NIV NAVA versus Nasal CPAP in Premature Infants: A Randomized Clinical Trial

Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) reduces extubation failures in preterm neonates-A systematic review and meta-analysis

AIM

To analyse the evidence of non-invasive neurally adjusted ventilatory assist (NIV-NAVA) in preterm neonates compared to nasal continuous positive airway pressure (nCPAP) or nasal intermittent positive pressure ventilation (NIPPV).

METHODS

We performed a systematic review and meta-analysis of randomised controlled trials and included studies where NIV-NAVA was analysed in preterm (<37 gestational weeks) born neonates. Our main outcomes were the need for endotracheal intubation, the need for surfactant therapy, and reintubation rates. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated.

RESULTS

A total of five studies were included. The endotracheal intubation rate was 25% in the NIV-NAVA group and 26% in the nCPAP group (RR 0.91, CI: 0.56-1.48). The respective rates for surfactant therapy were 30% and 35% (RR 0.85, CI: 0.56-1.29). The reintubation rate in neonates previously invasively ventilated was 8% in the NIV-NAVA group and 29% in the nCPAP/NIPPV group (RR 0.29, 95%CI: 0.10-0.81). Evidence certainty was rated as low for all outcomes.

CONCLUSIONS

NIV-NAVA as the primary respiratory support did not reduce the need for endotracheal intubation or surfactant therapy. NIV-NAVA seemed to reduce the reintubation rate after extubation in pre-term neonates.

The Diaphragmatic Initiated Ventilatory Assist (DIVA) trial: study protocol for a randomized controlled trial comparing rates of extubation failure in extremely premature infants undergoing extubation to non-invasive neurally adjusted ventilatory assist versus non-synchronized nasal intermittent positive pressure ventilation

BACKGROUND

Invasive mechanical ventilation contributes to bronchopulmonary dysplasia (BPD), the most common complication of prematurity and the leading respiratory cause of childhood morbidity. Non-invasive ventilation (NIV) may limit invasive ventilation exposure and can be either synchronized or non-synchronized (NS). Pooled data suggest synchronized forms may be superior. Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) delivers NIV synchronized to the neural signal for breathing, which is detected with a specialized catheter. The DIVA (Diaphragmatic Initiated Ventilatory Assist) trial aims to determine in infants born 240/7-276/7 weeks' gestation undergoing extubation whether NIV-NAVA compared to non-synchronized nasal intermittent positive pressure ventilation (NS-NIPPV) reduces the incidence of extubation failure within 5 days of extubation.

METHODS

This is a prospective, unblinded, pragmatic, multicenter phase III randomized clinical trial. Inclusion criteria are preterm infants 24-276/7 weeks gestational age who were intubated within the first 7 days of life for at least 12 h and are undergoing extubation in the first 28 postnatal days. All sites will enter an initial run-in phase, where all infants are allocated to NIV-NAVA, and an independent technical committee assesses site performance. Subsequently, all enrolled infants are randomized to NIV-NAVA or NS-NIPPV at extubation. The primary outcome is extubation failure within 5 days of extubation, defined as any of the following: (1) rise in FiO2 at least 20% from pre-extubation for > 2 h, (2) pH ≤ 7.20 or pCO2 ≥ 70 mmHg; (3) > 1 apnea requiring positive pressure ventilation (PPV) or ≥ 6 apneas requiring stimulation within 6 h; (4) emergent intubation for cardiovascular instability or surgery. Our sample size of 478 provides 90% power to detect a 15% absolute reduction in the primary outcome. Enrolled infants will be followed for safety and secondary outcomes through 36 weeks' postmenstrual age, discharge, death, or transfer.

DISCUSSION

The DIVA trial is the first large multicenter trial designed to assess the impact of NIV-NAVA on relevant clinical outcomes for preterm infants. The DIVA trial design incorporates input from clinical NAVA experts and includes innovative features, such as a run-in phase, to ensure consistent technical performance across sites.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov , trial identifier NCT05446272 , registered July 6, 2022.

