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Non-invasive respiratory support for preterm infants following extubation from mechanical ventilation. A narrative review and guideline suggestion
Journal Pre-proof Non-invasive Respiratory Support for Preterm Infants Following Extubation from Mechanical Ventilation A Narrative Review and Guideline Suggestion Ammar M.H. Shehadeh, MRCPCH, CABP, MSc PII:
S1875-9572(19)30523-6
DOI:
https://doi.org/10.1016/j.pedneo.2019.09.014
Reference:
PEDN 974
To appear in:
Pediatrics & Neonatology
Received Date: 25 April 2019 Revised Date:
11 June 2019
Accepted Date: 24 September 2019
Please cite this article as: Shehadeh AMH, Non-invasive Respiratory Support for Preterm Infants Following Extubation from Mechanical Ventilation A Narrative Review and Guideline Suggestion, Pediatrics and Neonatology, https://doi.org/10.1016/j.pedneo.2019.09.014. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Copyright © 2019, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. All rights reserved.
1
PEDN_2019_261_After Eng edited_final
Non-invasive Respiratory Support for Preterm Infants Following Extubation from Mechanical Ventilation A Narrative Review and Guideline Suggestion Running title (preterm post-extubation respiratory support) Ammar M.H. Shehadeh Paediatric senior specialist, Hatta Hospital, Dubai, DHA MRCPCH, CABP, MSc Contact:[email protected] 00971529541466
Key words: non-invasive ventilation; mechanical ventilation; preterm, infant; post-extubation
Acknowledgement: The help and support of Susan Smith and Southampton University Staff cannot be overlooked, as this review was a part of my neonatology Master degree requirements.
2
Non-invasive Respiratory Support for Preterm Infants Following Extubation from Mechanical Ventilation A Narrative Review and Guideline Suggestion
Running title (preterm post-extubation respiratory support) Key words: non-invasive ventilation; mechanical ventilation; preterm, infant; post-extubation 2
3
Abstract: The recent introduction of different non-invasive ventilation modes for preterm has decreased the need for intubation, invasive ventilation and sedation. However, specific guidelines for each non-invasive mode are still lacking. This paper reviews available evidence for each of the commonly used noninvasive mode. Electronic search was carried out as a step forward towards a more comprehensive and detailed neonatal noninvasive ventilation guideline.
4
Introduction: Mechanical ventilation (MV) causes lung injury through different mechanisms including volutrauma, barotrauma, rheotrauma, atelectotrauma and biotrauma1. The resulting ventilator induced lung injury is the major cause of bronchopulmonary dysplasia (BPD)2, which can lead to multiple respiratory problems in infancy and thereafter 3. Consequently, as a possible means to prevent lung injury and BPD, non-invasive ventilation (NIV) has gained ground in modern neonatology practice. Nevertheless, due to lung immaturity, weak respiratory drive and surfactant deficiency, up to 82% of the extremely premature infants still require MV to maintain oxygenation and ventilation4. In these infants, early extubation decreases BPD and the combined BPD/Death outcome5. However, premature extubation and the need to reintubate within 48 hours was shown to significantly increased the combined risk of death/BPD in preterm infants6. Notably, about one fourth of our babies had extubation failure7. Hence, there is need of more robust extubation criteria and better post-extubation NIV. This article examines the following post extubation NIV methods and modes: nasal continuous positive airway pressure (NCPAP), high flow nasal cannula (HFNC), nasal bilevel positive airway pressure (NBIPAP), non-invasive intermittent positive pressure ventilation (NIPPV), synchronized non-invasive intermittent positive pressure ventilation (SNIPPV), noninvasive high flow oscillatory ventilation (NHFOV), and non-invasive neurally adjusted ventilatory assist (NIV NAVA).
5
Methods: Databases including Medline, Embase and Cochrane neonatal were searched. Randomised controlled trials, Cochrane and systemic literature reviews were included, While Animal and model studies were excluded. Studies on each NIV mode was scrutinized. Cochrane reviews and consensus guidelines were the main pillars of this guideline recommendation as available. In other cases, summary of the studies was presented with a suggested approach depending on the available evidence.
6
Results and discussion: NCPAP In the immediate post-extubation period, immature lungs with insufficient respiratory drive require additional support to maintain ventilation and oxygenation. NCPAP provides continuous distending pressure that maintains functional residual capacity and decreases the workload on the respiratory muscles8. By Cochrane review, postextubation NCPAP, reduces the incidence of respiratory failure and need for additional ventilatory support (RR 0.62, RD - 0.17, NNT 6)9. There are several methods to deliver NCPAP. Bubble CPAP (BCPAP) has the most satisfactory outcome. When compared with ventilator CPAP (VCPAP), the success rate of BCPAP was markedly higher (82.5% vs. 63.2%)10. Additionally, BCPAP had a significantly lower extubation failure rate and 50% shorter CPAP support duration in comparison with infant flow driver (IFD)11. Different interphases were tested to keep a seal while avoiding nasal injury. Short binasal prongs proved more effective than single prongs in reducing the rate of reintubation12. Nasal masks were equally effective to binasal prongs and didn’t cause any severe nasal trauma (0 vs. 31%; p < .001)13. On the other hand, NCPAP requires bulky interphase with a difficult nursing approach and is associated with increased incidence of pneumothoraxes 14 and nasal trauma15. Therefore, other emerging noninvasive modes are gaining attention. HFNC HFNC refers to heated humidified blended oxygen given through a small loose nasal cannula at a flow of >1l/min16. Thanks to its better tolerability and easier application, HFNC is becoming popular. It does not require tight bulky interphase, it is easier to apply and maintain, and is less irritating to the baby than NCPAP. Most multicenter trials comparing HFNC with NCPAP as a primary mode showed a trend towards higher failure rate with HFNC, like the HIPSTER trial17. However, the final intubation rate difference is insignificant once failed cases on HFNC rescued by NCPAP were considered. As demonstrated clearly in HUNTER trial 18. Looking specifically at post-extubation trials, although still in the non-inferiority zone, treatment failure risk tends to be higher in HFNC than NCPAP (34.2% vs. 25.8%). Moreover, almost half the infants in whom treatment with HFNC failed were successfully rescued with NCPAP and the incidence of nasal trauma was significantly lower in the HFNC group 19. Another trial that recruited infants >28 weeks demonstrated a statistically non-significant difference in reintubation risk 11.6% and 6.5% in HFNC and NCPAP respectively20. Interestingly, when high flow is applied at a flow rate of 8 L/min, extubation failure with an HFNC was lower than that of NCPAP (except for less than 28 weeks of GA) at (22% in HFNC and 34% in NCPAP)21. The 2016 Cochrane review,
