Nasal Intermittent Positive Pressure Ventilation

(NIPPV)

Approved by Clinical Practice Committee

 

Feb 2015
 
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Introduction Indications Setup - VN 500 Setup - Babylog 8000
Maintenance Complications Troubleshooting References

Overview

Introduction

The spontaneously breathing preterm infant is faced with multiple challenges, such as reduced compliance of their lungs, high chest wall mobility, small upper airways, and periodic breathing with apnoeas.

Intubation and ventilation is an effective way to overcome these challenges, but is associated with side effects, such as chronic lung disease, upper airway damage and infection. The use of NIPPV, in particular if synchronized, seems to reduce the rate of extubation failure when compared to CPAP.

The mode of action is not entirely clear. Non-synchronised NIPPV pressure peaks only seem to cause a small increase in relative tidal volumes during spontaneous inspiration and occasionally result in chest inflation during apnoea3. The positive effect of NIPPV might also derive from increased main airway pressure, reduced work of breathing and/or improved gas exchange4.

Indications

NIPPV can be considered for preterm infants after extubation with on-going apnoeas and/or previous extubation failure. Those infants should be treated with an optimised dose of Caffeine Citrate (≥ 10 mg/kg/day). A high or increasing CO2 level is a sign of hypoventilation. Non-synchronized NIPPV might not sufficiently increase tidal volume and intubation and ventilation should be considered for infants with high or increasing CO2.

NIPPV Settings and Setup

NIPPV is NOT a replacement for endotracheal ventilation, it should be seen as ‘optimization of CPAP’.

Ventilator

Babylog 8000 plus (IMV) or Babylog VN 500 (PC-CMV).

Peak Inspiratory Pressure (PIP on Babylog 8000 / Pinsp on VN500)
  • 14 - 20 cm H2O, in discussion with a consultant may be increased to 24 cm H2O.
  • NIPPV is associated with a leak around the nose and through the mouth. The PIP / Pinsp should not be set higher than the ventilator can achieve. Eg.: if the set PIP / Pinsp is 20 cm H2O, but the measured pressure is 18 cm H2O, the ventilator will keep alarming.
Positive End Expiratory Pressure (PEEP) 5-8 cm H2O. PEEP is generally chosen in a similar way as for CPAP. Be aware of a potentially high mean airway pressure in cases where a high PEEP is used in combination with NIPPV.
Respiratory Rate (RR) 10 - 40 breaths/min, in discussion with a consultant may be increased to 60 breaths/min.
Inspiratory time (Ti) 0.3-0.5s, similar to Ti on the ventilator
Flow 10 l/min

 

Setup on VN 500

Mode

PC-CMV

Hudson CPAP Prongs Correct size for infant’s nares
Connectors Connectors from the ventilator circuit pack will fit the end of the blue and white circuit tubes and directly onto the Hudson CPAP prongs.
Flow sensor Turn the flow sensor off (right hand column ‘flow sensor’) and remove it from the circuit
Alarms The ‘Disconnection’ alarm will function
Oxygen An oxygen analyzer is not needed. Read FiO2 administered on the ventilator’s box measurement screen.
Resuscitation Use neopuff with mask for resuscitative measures


Setup on Babylog 8000

Mode

IMV

Hudson CPAP Prongs Correct size for infant’s nares
Connectors Connectors from the ventilator circuit pack will fit the end of the blue and white circuit tubes and directly onto the Hudson CPAP prongs.
Flow sensor The ventilator flow sensor is not used and the ventilator screen is not turned on.
Alarms
  • The flow alarm as a result will not sound and the flow sign will flash in the right hand column of the ventilator’s box information grid.
  • The ‘Leak in Hose’ alarm will function.
Oxygen An oxygen analyzer is not needed. Read FiO2 administered on the ventilator’s box measurement screen.
Resuscitation Use neopuff with mask for resuscitative measures

 

Maintenance of NIPPV

High / low CO2

NIPPV is NOT a replacement for endotracheal ventilation, it should be seen as ‘optimization of CPAP’. If the infant is deteriorating, do not change the settings as if the infant was ventilated but rather intubate and ventilate. For NIPPV, there is minimal evidence in regards to the effect of adjusting pressures and rates.

O2 concentration adjustment This is done on the ventilator and not on the oxygen/air blender at the bed space.
Charting Document on a ‘Level Three’ chart. Ventilator mode is charted as NIPPV to document it is not ventilation through an endotracheal tube.
Recordings Record FiO2, rate, pressures (PIP, PEEP), Ti and flow as well as vital signs hourly as per usual for ‘Level Three’ chart.
Gastric Tube A gastric tube needs to be in place and should ideally be left on free drainage while the baby is on NIPPV.
Suctioning Suctioning should be performed to maintain maximum airway patency and is the same as for babies on CPAP (see Airway Management for Babies on CPAP).
Kangaroo Care The same considerations as for CPAP apply for NIPPV with regard to kangaroo care (see ‘kangaroo care on CPAP).
 

Complications of NIPPV

Complications are similar to treatment with CPAP. (see ‘Complications of CPAP). Appropriate nursing care should prevent nasal septal erosion and nasal obstruction.
There have been concerns regarding NEC, feed intolerance, and intestinal perforation in association with NIPPV, but a recent Cochrane review could not confirm this (2). Given that the airway pressures with NIPPV are higher than those given with CPAP, a gastric tube needs to be in place and should ideally be left on free drainage while the infant is on NIPPV.

Troubleshooting NIPPV 

see also CPAP- troubleshooting

Flow sensor alarm

Leak in hose or disconnection alarm

Damage to nasal septum

Unsettled infant

References

1 Kirpalani H, Millar D, Lemyre B, Yoder BA, Chiu A, Roberts RS. A trial comparing noninvasive ventilation strategies in preterm infants. NEJM. 2013;369:611–20.
2 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. Cochrane database Syst Rev. 2014:CD003212.
3 Owen LS, Morley CJ, Dawson JA, Davis PG. Effects of non-synchronised nasal intermittent positive pressure ventilation on spontaneous breathing in preterm infants. Arch Dis Child Fetal Neonatal Ed. 2011;96:F422-8.
4 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;104:203–9.
5 De Paoli A, Davis P, Faber B, Morley C. Devices and pressure sources for administration of nasal continuous positive airway pressure ( NCPAP ) in preterm neonates. Cochrane Database Syst Rev. 2008;CD002977.