"In fact, discontinuing invasive ventilation in favor of noninvasive respiratory support has been considered the single best approach that neonatologists can implement to reduce BPD."
Does reduction of invasive respiratory support decrease incidence of BPD? As discussed in respiratory class readings volutrauma, barotrauma, and breath stacking can still occur when utilizing non-invasive support.
Accordingly, noninvasive respiratory support should be considered for clinical goals other than the reduction of BPD.
This article highlights the importance of viewing the whole patient picture when making clinical decisions. Though prevention of BPD is of utmost importance, we as practitioners have to be prepared to support our patient appropriately. Whether that means providing them with increased respiratory support, modifying ventilation due to abdominal distension, or providing ventilatory support to decrease the amount of intubations. Many of the studies used in this article yielded different results. No patient case is exactly the same. These concepts are ones I will carry with me moving forward in my career as a practitioner.
Because the distending pressure is not monitored, care should be taken to avoid pulmonary overinflation.
Though invasive ventilation has been shown to increase incidences of BPD in some literature, could invasive ventilation be more appropriate when accounting for lung compliance? SIMV-PC delivers set pressures and a variable tidal volume dependent upon lung compliance. Volume guarantee will provide a set tidal volume and variable pressures dependent upon lung compliance. Could accounting for patient lung compliance decrease incidence of BPD?
Although noninvasive NAVA is new, early studies suggest that it is safe and may provide improved synchronization, smaller PIPs, and decreased work of breathing compared with NIMV.
How does incidence of BPD compare in neonates on invasive NAVA vs SIMV? Is there a decreased incidence when utilizing neurally adjusted ventilation?
Thus, the goal of NAVA is to transduce, on a breath-by- breath basis, the timing and intensity of the patient’s own inspiratory effort into synchronous support provided by the ventilator.
NAVA has a set apnea time. I have observed in practice that the delay in initiation of support by the NAVA circuit can lead to a patient event. Where I have not experienced this issue as often when utilizing invasive ventilation like SIMV-PC. I have noticed especially with neonates, NAVA seems to fail to deliver a breath when the patient is initiating shallow breaths. NAVA recognizes shallow breaths as initiation of breathing even if the volume is not sufficient.
NAVA uses the infant’s integrated diaphragmatic activity to determine the onset of the assisted breath, the pressure employed during the breath, and the duration of assist.
A limitation to NAVA is it can only be utilized when in possession of a Servo ventilator. Due to this many centers may not have access to providing NAVA. Many health care professionals may not be trained on managing a NAVA circuit due to inexperience with Servo ventilators.
Notably, infants were similarly allowed to receive surfactant using the INSURE method, and a similar proportion of infants in each group (w70%) were given surfactant.
Did this study account for airway damage when intubating to provide surfactant? Would the patient have better outcomes if left intubated after administering surfactant versus multiple intubation attempts? Including less invasive surfactant administration would yield more accurate results on incidence of BPD with non-invasive ventilation.
NIV has shown similar success in newborns, preventing intubation in some neonates who would otherwise fail NCPAP.(32) In addition, NIV has been shown to reduce the magnitude and severity of apnea. (33) Commonly used approaches to NIV.
Is traditional NIV a better alternative to an invasive setting like SIMV-PC? Traditional NIV does not take the patients spontaneous breaths into account when delivering a rate. This means we are continuously causing breath stacking. Where as SIMV-PC works with the infant and pressure supports their spontaneous breaths.
In fact, an argument could be made for never using HFNC as an alternative to NCPAP, because the delivered pressure is unmonitored. However, infants in whom prolonged NCPAP has led to nasal trauma may be candidates for the brief use of HFNC at low flow rates
Though HFNC seems to be an inferior choice to CPAP when discussing extremely premature infants. Could it be beneficial to transition infants with large amounts of abdominal distension from CPAP to HFNC? This could allow for the stomach to shrink, which would then allow appropriate inflation of the lungs.
Notably, however, 4 large randomized, controlled trials evaluating routine CPAP versus routine intubation together found that 33% to 51% of high-risk infants initially treated with CPAP ultimately required intubation in the first week of postnatal age (Table 1). (15)(16)(17)(18)(19) Furthermore, approximately 25% of neonates required reintubation following surfactant plus a trial of NCPAP.
Was the risk of BPD after reintubation evaluated? What damage are we doing to the neonates airway by repeatedly intubating to attempt non-invasive ventilation or administer surfactant?
Increased leakage of NCPAP prongs at the nose results in decreased transmission of desired distending pressure to the upper airway. (14)Because measurement of intrathoracic pressures developed by application of NCPAP is not clinically available, it is critical for practitioners and respiratory therapists to ensure that prongs are appropriately sized for the patient.
Though the use of CPAP and RAM cannulas reduce the rate of BPD. Would this system be appropriately suited for recruiting the alveoli of an extremely premature infant? Due to the leak describe above a more occlusive system could be a better choice for extremely premature neonates.
These nasal CPAP (NCPAP) devices deliver airflow that is continuously regulated to produce a set pressure, usually 4 to 7 cm H 2 O. NCPAP provides distending pressure to the airways and alveoli throughout the respiratory cycle.
When researching the impact of CPAP on incidence of BPD did this study include CPAP on higher pressures? Will infants on a CPAP of 8 to 9cm experience BPD at similar rates of infants on invasive ventilation?
Because invasive ventilation has been associated with adverse effects on lung development, noninvasive approaches have been increasingly used.
Does the invasive ventilation included in this text also reference HFJV and HFOV? Are non-invasive forms of ventilation truly better at preventing BPD than high frequency ventilation, which offers smaller tidal volumes and continual inflation of the lungs?