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HFNC following extubation had comparable efficacy to NCPAP and was associated with lower rates of pneumothorax and nasal trauma16. Looking at the available trials, a few points of note should be considered. Most of the available trials involved infants older than 28 weeks. The protocol of HFNC is significantly different between trials (flow2 -8l/min, NCPAP 5-8). Additionally, most studies showed a trend toward higher failure risk with HFNC, although this didn’t reach statistically insignificance. in view of the low number of recruited infants and the seriousness of the failure outcome, this trend should be taken into consideration. In conclusion, Since HFNC is easier, more tolerable and has fewer side effects than NCPAP, it could be tried as post-extubation support for infants ≥28 weeks but rescue CPAP should be available. However, in infants <28 weeks NCPAP there is not enough data to support postextubation HFNC17. SNIPPV/IPPV/BIPAP NIPPV provides breaths at rate and pressures comparable to endotracheal IPPV. BIPAP delivers breaths with much smaller differences (<4 cm H2O) between high and low pressures, longer inflation times (0.5–1.0 second for the higher pressure), and lower cycle rates (10–30 per minute) 22. NIPPV was shown to decrease the length of hospital stay, reintubation and BPD rates 23. Similarly, the trend toward lower extubation failure rate was clear, although not statistically significant. In the trial conducted by Jasani et al (19.3% and 28.12% in asynchronized NIPPV and NCPAP respectively)24. It also revealed that the duration of NIV and supplementary oxygen was significantly lower in asynchronized NIPPV group as compared to NCPAP group. Moreover, the risk of BPD in asynchronized NIPPV (6.9%) was unquestionably lower than in the NCPAP group (32.14 %). Synchronizing NIPPV has shown a promising further reduction in reintubation risk. SNIPPV, attained by applying a pneumatic capsule, reduced reintubation rates markedly in comparison with NCPAP25,26. That was reproduced with even much lower reintubation rates with inspiratory flow sensor SNIPPV (6 vs. 39%, in SNIPPV and NCPAP respectively)27. However, 2017 Cochrane review, which concluded that NIPPV reduced the risk of extubation failure more effectively than NCPAP in the first two to seven days, was unable to reveal any proven effect on BPD or on mortality28. No strong conclusions for devices or synchronization could be elicited.
For BIPAP, the evidence is not as convincing as it is for the previous modes. While a small trial on 20 preterm infants showed an increase of PO2, and a significant reduction of PCO2 and respiratory rate 29, more recent RCTs failed to reveal any added benefit to
8
using BIPAP over NCPAP at equivalent mean airway pressure in preventing extubation failures30-32. This contradiction of evidence could be attributed to many factors, including, the difference in the standards of care between the two studies, the small sample size in the first trial and different settings of BIPAP. BIPAP and NIPPV can be considered as a continuum: the shorter the inspiration, the high the pressure and the frequency the more it will resemble NIPPV. NIV NAVA This is a mode of NIV in which the ventilation is synchronized and controlled by the diaphragmatic electrical activity. Stable synchronization regardless of the leak is the main advantage of NIV NAVA33,34. However, it involves insertion and maintaining a delicate Edi monitoring tube, which is not always an easy task. In a study by Yonehara et al, NIV-NAVA was favorable compared with NIPPV as post-extubation mode. Without a significant difference in adverse events, treatment failure occurred in 40% and 47.4% in NIV-NAVA and in NIPPV respectively35. Nevertheless, studies on NIV NAVA are still very limited and further research is still needed in order to bring synchronization to daily practice. NHFOV NHFOV combines the benefits of distending NCPAP pressure with the active ventilation of HFOV. It reliably removes Pco2 without the need of synchronization36. In a small observational study on NHFOV as a post-extubation mode, although PaCO2 was virtually unchanged from preextubation levels, it declined significantly at 32 h from 59.8 mmHg to 50.7 mmHg. Consequently, it returned to pre-extubation levels upon discontinuation of NHFOV37. Other studies demonstrated its safety and efficacy in removing Co238,39. Conclusion In conclusion, NCPAP has shown good outcomes as an initial postextubation mode. However, SNIPPV is the most effective and reliable mode of reducing reintubation rate, especially in extremely preterm babies, more research is needed on NIV NAVA and NHFOV. Even in its asynchronized version, SINPPV has decreased BPD risk in several RCTs22,23. Nevertheless, this could not be replicated in Cochrane review 27. Therefore, in extremely preterm babies (<28 weeks) with a high risk of extubation failure (preexisting pneumonia, sepsis, anaemia, PDA, severe lung disease or failed previous extubation trials [7]) Starting with NIPPV, weaning to NCPAP, then HFNC gradually is the recommended procedure. On the other hand, in older babies with low risk of extubation failure, starting with HFNC is more practical provided that NCPAP and SNIPPV are available for escalating support if needed. Those babies could be supported with NCPAP straightaway should they have high-risk factors for extubation failure.
9
Following the abovementioned clinical trials, a suggested table for each NIV mode criteria for application and weaning is included (Appendix A). Additionally, an integrated guideline algorithm is included (Appendix B). NHOFV and NIV NAVA could be tried if available as a rescue mode in cases which failed on other NIV modes before reintubation. Especially, in babies with good respiratory drive and without shock.
10
Abbreviations: NIV: non-invasive ventilation, MV: mechanical ventilation, BPD: bronchopulmonary dysplasia, NBIPAP: nasal bilevel positive airway pressure, HFNC: high flow nasal canula, NHFOV: nasal high frequency oscillatory ventilation, NIV NAVA: non-invasive neurally adjusted ventilatory assist, NCPAP: nasal continuous positive airway pressure, NIPPV: non-invasive intermittent positive pressure ventilation, SNIPPV: synchronised non-invasive intermittent positive pressure ventilation.
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References: 1. Attar MA, Donn SM. Mechanisms of ventilator-induced lung injury in premature infants. Seminars in Neonatology 2002 Oct;7(5):353-360. 2. Jobe AH. The new bronchopulmonary dysplasia. Current opinion in pediatrics 2011 Apr;23(2):167-172. 3. Davidson LM, Berkelhamer SK. Bronchopulmonary Dysplasia: Chronic Lung Disease of Infancy and Long-Term Pulmonary Outcomes. Journal of clinical medicine 2017 Jan 6;6(1):4. 4. Stoll BJ, Hansen NI, Bell EF, Walsh MC, Carlo WA, Shankaran S, et al. Trends in Care Practices, Morbidity, and Mortality of Extremely Preterm Neonates, 1993-2012. JAMA 2015 Sep 8;314(10):1039-1051. 5. Berger J, Mehta P, Bucholz E, Dziura J, Bhandari V. Impact of Early Extubation and Reintubation on the Incidence of Bronchopulmonary Dysplasia in Neonates. Amer J Perinatol 2014 Dec;31(12):1063-1072. 6. Shalish W, Kanbar L, Kovacs L, Chawla S, Keszler M, Rao S, et al. The Impact of Time Interval between Extubation and Reintubation on Death or Bronchopulmonary Dysplasia in Extremely Preterm Infants. The Journal of Pediatrics 2018 Nov 5,. 7. Hiremath GM, Mukhopadhyay K, Narang A. Clinical risk factors associated with extubation failure in ventilated neonates. Indian pediatrics 2009 Oct;46(10):887 8. Shalish W, Sant’ Anna G, Natarajan G, Chawla S. When and How to Extubate Premature Infants from Mechanical Ventilation. Curr Pediatr Rep 2014 Mar;2(1):18-25.
