Non Invasive Ventilation

Dr. dr. Rinawati Rohsiswatmo, Sp.A(K)

Neonatology Division
Child Health Department
Faculty of Medicine University of Indonesia
Dr. Cipto Mangunkusumo Hospital
Current treatments change
overtime
 ...treatment

Intubation and intermittent positive

pressure ventilation (IPPV) should be
used routinely on all extremely low birth
weight neonates (<1000gr) and should be
started as soon as the infant is on the
resuscitation trolley

Roberton : The baby under 1000g , 1989

The problems of endotracheal
intubation

Acute and chronic lung damage :

volutrauma (and barotrauma)

Local airway damage subglottic

stenosis

Pulmonary and systemic infection

 Endotracheal intubation is more
difficult than we realize
Success Rates and Duration of Attempts According to the Grade of
Doctor Attempting Intubation
Total Residents Fellow Consultants
No. of attempts 60 21 18 21

No. (%) of successful 37 (62) 5 (24) 14 (78) 18 (86)

attempts

Duration of attempts, mean 33 (19) 38 (20) 36 (16) 28 (19)

(SD), second

Duration of successful 31 (17) 51 (17) 32 (13) 25 (17)

attempts, mean (SD),
second

Colm P.F. ODonnell, C. Omar F. Kamlin, Peter G. Davis and Colin J. Morley. Endotracheal Intubation Attemps During
Neonatal Resuscitation : Success Rates, Duration and Adverse Effect. Pediatrics 2006; 117; e16-e21
Treatment for respiration problems
continues
 Role of Non-Invasive
Ventilation

1st Line therapy for Respiratory distress

syndrome
Post-extubation treatment
 CPAP Definition

Continuous positive airway pressure

(CPAP) is a device that maintains positive
pressure in the neonates airway during
spontaneous breathing.
Water-Seal CPAP
 How can CPAP help?

Increases pharyngeal cross sectional area

reduces upper airway obstructions
Reduces obstructive apnea
Increases Functional Residual Capacity
(FRC)
 How can CPAP help?

Reduces work of breathing

Improve ventilation perfusion mismatch
increase oxygenation
Conserves surfactant
 Indications of CPAP

Preterm neonates with respiratory distress

syndrome (RDS)
Neonates with transient tachypnea of the
newborn (TTN)
Neonates with meconium aspiration syndrome
(MAS)
Neonates with frequent apnea and
bradycardia of prematurity
 Indications of CPAP

Neonates with paralysis of the diaphragm

Neonates who are weaning from a
mechanical ventilator
Neonates with airway diseases such as
tracheomalacia and bronchiolitis
Neonates after abdominal or chest surgery
 Contraindications of CPAP

Diaphragmatic Hernia

No spontaneous breathing

Fistule tracheoesophagus

Choana atresia
 Risks of CPAP

Air leakage = pneumothorax

Overdistention improves venous return
decrease cardiac output
Tube obstruction
Gastric distention
 Clinical Procedure

Administer CPAP soon after

birth when signs of respiratory
distress occurs
 Setting of CPAP

1. CPAP should Commence at 5-7 cm of

water, it may increased at the discretion
of the consultant
2. FiO2 21-60 % according to saturation
3. Flow 6-8 L/ min for preterm infants,
8-10 L/ min for term infants
Delivery Systems for
Nasal CPAP
Ventilator Driven Nasal CPAP
Advantages of ventilator driven constant flow
NCPAP:
Does not require any new specialised
equipment.
Does not require specialised circuits.
If infants fails trial of extubation do not
require change of equipment.

Disadvantages of ventilator driven constant

flow NCPAP
Consumes ventilator use hours &
increases frequency of servicing of
equipment.
Alarm issues with leak.
Bubble Nasal
CPAP
Bubble CPAP is another form of
continuous flow CPAP.
Level of CPAP varied by
submerging expiratory limb of
CPAP circuit into a chamber of
water to the depth of desired
CPAP.
Flow may need to be increased
to assure continuous bubbling in
water chamber.
Bubble Nasal CPAP
Advantages of bubble NCPAP:
Relatively low cost of specialised equipment.
Do not require specialised circuits.
Possible physiological benefits from oscillations
in air flow generated by bubbling.

