EBNEO Commentary: Non-Invasive HFOV Versus Nasal CPAP for Preterm Infants

Abstract

The management of respiratory distress syndrome (RDS) in preterm infants is a critical aspect of neonatal care, and the choice of non-invasive ventilation strategies can significantly impact clinical outcomes. Among the various modalities available, non-invasive high-frequency oscillatory ventilation (NHFOV) and nasal continuous positive airway pressure (NCPAP) have garnered attention for their roles in supporting preterm infants with varying degrees of RDS. Both techniques, each with distinct mechanisms and clinical implications, aim to support breathing and reduce the need for invasive ventilation, depending on indication.

NHFOV employs rapid oscillatory pressures to enhance alveolar recruitment and improve gas exchange while providing continuous airway pressure. This maintains functional residual capacity and enhances ventilation-perfusion matching, potentially reducing the need for intubation [1]. Conversely, NCPAP delivers a constant pressure to keep the airways open, preventing atelectasis and supporting spontaneous breathing [2]. Both methods aim to minimise complications of mechanical ventilation, like ventilator-induced lung injury.

Recent publication by Fitzgerald et al., comparing NHFOV and NCPAP suggests that NHFOV may offer advantages in terms of oxygenation and a lower incidence of bronchopulmonary dysplasia (BPD) [3]. This is particularly important given the long-term implications of BPD on neurodevelopmental outcomes. Fitzgerald et al. suggested that NHFOV may lower intubation rates compared to NCPAP, particularly in very preterm infants or those with more severe respiratory distress, stating that NHFOV has been associated with a reduced need for intubation due to its effectiveness in providing respiratory support [3]. Likewise, reintubation rates can be influenced by the infant's underlying condition. Some studies report that NHFOV might lead to lower reintubation rates compared to NCPAP, particularly in infants with evolving respiratory failure [1]. However, NCPAP remains a cornerstone of respiratory support in neonatal units, with an established safety profile and ease of application. Its lower cost and simplicity further contribute to its widespread use in neonatal units [4].

This systematic review and meta-analysis comparing non-invasive high-frequency oscillatory ventilation (NHFOV) and nasal continuous positive airway pressure (NCPAP) for preterm infants [5] demonstrated that NHFOV significantly reduced the rate of intubation or reintubation compared to NCPAP, without increasing complications such as ventilator-induced lung injury. This corroborates insights from a growing body of literature. However, limitations of the study include the unblinded design, variations in sample size, gestational age, birth weight and respiratory interfaces used across all included RCTs, which may affect the generalisability of the results. The authors recommend further multi-centre research on a larger scale, incorporating subgroup analyses that account for differences in gestational age and birth weight, as this would provide a more comprehensive assessment of the effectiveness and safety of NHFOV. The choice between NHFOV and NCPAP should therefore consider clinical context, resource availability and institutional protocols, including the infant's condition and staff familiarity with each method.

While NHFOV appears more effective in reducing intubation rates, both modalities have unique advantages and challenges in managing respiratory distress in preterm infants. As our understanding evolves, the goal remains to provide the safest and most effective respiratory support for our most vulnerable patients.

URL link: https://ebneo.org/ebneo-commentary-ni-hfov-vs-ncpap.

Ugochinyere A. Uguru: writing – original draft, writing – review and editing, conceptualization, visualization. Ogbonnaya Nwagwu Ajah: writing – original draft.

The authors declare no conflicts of interest.