12 9. Davis PG, Henderson-Smart DJ. Nasal continuous positive airways pressure immediately after extubation for preventing morbidity in preterm infants. The Cochrane database of systematic reviews 2003(2):CD000143. 10. Tagare A, Kadam S, Vaidya U, Pandit A, Patole S. Bubble CPAP versus Ventilator CPAP in Preterm Neonates with Early Onset Respiratory Distress--A Randomized Controlled Trial. Journal of tropical pediatrics 2013 Apr;59(2):113-119. 11. Gupta, Samir, MD|Sinha, Sunil K., MD, PhD|Tin, Win, MD|Donn, Steven M., MD. A Randomized Controlled Trial of Post-extubation Bubble Continuous Positive Airway Pressure Versus Infant Flow Driver Continuous Positive Airway Pressure in Preterm Infants with Respiratory Distress Syndrome. Journal of Pediatrics, The 2009;154(5): 650.e2. 12. De Paoli AG, Davis PG, Faber B, Morley CJ. Devices and pressure sources for administration of nasal continuous positive airway pressure (NCPAP) in preterm neonates. The Cochrane database of systematic reviews 2008 Jan 23, (1):CD002977. 13. Chandrasekaran A, Thukral A, Jeeva Sankar M, Agarwal R, Paul V, Deorari A. Nasal masks or binasal prongs for delivering continuous positive airway pressure in preterm neonates—a randomised trial. Eur J Pediatr 2017 Mar;176(3):379-386. 14. Morley CJ, Davis PG, Doyle LW, Brion LP, Hascoet J, Carlin JB, et al. Nasal CPAP or Intubation at Birth for Very Preterm Infants. The New England Journal of Medicine 2008 Feb 14;358(7):700-708. 15. Fischer C, Bertelle V, Hohlfeld J, Forcada-Guex M, Stadelmann-Diaw C, Tolsa J. Nasal trauma due to continuous positive airway pressure in neonates. Archives of disease in childhood. Fetal and neonatal edition 2010 Nov;95(6): F451. 16. Wilkinson D, Andersen C, O'Donnell C, De Paoli AG, Manley BJ. High flow nasal cannula for respiratory support in preterm infants. Cochrane Database Syst Rev. 2016, Issue 2. Art. No.: CD006405.doi: 10.1002/14651858.CD006405.pub3.
13 17. Roberts CT, Owen LS, Manley BJ, Frøisland DH, Donath SM, Dalziel KM, et al. Nasal HighFlow Therapy for Primary Respiratory Support in Preterm Infants. The New England Journal of Medicine 2016 Sep 22;375(12):1142-1151. 18. Manley BJ, Roberts CT, Arnolda GRB, Wright IMR, Owen LS, Dalziel KM, et al. A multicentre, randomised controlled, non-inferiority trial, comparing nasal high flow with nasal continuous positive airway pressure as primary support for newborn infants with early respiratory distress born in Australian non-tertiary special care nurseries (the HUNTER trial): study protocol. BMJ Open 2017 Jun;7(6): e016746. 19. Manley BJ, Owen LS, Doyle LW, Andersen CC, Cartwright DW, Pritchard MA, et al. High-flow nasal cannulae in very preterm infants after extubation. The New England journal of medicine 2013 Oct 10,;369(15):1425-1433. 20. Bradley A Yoder, Ronald A Stoddard, Ma Li, Jerald King, Daniel R Dirnberger, Soraya Abbasi. Heated, Humidified High-Flow Nasal Cannula Versus Nasal CPAP for Respiratory Support in Neonates. Pediatrics 2013 May 1;131(5): e1490. 21. Collins, Clare L., MBChB, FRACP|Holberton, James R., MBBS, FRACP|Barfield, Charles, MBBS, FRACP|Davis, Peter G., MD, FRACP. A Randomized Controlled Trial to Compare Heated Humidified High-Flow Nasal Cannulae with Nasal Continuous Positive Airway Pressure Postextubation in Premature Infants. Journal of Pediatrics, The 2013;162(5): 954.e1. 22. Cummings JJ, Polin RA. Noninvasive respiratory support. Pediatrics 2016 Jan;137(1): e20153758. 23. Esmaeilnia T, Nayeri F, Taheritafti R, Shariat M, Moghimpour-Bijani F. Comparison of Complications and Efficacy of NIPPV and Nasal CPAP in Preterm Infants With RDS. Iranian journal of pediatrics 2016 Apr;26(2):e2352. 24. Jasani B, Nanavati R, Kabra N, Rajdeo S, Bhandari V. Comparison of non-synchronized nasal intermittent positive pressure ventilation versus nasal continuous positive airway pressure as postextubation respiratory support in preterm infants with respiratory distress syndrome: a
14 randomized controlled trial. The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 2016;29(10):1546-1551 25. Keith J Barrington, Dale Bull, Neil N Finer. Randomized trial of nasal synchronized intermittent mandatory ventilation compared with continuous positive airway pressure after extubation of very low birth weight infants. Pediatrics 2001 Apr 1,;107(4):638-641. 26. Khalaf MN, Brodsky N, Hurley J, Bhandari V. A Prospective Randomized, Controlled Trial Comparing Synchronized Nasal Intermittent Positive Pressure Ventilation Versus Nasal Continuous Positive Airway Pressure as Modes of Extubation. Pediatrics 2001 Jul 1,;108(1):1317. 27. Moretti C, Giannini L, Fassi C, Gizzi C, Papoff P, Colarizi P. Nasal flow‐synchronized intermittent positive pressure ventilation to facilitate weaning in very low‐birthweight infants: Unmasked randomized controlled trial. Pediatrics International 2008 Feb;50(1):85-91. 28. Lemyre B, Davis PG, De Paoli AG, Kirpalani H. Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for preterm neonates after extubation. The Cochrane database of systematic reviews 2017 Feb 1,;2:CD003212. 29. Migliori C, Motta M, Angeli A, Chirico G. Nasal Bilevel vs. Continuous Positive Airway Pressure in Preterm Infants. Pediatric Pulmonology 2005 Nov;40(5):426-430. 30. O'Brien K, Campbell C, Brown L, Wenger L, Shah V. Infant flow biphasic nasal continuous positive airway pressure (BP- NCPAP) vs. infant flow NCPAP for the facilitation of extubation in infants' 1,250 grams: a randomized controlled trial. BMC pediatrics 2012 Apr 4,;12(1):43. 31. Sadeghnia A, Barekateyn B, Badiei Z, Hosseini SM. Analysis and comparison of the effects of NBiPAP and Bubble-CPAP in treatment of preterm newborns with the weight of below 1500 grams affiliated with respiratory distress syndrome: A randomised clinical trial. Advanced biomedical research 2016;5(1):3.
