This document discusses noninvasive ventilation techniques for neonates. It provides background on the increasing use of nasal continuous positive airway pressure (NCPAP) and nasal intermittent positive pressure ventilation (NIPPV) as alternatives to invasive ventilation. The document describes various noninvasive ventilation methods including NCPAP, bi-level NCPAP, NIPPV, high flow nasal cannula (HFNC) and their physiological effects and clinical indications. Evidence is presented that both NIPPV and HFNC are effective for treating respiratory distress syndrome and hypoxic respiratory failure in preterm infants and that HFNC has similar outcomes to NCPAP for apnea of prematurity. The document concludes that NIPPV and HFNC reduce the risk

1. Noninvasive Ventilation In
Neonates

2. Objectives
✓ Introduction
✓Background
✓Response to NIV
✓Clinical indications
✓Contraindications
✓Evidence based decisions

3. Introduction
• Respiratory distress is a common problem seen in neonates, both
preterm and full term.
• Appropriate use of respiratory support can be life-saving in these
neonates.
• While invasive ventilation is unavoidable in some situations,
noninvasive ventilation may be sufficient in several neonates.
• In 1971, Gregory and colleagues reported successful use of
endotracheal tube continuous positive airway pressure (CPAP) in
neonates.
• In the last three decades, nasal CPAP/noninvasive ventilation
(NIV) has gradually emerged as the first choice of respiratory
support in neonates.

4. Background
⚫ In the United Kingdom,48% of 91 units use NIPPV.
⚫ In Ireland 61% of 28 units surveyed reported using
NIPPV.
⚫ In Brazil 98.7% of 81 units used NIPPV.
⚫ No such data are available from the United States.

8. What is Noninvasive Ventilation (NIV)?
•VENTILATION VIA NON INVASIVE
AIRWAY
i.e without an endotraceal tube
NIV refers to any method of providing respiratory
support, where an endotracheal tube is NOT used.

9. WHY:
• Intubation is single major preventable factor contributing to
Broncho pulmonary dysplasia (BPD).
• Even a single positive pressure breath can initiate biotrauma
/Baro/Volutrauma.

11. Non invasive ventilation: WHY?
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12. Non invasive ventilation: WHY & WHAT?
⚫ CPAP does not consistently improve ventilation and does not work in
infants with poor respiratory effort
(46-60% of babies with RDS may fail CPAP and
25-40% of intubated LBW babies fail extubation to CPAP)
⚫ Invasive ventilation causes baro/volutrauma, atelecto-trauma along
with bio-trauma resulting in ventilator induced lung injury( VILI).
⚫ In an effort to support ventilation and avoid need for invasive support
the use of intermittent positive pressure ventilation via nasal
devices has been proposed (positive pressure cycle delivered on
topofcontinuousdistendingpressurebynasalroute)
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2

13. Non invasive ventilation:
CLASSIFICATION OF NIV IN NEONATES:
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14. Terminology
Bi-level nasal CPAP
BPD:
Bronchopulmonary dysplasia
HFNC:
High flow nasal cannula
HHHFNC:
Heated humidified high-flow nasal
cannula
NAVA:
Neurally adjusted ventilatory assist
NCPAP:
Nasal continuous positive airway
pressure
nHFOV:
Nasal high-frequency oscillation
ventilation
NIMV:
Nasal intermittent mandatory
ventilation
NIPPV:
Nasal intermittent positive pressure
ventilation
NIV:
Non-invasive ventilation
NS-NIPPV:
Non-synchronized nasal intermittent
positive pressure ventilation
PEEP:
Positive end expiratory pressure
PIP:
Peak inspiratory pressure
SNIPPV:
Synchronized nasal intermittent
positive pressure ventilation

15. Advantages Of Noninvasive Ventilation
• NIV has several significant advantages over
endo tracheal intubation.
• NIV devices leave the upper airway intact,
decreasing the risk of airway trauma and
preserving the natural defense mechanisms of
the upper airways.
• patients receiving NIV do not require
paralytics, and the need for sedation is greatly
reduced.
• NIV is also less expensive than mechanical
ventilation, and studies have shown that it
decreases length of hospital stay and associated
cost.

16. Non invasive ventilation: HOW? Physiological effects of NIV
1. Apnea: Nasal IPPV may improve patency of the upper airway
by creating intermittently elevated pharyngeal pressures. This
intermittent inflation of the pharynx may activate respiratory
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drive, by Head’s paradoxical reflex, where lung inflation
provokes an augmented inspiratory reflex. This results in
resumption of breathing in infants with apnea following
cycling of the ventilator.
2. Work of breathing: has also been shown to be decreased
with the use of SNIPPV compared to nasal CPAP.

17. Non invasive ventilation: HOW? Physiological effects of NIV
3. Chest wall distortion: The negative pressure generated during spontaneous
inspiration often produces an inward motion of the chest wall weakening
the inspiratory effort and delaying lung expansion. N-SIMV at 10 breaths per
minute reduced thoraco-abdominal asynchrony in preterm infants compared
to N-CPAP immediately after extubation.
Inefficient ventilation and waste of work
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18. Signs of effective response To NIV

19. Clinical indications

20. Contraindications

21. CPAP
• Constant level of pressure support to the airways
during inspiration and expiration
• 5-10 cm H2O and up to 15
• Recomended NCPAP is 7 cm H2O
• Different external interfaces
• Hypoxemic respiratory failure

22. External interfaces

23. BiPAP
•
•
•
•
•
•
Provide two levels of positive airway pressure during
the respiratory cycle
Higher level (IPAP): “2-25” cm H2O ≈ “10 -16” cm H2O
Lower level(EPAP): “2-20” cm H2O ≈ “5 to 10” cm H2O
Leak compensation
Hypercapnic respiratory failure
Comes in 3 types:
1. PS: pt. trigger
2. PC: set RR
3. BiPAP: IPAP +EPAP.

24. SNIPPV
• Augmenting NCPAP (delivering ventilator
breaths via nasal prongs).
• Improves ( tidal volume, minute ventilation) and
decrease WOB compared to NCPAP.
• Intermittent peak inspiratory pressure.

25. HHHFNC
• “HHFNC* provides airway-distending pressure and
respiratory support in preterm neonates comparable to
nasal CPAP” (Saslow et al., 2006).
• Hypoxemic respiratory failure
• Flow rate 1-8 L/min for neonates
• Oxygen blinder
• FiO2 up to 1.0

26. Evidence Based Decisions
RDS :
•No differences between NSIPPV and BiPAP strategies in
terms of duration of ventilation and failures, suggesting
that both NIV techniques are effective in the early
treatment of RDS in VLBW infants.

27. RDS:
•HHFNC is well-tolerated by premature infants. Compared to infants
managed with NCPAP.
•No differences in deaths, ventilator-days, BPD, blood infections or
other outcomes. More infants were intubated for failing early
NCPAP compared to early HHFNC

28. Hypoxic respiratory failure:
•In hypoxic respiratory failure HFNC offers a good
balance between oxygenation and comfort compared
to NIV and Venturi mask and seems to be well
tolerated by patients.

29. AOP (HFNC vs. NCPAP)

30. AOP:
•HFNC is as effective as NCPAP in the management
of AOP.

31. • NIPPV appears to reduce the frequency of
apneas more effectively than NCPAP

32. Post Extubation:
•HHHFNC appears to have similar efficacy
and safety to NCPAP when applied
immediately post extubation

33. • The meta-analysis demonstrates a statistically
and clinically significant reduction in the risk of
meeting extubation failure criteria

34. Thank you for listening