Form Of Non-invasive Ventilation Research Articles

Neonatal Noninvasive Ventilation Nasal Mask Interface Pressure and the Inter-Individual Variation of Mask Placement.

The 2014 American Academy of Pediatrics recommendation for CPAP as an alternative to mechanical ventilation for treatment of neonatal respiratory distress prompted a rapid shift to noninvasive ventilation (NIV). Since most patients receive nasal bubble CPAP (a form of NIV), a concomitant increase in nasal pressure injuries followed. This prospective observational study aims to develop strategies to reduce nasal mask pressure injury in neonates by 1.) quantifying CPAP mask-interface pressure and 2.) assessing placement variability. A 1F MEMS Connect pressure sensor (Millar®) was modified for contact pressure measurements with silicone embedding and calibrated. The CPAP generator and interface components were sized for a 24-week neonatal simulator. Thirteen neonatal ICU staff placed the simulator on CPAP at 6 cmH2O and 8 L/min of flow with no humidification. Pressure was measured at three locations (the forehead, nasal bridge, and philtrum) in triplicate (three measurements per site). Descriptive statistics, a location-specific, one-way analysis of variance (ANOVA) with a Tukey post hoc test, and a two-sample paired t-test of the means of the first and last triplicate were performed (Minitab, LLC). Pressure ranged from 12.3 to 377.3 mmHg. The mean (SD) interface pressure at the philtrum was significantly higher than both the nasal bridge and the forehead (philtrum: 173.9 (101.3), nasal bridge: 67.79 (28.9), and forehead 79.02 (36.87), p ˂ 0.001). CPAP fixation varied, including bonnet placement, trunk angle, mask compression, use of hook and loop extenders, and level of vigorous bubble feedback achieved. This study developed a modified pressure sensor for quantifying the pressure exerted by a nasal mask on facial skin. Maximum pressures were higher than those previously reported. Inter-individual differences were present in both quantitative and qualitative measures of pressure. Reduction of NIV-associated pressure injuries may be achieved through NIV fixation technique training and improved nasal mask stability and size increments.

Management of protective lung ventilation in children with a critical course of acute respiratory distress syndrome caused by SARS-CoV-2 coronavirus infection

the pandemic of coronavirus disease COVID-19 has created a serious threat to the public health system worldwide. With the beginning of the pandemic, it became clear that children infected by SARS-CoV-2, for unknown reasons, have a milder course compared to adults. In some cases, children are asymptomatic carriers of the infection. In light of today's scientific discoveries, contrary to initial reports, recent studies have shown that children are just as likely to contract the virus as adults, while vague symptoms and a milder course more often characterize the disease itself. However, it is worth noting that the true prevalence of asymptomatic SARS-CoV-2 infection is most likely underestimated since children are not tested for COVID-19 without obvious clinical symptoms. This fact has been confirmed by multiple blood tests indicating high titers of IgG to SARS-CoV-2. Compared to adults, the typical clinical manifestations of COVID-19 in children are fever, runny nose, cough, and general weakness. The laboratory test results indicate a normal level of leukocytes, lymphopenia, and an increased level of aspartate aminotransferase, alanine aminotransferase, D-dimer, and MB creatine kinase. Currently, there is no sufficient evidence that the etiotropic therapy is 100% successful. Yet a course of action such as respiratory system protection, control of fluids and electrolyte homeostasis, anti-cytokine therapy, preventative measures for thrombosis, and treatment for bacterial superinfection proved to be efficient at preventing the development of possible complications caused by SARS-CoV-2. Therefore, it is important to collect and accumulate new experiences\cases of respiratory system protection management of an acute respiratory syndrome with a critical course of acute respiratory distress syndrome caused by COVID-19 and implement practical treatment plans for healthcare facilities. The results were analyzed using clinical epidemiology methods. Children were admitted to the intensive care unit on an average of 6,6±0,62 days of illness and were more associated with systemic disorders and water-electrolyte imbalance, which required prosthetic respiratory function, correction of hemodynamics and water-electrolyte disorders, which was carried out in the infectious diseases department of anesthesiology and intensive care for an average of 5,2±0,7 days. In children in the clinical group, SARS-CoV-2 was verified by reverse transcription polymerase chain reaction of a nasopharyngeal swab and/or exhaled air condensate based on its positive results. Comprehensive treatment of patients with severe and extremely severe respiratory distress syndrome in coronavirus disease included respiratory and hemodynamic support, antiviral and antibacterial therapy, parenteral glucocorticosteroids and anticoagulants, which was in line with current national regulatory guidelines and local protocols. According to the criteria for choosing a method of respiratory function prosthetics, in more than half of the patients (62,2%) with hemoglobin oxygen saturation of less than 92%, while maintaining active respiratory capacity, respiratory support was provided by supplementing humidified oxygen through a face mask or nasal cannulas. In another 29,7% of patients, non-invasive ventilation was performed by constant positive airway pressure, with an oxygenation index of 0,4-0,5 and a positive end-expiratory pressure of 4-5 cm of water column. Children who had a critical course of acute respiratory syndrome caused by coronavirus infection COVID-19 (8,1%) and in whom non-invasive methods of respiratory support did not bring the desired therapeutic result were on invasive ventilation in the mode of auxiliary controlled ventilation or in the mode of synchronized intermittent forced ventilation. It should be noted that children who received respiratory support in the form of non-invasive ventilation by means of constant positive airway pressure required a lower concentration of oxygen in the inhalation mixture compared to patients on free-flow oxygen supplementation. The need for admission to the intensive care unit of children with COVID-19 is primarily associated with respiratory disorders caused by interstitial pneumonia. Oxygen supplementation was of paramount importance in patient management, primarily through noninvasive ventilation with constant positive airway pressure or free flow. The use of a pulmonary protective strategy in the treatment of acute respiratory distress syndrome caused by coronavirus disease COVID-19 in children requiring invasive ventilation was accompanied by a pronounced positive result, as it was not accompanied by side effects and resulted in a rapid recovery of patients.

