Neonatal NIPPV in

Respiratory Distress

Risma Kerina Kaban

Neonatology Division
Child Health Department
Cipto Mangunkusumo Hospital
 Objectives
• Introduction

• Nomenclature

• Mechanism of Action SNIPPV

• NIPPV Indication and Contraindication

• Potential Hazards/Complication

• Clinical Management

• Use of Non-Invasive Respiratory Support in Specific

Clinical Circumstances
 Introduction

• Nasal intermittent positive pressure

ventilation (NIPPV) is a form of non-
invasive ventilatory assistance using a
nasal interface to deliver IPPV to provide
respiratory support.

Bhandari V. J of Perinatol. 2010;30:505-512

 …Introduction

• Endotracheal ventilation is a life-saving

treatment for many preterm infants.
However, it is associated with increased
mortality and morbidity, including
bronchopulmonary dysplasia.
• >40% of infants born < 28 weeks
gestation still develop BPD.

Roberts CT, et al. Neonatol. 2013;104:203-209

 …Introduction

• Although some infants born < 29 weeks’

gestation (46–83%) receive endotracheal
ventilation, many others at these
gestations can be successfully managed
non-invasively from birth, with nasal
continuous positive airway pressure
(NCPAP).

Roberts CT, et al. Neonatol. 2013;104:203-209

 Stepwise approach
towards optimal ventilation
NON-INVASIVE HFOV
FAILURE CRITERIA:
• Apneu FAILURE CRITERIA:
• Respiratory failure
(PO2 < 40 mmHg,
CMV Respiratory failure
(PO2 < 40 mmHg,
PaCO2>60 mmHg, PaCO2> 60 mmHg,
pH <7,25, BE > (-) 12) pH <7,25, BE > (-)12)
• FiO2 > 40%
NIPPV
LUNG INJURY
Mainly by high tidal volume
: > 8 mL/ kg may cause
CPAP overdistension
FiO2 > 60%

HFN INVASIVE
Optimal ventilation
•Work of breathing (–)
• The lowest possible FiO2 to reach targeted O2 saturation
•Acceptable pCO2 with pH > 7.25
• CXR- the 8th-9th ribs
 The problems of endotracheal
intubation

• Acute and chronic lung damage :

volutrauma – barotrauma – biotrauma
• Local airway damage
• Infections : pulmonary - systemic
• Technical problem
Endotracheal intubation is more
difficult than we realize

Colm P.F et al. Pediatrics January 2006, VOLUME 117 / ISSUE 1

NIV : is better than conventional
mechanical ventilation ?
Mechanical NIV
Ventilator
 Non Invasive Ventilatory Support

Constant airway Variable airway

pressure pressure

Nippv/
Nasal cannula CPAP nSIPPV nBiPAP nHFV

LFNC HFNC Constant Variable

flow flow
CPAP CPAP

Conventional Buble
CPAP CPAP
 Nasal Intermittent Positive
Pressure Ventilation (NIPPV)

• NIPPV superimposes an intermittent

peak pressure on CPAP and ventilator
using Hudson prongs

• is NOT a replacement for endotracheal

ventilation

• Should be seen as optimalization of

CPAP
Ventilator Machines delivering NIPPV

• 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)
• CNO Medin
Can we do better than CPAP?

NIPPV
 NIPPV
Nasal Intermittent Positive Pressure Ventilation

• CPAP + BUR = backuprate

• SNIPPV = synchronised NIPPV
• NV = nasal ventilation
• N-SIMV = nasal synchronised IMV
• N-IMV = nasal IMV
• N-BiPAP = nasal bipap
• NI-PSV = non-invasive pressure support
ventilation

Roberts CT, et al. Neonatol. 2013;104:203-209

 Nomenclature
• NIPPV may be synchronized (SNIPPV)
or non-synchronized to the infant’s
breathing efforts.
• The primary mode of (S)NIPPV refers to
its use soon after birth. This may or may
not include a short period (≤ 2 h) of
endotracheal intubation to deliver
surfactant before extubation.

