Nasal IPPV after Extubation

 Evidence Based Approach to Change in Clinical Practice: Introduction of Expanded Nasal Continuous Positive Airway Pressure in an Intensive Care Nursery.  Jackson JK, Vellucci J, Johnson P, et al.  Pediatrics (April 2003);111:e542-e547.

Objective. Recent studies provide evidence that nasal intermittent positive pressure ventilation (NIPPV) may stabilize the airway of extremely low birth weight infants after endotracheal extubation. The objective of this project was to introduce the use of NIPPV into a busy level 3 intensive care nursery.

Methods. This report describes the process of NIPPV introduction using a series of rapid-cycle improvement projects, as proposed by the Vermont Oxford Network.

Results. In the first cycle, 7 (88%) of 8 infants were successfully extubated with NIPPV after meeting criteria for reintubation on nasal continuous positive airway pressure alone. Proper positioning of the prongs in the nasopharynx was found to be an important determinant of success. In a second cycle, shorter 2.5-cm naso-pharyngeal prongs were more effective than standard 4-cm prongs in 12 recently extubated infants as assessed by objective measurements and subjective nursing reports. A third cycle confirmed the acceptance of this technique in our unit and demonstrated an associated decrease in markers of chronic lung disease in extremely low birth weight infants during the 22 months after its introduction.

Conclusion. This experience supports the role for the rapid-cycle change model in achieving effective evidence-based medical practices in a neonatal intensive care setting.

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Comments:  This approach differs from nasal SIMV (see 2-023) in that the ventilation was not synchronized.  The airflow sensitivity of the Drager Babylog 8000 ventilator was insufficient to reliably detect spontaneous respirations during nasal ventilation.  We prefer to use the Infant Star ventilator for nasal SIMV.  This ventilator uses a StarSync capsule that relies on chest wall movement (rather than changes in airflow) to detect spontaneous breaths.  The ability to synchronize during nasal ventilation should decrease the risk of abdominal distension.  A key clinical pearl from the present study was the importance of the proper length of nasopharyngeal prongs.  The authors reported much better success with 2.5 cm N-P prongs rather than 4 cm prongs in ELBW infants.  The proper distance to insert the prongs was equal to the distance from the tip of the infant’s nose to a point below the eye at the perpendicular to the middle of the eye.  ABK