Acceptance and Tolerability of Helmet CPAP in Pediatric Bronchiolitis and Pneumonia: A Feasibility Study.

Continuous positive airway pressure (CPAP) is a form of noninvasive ventilation used to support pediatric patients with acute respiratory infections. Traditional CPAP interfaces have been associated with inadequate seal, mucocutaneous injury, and aerosolization of infectious particles. The helmet interface may be advantageous given its ability to create a complete seal, avoid skin breakdown, and decrease aerosolization of viruses. We aim to measure tolerability and safety in a pediatric population in the United States and ascertain feedback from parents and health care providers. We performed a prospective, open-label, single-armed feasibility study to assess tolerability and safety of helmet CPAP. Pediatric patients 1 month to 5 years of age admitted to the pediatric intensive care unit with pulmonary infections who were on CPAP for at least 2 hours were eligible. The primary outcome was percentage of patients tolerating helmet CPAP for 4 hours. Secondary measures included the rate of adverse events and change in vital signs. Qualitative feedback was obtained from families, nurses, and respiratory therapists. Five patients were enrolled and 100% tolerated helmet CPAP the full 4-hour study period. No adverse events or significant vital sign changes were observed. All family members preferred to continue the helmet interface, nursing staff noted it made cares easier, and respiratory therapists felt the set up was easy. Helmet CPAP in pediatric patients is well-tolerated, safe, and accepted by medical staff and families in the United States future randomized controlled trials measuring its effectiveness compared with traditional CPAP interfaces are needed.

The Impact of BiLevel Positive Airway Pressure (BiPAP) Application Timing on Emergency Room Length of Stay in Patients With Pulmonary Edema: A Single-Center, Retrospective Cohort Study.

