non invasive respiratory support in newborn

Case scenario :1
A male baby weighing 1050 gm born to a 20 years old lady of para
1+0. She got admitted in BSMMU at 30 weeks gestation due to PET
and emergency LUCS done. Mother got single dose of antenatal
corticosteroid 12 hours before LUCS. Baby cried immediately after
birth & APGAR was good. Baby developed respiratory distress soon
after birth in the form of grunting and chest indrawing. Baby was
normothermic, euglycemic, reflex & activities were good.
What would be the optimum respiratory
management in delivery room?

Case Scenario: 2
• D/O Morium, inborn, got admitted in NICU at 10
minutes of her age due to prematurity (31weeks),
VLBW(1270g) and respiratory distress. The baby was
started O2 2L/min on the basis of Downe score 3. Later
on, the baby developed progressive respiratory distress
DOWNE’s Score became 5 at post natal age 3 hours
CPAP was initiated
Could we start CPAP earlier ?
IS there any alternative modalities other than CPAP ???

Case Scenario: 3
• D/O Sayeda, 30weeks, 1175g, inborn, got admitted in NICU at 10
minutes of her age due respiratory distress and DOWNE score was
5. Initially baby put on CPAP. As the baby couldn’t maintain
saturation CPAP settings were increased. She got Surfactant
therapy at 2 hours and put on Mechanical ventilation. At the age
of 120 hours baby was on low set up of MV-SIMV (pressure 10/5
cm of H20,Rate 20 b/m,Fio2 21%) and other clinical parameters
were good and extubation was planned.
What would be the next respiratory management after
extubation?

Non Invasive
Respiratory Support in newborn
Dr. Rahila Begum
Resident, Year – 1
Department of Paediatric Gastroenterology and nutrition
Dr. K.M.Mahbubur Rahman
Resident, Year – 3
Department of Neonatology
BSMMU

Content outline
• Supplemental O2 delivery apparatus.
• Different modalities of respiratory support.
• Different types of non invasive respiratory support.
• Delivery room management of respiratory distress.
• Evidences on current use of non invasive modalities.

Respiratory Therapeutic Modalities
• Supplemental Oxygen by nasal interface
• Noninvasive ventilation
 Continuous Positive Airway Pressure (CPAP)
 Heated Humidified High Flow Nasal Cannula(HHHFNC)
 Nasal intermittent Positive Pressure Ventilation( NIPPV)
 Neutrally Adjusted Ventilatory Assist( NAVA)
• Invasive modalities
MV(Mechanical Ventilation)

Respiratory Therapeutic Modalities
• Supplemental Oxygen by nasal interface
• Noninvasive ventilation
 Continuous Positive Airway Pressure (CPAP)
 HHHFNC(Heated Humidified High Flow Nasal Cannula)
 NIPPV(Nasal intermittent Positive Pressure Ventilation)
 NAVA(Neutrally Adjusted Ventilatory Assist)
• Invasive modalities
MV(Mechanical Ventilation)

Nasal prong / Nasal Cannula
• Disposable plastic device that
ends in 2 short tapered tubes
• Standard flow rate: 0.5–1 L/min
Advantages
• No risk of gastric
distension
Disadvantages
• Airway obstruction
• Dislodgement
• Skin irritation or breakdown
Oxygen therapy for Children- World Health Organization. 2016

Nasal Catheter
• Thin, flexible tube, passed into the
nose and ends with its tip in the
nasal cavity.
• Distance: Side of the nostril to inner
margin of eyebrow
• Maximum flow rate: 0.5–1 L/min
Advantage:
• Well tolerated
• Unlikely to be dislodged
Disadvantages:
• Block with mucus leads to
upper airway obstruction
• Gastric distension

Nasopharyngeal catheters
• 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).
• Maximum flow rate 0.5
- 1 L/min
Advantages:
• Cost effective
• Better oxygenation
Disadvantages:
• Drying of the nasal mucosa, bleeding
and airway obstruction.
• Gastric distension