15 32. Victor S, Roberts SA, Mitchell S, Aziz H, Lavender T. Biphasic positive airway pressure or continuous positive airway pressure: a randomized trial. Pediatrics 2016 Aug;138(2):e20154095. 33. Lee J, Kim H, Jung YH, Shin SH, Choi CW, Kim E, et al. Non-invasive neurally adjusted ventilatory assist in preterm infants: a randomised phase II crossover trial. Archives of Disease in Childhood: Fetal and Neonatal Edition 2015 Nov 15,;100(6):F513. 34. Stein, Howard|Beck, Jennifer|Dunn, Michael. Non-invasive ventilation with neurally adjusted ventilatory assist in newborns. Seminars in Fetal and Neonatal Medicine 2016;21(3):154-161. 35. Yonehara K, Ogawa R, Kamei Y, Oda A, Kokubo M, Hiroma T, et al. Non‐invasive neurally adjusted ventilatory assist versus nasal intermittent positive‐pressure ventilation in preterm infants born before 30 weeks’ gestation. Pediatrics International 2018 Oct;60(10):957-961. 36. De Luca D, Dell'Orto V. Non-invasive high-frequency oscillatory ventilation in neonates: review of physiology, biology and clinical data. Archives of disease in childhood. Fetal and neonatal edition 2016 Jun 28,;101(6):F570. 37. Czernik C, Schmalisch G, Bührer C, Proquitté H. Weaning of neonates from mechanical ventilation by use of nasopharyngeal high-frequency oscillatory ventilation: a preliminary study. Journal of Maternal-Fetal and Neonatal Medicine 2012 Apr;25(4):374-378. 38. Malakian A, Bashirnezhadkhabaz S, Aramesh M, Dehdashtian M. Noninvasive high-frequency oscillatory ventilation versus nasal continuous positive airway pressure in preterm infants with respiratory distress syndrome: A randomized controlled trial. The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 2018 Dec 4,:1-151. 39. Zhu X, Zhao J, Tang S, Yan J, Shi Y. Noninvasive high‐frequency oscillatory ventilation versus nasal continuous positive airway pressure in preterm infants with moderate‐severe respiratory distress syndrome: A preliminary report. Pediatric Pulmonology 2017 Aug;52(8):1038-1042.
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Appendix A MODE
HFNC
Method
Vapotherm
Settings
•
*Fio2 adjustable
•
Flow 5-6 L/min change at 0.5 L according to RD, RR, and PCO2.
•
Maximum 8L/min
Weaning criteria
Minimum 2-3 L/min then shift to low flow cannula.
Failure criteria
Fio2 >40% and Flow8L/min with one of the following:
indications
•
>twice apnea requiring PPV
•
Shock.
•
pH < 7.20
•
CO2 > 60
•
Post extubation for >28 weeks without high risk for extubation failure.
•
As a primary mode
•
As a weaning mode after NCPAP.
17
Mode
NCPAP
Method
BCPAP (VCPAP or IFD if not available)
Settings
•
CPAP 6 cm H2o
•
Decrease CPAP by 1 cm H2O if stable oxygen requirement and fewer than three minor apnea episodes over 12 hours.
•
Minimum CPAP 4
•
If the infant did not tolerate the decrease in CPAP, as judged by an increase in oxygen requirement by > 15% or more than 3 apneas in 12 hours, then increase CPAP by 1 cm H2O, to a maximum of 6 cm H2O. (Gupta et al 2009).
Weaning
•
PEEP 4 cm H2O
criteria
•
FiO2 < 0.3 with normal blood gases.
•
After CPAP place the infant in air or ambient oxygen or on low-flow nasal cannula at a flow of < 1 L/minute
Failure criteria
indications
•
Fio2 >40%
•
CPAP > 6
•
>twice apnea requiring PPV
•
Shock.
•
pH < 7.20
•
CO2 > 60
•
(Gupta et al 2009).
•
Post extubation as weaning of NIPPV
18 •
After failure of HFNC in >28 weeks or as initial mode.
Mode
NIPPV
Method
Synchronized NIPPV if available
Settings
Weaning Criteria
Failure criteria
Indications
•
Increase PIP by 4 cm H2O from the pre-extubation value
•
Keep PEEP at ≤ 5cm H2O
•
Rate the same as was being given before extubation;
•
FiO2: adjust to maintain oxygen saturation between 88 and 93%
•
Flow rate at 8 to 10 L/min (Jasani et al 2016)
•
PIP/PEEP 12/4 cm H2O,
•
Rate of <20/min,
•
FiO2 <0.3 with normal blood gases;
At least one of the following: •
pH ≤7.25 and PaCO2 ≥ 60 mm
•
apnea with ≥3 episodes /h associated with bradycardia
•
single episode of apnea that required PPV
•
PaO2 ≤50 mm Hg with FiO2 of ≥0.6
•
Primary post extubation mode for <28 weeks.
•
Primary post extubation mode for > 28weeks with risk factors for extubation failure.
•
Escalation of NCPAP
19
*Fio2 in all modes should be adjusted to keep Spo2 (90-94%). Fio2: fractional inspiratory O2. RD: respiratory distress. RR: respiratory rate. PPV: positive pressure ventilation. PIP: positive inspiratory pressure. PEEP: positive end expiratory pressure Extubation failure usually indicates either incomplete resolution of underlying illness or the development of new problems. High risk of extubation failure (Hiremath et al 2009): -
PDA
-
anemia any time during their course.
-
pre-existing pneumonia and sepsis.
-
prolonged duration of ventilation >7days.
-
severe lung disease characterized by high maximum as well as the pre-extubation AaDO2>200.
20
Appendix B
Post Extubation preterm
Above 28 weeks
Below 28 weeks
High risk*
Low risk**
High risk*
NCPAP
NIPPV
HFNC
Failure
Weaning***
Failure
Weaning***
* High Risk for Extubation failure: PDA, Anemia, preexisting pneumonia or sepsis, prolonged ventilation (> 7days), severe lung disease (AaDo2>200), previous Extubation failure (Hiremath et al 2009) ** Low Risk for Extubation failure: without the above-mentioned risk factors. *** weaning flow of NIPPV then NCPAP then HFNC: it is a case dependent decision. Frequently, weaning can go from NIPPV to HFNC or from NCPAP directly.
