Bi-Level Noninvasive Ventilation in Neonatal Respiratory Dis
Bi-level noninvasive ventilation (NIV) has been used in respiratory distress syndrome (RDS) as primary treatment, post-extubation, and to treat apnea. This review summarizes studies on bi-level NIV in premature infants with RDS.

Nonsynchronized nasal intermittent positive pressure ventilation (nsNIPPV) and synchronized NIPPV (SNIPPV) use pressure settings more than those used during mechanical ventilation (MV), and biphasic continuous positive airway pressure (BiPAP) use two nasal continuous positive airway pressure (NCPAP) levels less than 4 cm H2O apart.

24 randomized controlled trials that largely did not correct for mean airway pressure (MAP) and used outdated ventilators were included. Primary outcomes were bronchopulmonary dysplasia (BPD) and mortality. Secondary outcomes included NIV failure (intubation) and extubation failure (re-intubation). Data were pooled using a fixed-effects model to calculate the relative risk (RR) with 95% confidence interval (CI) between NIV modes.

--Compared with NCPAP, both nsNIPPV and SNIPPV resulted in less re-intubation (RR 0.88 with and RR 0.20, respectively) and BPD (RR 0.69 and RR 0.51 respectively).

--nsNIPPV also resulted in less intubation (RR 0.57 (0.45, 0.73) versus NCPAP, with no difference in mortality. One study showed less intubation in BiPAP versus NCPAP.

Finally, Bi-level NIV can help premature infants with RDS reduce mechanical ventilation and bronchopulmonary dysplasia. There is a need for studies comparing equivalent MAP using currently available machines.