Disadvantages of bubble NCPAP:

Require change of bedside equipment.
If infants fails trial of extubation require further
change of equipment.

To date, no studies comparing bubble CPAP to

ventilator CPAP have shown any clinically
relevant differences in measured outcomes.
Variable Flow Nasal CPAP
Requires dedicated flow generator eg
Infant Flow Driver.
Expiratory limb of circuit open
infant can draw extra gas from
expiratory limb to support inspiratory
flow.
CPAP pressure changed by varying
flow.
 Variable Flow Nasal CPAP
Infant Flow Driver
Uses special nose piece & nasal prongs to
achieve fluidic flip.
During inhalation gas flow entrained into
upper airway to achieve stable mean
airway pressure.
During exhalation gas flow redirected
into expiratory limb of circuit away from
infants airway.
Variable Flow Nasal CPAP
Advantages of variable flow NCPAP:
Possible physiological benefits from
variable flow generated by specialised
nose piece.
Disadvantages of variable flow NCPAP:
Require new specialised equipment that
can not be used for any other purpose.
Requires specialised circuits.
If infants fails trial of extubation require
change of equipment.
To date, no studies comparing Infant Flow
Driver CPAP to ventilator CPAP/bubble CPAP
have shown any clinically relevant differences
in measured outcomes.
 Airway Interface
De Paoli et al (2002) demonstrated that
binasal prongs are more effective than single
prongs for CPAP post extubation.
Commercially available CPAP airway
interface devices are predominantly based on
short binasal prongs.
Endotracheal tube CPAP increases work of
breathing dramatically.
Should not be used in preterm & term
infants.
 CPAP Failure
1. Neonates on nasal CPAP of 7-8 cm H2O will
need mechanical ventilation if any of the
following occurs:
FiO2 on CPAP >40%
paCO2 >65 mm Hg
Persistent metabolic acidosis with base deficit of
> -10
Marked retractions observed while on CPAP
Frequent episodes of apnea and/or bradycardia
Support (Surfactant, Positive pressure,
Support and Pulse Oximetry
Randomised Trial)

Randomized trial, multicentre (1316 Infants)

GA 24.0-27.6 weeks in delivery unit
CPAP (PEEP 5) vs Intubation (and surfactant at
1 hour after birth)
Primary outcome : Death or BPD

Finer, NEJM, 2010

 Support : Result
No difference for death nor BPD (better tendency
for CPAP, p=0.07 for standard definition of BPD)
Less likely to be intubated
Reduce use of steroid
Reduce duration of mechanical ventilation
No difference for Pneumothorax (6.8% vs 7.4%)

Finer, NEJM, 2010

Response on current evidence

For preterm infants who developed RDS

at birth, nCPAP is an appropriate first
line therapy
Heated Humidified High Flow
Nasal Cannula (HHHFNC)
Who When What Where How ?
Definition of Nasal High Flow
Delivery of heated and humidified
blended oxygen at optimal flow
rates directly into the nares via a
non-sealing nasal cannula.
 The Easys of HHHFNC

Easy to set up & maintain (disposable circuit)

Easy to use w/ only 3 variables (O2, flow, temp)
Easy to move (mobile circuit, battery)
Easy on the nose & baby (no prongs/bonnet)
Easy on the parents (can hold & Kangaroo)
Easy on the stomach (babies can be fed PO)
Easy on the budget (=/cheaper than CPAP)
Context and definition
 Available HHHFNC system

1. Vapoterm Precision Flow (USA)

2. Fischer & Paykel Optiflow (F&P, NZ)
 Mechanism: How it works?
Respiratory Airway
Comfort
support hydration
Reduction of Enables Ease of use
dead space comfortable Open system
Dynamic delivery of Patient
positive high flows comfort
airway Prevents
pressure desiccation of
Supplemental the airway
oxygen epithelium
Improves
mucus
clearance
 Why use HFNC?