Low risk**
S1875-9572(19)30523-6
DOI:
https://doi.org/10.1016/j.pedneo.2019.09.014
Reference:
PEDN 974
To appear in:
Pediatrics & Neonatology
Received Date: 25 April 2019 Revised Date:
11 June 2019
Accepted Date: 24 September 2019
Please cite this article as: Shehadeh AMH, Non-invasive Respiratory Support for Preterm Infants Following Extubation from Mechanical Ventilation A Narrative Review and Guideline Suggestion, Pediatrics and Neonatology, https://doi.org/10.1016/j.pedneo.2019.09.014. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Copyright © 2019, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. All rights reserved.
1
PEDN_2019_261_After Eng edited_final
Non-invasive Respiratory Support for Preterm Infants Following Extubation from Mechanical Ventilation A Narrative Review and Guideline Suggestion Running title (preterm post-extubation respiratory support) Ammar M.H. Shehadeh Paediatric senior specialist, Hatta Hospital, Dubai, DHA MRCPCH, CABP, MSc Contact:[email protected] 00971529541466
Key words: non-invasive ventilation; mechanical ventilation; preterm, infant; post-extubation
Acknowledgement: The help and support of Susan Smith and Southampton University Staff cannot be overlooked, as this review was a part of my neonatology Master degree requirements.
2
Non-invasive Respiratory Support for Preterm Infants Following Extubation from Mechanical Ventilation A Narrative Review and Guideline Suggestion
Running title (preterm post-extubation respiratory support) Key words: non-invasive ventilation; mechanical ventilation; preterm, infant; post-extubation 2
3
Abstract: The recent introduction of different non-invasive ventilation modes for preterm has decreased the need for intubation, invasive ventilation and sedation. However, specific guidelines for each non-invasive mode are still lacking. This paper reviews available evidence for each of the commonly used noninvasive mode. Electronic search was carried out as a step forward towards a more comprehensive and detailed neonatal noninvasive ventilation guideline.
4
Introduction: Mechanical ventilation (MV) causes lung injury through different mechanisms including volutrauma, barotrauma, rheotrauma, atelectotrauma and biotrauma1. The resulting ventilator induced lung injury is the major cause of bronchopulmonary dysplasia (BPD)2, which can lead to multiple respiratory problems in infancy and thereafter 3. Consequently, as a possible means to prevent lung injury and BPD, non-invasive ventilation (NIV) has gained ground in modern neonatology practice. Nevertheless, due to lung immaturity, weak respiratory drive and surfactant deficiency, up to 82% of the extremely premature infants still require MV to maintain oxygenation and ventilation4. In these infants, early extubation decreases BPD and the combined BPD/Death outcome5. However, premature extubation and the need to reintubate within 48 hours was shown to significantly increased the combined risk of death/BPD in preterm infants6. Notably, about one fourth of our babies had extubation failure7. Hence, there is need of more robust extubation criteria and better post-extubation NIV. This article examines the following post extubation NIV methods and modes: nasal continuous positive airway pressure (NCPAP), high flow nasal cannula (HFNC), nasal bilevel positive airway pressure (NBIPAP), non-invasive intermittent positive pressure ventilation (NIPPV), synchronized non-invasive intermittent positive pressure ventilation (SNIPPV), noninvasive high flow oscillatory ventilation (NHFOV), and non-invasive neurally adjusted ventilatory assist (NIV NAVA).
5
Methods: Databases including Medline, Embase and Cochrane neonatal were searched. Randomised controlled trials, Cochrane and systemic literature reviews were included, While Animal and model studies were excluded. Studies on each NIV mode was scrutinized. Cochrane reviews and consensus guidelines were the main pillars of this guideline recommendation as available. In other cases, summary of the studies was presented with a suggested approach depending on the available evidence.
6
Results and discussion: NCPAP In the immediate post-extubation period, immature lungs with insufficient respiratory drive require additional support to maintain ventilation and oxygenation. NCPAP provides continuous distending pressure that maintains functional residual capacity and decreases the workload on the respiratory muscles8. By Cochrane review, postextubation NCPAP, reduces the incidence of respiratory failure and need for additional ventilatory support (RR 0.62, RD - 0.17, NNT 6)9. There are several methods to deliver NCPAP. Bubble CPAP (BCPAP) has the most satisfactory outcome. When compared with ventilator CPAP (VCPAP), the success rate of BCPAP was markedly higher (82.5% vs. 63.2%)10. Additionally, BCPAP had a significantly lower extubation failure rate and 50% shorter CPAP support duration in comparison with infant flow driver (IFD)11. Different interphases were tested to keep a seal while avoiding nasal injury. Short binasal prongs proved more effective than single prongs in reducing the rate of reintubation12. Nasal masks were equally effective to binasal prongs and didn’t cause any severe nasal trauma (0 vs. 31%; p < .001)13. On the other hand, NCPAP requires bulky interphase with a difficult nursing approach and is associated with increased incidence of pneumothoraxes 14 and nasal trauma15. Therefore, other emerging noninvasive modes are gaining attention. HFNC HFNC refers to heated humidified blended oxygen given through a small loose nasal cannula at a flow of >1l/min16. Thanks to its better tolerability and easier application, HFNC is becoming popular. It does not require tight bulky interphase, it is easier to apply and maintain, and is less irritating to the baby than NCPAP. Most multicenter trials comparing HFNC with NCPAP as a primary mode showed a trend towards higher failure rate with HFNC, like the HIPSTER trial17. However, the final intubation rate difference is insignificant once failed cases on HFNC rescued by NCPAP were considered. As demonstrated clearly in HUNTER trial 18. Looking specifically at post-extubation trials, although still in the non-inferiority zone, treatment failure risk tends to be higher in HFNC than NCPAP (34.2% vs. 25.8%). Moreover, almost half the infants in whom treatment with HFNC failed were successfully rescued with NCPAP and the incidence of nasal trauma was significantly lower in the HFNC group 19. Another trial that recruited infants >28 weeks demonstrated a statistically non-significant difference in reintubation risk 11.6% and 6.5% in HFNC and NCPAP respectively20. Interestingly, when high flow is applied at a flow rate of 8 L/min, extubation failure with an HFNC was lower than that of NCPAP (except for less than 28 weeks of GA) at (22% in HFNC and 34% in NCPAP)21. The 2016 Cochrane review,
7
HFNC following extubation had comparable efficacy to NCPAP and was associated with lower rates of pneumothorax and nasal trauma16. Looking at the available trials, a few points of note should be considered. Most of the available trials involved infants older than 28 weeks. The protocol of HFNC is significantly different between trials (flow2 -8l/min, NCPAP 5-8). Additionally, most studies showed a trend toward higher failure risk with HFNC, although this didn’t reach statistically insignificance. in view of the low number of recruited infants and the seriousness of the failure outcome, this trend should be taken into consideration. In conclusion, Since HFNC is easier, more tolerable and has fewer side effects than NCPAP, it could be tried as post-extubation support for infants ≥28 weeks but rescue CPAP should be available. However, in infants <28 weeks NCPAP there is not enough data to support postextubation HFNC17. SNIPPV/IPPV/BIPAP NIPPV provides breaths at rate and pressures comparable to endotracheal IPPV. BIPAP delivers breaths with much smaller differences (<4 cm H2O) between high and low pressures, longer inflation times (0.5–1.0 second for the higher pressure), and lower cycle rates (10–30 per minute) 22. NIPPV was shown to decrease the length of hospital stay, reintubation and BPD rates 23. Similarly, the trend toward lower extubation failure rate was clear, although not statistically significant. In the trial conducted by Jasani et al (19.3% and 28.12% in asynchronized NIPPV and NCPAP respectively)24. It also revealed that the duration of NIV and supplementary oxygen was significantly lower in asynchronized NIPPV group as compared to NCPAP group. Moreover, the risk of BPD in asynchronized NIPPV (6.9%) was unquestionably lower than in the NCPAP group (32.14 %). Synchronizing NIPPV has shown a promising further reduction in reintubation risk. SNIPPV, attained by applying a pneumatic capsule, reduced reintubation rates markedly in comparison with NCPAP25,26. That was reproduced with even much lower reintubation rates with inspiratory flow sensor SNIPPV (6 vs. 39%, in SNIPPV and NCPAP respectively)27. However, 2017 Cochrane review, which concluded that NIPPV reduced the risk of extubation failure more effectively than NCPAP in the first two to seven days, was unable to reveal any proven effect on BPD or on mortality28. No strong conclusions for devices or synchronization could be elicited.
