Care of the Preterm Infant:

Non-invasive Ventilation and Other

Related Important Stuf

SE Courtney, MD MS
Professor of Pediatrics
Stony Brook University Medical Center

Opening the Lung

Congratulations! Baby is at OPTIMAL MEAN AIRWAY

PRESSURE

Optimal Mean Airway Pressure

Benefit
Overdistension
Atelectasis

Pressure

CPAP/PEEP: DR and beyond

CPAP/PEEP should be used from the
beginning
If a self-inflating bag must be used,
equip it with a PEEP valve
Consider T-piece resuscitator

Finer NN et al, Resuscitation

2001

Use of oxygen

Oxygen Toxicity

Retinopathy of prematurity
Increased days on ventilator
Increased days on oxygen
Increased incidence/severity of BPD

Finer N and Leone T. Oxygen saturation monitoring for the

preterm infant: The evidence basis for current practice. Pediatr

Oxygen in the Delivery Room

A blender and pulse oximeter

should be used
Start with 30 or 40% oxygen in the
preterm infant
Saturations of around 80% at 5
minutes are normal

Oxygen in the NICU

Saturations of 85-93% appear to be
safe

Temperature control
Admission temperature <36
degrees centigrade is an
independent risk factor for
mortality in the preterm infant.

CPAP and Non-invasive Ventilation

Goal of Mechanical
Ventilation
To get the patient OFF mechanical ventilation!
Airway trauma
Infection
Decreased mucus clearance
Over-ventilation
Air leak
Contribution to BPD

NCPAP is probably a good

thing
CPAP Reduces mortality and respiratory
failure in RDS

Early CPAP reduces need for mechanical

ventilation

CPAP post-extubation can prevent

extubation failure

NO STUDY has shown reduction in BPD

with use of CPAP under any conditions
(testimonials dont count)

NCPAP/NIV
Constant-flow
conventional
bubble

Variable-flow
Infant Flow
Bi-level

NIPPV

Not all CPAP is created equal:

Know your equipment

Variable-flow NCPAP recruits lung

volume well and decreases work of
breathing. Care must be taken to
avoid nasal trauma.
Bubble NCPAP: pressures must be
monitored; they will be higher than
the depth of the underwater
expiratory tube.

CPAP by Conventional
Ventilator
Constant flow of air/oxygen.
CPAP provided by changing orifice size at
expiratory port of the ventilator, thus providing
back-pressure.
Variety of prongs, usually bi-nasal.
Convenient, easily available, inexpensive.

Bubble NCPAP

12

Ventilator: open symbols

Bubble:
solid symbols

10
8

No Leak

2
4

10

12

Bias Flow (Liters/min)

Kahn DJ et al, Pediatric Research 2007;62:343.

(set NCPAP)

Mean (+/- SD) Pressure (cmH

2O)

Bubble NCPAP Do We Know

What Were Doing?

Kahn et al, Pediatrics, 2007

70

150
B-NCPAP

V-NCPAP

Heart Rate (min-1)

65

TcO2 (mmHg)

B-NCPAP

Pp=0.01

V-NCPAP

60

55

50

145

140

135
3

Set NCPAP (cmH2O)

Set NCPAP (cmH2O)

97
56

B-NCPAP
96

V-NCPAP

SaO2 (%)

TcCO2 (mmHg)

54
52
50

95
94
93

48
B-NCPAP

92

V-NCPAP

46

91
3

Set NCPAP (cmH2O)

Set NCPAP (cmH2O)

Courtney et al, Bubble vs ventilator NCPAP, J Perinatol 2010

Variable-Flow (Infant Flow)

CPAP
Flow is varied to deliver the required CPAP
pressure.

The direction of flow depends on the pressures

generated by the patient.
On inspiration, the CPAP flow is towards the
nasal cavity, assisting in inspiration
On exhalation, the flow is down the expiratory
branch of the CPAP tubing.

Childs, Neonatal Intensive Care, 2000

What Do We Know About

Variable-Flow NCPAP?
Provides a very stable mean
airway pressure
Decreases work of breathing
Increases lung volume recruitment

Adapted from Moa G and Nilsson K. Acta Paediatr 1993;82:210.

