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Non invasive ventilation Non invasive ventilation
Way forward for India Way forward for India
Dr. Ashok K. Deorari MD FAMS
Professor, Department of Pediatrics,
Division of Neonatology
WHO Collaborating Centre for Training and Research in
Newborn Care, AIIMS, New Delhi
Conflict of interest -None
Overview Overview
Physiological basis for NIPPV
Evidence supporting its use
Complications and concerns
Way forward for SE Asia
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Non invasive ventilation Non invasive ventilation
CPAP*
NIPPV Synchronized vs non synchronized
*Kandiraju H ..Neonatology 2012 Early vs Late rescue ST
Non invasive ventilation Non invasive ventilation
25- 50 % CPAP fails
Mechanical ventilation life saving but often
its a risk factor for morbidities
Pulmonary, Infections, Cost
Ind Ped 2009, Bangalore ; Ind Ped 2010 Hyderabad;
J Trop Ped 2010 Delhi
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Open the lungs and keep lungs open Open the lungs and keep lungs open
Low volume also induces lung injury
Adequate recruitment of lungs to FRC important
Low
FRC
Compliant
chest
Surfactant
deficiency
Easy fatigue of
respiratory
muscles
Lachmann et al Int Care Med 1992
Physiological basis Physiological basis- -NIPPV NIPPV
Increases pharyngeal dilation
Induces Heads paradoxical reflex
Increasing MAP allowing recruitment of alveoli
Increased FRC
NIPPV Possible advantages over CPAP
Increased MAP / V
T
Better Recruitment- Respiratory drive
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Respiratory Function
Improves
Gas exchange
Lower TCO
2
Higher SpO
2
Work of breathing
Reduced WOB
Reduced AB-T synchrony
Moretti et al , Early hum dev 1999
VLBW infants
Abdomino- Thoracic Synchrony
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Clinical uses of
NIPPV
Post
Extubation

Apnea of
Prematurity
Primary
modality
RDS

Post Post Extubation 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).
Trend towards CLD reduction in NIPPV
RR 0.73 (95% CI 0.49, 1.07),
Lemyre , Davis et al, 2009
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Apnea of Prematurity Apnea of Prematurity
NIPPV NIPPV vs vs NCPAP 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.
Lemyre , Davis et al, 2009
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,
26-33
6/7
N=100 in each arm
ns NIPPV
vs
B-CPAP
Binasal
Surf used rescue
Need for intubation first 72 hrs NS
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
ns NIPPV (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
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Should NIPPV replace early CPAP ? Should NIPPV replace early CPAP ?
What is the practice implications What is the practice implications
In preterm babies esp. 28-34 weeks and > 1000g
Reduced need for Intubation
A subset of infants with high index of CPAP
failure
Need for PPV in DR
Higher A-Ado2 (>180)
No ANS exposure
Higher FiO
2
( 40-50%)
CXR- Severe RDS
Downe score > 7
CPAP pressure x FiO2 1.28
Consider
early NIPPV
Synchronized Synchronized vs vs Non synchronized Non synchronized
Synchronization- mechanical inflation commencing within 100 ms
of the onset of inspiration
SIMV has outdone IMV
sNIPPV- delivered higher tidal volume
Non synchronized - increase work of breathing/ air leaks
No definite consensus
Non-synchronized NIPPV increasingly used
No definite adv effect reported
Difficulty in synchronization- need customized equipments
Non synchronized seems to be effective and safe
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Long term beneficial outcomes .. Long term beneficial outcomes ..
Evidence is encouraging Evidence is encouraging
NIV for RDS (RCT)
Preterm < 35 wks
Kugelman 2007
Might reduce BPD
33% vs 5%
Bi PAP Bi PAP
Is it synonymous with CPAP ! Is it synonymous with CPAP !
Two alternating levels of CDP
Also called Bi-level-NCPAP
Phasic change in delivered pressure
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NIPPV NIPPV - -advantages over CPAP advantages over CPAP
FRC switch- better recruitment
Higher Tidal volume -- phasic change in pressure
Reduced work of breathing
Nasal Bi PAP for RDS Nasal Bi PAP for RDS
might be superior to NCPAP might be superior to NCPAP
RCT( N=40); 28-34wks with RDS
No difference in serum cytokine markers
( No increased lung injury)
CPAP group
Longer length of hospital stay
Longer duration O
2
dependency
Longer respiratory support
No difference- BPD, ROP, intubation rates
Lista et a,l ADCFN 2009
18
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Latest in press.. But the answer Latest in press.. But the answer
has to come from India has to come from India
BPD NIPPV vs CPAP
Multisite only patients; POOR DESIGN
Key Messages 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
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Thank you Thank you Thank you Thank you Thank you Thank you Thank you Thank you