Easy to use Reduce CPAP belly

Safe Reduce nasal trauma
Decrease WOB No pneumothoraks
Nurse friendly
More convenient for the
infants
 Who & When to Use HFN

Who & When Comments

Post-extubation Good evidence base at 28 weeks
support At time of initial extubation
Primarily after neonatal RDS

Weaning off CPAP Off CPAP sooner ---but---

No difference in days NIV support, O2 days, BPD
May transition to oral feeding earlier
Once stable FiO2 & exam x 24 hrs
? CPAP pressure

Post-INSURE Only 1 study in moderate preterm infants

Primary RDS Rx Increased failure w/ HFNC; overall ET rate similar
 Who (RWH Melbourne)
1. Post-extubation: infants born 28 weeks
gestation, including term infants
Extremely preterm infants born <28 weeks
gestation should continue to receive CPAP as
initial post-extubation support

2. Primary non-invasive respiratory support: for

infants born 30 weeks gestation, with
FiO2<0.30
Infants born <30 weeks gestation should
continue to receive CPAP as primary non-
invasive respiratory support
 Who (RWH Melbourne)
3. Preterm or term infants: stable on CPAP,
where nHF may be preferred for reasons of
simplicity and infant comfort, and/or for
neurodevelopmental reasons (eg.
establishing suck feeds)
4. Infants receiving CPAP who have a nasal
trauma or significant pressure injury (eg.
head moulding)
 Who (RWH Melbourne)
5. Clinical deterioration in an infant not on
respiratory support who has previously
received nHF

6. Stable extremely preterm (<28 weeks

gestation at birth) or extremely low birth
weight (<1000g) infants should receive nHF
4 L/min in minimal oxygen on air until 34
weeks corrected gestation as an alternative
to receiving low flow oxygen (???!!!)
 <26 Weeks GA (N=63)
FAILURE OF THE ASSIGNED TREATMENT
WITHIN 7 DAYS

HFNC NCPAP
26/32 19/31
81% 61%
 26 Weeks GA (N=240)
FAILURE OF THE ASSIGNED TREATMENT
WITHIN 7 DAYS

HFNC NCPAP
26/120 20/120
22% 17%

Risk difference 5%
95% Cl (-5, 15) %
 How to use HFNC
Important Starting Points

Only use heated and humidified systems

MUST maintain a leak at the nose
Keep it warm! . temperature ~34-37oC
Position tubing down & away from baby
Starting at least 2 lpm/kg
HFNC should be managed like CPAP
Consensus Recommendations
Initiating High Flow

Start at 4-8 lpm

Consider higher starting flow if
FiO2 > 30%
Paw > 7
Increased WOB
Weight > 2500g
Consensus Recommendations
Escalating High Flow

Dont exceed 8 lpm flow in neonates

Increase flow for:
WOB
FiO2

Dont delay in escalating flow

Change to CPAP/NIMV if not improving
Consensus Recommendations
Weaning High Flow

Wean FiO2 first

Similar to CPAP until <25-30%

Flow rate:
Evaluate at least every 12-24 hrs to determine
if flow rate can be weaned or discontinued
May be able to wean infants > 2kg more quickly

Wean by decrements of 0,5 1 lpm

Consensus Recommendations
Discontinuing High Flow

Recommend stopping HFNC when:

Flow rate = 1 lpm/kg
FiO2 consistently <25%
Normal work of breathing
Stable for minimum of 12-24 hours
 Prescribing Gas Flow Rates

Starting gas flow

Regardless of indication, use 6-7L/min as the
starting gas flow

Changes to the gas flow

Require a medical order
Set gas flow should be reviewed at least 12-24
hourly. Changes to flow should be made in
increments or decrements of 1L/min.
 Increasing nHF support

Signs of insufficient respiratory support:

Increasing oxygen requirement, tachypnoea,
subcostal or intercostal recession, increasing
apnoea or respiratory acidosis

An increase in FiO2 >0.10 from the infants

baseline requirements is a sign of possible
deterioration and requires a medical review
Then consider increasing the gas flow by at
least 1 L/min. The maximum gas flow for
newborn infants in NICU is 8 L/min.
 Increasing nHF support

Gas flows above 8 L/min may be recommended

for mature (>1 month corrected gestational age)
infants only the Infant or Pediatric cannulae
can deliver these higher gas flows: use gas
flows of 2/L/kg/min.
If an infant is deteriorating despite receiving the
maximum gas flow of 8 L/min, consideration
should be given CPAP or ETT
 Decreasing nHF support

If an infants condition is improving, consider

weaning the gas flow by 1 L/min
In general, the maximum gas flow prescribed
should be 4L/min before ceasing HFNC
therapy. Cessation of HFNC therapy requires a
medical order.