Bilevel positive airway pressure (BiPAP) is a form of non-invasive ventilation (NIV) that is used to help and facilitate breathing. Our objective is to evaluate the impact of BiPAP application timeonthelength of emergency room (ER)stay in pulmonary edema patients. This is a retrospective cohort study that included patients whopresented to theERat King Abdullah Medical City (KAMC) from June2019 toJune2021. The eligibility criteriaforBiPAPapplication were congestive heart failure(CHF) and type 1 and type 2 respiratory failure, The data were collected from theTrack Caresystem.We defined early BiPAP as BiPAP application time within one hour from admission, and late BiPAP more than one hourand we calculated the percentage of discharge within four hours in each group. Out of 147 fulfilling study eligibility,64% had CHF, 23%had type 2 respiratory failure and 13%had type 1 respiratory failure.For patients discharged withinfour hours,85%wereintheearlyBiPAPand 15% were in the late BiPAP groups(p=0.001as compared to the late discharge group).Discharge within four hours was observed with the following percentages in the study subgroups:CHF early BiPAP(84%), late BiPAP (16%)(p = 0.004),type1 respiratory failure earlyBiPAP(79%),lateBiPAP(21%) (p = 0.71) and type 2 respiratory failure earlyBiPAP(94%), lateBiPAP(6%)(p = 0.89). Our results show that there is a significant outcome in earlyBiPAPapplication in decreasing the length of ER stay only in patients with pulmonary edema.

Inexpensive Multipatient Respiratory Monitoring System for Helmet Ventilation During COVID-19 Pandemic

Abstract Helmet continuous positive applied pressure is a form of noninvasive ventilation (NIV) that has been used to provide respiratory support to COVID-19 patients. Helmet NIV is low-cost, readily available, provides viral filters between the patient and clinician, and may reduce the need for invasive ventilation. Its widespread adoption has been limited, however, by the lack of a respiratory monitoring system needed to address known safety vulnerabilities and to monitor patients. To address these safety and clinical needs, we developed an inexpensive respiratory monitoring system based on readily available components suitable for local manufacture. Open-source design and manufacturing documents are provided. The monitoring system comprises flow, pressure, and CO2 sensors on the expiratory path of the helmet circuit and a central remote station to monitor up to 20 patients. The system is validated in bench tests, in human-subject tests on healthy volunteers, and in experiments that compare respiratory features obtained at the expiratory path to simultaneous ground-truth measurements from proximal sensors. Measurements of flow and pressure at the expiratory path are shown to deviate at high flow rates, and the tidal volumes reported via the expiratory path are systematically underestimated. Helmet monitoring systems exhibit high-flow rate, nonlinear effects from flow and helmet dynamics. These deviations are found to be within a reasonable margin and should, in principle, allow for calibration, correction, and deployment of clinically accurate derived quantities.

Prolonged Use of Noninvasive Ventilation in COVID-19 Geriatric Patients with Acute Respiratory Failure, can it be Tolerated?

We report six cases of the use of Non-invasive ventilation (NIV) in the COVID-19 geriatric patients with acute respiratory failure. The one case continued with intubation or invasive mechanical ventilation (IMV) and five cases did not do IMV. The novel Coronavirus disease 2019 (COVID-19) infection can occur acute respiratory failure from mild to severe. The Severe Acute respiratory failure due to COVID-19 requires oxygen therapy in the form of NIV or IMV. NIV can reduce complications related to IMV, especially the incidence of nosocomial infections and complications due to invasive procedures. The geriatric group with COVID-19 has higher risk than the young group. The many comorbidities, decreased immune function and organ systems that occur in geriatrics worsening of COVID-19 symptoms and course. NIV is only an introduction or the first step before IMV is done with close monitoring before the patients get worse. The use of NIV that is not in accordance with the indications and IMV delaying can increase the risk of COVID-19 patients mortality.

Non-invasive Positive Pressure Ventilation for Acute Cardiogenic Pulmonary Edema and Chronic Obstructive Pulmonary Disease in Prehospital and Emergency Settings.

