NON INVASIVE VENTILATION IN NEWBORN

1. DR.ANSHUMAN PARIA
POST DOCTORAL TRAINEE
DEPARTMENT OF NEONATOLOGY
SSKM HOSPITAL1
NON INVASIVE VENTILATION

2. Non invasive ventilation: TOPICS
2
1. NIV:
What?
why?
How?
2. IndicationsofNIV
3. EvidenceBasedPhysiology
4. EvidenceBasedDecisions:
NIVvsCMV
NIVvsCPAP
NIVvsSNIPPV
5. Synchronization:whyand
How?
6. NIV: GUIDELINES
 primary mode
 secondary mode
 reintubation criteria
 weaning criteria
7. Long term follow-up
8. Newer directions:
N-BIPAP
NIV-NAVA
N-HFV

3. Non invasive ventilation: WHY INTEREST IN NIV??
3
 In the United Kingdom, 48% of 91 use NIPPV(2009)
 in Ireland 61% of 28units surveyed reported using NIPPV(2011)
 in Brazil 98.7% of 81 units used NIPPV(2012)
 No such data are available from the United States

4. Non invasive ventilation: WHY & WHAT?
4
 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)

5. No inflation
5 inflations of
32 ml/kg
Bjorklund LJ, et al: Acta Anaesthesiol Scand 45:986, 2001
Non invasive ventilation: WHY INTEREST IN NIV??

6. Non invasive ventilation: WHY?
6

7. Non invasive ventilation:
CLASSIFICATION OF NIV IN NEONATES:
7

8. Non invasive ventilation: HOW?-machines delivering SNIPPV
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 Infant Star ventilator (CareFusion, Yorba Linda, CA) with the Star- Sync
module (CareFusion, Yorba Linda, CA) for synchronization
 Sechrist IV-200 SAVI ventilator (Sechrist Industries, Anaheim, CA)
 Nasal-flow synchronized ventilator (Giulia; Ginevri, Rome, Italy)
 Servo-i ventilator (Maquet Medical Systems, Wayne, NJ) with neurally
adjusted ventilator assist(NAVA)
 Infant Flow SiPAP Comprehensive (CareFusion, San Diego, CA)
ventilator (available in Europe and Canada, but not in the United States)- a bilevel
device providing higher and lower pressures with much longer inspiratory
times compared with SNIPPV mode. The PIPs generated by the SiPAP device
are between 9 to 11 cm H2O.
phased out, most of the S N I P P V
studies have used it. Recently
N I P P V studies have emerged as
INFANT STAR was phased out
NIV-NAVA, an extra module ,added to Servo-i for
synchronization was used in a small study of five
low-birth-weight infants

9. Non invasive ventilation: HOW? machines delivering NIPPV
9
 SLE 2000 (Specialized Laboratory Equipment, South Croydon, UK)
 VIP Bird -R Sterling (Viasys Health Care, Conshohocken, PA)
 Drager Babylog 8000 (Drager Medicals, Lubeck, Germany)
 Inter Neo (Intermed,Sao Paulo, Brazil)
 Avea ventilator (CareFusion, San Diego, CA)
 Bear Cub 750 PSV
 Servo-i ventilator (Maquet Medical Systems, Wayne, NJ)

10. Non invasive ventilation: CLINICAL INDICATIONS:
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APNEA OF
PREMATURITY
RESPIRATORY
DISTRESS SYNDROME
POST EXTUBATION
NNT=3 !

11. Non invasive ventilation: HOW? Physiological effects of NIV
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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)

12. Non invasive ventilation: HOW? Physiological effects of NIV
12
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

13. (the non-coincident motion of the rib cage and abdomen during breathing)
the rib cage is sucked in or retracted as
abdominal excursions occur (e.g., in
upper airway obstruction), or the
abdomen is retracted as the rib cage
expands (e.g., diaphragmatic paralysis)
Prisk GK Pediatric Pulmonology 2002; 34:462–472
Non invasive ventilation: physiology:Thoraco-abdominal Asynchrony

14. 25 weeks: Abdominal (red) & Chest Wall (green) Movements
Synchronized NIPPV: Better ventilation
NCPAP NIPPV
Courtesy of Simon Bignall
Thoraco-abdominal Asynchrony  Synchrony
Non invasive ventilation: physiology

15. Non invasive ventilation: Primary Mode VS Secondary Mode
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 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.

