Nasal respiratory support through the nares: its time has come

Abstract

Respiratory distress syndrome (RDS) is the most common respiratory morbidity in preterm infants. Surfactant therapy and invasive mechanical ventilation through the endotracheal tube (ETT) have been the cornerstones in RDS management. Despite improvements in the provision of mechanical ventilation, bronchopulmonary dysplasia (BPD), a multifactorial disease in which invasive mechanical ventilation is a known contributory factor, remains an important cause of morbidity among preterm infants. Barotrauma, volutrauma or oxygen-induced lung inflammation (oxy-trauma) contributes significantly to the development of BPD in neonates ventilated through an ETT. Recently, nasal respiratory support has been increasingly used in preterm infants in an attempt to decrease post-extubation failure and, perhaps, BPD, and for the treatment of apnea of prematurity in nonventilated neonates. Observational studies using noninvasive respiratory support, such as nasal continuous positive airway pressure (NCPAP), have shown a decrease in the incidence of BPD when used to avoid intubation or minimize the duration of invasive mechanical ventilation through the ETT. Moreover, synchronized as well as nonsynchronized nasal intermittent positive-pressure ventilation (NIPPV) have been shown to significantly decrease post-extubation failure compared with NCPAP and their use has been associated with a reduced risk of BPD in small randomized controlled clinical trials. More recently, early surfactant administration followed by extubation to NIPPV has been suggested to be synergistic in decreasing BPD. Although these findings are promising, additional studies evaluating different nasal interfaces, flow synchronization, synchronization using neurally adjusted ventilatory assist mode, and closed loop control of oxygen during nasal ventilation to minimize lung injury are needed in an attempt to further decrease the incidence of lung injury in preterm neonates requiring respiratory support.

Nasal Continuous Positive Airway Pressure Inhibits Gastroesophageal Reflux in Newborn Lambs

“…There has been a recent unprecedented development of nasal respiratory support for neonates in an attempt to prevent bronchopulmonary dysplasia and cerebral palsy, both of which have been associated with the use and duration of endotracheal intubation and ventilation in neonates [1], [2]. Hence, nasal continuous positive airway pressure (nCPAP) and various nasal intermittent positive pressure ventilation modalities are currently being used and tested for their relative advantages [3].…”

Comparison of Effort of Breathing for Infants on Nasal Modes of Respiratory Support

“…23 Other pediatric investigators found that NCPAP improved effort of breathing more than bi-level positive pressure in a cohort of children with UAO, largely because of asynchrony with the bi-level support. 24 Moreover, a recently published pediatric study showed improvements in electrical activity of the diaphragm as a surrogate for effort of breathing when better synchrony is achieved on NRS.…”

Neonatal nasal intermittent positive pressure ventilation efficacy and lung pressure transmission

“…25,26 There is also a move toward the use of modified RAM to deliver NCPAP and NIPPV. 27,28 However, to date, there is little clinical evidence of its physiological and clinical impact when delivering NIPPV. Further research is needed to understand the mechanics as well as clinical impact of such interfaces before their routine use for NIPPV can be recommended.…”