Non-invasive ventilation NIV and continuous positive airway pressure CPAP are forms of ventilatory support used in acute respiratory failure when a patient remains hypoxic despite optimisation of medical management. Both have additional indications in the chronic setting. These machines are commonly found on respiratory wards, high dependency units and intensive care. As a medical student or foundation doctor, you would not be expected to initiate or use a machine without senior input, but it is good to have an awareness of why they are used and how they work.
NIV is a form of breathing support delivering air, usually with added oxygen, via a facemask by positive pressure, used in respiratory failure. NIV delivers differing air pressure depending on inspiration and expiration. Therefore, ventilation is provided mainly by iPAP, whereas ePAP recruits underventilated or collapsed alveoli for gas exchange and allows for the removal of the exhaled gas. CPAP supplies constant fixed positive pressure throughout inspiration and expiration.
It, therefore, is not a form of ventilation, but splints the airways open. If delivered with oxygen, it can allow a higher degree of inspired oxygen than other oxygen masks. In the chronic setting it is used for severe obstructive sleep apnoea splinting the upper airway and in the acute setting for type 1 respiratory failure, for example in acute pulmonary oedema recruiting collapsed alveoli.
This article will focus on its use in respiratory failure. Positive airway pressure refers to the pressure outside the lungs being greater than the pressure inside of the lungs. This results in air being forced into the lungs down the pressure gradient , requiring less respiratory effort offloading respiratory muscles to reduce the work of breathing. The phase of breathing that requires the most energy is the process of overcoming the pressure required to re-expand collapsed segments of the lungs.
Therefore, by keeping these open, gas exchange efficiency is increased as less energy is required to breathe, and there is more surface area for gas exchange. As a medical student or junior doctor, you would not be expected to set up or adjust settings by yourself. If NIV provides a therapeutic benefit initially, it should be worn as much as possible during the first 24 hours.
If the patient is showing signs of clinical improvement, trials off NIV can take place to see how the patient manages. The period of time off NIV can then be gradually increased until it is felt the patient no longer requires it. Crit Care Med. Point-of-care lung ultrasound in neonatology: classification into descriptive and functional applications. Pediatr Res. Noninvasive high-frequency oscillatory ventilation as respiratory support in preterm infants: a meta-analysis of randomized controlled trials.
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Ann Intern Med. Download references. Chongqing, , China. Chongqing, ,China. Heifei, Anhui, , China. Beijing, , China. Wanzhou, Chongqing, ,China. Xiamen,Fujian,, China. Guangzhou,Guangdong, , China. Guangzhou, Guangdong,, China. Guangzhou,Guangdong,, China,. Guangzhou, Guangdong,,China. Guiyang, Guizhou, ,China. Zunyi, Guizhou, ,China. Lanzhou, Gansu, , China. Lanzhou, GanSu, ,China.
Harbin, Heilongjiang, , China. Xingxiang, Henan, , China. Zhengzhou,Henan, , China. Zhengzhou, Henan , China. Haikou, Hainan, , China. Shijiazhuang, Hebei,, China. Wuhan, Hubei, ,China. Nanjing, Jiangsu, , China. Changchun, Jilin,, China. Shanghai, , China. Xue Jiang, Department of neonatal intensive care unit, the second hospital of Shandong University. Jinan, Shandong, , China. Xian, Shanxi,, China. Chengdu, Sichuan, , China. Luzhou, Sichuan,, China.
Benqing Wu. Tianjin,, China. Yangfang Li, Canlin He, Department of neonatology, children's hospital of Kunming medical university. Kunming,Yunnan, , China. Mangshi, Yunnan, , China. Yinchuan, Ningxia,,China. Hangzhou, Zhejiang,, China. Beijing,, China. Changsha, Hunan,,China. Xining, Qinghai,,China.
Hohhot, Inner Mongolia,,China. Chen Jia, Department of Neonatology, Mianyang central hospital. Mianyang, Sichuan,, China. Ningbo, Zhejiang,, China. Qinhuangdao, Hebei, , China. Xuzhou, Jingsu, , China. Xianyang, Shanxi, , China. The trial is initiated and planned by the researchers and funded by Scientific Research Projects unit of Chongqing Project- cstcshms-ztzx Only this public funding will be used for the study, teleconferences, international panel meeting and for publication costs.
