seminar non invasive respiratory support

1. Case scenario
D/O Zakia, inborn, got admitted in NICU at 15 min of
her age due to prematurity (33weeks), LBW(1600g) and
respiratory distress soon after birth. Premature delivery
was done due to PET. Baby cried immediately after
birth & APGAR was good. Mother got single dose of
antenatal corticosteroid. On arrival baby was
normothermic, euglycemic, reflex & activities were
good, but having respiratory distress in the form of
tachypnea, nasal flaring, chest retraction & grunting.

2. Question - 1
Which support will you provide first to the
baby?

3. Question - 2
How will you select appropriate respiratory
support for this baby?

4. Non Invasive
Respiratory Support in newborn
Dr. Lubana Akram
Resident, Year – 1
Dr. Arif Hossain
Resident, Year – 5

5. Content
• Definition of respiratory distress
• Respiratory distress scoring system
• Delivery room management of respiratory distress
• Different modalities of respiratory support
• Supplemental O2 delivery apparatus
• Different types of non invasive respiratory support
• O2 toxicities
• O2 monitoring device

6. Suzanne Reuter et al. Respiratory Distress in the
Newborn. Pediatrics in Review. 2014;35(10):417 - 29
Respiratory distress in the newborn is defined as
one or more signs of increased work of breathing,
such as
- tachypnea,
- nasal flaring,
- chest retractions or
- grunting.

7. Assessment of respiratory distress
• The WHO provides the most simplified scoring
system.

8. Silverman score

9. Downes’ scoring system
0 1 2
Cyanosis none In room air In 40% Fio2
Retractions none Mild Severe
Grunting none Audible with
stethoscope
Audible without
stethoscope
Air entry Clear Decreased or
delayed
Barely audible
Respiratory rate <60 60-80 >80 or apnea

10. • Term newborn infant reach stable arterial
oxygen saturation values around 85% to 90%
by arterial oxygen saturation within 5 minutes.
• Preterm infants, especially extremely preterm
infants need almost 10 minutes to reach
preductal Sp02 of around 85%.
Delivery room management

11. Recommendation for pre term
• In spontaneously breathing babies
stabilise with CPAP of at least 6 cm H2O
• Intubation should be reserved for babies not
responding to positive pressure ventilation.
• Surfactant who require intubation for stabilisation.
Respiratory support in Delivery room

12. • T – piece resuscitator for resuscitation
in delivery room.
• Use an initial FiO2 of
- 0.30 for < 28 weeks of gestation
- 0.21–0.30 for 28–31 weeks
- 0.21 for 32 weeks of gestation
and above.
(European Consensus Guidelines on the Management of Respiratory
Distress Syndrome – 2019 )
Respiratory support in Delivery room

13. Rescue or therapeutic surfactant: Preterm who are -
o Suspected of having surfactant deficiency
o Required endotracheal intubation & MV
o Required an FiO2 > 0.40
o Clinical and radiographic evidence of neonatal RDS
AARC Clinical Practice Guideline.
Surfactant Replacement Therapy: 2013

14. • Using CPAP immediately after birth with
subsequent selective surfactant
administration considered as an alternative to
routine intubation with prophylactic or early
surfactant administration in preterm infants.
Respiratory support in Delivery room

15. CHIRUVOLU et al. Delivery room management of meconium-
stained newborns and respiratory support. PEDIATRICS. 2018;
142(6): 1 – 7
• The recent NRP guideline change in the delivery
room management of newborns who are
nonvigorous and born through MSAF avoided a large
number of intubations in the delivery room and was
not associated with an increased incidence of MAS.
• This change was associated with a higher incidence
of NICU respiratory admissions and increased needs
for mechanical ventilation, oxygen, and surfactant
therapy.

