle CPAP nasal cannula kit
-
1
X-small
-
2
Small
-
1
-
e
Neobar endotracheal tube holder
-
1
Ultra
-
2
Micro
-
3
Small
-
1
-
f
Tape
-
g
Surgical lube
-
h
Orogastric tube
-
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
-
a
Using V-SIL bi-nasal airway
-
1
Trim and apply neobar endotracheal tube holder to infant
-
2
Estimate appropriate size airway for infant:  <1000 g 2.5 MM/OD  >1000 g 3.0 MM/OD
-
3
Estimate depth of the airway in the nasopharynx by measuring from nose to posterior nasopharynx
-
4
Lubricate airway with surgical lube
-
5
Insert airway through nares to posterior nasopharynx
-
6
Secure airway to tube holder with tape
-
7
Insert orogastric tube, open to atmosphere
-
8
Place on ventilator
-
1
-
b
Using Argyle CPAP nasal cannula
-
1
Estimate appropriate size prongs for infant:newline <1000 g—x-small  >1000 g—small
-
2
Position the prongs in the infant's nose; the prongs should fit fully inside the infants nostrils
-
3
Slip the head cap behind the infant's head and secure to the prongs with the Velcro straps
-
4
Insert orogastric tube open to atmosphere
-
5
Place on ventilator
-
1
Clinical management
-
a
(S)NIPPV (primary mode)
-
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
Monitor SpO2, HR and respirations
-
3
Obtain blood gas in 15–30 min
-
4
Adjust ventilator settings to maintain blood gas parameters within normal limits
-
5
Suction mouth and pharynx and insert clean airway Q4, as necessary
-
6
Maximal support recommendations: ⩽1000 g MAP 14 cm H2O >1000 g MAP 16 cm H2O
-
1
-
b
(S)NIPPV (secondary mode)
-
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
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
Suction mouth and pharynx and insert clean airway Q4, as necessary
-
4
Maximal support recommendations: ⩽1000 g MAP 14 cm H2O > 1000 g MAP 16 cm H2O
-
1
-
c
Considerations for re-intubation
-
1
pH < 7.25; PaCO2 ⩾60 mm Hg
-
2
Episode of apnea requiring bag and mask ventilation
-
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
Frequent desaturation (< 85%) ⩾3 episodes per hour not responding to increased ventilatory settings
-
1
-
d
(S)NIPPV weaning to oxyhood/nasal cannula
-
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
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%
-
-
1
Rights and permissions
About this article
Cite this article
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
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1038/jp.2009.165
Keywords
This article is cited by
-
Safety of bubble nasal intermittent positive pressure ventilation (NIPPV) versus bubble nasal continuous positive airway pressure (NCPAP) in preterm infants with respiratory distress
Journal of Perinatology (2024)
-
Pressure transmission and electrical diaphragm activity in preterm infants during nasal intermittent positive pressure ventilation—an exploratory prospective physiological study
Journal of Perinatology (2023)
-
Nasal intermittent positive pressure ventilation as a rescue therapy after nasal continuous positive airway pressure failure in infants with respiratory distress syndrome
Journal of Perinatology (2023)
-
Aerosol drug delivery to spontaneously-breathing preterm neonates: lessons learned
Respiratory Research (2021)
-
Bubble bilevel ventilation facilitates gas exchange in anesthetized rabbits
Pediatric Research (2021)