Carbon Dioxide Level between Nasal High-Frequency Oscillatory Ventilation and Synchronized Nasal Intermittent Positive Pressure Ventilation after Extubation in Neonates: A Cross-over Randomized Controlled Trial

Abstract

Objective Nasal high-frequency oscillatory ventilation (nHFOV) and synchronized nasal intermittent positive pressure ventilation (sNIPPV) yield a lower partial pressure of carbon dioxide (pCO₂) after extubation than nasal continuous positive airway pressure. Our aim was to clarify which of the two was superior.

Study Design We performed a crossover randomized study to evaluate pCO₂ level among 102 participants from July 2020 to June 2022. Intubated preterm and term neonates with arterial lines were randomly allocated to nHFOV–sNIPPV or sNIPPV–nHFOV sequences; their pCO₂ levels were measured after 2 hours in each mode. Subgroup analyses were performed for preterm (gestational age <37 weeks) and very preterm (gestational age <32 weeks) neonates.

Results The mean gestational age (nHFOV–sNIPPV, 32.8 vs. sNIPPV–nHFOV, 33.5 weeks) and median birth weight (1,850 vs. 1,930 g) did not differ between the sequences. The mean ± standard deviation pCO₂ level after nHFOV (38.7 ± 8.8 mm Hg) was significantly higher than that after sNIPPV (36.8 ± 10.2 mm Hg; mean difference: 1.9 mm Hg; 95% confidence interval: 0.3–3.4 mm Hg; treatment effect [p = 0.007] but no sequence [p = 0.92], period [p = 0.53], or carryover [p = 0.94] effects). However, the difference in pCO₂ level between the sequences was not statistically significant in the subgroup analyses of preterm and very preterm neonates.

Conclusion After neonatal extubation, the sNIPPV mode was associated with a lower pCO₂ level than the nHFOV mode with no significant difference in preterm and very preterm neonates.

Key Points

• Full noninvasive ventilation support is suggested in neonatal ventilation.

• pCO₂ level in sNIPPV was lower than in nHFOV.

• No differences in pCO₂ levels were observed in either preterm or very preterm neonates.

Keywords

airway extubation - carbon dioxide - high-frequency ventilation - intermittent positive pressure ventilation - newborn - noninvasive ventilation

Clinical Trial Registration

This trial has been registered in the ClinicalTrials.gov database ( https://clinicaltrials.gov/ct2/show/NCT04323397 ). First posted registration: March 26, 2020.

Note

This study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving research study participants were approved by the institutional ethics committee. Written informed consent was obtained from all participants.

Authors' Contributions

K.B., M.P., and A.T. designed the data collection instruments, collected data, performed the initial analyses, drafted the initial manuscript, and reviewed and revised the manuscript. A.T., G.M., S.D., and W.J. conceptualized and designed the study, coordinated and supervised data collection, and critically reviewed the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Publication History

