Download PDF
Am J Perinatol 2024; 41(12): 1616-1624
DOI: 10.1055/a-2242-7391
Review Article

Continuous Positive Airway Pressure versus Nasal Intermittent Positive Pressure Ventilation in Preterm Neonates: What if Mean Airway Pressures Were Equivalent?

Amit Mukerji
1   Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
,
Martin Keszler 
2   Department of Pediatrics, Brown University, Providence, Rhode Island
› Author Affiliations Funding A.M. is supported by a Research Early Career Award from Hamilton Health Sciences Foundation (2019–2024).
› Further Information
Also available at
    Permissions and Reprints

Abstract

Respiratory support for preterm neonates in modern neonatal intensive care units is predominantly with the use of noninvasive interfaces. Continuous positive airway pressure (CPAP) and nasal intermittent positive pressure ventilation (NIPPV) are the prototypical and most commonly utilized forms of noninvasive respiratory support, and each has unique gas flow characteristics. In meta-analyses of clinical trials till date, NIPPV has been shown to likely reduce respiratory failure and need for intubation compared to CPAP. However, a significant limitation of the included studies has been the higher mean airway pressures used during NIPPV. Thus, it is unclear to what extent any benefits seen with NIPPV are due to the cyclic pressure application versus the higher mean airway pressures. In this review, we elaborate on these limitations and summarize the available evidence comparing NIPPV and CPAP at equivalent mean airway pressures. Finally, we call for further studies comparing noninvasive respiratory support modes at equal mean airway pressures.

Key Points

  • Most current literature on CPAP vs. NIPPV in preterm neonates is confounded by use of higher mean airway pressures during NIPPV.

  • In this review, we summarize existing evidence on CPAP vs. NIPPV at equivalent mean airway pressures.

  • We call for future research on noninvasive support modes to account for mean airway pressures.

Keywords

noninvasive respiratory support - CPAP - NIPPV - distending pressure - future research

Authors' Contributions

A.M. co-devised the manuscript concept, and wrote the initial draft. M.K. co-devised the manuscript concept and critically reviewed and edited the manuscript draft. Both authors approve the final submitted version of the manuscript.