Novel forms of ventilation in neonates: Neurally adjusted ventilatory assist and proportional assist ventilation

Patient-triggered modes of ventilation are currently the standard of practice in the care of term and preterm infants. Maintaining spontaneous breathing during mechanical ventilation promotes earlier weaning and possibly reduces ventilator-induced diaphragmatic dysfunction. A further development of assisted ventilation provides support in proportion to the respiratory effort and enables the patient to have full control of their ventilatory cycle. In this paper we will review the literature on two of these modes of ventilation: neurally adjusted ventilatory assist (NAVA) and proportional assist ventilation (PAV), propose future studies and suggest clinical applications of these modes.

Noninvasive Neurally Adjusted Ventilation versus Nasal Continuous or Intermittent Positive Airway Pressure for Preterm Infants: A Systematic Review and Meta-Analysis

The noninvasive neurally adjusted ventilatory assist (NIV-NAVA) is a newly developed noninvasive ventilation technique with promising clinical and ventilatory outcomes for preterm infants. This systematic review and meta-analysis aimed to investigate whether NIV-NAVA has better clinical and ventilatory outcomes than nasal continuous airway pressure (NCPAP) or noninvasive positive pressure ventilation (NIPP) on premature infants. MEDLINE, Embase, and CENTRAL were searched, and randomized controlled trials (RCTs) that compared NIV-NAVA with NCPAP or NIPP for preterm infants (gestational age: <37 weeks) were included. We evaluated the following outcomes in the neonatal intensive care unit: the desaturation rate, failure of noninvasive modality requiring intubation when received as the primary mode or the need for re-intubation after extubation from mechanical ventilation in the secondary mode (weaning), length of stay, and fraction of inspired oxygen. The mean difference and risk ratio were used to represent continuous and dichotomous outcomes, respectively. We included nine RCTs involving 339 preterm infants overall. NIV-NAVA showed similar clinical and ventilatory outcomes to NCPAP or NIPP, except for the maximum diaphragmatic electrical activity. The rate of failure of the noninvasive modality was not statistically different between NIV-NAVA and NCPAP. The pooled estimates for the maximum electrical activity were significantly reduced in NIV-NAVA compared with those in NIPP. The findings suggest that NIV-NAVA may be as safe and effective as NCPAP and NIPP for preterm neonates, particularly those who may not tolerate these alternative noninvasive methods. However, further trials are recommended for greater evidence.

Positive pressure ventilation in the weaning of preterm newborns

BACKGROUND

Weaning from invasive mechanical ventilation (IMV) of preterm newborns (PTNB) is one of the critical stages of life support in the Neonatal Intensive Care Unit (NICU). Noninvasive positive pressure ventilation (NPPV) has been used to facilitate weaning from IMV and includes continuous positive airway pressure (CPAP) without or with inspiratory pressure support (bilevel NPPV). Nevertheless, there is little information about their adherence and success rate during weaning process.

METHODS

In this retrospective cohort study, weaning data from patients admitted to a NICU from the northeast region of Brazil were analyzed. Sample was composed of PTNB submitted to IMV and divided in two groups according to the weaning strategy adopted: bilevel NPPV or NCPAP. Weaning failure was defined as returning to IMV within less than 48 h after extubation.

RESULTS

Fifty-seven PTNB were included. Majority were females, had caesarean delivery, very low weight upon birth (760-1480 g) and neonatal hypoxemia scores (Apgar) <7 in the first minute. Respiratory distress syndrome occurred in 56.7% of PTNB whilst respiratory infections occurred in 35.1% of patients. Bilevel NPPV was the most chosen modality of weaning. No difference in success rate was found between bilevel NPPV and NCPAP (P=0.17).

CONCLUSIONS

In this study, the application of noninvasive ventilation in preterm newborns for weaning from IMV was similar success rate between bilevel NPPV and NCPAP.

