Review
Nasal intermittent positive pressure ventilation in preterm infants: Equipment, evidence, and synchronization

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Summary

The use of nasal intermittent positive pressure ventilation (NIPPV) as respiratory support for preterm infants is well established. Evidence from randomized trials indicates that NIPPV is advantageous over continuous positive airway pressure (CPAP) as post-extubation support, albeit with varied outcomes between NIPPV techniques. Randomized data comparing NIPPV with CPAP as primary support, and for the treatment of apnea, are conflicting. Intrepretation of outcomes is limited by the multiple techniques and devices used to generate and deliver NIPPV. This review discusses the potential mechanisms of action of NIPPV in preterm infants, the evidence from clinical trials, and summarizes recommendations for practice.

Introduction

NIPPV has been used as a form of non-invasive respiratory support in newborn infants since the 1970s [1]; however, uncertainty remains regarding its mechanism of action, and how best to apply it and in which infants.

This review evaluates the evidence currently available to assess whether NIPPV should be used, and under which clinical circumstances. It examine hows NIPPV may be applied, with particular reference as to whether or not NIPPV should be synchronized (sNIPPV) with spontaneous breathing.

Section snippets

Terminology and techniques

“NIPPV” is an umbrella term for multiple techniques combining the application of positive distending pressure (continuous positive airway pressure: CPAP) with intermittent pressure increases applied at the nose, without an endotracheal tube. The various abbreviations used to describe NIPPV in the literature reflect whether synchronization was attempted, and the ventilation strategy applied, e.g. N-SIMV: nasal synchronized intermittent mandatory ventilation [2]; or NI-PSV: non-invasive pressure

Pressure

In theory, any ventilator can be used to generate non-synchronized (ns)NIPPV and many have been used in published studies [6], [7], [8], [9]. However, the most cited ventilator in the NIPPV literature, and one of very few that have been used to provide sNIPPV, is the Infant Star (Infrasonics Inc., San Diego, CA, USA). However, this ventilator is no longer in production and consequently its use has almost ceased. Some manufacturers are introducing ventilators with incorporated synchronization

NIPPV: pressure and volume

It has been suggested that NIPPV pressure changes micro-recruit alveoli and improves functional residual capacity (FRC) [16], [29], [30], but no clinical trials support these theories. Nasal intermittent positive pressure ventilation is so called because it was initially presumed that pressure changes delivered into the nose would translate into lung inflations. However, observational data have shown that during NIPPV the delivered peak pressure is variable and often substantially below the set

How do clinicians apply NIPPV and biphasic CPAP?

NIPPV is widely used to treat preterm infants, with reported rates ranging from 48% in the UK (2006) [45] to 71% in Ireland [46] and 88% in Brazil [47] in 2009. Surveys have not distinguished between NIPPV and biphasic CPAP. The devices, and consequently the settings, vary between countries; in Brazil, ventilator-generated NIPPV was almost exclusively used, whereas the UK and Ireland predominantly used flow drivers (e.g. SiPAP). Typical pressure settings during ventilator-generated NIPPV were

Animal and adult studies

Extrapolation of the use of synchronization during endotracheal ventilation to synchronize NIPPV seems logical, but does it work? Does the interposition of the larynx reduce our ability to deliver effective synchronized pressure changes?

Animal studies have shown that applying positive pressure at the nose results in laryngeal narrowing and consequently reduced lung inflation [48]. Physiological studies have shown that if applied pressures reach the upper airway, glottic function is unaltered,

Comparisons with CPAP

Kirpalani published the largest NIPPV trial, studying NIPPV as primary (49%) and post-extubation support (51%), either synchronized or not, and using any NIPPV delivery device [65]. The trial randomized 1009 infants at <30 weeks of gestation, to NIPPV or CPAP. There were no differences in primary (combined outcome of death or moderate/severe bronchopulmonary dysplasia, BPD) or secondary outcomes between groups.

Direct comparisons between ventilator-generated and CPAP-driver-generated NIPPV, and between sNIPPV and nsNIPPV

No randomized controlled trials (RCTs) have directly examined differences between

Summary and practice points

NIPPV includes a spectrum of support, from low-pressure, low-rate, biphasic CPAP, to high-pressure support fully synchronized with spontaneous breathing. Devices and preferences for NIPPV delivery vary around the world, but its use is widespread.

Pressure and lung volume change do not appear to be predominant mechanisms of action during NIPPV, and it has been hard to delineate benefits of NIPPV in infants who are already established on CPAP. Studies of infants immediately post extubation, or

Conclusion and research agenda

Few studies have examined long-term effects of NIPPV, or the relative benefits of sNIPPV versus nsNIPPV. Currently, ventilator-generated NIPPV appears most likely to confer benefit but there are barriers to assessing whether ventilator-generated sNIPPV is superior to ventilator-generated nsNIPPV, in terms of practicality and cost. Encouragingly, there is little evidence of harm during NIPPV, with no increase in abdominal adverse events, in contrast to early fears with the technique [75].

What is

Conflict of interest statement

None declared.

Funding sources

None.

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