Factors Associated With Failure of Non-invasive Ventilation in Preterm Neonates Requiring Initial Respiratory Support

Abstract

Background: Non-invasive ventilation (NIV) modalities minimize the requirement for invasive mechanical ventilation (IMV) in preterm neonates, therefore improving neonatal outcomes, as IMV is linked to increased complications. However, NIV has demonstrated an elevated likelihood of failure, for which various studies have been done, but very little research is available addressing the factors that are responsible for NIV failure in resource-limited areas of developing nations. Understanding the underlying factors and their association with NIV failure in very and moderately preterm neonates at a tertiary care hospital would be important in devising targeted strategies to increase NIV success and newborn outcomes.

Objective: To compare the following factors in neonates of 28-34 weeks gestational age with or without failure of NIV: fraction of inspired oxygen (FiO₂) at the time of initiating NIV, time at surfactant administration, respiratory distress syndrome presence, antenatal steroid use, time taken for post-surfactant administration stabilization, gestational age, development of bronchopulmonary dysplasia, and average weight gained or lost.

Study design and participants: This was a longitudinal observational study. One hundred two preterm neonates with a gestational age of 28-34 weeks in the neonatal intensive care unit (NICU) requiring NIV support within 24 hours of admission.

Methods: Eligible newborns were re-evaluated at 72 hours after commencing NIV. Outcome was evaluated as success (no NIV or NIV with positive end-expiratory pressure (PEEP)<8 cm H₂O and FiO₂<0.7) or failure (NIV with PEEP≥8 cm H₂O or FiO₂≥0.7, intubation, or death). It was compared with regard to many parameters.

Results: About 40 (39%) study participants reported NIV failure within 72 hours of initiating NIV. In the NIV failure group, male babies constituted 75% (P = 0.027), the median gestational age (IQR) was 29 (29-31) weeks (P = 0.015), the median birth weight (IQR) was 1088 (960-1293.5) grams (P = 0.003), and the median weight gain or loss (IQR) was a loss of 21 (-70.5 to 11.75) grams (P<0.001). Vaginal birth comprised 67.5% of the NIV failure group, showing greater failure rates than births out of lower segment cesarean section (LSCS) (P = 0.003) Conclusion: NIV failure showed a significant association with lesser gestational age, male sex, lower birth weight, vaginal method of delivery, and lesser weight gain during hospital stay.

Keywords: continuous positive airway pressure (cpap); failure factors; fio2; nasal intermittent positive pressure ventilation (nippv); noninvasive ventilation (niv); preterm neonates; surfactant.

Figure 1. Flowchart of enrollment and evaluation.

CPAP: continuous positive airway pressure, NIPPV: nasal intermittent positive pressure ventilation, NIV: non-invasive ventilation.

Figure 2. NIV machines. (A) Mediserv Bubble CPAP machine; (B) Bellavista ventilator.

CPAP: continuous positive airway pressure; NIV: non-invasive ventilation.

Figure 3. NIV status at 72 hours of NIV and causes of failure.

NIV: non-invasive ventilation, PEEP: positive end-expiratory pressure, FiO₂: fraction of inspired oxygen.