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 Applications

SNIPPV. Synchronized nasal intermittend positive pressure ventilation

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Coordinated inspiration

SNIPPV is the synchronized variant of the NIPPV respiratory support. In NIPPV, the breaths are administered by the device independent of the patient’s own breathing. This can lead to conflicts in the synchronization between the patient and the device. In SNIPPV, the breaths are coordinated to the patient’s inspiration and conflicts are minimized.

Studies were not only able to demonstrate the efficacy of SNIPPV. SNIPPV is superior in many indications compared to conventional modes such as nCPAP and 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​, Eun Mi Choi, M.D., Jae Hyun Park, M.D., Chun Soo Kim, M.D., and Sang Lak Lee, M.D. Pulmonary Outcomes of Early Extubation in Extremely Premature Infants (Gestational Age: 25–26 Weeks) with Synchronized Nasal Intermittent Positive-Pressure Ventilation Neonatal Med 2016 May;23(2):81-87, http://dx.doi.org/10.5385/nm.2016.23.2.81pISSN 2287-9412 . eISSN 2287-98033​)

  • Apnea-bradycardia syndrome
  • Reintubation rate
  • Reduction in breathing effort

  • Effective synchronized support

  • MediTRIG technology without an additional sensor

  • Apnea treatment (and backup frequency)

  • Available in the medinCNO device

Detecting the patient’s airway pressures

The type of trigger system plays an important role. The innovative pressure trigger system MediTRIG detects the patient’s airway pressures and from them, it can identify the start of inspiration. The spontaneous breaths are supported by breaths from the device with additional pressure.

MediTRIG does not require any additional sensor to record the patient’s own breathing, such as in the case of an abdominal capsule. MediTRIG gently detects the necessary signals directly at the nose of the small patient.

Apnea functions

The apnea functions are also available in SNIPPV mode. The SNIPPV and MediTRIG parameters can be individually adapted to the patient.

SNIPPV is defined by inspiration times which are as short as possible (0.2-0.5 sec) and breath rates up to 90/100 BPM. SNIPPV is a time-controlled mode, that is, the breath frequency is first and foremost set via the inspiration time and an expiration pause. In the expiration pause, the patient breathes on the CPAP level and the device does not emit any supportive breaths. In this way, the support can be individually adapted to the patient's needs. The level of pressure support is individually coordinated to the patient's needs with the aid of a second flow level. 

The following parameters are to be set

  • 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
  • Inspiration time: From 0.2 s to 2 s; duration of breath
  • Expiration pause: In sec.; time window during which no breaths are emitted to the patient
  • Sensitivity trigger: +/- mbar; upper and lower trigger threshold as pressure difference with regard to the PEEP;
  • Apnea time: From 2 s to 20 s; duration of breathing pause until device reacts
  • Inspiration time: From 0.2 s to 2 s; duration of breath
  • Push flow: Additional adjustable breathing gas flow with which a peak pressure can be generated
  • Backup rate: number of automatic breaths per minute which are administered to the patient after the end of apnea time
  • Oxygen supply
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  1. Trigger breath
  2. Push/breath
  3. Pause expiration
  4. Trigger breath
  5. Apnea

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. Eun Mi Choi, M.D., Jae Hyun Park, M.D., Chun Soo Kim, M.D., and Sang Lak Lee, M.D. Pulmonary Outcomes of Early Extubation in Extremely Premature Infants (Gestational Age: 25–26 Weeks) with Synchronized Nasal Intermittent Positive-Pressure Ventilation Neonatal Med 2016 May;23(2):81-87, http://dx.doi.org/10.5385/nm.2016.23.2.81pISSN 2287-9412 . eISSN 2287-9803

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.

Pulmonary Outcomes of Early Extubation in Extremely Premature Infants (Gestational Age: 25–26 Weeks) with Synchronized Nasal Intermittent Positive-Pressure Ventilation

Eun Mi Choi, M.D., Jae Hyun Park, M.D., Chun Soo Kim, M.D., and Sang Lak Lee, M.D. Pulmonary Outcomes of Early Extubation in Extremely Premature Infants (Gestational Age: 25–26 Weeks) with Synchronized Nasal Intermittent Positive-Pressure Ventilation Neonatal Med 2016 May;23(2):81-87, http://dx.doi.org/10.5385/nm.2016.23.2.81pISSN 2287-9412 . eISSN 2287-9803