Non-Invasive Ventilation in Neonates

Non Invasive Ventilation in
Neonates
Mrs. Geetanjli
Clinical Instructor
National Institute of Nursing Education
PGIMER, Chandigarh
Geetanjli NINE, PGIMER
copyright@

OBJECTIVES
At the end of the class the participants will be
able to
Explain NIV and its need
Explain modes of NIV
Provide care to baby on CPAP
Explain benefits of NIV over invasive ventilation and
CPAP
Describe physiological basis for NIPPV
Indications and Evidence supporting its use
Identify complications and contraindications of NIV
Provide nursing care to babies on NIV effectively

Why??? NEED
Respiratory problem is one of the major
among all complications of preterm
NEONATES
Causes include lack of
Inadequate lung development and surfactant,
and inadequate surface area for gas exchange.
further it is complicated by
apnea and inability to maintain the high work of
breathing

NIV
Non invasive ventilation means the delivery of
ventilatory support without the use of an
invasive artificial airway to babies
having poor respiratory efforts
And are not spontaneously breathing

Invasive vs NIV
Invasive ventilation causes
Ventilator induced lung injury VILI
Volutrauma
Barotrauma
Atelectrauma
Biotrauma
De Paoli AG, Davis PG, Faber B, Morley CJ.

Invasive vs NIV contd…..
Other complications include
bronchopulmonary dysplasia (BPD).
Airway injury
Increase risk of infection
Air leak
Decreased cardiac output.

Invasive vs NIV contd…..
In addition to that certain tube complication
like
Dislodgement
Obstruction
Malposition

What is CPAP?
Application of positive pressure to the airway of
a spontaneously breathing infant through out
the respiratory cycle (inspiration & expiration)

How it works?
Prevents collapse of alveoli at the end of
expiration
Fluid lined alveoli tend to collapse!Fluid lined alveoli tend to collapse!Geetanjli NINE, PGIMER

LETS
Understand opening pressure

Blowing the balloon

Introduction
Atelectatic Lung – HARD balloon

1 2 3 4 5 6 7 8 9
pressure
Pressure builds as flat empty balloon fills
with flow of gases

1 2 3 4 5 6 7 8 9
pressure
More Pressure builds as balloon fillsMore Pressure builds as balloon fills
with flow of gaseswith flow of gases
13/2/14 Geetanjli NINE, PGIMER

1 2 3 4 5 6 7 8 9
pressure
volume
Opening pressure

Let go the balloon – deflate
Restart the exercise

1 2 3 4 5 6 7 8 9
pressure
volumeDeflate to opening pressure –Deflate to opening pressure –
partial deflationpartial deflation

1 2 3 4 5 6 7 8 9
pressure
volumeEasy to blowEasy to blow
if full collapse not allowedif full collapse not allowed

1 2 3 4 5 6 7 8 9
pressure
volume
Deflate to opening pressureDeflate to opening pressure

1 2 3 4 5 6 7 8 9
pressure
volume
Don’t allow pressure to fall belowDon’t allow pressure to fall below
opening pressureopening pressure

Continuous distending pressure
Aim is to keep distending pressure in alveoli
always (even in expiration) above “opening
pressure” = PEEP = CPAP

How it works?

Basic Elements of CPAP circuit

Basic Elements
O2
Gas
Source
Pressure
Generator
Patient
interface
Air
Blender Humidifier
Warmer

Patient
Interface
Heated
humidifier
Bottle with
sterile water
Inspiratory line
Oxygen blender
Flowmeter
Expiratory line
Manometer
Bubble CPAP
Gas
Source
Pressure
Generator
Patient
interface
Humidifier
Blender

Procedure- CPAP
Select CPAP machine- eg Bubble, machine
Aseptic precautions
Prepare circuit
Choose prongs- appropriate size
Connect prongs to Circuit- check connections
Keep gas flow 4-6 l/min
Adjust CPAP pressures to desired level – acc. to disease
Stabilize head of baby and insert prongs
Titrate according to needs of the baby
Don’t forget to put
oro-gastric tube

How to initiate CPAP
Starting CPAP pressure levels 5 cm H2O can
increase upto 8 cm H2O
Apnea: 5cm H2O
RDS: 5 cm H2O
Starting FiO2:
30 Titrate to maintain SpO2 Target- 87-93/91-95%
(depending upon institution policy)
Depends on indication
Flow of gases- 2-6 L/minGeetanjli NINE, PGIMER

