Non-Invasive Ventilation in the Newborn Infant

Publication: 08/07/2014  --
Last review: 28/06/2018  
Next review: 28/06/2021  
Standard Operating Procedure
CURRENT 
ID: 3892 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Non-Invasive Ventilation in the Newborn Infant

Background and indications for standard operating procedure/protocol

Non-invasive ventilation is increasingly used in the neonatal population as a primary form of respiratory support and secondary support after invasive ventilation. Non invasive ventilation includes CPAP (Continuous Positive Airway Pressure), biphasic positive airways pressure (BiPAP) and heated, humidified high flow oxygen therapy (HFT or high flow). There is an increasing body of evidence supporting their use.

CPAP
CPAP can be delivered by different means but the Viasys Infant Flow system is most commonly used in LTHT.

CPAP delivers a humidified variable air/oxygen blend to the baby at a pre-set pressure. In neonates it is delivered through the nose using a mask or bi-nasal short prongs as the interface. The gas delivered to the nose will be cooler and dryer than when leaving the humidifier as the circuit is not heated. The success of CPAP requires a good seal with the nares in order to deliver the pre-set pressure. Nasal trauma is a recognised consequence of nasal CPAP. Alternating the type of interface may help avoid this.
The optimum CPAP pressure may vary between patients but in general a higher pressure than PEEP is needed- 6-8cmH20

BiPAP
BiPAP is delivered by the same machine, circuit and interface as CPAP. There are several different types of BiPAP. The following are available at LTHT:

  1. Trigger pressure assist - the machines supports every breath the baby initiates with an increased level of pressure that is pre-determined by the operator. A lower level of continuous positive pressure underlies this.
  2. Pressure assist - the machine supports a set number of breaths per minute with the increased pre-set pressure whilst the underlying continuous positive pressure underlies the remaining part of the cycle.

High Flow Therapy
High flow therapy (HFT) delivers warmed, humidified blended oxygen/air mixture to the patient via a heated circuit and nasal cannulae at flow rates >1 L/min. HFT washes out excess carbon dioxide (CO2) from the large dead space of the newborn upper airways via an intentionally large leak at the nares. It is this washout that decreases the work of breathing for the baby rather than any pressure effect. In contrast to CPAP the pressure delivered to the airway in not measured with HFT but it is the nasal leak of expiratory gas that is important for success.

No more than 50% of the cross sectional area of the nares should be occluded by the cannulae to enable successful washout. Single prongs are available to deliver HFT and should be used preferentially. This enables a nasogastric tube (NGT) to be used at the same time. If binasal prongs are used any gastric tube should be used orally, as a nasal tube will occlude more of the airway and decrease the leak.

INDICATIONS

CPAP

HFT

  • Any signs of significant respiratory distress
    • Tachypnoea
    • Nasal flaring
    • Grunting
    • Recession
    • O2 requirement
  • RDS
  • TTN
  • Pulmonary oedema
  • Apnoea and bradycardia of prematurity
  • Weaning from mechanical ventilation
  • Tracheomalacia
  • Chronic lung disease
  • Meconium Aspiration Syndrome
  • Any signs of significant respiratory distress
    • Tachypnoea
    • Nasal flaring
    • Grunting
    • Recession
    • O2 requirement
  • RDS
  • TTN
  • Pulmonary oedema
  • Apnoea & bradycardia of prematurity
  • Weaning from mechanical ventilation
  • Tracheomalacia
  • Chronic lung disease
  • Nasal trauma and CPAP is difficult or impossible

 

CONTRAINDICATIONS

CPAP

HFT

  • The need for intubation and/or mechanical ventilation e.g. cardiovascular instability or unstable respiratory drive with frequent apnea
  • Ventilatory failure as indicated by the inability to maintain acceptable blood gases
  • Upper airways abnormalities that make it ineffective or potentially dangerous (e.g. choanal atresia, tracheo-esophageal fistula)
  • Congenital abnormality e.g. congential diaphragmatic hernia, cleft palate
  • Nasal trauma/severe deformity that might be exacerbated by use of nasal prongs.
  • The need for intubation and/or mechanical ventilation e.g. cardiovascular instability or unstable respiratory drive with frequent apnea
  • Ventilatory failure as indicated by the inability to maintain acceptable blood gases
  • Upper airways abnormalities that make it ineffective or potentially dangerous (e.g. choanal atresia, tracheo-esophageal fistula)
  • Congenital abnormality e.g. congential diaphragmatic hernia, cleft palate

 

