Nasal respiratory support through the nares: its time has come

Respiratory distress syndrome (RDS) is the most common respiratory morbidity in preterm infants. Surfactant therapy and invasive mechanical ventilation through the endotracheal tube (ETT) have been the cornerstones in RDS management. Despite improvements in the provision of mechanical ventilation, bronchopulmonary dysplasia (BPD), a multifactorial disease in which invasive mechanical ventilation is a known contributory factor, remains an important cause of morbidity among preterm infants. Barotrauma, volutrauma or oxygen-induced lung inflammation (oxy-trauma) contributes significantly to the development of BPD in neonates ventilated through an ETT. Recently, nasal respiratory support has been increasingly used in preterm infants in an attempt to decrease post-extubation failure and, perhaps, BPD, and for the treatment of apnea of prematurity in nonventilated neonates. Observational studies using noninvasive respiratory support, such as nasal continuous positive airway pressure (NCPAP), have shown a decrease in the incidence of BPD when used to avoid intubation or minimize the duration of invasive mechanical ventilation through the ETT. Moreover, synchronized as well as nonsynchronized nasal intermittent positive-pressure ventilation (NIPPV) have been shown to significantly decrease post-extubation failure compared with NCPAP and their use has been associated with a reduced risk of BPD in small randomized controlled clinical trials. More recently, early surfactant administration followed by extubation to NIPPV has been suggested to be synergistic in decreasing BPD. Although these findings are promising, additional studies evaluating different nasal interfaces, flow synchronization, synchronization using neurally adjusted ventilatory assist mode, and closed loop control of oxygen during nasal ventilation to minimize lung injury are needed in an attempt to further decrease the incidence of lung injury in preterm neonates requiring respiratory support.