Bhandari V. J of Perinatol. 2010;30:505-512

 …Nomenclature

• The secondary mode refers to its use

after a longer period (>2 h to days to
weeks) of endotracheal IPPV, usually for
respiratory distress syndrome (RDS).

Bhandari V. J of Perinatol. 2010;30:505-512

 Mechanism of Action SNIPPV
• Decreased Thoraco-abdominal motion asynchrony
• Decreased flow resistance through the nasal prongs
• Improved stability of the chest wall and pulmonary
mechanics.

Kiciman NM et al. Pediatr Pulmonol 1998; 25: 175–181.

• Addition of a peak inspiratory pressure (PIP) above

positive end expiratory pressure (PEEP) by using
SNIPPV could be adding increased intermittent
distending pressure above PEEP, with increased flow
delivery in the upper airway

Friedlich P et al. J Perinatol 1999; 19: 413–418.

 …Mechanism of Action
• increased tidal and minute volumes when
compared with nasal continuous positive
airway pressure (NCPAP) in the same infant.

Moretti C et al. Early Hum Dev 1999; 56: 167–177.

• recruits collapsed alveoli and increases

functional residual capacity.
• decreased work of breathing.

Aghai ZH et al. Pediatr Pulmonol 2006; 41: 875 – 881.

 Technique
• A majority have used the short bi-nasal or
nasopharyngeal prongs.
Bhandari V. J of Perinatol. 2010;30:505-512

• Thoraco-abdominal synchronization with

SNIPPV may account, in part, for its efficacy.
Owen LS et al. Arch Dis Child Fetal Neonatal Ed 2007;
92: F414–F418
 NIPPV Indication
• Apnea of Prematurity

• Respiratory distress syndrome

• Post extubation with on going apneas and/or previous

extubation failure
-- should be treated with an optimized dose of Caffeine
Citrate (≥ 10 mg/kg/day)
-- non-synchronized NIPPV might not sufficiently increase
tidal volume and intubation and ventilation should be
considered for infants with high or increasing CO2
Non Invasive Ventilation :
CLINICAL INDICATIONS

Apnea of Respiratory
Prematurity Distress Syndrome

Post
extubation
NNT = 3 !
 NIPPV Contraindication
• Upper airway abnormalities :
1. Choanal atresia
2. Cleft palate
3. Tracheoesophageal fistula

• Severe cardiovascular instability

Bhandari V. J of Perinatol. 2010;30:505-512

 Potential Hazards/Complication
• Obstruction of prongs because of mucus
plugging
• Feeding intolerance
• Abdominal distension
• Abdominal perforation
• Ventilator-induced lung injury
• Hypoventilation
• Infection
• Nose bleed/nasal irritation
• Skin irritation and pressure necrosis

Bhandari V. J of Perinatol. 2010;30:505-512

 Clinical Management
(S)NIPPV (primary mode)
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

Bhandari V. J of Perinatol. 2010;30:505-512

 …Clinical Management
• FiO2 adjusted to maintainSpO2of 85 – 93%
• Flow 8–10 l m –1
• Caffeine 15 – 25 mcg ml or aminophylline
level ≥ 8mcgml–1
• Hematocrit ≥ 35%
2. Monitor SpO2, HR and respirations
3. Obtain blood gas in 15–30min
4. Adjust ventilator settings to maintain blood
gas parameters within normal limits

Bhandari V. J of Perinatol. 2010;30:505-512

 …Clinical Management
5. Suction mouth and pharynx and insert clean
airway Q4, as necessary.

