Hi guys! 

What's your first choice of ventilation suport for extreme preterm babys after delivery Room? nCPAP, NIPPV or HFNC?

Most places I know uses nCPAP. But, the last Cochrane Review (2017) about this issue states that NIPPV reduces respiratory failure and need for intubation, without worsening of adverse effects. 

Any thoughts?

The same goes for post extubation treatment..

 

Hi,

thanks to the Cochrane review that you've mentioned we currently use nIPPV as 1st line treatment for RDS, regardless of the GA of the baby and as 1st line in the post-extubation period as well

Thanks

NIPPV

nCPAP after delivery room stabilization and also post-extubation

We use NIPPV in all gestational ages if possible. 

For those of you who choose NIPPV: do you use synchronized NIPPV?

What initial settings do you use for NIPPV for babies less than 1000g?

We tend to start with PIP 20/PEEP6-8, Rate 40, ITime 0.5.

Wean PIP for PCO2 less than 40 to min 16. Then wean the rate if PCO2 is still less than 40.

In case we have the right ventilator - we use synchronized NIPPV with a Grasby detector (cheap and easy to use compared with NAVA)

Peep at least 6 cmH2O, PIP around 16.

 

We always use s-nippv (Graseby Capsule) with PEEP of 6-8(-10) and starting PIP of 15-17 - changing PIP according to development of CO2. 

Tinsp 0,4.

Around 30-32 GA we tend to use nCPAP with Backup s-Nippv. From 32GA we start with nCPAP alone.

 

NIPPV synchronized mode 

We are starting to use NIPPV more on the ELBW babies but have trouble with alot of air in the belly, Causing feeding issues (vomiting from excess air)Trying the RAM cannula but doesn't seem much better with the air. What do you do about the excess air besides aspirating every hour. Also do you get the PIP set? We use the Draeger VN500 and if we set a PIP of 20 we may get 13 if we're lucky. 

About trying to get the PIP set:

Usually, the problema ia about a too shot inspiratory time (you may need to use 0,4 or 0,5s, even for preemies) or air leakage (usually around the nose). We use prongs with a hydrocolloid around the nose.

Start with ncpap to detect easy baby need LASA if need fo2 more than 30% with peep 6-7,, once surfactant given within frist 2-3 hours,, Snippv appled as it deceased rate NIV failure... 

My review article in this topic

https://www.sciencedirect.com/science/article/abs/pii/S1526054222000641

18 hours ago, Flavio Martins said:

About trying to get the PIP set:

Usually, the problema ia about a too shot inspiratory time (you may need to use 0,4 or 0,5s, even for preemies) or air leakage (usually around the nose). We use prongs with a hydrocolloid around the nose.

We do use iT of .5 sec. The leak is not the nose  but the mouth. Even with a chin strap  sometimes. Too much air in the belly is the main problem for these little babies.  

@Flavio Martins Glad to see how this discussion developed, with input from all corners of the globe, 🇧🇷 🇬🇷 🇮🇷 🇰🇪 🇺🇸 🇩🇪 🇦🇹 🇸🇦 and 🇪🇬 !

 

And what about Sweden, Dr? What do you do at your NICU?

Sweden is CPAP-land

 

Hehe. Same here..

Talking about CPAP, how high PEEP do you use? We increase It until 8 cmH2O. No higher.

 

Have a good Sunday! Ending night shift now 🥲

Sweden used be "low CPAP land", practically everyone got 4 cm for everything   But higher levels are now the standard, starting at 6 and going up to 8 cm. Disclaimer: since 2014, I work in a level 2+ unit (with inborns from 28+0) so I am not fully updated.

Have a good sleep, I am also on shift, now taking lunch!

In the VLBW we tend to give a try with nHFO. Especially if intubation is required first (https://doi.org/10.1016/j.chest.2019.01.014) but also as first treatment after successfull LISA in the delivery room

At our institution, after initial stabilization and resuscitation, we use pressure-triggered nIPPV at relatively high rates 60 per minute or higher, maintaining a 1:1 I/E ratio, with variable PIP, according to chest expansibility and blood gases, and PEEP of 6-7. Later we went to CPAP according to the evolution in the following hours. We also used RAM cannulae with the spouts fixed with hydrocolloid tape around the nasal grits.

CPAP than NIPPV 

Sorry to be late to the party. Been busy.

NIPPV is mostly a stealth way to increase distending pressure to levels most people are unwilling to use with CPAP. The fundamental flaw with all the studies comparing CPAP and NIPPV is that the mean airway pressure is substantially higher with NIPPV than with CPAP. When compared at the same mean airway pressure, there is no difference in short-term outcomes. Luise Owen long ago showed that very few NIPPV cycles generate a measurable tidal volume. This appears to be because the glottis is not open unless the baby is breathing in. Theoretically, synchronization should help this, but it is not always available or effective. Sherry Courtney's group showed that when used with the RAM cannula there is virtually no generated TV whether in synchrony or not. The RAM cannula is a terrible interface, it is really NOT appropriate for CPAP or NIPPV, it is really just a high-flow cannula (no expiratory limb, must not be occlusive). NIV NAVA is probably the only form of NIPPV that truly works - study is in progress to show that. Some of my colleagues like to use NIPPV. When I take over, I switch to CPAP at the same mean pressure and the baby never notices - except for less gas in the belly.....

Cheers,
Martin Keszler, Brown University, Providence, RI

Thank you Professor Keszler!

How high on PEEP would you go? 'cos, sometimes, MAP on NIPPV could be as high as 12 cmH2O, which is usually higher than the pressure people tend to fell confortable setting on the CPAP.