16. Respiratory Therapeutic Modalities
• Supplemental Oxygen
• Noninvasive ventilation
CPAP, HFNC
NIPPV
• Invasive modalities
MV

17. Nasal prongs
• Nasal prongs are a
disposable plastic device
that ends in two short
tapered tubes (about 1
cm in length) designed to
lie just within the nostrils.
They are also called nasal
cannula.
• Standard flow rates
through nasal prongs are
0.5–1 L/min for neonates

18. Nasal prongs
Advantages
• No risk of gastric
distension
• Humidification is not
required with standard
oxygen flow rates

19. Disadvantages
• Airway will become
obstructed by mucus
• Unable to use with nasal
obstruction
• Can dislodge from nares
easily
• Causes skin irritation or
breakdown over ears or
at nares
Nasal prongs

20. Nasal catheter
• A nasal catheter is a
thin, flexible tube that is
passed into the nose
and ends with its tip in
the nasal cavity.
• In neonates and
infants, 8-French (F) size
catheters should be
used.
• The maximum flow rate
should be set at 0.5–1
L/min for neonates and
1–2 L/min for infant.

21. • Catheter passed for a
distance equal to the
distance from the side
of the nostril to the
inner margin of the
eyebrow usually
reaches the posterior
part of the nasal cavity.
• The tip of the catheter
should not be visible
below the uvula.

22. Advantage:
The oxygen does not
have to be humidified
because the tip of the
catheter lies in the nasal
cavity.
Disadvantage:
 Catheters can become
blocked with mucus,
which can cause upper
airway obstruction
 There is little risk of
displacement into the
oesophagus, with a
consequent risk of
gastric distension
Nasal catheter

23. Nasopharyngeal catheters
• Nasopharyngeal catheters are inserted into the nose
to a depth 1 cm less than the distance from the side
of the nose to the front of the ear (tragus).
• In neonates and infants, 8-F catheters should be
used.
• Maximum flow rate 0.5 L/min for neonates

25. Nasopharyngeal catheters
Disadvantage
• Higher flow rates without
effective humidification
may cause drying of the
nasal mucosa, with
associated bleeding and
airway obstruction.
• Can be displaced
downwards into the
oesophagus and cause
gagging, vomiting and
gastric distension.
Advantages:
• Oxygen delivery is most
economical of all the
methods described
here.
• Better oxygenation is
achieved with a lower
oxygen flow than with
nasal prongs

26. • An oxygen hood (cube)
is a plastic enclosure
that surrounds the head
of the neonate, to
which a continuous flow
of humidified oxygen is
supplied
• Gas flow rate 3 – 10
L/min.
Head box

27. Head box
Advantages
 No increased risk for
airway obstruction or
gastric distension
 Humidification is not
necessary.
Disadvantage
 Carbon dioxide toxicity
can occur if the flow of
oxygen is inadequate. A
gas flow of 2–3 L/kg per
min is necessary to
avoid rebreathing of
carbon dioxide in a
head box .
• Head boxes interfere
with feeding.

28. Face mask
• Simple mask is made of
clear, flexible,plastic or
rubber that can be
molded to fit the face
• Not use in neonates

29. Supplemental Oxygen via the Incubator
 Is the most common
method of low-level
supplemental O2 delivery
in Europe
 These incubators have
respiratory gas connection
ports, a microprocessor,
and an oxygen sensor that
control O2 content

30. Advantages:
• Servo controlled
incubators provides
steady oxygen
• Avoid the skin
breakdown
• Noise is low
Disadvantages:
 Infant must be
maintained in an
incubator
Supplemental Oxygen via the Incubator

31. O2 Administration By Holding O2 Source Near The
Infant’s Face
This kind of oxygen
administration is widely
used for short periods-
- after extubation
- during breast feeding who
is on headbox O2

32. Oxygen Delivery Devices and Flow Limit
• Nasal prongs : 1-2L /min
• Nasal cannula: 1-2 L/min
• Nasal catheter : 1-2L /min
• Nasopharyngeal catheter : 1-2L /min
• Head Box : 3-10L /min
• CPAP : 3-10 L /min
• HFNC: 3 – 8 L/min
• Ventilator : As much as