Non-invasive ventilation is an important intervention in treating acute respiratory failure caused by acute cardiogenic pulmonary edema (ACPE) and acute exacerbations of chronic obstructive pulmonary disease (COPD). Although there are studies that give evidence on the efficacy and safety of non-invasive ventilation over standard medical care for COPD and cardiogenic pulmonary edema, less are known about the form of non-invasive ventilation, continuous positive airway pressure (CPAP), or bilevel positive airway pressure (BiPAP) as an effective intervention for respiratory failure and its efficacy and safety in prehospital settings. We conducted a systematic review by using PubMed and Google Scholar as databases for collecting studies related to the effectiveness of CPAP and BiPAP for cardiogenic pulmonary edema and COPD; the major outcome studied was reducing rates of endotracheal intubation secondary and tertiary outcomes included mortality reduction and shortening length of hospital stay. The study follows the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) checklist 2009. Sixteen studies were identified, including systematic reviews, randomized control trials, and observational studies. Studies published on or after 2010 in a population greater than 40 years old suffering from acute COPD and cardiogenic pulmonary edema were taken for review. Studies that described other respiratory diseases treated with non-invasive ventilation were excluded. Quality appraisal was done using the Cochrane risk bias tool for randomized control trials, Amstar-2 for systematic reviews, and New Castle Ottawa Tool for observational studies. Five studies compared the effectiveness of CPAP and BiPAP with standard medical care in prehospital and emergency settings. Six studies described prehospital intervention. Both forms of non-invasive ventilation were equally significant and effective. Prehospital use had tremendously reduced intubation rates, with not much variability noticed for mortality and hospital stay. Non-invasive ventilation is an effective measure for respiratory failure secondary to COPD and ACPE. Early out of hospital utilization of CPAP and BiPAP reduces the rate of invasive ventilation and reduces complications due to endotracheal intubation. Endotracheal intubation is associated with a considerable incidence of complications like failed intubation, hypotension, or circulatory arrest, even if the emergency physician is well trained, making these forms of non-invasive ventilation safe and effective interventions in the prehospital settings.

Phenotyping COVID-19 Patients by Ventilation Therapy: Data Quality Challenges and Cohort Characterization.

The COVID-19 pandemic introduced unique challenges for treating acute respiratory failure patients and highlighted the need for reliable phenotyping of patients using retrospective electronic health record data. In this study, we applied a rule-based phenotyping algorithm to classify COVID-19 patients requiring ventilatory support. We analyzed patient outcomes of the different phenotypes based on type and sequence of ventilation therapy. Invasive mechanical ventilation, noninvasive positive pressure ventilation, and high flow nasal insufflation were three therapies used to phenotype patients leading to a total of seven subgroups; patients treated with a single therapy (3), patients treated with either form of noninvasive ventilation and subsequently requiring intubation (2), and patients initially intubated and then weaned onto a noninvasive therapy (2). In addition to summary statistics for each phenotype, we highlight data quality challenges and importance of mapping to standard terminologies. This work illustrates potential impact of accurate phenotyping on patient-level and system-level outcomes including appropriate resource allocation under resource constrained circumstances.

Obstructing Sleep Apnea in Children with Genetic Disorders-A Special Need for Early Multidisciplinary Diagnosis and Treatment.

Background—Children with genetic disorders have multiple anatomical and physiological conditions that predispose them to obstructive sleep apnea syndrome (OSAS). They should have priority access to polysomnography (PSG) before establishing their therapeutic protocol. We analyzed the prevalence and the severity of OSAS in a particular group of children with genetic disorders and strengthened their need for a multidisciplinary diagnosis and adapted management. Methods—The retrospective analysis included children with genetic impairments and sleep disturbances that were referred for polysomnography. We collected respiratory parameters from sleep studies: apnea–hypopnea index (AHI), SatO2 nadir, end-tidal CO2, and transcutaneous CO2. Subsequent management included non-invasive ventilation (NIV) or otorhinolaryngological (ENT) surgery of the upper airway. Results—We identified 108 patients with neuromuscular disorders or multiple congenital anomalies. OSAS was present in 87 patients (80.5%), 3 of whom received CPAP, 32 needed another form of NIV during sleep, and 15 patients were referred for ENT surgery. The post-therapeutic follow-up PSG parameters confirmed the success of the treatment. Conclusions—The upper airway obstruction diagnostics and management for children with complex genetic diseases need a multidisciplinary approach. Early detection and treatment of sleep-disordered breathing in children with genetic disorders is a priority for improving their quality of life.

Clinical application of noninvasive high-frequency ventilation in neonatal respiratory support

Noninvasive high-frequency ventilation (NIHFV) is a new form of noninvasive ventilation which distends positive pressure continuously with oscillations superimposed on spontaneous tidal breathing, through a noninvasive interface.NIHFV, which provides the advantages of nasal continuous positive airway pressure and high frequency ventilation, can rapidly improve oxygenation, effectively remove carbon dioxide, and does not require synchronous techno-logy.It is considered as a new and effective noninvasive ventilation mode.In this paper, the application of NIHFV to neonates were reviewed, including mechanics of gas exchange, research advances and approach to the use of NIHFV. Key words: Noninvasive high-frequency ventilation; Infant, newborn; Respiratory failure; Noninvasive respiratory support

Development of a High-Flow Nasal Cannula and Pharmaceutical Aerosol Combination Device.

