Original Article 171

Use of Noninvasive High-Frequency Ventilation

in the Neonatal Intensive Care Unit:
A Retrospective Review
Amit Mukerji, MD1 Balpreet Singh, MD2 Salhab el Helou, MD2 Christoph Fusch, MD2
Michael Dunn, MD3 Jaques Belik, MD1 Vibhuti Shah, MD4

1 Department of Paediatrics, Hospital for Sick Children, Toronto, Address for correspondence Vibhuti Shah, MD, Department of
Ontario, Canada Paediatrics, Mount Sinai Hospital, 600 University Avenue, Toronto,
2 Department of Paediatrics, McMaster Children’s Hospital, Hamilton, Ontario, Canada M5G 1X5 (e-mail: vshah@mtsinai.on.ca).
Ontario, Canada

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3 Department of Paediatrics, Sunnybrook Health Sciences Center,
Toronto, Ontario, Canada
4 Department of Paediatrics, Mount Sinai Hospital, Toronto,
Ontario, Canada

Am J Perinatol 2015;32:171–176.

Abstract Objective The aim of the article is to review the effectiveness of neonatal noninvasive
high-frequency ventilation (NIHFV) in preventing endotracheal mechanical ventilation.
Study Design Retrospective case series including all 79 instances of NIHFV use at four
participating centers between July 2010 and September 2012.
Results In 73% of cases, NIHFV was used as rescue after another noninvasive mode,
Keywords and prophylactically (postextubation) in the remainder. In 58% of cases, infants
► noninvasive transitioned to another noninvasive mode, without requiring intubation. There were
ventilation significant reductions in the mean (SD) number of apneas, bradycardias, or desatura-
► ventilator-induced tions (over 6 hours) (3.2 [0.4] vs. 1.2 [0.3]; p < 0.001), FiO2 (48 [3] vs. 40 [2]%;
lung injury p < 0.001) and CO2 levels (74 [6] vs. 62 [4] mm Hg; p ¼ 0.025] with NIHFV. No NIHFV-
► bronchopulmonary related complications were noted.
dysplasia Conclusions NIHFV is a promising NIV mode that may help prevent or delay intubation
► intubation and deserves further clinical research.

Endotracheal mechanical ventilation (EMV) in preterm infants
has been linked with various forms of lung injury including
bronchopulmonary dysplasia, infections, and air leak syn-
dromes—collectively termed ventilator-induced lung injury
(VILI).1–3 As such, there has been a trend of increasing use of
noninvasive ventilation (NIV) modes in neonatal intensive care
units (NICUs) over the last decade in an attempt to reduce
VILI,4–6 with recent reports demonstrating equal effectiveness
of NIV when compared with EMV in preterm infants.7,8
Various forms of NIV are available for use in clinical
practice including nasal continuous positive airway pressure
(NCPAP), biphasic NCPAP (BP-NCPAP), and noninvasive inter-
mittent positive airway pressure (NIPPV).5 Many studies
comparing these different modes of NIV have yielded incon-
sistent results with regards to effectiveness in preventing
reintubation,9–12 and the choice of the mode of NIV used is
largely based on local practices and comfort.4 In recent years,
NIPPV is gaining wider acceptance but a recently completed
large multicenter trial by Kirpalani et al failed to demonstrate
superiority over NCPAP.13 However, in this study the NIPPV
arm included a wide range of pressures and inspiratory times,
some of which could be considered as BP-NCPAP.
Despite efforts to minimize EMV, many patients fail to
sustain on NIV modes and require intubation. Stefanescu et al

