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Noninvasive (NIV) techniques of neonatal respiratory support are increasing. Intubating all infants with significant respiratory distress for transport is no longer the only acceptable option.
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Determining the best technique requires more study. It is likely that many neonates can be transported on any of the NIV modes.
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Determining those infants who require a specific NIV mode is challenging.
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All transport teams need to collect and report data relevant to NIV transport experiences to assist in
Noninvasive Respiratory Support During Transportation
Section snippets
Key points
High-flow nasal cannula
This technique has gained popularity due to its ease of application, decrease in nasal injury, success in reducing need for invasive ventilation and recently reported comparability to nasal continuous positive airway pressure (CPAP) for postextubation support of neonates4, 5, 6, 7 (Table 1). Limited data are available for high-flow nasal cannula (HFNC) support during transport. Two reports have documented the use of HFNC in neonates and infants or pediatric patients. In a brief commentary,
Nasal continuous positive airway pressure
CPAP for neonates with RDS was introduced by Gregory and colleagues10 in 1971. Over the past 1 to 2 decades there has been a marked resurgence in the use of nasal CPAP as a NIV technique of respiratory support in neonates. It is the oldest and best studied of the available NIV modes.11, 12 There are several retrospective reports regarding neonatal transport with nasal CPAP.13, 14, 15, 16 The 2 largest reports are from Australia and demonstrate increasing successful use of nasal CPAP for the
Nasal intermittent positive pressure ventilation
Although controversial, some studies suggest that the addition of intermittent positive-pressure breaths added to nasal CPAP may improve overall ventilation and/or oxygenation, especially in very preterm neonates with apnea.17, 18, 19, 20, 21 It is possible to incorporate NIV during neonatal transport but, to date, there are no published reports describing this approach.
High-frequency nasal ventilation
High-frequency pulsations with variable rate and amplitude can be delivered nasally. This NIV mode has been described in several clinical reports as a means of improving oxygenation and ventilation in neonates with more severe lung disease and/or with significant apnea.22, 23, 24, 25, 26, 27 Varieties of ventilators are capable of providing high-frequency nasal ventilation (HFNV) (Table 4). The authors have primarily used the Percussionaire Bronchotron (Percussionaire Inc, Sandy Point, ID, USA)
Pulmonary hypertension
Persistent pulmonary hypertension of the newborn (PPHN) is a common problem seen in all gestational age infants with respiratory distress. Echocardiograms are frequently not available for patients being transported. Preductal SpO2 greater than 5% higher than postductal SpO2 suggests probable underlying PPHN. Clinically, a patient who desaturates when being handled and slowly recovers (minute to minutes) may have a component of PPHN. Nitric oxide can be used with any of the NIV techniques
Monitoring during transport
Due to the ease with which pressure support may be temporarily lost, NIV respiratory support modes are inherently less stable than invasive mechanical ventilation. Thus, the authors recommend aggressive application of appropriate monitoring tools to facilitate the safe transport of these infants (Box 4). In particular, the authors strongly recommend the use of both preductal and postductal SpO2 monitoring for those infants at risk of or diagnosed with pulmonary hypertension, as well as the
Altitude
During air transport (or ground transport in mountains) adjusting NIV support may be needed due to increases in lung volumes or abdominal gas volumes (Table 7). Appropriate adjustments are critical for infants with underlying thoracic or abdominal problems such as diaphragmatic hernia, bowel obstruction or pneumoperitoneum, pneumothorax, or relative increased lung volumes.
Summary
NIV ventilation continues to expand as a primary support for neonatal patients with various respiratory disorders during the past 15 years. It has now become necessary for transport teams to be able to move patients on various modes of NIV support. It is important that both inclusion and exclusion criteria are developed to ensure safe as well as effective neonatal transport. Understanding the utility of specific modes of NIV support for various pulmonary pathophysiology is paramount to success
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Cited by (7)
Recommendations on the skills profile and standards of the neonatal transport system in Spain
2021, Anales de PediatriaPrehospital Noninvasive Ventilation: An NAEMSP Position Statement and Resource Document
2022, Prehospital Emergency CareNoninvasive ventilation for pediatric interfacility transports: a retrospective study
2020, World Journal of PediatricsNeonatal respiratory support on transport
2019, NeoReviewsCritically ill neonates displayed stable vital parameters and reduced metabolic acidosis during neonatal emergency airborne transport in Sweden
2018, Acta Paediatrica, International Journal of PaediatricsIntroducing high-flow nasal cannula to the neonatal transport environment
2017, Acta Paediatrica, International Journal of Paediatrics