Publication History

Received: 05 September 2023

Accepted: 10 January 2024

Accepted Manuscript online:
11 January 2024

Article published online:
09 February 2024

© 2024. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Jobe AH, Kramer BW, Moss TJ, Newnham JP, Ikegami M. Decreased indicators of lung injury with continuous positive expiratory pressure in preterm lambs. Pediatr Res 2002; 52 (03) 387-392
    CrossrefPubMedSearch in Google Scholar
  • 2 Thomson MA, Yoder BA, Winter VT, Giavedoni L, Chang LY, Coalson JJ. Delayed extubation to nasal continuous positive airway pressure in the immature baboon model of bronchopulmonary dysplasia: lung clinical and pathological findings. Pediatrics 2006; 118 (05) 2038-2050
    CrossrefPubMedSearch in Google Scholar
  • 3 Schmölzer GM, Kumar M, Pichler G, Aziz K, O'Reilly M, Cheung PY. Non-invasive versus invasive respiratory support in preterm infants at birth: systematic review and meta-analysis. BMJ 2013; 347: f5980
    CrossrefPubMedSearch in Google Scholar
  • 4 Serenius F, Ewald U, Farooqi A, Holmgren PA, Håkansson S, Sedin G. Short-term outcome after active perinatal management at 23-25 weeks of gestation. A study from two Swedish perinatal centres. Part 3: neonatal morbidity. Acta Paediatr 2004; 93 (08) 1090-1097
    CrossrefPubMedSearch in Google Scholar
  • 5 Manley BJ, Buckmaster AG, Travadi J. et al; and the Australian and New Zealand Neonatal network (ANZNN). Trends in the use of non-invasive respiratory support for term infants in tertiary neonatal units in Australia and New Zealand. Arch Dis Child Fetal Neonatal Ed 2022; 107 (06) 572-576
    CrossrefPubMedSearch in Google Scholar
  • 6 Gagliardi L, Tagliabue P, Bellù R, Corchia C, Mosca F, Zanini R. Network Neonatale Italiano. Survey of neonatal respiratory support use in very preterm infants in Italy. J Matern Fetal Neonatal Med 2012; 25 (Suppl. 03) 1-5
    CrossrefPubMedSearch in Google Scholar
  • 7 Read B, Ethier G, Mehrem AA, Dunn M, Mukerji A. Canadian EPIQ Lung Health Group, Canadian Neonatal Network. Prevention of bronchopulmonary dysplasia: a cross-sectional survey of clinical practices in Canada. J Perinatol 2022; 42 (09) 1255-1257
    CrossrefPubMedSearch in Google Scholar
  • 8 Mahmoud RA, Schmalisch G, Oswal A, Christoph Roehr C. Non-invasive ventilatory support in neonates: an evidence-based update. Paediatr Respir Rev 2022; 44: 11-18
    PubMedSearch in Google Scholar
  • 9 Mukerji A, Shah PS, Shivananda S. et al; Canadian Neonatal Network Investigators. Survey of noninvasive respiratory support practices in Canadian neonatal intensive care units. Acta Paediatr 2017; 106 (03) 387-393
    CrossrefPubMedSearch in Google Scholar
  • 10 Lemyre B, Deguise MO, Benson P, Kirpalani H, De Paoli AG, Davis PG. Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for preterm neonates after extubation. Cochrane Database Syst Rev 2023; 7 (07) CD003212
    PubMedSearch in Google Scholar
  • 11 Lemyre B, Deguise MO, Benson P, Kirpalani H, Ekhaguere OA, Davis PG. Early nasal intermittent positive pressure ventilation (NIPPV) versus early nasal continuous positive airway pressure (NCPAP) for preterm infants. Cochrane Database Syst Rev 2023; 7 (07) CD005384
    PubMedSearch in Google Scholar
  • 12 Dysart KC. Physiologic basis for nasal continuous positive airway pressure, heated and humidified high-flow nasal cannula, and nasal ventilation. Clin Perinatol 2016; 43 (04) 621-631
    CrossrefPubMedSearch in Google Scholar
  • 13 Diblasi RM. Nasal continuous positive airway pressure (CPAP) for the respiratory care of the newborn infant. Respir Care 2009; 54 (09) 1209-1235
    PubMedSearch in Google Scholar
  • 14 Jane Pillow J. Which continuous positive airway pressure system is best for the preterm infant with respiratory distress syndrome?. Clin Perinatol 2012; 39 (03) 483-496
    CrossrefPubMedSearch in Google Scholar
  • 15 De Paoli AG, Davis PG, Faber B, Morley CJ. Devices and pressure sources for administration of nasal continuous positive airway pressure (NCPAP) in preterm neonates. Cochrane Database Syst Rev 2008; 2008 (01) CD002977
    PubMedSearch in Google Scholar
  • 16 Bashir T, Murki S, Kiran S, Reddy VK, Oleti TP. ‘Nasal mask’ in comparison with ‘nasal prongs’ or ‘rotation of nasal mask with nasal prongs’ reduce the incidence of nasal injury in preterm neonates supported on nasal continuous positive airway pressure (nCPAP): a randomized controlled trial. PLoS ONE 2019; 14 (01) e0211476
    CrossrefPubMedSearch in Google Scholar
  • 17 Maram S, Murki S, Nayyar S. et al. RAM cannula with Cannulaide versus Hudson prongs for delivery of nasal continuous positive airway pressure in preterm infants: an RCT. Sci Rep 2021; 11 (01) 23527