Invasive and non-invasive ventilatory strategies for early and evolving bronchopulmonary dysplasia

In the age of surfactant and antenatal steroids, neonatal care has improved outcomes of preterm infants dramatically. Since the early 2000's neonatologists have strived to decrease bronchopulmonary dysplasia (BPD) by decreasing ventilator-associated lung injury and utilizing many novel modes of non-invasive respiratory support. After the initial success with nasal continuous positive airway pressure, it was established that discontinuing invasive ventilation early in favor of non-invasive respiratory support is the most effective way to reduce the incidence of BPD. In this review, we discuss the management of the preterm lung from the time of delivery, through the phases of respiratory distress syndrome (early BPD) and then evolving BPD. The goal remains to optimize respiratory support of the preterm lung while minimizing ventilator-associated lung injury and oxygen toxicity. A multidisciplinary approach involving the medical team and family is quintessential in reaching this goal and involves adequate respiratory support, optimizing nutrition and fluid balance as well as preventing infections.

State of the art on neonatal noninvasive respiratory support: How physiological and technological principles explain the clinical outcomes

Noninvasive respiratory support has gained significant popularity in neonatal units because of its potential to reduce lung injury associated with invasive mechanical ventilation. To minimize lung injury, clinicians aim to apply for noninvasive respiratory support as early as possible. However, the physiological background and the technology behind such support modes are not always clear, and many open questions remain regarding the indications of use and clinical outcomes. This narrative review discusses the currently available evidence for various noninvasive respiratory support modes applied in Neonatal Medicine in terms of physiological effects and indications. Reviewed modes include nasal continuous positive airway pressure, nasal high-flow therapy, noninvasive high-frequency oscillatory ventilation, nasal intermittent positive pressure ventilation (NIPPV), synchronized NIPPV and noninvasive neurally adjusted ventilatory assist. To enhance clinicians' awareness of each support mode's strengths and limitations, we summarize technical features related to the functioning mechanisms of devices and the physical properties of the interfaces commonly used for providing noninvasive respiratory support to neonates. We finally address areas of current controversy and suggest possible areas of research for implementing noninvasive respiratory support in neonatal intensive care units.

NIV-NAVA versus NCPAP immediately after birth in premature infants: A randomized controlled trial

OBJECTIVE

To evaluate whether noninvasive-neurally adjusted ventilatory assist (NIV-NAVA) decrease respiratory efforts compared to nasal continuous positive airway pressure (NCPAP) during the first hours of life.

METHODS

Twenty infants born between 28⁺⁰ and 31⁺⁶ weeks were randomized to NIV-NAVA or NCPAP. Positive end-expiratory pressure was constantly kept at 6 cmH₂O for both groups and the NAVA level was 1.0 cmH₂O/µV for NIV-NAVA group. The electrical activity of diaphragm (Edi) were recorded for the first two hours.

RESULTS

Peak and minimum Edi decreased similarly in both groups (P = 0.98 and P = 0.59, respectively). Leakages were higher in the NIV-NAVA group than in the NCPAP group (P < 0.001). The neural apnea defined as a flat Edi for ≥ 5 s were less frequent in NIV-NAVA group than in NCPAP group (P = 0.046).

CONCLUSIONS

Immediately applied NIV-NAVA in premature infants did not reduce breathing effort, measured as peak Edi. However, NIV-NAVA decreased neural apneic episodes compared to NCPAP.

Noninvasive Neurally Adjusted Ventilation in Postextubation Stabilization of Preterm Infants: A Randomized Controlled Study

OBJECTIVE

To compare the effects of noninvasive neurally adjusted ventilatory assist (NIV-NAVA) to nasal continuous positive airway pressure (NCPAP) in achieving successful extubation in preterm infants.

STUDY DESIGN

This prospective, single-center, randomized controlled trial enrolled preterm infants born at <30 weeks of gestation who received invasive ventilation. Participants were assigned at random to either NIV-NAVA or NCPAP after their first extubation from invasive ventilation. The primary outcome of the study was extubation failure within 72 hours of extubation. Electrical activity of the diaphragm (Edi) values were collected before extubation and at 1, 4, 12, and 24 hours after extubation.