Gas flows of 1-3L/min may be used in infants

with chronic lung disease, at physician
discretion
 Decreasing nHF support

Extremely preterm or extremely low birth weight

infants up to 34 weeks corrected gestation
should continue on nHF 4 L/min in minimal
oxygen or air as an alternative to receiving low
flow oxygen.

In all other infants, once nHF therapy has been

weaned to 4L/min with FiO2 <0.30, cease nHF
and trial the infant in air or low-flow oxygen.
 CPAP Pressures with HFNC

Wilkinson et al measured infants

pharyngeal pressure using HNFC with 2-8
L/min flow

(J Perinatol 2007)
 Result
Pharyngeal pressure measurements on different flow in one infants
(BW 1398 gr)
 A consistent range of usage
Below is a visual summary of the flow ranges used in the 3 RCTs published in 2013.
The studies below use starting flows between 3 and 8 L/min.

1 Collins et al. J. Pediatr. 2013. 2 Manley et al. New Engl J Med. 2013. 3 Yoder et al. Pediatrics. 2013.
 Conclusion of HFNC
HFNC with 2-8 L/min flow increase pharyngeal
pressure for premature infants
HFNC gives equal pharyngeal pressure with CPAP usage
Flow rate & body weight important determinant
Mouth condition ( closed / open ) have no influence
CPAP has a role in the initial management of RDS
Double prongs/bubbly bottles are equally good to other
equipment

Continue to follow clinical trial of HFNC

Nasal Intermittent Positive Pressure Ventilation

Can be delivered as either synchronised or non-synchronised

nasal ventilation.
Synchronised NIPPV provides the benefits of NCPAP with
the addition of positive pressure breaths.
Delivers larger tidal volumes by enhancing
transpulmonary pressure during inspiration.
? Augmented inspiratory reflexes & sigh breaths
Reduction in respiratory rate.
Decreased respiratory effort.
Reduction in PaCO2.
Enhanced chest wall stabilisation / decreased
asynchronous thoracoabdominal motion.
? Further recruitment atelectatic terminal air spaces.
Nasal Intermittent Positive Pressure Ventilation
Infant Flow SiPAP
Provides bi-level nasal CPAP for the
spontaneously breathing neonate
through delivery of sighs above a
baseline NCPAP pressure.
Sigh breaths can be patient triggered
Uses fluidic flip nasal prongs as nasal
CPAP interface.
Nasal Intermittent Positive Pressure Ventilation

Effects of non-synchronised NIPPV not studied in

detail.
May trigger respiratory efforts by Heads
paradoxical reflex.
May provide assisted ventilation during apnoeic
episodes.
May provide additional positive pressure to
maintain airway patency during obstructive
apnoea.
Apnoea whilst on non
synchronised NIPPV
vs
Apnoea without non
synchronised NIPPV
Nasal Intermittent Positive Pressure Ventilation

Meta-analysis of 3 trials using NIPPV (all

synchronised) post extubation.
NIPPV is a useful method of
augmenting the beneficial effects of
NCPAP in preterm infants. Its use
reduces the incidence of symptoms of
extubation failure more effectively than
NCPAP.
Nasal Intermittent Positive Pressure Ventilation