received Copyright © 2015 by Thieme Medical DOI http://dx.doi.org/

November 24, 2013 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0034-1381317.
accepted after revision New York, NY 10001, USA. ISSN 0735-1631.
April 21, 2014 Tel: +1(212) 584-4662.
published online
June 10, 2014
172 Noninvasive High-Frequency Ventilation in Neonates Mukerji et al.
reported a failure rate of approximately 40% within 1 week of
extubation in a cohort of infants less than 1,000 g.14 Similarly,
Barrington et al reported a failure rate of 44% within 72 hours
in a cohort of infants less than 1,251 g.9 As such, to minimize
the risk of EMV and VILI, a relatively newer form of NIV that is
emerging is noninvasive high-frequency ventilation (NIHFV).
In this modality, high-frequency ventilation is delivered via
nasopharyngeal tubes, short nasal prongs or masks. While
this modality holds promise, there are only a limited number
of clinical studies evaluating it in the neonatal population, as
described later.15–18
To date, the clinical use of NIHFV has only been evaluated in
four studies. Two small case series studies on 21 and 14 infants
reported a decrease in carbon dioxide (CO2) with NIHFV
use.15,16 A randomized controlled trial involving 46 term
infants with transient tachypnea of the newborn (TTN) dem-
onstrated faster clinical recovery with the use of NIHFV com-
pared with NCPAP.17 Lastly, a recent case series reporting
NIHFV use after extubation in a group of high-risk infants
demonstrated sustained extubation in 14 of the 20 infants.18 All
of these studies have been relatively small in sample size, and
some with a heterogeneous population. With the exception of
the study on term neonates with TTN, all were performed
without control groups. However, despite some limitations,
these studies have demonstrated the feasibility of the use of
NIHFV, with no reports of any associated adverse events.
Over the last few years, with the goal of minimizing EMV,
NIHFV has gained acceptance for use in a select group of high-
risk patients at our centers based on positive experience at one
European institution in Cologne, Germany (Dr. André Ober-
thür, MD; written communication, September 16, 2010).
However, there is still very limited data on its effectiveness,
indications for use, and safety profile. We conducted a retro-
spective review of the experience with the use of NIHFV at our
centers, with the goal of addressing these specific questions.
We hypothesized that the use of NIHFV will be associated with
successful sustained extubation in a significant proportion of
high-risk patients placed on this mode, while reducing the
number of apneas, bradycardias, and desaturations as well as
improving both oxygenation and ventilation.
Methods
Research Design
This was a retrospective case series study conducted at four
large Canadian tertiary care NICUs. All infants who were placed
on NIHFV at these centers between July 2010 (time when
NIHFV use was adopted) and September 2012 were included.
Data Collection
Data were collected from health records of all patients on
NIHFV by two authors (A.M. and B.S.) using a standardized
data collection form. At each site, log files kept by respiratory
therapists for all patients trialed on NIHFV were reviewed.
Data were collected on baseline characteristics of each “in-
stance” including sex, birth gestational age and weight, as
well as age (in days), postmenstrual age (PMA), and weight at
time of NIHFV use. Each instance refers to a unique NIHFV
American Journal of Perinatology Vol. 32 No. 2/2015
trial. If NIHFV was utilized on one patient on three separate
occasions, this patient contributed on three instances to all
data, including baseline characteristics. Other parameters
such as mode of delivery, maternal chorioamnionitis, surfac-
tant administration, use of antenatal steroids (complete
defined as two doses, incomplete defined as one dose before
delivery), chronic lung disease (defined as supplemental
oxygen or respiratory support requirement at 36 weeks’
PMA) were also documented. Data collected for NIHFV use
included indications and duration of use, all recorded set-
tings, (including mean airway pressure [MAP], amplitude, and
frequency) and the mode of ventilation immediately preced-
ing and following NIHFV initiation. Indication of NIHFV use
was divided into “rescue” (when transitioned from another
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NIV mode) or “prophylactic” (when extubated directly to
NIHFV).
Other outcome data collected included number of apneic,
bradycardic (heart rate < 100 bpm) or desaturation (oxygen
saturation < 85%) episodes denoted collectively as “spells” as
per nursing chart records, fraction of inspired oxygen (FiO2),
and CO2 levels as measured transcutaneously (or from a blood
gas sample where available) preceding and following NIHFV
initiation. Because of the retrospective nature of this study,
there were some instances where one or more of these data
were not available for analysis. Any documented adverse
outcomes attributed to NIHFV use were searched for in
each patient’s chart. Furthermore, all cranial ultrasonography
results preceding and following NIHFV initiation were docu-
mented, and intraventricular hemorrhage (IVH) was reported
according to the Papile classification.19
Instruments and Devices
NIHFV was administered using either short nasal prongs or
masks (BC series, Fisher and Paykel Healthcare, Laval, Québec,
Canada) at each participating site. If required due to pressure
leak, chinstraps were used at the discretion of the attending
medical team. Two sites used the Babylog 8000 (Drager,
Lubeck, Germany), one of which also used the Leoni Plus
(Heinen þ Lowenstein, Deutschland, Germany) and the re-
maining two sites used the VN500 (Drager, Lubeck, Germany)
to deliver NIHFV. The ventilators were connected to the nasal
interface using nonrigid circuits (RT series, Fisher and Paykel
Healthcare, Laval, Québec, Canada).
Noninvasive Ventilation Use
The use of NIHFV at each institution was based on locally
developed guidelines that provided indications for NIHFV use,
initial settings of various parameters and weaning/adjust-
ment strategies. These guidelines were used in addition to
clinical judgment of the attending medical team. Supplemen-
tary file number 1 (available online only) summarizes the
guidelines from each institution. Similarly, each unit also had
guidelines for CPAP, BP-NCPAP and NIPPV use—provided as
supplementary file number 2 (available online only).
Outcomes
The primary outcome was the rate of successful transition to
another mode of NIV without the need for intubation on
 Noninvasive High-Frequency Ventilation in Neonates Mukerji et al. 173