How to stabilize on CPAP
How to titrate CPAP
Pressure levels
According to the work of breathing
FiO2 requirement
Increase to maintain 6-8 posterior rib spaces
FiO2 21-60% ideal
Flow-2-6 L/min
PaO2 - >50mmhg

Humidification and Oxygen dose
Humidity
Target SPO2– 87 to 95%
Blenders

Adequacy of CPAP
Baby is stable and comfortable with minimal
chest retractions on clinical monitoring
Normal CFT AND BP
SpO2 Target- 87-93%
Blood gases targets
PaO2-50-80 mm Hg
PCO2-35-45 mm Hg/40-60mm Hg
• Ph- 7.35-7.45

Weaning
• When to Wean
• Natural history of disease
• Depends upon indication
– RDS- No Respiratory distress/ ↓ FiO2 requirement
– Apnea- 24 -48 hr apnea free
• How to Wean
• In steps of
– First wean off oxygen to 21% in steps
– Than wean form PEEP to 4 cm H2O in step of 1 cm
H2O

Remove
• PEEP -4 cm H2O AND
• FiO2 – 21 %
• Baby maintain normal saturation and minimal
retraction is there.
• After removal frequent observation till 24
hours for apnea, tachypnea, retractions
bradycardia.

CPAP failure criteria
• Increased WOB
– CPAP- 7 cm H2O
– FiO2- 80%
• ABG
– PaO2 <50 mmHg on FiO2 80%
– PaCO2 >60 mmHg or >55 mmHg if pH <7.2
• Recurrent Apnea
Ensure before declaring CPAP Failure
1.Interface correctly fitting
2.Equipment working properly
3.Oxygen source connected
4.No obstruction to flow of gases
5.Airways clear
6.Baby not fighting

Failure criteria
– PaO2>50mmhg AND PaCO2>60mmhg ON
– FiO2 >60 %
– PEEP >7 cm H2O AND
– not maintaining Spo2 > 85%
• Baby
– have severe retraction and
– apnea,
AT THIS TIME BABY REQUIRES MECHANICAL VENTILATION

Evidence NIV vs CPAP

NIV vs CPAP
• CPAP ????
• Neonates having poor respiratory efforts
CPAP does not sufficiently off-load the burden
of high WOB, nor is capable of providing
effective alveolar ventilation.

“Open the lungs and keep lungs
open”
• Low volume also induces lung injury
• Adequate recruitment of lungs to FRC important
Lachmann et al Int Care Med 1992

Physiological effect of NIPPV
• Increases pharyngeal dilation
• Induces Head’s paradoxical reflex/Hering –breuer
inflation reflex
• Improves the respiratory drive
• Increasing MAP allowing recruitment of alveoli
• Increased FRC

Clinical uses of
NIV
Post Extubation
3 trials (n=159), VLBW
NIPPV 80% reduction in
extubation, no
gastrointestinal
perforation , less
CLD
Lemyre , Davis et al, 2009
Apnea of
Prematurity
2 trials(n=54)
One study-
reduction in
apnea
Primary
modality
RDS

Post Extubation
• Three trials (n=159), VLBW infants
• All synchronised form of NIPPV (Infant Star ventilator)
• 2 studies- Short Bi Nasal , one used- NP prongs
• 80% reduction in extubation failure, NNT 3 (95% CI 2, 5).
• No reports of gastrointestinal perforation
• Trend towards CLD reduction in NIPPV
– RR 0.73 (95% CI 0.49, 1.07),

Apnea of Prematurity
NIPPV vs NCPAP
• No reduction in need for intubation
• No reduction in rate of apnea
• One study- reduction in apnea
• 2 trials(n=54)
• Preterm < 37 weeks with apnea
NIPPV might augment the beneficial effects of NCPAP
Appears to reduce the frequency of apneas more
effectively than NCPAP.
Apnea on CPAP a trial of NIPPV may be given before IMV

