Flow-synchronized nasal intermittent positive pressure ventilation for prevention of extubation failure in neonates: a review of literature and a case series of neonates with congenital diaphragmatic hernia successfully managed with this strategy.

BACKGROUND

Advances in neonatal medicine have improved survival rates in neonatal intensive care units, especially for high-complexity cases like congenital diaphragmatic hernia (CDH). Despite these advances, managing respiratory failure in CDH infants remains challenging due to lung hypoplasia, respiratory insufficiency, and pulmonary hypertension. Lung-protective ventilation strategies are crucial to minimize ventilator-induced lung injury, but weaning them from invasive mechanical ventilation remains complex, and extubation failure rates are high.

CASE PRESENTATION: This retrospective case series describes the use of Flow-Synchronized Nasal Intermittent Positive Pressure Ventilation (sNIPPV) in four neonates with surgically corrected left CDH admitted to the "Bambino Gesù" Children's Hospital in Rome (Italy) from 2022 onwards. Flow-sNIPPV was administered using the Giulia® ventilator, which features a flow sensor for synchronization. We observed improved outcomes in terms of extubation success, in comparison to non-synchronized Nasal Intermittent Positive Pressure Ventilation (NIPPV). Synchronization reduced work of breathing (WOB), improved lung ventilation, and enhanced gas exchange without increasing ventilation-related complications. Additionally, this study reviews the current literature on the use of sNIPPV in neonates, highlighting the need for more research on its role in weaning post-extubation in CDH infants.

CONCLUSIONS

Flow-sNIPPV shows promise in preventing extubation failure in neonates with CDH by improving ventilation and reducing WOB. Synchronization enhances lung ventilation, stabilizes the chest wall, and may reduce thoraco-abdominal asynchrony in CDH infants. While the findings are promising, larger multicenter studies are required to confirm the efficacy and safety of sNIPPV as a routine weaning strategy in CDH neonates after repair surgery.