Received: 07 April 2023

Accepted: 16 June 2023

Accepted Manuscript online:
20 June 2023

Article published online:
29 July 2023

• References

• 1 Miller JD, Carlo WA. Pulmonary complications of mechanical ventilation in neonates. Clin Perinatol 2008; 35 (01) 273-281 , x–xi
• 2 Thatrimontrichai A, Rujeerapaiboon N, Janjindamai W. et al. Outcomes and risk factors of ventilator-associated pneumonia in neonates. World J Pediatr 2017; 13 (04) 328-334
• 3 Thatrimontrichai A, Janjindamai W, Dissaneevate S, Maneenil G, Kritsaneepaiboon S. Risk factors and outcomes of ventilator-associated pneumonia from a neonatal intensive care unit, Thailand. Southeast Asian J Trop Med Public Health 2019; 50: 537-545
• 4 Thatrimontrichai A. Evidence-based neonatal care. J Health Sci Med Res 2019; 37: 163-169
• 5 Moretti C, Gizzi C. Synchronized nasal intermittent positive pressure ventilation. Clin Perinatol 2021; 48 (04) 745-759
• 6 De Luca D, Centorrino R. Nasal high-frequency ventilation. Clin Perinatol 2021; 48 (04) 761-782
• 7 Rüegger CM, Owen LS, Davis PG. Nasal intermittent positive pressure ventilation for neonatal respiratory distress syndrome. Clin Perinatol 2021; 48 (04) 725-744
• 8 Moretti C, Giannini L, Fassi C, Gizzi C, Papoff P, Colarizi P. Nasal flow-synchronized intermittent positive pressure ventilation to facilitate weaning in very low-birthweight infants: unmasked randomized controlled trial. Pediatr Int 2008; 50 (01) 85-91
• 9 Khalaf MN, Brodsky N, Hurley J, Bhandari V. A prospective randomized, controlled trial comparing synchronized nasal intermittent positive pressure ventilation versus nasal continuous positive airway pressure as modes of extubation. Pediatrics 2001; 108 (01) 13-17
• 10 Friedlich P, Lecart C, Posen R, Ramicone E, Chan L, Ramanathan R. A randomized trial of nasopharyngeal-synchronized intermittent mandatory ventilation versus nasopharyngeal continuous positive airway pressure in very low birth weight infants after extubation. J Perinatol 1999; 19 (6 Pt 1): 413-418
• 11 Li J, Li X, Huang X, Zhang Z. Noninvasive high-frequency oscillatory ventilation as respiratory support in preterm infants: a meta-analysis of randomized controlled trials. Respir Res 2019; 20 (01) 58
• 12 Buzzella B, Claure N, D'Ugard C, Bancalari E. A randomized controlled trial of two nasal continuous positive airway pressure levels after extubation in preterm infants. J Pediatr 2014; 164 (01) 46-51
• 13 Lou W, Zhang W. Noninvasive high-frequency oscillatory ventilation versus nasal continuous positive airway pressure in premature infants with respiratory distress syndrome after weaning: a randomized controlled trial. Guangdong Yixue 2017; 13: 2037-2040
• 14 Seth S, Saha B, Saha AK, Mukherjee S, Hazra A. Nasal HFOV versus nasal IPPV as a post-extubation respiratory support in preterm infants-a randomised controlled trial. Eur J Pediatr 2021; 180 (10) 3151-3160
• 15 Li Y, Wei Q, Zhao D. et al. Non-invasive high-frequency oscillatory ventilation in preterm infants after extubation: a randomized, controlled trial. J Int Med Res 2021; 49 (02) 300060520984915
• 16 Ramaswamy VV, Bandyopadhyay T, Nanda D. et al. Efficacy of noninvasive respiratory support modes as postextubation respiratory support in preterm neonates: a systematic review and network meta-analysis. Pediatr Pulmonol 2020; 55 (11) 2924-2939
• 17 Wang K, Zhou X, Gao S, Li F, Ju R. Noninvasive high-frequency oscillatory ventilation versus nasal intermittent positive pressure ventilation for preterm infants as an extubation support: a systematic review and meta-analysis. Pediatr Pulmonol 2023; 58 (03) 704-711
• 18 Kieran EA, Twomey AR, Molloy EJ, Murphy JF, O'Donnell CP. Randomized trial of prongs or mask for nasal continuous positive airway pressure in preterm infants. Pediatrics 2012; 130 (05) e1170-e1176
• 19 Razak A, Patel W. Nasal mask vs binasal prongs for nasal continuous positive airway pressure in preterm infants: a systematic review and meta-analysis. Pediatr Pulmonol 2020; 55 (09) 2261-2271
• 20 Hochwald O, Riskin A, Borenstein-Levin L. et al. Cannula with long and narrow tubing vs short binasal prongs for noninvasive ventilation in preterm infants: noninferiority randomized clinical trial. JAMA Pediatr 2021; 175 (01) 36-43
• 21 Zhu X, Qi H, Feng Z, Shi Y, De Luca D. Nasal Oscillation Post-Extubation (NASONE) Study Group. Noninvasive high-frequency oscillatory ventilation vs nasal continuous positive airway pressure vs nasal intermittent positive pressure ventilation as postextubation support for preterm neonates in China: a randomized clinical trial. JAMA Pediatr 2022; 176 (06) 551-559
• 22 Zheng YR, Liu JF, Lei YQ, Wu HL, Cao H, Chen Q. Synchronized nasal intermittent positive pressure ventilation versus nasal continuous positive airway pressure for prevention of extubation failure in infants after congenital heart surgery. Heart Surg Forum 2021; 24 (02) E249-E255
• 23 Gizzi C, Papoff P, Giordano I. et al. Flow-synchronized nasal intermittent positive pressure ventilation for infants <32 weeks' gestation with respiratory distress syndrome. Crit Care Res Pract 2012; 2012: 301818
• 24 Bhandari V, Finer NN, Ehrenkranz RA. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Synchronized nasal intermittent positive-pressure ventilation and neonatal outcomes. Pediatrics 2009; 124 (02) 517-526
• 25 Bhandari V, Gavino RG, Nedrelow JH. et al. A randomized controlled trial of synchronized nasal intermittent positive pressure ventilation in RDS. J Perinatol 2007; 27 (11) 697-703
• 26 Ding F, Zhang J, Zhang W. et al. Clinical study of different modes of non-invasive ventilation treatment in preterm infants with respiratory distress syndrome after extubation. Front Pediatr 2020; 8: 63
• 27 Łoniewska B, Tousty J, Michalczyk B, Kordek A, Jankowska A. The use of noninvasive ventilation with high frequency in newborns-a single-center experience. Am J Perinatol 2019; 36 (13) 1362-1367
• 28 Klotz D, Schneider H, Schumann S, Mayer B, Fuchs H. Non-invasive high-frequency oscillatory ventilation in preterm infants: a randomised controlled cross-over trial. Arch Dis Child Fetal Neonatal Ed 2018; 103 (04) F1-F5
• 29 Chen L, Wang L, Ma J, Feng Z, Li J, Shi Y. Nasal high-frequency oscillatory ventilation in preterm infants with respiratory distress syndrome and ARDS after extubation: a randomized controlled trial. Chest 2019; 155 (04) 740-748