Primary treatment of RDS
Author Year Population
Design
Intervention Findings
Meneses et al
2011
RCT,
26-336/7
N=100 in each arm
ns NIPPV
vs
B-CPAP
Binasal
Surf used rescue
•Need for intubation in first 72 hrs –
No difference
•55% reduced need for IMV
•Benefit seen in > 1000 g
•Overall 30% failed on non invasive
•No difference in Duration of MV/
BPD
Sai Sunil
Kishore
2009
RCT
28-34 wks
Bwt > 750 g
nsNIPPV (n-37)
Vs
NCPAP(n-39)
NP delivery
• Lesser intubation with NIPPV (48hrs)
•13.5% vs 35% ( RR=0.38; 0.15, 0.89)
•Failure rate in first week also lesser
•No difference in airleak, duration of
ventilation, BPD rates, NEC etc
•Increased abd girth in NIPPV
Kugelman
2007
RCT
24-34wks
NIMV (n=43)
vs NCPAP(n=41)
NIMV lesser intubation 25% vs 49%
Reduced BPD rates in NIMV( 2% vs
17%)
Bhandari etal RCT rapid extubation to NIPPV vs MV Reduction of CLD / Death 52% v
25% p=0.03 at 22 months longterm no difference J of Perinatology 2007

Nasal devices and evidence
• Devices previously used
• Currently used

• Hudson
• Fisher & Paykel
• Argyle
Nasal devices –binasal
Prongs
Devices previously used

HUDSON SIZES
• 0- wt<700gm,
• 1- 700-1000gm,
• 2- 1000-2000gm,
• 3- 2000-3000gm,
• 4- 3000-4000gm,
• 5- >4000gm

Nasal devices
• NIV was earlier delivered by
• Nasal cannulae (measure from earlobe to tip
of the chin or nose) : now not used because it
causes nasal mucosa damage ×
• Face masks: minimal nasal trauma but
difficulty in obtaining tight seal. ×
• Nasopharyngeal tubes: using a cut endotracheal tube
×13/2/14 Geetanjli NINE, PGIMER

Binasal prong vs single nasal prong
• Bi-nasal prongs are more effective at
preventing reintubation than single nasal
prongs , preventing reintubation in as many as
1 out of every 5 babies in which they are used
[RR 0.59 (0.41, 0.85), NNT 5 (3, 14)].
De Paoli AG, Davis PG, Faber B, Morley CJ.

Nasal masks vs binasal prongs

Nasal masks vs binasal prongs
• Enrolled 120 preterm babies < 31 weeks
gestation
• to receive nasal CPAP or SiPAP through either
nasal mask or prongs,
• it was found that only 28% babies recruited
to nasal mask group required intubation at
<72 hours age against 52% infants in the nasal
prongs limb.
• Masks also cause less trauma
Kieran EA, Twomey A, Molloy EJ,Murphy JFA,
O’Donnell CPF

Hudson vs Argyle
• Both were equally effective
• But to keep argyle in place is bit difficult and
there more chances of having nasal
hyperemia
Rego MA, Martinez FE.

The Best Ventilator… Least
damage

Prevention of complications
contd…
Possible Solutions toPossible Solutions to
Prevent Nasal InjuriesPrevent Nasal Injuries

Currently used nasal devices
• Cannulaide and Ram’s cannuala
• Cannulaide
– Extremely soft and made of gentle hydrocolloid
material anatomically designed for a good fit on
the neonate.
– It helps in prevention of damage to the nasal
septum since the nCPAP seal is established on
contact with the cannulaide rather than the
infants nose.

Cannulaide

RAMS Cannula
It is flexible, soft, gently curved nasal prong.

Nasal devices contd…
NASAL MASK

Contraindications to NIV
• Respiratory failure defined as pH < 7.25, Pco2
> 60,
• Congenital malformations of the upper airway
– T-E fistula,
– choanal atresia,
– cleft palate
– Congenital diaphragmatic hernia,
– bowel obstruction, omphalocele, or gastroschisis,
– Severe cardiovascular instability, Poor respiratory
drive Geetanjli NINE, PGIMER

Weaning form NIV
• Taper the setting to FiO2 <30%, PEEP 5, PIP
14, Rate of 30 those having weight less <2kg
can be put on nCPAP for few hours

RDS
• Assess for
– RR: if (>60)
• Look for
– Chest retractions
• Listen for
– Expiratory grunt
• If any of the two present RDS +ve
• And the scoring of the same can be done by
– Downe’s score
– Silverman Geetanjli NINE, PGIMER

Downes’ Score is more comprehensive
and can be applied to any gestational
age and condition.

