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Work of breathing during HHHFNC and synchronised NIPPV following extubation

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Our aim was to compare the work of breathing (WOB) during synchronised nasal intermittent positive pressure ventilation (SNIPPV) and heated humidified high flow nasal cannula (HHHFNC) when used as post-extubation support in preterm infants. A randomised crossover study was undertaken of nine infants with a median gestational age of 27 (range 24–31) weeks and post-natal age of 7 (range 2–50) days. Infants were randomised to either SNIPPV or HHHFNC immediately following extubation. They were studied for 2 h on one mode and then switched to the other modality and studied for a further 2-h period. The work of breathing, assessed by measuring the pressure time product of the diaphragm (PTPdi), and thoracoabdominal asynchrony (TAA) were determined at the end of each 2-h period. The infants’ inspired oxygen requirement, oxygen saturation, heart rate and respiratory rate were also recorded. The median PTPdi was lower on SNIPPV than on HHHFNC (232 (range 130–352) versus 365 (range 136–449) cmH2O s/min, p = 0.0077), and there was less thoracoabdominal asynchrony (13.4 (range 8.5–41.6) versus 36.1 (range 4.3–50.4) degrees, p = 0.038).

Conclusion: In prematurely born infants, SNIPPV compared to HHHFNC post-extubation reduced the work of breathing and thoracoabdominal asynchrony.

What is Known:

• The work of breathing and extubation failure are not significantly different in prematurely-born infants supported by HHHFNC or nCPAP.

• SNIPPV reduces inspiratory effort and increases tidal volume and carbon dioxide exchange compared to nCPAP in prematurely born infants.

What is New:

• SNIPPV, as compared to HHHFNC, reduced the work of breathing in prematurely-born infants studied post-extubation.

• SNIPPV, as compared to HHHFNC, reduced thoracoabdominal asynchrony in prematurely born infants studied post-extubation.

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Fig. 1

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Abdominal movement


Difference between inspiratory and expiratory abdominal positions at mid-RC excursion


Maximum abdominal excursion


Bronchopulmonary dysplasia


Continuous positive airway pressure

FiO2 :

Inspired oxygen fraction


Heated humidified high flow nasal cannula


Transdiaphragmatic pressure


Positive end expiratory pressure


Gastric pressures


Peak inspiratory pressures


Oesophageal pressure

PTPdi :

Pressure time product of the diaphragm


Rib cage movement


Respiratory inductance plethysmography


Synchronised nasal intermittent positive pressure ventilation


Thoracoabdominal asynchrony


Work of breathing


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Dr. Hunt was supported by the Charles Wolfson Charitable Trust and additionally by SLE. Dr. Elinor Charles was supported by the Isaac Shapera Fund. The research was supported by the National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Professor Janet Peacock is an NIHR Senior Investigator. The Guilia ventilated was loaned to us by Gineviri Medical Technologies (see comments re competing interests).

Author information

Authors and Affiliations



AG, KAH and GFR designed the study. EC and KAH collected the data. JFP, EC, KAH and AG analysed the data. All authors were involved in the production of the manuscript and approved the final version.

Corresponding authors

Correspondence to Elinor Charles, Katie A. Hunt or Anne Greenough.

Ethics declarations

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Conflict of interest

Professor Greenough has held grants from various manufacturers (Abbot Laboratories, MedImmune) and ventilator manufacturers (SLE). Professor Greenough has received honoraria for giving lectures and advising various manufacturers (Abbot Laboratories, MedImmune) and ventilator manufacturers (SLE). Professor Greenough is currently receiving a non-conditional educational grant from SLE. The Guilia ventilator was loaded to us by Ginevri Medical Technologies; they have not been involved in the data collection analysis or production of the manuscript.

Informed consent

Infants whose parents gave informed written consent were enrolled into the study.

Additional information

Communicated by Patrick Van Reempts

Elinor Charles and Katie A Hunt are joint first authors.

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Charles, E., Hunt, K.A., Rafferty, G.F. et al. Work of breathing during HHHFNC and synchronised NIPPV following extubation. Eur J Pediatr 178, 105–110 (2019).

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