NIHFV. The decision to intubate a patient was based on the
medical team’s discretion at each site, with no specific
predefined guidelines. Secondary outcomes included a com-
parison of the mean of the number of spells 6 hours before
and 6 hours after NIHFV use. FiO2 and transcutaneous CO2
(TcCO2), or PaCO2 where available, levels immediately before
and 1 hour after NIHFV use were also comparatively analyzed.
The data for spells was collected for rescue NIHFV use only, as
in instances of prophylactic use, the patient was intubated
before NIHFV use. Any adverse outcomes attributed to the use
of NIHFV were reported, as well as grades of IVH before and
after NIHFV use.
Statistical Analysis
deviation [SD]) when describing the secondary outcomes such
as spells, oxygenation, and ventilation.
Ethics Review
This study was approved by the research ethics boards of each
participating institution.
Results
Patient Characteristics
Over the study period, 52 infants underwent NIHFV at the
four study sites and contributed to a total of 79 instances of its
use. ►Table 1 depicts the baseline characteristics of all
instances of NIHFV use based on the primary outcome.

All statistical analyses were performed using SAS version 9.3
(SAS Institute, Cary, NC). Baseline characteristics were
described using descriptive statistics. When comparing out-
comes data, t-test, Wilcoxon rank sum test, chi-squared test, or
Fisher exact test were used as appropriate. All data are
reported as median (range) when describing the baseline
characteristics and duration of NIHFV use, or mean (standard
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Only the mode of delivery was significantly different between
the two groups (p ¼ 0.0170).
Indications and Settings of Noninvasive High-
Frequency Ventilation Use
NIHFV was used as a rescue mode in 58 of the 79 instances
(73% of all use) and as a prophylactic mode in the remainder.

Table 1 Baseline characteristics

Variables All instances of Instances of NIHFV Instances of p Value

NIHFV use (n ¼ 79) transitioned to NIV NIHFV requiring
(n ¼ 46) intubation
(n ¼ 33)
Birth weighta (g) 740 (500–2,860) 765 (510–1,430) 720 (500–2,860) 0.2666
a
Gestational age (wk) 25 (23–35) 25 (23–28) 24 (23–35) 0.1237
a
Weight (g) at study entry 830 (480–3,600) 865 (500–3,600) 770 (480–2,703) 0.2840
Small for gestational age, % 11.4 10.9 12.1 0.8629
Postmenstrual age at study entrya (wk) 28 (24–46) 28 (24–26) 27 (24–38) 0.2522
a
Age at the time of initiation of NIHFV (d) 20 (2–147) 21 (3–147) 15 (2–94) 0.2838
Sex
Male, % 51 50 48 0.8963
Female, % 49 50 52
Antenatal steroids
Complete, % 50 42 60 0.2218
Incomplete, % 18 22 12
None, % 23 29 15
Unknown, % 9 7 9
Surfactant therapy, % 92 88 97 0.2163
Mode of delivery
Vaginal, % 45 33 59 0.0170b
Cesarean section, % 54 67 38
Unknown, % 1 0 3
Presence of chorioamnionitis, % 11.5 13.3 9.1 0.7259
Chronic lung disease, % 70.8 60.6 81.3 0.0673
a
Results presented as median (range) and p values calculated using Wilcoxon rank sum test.
b
p Value < 0.05.

