Nasopharyngeal CPAP allows the delivery of continuous distending airway pressure with a system secured in the same manner as an endotracheal tube. This allows flexibility of patient positioning and more reliable delivery than other minimally invasive methods. After observing that this resulted in minimal gastric distension we conducted a pilot study to determine the feasibility of combining NP-CPAP with IMV (NP-CPAP-IMV) in premature infants with apnea or respiratory failure following extubation and NP-CPAP. Fourteen infants (mean BW=1106g, GA=28wks) received a total of 16 NP-CPAP-IMV courses. All had been electively or accidentally extubated and had apnea or increased respiratory failure on NP-CPAP. After stabilization of the prongs at the posterior pharynx, infants were ventilated with a conventional ventilator. Demographic, ventilatory support and blood gas data were obtained prior to, at extubation and during NP-CPAP-IMV. Length of time on the combined mode, need and indications for reintubation, and x-rays were reviewed. Postnatal age at institution was 25 days; with mean duration 68 hrs. 12 infants placed on NP-CPAP-IMV for increasing PaCO2 had progressive improvement in ventilation. No infant had increased PaCO2. 4/16 required reintubation within a week of termination of NP-CPAP-IMV. One was reintubated from NP-CPAP-IMV; 2 for apnea 12+ hours after discontinuation. There were no changes in lung inflation, edema or atelectasis related to the combined mode. Two infants developed moderate increases in bowel gas as estimated radiographically. None had enteral feedings reduced, developed perforation, or NEC. Based on these preliminary data the combined use of IMV and NPCPAP may be a safe and effective means of providing minimally invasive assisted ventilation in infants with respiratory failure or apnea following extubation. Prospective controlled trials are needed to fully evaluate the efficacy and safety of this approach.

(Supported by the Hastings Foundation)