For BIPAP, the evidence is not as convincing as it is for the previous modes. While a small trial on 20 preterm infants showed an increase of PO2, and a significant reduction of PCO2 and respiratory rate 29, more recent RCTs failed to reveal any added benefit to
8
using BIPAP over NCPAP at equivalent mean airway pressure in preventing extubation failures30-32. This contradiction of evidence could be attributed to many factors, including, the difference in the standards of care between the two studies, the small sample size in the first trial and different settings of BIPAP. BIPAP and NIPPV can be considered as a continuum: the shorter the inspiration, the high the pressure and the frequency the more it will resemble NIPPV. NIV NAVA This is a mode of NIV in which the ventilation is synchronized and controlled by the diaphragmatic electrical activity. Stable synchronization regardless of the leak is the main advantage of NIV NAVA33,34. However, it involves insertion and maintaining a delicate Edi monitoring tube, which is not always an easy task. In a study by Yonehara et al, NIV-NAVA was favorable compared with NIPPV as post-extubation mode. Without a significant difference in adverse events, treatment failure occurred in 40% and 47.4% in NIV-NAVA and in NIPPV respectively35. Nevertheless, studies on NIV NAVA are still very limited and further research is still needed in order to bring synchronization to daily practice. NHFOV NHFOV combines the benefits of distending NCPAP pressure with the active ventilation of HFOV. It reliably removes Pco2 without the need of synchronization36. In a small observational study on NHFOV as a post-extubation mode, although PaCO2 was virtually unchanged from preextubation levels, it declined significantly at 32 h from 59.8 mmHg to 50.7 mmHg. Consequently, it returned to pre-extubation levels upon discontinuation of NHFOV37. Other studies demonstrated its safety and efficacy in removing Co238,39. Conclusion In conclusion, NCPAP has shown good outcomes as an initial postextubation mode. However, SNIPPV is the most effective and reliable mode of reducing reintubation rate, especially in extremely preterm babies, more research is needed on NIV NAVA and NHFOV. Even in its asynchronized version, SINPPV has decreased BPD risk in several RCTs22,23. Nevertheless, this could not be replicated in Cochrane review 27. Therefore, in extremely preterm babies (<28 weeks) with a high risk of extubation failure (preexisting pneumonia, sepsis, anaemia, PDA, severe lung disease or failed previous extubation trials [7]) Starting with NIPPV, weaning to NCPAP, then HFNC gradually is the recommended procedure. On the other hand, in older babies with low risk of extubation failure, starting with HFNC is more practical provided that NCPAP and SNIPPV are available for escalating support if needed. Those babies could be supported with NCPAP straightaway should they have high-risk factors for extubation failure.
9
Following the abovementioned clinical trials, a suggested table for each NIV mode criteria for application and weaning is included (Appendix A). Additionally, an integrated guideline algorithm is included (Appendix B). NHOFV and NIV NAVA could be tried if available as a rescue mode in cases which failed on other NIV modes before reintubation. Especially, in babies with good respiratory drive and without shock.
10
Abbreviations: NIV: non-invasive ventilation, MV: mechanical ventilation, BPD: bronchopulmonary dysplasia, NBIPAP: nasal bilevel positive airway pressure, HFNC: high flow nasal canula, NHFOV: nasal high frequency oscillatory ventilation, NIV NAVA: non-invasive neurally adjusted ventilatory assist, NCPAP: nasal continuous positive airway pressure, NIPPV: non-invasive intermittent positive pressure ventilation, SNIPPV: synchronised non-invasive intermittent positive pressure ventilation.
11
References: 1. Attar MA, Donn SM. Mechanisms of ventilator-induced lung injury in premature infants. Seminars in Neonatology 2002 Oct;7(5):353-360. 2. Jobe AH. The new bronchopulmonary dysplasia. Current opinion in pediatrics 2011 Apr;23(2):167-172. 3. Davidson LM, Berkelhamer SK. Bronchopulmonary Dysplasia: Chronic Lung Disease of Infancy and Long-Term Pulmonary Outcomes. Journal of clinical medicine 2017 Jan 6;6(1):4. 4. Stoll BJ, Hansen NI, Bell EF, Walsh MC, Carlo WA, Shankaran S, et al. Trends in Care Practices, Morbidity, and Mortality of Extremely Preterm Neonates, 1993-2012. JAMA 2015 Sep 8;314(10):1039-1051. 5. Berger J, Mehta P, Bucholz E, Dziura J, Bhandari V. Impact of Early Extubation and Reintubation on the Incidence of Bronchopulmonary Dysplasia in Neonates. Amer J Perinatol 2014 Dec;31(12):1063-1072. 6. Shalish W, Kanbar L, Kovacs L, Chawla S, Keszler M, Rao S, et al. The Impact of Time Interval between Extubation and Reintubation on Death or Bronchopulmonary Dysplasia in Extremely Preterm Infants. The Journal of Pediatrics 2018 Nov 5,. 7. Hiremath GM, Mukhopadhyay K, Narang A. Clinical risk factors associated with extubation failure in ventilated neonates. Indian pediatrics 2009 Oct;46(10):887 8. Shalish W, Sant’ Anna G, Natarajan G, Chawla S. When and How to Extubate Premature Infants from Mechanical Ventilation. Curr Pediatr Rep 2014 Mar;2(1):18-25.