Silverman Anderson score (more
suited to preterm's with HMD)
A score of >failure.
A score of >6 is indicative of impending respiratory
failure. Geetanjli NINE, PGIMER

Clinical monitoring Electronic Monitoring
Vital signs : RR, HR , BP
Severity of RDS
Perfusion (Circulation)
•CFT, BP, PP, CP, UO
•Cyanosis
Abdominal girth
•Bowel sound
•Gastric aspirate to prevent
CPAP belly
Neurological status
•Tone, activity,
responsiveness
RR, HR, SPO2 (87-93%)
PEEP 4-8 CM H2O
Fio2 21-60%

Clinical monitoring
ABG
•PaO2 = 50-80mmg
•PaCO2= 35-45mmg
•Ph-7.35-7.45

CLINICAL AND ELCTRONIC
MONITORING
Time H
R
RR C
F
T
SILVERM
AN.
SCORE
BREATH
SOUND
u/o Abd
girth
PEEP FIO2 SPO2
8am
10 am
12 md

Patient end monitoring
Time Distance
between
cannula and
interface
Nasal skin
blanched
Columella/ setal
excoriation
Oral/
nasal suction
OG in situ
and end
open
8am
10 am

Machine end
Time Bubble
present
Temperature
correct
Tubing below
the patient
level
Flow
rate 5-
8 l/min
Water level in the
container and
humidifier up to
the mark.
8am
10 am

Complications

NASAL
Respiratory
Cardiac
GI tract
CPAP ComplicationsCPAP Complications

Nasal InjuryNasal Injury
Between 20-60%

 Risk factor:
- Duration of CPAP
- Lower gestational age
- Low birth weight
- Type of CPAP patient interface
- Immature skin, mucous membranes and cartilage,
bone
Nasal InjuryNasal Injury

Causes:
• Difficulty keeping the device in place
• Misalignment or improper fixation of
nasal prongs.
• Hard to maintain an effective seal on the
infant’s nares

Types of Injuries

Irritation, Columellar Notch, and
circumferential distortion

Columellar transection andColumellar transection and widening of
nostrils

Nasal septum damageNasal septum damage

Persistent snubbing afterPersistent snubbing after
removal of NCPAPremoval of NCPAP

Laceration of alae nasiLaceration of alae nasi
Arch. Dis. Child. Fetal Neonatal Ed. 2007;92;F18

Assess, Prevent and
Treat

Assessing NoseAssessing Nose
– Note the size, shape, and position in relation to
the rest of the face
– Are the nares symmetrical, stretched out?
– Is there any blanching of skin at nares?
– Is there a skin breakdown?
– Septum position; is it straight or does it appear
crooked?
Advances in Neonatal Care.8,(2),116-124,2008Geetanjli NINE, PGIMER

Tip of Nose 0=Normal , 1= Red , 2= Red + indent
3=Red/indent/skin breakdown , 4=As above +tissue loss
Nasal Septum 0=Normal , 1= Red , 2= Red + indent
3=Red/indent/skin breakdown , 4=As above +tissue loss
Nostrils 0=Normal , 1= Enlarged , 2= Enlarged and prong shape
3=Red, bleeding , 4=As above + skin breakdown
Nose Shape 0= Normal , 1=Pushed up/back but normal , 2=Pushed up and
shortened., No normal orientation when prongs removed.
Scoring:
0= No injury
1-4= mild injury
5-6= moderate injury
>7= severe injury

Assessing the nasal interfaceAssessing the nasal interface
• Is the cap appropriately
placed?
• Is the nasal interface
component twisted?
• Is the nasal prong of
appropriate size?
• Compress the tip of the
noseGeetanjli NINE, PGIMER

• Use correct prong size
• Use normal saline as a lubricant when
inserting the nasal prongs
• If blanching of the skin occurs, use smaller
prongs
• Massage the nasal septum
• Minimize points of contact
• Keep dry and clean
• Avoid topical applications – spirit x
Monitor/view the infant and the device every hourGeetanjli NINE, PGIMER

Maintain distance of 2-3 mm between bridge of
prongs and septum
Prevent the cap/tube to cause upward pull on
the nose
 Do not allow weight of tubing to bear on face
 Use Velcro mustache
Prevent excessive movement
– Interferes with a good seal
– Swaddling helps decrease movement

Make sure there is no tension on the
tubing as this will put pressure on the
baby’s nares.
• Use skin friendly adhesive over the nose
and moustache
– Tegaderm
– Cannulaide (Beevers Manufacturing,
McMinnville, Oregon) is a tailored
hydrocolloid material with an adhesive
backing

Other complications
• Pulmonary
– At high pressures, thoracic air leaks can
occur
• Cardiovascular
– Decrease Venous return and cardiac output
– Increase CVP
– Increased pulmonary resistance

• Gatro
– Abdominal distention
– Feeding disturbances because of the gas flow to
the stomach.
• CNS
– Increase intracranial pressure
– Decrease cerebral perfusion
Other complications contd…..

