Non Invasive Ventilation In

Preterm Infants
Manuel Sanchez Luna
Hospital General Universitario Gregorio Marañón
Complutense University
Madrid
Summary
• Noninvasive ventilation begings in the delivery room
• Nasal CPAP
• CPAP failure
• SNIPPV

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Pulmonary Function Monitoring during
resuscitation
Airway Obstruction Air Leaks
14/ 56 (26%) 27/ 56 (51%)

19/07/2017 M Sanchez Luna Schmölzer GM Arch Dis Child Fetal Neonatal Ed 2011 4
PFM in the delivery room
• RCT
• Recordings of 64 preterm infants < 32 week’s gestation were analyzed
• 32 infants RFM visible
• 32 masked.

G Zeballos 2017, unpublished data

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PFM
Masked PFM Median, Un-Masked PFM P
(SD) Median, (SD)

Expired volume 5.85 mL/kg (2.54) 4.95 mL/kg (1,97) 0.3

tidal (VTe)

Respiratory Rate 40 (11,2) 33 (8,5) 0.02

Minute Ventilation 220 (0.15) mL/kg/min 0.15 (0,07) mL/kg/min 0.09

EtCO2 29.74mmHg (8) 41.83mmHg (13,9) 0.012

G Zeballos 2017, unpublished data

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 PFM
Events CPAP CPAP P NIPPV NIPPV P
Masked Un-Masked Masked Un-Masked
PFM PFM PFM PFM
Number of 347 1880 417 117
breaths
analyzed
Adverse 202 2 (16.74%) <0.001 125 21 (17.9%) 0.01
Events (10.74%) (29.9%)
Mask 69/492 119/202 (59%) <0.01 7/125 14/21 (66%) <0.001
Repositioni (14%) (5.6%)
ng

G Zeballos 2017, unpublished data

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PFM
• Observational study of infants <32 week’s gestation
• between October 2014-June 2016
• Single tertiary center receiving mask NIPPV in the delivery-room.
• The RFM display was Masked to the resuscitator.
• PFM data and videos were recorded during the first 10 min of
stabilization with mask respiratory support

G Zeballos 2017, unpublished data

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 4885 inflations
PFM N= 32 babies

< 28weeks, ≥28weeks, n=18

n=14
Gestational Age
(weeks) 26+5 [1.22] 30+4 [1.68]
Mean (SD)

Weight (gr) 817.5 [140] 1416.9 [384]

Mean (SD)

G Zeballos 2017, unpublished data

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PFM Masked Monitoring

< 28weeks, n=14 ≥28weeks, n=18

CPAP NIPPV p CPAP NIPPV p

944 528 breaths 3008 405
breaths breaths breaths

Expired tidal 4.87 (0.4) 9.96 (2.11) <0.01 5.35 (2.2) 6.5 (2.5) 0.18
volumes (mL /kg)
Mean (SD)

G Zeballos 2017, unpublished data

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Monitoring lung in preterm infants at birth

• N= 51, < 37 week’s gestation

• Mean GA (SD): 28 (3)
• NM3 Philips-Respironics PFMonitor

Kang LJ, et al PLoS One 2014; 9 (7): e102729

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 ECO2 CPAP

ECO2 PPV

VT PPV

VT CPAP

Kang LJ, et al PLoS One 2014; 9 (7): e102729

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Mask CPAP at delivery

Courtesy from Zeballos G

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 Noninvasive PPIV at delivery

Courtesy from Zeballos G

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 Non invasive Hand Bag Ventilation in the DR

Courtesy from Zeballos G

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 Non invasive T-Tube Ventilation in the DR

Courtesy from Zeballos G

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PFM

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PFM

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nCPAP failure

Retrospective
Bubble CPAP
U Columbia, NY Ammari A, et al J Pediatr 2005;147:341-7

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nCPAP Failure

Ammari A, et al J Pediatr 2005;147:341-7

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CPAP failure
• What else can we do?
• Nasal ventilation?

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Noninvasive
Mechanical Ventilation
• NIPPV, conventional ventilation, Unsynchronized
• Nasal Bipap

• SNIPPV
• The positive pressure ventilator breath is delivered only after initiation of
respiratory effort, when the glottis is likely to be open, or after an apneic
interval.

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 Does BiPaP increase ventilation?

NIPPV/SNIPPV Bi-level CPAP (BiPAP/SiPAP)

NIPPV commonly uses a ventilator to provide intermittent breaths BiPAP systems provide sigh breaths with small differences
at peak pressures (10–25 cm H2O), rates (20–60/min) and between high and low NCPAP pressure
inflation times (0.3–0.5 sec) (< 4-5 cm H2O), longer inflation times (0.5–1.0 sec)
similar to those used for mechanical ventilation and lower cycle rates (10–30 per minute)

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Bi-level CPAP does not improve gas exchange when compared with conventional CPAP
for the treatment of neonates recovering from respiratory distress syndrome.

- Comparison between NCPAP and Bi-level CPAP, in a randomised crossover study

in twenty low-birthweight infants (weight at study entry 1310 g ) requiring oxygen
therapy and recovering from RDS

PIP: 8 cm H2O

PEEP: 6 cm H2O

- BiPAP, administered at the same MAP as NCPAP, confers no benefit in augmenting

ventilation and does not significantly impact oxygenation, apnoea, bradycardia or
desaturation events
Lampland AL et al, Arch Dis Child Fetal Neonatal Ed 2015; 100 (1): F31-4.
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 A comparison of bilevel and ventilator-delivered non-invasive respiratory
support.
non-randomised comparison of infants randomised to the NIPPV arm of the NIPPV trial

- There is an increase in mortality in infants who received BiPAP

- BiPAP and NIPPV may not be equivalent
Millar D et al Arch Dis Child Fetal Neonatal Ed 2016; 101 (1): F21-5.