    CrossrefPubMedSearch in Google Scholar
  • 18 Gerdes JS, Sivieri EM, Abbasi S. Factors influencing delivered mean airway pressure during nasal CPAP with the RAM cannula. Pediatr Pulmonol 2016; 51 (01) 60-69
    CrossrefPubMedSearch in Google Scholar
  • 19 Singh N, McNally MJ, Darnall RA. Does the RAM cannula provide continuous positive airway pressure as effectively as the Hudson prongs in preterm neonates?. Am J Perinatol 2019; 36 (08) 849-854
    Thieme ConnectPubMedSearch in Google Scholar
  • 20 Owen LS, Manley BJ. Nasal intermittent positive pressure ventilation in preterm infants: equipment, evidence, and synchronization. Semin Fetal Neonatal Med 2016; 21 (03) 146-153
    CrossrefPubMedSearch in Google Scholar
  • 21 Owen LS, Morley CJ, Davis PG. Do the pressure changes of neonatal non-synchronised NIPPV (NS nasal intermittent positive pressure ventilation) confer advantages over CPAP, or are high CPAP pressures as effective?. Pediatr Res 2011; 70 (05) 16-16
    CrossrefPubMedSearch in Google Scholar
  • 22 Mukerji A, Belik J. Neonatal nasal intermittent positive pressure ventilation efficacy and lung pressure transmission. J Perinatol 2015; 35 (09) 716-719
    CrossrefPubMedSearch in Google Scholar
  • 23 Kirpalani H, Millar D, Lemyre B, Yoder BA, Chiu A, Roberts RS. NIPPV Study Group. A trial comparing noninvasive ventilation strategies in preterm infants. N Engl J Med 2013; 369 (07) 611-620
    CrossrefPubMedSearch in Google Scholar
  • 24 Millar D, Lemyre B, Kirpalani H, Chiu A, Yoder BA, Roberts RS. A comparison of bilevel and ventilator-delivered non-invasive respiratory support. Arch Dis Child Fetal Neonatal Ed 2016; 101 (01) F21-F25
    CrossrefPubMedSearch in Google Scholar
  • 25 Owen LS, Morley CJ, Davis PG. Neonatal nasal intermittent positive pressure ventilation: what do we know in 2007?. Arch Dis Child Fetal Neonatal Ed 2007; 92 (05) F414-F418
    CrossrefPubMedSearch in Google Scholar
  • 26 Lemyre B, Davis PG, de Paoli AG. Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for apnea of prematurity. Cochrane Database Syst Rev 2002; (01) CD002272
    PubMedSearch in Google Scholar
  • 27 Sabsabi B, Harrison A, Banfield L, Mukerji A. Nasal intermittent positive pressure ventilation versus continuous positive airway pressure and apnea of prematurity: a systematic review and meta-analysis. Am J Perinatol 2022; 39 (12) 1314-1320
    Thieme ConnectPubMedSearch in Google Scholar
  • 28 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 (06) F422-F428
    CrossrefPubMedSearch in Google Scholar
  • 29 Aghai ZH, Saslow JG, Nakhla T. et al. Synchronized nasal intermittent positive pressure ventilation (SNIPPV) decreases work of breathing (WOB) in premature infants with respiratory distress syndrome (RDS) compared to nasal continuous positive airway pressure (NCPAP). Pediatr Pulmonol 2006; 41 (09) 875-881
    CrossrefPubMedSearch in Google Scholar
  • 30 Miedema M, van der Burg PS, Beuger S, de Jongh FH, Frerichs I, van Kaam AH. Effect of nasal continuous and biphasic positive airway pressure on lung volume in preterm infants. J Pediatr 2013; 162 (04) 691-697
    CrossrefPubMedSearch in Google Scholar
  • 31 Matlock DN, Bai S, Weisner MD. et al. Tidal volume transmission during non-synchronized nasal intermittent positive pressure ventilation via RAM cannula. J Perinatol 2019; 39 (05) 723-729
    CrossrefPubMedSearch in Google Scholar
  • 32 Hochwald O, Borenstein-Levin L, Dinur G. et al. The effect of changing respiratory rate settings on CO2 levels during nasal intermittent positive pressure ventilation (NIPPV) in premature infants. J Perinatol 2023; 43 (03) 305-310
    CrossrefPubMedSearch in Google Scholar
  • 33 Bamat N, Fierro J, Mukerji A, Wright CJ, Millar D, Kirpalani H. Nasal continuous positive airway pressure levels for the prevention of morbidity and mortality in preterm infants. Cochrane Database Syst Rev 2021; 11 (11) CD012778
    PubMedSearch in Google Scholar
  • 34 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
    CrossrefPubMedSearch in Google Scholar
  • 35 Khalid L, Al-Balushi S, Manoj N. et al. Toward optimal high continuous positive airway pressure as postextubation support in preterm neonates: a retrospective cohort study. Am J Perinatol 2024; 41 (suppl S1): e664-e670
    Thieme ConnectPubMedSearch in Google Scholar
  • 36 Kidman AM, Manley BJ, Boland RA. et al. Higher versus lower nasal continuous positive airway pressure for extubation of extremely preterm infants in Australia (ÉCLAT): a multicentre, randomised, superiority trial. Lancet Child Adolesc Health 2023;7(12):
    PubMed
