The document discusses non-invasive ventilation (NIV) techniques for neonates, particularly nasal intermittent positive pressure ventilation (NIPPV) and its advantages over nasal continuous positive airway pressure (NCPAP). It highlights studies indicating lower extubation failure rates and better outcomes for apnea of prematurity with NIPPV, and provides guidelines for the application and settings of NIPPV in primary and secondary modes. Additionally, it covers the effectiveness of high-flow nasal cannula and other NIV modes, emphasizing the need for further research on their comparative efficacy.

1. Non invasive ventilation
Neonates -2
Dr. ADHI ARYA
SENIOR RESIDENT –GMCH -32 CHANDIGARH

3. nIPPV
• intermittent positive pressure ventilation via nasal devices
positivepressurecycledeliveredontopofcontinuousdistending
pressurebynasalroute
Similar to CPAP, unassisted spontaneous breathing occurs at a
pre-set PEEP level, but mandatory pressure control breaths
are either patient-triggered (synchronized) or machine-
triggered (non-synchronized).

4. How is synchronization done
• Infant star—)
• Phased out
• Servo –I ventilators ( for NAVA)
• Infant Flow SiPAP Comprehensive by pneumatic capsule grasby(
detecting abd movements

5. Is synchronization required
• In theory, patient-triggered nasal IMV is preferred because the
inflations are timed with the respiratory effort, and when the glottis is
open, the inflations are more likely to be transmitted effectively to
the lungs.

6. Non invasive ventilation: 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 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 (Kiciman NM Pediatr Pulmonol 1998; 25: 175–81)
6

7. Non invasive ventilation: Primary Mode VS
Secondary Mode
• NIPPV in the primary mode refers to its use soon after birth with or
without a short period ( 2 hours) of intubation for surfactant delivery,
followed by extubation.
• The secondary mode refers to its use after a longer period
(>2 hours to days to weeks) of intubation.
7

8. Non invasive ventilation:
NIPPV STUDIES IN NEONATE
8
Adopted from: Noninvasive Respiratory Support in the P r e term Infant, Bhandari.V. Clin Perinatol 39 (2012) 497–511

10. Non invasive ventilation: EvidenceBasedDecisions
SNIPPV STUDIES IN NEONATE(primary mode)
10
Adopted from: Noninvasive Respiratory Support in the P r e term Infant, Bhandari.V. Clin Perinatol 39 (2012) 497–511

11. Non invasive ventilation:
SNIPPV STUDIES IN NEONATE(secondary mode)
11Adopted from: Noninvasive Respiratory Support in the P r e term Infant, Bhandari.V. Clin Perinatol 39 (2012) 497–511

12. Non invasive ventilation: Evidence Based
Decisions : NIPPV VS NCPAP
12
EXTUBATION FAILURE RATE:NIPPV VS NCPAP
Nasal Intermittent Positive Pressure Ventilation versus Nasal Continuos Positive Airway Pressure in Neonates: A
Systematic Review and Meta-analysis: Tang et al, Indian pediatrics,2012
Five papers reported the rate of extubation failure of NIPPV
versus nCPAP following ETT and mechanical ventilation.
Meta-analysis showed that the rate of extubation
failure of NIPPV was significantly lower than that of
nCPAP [OR=0.15 (95% CI: 0.08 0.31)]; P<0.001.

13. Non invasive ventilation: Evidence Based
Decisions : NIPPV VS NCPAP
13
FAILURE RATE as a primary mode in RDS :NIPPV VS NCPAP
Nasal Intermittent Positive Pressure Ventilation versus Nasal Continuos Positive Airway Pressure in Neonates: A
Systematic Review and Meta-analysis: Tang et al, Indian pediatrics,2012
Six papers reported the failure rate of NIPPV versus nCPAP as a primary
respiratory mode, which was indicated by whether or not requiring ETT and
mechanical ventilation.
Metaanalysis showed that the failure rate in NIPPV group was
significantly lower than that in nCPAP group as a primary
respiratory mode [OR=0.44 (95% CI: 0.31-0.63); P<0.0001)

14. Non invasive ventilation: Evidence Based
Decisions : NIPPV VS NCPAP
14
META-ANALYSIS OF SECONDARY OUTCOMES BETWEEN NIPPV AND NCPAP GROUPS
Nasal Intermittent Positive Pressure Ventilation versus Nasal Continuos Positive Airway Pressure in Neonates: A
Systematic Review and Meta-analysis: Tang et al, Indian pediatrics,2012
• FINAL OUTCOME (DEATH AND/OR BPD): NIPPV was significantly better than that of nCPAP as a primary
respiratory mode [OR=0.57 (95% CI: 0.37-0.88); P=0.01]
• APNEA OF PREMATURITY: NIPPV showed a statistically lower rate of apnea (episodes per hour) as compared
with nCPAP group [WMD=-0.48 (95%CI:-0.58-0.37; P<0.001]
• DURATION OF HOSPITALIZATION : (primary respiratory mode /extubation mode) : No significant difference in
duration of hospitalization between NIPPV and nCPAP group [WMD=-0.51 (95%CI:-5.62-4.61;
• INCIDENCE OF BPD : NIPPV led to a marginally significant reduction in the incidence of BPD as compared
with nCPAP. [OR(95%CI)=0.39-1.00,P=0.05]
• incidence of IVH, PVL, ROP, PDA, Pneumothorax or air leak, abdominal distention, necrotizing enterocolitis :
no significant differences