BENEFITS

CPAP

HFT

  • Well evidenced
  • Early CPAP may prevent ventilation
  • Can aid successful extubation
  • May help to avoid ventilation for apnoea of prematurity
  • Familiarity of use for staff
  • Growing body of evidence
  • As good as CPAP for primary or secondary respiratory support
  • Safety profile v good
  • Better for developmental care, feeding etc
  • Less intensive for nursing
  • Parent friendly

 

ADVERSE EFFECTS

CPAP

HFT

  • Air leaks
    Increased rate of pneumothorax. May occur due to the disease particularly when the lungs are improving and lung compliance increasing.
  • Gastric dilatation “CPAP belly”
    The delivered gas is able to enter GI tract.
    Can be reduced by an oro-gastric tube on free drainage and/or nursing the baby with the cot tilted to about 30 degrees.
    Small risk of aspiration, further respiratory compromise and visceral rupture.
  • Nasal Irritation
    The fixation devices can cause irritation, damage or necrosis to the nasal septum or skin. The area should be inspected on a regular basis to avert these complications.
  • Obstruction of the prongs
    Obstruction of the prongs by secretions or other means will stop delivery of continuous distending pressure to the lungs and airways. The pressure will be maintained by the obstruction and the alarms will not detect a problem. Humidification of gases and selective, gentle suction of the airways are important strategies to prevent this problem.

One report of outbreak of infection after contamination in Vapotherm circuits. Issues addressed and no further reports (Jhung and Sunenshine, Pediatrics 2007:119:1061-1068)

One case report of scalp emphysema and pneumo-orbitus that resolved with discontinuation of HFT. Thought to be secondary to concomitant nasal trauma.

No reports of air leaks, intestinal dilation etc.

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Procedure method (step by step)

The decision on which form of non-invasive ventilation is clinical.

INITIATION OF NIV

Babies less than 28 weeks gestation
There is an absence of evidence for HFT in these babies. Infants born at less than 27 weeks gestation will be intubated and given surfactant in the delivery room. When they are ready for extubation they should be put onto CPAP, unless contraindicated.

Babies more than 28 weeks gestation
HFT has been shown to be as effective as CPAP in treating these infants for primary respiratory support (i.e. from delivery) or as secondary support (i.e. after ventilation). The choice should therefore be made by the senior health professional.

CPAP
Correct hat size and interface size is essential. See appendix.

CPAP should be started at a pressure of 6-7 cms of water.

HFT
If bi-nasal prongs are used they should fill less than half the nostril to ensure adequate leak. An oro-gastric tube should be used.

If a single prong (one size only) is used a nasogastric tube may be used in the other nostril.

Flow should be started at 6L/min in babies less than 1kg. Flows up to 8L/min may be used in bigger babies.

CHANGING NIV
If a baby is stable on CPAP consideration should be given to changing to HFT. This decision should be taken considering the infants gestational age.

If a baby is not coping with the form of NIV that is being administered (e.g. unsettled and restless or not maintaining adequate blood gases) changing to the other form of NIV should be considered i.e. HFT to CPAP or vice versa. Keep circuit that has been removed in patient space for re-use if necessary.

BiPAP should be considered only as a rescue therapy, when a baby is not coping on HFT or CPAP and to try to avoid re-intubation.

WEANING NIV
CPAP can be weaned by one of two methods once the baby has been stable for 24 hours:

  1. Wean pressure 12 hourly by 1cm of water to 5cm of water. When the baby is settled and not disturbed take the CPAP off. Closely monitor the baby for heart rate (HR), saturations, respiratory rate (RR) and work of breathing (WOB). If the baby show signs of tiring (e.g. increase in HR, RR, WOB or increasing oxygen demand or apnoeas) reapply the CPAP at 5 cms of water.
    Repeat this each 12 hour period. Gradually increase the frequency and length of the time off CPAP until the baby remains off. Low flow oxygen may be required.
  2. Gradually wean pressures 12-24 hourly by 1 cm of water until the baby has been stable on 3 cms of water for 24 hours then remove. Low flow oxygen may be required. The baby should be monitored (see above) to assess for signs of tiring but weaning to these pressures should ensure successful removal of respiratory support other than low flow oxygen.

HFT should be weaned when the baby has been stable for 24 hours. Wean the flow rate by 0.5L/min every 12 hours if weight less than 1500g in weight or 1L/min every 12 hours if more than 1500g. Adjust according to clinical response (if FiO2 rises significantly return to the previous higher flow rate for 12-24 hrs). When the flow rate has been stable at 2l/min for at least 12 hours the HFT can be removed. Low flow oxygen may be required.

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Provenance

Record: 3892
Objective:

To standardise and optimise the use of non-invasive ventilation in the newborn infant

Clinical condition:

Respiratory distress in the newborn

Target patient group: Newborn infant
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

Not supplied

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

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