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 Applications

NIPPV. Nasal intermittend positive pressure ventilation

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Nasal Intermittend Positive Pressure Ventilation

The umbrella term NIPPV includes modes in which -  in addition to CPAP/PEEP - controlled breaths are applied to support the patient. These breaths have a higher pressure level and are not emitted in a synchronized manner. A differentiation is made between the different variants of this form of respiratory support (Owen LS, Manley BJ. Nasal intermittent positive pressure ventilation in preterm infants: Equipment, evidence, and synchronization. Semin Fetal Neonatal Med. 2016;21(3):146-153. doi:10.1016/j.siny.2016.01.0031​, Roberts CT, Davis PG, Owen LS. Neonatal non-invasive respiratory support: synchronised NIPPV, non-synchronised NIPPV or bi-level CPAP: what is the evidence in 2013?. Neonatology. 2013;104(3):203-209. doi:10.1159/0003534482​, Davis PG, Morley CJ, Owen LS. Non-invasive respiratory support of preterm neonates with respiratory distress: continuous positive airway pressure and nasal intermittent positive pressure ventilation. Semin Fetal Neonatal Med. 2009;14(1):14-20. doi:10.1016/j.siny.2008.08.0033​).

NIPPV (Owen LS, Manley BJ. Nasal intermittent positive pressure ventilation in preterm infants: Equipment, evidence, and synchronization. Semin Fetal Neonatal Med. 2016;21(3):146-153. doi:10.1016/j.siny.2016.01.0031​, Roberts CT, Davis PG, Owen LS. Neonatal non-invasive respiratory support: synchronised NIPPV, non-synchronised NIPPV or bi-level CPAP: what is the evidence in 2013?. Neonatology. 2013;104(3):203-209. doi:10.1159/0003534482​) defines itself in this group with short inspiration times (0.3 – 0.5 sec) and breath rates of 10-60 BPM. Ideally, the patient adapts to the NIPPV rate. NIPPV is a time-controlled mode, that is, the breath frequency is first and foremost set via the inspiration time. 

  • Controlled respiratory support for neonates

  • Effective support after extubation and during apnea (1,2)

  • Easy to use and adjust

  • Available in the medinCNO, medinCNOmini, medin-NC3 devices

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The BiLevel (Owen LS, Manley BJ. Nasal intermittent positive pressure ventilation in preterm infants: Equipment, evidence, and synchronization. Semin Fetal Neonatal Med. 2016;21(3):146-153. doi:10.1016/j.siny.2016.01.0031​, Roberts CT, Davis PG, Owen LS. Neonatal non-invasive respiratory support: synchronised NIPPV, non-synchronised NIPPV or bi-level CPAP: what is the evidence in 2013?. Neonatology. 2013;104(3):203-209. doi:10.1159/0003534482​) mode differs from NIPPV in the longer inspiration time (0.5 s – 1 s) and accordingly lower breath rates (10-30 BPM). The objective is to allow the patient to breathe at both pressure levels. As a result of the longer time with higher pressure, the mean airway pressure can be increased. 

1 Mechanical breath
2 Spontaneous breathing on the second, higher pressure level

When is NIPPV used?

The effects and efficacy of NIPPV were investigated in numerous studies (Owen LS, Manley BJ. Nasal intermittent positive pressure ventilation in preterm infants: Equipment, evidence, and synchronization. Semin Fetal Neonatal Med. 2016;21(3):146-153. doi:10.1016/j.siny.2016.01.0031​, Roberts CT, Davis PG, Owen LS. Neonatal non-invasive respiratory support: synchronised NIPPV, non-synchronised NIPPV or bi-level CPAP: what is the evidence in 2013?. Neonatology. 2013;104(3):203-209. doi:10.1159/0003534482​, Davis PG, Morley CJ, Owen LS. Non-invasive respiratory support of preterm neonates with respiratory distress: continuous positive airway pressure and nasal intermittent positive pressure ventilation. Semin Fetal Neonatal Med. 2009;14(1):14-20. doi:10.1016/j.siny.2008.08.0033​) . The indications are 

  • Apnea-bradycardia syndrome
  • Post extubation
  • Initial treatment of RDS

The medin system

The specialized CPAP devices from medin in connection with the Medijet nCPAP generator are ideally suited for the use of NIPPV and BiLevel. With basic flow, the patient is provided with the desired CPAP/PEEP. With the aid of a second flow level which is set in addition to the basic flow via an additional electronic flow meter, Medijet generates a higher pressure level.

Since Medijet allows expiration at any point in time, the patient can breathe freely at both pressure levels. Because of this, the medin CPAP devices allow all NIPPV respiratory support options.