RESULTS

A total of 78 infants were enrolled, including 35 infants in the NIV-NAVA group and 35 infants in the NCPAP group. Extubation failure within 72 hours of extubation was higher in the NCPAP group than in the NIV-NAVA group (28.6% vs 8.6%; P = .031). The duration of respiratory support and incidence of severe bronchopulmonary dysplasia were similar in the 2 groups. Peak and swing Edi values were comparable before and at 1 hour after extubation, but values at 4, 12, and 24 hours after extubation were lower in the NIV-NAVA group compared with the NCPAP group.

CONCLUSIONS

In the present trial, NIV-NAVA was more effective than NCPAP in preventing extubation failure in preterm infants.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02590757.

Respiratory muscle function in the newborn: a narrative review

Our aim was to summarise the current evidence and methods used to assess respiratory muscle function in the newborn, focusing on current and future potential clinical applications. The respiratory muscles undertake the work of breathing and consist mainly of the diaphragm, which in the newborn is prone to dysfunction due to lower muscle mass, flattened shape and decreased content of fatigue-resistant muscle fibres. Premature infants are prone to diaphragmatic dysfunction due to limited reserves and limited capacity to generate force and avoid fatigue. Methods to assess the respiratory muscles in the newborn include electromyography, maximal respiratory pressures, assessment for thoraco-abdominal asynchrony and composite indices, such as the pressure-time product and the tension time index. Recently, there has been significant interest and a growing body of research in assessing respiratory muscle function using bedside ultrasonography. Neurally adjusted ventilator assist is a novel ventilation mode, where the level of the respiratory support is determined by the diaphragmatic electrical activity. Prolonged mechanical ventilation, hypercapnia and hypoxia, congenital anomalies and systemic or respiratory infection can negatively impact respiratory muscle function in the newborn, while caffeine and synchronised or volume-targeted ventilation have a positive effect on respiratory muscle function compared to conventional, non-triggered or pressure-limited ventilation, respectively. IMPACT: Respiratory muscle function is impaired in prematurely born neonates and infants with congenital anomalies, such as congenital diaphragmatic hernia. Respiratory muscle function is negatively affected by prolonged ventilation and infection and positively affected by caffeine and synchronised compared to non-synchronised ventilation modes. Point-of-care diaphragmatic ultrasound and neurally adjusted ventilator assist are recent diagnostic and therapeutic technological developments with significant clinical applicability.

Respiratory and Gastrointestinal Management of an Infant with a Birth Weight of 258 Grams

Today, more infants weighing less than or equal to 300 g are born, and they survive because of the improvements in neonatal care and treatment. However, their detailed clinical course and neonatal intensive care unit management remain unknown due to their low survival rate and dearth of reports. A male infant was born at 24 weeks and 5 days of gestation and weighed 258 g. The infant received 72 days of invasive and 92 days of noninvasive respiratory support, including high-frequency oscillatory ventilation with volume guarantee and noninvasive neurally adjusted ventilatory assist. Meconium-related ileus was safely treated using diatrizoate. Although the infant was diagnosed with severe bronchopulmonary dysplasia and retinopathy of prematurity requiring laser photocoagulation, he had no other severe complications. He was discharged 201 days postdelivery (3 months of corrected age) with a weight of 3.396 kg. Although managing infants weighing less than or equal to 300 g is difficult, our experience shows that it is possible by combining traditional and modern management methods. The management of such infants requires an understanding of the expected difficulties and adaptation of existing methods to their management. The management techniques described here should help improve their survival and long-term prognosis.