Background: Aerosol drug delivery to the lungs is known to be very inefficient during all forms of noninvasive ventilation, especially when the aerosol is administered simultaneously with high-flow nasal cannula (HFNC) therapy. The objective of this study was to develop a new combination device based on vibrating mesh nebulizers that can provide continuously heated and humidified HFNC therapy as well as on-demand pharmaceutical aerosols with high efficiency. Methods: The combination device implemented separate mesh nebulizers for generating humidity (humidity nebulizer) and delivering the medical aerosol (drug nebulizer). Nebulizers were actuated in an alternating manner with the drug nebulizer delivering the medication during a portion of an adult inhalation cycle. Aerosol entered a small-volume mixing region where it was combined with ventilation gas flow and then entered a heating channel to produce small particles that are desirable for nose-to-lung administration and potentially excipient enhanced growth delivery. Three assessment methods (analytical calculations, computational fluid dynamics [CFD] simulations, and in vitro experiments in three-dimensional [3D] printed devices) were used to improve the mixer-heater design to minimize depositional drug losses, maintain a small device volume, ensure sufficient droplet evaporation, and control the outlet thermodynamic conditions. Results: For an initial configuration (Design 1), good agreement in performance metrics was found using the three assessment methods. Based on insights gained from the CFD simulations of Design 1, two new designs were developed and produced with 3D printing. Experimental analysis indicated that the new designs both achieved <5% depositional loss in the mixer-heater even with cyclic operation and sufficiently dried the aerosol from an initial size of 5.3 μm to an outlet size of ∼1.0 μm. A combination of the applied methods indicated that the desired thermodynamic conditions of HFNC therapy were also met. Conclusions: Multiple methodological approaches were used concurrently to develop a new combination device for administering HFNC therapy and simultaneous on-demand pharmaceutical aerosols to the lungs with high efficiency. The use of a small-volume mixer-heater (<100 mL), synchronization of the drug nebulizer with inhalation, and small outlet particle size should enable high efficiency lung delivery of the aerosol.

Non-invasive ventilation and surfactant treatment as the primary mode of respiratory support in surfactant-deficient newborn piglets.

BackgroundNasal continuous positive airway pressure (NCPAP) and nasal intermittent positive pressure ventilation (NIPPV), forms of non-invasive ventilation (NIV) for respiratory support, are increasingly being chosen as the initial treatment for neonates with surfactant (SF) deficiency. Our objective was to compare NCPAP with NIPPV with or without SF administration as a primary mode of ventilation.MethodsTwenty-four newborn piglets with SF-deficient lung injury produced by repetitive bronchoalveolar lavages were randomly assigned to NCPAP or NIPPV, with or without SF administration (InSurE method). We evaluated pulmonary, systemic (hemodynamic and oxygen metabolism), and cerebral effects.ResultsSF-deficient piglets developed respiratory distress (FiO2:1, pH<7.2, PaCO2>70 mm Hg, PaO2<70 mm Hg, and Cdyn<0.5 ml/cmH2O/kg). Gradual improvements in pulmonary status were observed in both NIV groups, with NIPPV achieving lower lung inflammation markers and injury scores. Both SF-treated groups obtained significantly better respiratory outcomes than groups not treated with SF before NIV. All NIV-treated groups showed low brain injury scores.ConclusionIn spontaneously breathing SF-deficient newborn piglets, NIPPV is a suitable NIV strategy. SF administration in combination with NCPAP or NIPPV improves pulmonary status providing extra protection against pulmonary injury. No injury to the developing brain was observed to be associated with these NIV strategies, with or without SF therapy.

Non-invasive respiratory support in newborn infants

Abstract Respiratory failure is the most common morbidity in newborn infants, often requiring respiratory support. Traditionally, invasive mechanical ventilation was the preferred method of neonatologists. Over the last two decades, various forms of non-invasive ventilation have become popular as modes of respiratory support in newborn infants, especially if they are born preterm. These modes differ from mechanical ventilation in not needing an endo-tracheal tube, and are commonly delivered by bi-nasal prongs. We review the common modes of non-invasive respiratory support in newborn infants, including their proposed mechanisms of action and the evidence supporting their use.