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

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

19. Non invasive ventilation: EvidenceBasedDecisions
SNIPPV STUDIES IN NEONATE(secondary mode)
19
Adopted from: Noninvasive Respiratory Support in the P r e term Infant, Bhandari.V. Clin Perinatol 39 (2012) 497–511

20. META-ANALYSIS?
NIV:EvidenceBasedDecisions:
20

21. 21
META-ANALYSIS?
The meta-analysis demonstrates a statistically and clinically significant reduction in
the risk of meeting extubation failure criteria [typical RR 0.21 (95% CI 0.10, 0.45),
NNT 3 (95% CI 2, 5)]
NIPPV may be a useful method of augmenting the beneficial effects of NCPAP in
preterm infants with apnea that is frequent or severe. Its use appears to reduce the
frequency of apneas more effectively than NCPAP. Additional safety and efficacy
data are required before recommending NIPPV as standard therapy for apnea.

22. Non invasive ventilation: EvidenceBasedDecisions : NIPPV VS NCPAP
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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.

23. Non invasive ventilation: EvidenceBasedDecisions : NIPPV VS NCPAP
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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)

24. Non invasive ventilation: EvidenceBasedDecisions : NIPPV VS NCPAP
24
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

25. Non invasive ventilation: SNIPPV VERSUS NIPPV
“does synchronization matter?”
25
 There is only one retrospective study [from YALE NEW HAVEN NICU](Dumpa
V, Katz K, Northrup V, et al. SNIPPV vs NIPPV: does synchronization matter? J
Perinatol 2012;32(6):438–42).
 At Yale, before 2007, NIPPV was delivered through a ventilator, which synchronized
breaths with infant’s respiratory efforts (SNIPPV), using the Infant Star ventilator
with StarSync and synchronization with infant’s respiratory efforts was achieved
utilizing the Graseby capsule. NIPPV replaced SNIPPV, as the Infant Star ventilator
was phased out of production in the United States. From 2007, NIPPV has been
utilized using the Bear Cub 750 psv ventilator.
 Retrospectively they compared the clinical outcomes of the two
eras (SNIPPV=2004-2006) and (NIPPV=2007-2009).

26. Non invasive ventilation: SNIPPV VERSUS NIPPV
“does synchronization matter?”
26
 Study groups: There was no significant difference in the mean gestational
age and birth weight in the two groups: SNIPPV (n = 172; 27w; 1016 g) and
NIPPV (n = 238; 27.7w; 1117 g).
There were no significant differences in maternal demographics, use of
antenatal steroids, gender, multiple births, small for gestational age or
Apgar scores in the two groups.
More infants in the NIPPV(63%) group were given resuscitation in the
delivery room as compared to SNIPPV(44%). Use of surfactant (84.4 vs
70.2%; P<0.001) was significantly higher in the SNIPPV group.

27. Non invasive ventilation: SNIPPV VERSUS NIPPV
“does synchronization matter?”
27
 Results: After adjusting for significant confounding variables,
use of NIPPV versus SNIPPV (odds ratio, 0.74; 95% confidence
interval, 0.42–1.30) was not associated with BPD/death or
other common neonatal morbidities.
Conclusion: These data suggest that use of SNIPPV vs NIPPV is not
significantly associated with a differential impact on clinical outcomes

28. Non invasive ventilation: NIPPV VS SNIPPV (PHYSIOLOGY)
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There have been two reports, comparing SNIPPV with NIPPV, evaluating
short-term effects.
1) Chang et al. studied the effects of synchronization during nasal ventilation
comparing NIPPV,SNIPPV,NCPAP in a randomized manner, each for 1 h. They
concluded that SNIPPV reduced breathing effort and resulted in
better infant –ventilator interaction than NSIPPV.
2) Owen et al effects of NIPPV on spontaneous breathing and proposed that
synchronization of NIPPV pressure peaks with spontaneous
inspirations may increase the benefits of NIPPV

29. Non invasive ventilation: flow synchronized nasal ventilation
newer alternative?
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 Gizzi et al (Flow-Synchronized Nasal Intermittent Positive Pressure Ventilation for Infants <32 Weeks’
Gestation with Respiratory Distress Syndrome, Crit care res and prac, 2012) retrospectively evaluated
whether SNIPPV(“Giulia” Neonatal Nasal Ventilator-Ginevri Medical Technologies,
Rome, Italy) used after the INSURE procedure can reduce mechanical ventilation
(MV) need in preterm infants<32wks with RDS more effectively than NCPAP and also
compared the clinical course and the incidence of short-term outcomes of infants
managed with SNIPPV or NCPAP.
 INSURE failure was defined as FiO2 need >0.4,
respiratory acidosis, or intractable apnea that
occurred within 72 hours of surfactant
administration.