Neurally Adjusted Ventilatory Assist in Newborns

Patient-ventilator asynchrony is very common in newborns. Achieving synchrony is quite challenging because of small tidal volumes, high respiratory rates, and the presence of leaks. Leaks also cause unreliable monitoring of respiratory metrics. In addition, ventilator adjustment must take into account that infants have strong vagal reflexes and demonstrate central apnea and periodic breathing, with a high variability in breathing pattern. Neurally adjusted ventilatory assist (NAVA) is a mode of ventilation whereby the timing and amount of ventilatory assist is controlled by the patient's own neural respiratory drive. As NAVA uses the diaphragm electrical activity (Edi) as the controller signal, it is possible to deliver synchronized assist, both invasively and noninvasively (NIV-NAVA), to follow the variability in breathing pattern, and to monitor patient respiratory drive, independent of leaks. This article provides an updated review of the physiology and the scientific literature pertaining to the use of NAVA in children (neonatal and pediatric age groups). Both the invasive NAVA and NIV-NAVA publications since 2016 are summarized, as well as the use of Edi monitoring. Overall, the use of NAVA and Edi monitoring is feasible and safe. Compared with conventional ventilation, NAVA improves patient-ventilator interaction, provides lower peak inspiratory pressure, and lowers oxygen requirements. Evidence from several studies suggests improved comfort, less sedation requirements, less apnea, and some trends toward reduced length of stay and more successful extubation.

Synchronized Nasal Intermittent Positive Pressure Ventilation

Avoiding MV is a critical goal in neonatal respiratory care. Different modes of noninvasive respiratory support beyond nasal CPAP, such as nasal intermittent positive pressure ventilation (NIPPV) and synchronized NIPPV (SNIPPV), may further reduce intubation rates. SNIPPV offers consistent benefits over nonsynchronized techniques such as a more efficient positive pressure transmission to the lung, an effective increase in transpulmonary pressure during ventilation, and a better stabilization of the chest wall during inspiration. This review discusses mechanisms of action, benefits and limitations of synchronized noninvasive ventilation, describes the different modes of synchronization, and analyzes properties and clinical results.

The Intertemporal Role of Respiratory Support in Improving Neonatal Outcomes: A Narrative Review

Defining improvements in healthcare can be challenging due to the need to assess multiple outcomes and measures. In neonates, although progress in respiratory support has been a key factor in improving survival, the same degree of improvement has not been documented in certain outcomes, such as bronchopulmonary dysplasia. By exploring the evolution of neonatal respiratory care over the last 60 years, this review highlights not only the scientific advances that occurred with the application of invasive mechanical ventilation but also the weakness of the existing knowledge. The contributing role of non-invasive ventilation and less-invasive surfactant administration methods as well as of certain pharmacological therapies is also discussed. Moreover, we analyze the cost-benefit of neonatal care-respiratory support and present future challenges and perspectives.

Cardiorespiratory effects of NIV-NAVA, NIPPV, and NCPAP shortly after extubation in extremely preterm infants: A randomized crossover trial

OBJECTIVE

Investigate the cardiorespiratory effects of noninvasive neurally adjusted ventilatory assist (NIV-NAVA), nonsynchronized nasal intermittent positive pressure ventilation (NIPPV), and nasal continuous positive airway pressure (NCPAP) shortly after extubation.

HYPOTHESIS

Types of noninvasive pressure support and the presence of synchronization may affect cardiorespiratory parameters.

STUDY DESIGN

Randomized crossover trial.

PATIENT-SUBJECT SELECTION

Infants with birth weight (BW) 1250 g or under, undergoing their first planned extubation were randomly assigned to all three modes using a computer-generated sequence.

METHODOLOGY

Electrocardiogram and electrical activity of the diaphragm (Edi) were recorded for 30 min on each mode. Analysis of heart rate variability (HRV), diaphragmatic activity (Edi area, breath area, amplitude, inspiratory and expiratory times), and respiratory variability were compared between modes.

RESULTS

Twenty-three infants had full data recordings and analysis: Median (IQR) gestational age = 25.9 weeks (25.2-26.4), BW = 760 g (595-900), and postnatal age 7 (4-19) days. There were no differences in HRV between modes. A significantly reduced Edi area and breath amplitude, and increased coefficient of variation (CV) of breath amplitude were observed during NIV-NAVA and NIPPV compared to NCPAP. A higher proportion of assisted breaths (99% vs. 51%; p < .001) provided a higher mean airway pressure (MAP; 9.4 vs. 8.2 cmH₂ O; p = .002) with lower peak inflation pressures (PIPs; 14 vs. 16 cmH₂ O; p < .001) during NIV-NAVA compared to NIPPV.