15. Non invasive ventilation: GUIDELINES:
(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 lpm
2. Caffeine loading → maintenance
3. Hematocrit 35%
4. Monitor SpO2, HR and respirations
5. Obtain blood gas in 15–30 min
6. Adjust ventilator settings to maintain blood gas parameters within normal limits
7. Suction mouth and pharynx and insert clean airway Q4, as necessary
8. Maximal support recommendations:
 1000 g MAP 14 cm H2O
>1000 g MAP 16 cm H2O
15

16. Non invasive ventilation: GUIDELINES:
(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 loading →maintenance
 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 lpm
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
16

17. Non invasive ventilation: GUIDELINES:
REINTUBATION CRITERIA
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 caffeine
therapy
4. Frequent desaturation (<85%)=3 episodes per hour not responding to increased
ventilator settings
17
Adopted from: Noninvasive Respiratory Support in the P r e term Infant, Bhandari.V. Clin Perinatol 39 (2012) 497–511

18. Non invasive ventilation-weaning
to oxy hood/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 lpm
 Blood gases within normal limits
2. Wean to:
 Oxy hood adjust FiO2 to keep SpO2 85–93%
 NC adjust flow (1–2 l m–1) and FiO2 to keep SpO2 85–93%
18
Adopted from: Noninvasive Respiratory Support in the P r e term Infant, Bhandari.V. Clin Perinatol 39 (2012) 497–511

19. Bipap /Sipap

20. Non invasive ventilation: NASAL BIPAP vs CPAP
20
Lista etal,Arch Dis Child Fetal Neonatal Ed. 2010 Mar;95(2)

21. Non invasive ventilation: NASAL BIPAP vs SNIPPV
21

22. HHFNC

23. LOW FLOW V/S HIGH FLOW
• HIGH FLOW--MORE THAN INPIRATORY FLOW
• NO CONSENSUS
• BUT IN NEONATES FLOWS >2L/MIN

24. MOA
• warmed and humidified flow of air and/or air-oxygen.—DEC WOB
• some degree of end distending pressure – COMPARABLE TO nCPAP
• Reduced dead space- reduced co2 rebreathing

25. ADVANTAGES OVER CPAP
• HHF may be better tolerated by infants becoming unsettled with
HCPAP.
• Less nasal injuries
• Sucking feeds and Kangaroo care are more easily attempted with HHF
than HCPAP.

26. COMPARISON WITH CPAP
• Yoder et al 2013
• Similar in efficacy in post extubation and as initial respiratory support
• No increased risk of air leaks
• No difference in different machines

27. COMPARISON WITH CPAP AND OTHER NIV
MODES
High flow nasal cannula for
respiratory support in preterm infants
Cochrane Neonatal Group FEB 2016
DOI: 10.1002/14651858.CD006405

28. CONCLUSION
• similar rates of efficacy to other forms of non-invasive respiratory
support in preterm infants for preventing treatment failure, death
and CLD.
• Most evidence is available for the use of HFNC as post-extubation
support. Following extubation, HFNC is associated with less nasal
trauma, and may be associated with reduced pneumothorax
compared with nasal CPAP.

29. • Further RCTs needed for comparing HFNC with other forms of
primary non- invasive support after birth and for weaning from non-
invasive support.
• also for evaluating the safety and efficacy of HFNC in extremely
preterm and mildly preterm subgroups, and for comparing different
HFNC devices.

30. DEVICES AVAILABLE
• Optiflow System ( AIRVO- Fisher and Paykel,
• Precision Flow (VAPOTHERM), and
• Comfort-Flo®(Teleflex)

31. General considerations
• Nasal cannula size is important
• Outer diameter of cannula should not be > 50% of internal diameter of
nares
Flow rate is size dependent
• 1000-1999 -- 3 –lpm
• 2000-2999—4
• >3000—5
Flow rate can increase in any slab by max of 3 Lpm

32. Non invasive ventilation: NAVA
32
NAVA/Neurally adjusted
ventilator assist is a mode of
synchronisation which uses
diaphragmatic
electromyography to
synchronise not only the time
of breath according to
patients initiation of
inspiration ,but also it gives
breath proportionate to
electrical activity of
diaphragm.