12 9. Davis PG, Henderson-Smart DJ. Nasal continuous positive airways pressure immediately after extubation for preventing morbidity in preterm infants. The Cochrane database of systematic reviews 2003(2):CD000143. 10. Tagare A, Kadam S, Vaidya U, Pandit A, Patole S. Bubble CPAP versus Ventilator CPAP in Preterm Neonates with Early Onset Respiratory Distress--A Randomized Controlled Trial. Journal of tropical pediatrics 2013 Apr;59(2):113-119. 11. Gupta, Samir, MD|Sinha, Sunil K., MD, PhD|Tin, Win, MD|Donn, Steven M., MD. A Randomized Controlled Trial of Post-extubation Bubble Continuous Positive Airway Pressure Versus Infant Flow Driver Continuous Positive Airway Pressure in Preterm Infants with Respiratory Distress Syndrome. Journal of Pediatrics, The 2009;154(5): 650.e2. 12. De Paoli AG, Davis PG, Faber B, Morley CJ. Devices and pressure sources for administration of nasal continuous positive airway pressure (NCPAP) in preterm neonates. The Cochrane database of systematic reviews 2008 Jan 23, (1):CD002977. 13. Chandrasekaran A, Thukral A, Jeeva Sankar M, Agarwal R, Paul V, Deorari A. Nasal masks or binasal prongs for delivering continuous positive airway pressure in preterm neonates—a randomised trial. Eur J Pediatr 2017 Mar;176(3):379-386. 14. Morley CJ, Davis PG, Doyle LW, Brion LP, Hascoet J, Carlin JB, et al. Nasal CPAP or Intubation at Birth for Very Preterm Infants. The New England Journal of Medicine 2008 Feb 14;358(7):700-708. 15. Fischer C, Bertelle V, Hohlfeld J, Forcada-Guex M, Stadelmann-Diaw C, Tolsa J. Nasal trauma due to continuous positive airway pressure in neonates. Archives of disease in childhood. Fetal and neonatal edition 2010 Nov;95(6): F451. 16. Wilkinson D, Andersen C, O'Donnell C, De Paoli AG, Manley BJ. High flow nasal cannula for respiratory support in preterm infants. Cochrane Database Syst Rev. 2016, Issue 2. Art. No.: CD006405.doi: 10.1002/14651858.CD006405.pub3.
13 17. Roberts CT, Owen LS, Manley BJ, Frøisland DH, Donath SM, Dalziel KM, et al. Nasal HighFlow Therapy for Primary Respiratory Support in Preterm Infants. The New England Journal of Medicine 2016 Sep 22;375(12):1142-1151. 18. Manley BJ, Roberts CT, Arnolda GRB, Wright IMR, Owen LS, Dalziel KM, et al. A multicentre, randomised controlled, non-inferiority trial, comparing nasal high flow with nasal continuous positive airway pressure as primary support for newborn infants with early respiratory distress born in Australian non-tertiary special care nurseries (the HUNTER trial): study protocol. BMJ Open 2017 Jun;7(6): e016746. 19. Manley BJ, Owen LS, Doyle LW, Andersen CC, Cartwright DW, Pritchard MA, et al. High-flow nasal cannulae in very preterm infants after extubation. The New England journal of medicine 2013 Oct 10,;369(15):1425-1433. 20. Bradley A Yoder, Ronald A Stoddard, Ma Li, Jerald King, Daniel R Dirnberger, Soraya Abbasi. Heated, Humidified High-Flow Nasal Cannula Versus Nasal CPAP for Respiratory Support in Neonates. Pediatrics 2013 May 1;131(5): e1490. 21. Collins, Clare L., MBChB, FRACP|Holberton, James R., MBBS, FRACP|Barfield, Charles, MBBS, FRACP|Davis, Peter G., MD, FRACP. A Randomized Controlled Trial to Compare Heated Humidified High-Flow Nasal Cannulae with Nasal Continuous Positive Airway Pressure Postextubation in Premature Infants. Journal of Pediatrics, The 2013;162(5): 954.e1. 22. Cummings JJ, Polin RA. Noninvasive respiratory support. Pediatrics 2016 Jan;137(1): e20153758. 23. Esmaeilnia T, Nayeri F, Taheritafti R, Shariat M, Moghimpour-Bijani F. Comparison of Complications and Efficacy of NIPPV and Nasal CPAP in Preterm Infants With RDS. Iranian journal of pediatrics 2016 Apr;26(2):e2352. 24. Jasani B, Nanavati R, Kabra N, Rajdeo S, Bhandari V. Comparison of non-synchronized nasal intermittent positive pressure ventilation versus nasal continuous positive airway pressure as postextubation respiratory support in preterm infants with respiratory distress syndrome: a
14 randomized controlled trial. The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 2016;29(10):1546-1551 25. Keith J Barrington, Dale Bull, Neil N Finer. Randomized trial of nasal synchronized intermittent mandatory ventilation compared with continuous positive airway pressure after extubation of very low birth weight infants. Pediatrics 2001 Apr 1,;107(4):638-641. 26. Khalaf MN, Brodsky N, Hurley J, Bhandari V. A Prospective Randomized, Controlled Trial Comparing Synchronized Nasal Intermittent Positive Pressure Ventilation Versus Nasal Continuous Positive Airway Pressure as Modes of Extubation. Pediatrics 2001 Jul 1,;108(1):1317. 27. Moretti C, Giannini L, Fassi C, Gizzi C, Papoff P, Colarizi P. Nasal flow‐synchronized intermittent positive pressure ventilation to facilitate weaning in very low‐birthweight infants: Unmasked randomized controlled trial. Pediatrics International 2008 Feb;50(1):85-91. 28. Lemyre B, Davis PG, De Paoli AG, Kirpalani H. Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for preterm neonates after extubation. The Cochrane database of systematic reviews 2017 Feb 1,;2:CD003212. 29. Migliori C, Motta M, Angeli A, Chirico G. Nasal Bilevel vs. Continuous Positive Airway Pressure in Preterm Infants. Pediatric Pulmonology 2005 Nov;40(5):426-430. 30. O'Brien K, Campbell C, Brown L, Wenger L, Shah V. Infant flow biphasic nasal continuous positive airway pressure (BP- NCPAP) vs. infant flow NCPAP for the facilitation of extubation in infants' 1,250 grams: a randomized controlled trial. BMC pediatrics 2012 Apr 4,;12(1):43. 31. Sadeghnia A, Barekateyn B, Badiei Z, Hosseini SM. Analysis and comparison of the effects of NBiPAP and Bubble-CPAP in treatment of preterm newborns with the weight of below 1500 grams affiliated with respiratory distress syndrome: A randomised clinical trial. Advanced biomedical research 2016;5(1):3.
