Clinical report reviews noninvasive respiratory support modalities
Dr. Cummings Mechanical ventilation has increased the survival of preterm infants but also is associated with an increased incidence of chronic lung disease (bronchopulmonary dysplasia). Nasal continuous positive airway pressure (nCPAP) is a form of noninvasive ventilation that reduces the need for mechanical ventilation and decreases the combined outcome of death or bronchopulmonary dysplasia. nCPAP also has been used to treat apnea of prematurity and is considered an evidence-based strategy to decrease post-extubation failure.
The most immature infants (less than 26 weeks’ gestational age) may benefit most from noninvasive ventilation strategies; however, all randomized trials to date have shown a high rate of nCPAP failure in these infants. Other modes of noninvasive ventilation, including nasal intermittent positive pressure ventilation (NIPPV), biphasic positive airway pressure (BiPAP) and high-flow nasal cannula (HFNC), recently have been introduced into the neonatal intensive care unit setting as potential alternatives to nCPAP. Randomized controlled trials suggest that these newer modalities may be effective alternatives to nCPAP and may offer some advantages over nCPAP, but efficacy and safety data are limited.
The new clinical report Noninvasive Respiratory Support from the AAP Committee on Fetus and Newborn briefly describes the technical aspects and physiologic principles underlying these various noninvasive respiratory support modalities. The report also reviews the clinical evidence for the utility of NIPPV, BiPAP or HFNC for the management of various neonatal respiratory conditions, including respiratory distress syndrome (RDS), apnea and post-extubation failure.
The report is available at www.pediatrics.org/cgi/doi/10.1542/peds.2015-3758 http://www.pediatrics.org/cgi/doi/10.1542/peds.2015-3758 and is published in the January issue of Pediatrics.
Although there have been numerous observational studies, only randomized clinical trials with direct comparisons to nCPAP were used to inform this report. It is important to note that when nCPAP is used for comparison, the technologies employed to provide positive pressure (ventilator or bubble CPAP) and the strategies used to decrease air-leak through the mouth (chin strap or pacifier) differ between studies. It also is important to note that NIPPV may be synchronized or nonsynchronized; synchronized NIPPV is used infrequently in the U.S.
Compared to nCPAP, synchronized NIPPV decreases the frequency of post-extubation failure, but studies using nonsynchronized NIPPV or BiPAP for post-extubation failure are inconclusive. HFNC devices that precondition the inspiratory gas mixture (37 degrees Celsius and 100% relative humidity) and deliver 2 to 8 liters/minute flow may be associated with less nasal trauma than nCPAP and may be an effective alternative to prevent post-extubation failure. HFNC may generate unpredictably high nasopharyngeal pressures and has the potential for traumatic air dissection; careful attention to the size of the prongs, demonstration of an adequate air leak between the prongs and the nares, and use of the lowest clinically effective flow rates will reduce this risk. There is insufficient prospective randomized clinical data to support the use of NIPPV/BiPAP (either synchronized or nonsynchronized) or HFNC for the management of RDS or apnea. Dr. Cummings is a lead author of the clinical report and a member of the AAP Committee on Fetus and Newborn.
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