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Noninvasive MV and BPD prevention
• 3 trials were included n=360.
• Need for invasive ventilation
• (risk ratio, 0.60; 95% CI, 0.43-0.83).
• BPD effect
• (risk ratio, 0.56; 95% CI, 0.09-3.49).

Jucille Meneses, Arch Pediatr Adolesc Med. 2012

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 - 10 preterm infants
- GA 25.3 w
- BW 800 g
- 24 d old
- Rate 10-40
- PIP + 20/25 cm H2O
- PEEP + 6/7 cm H2O

… only when pressure peaks occurred during

spontaneous inspiration tidal volume increased
(p=0.01)

RIP: respiratory inductance plethysmography

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 - 16 stable preterm infants
- GA 27.5
- BW 950
- 10 d old
- PIP + 15 cm H2O
- PEEP + 5 cm H2O
- most of them on 0.21 FiO2

Less inspiratory
effort

Chang et al Pediatr Res 2011; 69 (1): 84-9.

Reduction of the inspiratory efforts during synchronized nasal ventilation

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 Forced expiration

Alteration of
spontaneous rhythm
of breathing

Chang et al Pediatr Res 2011; 69 (1): 84-9.

Increased positive pressure deflection in PES during exhalation and prolongation of the expiration with
asynchronous nasal ventilation (20 cycles/min)
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Synchronized nasal ventilation

• Synchronized NIMV is associated with:

• increased tidal volume and minute volume as compared
with NCPAP.
• Moretti C et al, Early Hum Dev 1999

• reduction in thoracoabdominal asynchrony, and thus

stabilized the chest wall, and improved lung mechanics.
• Kiciman NM et al, Pediatr Pulmonol 1998

• decrease the work of breathing.

• Lin CH et al, Pediatr Pulmonol 1998

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 a
flow sensors
b

c prongs

Pressure
leak

Vt 3-5 ml
Ti 0.3 d test lung

Flow
response time
activation volume
~~ 60 msec
0,025 ml

Simulated Neonatal Lung Model

 Flow-Synchronized NPP <32 Weeks’
Gestation with RDS
• SNIPPV+INSURE vs nCPAP+INSURE

• INSURE if:
• FiO2 on nCPAP (5-6 cm H2 O) > 0.4 >30min, SpO2(85- 93%)

• INSURE failure defined as:

• FiO2 > 0.4 to maintain SpO2 85–93%
• significant apnoea
• respiratory acidosis (pCO2 > 65mmHg)

C Gizzi et al Critical Care Research and Practice 2012

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 Flow-Synchronized NPP <32 Weeks’
Gestation with RDS
• N=64
• INSURE failure:

CPAP SNIPPV p
11 (35.5%) 2 (6.1%) 0.004

C Gizzi et al Critical Care Research and Practice 2012

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 SNIPPV HGUGM

• Prospective observational study of SNIPPV use in < 32weeks of

gestation from January 2012 to December of 2015
• Giulia Non Invasive flow-sensor Ventilator, GINEVRI ®

Ramos Navarro C, Sanchez Luna M et al AJP Rep 2016; 6 (3): e264-71.

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 SNIPPV HGUGM

Indications of SNIPPV use

nCPAP failure: Electively For extubation:

Prolonged mechanical
Preterm infants supported
Preterm infants in which ventilation (more than 15
with nCPAP that meet
nCPAP extubation has days) with high respiratory
intubation criteria if they are
previously failed. parameters(PMAP > 10
in a stable situation
cmH2O and FiO2>35%).

Ramos Navarro C, Sanchez Luna M et al AJP Rep 2016; 6 (3): e264-71.

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SNIPPV HGUGM
Elective use (n=25) nCPAP failure(n=53) p

GA (median;IQR) 25+5; 1.5 27+5; 2.6 0,001

Weight at birth (g)
680; 360 930; 405 0,002
(median; IQR)
Days of life
39; 43 11; 18.5 0,022
(median; IQR)
Prenatal
76% (19) 84,9% (45) 0,517
corticosteroids
Rate of intubation
72% (18) 43.4% (23) 0,061
at delivery
Surfactant 88% (22) 86.8% (46) 0,356
Nasal injury 0 1.9%(1) 0,489
Neurological
4%(1)1 7.5%(4)1 0,551
impairment
92% (23) 66%(35) 0,014
Ventilator
Previously nCPAP Respiratory
dependent Apnea Hipoxemia
Success extubation acidosis
patients (n=23) (n=15)
failure (n=12) (n=15)
(n=13)
91.7%(11) 92.3%(12) 62.5%(15) 60%(9) 73.3%(11) 0,081

Ramos Navarro C, Sanchez Luna M et al AJP Rep 2016; 6 (3): e264-71.

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SNIPPV HGUGM
SNIPPV use Rate of non-invasive failure
27,70%
54,80%
25%

45%

33%
27,20%

9,40%

0,80%

2012 2013 2014 2015 "2012" "2013" "2014" "2015"

Ramos Navarro C, Sanchez Luna M et al AJP Rep 2016; 6 (3): e264-71.

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 Nasal ventilation of Apnoea of prematurity

All infants were in stable conditions except for their apnoeic episodes

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The “New Flow-Sensor”

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 Ester Sanz
Elena Maderuelo
Cristina Ramos
Paz Chimenti
Susana Zeballos
Noelia González
Gonzalo Zeballos
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