Respiratory physiotherapy with assistance of biphasic cuirass ventilation for patients with neurological disease on tracheostomy positive pressure ventilation

Background: Biphasic Cuirass Ventilation (BCV) is a form of non-invasive ventilation that covers the thorax with a cuirass, stiff plastic shell and provides positive and negative pressure. BCV is useful for assistance during respiratory physiotherapy as well as management of respiratory insufficiency.

High-flow ventilation in newborn infants – what is the evidence?

Abstract Heated Humidified High Flow Nasal Cannula (HHHFNC) devices deliver an adjustable mixture of heated and humidified oxygen and air at a variable flow rate. Over recent years HHHFNC devices have become a popular method of non-invasive respiratory support in infants and preterm neonates due to ease of use and being well tolerated by infants. Recent evidence suggests that HHHFNC therapy may reduce work of breathing and improve the efficiency of ventilation in newborn infants, possibly with clinically significant outcomes such as avoidance of the need for nasal continuous positive airways pressure (nCPAP) and a reduced requirement for invasive ventilation. Despite its rapid adoption, there is relatively limited data about the exact mechanisms of action of HHHFNC. There is growing evidence of the feasibility of HHHFNC as an alternative to other forms of non-invasive ventilation in preterm infants. We review the mechanisms of action, and the supporting evidence in favour of using heated humidified high-flow nasal cannula therapy in newborn infants.

Early nasal intermittent positive pressure ventilation (NIPPV) versus early nasal continuous positive airway pressure (NCPAP) for preterm infants.

Nasal continuous positive airway pressure (NCPAP) is a strategy for maintaining positive airway pressure throughout the respiratory cycle through the application of bias flow of respiratory gas to an apparatus attached to the nose. Treatment with NCPAP is associated with decreased risk of mechanical ventilation and might be effective in reducing chronic lung disease. Nasal intermittent positive pressure ventilation (NIPPV) is a form of noninvasive ventilation during which patients are exposed intermittently to higher levels of airway pressure, along with NCPAP through the same nasal device. To examine the risks and benefits of early NIPPV versus early NCPAP alone for preterm infants at risk of or in respiratory distress within the first hours after birth.Primary endpoints are respiratory failure and the need for intubated ventilatory support during the first week of life. Secondary endpoints include chronic lung disease (CLD) (oxygen therapy at 36 weeks' postmenstrual age), air leaks, duration of respiratory support, duration of oxygen therapy, intraventricular hemorrhage, and incidence of mortality. We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 9), MEDLINE via PubMed (1966 to September 28, 2015), Embase (1980 to September 28, 2015), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to September 28, 2015). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials. A member of the Cochrane Neonatal Review Group handsearched abstracts from the European Society of Pediatric Research (ESPR). We contacted the authors of ongoing clinical trials to ask for information. We considered all randomized and quasi-randomized controlled trials. Studies selected compared NIPPV versus NCPAP treatment, starting at birth or shortly thereafter in preterm infants (< 37 weeks' gestational age). We performed data collection and analysis using the recommendations of the Cochrane Neonatal Review Group. Ten trials, enrolling a total of 1061 infants, met criteria for inclusion in this review. Meta-analyses of these studies showed significantly reduced risk of meeting respiratory failure criteria (typical risk ratio (RR) 0.65, 95% confidence interval (CI) 0.51 to 0.82; typical risk difference (RD) -0.09, 95% CI -0.13 to -0.04) and needing intubation (typical RR 0.78, 95% CI 0.64 to 0.94; typical RD -0.07, 95% CI -0.12 to -0.02) among infants treated with early NIPPV compared with early NCPAP. The meta-analysis did not demonstrate a reduction in the risk of CLD among infants randomized to NIPPV (typical RR 0.78, 95% CI 0.58 to 1.06). Investigators observed no evidence of harm. Review authors graded the quality of the evidence as moderate (unblinded studies). Early NIPPV does appear to be superior to NCPAP alone for decreasing respiratory failure and the need for intubation and endotracheal tube ventilation among preterm infants with respiratory distress syndrome. Additional studies are needed to confirm these results and to assess the safety of NIPPV compared with NCPAP alone in a larger patient population.

