Abstract
Majority of extremely preterm infants require positive pressure ventilatory support at the time of delivery or during the transitional period. Most of these infants present with respiratory distress (RD) and continue to require significant respiratory support in the neonatal intensive care unit (NICU). Bronchopulmonary dysplasia (BPD) remains as one of the major morbidities among survivors of the extremely preterm infants. BPD is associated with long-term adverse pulmonary and neurological outcomes. Invasive mechanical ventilation (IMV) and supplemental oxygen are two major risk factors for the development of BPD. Non-invasive ventilation (NIV) has been shown to decrease the need for IMV and reduce the risk of BPD when compared to IMV. This article reviews respiratory management with current NIV support strategies in extremely preterm infants both in delivery room as well as in the NICU and discusses the evidence to support commonly used NIV modes including nasal continuous positive airway pressure (NCPAP), nasal intermittent positive pressure ventilation (NIPPV), bi-level positive pressure (BI-PAP), high flow nasal cannula (HFNC), and newer NIV strategies currently being studied including, nasal high frequency ventilation (NHFV) and non-invasive neutrally adjusted ventilatory assist (NIV-NAVA). Randomized, clinical trials have shown that early NIPPV is superior to NCPAP to decrease the need for intubation and IMV in preterm infants with RD. It is also important to understand that selection of the device used to deliver NIPPV has a significant impact on its success. Ventilator generated NIPPV results in significantly lower rates of extubation failures when compared to Bi-PAP. Future studies should address synchronized NIPPV including NIV-NAVA and early rescue use of NHFV in the respiratory management of extremely preterm infants.
Highlights
Providing optimal ventilation strategies remains the key to success of managing extremely preterm infants
Majority of the extremely preterm infants have respiratory distress (RD) needing significant respiratory support immediately after birth or after admission to the neonatal intensive care unit (NICU) due to poor inspiratory effort, weak intercostal muscles, and poor diaphragmatic function. These infants are at very high risk of developing bronchopulmonary dysplasia (BPD) and adverse neurodevelopmental outcomes, which are directly related to the duration of invasive mechanical ventilation (IMV) and supplemental oxygen
Use of nasal continuous positive airway pressure (NCPAP) in the delivery room and nasal intermittent positive pressure ventilation (NIPPV) in the NICU has been shown to decrease the need for IMV in extremely preterm infants without increasing major morbidities [3]
Summary
Providing optimal ventilation strategies remains the key to success of managing extremely preterm infants. Use of nasal continuous positive airway pressure (NCPAP) in the delivery room and nasal intermittent positive pressure ventilation (NIPPV) in the NICU has been shown to decrease the need for IMV in extremely preterm infants without increasing major morbidities [3]. In a retrospective study in very low birth weight infants, comparing positive pressure ventilation (PPV) using a face mask to directly placing on NIPPV with RAM nasal cannula at birth, NIPPV use was associated with a significantly decreased need for intubation in the DR (31 vs 85%) including among the extremely preterm infants born at 24–27 weeks of gestation, decreased need for chest compressions (11 vs 31%), and decreased the need for IMV at 24 h of age (38 vs 66%) [28]. SLI procedure creates a transepithelial pressure gradient across the alveolar-capillary membrane and helps to move fluid from the alveoli into the interstitial space and subsequent removal of this fluid via lung lymphatics
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