C = Cannula
A = Aladdin (Infant
Flow)
I = Inca Prongs
(Conventional
Ventilator)

Courtney SE, Pyon KH,

Saslow JG et al. Pediatrics
2001;107:304-308

Pandit PB, Courtney

SE, Pyon KH et al.
Pediatrics 2001;108:
682-685

Stefanescu et al, Pediatrics 2003;112:1031

Secondary Outcomes
Conv
Days on O2

IF

77.2

65.7

0.03

Length of Stay 86.3

73.7

0.02

Stefanescu et al, Pediatrics 2003;112:1031

Apnea

Hypoxia

Hypercarbia

Stefanescu et al, Pediatrics 2003;112:1031

NCPAP with a Rate:

(NIMV, NIPPV)

NIMV for reducing apnea and extubation failure

Synchronized (?)NIMV reduces the incidence of
extubation failure and possibly apnea more
effectively than NCPAP.
Synchrony done with Graesby capsule and
Infant Star ventilator
No information is available on non-synchronized
NIMV.
Current studies ongoing

Owen LS, Morley CJ, Davis PG. PAS 2009

SiPAP
What is SiPAP?
A small (2-3 cmH2O),
slow, intermittent
increase in CPAP
pressure for a duration
up to 3 seconds to
produce a Sigh
Enables the infant to
spontaneously breathe
throughout the cycle

Small increases in IF
CPAP
pressure can change
lung
14
volume by 4-6 ml/kg.
12
Volume Change (ml/kg)

Unlike NIPPV,
10
SiPAP pressure rise
8
is only 2-3 cmH2O
6

5.5 ml/kg

4
2
0
0

10

CPAP Pressure

Adapted from Pandit PB, Courtney SE, Pyon KH et al.

Pediatrics 2001;108: 682-685

SiPAP can therefore

potentially:

Recruit lung volume

Decrease work of
breathing
Stimulate the respiratory
center

Patients who may benefit from

SiPAP:
Infants weaning from
mechanical ventilation
Premature infants that dont
require aggressive support
Infants with apnea

Nasal Bilevel vs Continuous Positive Airway

Pressure in Preterm Infants. Migliori C et al,
Pediatr Pulmonol 2005;40:426.

Nasal CPAP vs Bi-level nasal CPAP in preterm infants with RDS:

a randomized control study. Lista G et al, Arch Dis Child Fetal
Neonatal Ed. 2009

40 infants enrolled, mean GA 30wks, BW 1400g.

IF-CPAP

SiPAP

Respiratory support (d)

6.2 2

3.8 10

0.025

O2 dependency (d) 13.88

6.5 4
0.027
GA at discharge (wk)
36.7 2.5
35.61.2 0.02

SiPAP vs NCPAP
Work of Breathing and Respiratory
Parameters
S. Courtney, M. Weisner, V. Boyar, R. Habib
17 infants <1200gms birth weight, on NCPAP for mild
respiratory distress
Each infant own control; order of application randomized
and data collected in two periods for a minimum of one hour,
with 15 min on each device in each period (ie, CPAP/SiPAP,
CPAP/SiPAP
Data collected using calibrated respiratory inductance
plethysmography; esophageal balloon for estimation of
pleural pressure
Continuous monitoring of saturation, pulse,
transcutaneous oxygen and carbon dioxide

Minute Ventilation
320

Minute Ventilation

280
260
240
220

MV (ml/kg/min)

300

n=13
P=0.037

CPAP

SiPAP
Period I

CPAP

SiPAP
Period II

Synchronized Non-invasive
ventilation

Shortcut to Graph.PNG.lnk

Conclusions about SiPAP

Appears to be at least as effective as NCPAP
May improve gas exchange and decrease
minute ventilation (?decrease WOB)
Synchrony may be useful

NCPAP by Nasal Cannula

NCPAP by Cannula
Uncontrolled positive pressure may be
generated with nasal cannula
Amount of positive pressure generated
will depend on cannula size, flow rate, and
shape of nasal passages.
High humidity, high flow cannulas also
may pose an infection risk.

Nasal Cannula Use

Current literature would support
that gas delivered by nasal
cannula:
be heated and humidified
not exceed 1 L/min in infants
<1500gm
not exceed 2 L/min in infants
>1500gm
If CPAP is desired, a CPAP device

Non-invasive Ventilation is not

appropriate when

Infant cannot maintain

oxygenation (FiO2 > 0.5-0.6)
PCO2 >60
pH < 7.25
Increased work of breathing
Apnea

Questions.
Over the long term, is any one form of NCPAP
more advantageous than any other?
Is non-invasive ventilation combined with NCPAP
advantageous? Is S-NIPPV better?
When should NCPAP be initiated?
When and how should surfactant be given for
babies on NCPAP only?
What levels of pH and PCO2 are safe for babies
on NCPAP?

Keep an open mind and something

useful may fall into it.