A Comparative Study of Different Modes of Noninvasive Ventilation as Postextubation Respiratory Support and Their Effect on Hemodynamic Changes in Preterm infants
Authors: Shafik Safaa , Elfarrash Rania Ali , Soliman Nanies Salah El Din , Aboraia Nourhan Mohammed , Shaaban Hebatallah Ali 
Published: November 2024

Abstract

Background
Noninvasive respiratory support has reduced the need for invasive mechanical ventilation (MV). This may reduce the incidence of bronchopulmonary dysplasia (BPD) in preterm infants. There are many different forms of noninvasive respiratory support which include nasal continuous positive airway pressure (NCPAP), Non-invasive high-frequency oscillatory ventilation (NHFOV) and High velocity nasal insufflation (HVNI). Little is known about the hemodynamic changes that occur during NIV, particularly during the weaning phase when lung compliance has improved.

Aim of the Work
To evaluate the outcome of NHFOV and Hi-VNI Vapotherm in comparison to nasal CPAP as a post extubation noninvasive respiratory support in preterm neonates. 2ry aim is to assess hemodynamic changes during periods of non-invasive respiratory support including echocardiographic, cerebral blood flow and mesenteric blood flow changes.

Study Design
This was a randomized control prospective study at Ain Shams Children Hospital, Cairo, Egypt. conducted on 61 mechanically ventilated preterm neonates 32-36 weeks gestational age with RDS, who were on invasive ventilatory support then extubated to non-invasive mode: Group A, 21 preterm neonates extubated on NCPAP. Group B, 20 preterm neonates extubated on NHFOV and Group C, 20 preterm extubated on Hi-VNI Vapotherm. The Three groups were studied for the need for re-intubation within the first 24 hours after extubation, length of hospital stay and duration of non- invasive ventilation (NIV), Retinopathy of prematurity (ROP), air leak syndromes, Intraventricular hemorrhage (IVH), Necrotizing enterocolitis (NEC), nasal trauma, Bronchopulmonary dysplasia (BPD) and mortality. Also assessing hemodynamic changes during and after weaning of non-invasive respiratory support including echocardiography, Anterior cerebral artery resistive index (ACA) RI, Middle cerebral arteries resistive index (MCA) RI, and superior mesenteric artery resistive index (SMA) RI.

Results
PaCO2 was unchanged from preextubation levels after weaning in the NCPAP and NHFOV but increased significantly after weaning from vapotherm. NCPAP had the shortest length of hospital stay median (IQR) 18 while the NHFOV has the longest duration of hospital stay median (IQR) 28. NHFOV had the least failure rate10% while post extubation to Vapotherm had the highest failure rate 40%, yet this did not reach statistical significance. Significant association found between failure on vapotherm and birth weight less than or equal to 1.75 kg with OR (95% CI) of 77.00 (4.114 – 1441.049) and with p-value = 0.004. A significant higher incidence of mortality was found in vapotherm failed group as compared to the succeed group (75% vs. 0%, p = 0.03). There was significantly higher nasal trauma among NHFOV group compared to the NCPAP and Vapotherm groups (P = 0.001). NHFOV had the least mortality rate 0% while post extubation to Vapotherm had the highest mortality rate 30%, yet this did not reach statistical significance. NCPAP had the least incidence of sepsis while the vapotherm had the highest incidence (P = 0.02). No significant difference between the 3 modes of noninvasive respiratory support in the occurrence of comorbidities as NEC, IVH, ROP and BPD. By Doppler echocardiography, NHFOV showed that both RVO, SVC flow significantly increased after weaning. ACA RI significantly increased after weaning from NHFOV. Also, it showed significant increase in RVO after weaning vapotherm with no significant effect on cerebral blood flow. NCPAP didn’t have significant effect on systemic & pulmonary venous return by Doppler echocardiography. Although it showed that both ACA and MCA RI significantly increased after weaning.

Conclusion
Overall, these findings suggest that NHFOV may be a favorable option for respiratory support in preterm infants following extubation, as it was associated with better outcomes compared to NCPAP and Vapotherm. However, further research is needed to fully understand the potential benefits and risks of each mode of noninvasive respiratory support in this population. Infants in the Hi-VNI Technology group had significantly lower nasal trauma scores than those in the NCPAP and NHFOV groups with increased failure rate in preterm infants with a birth weight less than or equal to 1.75 kgs.