33. Non invasive respiratory support(NIRS)
NIRS
Typical
Non Typical
eg. HHHFNC
CPAP NIMV/NIPPV NHFV NIV-NAVA

34. Choice of respiratory support
• CPAP should be initiated at the earliest or subtle signs of
respiratory distress in neonates at risk for RDS.
• Some arbitrary criteria can be Silverman score of ≥ 4 or
FiO2 requirement ≥ 0.3.
• For preterm baby especially in extremely low birth
weight baby
as tachypnea is the earliest sign of respiratory distress.
Tachypnea = CPAP

35. A. B. Hedstrom et al. Performance of the Silverman Andersen Respiratory
Severity Score in predicting PCO2 and respiratory support in newborns.
Journal of Perinatology. February 2018.

36. Continuous Positive Airway Pressure (CPAP)
Types:
1) Continuous Flow CPAP
- Ventilator derived CPAP
- Bubble CPAP
2) Variable Flow CPAP
- Infant Flow Driver
- Sigh Intermittent Positive Airway Pressure (SiPAP)

38. Most widely used CPAP is Bubble CPAP
Indications: Presence of good respiratory drive is pre
requisite of CPAP support.
- Respiratory disorder (RDS, MAS, Pneumonia, PPHN)
- Apnea of prematurity
- Disorder causing excessive lung fluid (TTN, PDA, CCF,
Hydrops fetalis ect.)
- Laryngo/tracheo/broncho malacia
- After extubation

39. Contraindications of CPAP
• Poor respiratory drive that is not improved by CPAP
• Cleft palate
• Choanal atresia
• Tracheoesophageal fistula
• Unrepaired CDH
• Severe cardiovascular instability (Hypotension)
• Severe apneic episode
• Severe ventilatory impairment (PH < 7.25, PCO2>60)

40. How CPAP work?
• Increase FRC
• Improve lung compliance
• Aid in the stabilization of highly complaint
infant chest wall
• Decrease thoracoabdominal asynchrony
• Decrease intrapulmonary shunting
• Reduce tachypnea
• Decrease labored breathing

41. Time of application of CPAP
• Prophylactic CPAP in delivery room
• Early : within 2 hours of distress
• Late : after FiO2 requirement > 0.40
CPAP does not work as expected if it is started after
atelectasis have been already occurred.
Early CPAP is beneficial. It enhance
- surfactant conservation
- lower PEEP
- reduce the need for MV

42. Devices used for interface
• Nasal prong
• Nasopharyngeal prong
• Nasal mask
• Face mask
Widely used nasal prong.
No published data concerning the safety and efficacy
of nasal mask.

43. Bipin.Is nasal mask better than nasal prongs for delivering nasal
continuous positive airway pressure in preterm infants with
respiratory distress syndrome? 2018
CONCLUSION
Nasal Continuous positive airway pressure (NCPAP)
with mask interface is equally effective as nasal
continuous positive airway pressure (NCPAP) with
prongs interface. Incidence of stage II nasal trauma
was significantly lower in mask group than in the
prongs group.

44. Setting of PEEP, FiO2 & Flow
• Set up is disease specific.
• Pressure ranges 4 – 7 cmH2O
• FiO2 0.21 – 0.60
• Flow rate 2 – 8 L/min
General rules of initial setup is rules of “5”.
- Pressure: 5 cmH2O
- FiO2: 0.50
- Flow: 5 L/min
Always insert orogastric tube while baby on CPAP and keep
open & above the level of stomach

45. How to assess optimum CPAP
• Baby is comfortable in CPAP
• Minimal or no retraction
• No grunt
• Normal CRT & BP
• Maintain SpO2 within 90 – 95%
• CXR: Presence of 8 posterior ICS above diaphragm.
• Achieve expected blood gas level in high set up
(PH > 7.25, PCO2 < 60 & PO2 > 50)

46. Adjustment of PEEP, FiO2 & Flow
• ↑ PEEP by 1 cmH20 in every 15 to 20 min to maintain
SpO2 between 90 – 95%
• Adjust PEEP by seeing the chest retraction. Increase
PEEP upto 8 cmH2O
• Do not raise FiO2 before pressure.
• ↑ FiO2 upto 0.60 to maintain SpO2
• No bubbling inadequate flow to generate pressure
or may be leak in circuit.
• Excess bubbling wastage of gases or turbulence in
flow.