Noninvasive Respiratory Support.

Mechanical ventilation is associated with increased survival of preterm infants but is also associated with an increased incidence of chronic lung disease (bronchopulmonary dysplasia) in survivors. Nasal continuous positive airway pressure (nCPAP) is a form of noninvasive ventilation that reduces the need for mechanical ventilation and decreases the combined outcome of death or bronchopulmonary dysplasia. Other modes of noninvasive ventilation, including nasal intermittent positive pressure ventilation, biphasic positive airway pressure, and high-flow nasal cannula, have recently been introduced into the NICU setting as potential alternatives to mechanical ventilation or nCPAP. Randomized controlled trials suggest that these newer modalities may be effective alternatives to nCPAP and may offer some advantages over nCPAP, but efficacy and safety data are limited.

Nitric oxide delivery by neonatal noninvasive respiratory support devices.

Inhaled nitric oxide (INO) has been used with heated and humidified high-flow nasal cannula (HFNC), nasal CPAP and several forms of noninvasive ventilation (NIV). This study was designed to evaluate the delivered dose of INO, level of NO2 generation, and effect of net gas delivery (addition of INO to the ventilator circuit--gas removed for sampling) on lung pressure at different NO doses during noninvasive respiratory support. An infant lung model was supported with the different noninvasive modes during INO therapy. NO and NO2 were measured from within the patient circuit of the noninvasive devices and simulated neonatal trachea at several NO levels. Lung pressures were compared with and without INO and at several INO settings. Accuracy of NO delivery was determined to be within the stated accuracy by the manufacturer with nasal CPAP and NIV, but accuracy was compromised during HFNC. INO and NO2 measured by the INOmax DSIR (Ikaria, Hampton, New Jersey) did not consistently reflect the delivered dose of NO or formation of NO2 across all types of neonatal noninvasive respiratory support. Tracheal NO2 levels were <1.5 ppm with all forms of noninvasive support, except nasal intermittent mandatory ventilation at 40 ppm INO. Lung model mean airway pressures were mildly affected by gas sampling/delivery during combined INO therapy/HFNC at certain flows but remained stable with all other forms of noninvasive support. Clinicians cannot always assume that the set INO level results in a similar lung dose when using all forms of neonatal noninvasive support. Clinical decisions regarding ways to improve INO delivery may need to include changing settings or placing patients on a different form of noninvasive support. The NO2 level delivered to the patient could be greater than the value recorded by the INO delivery system.

Neonatal Noninvasive Ventilation Techniques: Do We Really Need to Intubate?

The current trend for supporting neonates with respiratory distress syndrome is nasal continuous positive airway pressure (CPAP). Nearly half of all neonates who are supported with CPAP will still develop respiratory failure that requires potentially injurious endotracheal intubation and invasive ventilation. Thus, the role of any neonatal clinician is to minimize invasive ventilation whenever possible, to avoid the multitude of complications that can arise when using this form of therapy. Noninvasive ventilation (NIV) is a form of respiratory assistance that provides greater respiratory support than does CPAP and may prevent intubation in a larger fraction of neonates who would otherwise fail CPAP. With the inception of nasal airway interfaces, clinicians have ushered in many different forms of NIV in neonates, often with very little experimental data to guide management. This review will explore in detail all of the different forms of neonatal NIV that are currently focused within an area of intense clinical investigation.

Non-invasive ventilation in chronic obstructive pulmonary disease: management of acute type 2 respiratory failure

Non-invasive ventilation (NIV) in the management of acute type 2 respiratory failure in patients with chronic obstructive pulmonary disease (COPD) represents one of the major technical advances in respiratory care over the last decade. This document updates the 2002 British Thoracic Society guidance and provides a specific focus on the use of NIV in COPD patients with acute type 2 respiratory failure. While there are a variety of ventilator units available most centres now use bi-level positive airways pressure units and this guideline refers specifically to this form of ventilatory support although many of the principles encompassed are applicable to other forms of NIV. The guideline has been produced for the clinician caring for COPD patients in the emergency and ward areas of acute hospitals.