• An oxygen hood (cube) that
surrounds the head of the
neonate, to provide continuous
flow of humidified oxygen.
• Flow rate 3 – 10 L/min.
Head box
Advantage:
• Less risk of airway
obstruction or gastric
distension.
Disadvantage:
• Carbon dioxide toxicity
if inadequate oxygen
flow

Face mask
• Flexible, plastic or
rubber that can be
molded to fit the face
• Not used in neonates
Holding O2 Source Near
The Infant’s Face
Used for short periods-
• After extubation
• During breast feeding

Supplemental Oxygen via Incubator
• 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
Advantages:
• Provides steady oxygen
• Avoids skin breakdown
• Noise is low
Disadvantage:
• Infant must be
maintained in an
incubator

The basic goal of using these devices
To recruit collapsed alveoli and terminal
airways
Maintain end-expiratory lung volume
Preserve gas exchange
Minimize
work of
breathing
Assisted Ventilation of the Neonate
6th Edition

WHY NON INVASIVE
RESPIRATORY
SUPPORT?
Less volutrauma and less Barotrauma
Avoid “ventilator associated Pneumonia, subglottic stenosis
and tracheal lesions
Avoid cardiovascular and cerebrovascular instability related to
intubation

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

Continuous Positive Airway Pressure
Application of positive
pressure to airway of a
spontaneously breathing
infant throughout the
respiratory cycle.
Most widely used CPAP is Bubble CPAP
Types:
1) Continuous Flow CPAP
- Ventilator derived CPAP
- Bubble CPAP
2) Variable Flow CPAP
- Infant Flow Driver
- Sigh Intermittent Positive Airway Pressure (SiPAP)
Gas source with 02
blender
Humidification
chamber
Pressure generator
Nasal interface

Indications
ABG Criteria:
FiO₂ requirement >0.40 to
maintain PaO₂ .50 mm Hg
Clinical Conditions:
•Respiratory disorders
•Apnea of prematurity
•Disorder causing excessive
lung fluid
•Laryngo/tracheomalacia
•Post extubation
Management protocol of newborn, NICU,
BSMMU, January 2016
Contra-indications
6th Edition
•Poor respiratory drive
•Congenital malformations
•Severe cardiovascular
instability
•Severe apnoeic episode
• Ventilatory impairment (PH
< 7.25, PCO2>60)

How CPAP works?
6th Edition

Timing of CPAP Initiation
• Prophylactic CPAP in delivery room
• Early : within 2 hours of distress
• Late : If FiO2 requirement > 0.40
CPAP does not work as
expected if it is started
after atelectasis have
been already occurred.
Early CPAP enhances
- surfactant conservation
- lower PEEP
- reduce the need for MV
6th Edition

CPAP Setting
• 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

How to assess optimum CPAP?
• Clinical:
Baby is comfortable in CPAP
Reduced respiratory distress
Normal CRT & BP
Maintain SpO₂ within 90 – 95%
• Chest X-Ray: Optimum chest expansion.
• Arterial blood gas:
pH: 7.30 – 7.40
PCO₂: 40 – 45 mm Hg
PO₂: 60 – 80 mm Hg
BSMMU, January 2016

Adjustment CPAP Settings
• ↑ 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.
6th Edition

CPAP Weaning
• Weaning should be slow and steady.
• Every 1 cm H₂O 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 cm H₂O.
• When pressure 4 and FiO₂ < 30% with normal SpO₂
and minimal retraction, CPAP may be weaned to air
or head hood.
6th Edition

CPAP Failure
• Presence of retraction / grunt
• Recurrent or severe apnoea ( ≥ 3 apnoea/ hour or
that requiring bag & mask ventilation)
• PO₂ < 50 mm Hg in FiO₂ >0.60
• PCO₂ > 60 mm Hg or pH < 7.25
BSMMU, January 2016

Complications of CPAP
• Pulmonary air leak syndrome
• Decreased cardiac out put
• 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.
6th Edition

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

• Conclusion: 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.

Early CPAP versus Surfactant in Extremely Preterm Infants.
NEJM. 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.

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.