This is a non-promoted study and investigators did not receive and will not receive any fee from any industry. In no way industry or commercially interested subjects will have access to the data, before their publication. The study only received public funding from Chongqing Government.
You can also search for this author in PubMed Google Scholar. YS and DDL equally contributed to the protocol preparation and the paper writing; they read and approved the final manuscript. Correspondence to Daniele De Luca. The trial is registered in the clinicaltrial. Any modification to the protocol which may impact on the conduct of the study, potential benefit of the patient or may affect patient safety, including changes of study objectives, study design, patient population, sample sizes, study procedures, or significant administrative aspects will require a formal amendment to the protocol.
Thus, they will have to be approved by all investigators and will require a new ethical approval. Those are industries producing neonatal ventilators. These companies are not involved at all in the study and will not have any role in the conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, approval of the manuscript or decision to submit it for publication.
Many different ventilators will be variably used in the trial see Methods and design. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Reprints and Permissions.
Shi, Y. Continuous positive airway pressure CPAP vs noninvasive positive pressure ventilation NIPPV vs noninvasive high frequency oscillation ventilation NHFOV as post-extubation support in preterm neonates: protocol for an assessor-blinded, multicenter, randomized controlled trial.
BMC Pediatr 19, Download citation. Received : 23 October Accepted : 12 July Published : 26 July Anyone you share the following link with will be able to read this content:.
Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Skip to main content. Search all BMC articles Search. Download PDF. Abstract Background Various noninvasive respiratory support modalities are available in neonatal critical care in order to minimize invasive ventilation.
Discussion The study is applying the best trial methodology to neonatal ventilation, a field where it is often difficult to do so for practical reasons. Trial registration NCT registered on June 9, Need for a physiology-driven trial The noninvasive respiratory support policy may fail for several reasons such as, for instance, apneas, upper airways obstruction, technical malfunctioning or increasing work of breathing due to worsening of parenchymal lung disorder.
Methods and design Trial design This will be an assessor-blinded, multi-center, three-arms, parallel, randomized, controlled trial with a superiority design, conducted in Chinese NICUs.
Full size image. Discussion On the trial methods and limitations Ours is a study trying to apply the methodology of pharmacological trials to neonatal mechanical ventilation, a field where it is often difficult to do so for practical reasons blinding difficulties, long study times, difficult recruitment, lack of funding. This could be considered as a trial limitation, albeit we must consider that: the use of higher CPAP levels is controversial and not standardized.
Ethical considerations This trial is worth to be conducted given the uncertainty about the superiority of one respiratory technique over the others, especially for babies at highest risk. Appendix Clarifications for exclusion criteria Neonates who never needed intubation and IMV are not eligible for the study; similarly, a neonate randomized but never extubated is not eligible.
Blood gas analysis Blood gas values may only be obtained in following three ways venous blood gas analysis is not allowed in the study. Availability of data and materials Not applicable for the study protocol.
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Quanzhou,Fujian,,China Guangzhou, Guangdong,, China Guangzhou,Guangdong,, China, Taiyuan, Shanxi,, China. Funding The trial is initiated and planned by the researchers and funded by Scientific Research Projects unit of Chongqing Project- cstcshms-ztzx Their goal is to avoid potentially severe scarring and inflammation of the lungs that can result from the more invasive respiratory technique of endotracheal intubation and mechanical ventilation.
Bronchopulmonary dysplasia BPD is a leading cause of neurological injury and death in this cohort. Previously, a meta-analysis of trials of early nasal CPAP vs. Still, Dr. Meanwhile, nasal IPPV has been associated with nasal trauma and necrotizing enterocolitis. Researchers in the current study enrolled infants in 10 countries between May 7, , and June 29, Eligible infants weighed less than 1, grams, had a gestational age of less than 30 weeks, and were candidates for noninvasive respiratory support.
Infants expected to die were excluded, as were those with congenital abnormalities, a need for surgery, or a neuromuscular disorder. Key baseline characteristics in the study were similar, although the proportion of male infants was higher in the nasal IPPV group
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