Non-invasive therapies in the NICU

Newborn after being delivered in the hospital

An overview of the clinical literature:

Continuous positive airway pressure (CPAP) and nasal high flow (NHF) for the neonatal population

CPAP continues to be the standard of care in neonates < 28 weeks gestational age (GA). However there are several pathways of care supporting the use of NHF when rescue CPAP is available, as shown below:

Primary Respiratory Support^1,9-12
< 28 weeks GA CPAP CPAP continues to be the standard of care and is used routinely as an alternative to invasive mechanical ventilation. There is emerging data describing the use of NHF in this population.	≥ 28 Weeks GA CPAP or NHF + Rescue CPAP Emerging evidence suggests that the use of NHF (with rescue CPAP available) may be considered once infants are stable, with no significant difference to intubation rates. The benefits of NHF for older preterm infants are demonstrated in the body of literature.	Evidence General Support Emerging RCT data and consensus of published expert opinion
As an alternative to prolonged CPAP^1,7,8
< 28 weeks GA CPAP CPAP continues to be the standard of care, however, NHF may be considered once infants are stable.	≥ 28 Weeks GA CPAP, then NHF once stable at the clinician's discretion ⁴ The use of NHF as an alternative to prolonged CPAP may be considered once infants are stable. The benefits of NHF for older preterm infants are demonstrated in the body of the literature.	Evidence ✔ Strong Support Consensus of published expert opinion.^3,8
Postextubation support ^1-6
< 28 weeks GA CPAP CPAP continues to be the standard of care, however, NHF may be considered once infants are stable.	≥ 28 Weeks GA NHF + Rescue CPAP The use of NHF as an alternative to CPAP is associated with no difference in the rate of treatment failure, reintubation, and adverse outcomes (such as death, BPD and pneumothorax) and significantly less nasal trauma.	Evidence ✔ Strong Support Cochrane Review.¹

Disclaimer: Clinical judgement is necessary to assess the appropriate treatment for an individual patient. The use of NHF therapy is not typically supported for infants with extreme prematurity, severe respiratory distress syndrome, or untreated surfactant deficiency.

Optiflow™ Junior 2 Blender Transition Kit

The Blender Transition Kit allows patients to receive NHF therapy as an alternative to prolonged CPAP therapy without changing the circuit. The kit comes with an Optiflow Junior 2 nasal cannula, pressure manifold and an adaptor which connects to the inspiratory limb of the CPAP circuit.

CPAP with FlexiTrunk™ Interface

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Optiflow™ Junior 2 Blender Transition Kit

NHF with Optiflow™ Junior 2 Interface

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The Rosie Maternity Hospital Documentary Series

The reason, the rollout and the results: The Rosie Hospital, a Cambridge University Hospital, shares its successful implementation of noninvasive therapies for neonatal patients.

NeoHeart Conference Webinar Series

Leading US neonatology experts present webinars on NHF, CPAP and NIPPV, along with an expert Masterclass Discussion, about the modes of non-invasive ventilation.

Wilkinson, D., Andersen, C., O’Donnell, C. P. F., De Paoli, A. G., & Manley, B. J. High flow nasal cannula for respiratory support in preterm infants. Cochrane Database Syst. Rev. 2, CD006405 (2016).  View abstract here.
Campbell, D. M., Shah, P. S., Shah, V. & Kelly, E. N. Nasal continuous positive airway pressure from high flow cannula versus Infant Flow for Preterm infants. J. Perinatol. 26, 546–9 (2006). View abstract here.
Yoder, B. et al. Heated, humidified high-flow nasal cannula versus nasal CPAP for respiratory support in neonates. Pediatrics 131, e1482–1490 (2013). View abstract here.
Manley, B. et al. High-flow nasal cannulae in very preterm infants after extubation. N. Engl. J. Med. 369, 1425–1433 (2013). View abstract here. 
Collins, C. L., Holberton, J. R. J., Barfield, C., & Davis, P. G. P. A randomized controlled trial to compare heated humidified high-flow nasal cannulae with nasal continuous positive airway pressure postextubation in premature infants. J. Pediatr. 162, 949–954.e1 (2013).  View abstract here.
Liu C, Collaborative Group for the Multicenter study on Heated Humidified High-flow Nasal Cannula Ventilation. Efficacy and safety of heated humidified high-flow nasal cannula for prevention of extubation failure in neonates. Chinese Journal of Pediatrics 52, 271-276 (2016). View abstract here.
Yoder, B. et al. Consensus approach to nasal high-flow therapy in neonates. J Perinatol 37, 809–813 (2017). View abstract here.
Roehr, C. C., Yoder, B. A., Davis, P. G., & Ives, K. Evidence support and guidelines for using heated, humidified, high-flow nasal cannulae in neonatology: Oxford Nasal High-Flow Therapy Meeting, 2015. Clin. Perinatol. 43, 693–705 (2016).  View abstract here.
Lavizzari, A. et al. Heated, humidified high-flow nasal cannula vs nasal continuous positive airway pressure for respiratory distress syndrome of prematurity: a randomized clinical noninferiority trial. JAMA Pediatr. (2016). doi:10.1001/jamapediatrics.2016.1243.  View abstract here.
Murki, S. et al. High-flow nasal cannula versus nasal continuous positive airway pressure for primary respiratory support in preterm infants with respiratory distress: a randomized controlled trial. Neonatology 113, 235–241 (2018). View abstract here.
Roberts, C. et al. Nasal high-flow therapy for primary respiratory support in preterm infants. N. Engl. J. Med. 375, 1142–1151 (2016).  View abstract here.
Manley, B. J. et al. Nasal High-Flow Therapy for Newborn Infants in Special Care Nurseries. N. Engl. J. Med. 380, 2031–2040 (2019). View abstract here.

Non-invasive therapies in the NICU

An overview of the clinical literature:​

Continuous positive airway pressure (CPAP) and nasal high flow (NHF) for the neonatal population

Primary Respiratory Support1,9-12

CPAP

CPAP or NHF + Rescue CPAP

General Support

As an alternative to prolonged CPAP1,7,8

CPAP

CPAP, then NHF once stable at the clinician's discretion 4

✔ Strong Support

Postextubation support 1-6

CPAP

NHF + Rescue CPAP

✔ Strong Support

Optiflow™ Junior 2 Blender Transition Kit

CPAP with FlexiTrunk™ Interface

Optiflow™ Junior 2 Blender Transition Kit

NHF with Optiflow™ Junior 2 Interface

The Rosie Maternity Hospital Documentary Series

NeoHeart Conference Webinar Series

View references

An overview of the clinical literature:

Primary Respiratory Support^1,9-12

As an alternative to prolonged CPAP^1,7,8

CPAP, then NHF once stable at the clinician's discretion ⁴

Postextubation support ^1-6