6. Maximal support recommendations:

≤1000 g MAP 14 cm H2O
>1000 g MAP 16 cm H2O

Bhandari V. J of Perinatol. 2010;30:505-512

 …Clinical Management
(S)NIPPV (secondary mode)
1. Extubation criteria while on CV:
• Frequency ~ 15 – 25/minute
• PIP ≤ 16 cm H2O
• PEEP ≤ 5 cm H2O
• FiO2 ≤ 0.35
• Caffeine 15 – 25 mcg ml –1 or aminophylline
level ≥ 8mcg ml–1
• Hematocrit ≥ 35%

Bhandari V. J of Perinatol. 2010;30:505-512

 …Clinical Management
2. Place on (S)NIPPV
• Frequency ~ 15 – 25/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 l m-1.

Bhandari V. J of Perinatol. 2010;30:505-512

 …Clinical Management
3. Suction mouth and pharynx and insert clean
airway Q4, as necessary
4. Maximal support recommendations:
≤1000 g MAP 14 cm H2O
> 1000g MAP 16cm H2O

Bhandari V. J of Perinatol. 2010;30:505-512

 Consideration for Re-intubation
• pH < 7.25; PaCO2 ≥ 60 mm Hg
• Episode of apnea requiring bag and mask
ventilation
• 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
theophylline/caffeine therapy
• Frequent desaturation (< 85%) ≥ 3 episodes
per hour not responding to increased
ventilatory settings

Bhandari V. J of Perinatol. 2010;30:505-512

 (S)NIPPV Weaning to
Oxyhood/Nasal Canula
1. Minimal (S)NIPPV settings :
• Frequency ≤ 20 per minute
• PIP ≤ 14 cm H2O
• PEEP ≤ 4 cm H2O
• FiO2 ≤ 0.3
• Flow 8–10 lm–1
• Blood gases within normal limits
2. Wean to :
• Oxyhood adjust FiO2 to keep SpO2 85–
93%
• NC adjust flow (1–2 lm–1) and FiO2 to keep
SpO2 85–93%
Bhandari V. J of Perinatol. 2010;30:505-512
 Use of Non-Invasive Respiratory
Support in Specific Clinical
Circumstances

1. Treatment of Apnoea of Prematurity

2. Primary Respiratory Support
3. Respiratory Support Post-Extubation
- SNIPPV Post-Extubation
- nsNIPPV Post-Extubation
- Biphasic CPAP Post-Extubation

Roberts CT, et al. Neonatol. 2013;104:203-209

Treatment of Apnoea of Prematurity
…Treatment of Apnoea of Prematurity
 Conclusions

A Cochrane review including the studies by Lin and

Ryan concluded that NIPPV may augment the
effects of NCPAP in apnoea that is frequent or
severe, but only short-term effects were studied, and
more data are required before NIPPV could be
recommended as a therapy for apnoea

Roberts CT, et al. Neonatol. 2013;104:203-209

 Primary Respiratory Support

Need for intubation and invasive mechanical ventilation within 72 hours of life. M-H indicates Mantel-Haenszel test; NCPAP, nasal
continuous positive airway pressure; and NIPPV, nasal intermittent positive-pressure ventilation

Need for invasive mechanical ventilation within 72 hours of life among infants who received surfactant. M-H indicates
Mantel Haenszel test; Control or NCPAP, nasal continuous positive airway pressure; and Experimental or NIPPV, nasal
intermittent positive-pressure ventilation

Jucille Meneses, et al. Arch Pediatr Adolesc Med. 2012;166(4):372-376.

 Conclusions

A recent meta-analysis combined this

‘SNIPPV’ study with two nsNIPPV studies and
demonstrated a relative risk reduction for
intubation in the first 72 h in the NIPPV group
compared to NCPAP (RR 0.60, 95% CI 0.43,
0.83)

Jucille Meneses, et al. Arch Pediatr Adolesc Med. 2012;166(4):372-376.