American Journal of Perinatology Vol. 32 No. 2/2015

174 Noninvasive High-Frequency Ventilation in Neonates
Fig. 1 (A) Rescue use made up 73% of all instances of NIHFV use. (B)
Duration of NIHFV, with a median of 57 hours (range, 1.3–415 hours).
NIHFV, noninvasive high-frequency ventilation. WOB, work of
breathing.
The most common indication for its use was spells in 31 cases,
accounting for 39% of all NIHFV use. Among the 58 instances
of rescue use, the patient was either on BP-NCPAP (at one site
where NIPPV is not routinely used) or NIPPV in 49 cases (84%)
preceding the use of NIHFV, whereas in the remaining nine
cases, patients were on NCPAP. The mean peak inspiratory
pressure (PIP) on NIPPV, the mean airway pressure (MAP) on
BP-NCPAP and MAP on NCPAP before NIHFV initiation were
19.2 (3.1) cm H2O, 7.5 (0.9) cm H2O, and 9.3 (1.5) cm H2O,
respectively. The median duration of NIHFV use was 57 hours
(range, 1.3–415 hours). ►Fig. 1 depicts the distributions of
the prevalence of each indication (panel A) and duration
(panel B) of NIHFV use.
The settings used on NIHFV were highly variable. The
ranges for MAP and frequency were 8 to 24 cm H2O and 6
to 14 Hz, respectively. The amplitude ranged from 20 to 100%
when the Babylog 8000 was used and 20 to 60 cm H2O with
the use of the VN500.
Outcomes
Of all instances of NIHFV use, 46 (58%) patients were success-
fully transitioned to another NIV mode, precluding the need
for intubation. In the remaining 33 instances (42%), patients
required intubation. When all NIHFV instances were stratified
by weight at NIHFV initiation (< 1,000 vs. > 1,000 g) or by
indication (prophylactic vs. rescue), the rate of successful
transition to another NIV remained greater than 50% for all
American Journal of Perinatology Vol. 32 No. 2/2015
Mukerji et al.
Table 2 Outcome after noninvasive high-frequency
ventilation use
Cohort/Subgroup Successful
transition
to NIV [n (%)]
All NIHFV use 46/79 (58)
Weight < 1,000 g at time of NIHFV use 27/51 (53)
Weight > 1,000 g at time of NIHFV use 19/28 (68)
Rescue use 32/58 (55)
Prophylactic use 14/21 (67)
Abbreviations: NIHFV, noninvasive high-frequency ventilation; NIV,
noninvasive ventilation.
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subgroups, as shown in ►Table 2. Amongst those intubated
after NIHFV use, the two most common indications were spells
(52%) and ventilation failure (42%), as defined by CO2 retention.
Data for number of spells were available for 49 instances,
and the number of spells over 6 hours decreased from 3.2 (0.4)
to 1.2 (0.3) per hour (p < 0.001). The oxygenation (n ¼ 53) and
ventilation (n ¼ 19) comparisons showed a decrease in FiO2
from 48 (3) to 40 (2)% (p < 0.001) and decrease in CO2 from 74
(6) to 62 (4) mm Hg (p ¼ 0.025) before and after the use of
NIHFV. These results are depicted in ►Fig. 2.
No adverse events attributable to NIHFV were reported.
Cranial ultrasonography results preceding and following
NIHFV initiation were available in 73 instances. There was
progression of IVH in two patients—no IVH to unilateral grade
II IVH in one, and unilateral grade I to bilateral grade II IVH in
the other. In the remaining instances, there was either no
change (n ¼ 68) or regression of IVH grades (n ¼ 3). There
were no reports of nasal septum injury, necrotizing entero-
colitis, or bowel perforations attributed specifically to NIHFV
use.
Discussion
In this retrospective analysis of our experience, NIHFV was
utilized in 79 instances, and in the majority of cases its use
was as a rescue mode. About 58% of all NIHFV instances
(rescue or prophylactic) resulted in a successful transition to
another NIV mode, thus preventing intubation in the majority
of this high-risk patient group. The use of NIHFV was associ-
ated with a decrease in the number of “spells”, as well as an
improvement in oxygenation and ventilation. No adverse
events were reported as a result of NIHFV use.
To our knowledge, this is the largest reported case series of
patients on NIHFV, and the first to report its use on such a
large group of patients at high risk of requiring intubation
from North America. These results confirm the feasibility and
add to the growing body of literature supporting the use of
NIHFV as an effective modality in preventing intubation.
Arguably, in many of the cases in our study, patients would
have been intubated had it not been for the use of NIHFV. This
is particularly evident given that the majority of these
patients were already on what is perceived to be maximum
NIV support with either BP-NCPAP or NIPPV preceding rescue
 Noninvasive High-Frequency Ventilation in Neonates
Fig. 2 Spells, FiO 2, and CO 2 pre- and post-NIHFV. There was a decrease in spells and an improvement in FiO 2 and CO 2 levels, all of which were
statistically significant.
NIHFV use. It also demonstrates that patients may have fewer
spells, and have improved oxygenation and ventilation on
NIHFV.
Previously, a study by van der Hoeven et al demonstrated
the use of NIHFV in a heterogeneous patient population (21
preterm and term infants) with NCPAP failure based on either
higher PaCO2 levels, acidosis, or higher FiO2 requirements and
reported a decrease in PaCO2 levels.15 NIHFV was used for a
median of 35 hours and demonstrated a decrease in the CO2
levels from 8.3 to 7.2 kPa, with no adverse effects. Although
many of the patients remained extubated, many of these
infants were term and were unlikely to require intubation in
the first place. Colaizy et al studied a group of infants who
were stable on NCPAP after putting them on NIHFV for 2
hours, and showed a decrease in TcCO2 levels in this group of
14 infants. However, it is difficult extrapolate these results to
high-risk patient population.16 Neither of these two studies
examined extubation failure rates or change in number of
spells.
A randomized controlled trial comparing NIHFV with
NCPAP in 46 term infants showed a reduction in time to
clinical improvement of TTN from 377 to 105 minutes.17
However, it can be argued that many of these infants did
not require NIHFV (or NCPAP) in the first place, and were
unlikely to be at high risk of requiring intubation. Further-
more, the unblinded nature of the study inherently introdu-
ces biases, and the reported benefit of NIHFV over NCPAP in