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  • Basic flow: In L/min; generates the CPAP/PEEP in the Medijet nCPAP generator
  • Push flow: In L/min; generates a second pressure level, PIP, in the Medijet nCPAP generator, in addition to the basic flow
  • Amplitude: In increments of 1 to 10; defines the level of the pressure amplitude via the depth of closure of the high-frequency valve; level 10 = highest amplitude; level 1 = lowest amplitude
  • Frequency: In BPM; number of breaths per minute depending on the inspiration time
  • oxygen supply

References

  1. 1. Owen LS, Manley BJ. Nasal intermittent positive pressure ventilation in preterm infants: Equipment, evidence, and synchronization. Semin Fetal Neonatal Med. 2016;21(3):146-153. doi:10.1016/j.siny.2016.01.003
  2. 2. Roberts CT, Davis PG, Owen LS. Neonatal non-invasive respiratory support: synchronised NIPPV, non-synchronised NIPPV or bi-level CPAP: what is the evidence in 2013?. Neonatology. 2013;104(3):203-209. doi:10.1159/000353448

 

  1. 3. Davis PG, Morley CJ, Owen LS. Non-invasive respiratory support of preterm neonates with respiratory distress: continuous positive airway pressure and nasal intermittent positive pressure ventilation. Semin Fetal Neonatal Med. 2009;14(1):14-20. doi:10.1016/j.siny.2008.08.003

Fußnoten

 

Nasal intermittent positive pressure ventilation in preterm infants: Equipment, evidence, and synchronization.

Owen LS, Manley BJ. Nasal intermittent positive pressure ventilation in preterm infants: Equipment, evidence, and synchronization. Semin Fetal Neonatal Med. 2016;21(3):146-153. doi:10.1016/j.siny.2016.01.003

The use of nasal intermittent positive pressure ventilation (NIPPV) as respiratory support for preterm infants is well established. Evidence from randomized trials indicates that NIPPV is advantageous over continuous positive airway pressure (CPAP) as post-extubation support, albeit with varied outcomes between NIPPV techniques. Randomized data comparing NIPPV with CPAP as primary support, and for the treatment of apnea, are conflicting. Intrepretation of outcomes is limited by the multiple techniques and devices used to generate and deliver NIPPV. This review discusses the potential mechanisms of action of NIPPV in preterm infants, the evidence from clinical trials, and summarizes recommendations for practice.

Neonatal non-invasive respiratory support: synchronised NIPPV, non-synchronised NIPPV or bi-level CPAP: what is the evidence in 2013?

Roberts CT, Davis PG, Owen LS. Neonatal non-invasive respiratory support: synchronised NIPPV, non-synchronised NIPPV or bi-level CPAP: what is the evidence in 2013?. Neonatology. 2013;104(3):203-209. doi:10.1159/000353448

Nasal continuous positive airway pressure (NCPAP) has proven to be an effective mode of non-invasive respiratory support in preterm infants; however, many infants still require endotracheal ventilation, placing them at an increased risk of morbidities such as bronchopulmonary dysplasia. Several other modes of non-invasive respiratory support beyond NCPAP, including synchronised and non-synchronised nasal intermittent positive pressure ventilation (SNIPPV and nsNIPPV) and bi-level positive airway pressure (BiPAP) are now also available. These techniques require different approaches, and the exact mechanisms by which they act remain unclear. SNIPPV has been shown to reduce the rate of reintubation in comparison to NCPAP when used as post-extubation support, but the evidence for nsNIPPV and BiPAP in this context is less convincing. There is some evidence that NIPPV (whether synchronised or non-synchronised) used as primary respiratory support is beneficial, but the variation in study methodology makes this hard to translate confidently into clinical practice. There is currently no evidence to suggest a reduction in mortality or important morbidities such as bronchopulmonary dysplasia, with NIPPV or BiPAP in comparison to NCPAP, and there is a lack of appropriately designed studies in this area. This review discusses the different approaches and proposed mechanisms of action of SNIPPV, nsNIPPV and BiPAP, the challenges of applying the available evidence for these distinct modalities of non-invasive respiratory support to clinical practice, and possible areas of future research.

Non-invasive respiratory support of preterm neonates with respiratory distress: continuous positive airway pressure and nasal intermittent positive pressure ventilation.

Davis PG, Morley CJ, Owen LS. Non-invasive respiratory support of preterm neonates with respiratory distress: continuous positive airway pressure and nasal intermittent positive pressure ventilation. Semin Fetal Neonatal Med. 2009;14(1):14-20. doi:10.1016/j.siny.2008.08.003

Non-invasive techniques of respiratory support were developed in order to reduce the adverse effects associated with ventilation via an endotracheal tube. Short bi-nasal prongs provide the most effective nasal interface for delivery of nasal continuous positive airway pressure (nCPAP). Devices used to generate CPAP include conventional ventilators, the 'bubbly bottle' system and the infant flow driver. NCPAP improves the rate of successful extubation. It is useful for preterm infants with respiratory distress syndrome, reducing time spent on an endotracheal tube and oxygen requirement at 28d. However, nCPAP is associated with an increased rate of pneumothorax. Nasal intermittent positive pressure ventilation (NIPPV) is useful for augmenting the effectiveness of nCPAP. It further improves rates of successful extubation and shows promise as an initial method of respiratory support. Further research is required to determine the optimal settings for both nCPAP and NIPPV.