Effectiveness Continuous Positive
Airway Pressure Versus Nasal
Intermittent Positive Pressure
Ventilation in The Respiratory
Distress of Neonate
Thomas Harry Adoe

Faculty of Medicine University of Indonesia

2015
 Methods
• Restrospective cohort study conducted to respiratory
distress syndrome of neonate with gestation age (GA)
28 – 40 weeks who were born at General Hospital of
Bekasi City in January 2013-June 2015

• Certainty of consecutive subjects and met inclusion

criteria

• The ventilation of early CPAP and NIPPV, repectively

each 50 subjects
Harry, Thomas. 20015. Perbandingan Efektivitas CPAP vs NIPPV Pada Neonatus dengan
Gawat Napas.
Neonatal Non Invasive Ventilation in Respiratory Distress

Total of Primary Outcomes CPAP NIPPV Value

n = 50 n = 50 P
Intubation. N (%) 16 (32) 5 (10) 0.007
NIV Duration (Day) 3 (1-12) 4 (1-56) 0.03
Oxygen Duration (Day) 3.5 (1-14) 5 (1-56) 0.01
Death. n (%) 8 (16) 4 (8) 0.2

Gestation age ≤ 32 weeks CPAP NIPPV Value

n = 17 n = 20 P
Intubation. N (%) 7 (41,8) 3 (15) 0.6
NIV Duration (Day) 4 (1-9) 6.5 (2-56) 0.02
Oxygen Duration (Day) 5 (1-14) 6.5 (2-56) 0.1
Death. n (%) 5 (13.5) 3 (8.1) 0.4

Birth weight ≤ 1500 grams CPAP NIPPV Value

n = 16 n = 14 P
Intubation. N (%) 8 (50) 4 (8.6) 0.3
NIV Duration (Day) 4 (1-9) 6.5 (2-56) 0.04
Oxygen Duration (Day) 5.5 (1-14) 7 (2-56) 0.18
Death. n (%) 6 (37.5) 3 (21.4) 0.4
* Categorical Variable in amount (percentage) : Fisher's Exact test and Chi Square Test
** Numeric Variable in median, mean : Mann-Whitney Test

Harry , Thomas. Comparison of the Effectiveness of CPAP vs NIPPV on Neonatal with Respiratory Distress. 2015;
 Failure of Neonatal NIV in
Respiratory Distress

Non Invasive Ventilation CPAP NIPPV Value

n = 12 n=4 P
Intubation
≤ 72 hours n (%) 5 (50) ─ ─
> 72 hours n (%) * 5 (50) 4 (100)
* Intubation < 7 days

Harry , Thomas. Comparison of the Effectiveness of CPAP vs NIPPV on Neonatal with Respiratory Distress. 2015;
 Conclusion
• Intubation, BPD, and mortality in
neonates with RDS are less in NIPPV
than CPAP
• Mean of daily non-invasive ventilation
and Oxygen using in neonates with
respiratory distress is longer on NIPPV
than CPAP
Respiratory Failure Post-Extubation
(non-synchronisation)

Lemyre B et al. 2008. The Cochrane Review

Respiratory Failure Post-Extubation
(by device)

Lemyre B et al. 2008. The Cochrane Review

BPD

Lemyre B et al. 2008. The Cochrane Review

Pneumothorax

Lemyre B et al. 2008. The Cochrane Review

 NIPPV OUTCOME:
The International Randomized
Controlled Trial

Haresh Kirpalani, David Millar, Brigitte

Lemyre, Bradley Yoder, Aaron Chiu, Robin
Roberts

NEJM, 2013
 Methods
• Eligibility criteria: GA<30 weeks and
BW<1000 g; requiring non-invasive support in
first 7 days of life, or post- extubation within
first 28 days.
• Manoeuvre: Randomized to either NIPPV
(synchronized or not) or nCPAP.
• Primary Outcome : Composite of death or
BPD.
 Results
• 36 sites randomized 1009 infants.
• Key baseline characteristics were balanced
– Mean BW 801 g vs 805 g
– 92% vs 91% received steroids
• No difference in rates of death or BPD
• Subgroup analyses:
– No differences - early vs later use of NIPPV
– No differences - synchronized or not
 Conclusions
• For infants <1000 g BW who require non-
invasive respiratory support, current devices
for NIPPV do not confer additional benefit or
risk