this context must be interpreted with caution. Czernik et al
have reported the prophylactic use of NIHFV in 20 infants
after extubation.18 Of the 20 infants, 14 remained extubated
and were transitioned to another NIV mode, after remaining
on NIHFV for a minimum of 32 hours. However, although
these infants were deemed to be at a high risk of extubation
failure, without a control group, it is difficult to predict as to
how many infants would have remained extubated even
without the use of NIHFV.
NIHFV holds promise as a mode of NIV that might help
reduce the risk of intubation in a select group of high-risk
patients. It may help reduce the number of spells, and
Mukerji et al. 175
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improve ventilation as well as oxygenation. An additional
advantage conferred by NIHFV may be the lack of the need for
synchronization, something that remains a challenge with
current use of NIPPV.5,11 Even though NIHFV was used
successfully in preterm infants less than 1,000 g without
any reported adverse effects, the safety profile remains
unknown, particularly in the extremely preterm infants. To
our knowledge, no study has been planned or powered
appropriately to address the safety profile specifically. Fur-
ther work needs to be done to elucidate the group of patients
most likely to benefit from this modality, and to adequately
address its safety profile.
Yet another area of uncertainty is the parameters for use in
NIHFV. As noted earlier, there is a significant range of MAPs
used, which raises the possibility that it may be the higher
recruitment pressure, rather than the oscillatory effect that
leads to these improved outcomes. The use of this large range
of MAPs also raises the question of what should the appropri-
ate limit be. On the one hand, positive end expiratory pressures
with the use of NCPAP rarely exceed 8 to 10 cm H2O,5 whereas
similar MAP ranges as reported here in NIHFV are routinely
used in intubated patients on high-frequency ventilation.20,21
Therefore, while seemingly acceptable for intubated patients, it
is unclear whether there is an increased risk of harm when
such MAPs are administered via noninvasive interfaces. The
ventilation tubing and leak at the level of the nasopharynx
leads to a much lower delivered MAP and amplitude than that
set at the ventilator—however the quantification of this damp-
ening effect is currently unknown and requires further re-
search. Although no cases were identified in the present
review, the risk of abdominal distension and associated com-
plications including perforation need to be carefully consid-
ered. These questions remain unanswered but with rigorously
planned prospective studies to help address them and with
further experience with its use, NIHFV has the potential to
minimize the long-term morbidities associated with EMV.
One of the limitations of the study is the lack of a control
group. However, given that the majority of NIHFV use was as a
rescue mode in patients at high risk of being intubated, our
American Journal of Perinatology Vol. 32 No. 2/2015
176 Noninvasive High-Frequency Ventilation in Neonates
conclusions are promising. Another limitation is the retro-
spective nature of the study that inherently leads to the risk of
missed data, evident by the lack of proper documentation of
oxygenation requirements and CO2 levels in many of the
instances of NIHFV use. Also, there remains a risk of selection
bias in that more unstable patients may have been tried on
NIHFV, and the benefit of NIHFV may be overestimated. Lastly,
the lack of a control group meant study was not powered to
look specifically at complications that may have arisen from
NIHFV, or may not have been adequately documented. De-
spite some limitations, this retrospective review demon-
strates that NIHFV can prevent intubation in a significant
proportion of high-risk patients after other noninvasive
modes of ventilation have failed. To provide definitive an-
swers regarding the role of NIHFV in neonatal intensive care
including indications, parameters of settings and its safety
profile, rigorously planned prospective trials are warranted.
Conflicts of Interest
None.
Acknowledgments
The authors acknowledge the contributions of all the
respiratory therapists at each site for their assistance
with identifying the patients and data collection. The
authors also acknowledge Eugene Yoon for help with
statistical analyses.
C.F. holds the inaugural Jack Sinclair Endowed Research
Chair of Neonatology at McMaster University.
The data presented in this article were presented in
abstract form at the Pediatric Academic Societies 2013
meeting, Washington DC.
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 Noninvasive High-Frequency Ventilation in Neonates
Supplementary File # 1: Guidelines for NIHFV use
Indications for initiation Starting parameters and
monitoring
Site 1 • Post-extubation in an infant • Use a MAP 2-5 cm H20 above
with multiple previous failed biphasic MAP or higher if re-
attempts quired
• Ensure oro-gastric tube is in and
venting
• Do a chest radiograph to assess
aeration within 1 – 2 hours
• Set up a transcutaneous CO2
monitor and set the AMP to
achieve adequate shake when
the infant is at rest
Site 2 • N/A • Set PEEP to adjust MAP (2 cms
H2O) above the current CPAP
level
• Set the desired frequency (6-8
Hz)
• Adjust amplitude (percentage)
as needed for adequate shake
• Adjust FiO2 as needed, but start
at 0.4
Site 3 • Apnea of Prematurity • Initial settings should be set at:
frequency of 10 Hz, MAP higher
by 2 cm H20 than the CPAP/
PEEP or upper biphasic CPAP
level of 10 and amplitude to
provide adequate chest shake
with the use of nasal prongs/
mask
• A chest x-ray should be per-
formed 2 hours after com-
mencement of NIHFV or earlier
based on the clinical status of
the infant
• Transcutaneous pCO2 monitor
should be applied for trending
and correlated with gases if
possible
• Blood gas PRN
Site 4 • Respiratory insufficiency in • Mean Airway Pressure (MAP) -
term and preterm infants set at previous CPAP level
• CO2 retention • Amplitude set to obtain chest
• Air leak wall or upper airway vibration
• Apneas (anterior neck) Start at 100%
(Babylog 8000) and move
down
• Frequency 10-12 Hz
• FiO2 titrated to maintain or-
dered SpO2 goal
• Chest x-ray after 1 hour of
NIHFV