Prevention of complications
contd…
• Insert oral gastric tube on free drainage

Prevention of complications contd…
• Check circuit for any leakage in circuit and
leakage from open mouth so that CPAP
pressure maintained
Ensure the bubble system &
humidification are always kept lower than
the baby to avoid condensation draining
into infants airway.

- Do not ignore alarms
- Look for the cause of desaturation rather
than just increasing Fio2

• Excessive movement
– Interferes with a good seal
– Swaddling helps decrease movement

Nursing care
• Ensure good seal
• Close assessment
• Manage the airway
• Close (hourly) clinical and electronic
monitoring
• Respiratory report
• Blood gases monitoring
• Prevent abdominal distension
• Monitoring and early reporting of
complications of NIV
Debbie Fraser Askin

Limitations
Excessive airway leak from nose and mouth
during NIV

Key Messages
• NIPPV seems to safe promising better
alternative modality of Non invasive ventilation
• Tested Indications
– RDS, AOP and Post Extubation
• Subset of infants
– severe RDS and babies with clinical predictors of
CPAP failure or recurrent apnea seems best suited
• Reduction in BPD is encouraging
• Safety/ Efficacy in < 28 weeks, Long term
benefits/ outcomes - yet to be established

References
• Ramanathan R, Sekar K, Rasmussen M, Bhatia J, Soll R. Nasal intermittent
positive pressure ventilation (nippv) versus synchronized intermittent
mandatory ventilation (simv) after surfactant treatment for respiratory
distress syndrome (rds) in preterm infants_30weeks’gestation:
multicenter, randomized, clinical trial. Available from URL:
http://www.pas-meeting.org/ 2009 baltimore/abstracts/lb%20pub
%20all_full%20text%2009.pdf.
• Sai Sunil Kishore M, Dutta S, Kumar P. Early nasal intermittent positive
pressure ventilation versus continuous positive airway pressure for
respiratory distress syndrome. Acta Paediatr 2009;98(9):1412-1415
• Robert M DiBlasi. Neonatal Noninvasive Ventilation Techniques: Do We
Really Need to Intubate?.Respiratory care. September 2011; 56 (9):1273-
1293

• Debbie Fraser Askin. Noninvasive Ventilation in the Neonate. J Perinat
Neonat Nurs 2007;21 (4) : 349–358
• De Paoli AG, Davis PG, Faber B, Morley CJ. Devices and pressure sources
for administration of nasal continuous positive airway pressure (NCPAP) in
preterm neonates. Cochrane Database Syst Rev 2008; (1): CD002977.
• Kieran EA, Twomey A, Molloy EJ,Murphy JFA, O’Donnell CPF. A
randomised controlled trial of prongs or mask for nasal continuous
positive airways pressure (NCPAP) in preterm infants: The POM trial. Arch
Dis Child 2011; 96 (Suppl 1): P5.
• C Aparna, Deorari A. Noninvasive Ventilation in Newborn. Workshop on
Advances Neonatal Ventialtion. In: K. Parveen etal, editors. Neonatal unit
Department of PGIMER, Chandigarh.

• Kieran EA, Twomey AR, Molloy EJ, Murphy JF, O'Donnell CP.
Randomized trial of prongs or mask for nasal continuous positive airway pressu
Pediatrics. 2012 Nov;130(5):e1170-6. doi: 10.1542/peds.2011-3548.
Epub 2012 Oct 22. PubMed PMID: 23090339.
• Shaffer TH, Alapati D, Greenspan JS, Wolfson MR.
Neonatal non-invasive respiratory support: physiological implications.
Pediatr Pulmonol. 2012 Sep;47(9):837-47. doi: 10.1002/ppul.22610. Epub
2012 Jul 6. Review. PubMed PMID: 22777738.
• Deorari A, K. Parveen, M Srinivas, editors. Workbook on CPAP Science,
Evidence and Practice. Chetna. 2010.
• Lemyre B, Davis PG, de Paoli AG. Nasal intermittent positive pressure
ventilation (NIPPV) versus nasal continuous positive airway pressure
(NCPAP) for apnea of prematurity. Available from URL:
http://www.ncbi.nlm.nih.gov/pubmed/11869635
• Meneses J, Bhandari V, Alves JG, Herrmann D. Noninvasive ventilation for
respiratory distress syndrome. A randomized controlled trial. Pediatrics
2011; 127:300-307. Geetanjli NINE, PGIMER

Thank you

Non-Invasive Ventilation in Neonates

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