47. CPAP & FiO2 proportionality
CPAP 4 FiO2 25 – 40%
CPAP 5 FiO2 50%
CPAP 6 FiO2 60%
CPAP 7 FiO2 70%
If there is any discrepancy between CPAP and pressure & FiO2
think about
- PPHN
- CHD
- Metabolic acidosis
- Over distended lungs

48. Weaning of CPAP
• The process of weaning should be slow and steady.
• Every 1 cmH2O decrease in CPAP aims to decrease
FiO2 10%.
• When baby comes down to PEEP 5 & FiO2 50% then
first decrease FiO2 upto 30% and then decrease
pressure from 5 to 4 cmH2O.
• When pressure 4 and FiO2 < 30% with normal SpO2
and minimal retraction, CPAP may be weaned to air
or head hood.

49. CPAP Failure
• Presence of retraction/grunt despite giving optimum
CPAP
• Recurrent or severe apnea (significant apnea means
3 apnea/ hour or that requiring bag & mask
ventilation)
• Significant bradycardia
• PO2 < 50 in FiO2 >0.60
• PCO2 > 60 or PH < 7.25
Most common cause for CPAP failure is delayed in
initiation after birth.

50. Complications of CPAP
• Pulmonary air leak syndrome
• Decreased cardiac out put due to reduction in
venous return
• Impedance of pulmonary blood flow with increased
pulmonary vascular resistance
• Gastric distension & CPAP belly syndrome
• Nasal irritation, damage to the septal mucosa, skin
damage and necrosis from fixing devices.

51. Other CPAP devices
Infant Flow Driver:
This device generate CPAP at the airway proximal to
infants nose.
Principles:
- Bernoullis effect (maintain constant pressure)
- Venturi effect (flow variation acc. to baby needs)
- Coanda effect (causes fluidic flip & hence ↓ WOB)

52. Sigh Intermittent Positive Airway Pressure (SiPAP)
• It is newer mode of NIV which provides bilevel CPAP
• SiPAP is not a nasal IMV
• Small (2-3 cmH2O), slow, intermittent increase in
CPAP pressure for duration up to 3 sec →sigh breath.
• SiPAP setting:
- Baseline CPAP level
- Frequency (usually 6)
- Pressure rise (2-3 cm H2O)
- Duration of pressure rise (1-2 sec)

53. Advantages of different types of NCPAP
• Bubble CPAP → continuous bubbling & pressure
oscillates in the circuit → facilitates gas exchange by
facilitated diffusion.
• Sea-PAP → more oscillation by bending at an angle of
135 degree in expiratory tube.
• IFD → more uniform pressure.
• SiPAP → more alveoli recruitment, stimulate resp center.
There are no definite data to support or refute using one
NCPAP system to another.

54. Trouble Shoot in CPAP
SpO2 Retraction Air entry Bubbling Diagnosis
Low +++ Poor Yes Lung disease
Low +/nil Good Yes PPHN/CHD
Normal +++ Good Yes Metabolic acidosis
Low +++ Poor Yes Obstruction
Low +++ Poor Nil Leaks

55. Colin et al. Nasal CPAP or Intubation at Birth for Very Preterm
Infants. n engl j med.2008; 358(7). COIN trial
Conclusion:
 Infants who were born at 25-28 weeks’ gestation and
were breathing spontaneously were treated with
CPAP shortly after birth. Half were subsequently
intubated.
 Infants in the CPAP group had a better outcome at 28
days.
 Two groups had a similar outcome at 36 weeks’
gestational age, but there was an increased incidence
of pneumothorax in the CPAP group.