15 32. Victor S, Roberts SA, Mitchell S, Aziz H, Lavender T. Biphasic positive airway pressure or continuous positive airway pressure: a randomized trial. Pediatrics 2016 Aug;138(2):e20154095. 33. Lee J, Kim H, Jung YH, Shin SH, Choi CW, Kim E, et al. Non-invasive neurally adjusted ventilatory assist in preterm infants: a randomised phase II crossover trial. Archives of Disease in Childhood: Fetal and Neonatal Edition 2015 Nov 15,;100(6):F513. 34. Stein, Howard|Beck, Jennifer|Dunn, Michael. Non-invasive ventilation with neurally adjusted ventilatory assist in newborns. Seminars in Fetal and Neonatal Medicine 2016;21(3):154-161. 35. Yonehara K, Ogawa R, Kamei Y, Oda A, Kokubo M, Hiroma T, et al. Non‐invasive neurally adjusted ventilatory assist versus nasal intermittent positive‐pressure ventilation in preterm infants born before 30 weeks’ gestation. Pediatrics International 2018 Oct;60(10):957-961. 36. De Luca D, Dell'Orto V. Non-invasive high-frequency oscillatory ventilation in neonates: review of physiology, biology and clinical data. Archives of disease in childhood. Fetal and neonatal edition 2016 Jun 28,;101(6):F570. 37. Czernik C, Schmalisch G, Bührer C, Proquitté H. Weaning of neonates from mechanical ventilation by use of nasopharyngeal high-frequency oscillatory ventilation: a preliminary study. Journal of Maternal-Fetal and Neonatal Medicine 2012 Apr;25(4):374-378. 38. Malakian A, Bashirnezhadkhabaz S, Aramesh M, Dehdashtian M. Noninvasive high-frequency oscillatory ventilation versus nasal continuous positive airway pressure in preterm infants with respiratory distress syndrome: A randomized controlled trial. The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 2018 Dec 4,:1-151. 39. Zhu X, Zhao J, Tang S, Yan J, Shi Y. Noninvasive high‐frequency oscillatory ventilation versus nasal continuous positive airway pressure in preterm infants with moderate‐severe respiratory distress syndrome: A preliminary report. Pediatric Pulmonology 2017 Aug;52(8):1038-1042.
16
Appendix A MODE
HFNC
Method
Vapotherm
Settings
•
*Fio2 adjustable
•
Flow 5-6 L/min change at 0.5 L according to RD, RR, and PCO2.
•
Maximum 8L/min
Weaning criteria
Minimum 2-3 L/min then shift to low flow cannula.
Failure criteria
Fio2 >40% and Flow8L/min with one of the following:
indications
•
>twice apnea requiring PPV
•
Shock.
•
pH < 7.20
•
CO2 > 60
•
Post extubation for >28 weeks without high risk for extubation failure.
•
As a primary mode
•
As a weaning mode after NCPAP.
17
Mode
NCPAP
Method
BCPAP (VCPAP or IFD if not available)
Settings
•
CPAP 6 cm H2o
•
Decrease CPAP by 1 cm H2O if stable oxygen requirement and fewer than three minor apnea episodes over 12 hours.
•
Minimum CPAP 4
•
If the infant did not tolerate the decrease in CPAP, as judged by an increase in oxygen requirement by > 15% or more than 3 apneas in 12 hours, then increase CPAP by 1 cm H2O, to a maximum of 6 cm H2O. (Gupta et al 2009).
Weaning
•
PEEP 4 cm H2O
criteria
•
FiO2 < 0.3 with normal blood gases.
•
After CPAP place the infant in air or ambient oxygen or on low-flow nasal cannula at a flow of < 1 L/minute
Failure criteria
indications
•
Fio2 >40%
•
CPAP > 6
•
>twice apnea requiring PPV
•
Shock.
•
pH < 7.20
•
CO2 > 60
•
(Gupta et al 2009).
•
Post extubation as weaning of NIPPV
18 •
After failure of HFNC in >28 weeks or as initial mode.
Mode
NIPPV
Method
Synchronized NIPPV if available
Settings
Weaning Criteria
Failure criteria
Indications
•
Increase PIP by 4 cm H2O from the pre-extubation value
•
Keep PEEP at ≤ 5cm H2O
•
Rate the same as was being given before extubation;
•
FiO2: adjust to maintain oxygen saturation between 88 and 93%
•
Flow rate at 8 to 10 L/min (Jasani et al 2016)
•
PIP/PEEP 12/4 cm H2O,
•
Rate of <20/min,
•
FiO2 <0.3 with normal blood gases;
At least one of the following: •
pH ≤7.25 and PaCO2 ≥ 60 mm
•
apnea with ≥3 episodes /h associated with bradycardia
•
single episode of apnea that required PPV
•
PaO2 ≤50 mm Hg with FiO2 of ≥0.6
•
Primary post extubation mode for <28 weeks.
•
Primary post extubation mode for > 28weeks with risk factors for extubation failure.
•
Escalation of NCPAP
19
*Fio2 in all modes should be adjusted to keep Spo2 (90-94%). Fio2: fractional inspiratory O2. RD: respiratory distress. RR: respiratory rate. PPV: positive pressure ventilation. PIP: positive inspiratory pressure. PEEP: positive end expiratory pressure Extubation failure usually indicates either incomplete resolution of underlying illness or the development of new problems. High risk of extubation failure (Hiremath et al 2009): -
PDA
-
anemia any time during their course.
-
pre-existing pneumonia and sepsis.
-
prolonged duration of ventilation >7days.
-
severe lung disease characterized by high maximum as well as the pre-extubation AaDO2>200.
20
Appendix B
Post Extubation preterm
Above 28 weeks
Below 28 weeks
High risk*
Low risk**
High risk*
NCPAP
NIPPV
HFNC
Failure
Weaning***
Failure
Weaning***
* High Risk for Extubation failure: PDA, Anemia, preexisting pneumonia or sepsis, prolonged ventilation (> 7days), severe lung disease (AaDo2>200), previous Extubation failure (Hiremath et al 2009) ** Low Risk for Extubation failure: without the above-mentioned risk factors. *** weaning flow of NIPPV then NCPAP then HFNC: it is a case dependent decision. Frequently, weaning can go from NIPPV to HFNC or from NCPAP directly.
Low risk**