Use of NIPPV as the primary mode of respiratory

support of infants with RDS.
Kugelman et al. conducted a randomized trial of
NIPPV (n=84) compared with CPAP in preterm
infants with RDS.
Infants managed with NIPPV required less
endotracheal intubation and had a lower
incidence of CLD.
Bisceglia et al. enrolled 88 preterm infants with
RDS and found that those managed with NIPPV
had shorter duration of respiratory support and
fewer apnoeic episodes.
Using Non-Invasive
Ventilation
Post extubation studies commenced with
PEEP 6 cmH2O & PIP maximum of 16
cmH2O, rate 15 & IT 0.4 seconds.
At these settings did not report increased
abdominal distension or feed intolerance.
Authors report using lower settings for
managing apnoea of prematurity.
Kugelman et al (2007): Preterm infants with
RDS.
PEEP 6-7 cmH2O, PIP 14-22 cmH2O,
Rate 12-30, IT 0.3 seconds.
Sai Sunil Kishore et al (2009):
PEEP 5 cmH2O, PIP 15-16 cmH2O, Rate
50, IT 0.3-0.35 seconds.
 Nasal HFOV
as a new modality
Aim: short-term application of bi-level nasal continuous positive airway pressure CPAP(SiPAP) compared with
conventional nasal CPAP (nCPAP) at the same mean airway pressure in infants with persistent oxygen need
recovering from RDS could improve CO2 removal with no change in oxygen requirement.
Design: Non-blinded, randomised, observational fourperiod crossover study.
Setting/population: Level III NICU; low-birthweight infants requiring CPAP and oxygen while recovering from RDS.
Results: Twenty low-birthweight infants were studied at an average of 33 days of age There were no differences in
tcCO2 or other physiological parameters except mean blood pressure.
Conclusions: At similar mean airway pressures, SiPAP does not improve CO2 removal, oxygenation or other studied
physiological parameters with the exception of mean blood pressure, which was not clinically significant.
Criteria for starting nHFV were: deterioration on nasal CPAP expressed by a median pH of 7.24 and
pCO2 of 8.3 kPa, or increasing FIO2. nHFV was delivered using the Infant Star ventilator.

ResultspCO2 decreased significantly from 8.3 kPa to 7.2 kPa after nHFV was started. In five patients
nHFV was discontinued after a median period of 6 12 hours due to CO2 retention and high oxygen
need, and endotracheal mechanical ventilation was started.

ConclusionsnHFV can reduce pCO2 in neonates with moderate respiratory insufficiency and,
therefore, could be used to decrease the need for endotracheal mechanical ventilation.
nHFOV delivered via a
single nasopharyngeal
tube
A potential advantage of nasal high-frequency ventilation over NIPPV is that synchronization is
not necessary. Synchronization of ventilatory support during NIPPV can be difficult with the new
ventilators that rely on inspiratory flow to trigger the ventilator as frequently there is an inspiratory
leak through the nasal prongs. Furthermore, the amount of leak is quite variable, making it difficult
to use a fixed level of flow to trigger inspiration.
[]
The current literature suggests that nasal ventilation, and specifically, nasal high-frequency
ventilation can improve CO2 elimination.

Further research on the effectiveness and safety of nasal high-frequency ventilation in sicker
patients is necessary before this therapy can be recommended for widespread use.
How to act on gas exchange by adjusting the

parameters of ventilation on nHFOV modality

 nHFOV Strategy

Oxygenation Ventilation

CDP/CPAP FiO2 VThf

RR (Hz) P

I:E
Hypercapnia with variable flow generators:

Increase minute ventilation

1) Increase Level of Amplitude

2) Decrease Frequency
3) Increase CPAP level
 Hypoxia with variable flow generators:

Increase Ventilation/Perfusion Ratio

1) Increase CPAP level

2) Increase FiO2
 Experience in NICU Policlinico Gemelli,
Rome

nHFOV performed with ventilator as a

rescue strategy
nHFOV rescue in three patients with incoming BPD, after extubation

Respirato FiO2 pH pCO pO2

ry 2 mmHg
mmHg
Support
A NIPPV 0.85 7.22 67.4 36.9
(cap)
B NIPPV 0.60 7.30 53 40
(cap)
C Bi-level 0.60 7.28 65 40

Two hours later on nHFOV with VN-500

CDP RR I:E P FiO2 pH pCO pO2

cmH2 Hz cmH2 2 mmHg
O O mmHg

A 12 10 1:1 26 0.45 7.33 42.6 49

(cap
)
B 12 10 1:1 25 0.45 7.35 40.4 55

C 12 10 1:1 25 0.45 7.32 47.9 55

 Thanks to :
Dr. dr. Risma Kerina Kaban, Sp.A(K)
Dr. Philips Henscke