56. Early CPAP versus Surfactant in Extremely Preterm Infants. n engl
j med. 2010; 362(21). SUPPORT trial
Conclusion:
No significant difference in the primary outcome of
death or bronchopulmonary dysplasia between two
groups.
CPAP results lower rate of intubation, reduced rate of
postnatal corticosteroid use, shorter duration of
ventilation without an increased risk of any adverse
neonatal outcome.
Data supports CPAP as an alternative to routine
intubation and surfactant administration in preterm
infants.

57. SANDRI et a. Prophylactic or Early Selective Surfactant Combined
With nCPAP in Very Preterm Infants. PEDIATRICS.2010;125(6).
CURPAP trial.
CONCLUSIONS:
• Prophylactic surfactant was not superior to nCPAP.
• Early selective surfactant decreases the need for MV
in the first 5 days of life and the incidence of main
morbidities of prematurity in spontaneously
breathing very preterm infants on nCPAP.

58. DUNN et a. Randomized Trial Comparing 3 Approaches to the Initial
Respiratory Management of Preterm Neonates. PEDIATRICS.
2011;128(5). VON DRM trail
CONCLUSIONS:
Preterm neonates were initially managed with either
nCPAP or PS with rapid extubation to nCPAP had
similar clinical outcomes to those treated with PS
followed by a period of mechanical ventilation.
An approach that uses early nCPAP leads to a
reduction in the number of infants who are
intubated and given surfactant.

60. Humidified High Flow Nasal Cannula(HHFNC)
• Same as CPAP but
without having in-
build PEEP.
• Here PEEP is created
by high flow (3-8
L/mi) which is
dynamic pressure.

61. HHFNC cont…
Mechanism by which it works:
 Flushing the upper airway dead space of CO2,
allowing for better alveolar gas exchange.
 Providing a flow adequate to support inspiration,
thereby reducing inspiratory WOB.
 Improving lung & airway mechanics by eliminating
the effect of drying/cooling.
 Reducing or eliminating the metabolic cost of gas
conditioning.
 Provide end distending pressure.

62. Indications of HHFNC
• In post extubation setting
• Weaning from nCPAP
• As primary mode of support in respiratory
distress though enough evidence for safety
and efficacy lacking.

63. Protocol for initiating set up of HHFNC
• First appropriate size nasal cannula is attached to
circuit tube.
• Set FiO2 at same or 5-10% higher from previous
mode of support in post extubation cases. Start with
FiO2 0.40 in case of primary support.
• A rule of thumb for initial flow rate setting, use 1-2-3,
2-3-4, 3-4-5 formula
1 to 2 kg = 3 L/min
2 to 3 kg = 4 L/min
> 3 kg = 5 L/min

64. Maintain & weaning of HHFNC
• ↑flow rate 1 L/min if FiO2 increases > 10% and PCO2
increases > 10 mmHg above baseline.
• Titrate flow & FiO2 to keep SpO2 between 90-95%.
• First decrease FiO2 during weaning upto 40% then
decrease flow rate slowly by 1 L/min upto 3L/min.
• Then further decrease FiO2.
• Then wean to air or headhood.

65. Non Invasive Ventilation (NIV)
 NIV or NIPPV is used for patient failing NCPAP or
following extubation from MV.
 Synchronized & nonsynchronized NIMV with a
conventional ventilation is the most common form.
 NIV avoid complications of prolonged invasive
ventilator (volutrauma, infection & subglottic
stenosis.)
 One study showed that NPSIMV may be less injurious
to lungs & provide better ventilation with less need
for support than invasive SIMV.

66. NIPPV cont…
• Short binasal prongs are the most commonly used
interface for NIPPV.
• Nasal mask & nasopharyngeal prongs can be used.
• Set up:
 Short inflation times (0.3–0.5 s),
 Variable inflation rates of 10–60/min and
 Peak pressures and positive end expiratory pressure
similar to those used with endotracheal ventilation.

67. Neurally Adjusted Ventilatory Assist (NAVA)
• NAVA is new & unique form of assisted ventilation.
• It can be used in both intubated & non intubated
patients.
• It controls the ventilator by using the electrical
activity of the diaphragm (EAdi).
• EAdi signal is obtained by nine miniaturized
electrodes embedded on a conventional naso/oro
gastric tube, positioned in the lower esophagus.