  • 37 Morley CJ, Davis PG, Doyle LW, Brion LP, Hascoet JM, Carlin JB. COIN Trial Investigators. Nasal CPAP or intubation at birth for very preterm infants. N Engl J Med 2008; 358 (07) 700-708
    CrossrefPubMedSearch in Google Scholar
  • 38 Gupta A, Rodriguez L, Szynal A, Hallinan S, Keszler M. CPAP vs. unsynchronized NIPPV at equal mean airway pressure (MAP). Paper presented at: Pediatric Academic Societies Conference. April 24-May 1, 2019. Baltimore, MD, USA; 2851.442.
    PubMed
  • 39 Hsu HS, Chen W, Wang NK. Effect of continuous positive airway pressure on cardiac output in neonates. Zhonghua Min Guo Xiao Er Ke Yi Xue Hui Za Zhi 1996; 37 (05) 353-356
    PubMedSearch in Google Scholar
  • 40 Abdel-Hady H, Matter M, Hammad A, El-Refaay A, Aly H. Hemodynamic changes during weaning from nasal continuous positive airway pressure. Pediatrics 2008; 122 (05) e1086-e1090
    CrossrefPubMedSearch in Google Scholar
  • 41 Beker F, Rogerson SR, Hooper SB, Wong C, Davis PG. The effects of nasal continuous positive airway pressure on cardiac function in premature infants with minimal lung disease: a crossover randomized trial. J Pediatr 2014; 164 (04) 726-729
    CrossrefPubMedSearch in Google Scholar
  • 42 Moritz B, Fritz M, Mann C, Simma B. Nasal continuous positive airway pressure (n-CPAP) does not change cardiac output in preterm infants. Am J Perinatol 2008; 25 (02) 105-109
    Thieme ConnectPubMedSearch in Google Scholar
  • 43 Mukerji A, Wahab MGA, Mitra S. et al. High continuous positive airway pressure in neonates: a physiological study. Pediatr Pulmonol 2019; 54 (07) 1039-1044
    CrossrefPubMedSearch in Google Scholar
  • 44 Mukerji A, Abdul Wahab MG, Razak A. et al. High CPAP vs. NIPPV in preterm neonates - a physiological cross-over study. J Perinatol 2021; 41 (07) 1690-1696
    CrossrefPubMedSearch in Google Scholar
  • 45 Ahmad HA, Deekonda V, Patel W, Thabane L, Shah PS, Mukerji A. Comparison of high CPAP versus NIPPV in preterm neonates: a retrospective cohort study. Am J Perinatol 2022; 39 (16) 1828-1834
    Thieme ConnectPubMedSearch in Google Scholar
  • 46 Mukerji A, Read B, Shah PS, Network CN. NIPPV vs. CPAP post-extubation in neonates <29 weeks' gestation: a pragmatic, comparative effectiveness trial using network-based real-world data. Pediatric Academic Societies Conference. April 27-May 1, 2023. Washington DC, USA; 2160.2.
    PubMed
  • 47 Lampland AL, Plumm B, Worwa C, Meyers P, Mammel MC. Bi-level CPAP does not improve gas exchange when compared with conventional CPAP for the treatment of neonates recovering from respiratory distress syndrome. Arch Dis Child Fetal Neonatal Ed 2015; 100 (01) F31-F34
    CrossrefPubMedSearch in Google Scholar
  • 48 Victor S, Roberts SA, Mitchell S, Aziz H, Lavender T. Extubate Trial Group. Biphasic positive airway pressure or continuous positive airway pressure: a randomized trial. Pediatrics 2016; 138 (02) e20154095
    CrossrefPubMedSearch in Google Scholar
  • 49 Mukerji A, Rempel E, Thabane L. et al; NOVEL Trial Group. High continuous positive airway pressures versus non-invasive positive pressure ventilation in preterm neonates: protocol for a multicentre pilot randomised controlled trial. BMJ Open 2023; 13 (02) e069024
    CrossrefPubMedSearch in Google Scholar
  • 50 Roy B, Samson N, Moreau-Bussière F. et al. Mechanisms of active laryngeal closure during noninvasive intermittent positive pressure ventilation in nonsedated lambs. J Appl Physiol (1985) 2008; 105 (05) 1406-1412
    CrossrefPubMedSearch in Google Scholar
  • 51 Jounieaux V, Aubert G, Dury M, Delguste P, Rodenstein DO. Effects of nasal positive-pressure hyperventilation on the glottis in normal sleeping subjects. J Appl Physio (1985) 1995; 79 (01) 186-193
    CrossrefPubMedSearch in Google Scholar
  • 52 Mowitz ME, Zupancic JA, Millar D. et al. Prospective economic evaluation alongside the non-invasive ventilation trial. J Perinatol 2017; 37 (01) 61-66
    CrossrefPubMedSearch in Google Scholar
  • 53 Crawshaw JR, Kitchen MJ, Binder-Heschl C. et al. Laryngeal closure impedes non-invasive ventilation at birth. Arch Dis Child Fetal Neonatal Ed 2018; 103 (02) F112-F119
    CrossrefPubMedSearch in Google Scholar
  • 54 Gizzi C, Montecchia F, Panetta V. et al. Is synchronised NIPPV more effective than NIPPV and NCPAP in treating apnoea of prematurity (AOP)? A randomised cross-over trial. Arch Dis Child Fetal Neonatal Ed 2015; 100 (01) F17-F23
    CrossrefPubMedSearch in Google Scholar
  • 55 Stein H, Beck J, Dunn M. Non-invasive ventilation with neurally adjusted ventilatory assist in newborns. Semin Fetal Neonatal Med 2016; 21 (03) 154-161
    CrossrefPubMedSearch in Google Scholar