30. Non invasive ventilation: EvidenceBasedDecisions
flow synchronized nasal ventilation-newer alternative?
30
 Results:
35.5% infants in the NCPAP group and 6.1%infants in the SNIPPV group
failed the INSURE approach and underwent MV (P < 0.004).
Fewer infants in the INSURE/SNIPPV group needed a second dose of surfactant, a
high caffeine maintenance dose, and pharmacological treatment for PDA.
Differences in O2 dependency at 28 days and 36 weeks of postmenstrual age were at
the limit of significance in favor of SNIPPV treated infants.
 Conclusions. Flow Synchronized Nasal Ventilation use after INSURE technique
reduced MV need and favorably affected short-term morbidities of premature
infants

31. Non invasive ventilation: GUIDELINES:
(S)NIPPV (primary mode)
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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
Adopted from: Noninvasive Respiratory Support in the P r e term Infant, Bhandari.V. Clin Perinatol 39 (2012) 497–511

32. Non invasive ventilation: GUIDELINES:
(S)NIPPV (secondary mode)
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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
Adopted from: Noninvasive Respiratory Support in the P r e term Infant, Bhandari.V. Clin Perinatol 39 (2012) 497–511

33. Non invasive ventilation: GUIDELINES:
REINTUBATION CRITERIA
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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
Adopted from: Noninvasive Respiratory Support in the P r e term Infant, Bhandari.V. Clin Perinatol 39 (2012) 497–511

34. Non invasive ventilation: GUIDELINES:
(S)NIPPV WEANING to oxy hood/nasal cannula
34
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%
Adopted from: Noninvasive Respiratory Support in the P r e term Infant, Bhandari.V. Clin Perinatol 39 (2012) 497–511

35. Non invasive ventilation: in which preterms do we choose NIPPV?
35
MORE SUCCESSFUL IN 28-34 WKS & >1000 GM

36. 36
Non invasive ventilation: SIPAP
Two alternating levels of CDP
Also called Bi-level-NCPAP
Phasic change in delivered pressure
TI RATE PRESSURE
NIV SIMULATES IMV,WITHOUT ET 0.3-0.5 30-60 MAP=14
ATLEAST
SIPAP 2 LEVELS OF CDP, OVER WHICH
BABY BREATHES SPONTANEOUSLY
0.5-1 10-30 11 AND 4
ABOVE IT
4
better recruitment
Higher Tidal volume
Reduced work of breathing

37. Non invasive ventilation: NASAL BIPAP vs CPAP
37
Lista etal,Arch Dis Child Fetal Neonatal Ed. 2010 Mar;95(2)

38. Non invasive ventilation: NASAL BIPAP vs SNIPPV
38
28.6+/-1.8 WKS…78 NEWBORNS…RETROSPECTIVE
Ricotti Etal

39. Non invasive ventilation: NASAL HIGH FREQUENCY VENTILATION
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 In a small study by Colaizy (Acta Paediatr 2008;97:1518–1522) ,14 very low-birth-weight
infants, who were stable on NCPAP, were placed on NHFV (using the
Infant Star) for 2 h. The investigators noted that NHFV was effective in
decreasing pCO2.
 These results are similar to an earlier report(Van der hooven 1998)
 A significant amount of additional research needs to be done to
determine the clinical utility of this technique, if any, in the prevention
and/or treatment of BPD.

40. Non invasive ventilation: NAVA
40
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.

41. Non invasive ventilation: EvidenceBasedDecisions:follow up: BPD
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 Bhandari(2007) compared invasive with non invasive in
terms of long term outcome and opined that those with
early extubation to SNIPPV had 20% chance of BPD/DEATH
as compared to 52% among those who were cont on MV.

42. Non invasive ventilation: EvidenceBasedDecisions:follow up:BPD
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secondary

43. Non invasive ventilation: EvidenceBasedDecisions:follow up:BPD
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Biggest RCT till date….all babies<1000 gm
…all babies<30 wks…500 in each arm

44. 44
Non invasive ventilation: SUMMINGITUP!
BANCALARI ,2013

45. 45
THANK YOU