69. NAVA cont…
• EAdi signal will not be present during apnea,
oversedation or severe brain injury.
• NIV-NAVA is possible only when the infant has a
reasonably stable respiratory drive.
• A RCT of 15 infants of <32 weeks compared NIV-
NAVA with NIV-Pressure Support and found better
patient ventilator synchrony with NAVA.

70. Nasal High Frequency Ventilation (NHFV)
• NHFV breath can be delivered by nasopharyngeal or
nasal prongs.
• NHFV with Drager VN500 ventilator showed nearly
threefold more efficient CO2 clearance than NIMV.
• Potential advantage of NHFV over NIMV is that
synchronization is not necessary, because of
relatively high frequencies.

71. HFNC
CPAP NIPPV
Answer is
Which non invasive modality is the best?
?

73. The aim : was to assess the clinical effectiveness and
safety of HFNC compared to CPAP as a noninvasive
respiratory support for the initial respiratory
management of respiratory distress in preterm infants.
Conclusion : There is no evidence to support the non
inferiority of HFNC compared to CPAP as an initial
management of respiratory distress in premature infants
at between 30 and 35 weeks gestational age. The
difference in failure rate is not significant without an
increase in the incidence of complications.
HFNC Vs CPAP cont…

74. Sarah et al.Safety and Efficacy of High-Flow Nasal Cannula
Therapy in Preterm Infants: A Meta-analysis.PEDIATRICS Volume
136, number 3, September 2015
RESULTS:
 High-flow therapy was similar in efficacy to other
modes of NIV in preterm infants when used as
primary support (odds ratio of failure of therapy, 1.02)
as well as after extubation (1.09).
 There were no significant differences in odds of death
(0.48) between the groups. Preterm infants supported
on high flow had significantly lower odds of nasal
trauma (0.13)

79. HFNC
CPAP
More trials is required to find out
optimum non invasive ventilation
NIPPV
Answer is
Which non invasive modality is the best?

80. Oxygen is Life Saving, but….
• Oxygen is the energy source of cellular life.
• It is the biomedical double –edged sword.
• It is mandatory to avoid hypoxia, but prolonged
hyperoxia leads to oxidative stress and cellular
injury.

81. Complications of Oxygen Therapy
• Skin irritation
• Drying of nasal and pharyngeal mucosa
• Induced hypoventilation
• Absorption atelectasis
• Adverse effect on retina
• Adverse effect on lung eg CLD

82. Noninvasive monitoring of Gas Exchange?
 Pulse oximetry: by which SpO2 is measured.
 Transcutaneous oxygen monitoring (TcPO2)
 Capnography & End – Tidal CO2 monitoring
- Mainstream capnography
- Sidestream devices
 Transcutaneous CO2 monitoring
 Tissue oxygen saturation monitoring using Near
Infrared Spectroscopy (NIRS)

83. Target Range of Saturation spo2
• Preterm : 88-92%
• The optimal SpO 2
target of ELBW
infants is not known
• Term : 93-97%

84. Take home message
• Stabilization in the delivery room should be
done with 30% O2 in gestation ≤ 32 weeks.
• CPAP immediately after birth with
subsequent selective surfactant
administration is an alternative to routine
intubation with prophylactic or early
surfactant administration in preterm.
• Noninvasive ventilator (NIV) support is
preferred in comparison to invasive
supports.

85. References
• Rennie & Roberton’s textbook of neonatolog. 5th edition
• Neonatolog. management, procedure, no-call problems, and
drugs. 7th editiom
• Manual of neonatal care. 8th edition
• Avery’s diseases of the newborn. 7th edition
• Nelson textbook of pediatrics. 20th edition
• Assisted ventilation of the neonate. 5th edition
• CPAP bedside application in the newborn. 2nd edition
• Workshop on CPAP. Science, evidence & practice. 4th edition
• Online journal