Use of Bubble Continuous Positive Airway Pressure (BCPAP) for
Prevention of Respiratory Distress in Preterm Infants
Dr. Mohammed Shaheen ,Department of Neonatology
Bangabandhu Sheikh Mujib Medical University (BSMMU Dhaka .October: 2014
Conclusion: Prophylactic use of Bubble CPAP did not show any significant
distress in preterm infants of 28-32 weeks gestation.
Therefore, unnecessary intervention can be avoided in a group of preterm
infants who make up a large proportion of those admitted to neonatal
intensive care units.

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)

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)
• Two pressure settings: Inhalation (High pressure)Exhalation (Low pressure)
• Initial pressure setting: IPAP: 8 – 12 cm H2O EPAP: 4 – 5 cm H2O

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.

Bipin Karki.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.

King B.C et al. Mask versus Prongs for Nasal Continuous
Positive Airway Pressure in Preterm Infants: A Systematic
Review and Meta-Analysis,4th june 2019
Conclusions
We found low- to very-low-certainty evidence to suggest that delivering NCPAP
through the use of a nasal mask decreases the rate of NCPAP failure and the
incidence of skin injury among all infants requiring NCPAP. There were no
differences between the two interfaces with respect to mortality and other
morbidities. The current evidence supports the use of nasal masks for preterm
infants; however, further evidence is needed to improve the certainty of the
evidence, in particular with regard to the clinically significant long-term outcome of
moderate-to-severe BPD.

Heated 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.

Why consider high Flow Nasal Cannula?
• Easier to apply than CPAP
• Greater access to the baby’s face.
 May improve feeding and bonding
 Less prone to nasal injury
 Nursing and parental satisfaction

How HHFNC works?
Flushing the upper airway dead space of CO2,
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.

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.

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

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 headbox/oxyhood

• Results :Twenty-eight babies were enrolled after written parental
consent had been obtained. 25/28 were successfully stabilised
in the DR and transferred to the NICU on nHF. The average
admission temperature for babies transferred on nHF was 36.9°C
and the average inspired oxygen at admission was 29%. Less than
half (48%) required surfactant and 60% were still on nHF 72 h
after admission
• Conclusions: using nHF for stabilisation of premature infants
in the DR and subsequent transfer to NICU is feasible

Non Invasive Ventilation (NIV)
 Synchronized & non synchronized NIMV with a
conventional ventilation is the most common form.
 Short binasal prongs are the most commonly used
interface for NIPPV.
 Nasal mask & nasopharyngeal prongs can be used.
 NIV avoid complications of prolonged invasive
ventilator (volutrauma, infection & subglottic
stenosis.)

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.

Nasal Intermittent Positive Pressure Ventilation
Indication:
• Failing nCPAP
• Following extubation from mechanical ventilation
•As a primary supports sometimes
Benefits:
• Improves gas exchange and ventilation
• Reduces need for intubation
• Reduces duration of invasive mechanical ventilation
• Reduces extubation failure

• Conclusion: NIPPV was safely and effectively used in the
delivery room settings to provide respiratory support for VLBW
infants with less need for intubation, chest compressions,
epinephrine administration and subsequent invasive ventilation.

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.

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.

HFNC
CPAP NIPPV
Which non invasive modality is the best as
primary respiratory support?
?

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.
The aim : to assess the
effectiveness and safety of HFNC
compared to CPAP as a
noninvasive respiratory support
for the initial respiratory
management of respiratory
distress in preterm infants.

HFNC
CPAP NIPPV
Which non invasive modality is the best
during post-extubation?
?

Conclusion
HFNC is non-inferior to CPAP as respiratory support after extubation of preterm
newborns with gestational age of 32 weeks or less, and has similar reintubation
rates, although its use should be cautious in extremely preterm newborns with
gestational age <26 weeks, as it is not yet possible to determine its efficacy in this
age group.
The lower risk of nasal trauma should be taken into account when choosing between
therapies. The use of HFNC appears to be safe and efficient. Multicenter studies
with different gestational ranges are required.

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

Take home message
• Improvement of respiratory supports in neonatal
care have led to increased survival of smaller and
more critically ill infants.
• 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.
• More research required to understand relative
benefit of various NRS mode

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

non invasive respiratory support in newborn

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