MAP ¼ mean airway pressure, CO2 ¼ carbon-dioxide, AMP ¼ amplitude, CPAP ¼ continuous positive airway pressure, PEEP ¼ positive end-expiratory
pressure, FiO2 ¼ fractional inspired oxygen, PPV ¼ positive pressure ventilation.
American Journal of Perinatology
Mukerji et al. 177
Weaning/Adjustments
• Wean AMP and MAP as re-
quired based on responses
to therapy
• Consider moving back to
CPAP when MAP has come
down <12 cm H20 on infants
weighing > 2,500 grams and
less than 8-10 cm H20 on
infants weighing < 2,500
• Adjust AMP (percentage) as
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
needed for adequate shake
• The maximum MAP that will
be used is 13-15 cm H2O
• The frequency should be
adjusted to ensure adequate
chest vibrations and comfort
of the infant
• Once the infant is stable, the
infant should be weaned
from NIHFV. If there is ade-
quate chest movement, AMP
should be weaned first. If
not, MAP should be weaned
• The infant will be switched
back to conventional CPAP
or biphasic CPAP if the infant
is stable and the MAP has
been weaned to 8 cm H2O or
lower with FiO2 of 0.35
• If in spite of above measures,
the infant continues to have
frequent apneic spells with
bradycardia requiring stimu-
lation (more than 4/hr) or
more than 1/hr requiring
PPV via bag and mask to
resolve, intubation should be
considered
• MAP: if lung volumes are low
or atelectatic: increase the
MAP. If retractions are sig-
nificant increase the MAP. If
oxygenation is decreased,
increase the MAP
• If CO2 retention persists de-
spite adjustments to ampli-
tude, drop the frequency
and manipulate amplitude
Vol. 32 No. 2/2015
178 Noninvasive High-Frequency Ventilation in Neonates Mukerji et al.

