Invasive and non-invasive ventilation for prematurely born infants – current practice in neonatal ventilation

ABSTRACT

Non-invasive techniques, include nasal continuous positive airways pressure (nCPAP), nasal intermittent positive pressure ventilation (NIPPV) and heated, humidified, high flow cannula (HHFNC). Randomised controlled trials (RCTs) of nCPAP versus ventilation have given mixed results, but one demonstrated fewer respiratory problems during infancy. Meta-analysis demonstrated NIPPV rather than nCPAP provided better support post extubation. After extubation or initial support HHFNC has similar efficacy to CPAP. Invasive techniques include those that synchronise inflations with the patient’s respiratory efforts. Assist control/ synchronised intermittent mandatory ventilation compared to non triggered modes only reduce the duration of ventilation. Further data are required to determine the efficacy of proportional assist ventilation and neurally adjusted ventilatory assist. Other techniques aim to minimise volutrauma. RCTs of volume targeted ventilation demonstrated reductions in BPD and respiratory medication usage at follow-up. Prophylactic high frequency oscillatory ventilation does not reduce BPD, but is associated with superior lung function at school age.

KEY WORDS:

• continuous positive airway pressure
• heated
• humidified
• high flow nasal cannula
• patient triggered ventilation
• volume targeted ventilation
• high frequency oscillatory ventilation

Key issues

• The evidence for efficacy of non-invasive and invasive respiratory support techniques in prematurely born infants has been reviewed

• RCTs of nCPAP versus ventilation have given mixed results, but follow-up demonstrated fewer respiratory problems during infancy.

• Meta-analysis of RCTs demonstrated NIPPV rather than CPAP provided more effective support postextubation.

• After extubation or as initial support, HHFNC appears to have similar efficacy to CPAP.

• ACV and SIMV only reduce the duration of ventilation and should be used as weaning modes. ACV or pressure support are the preferred triggered modes as they provide support to all of the infant’s breaths.

• During both PAV and NAVA, the applied pressure is servo-controlled by continuous input from the infant’s breathing, but there are too few data in prematurely born infants to draw meaning full conclusions on their efficacy.

• RCTs of VTV demonstrated reductions in BPD, intracerebral hemorrhage, pneumothorax, hypocarbia, and respiratory medication usage at follow-up.

• Prophylactic HFOV does not reduce BPD, but is associated with superior lung function at school age.

• A minority of RCTs have incorporated long-term follow-up and more research is required to determine the optimum technique for chronically ventilator-dependent infants.

Financial & competing interests disclosure

A Greenough has held grants from various ventilator manufacturers and received honoraria for giving lectures and advising various ventilator manufacturers. The paper has been supported by King’s College London and NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.