Supplementary File # 2: Guidelines for NIV use and intubation criteria

NCPAP BP-NCPAP NIPPV Intubation Criteria

Site 1 • Initial settings • Initial Settings • Initial Settings • More than 1 major
 PEEP: 5-6 cm H2O  P Low: 5-6 cm H2O  Rate: 40 bpm (defined as requiring
• Maximum settings  P High: 8-9 cm H2O  PIP: 10-15 cmH2O bag-mask ventilation)
 PEEP: 8 cm H2O  Rate: 10 cycles/min above PEEP or 6 minor episodes
 T High: 1 sec  PEEP: 5 cm H2O of apnea in a 6 hour
• Maximum Settings  I-time: 0.5 sec period
 P Low: 8 cm H2O • Maximum Settings • FiO2 > 0.50
 P High: 11 cm H2O  Rate: 40 bpm • pH < 7.22 & PaCO2
 Rate: 15 cycles/min  PIP: 20 cmH2O > 60 mmHg on 2
 T High: 3 sec  PEEP: 7-8 cm H2O consecutive arterial/
 I-time: 1 sec capillary blood gases
• Extreme cardiovascu-
lar instability

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Site 2 • Initial settings • Initial Settings • Initial Settings • N/A
 PEEP: 4-5 cm H2O  P Low: 5 cm H2O  Rate: 30 bpm
• Maximum settings  P High: 8 cm H2O  PIP: 10-15 cmH2O
 PEEP: 8 cm H2O  Rate: 20 cycles/min above PEEP
 T High: 1 sec  PEEP: 5 cm H2O
• Maximum Settings  I-time: 0.5 sec
 P Low: 7 cm H2O • Maximum Settings
 P High: 10 cm H2O  Rate: 40 bpm
 Rate: 30 cycles/min  PIP: 20 cmH2O
 T High: 1.5 sec  PEEP: 8 cm H2O
 I-time: 0.5 sec

Site 3 • Initial settings • Initial Settings • Initial Settings • N/A

 PEEP: 5-6 cm H2O  P Low: 5-6 cm H2O  Rate: 10-14 bpm
• Maximum settings  P High: 8-9 cm H2O  PIP: 10-15 cmH2O
 PEEP: 8 cm H2O  Rate: 10 cycles/min  PEEP: 4-7 cm H2O
 T High: 0.5 sec  I-time: n/a
• Maximum Settings • Maximum Settings
 P Low: 8-9 cm H2O  N/A
 P High: 10-11 cm
H2 O
 Rate: 20 cycles/min
 T High: 2 sec

Site 4 • Initial settings • N/A • Initial Settings • pH <7.2 on maximum

 PEEP 5 cm H2O  Rate: 15 -25 bpm non-invasive settings
• Maximum settings  PIP:10 cmH2O • Apneic episode re-
 PEEP: >7 cm H2O above PEEP quiring bag/mask
to be discussed  PEEP: 4 -7 cm H2O ventilation
with MRP  I-time: 0.3 – 0.45 sec • Frequent (> 2-3 epi-
• Maximum Settings sodes/hour) apnea/
(not defined by bradycardia (cessa-
protocol) tion of respiration for
 Rate: 40 bpm > 20 seconds associ-
 PIP: 15 cmH2O ated with a heart rate
above PEEP < 100/min)
 PEEP:  10-12 cm • FiO2 of 40% or " FiO2
H2 O requirements of
 I-time: 0.5 >20% for >1 hr

NCPAP: Nasal continuous positive airway pressure; BP-NCPAP: Biphasic NCPAP; NIPPV: non-invasive positive pressure ventilation; PEEP: positive end
expiratory pressure; PIP: peak inspiratory pressure; FiO 2: fraction of inspired oxygen; PaCO2: partial pressure of carbon-dioxide; MRP: Most responsible
physician.

American Journal of Perinatology Vol. 32 No. 2/2015

Copyright of American Journal of Perinatology is the property of Thieme Medical Publishing
Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv
without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.
Copyright of American Journal of Perinatology is the property of Thieme Medical Publishing
Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv
without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.