CONCLUSIONS

NIV-NAVA and NIPPV applied shortly after extubation were associated with lower respiratory efforts and higher respiratory variability. These effects were more evident for NIV-NAVA where optimal patient-ventilator synchronization provided a higher MAP with lower PIPs.

Proportional assist and neurally adjusted ventilation: Clinical knowledge and future trials in newborn infants

Different types of patient triggered ventilator modes have become the mainstay of ventilation in term and preterm newborn infants. Maintaining spontaneous breathing has allowed for earlier weaning and the additive effects of respiratory efforts combined with pre-set mechanical inflations have reduced mean airway pressures, both of which are important components in trying to avoid lung injury and promote normal lung development. New sophisticated modes of assisted ventilation have been developed during the last decades where the control of ventilator support is turned over to the patient. The ventilator detects the respiratory effort and adjusts ventilatory assistance proportionally to each phase of the respiratory cycle, thus enabling the patient to have full control of the start, the duration and the amount of ventilatory assistance. In this paper we will review the literature on the ventilatory modes of proportional assist ventilation and neurally adjusted ventilatory assistance, examine the different ways the signals are analyzed, propose future studies, and suggest ways to apply these modes in the clinical environment.

Non-Invasive Ventilatory Strategies to Decrease Bronchopulmonary Dysplasia-Where Are We in 2021?

Recent advances in neonatology have led to the increased survival of extremely low-birth weight infants. However, the incidence of bronchopulmonary dysplasia (BPD) has not improved proportionally, partly due to increased survival of extremely premature infants born at the late-canalicular stage of lung development. Due to minimal surfactant production at this stage, these infants are at risk for severe respiratory distress syndrome, needing prolonged ventilation. While the etiology of BPD is multifactorial with antenatal, postnatal, and genetic factors playing a role, ventilator-induced lung injury is a major, potentially modifiable, risk factor implicated in its causation. Infants with BPD are at a higher risk of developing complications including sepsis, pulmonary arterial hypertension, respiratory failure, and death. Long-term problems include increased risk of hospital readmissions, respiratory infections, and asthma-like symptoms during infancy and childhood. Survivors who have BPD are also at increased risk of poor neurodevelopmental outcomes. While the ultimate solution for avoiding BPD lies in the prevention of preterm births, strategies to decrease its incidence are the need of the hour. It is time to focus on gentler modes of ventilation and the use of less invasive surfactant administration techniques to mitigate lung injury, thereby potentially decreasing the burden of BPD. In this article, we discuss the use of non-invasive ventilation in premature infants, with an emphasis on studies showing an effect on BPD with different modes of non-invasive ventilation. Practical considerations in the use of nasal intermittent positive pressure ventilation are also discussed, considering the significant heterogeneity in clinical practices and management strategies in its use.

Continuous neurally adjusted ventilation: a feasibility study in preterm infants

OBJECTIVES

To assess the feasibility and tolerance of NeuroPAP, a new non-invasive ventilation mode which continuously adjusts (during both inspiration and expiration) the pressure support proportionally to the diaphragm electrical activity (Edi), in preterm infants and to evaluate the impact on ventilation pressure and Edi.

DESIGN

Prospective cross-over single-centre feasibility study.

SETTING

One level 3 neonatal intensive care unit in Canada.

PATIENTS

Stable preterm infants ventilated with non-invasive positive pressure ventilation (NIPPV).

INTERVENTIONS

Subjects were successively ventilated in NIPPV with prestudy settings (30 min), in NeuroPAP with minimal pressure similar to NIPPV PEEP (positive end-expiratory pressure) (60 min), in NeuroPAP with minimal pressure reduced by 2 cmH₂0 (60 min), in continuous positive airway pressure (15 min) and again in NIPPV (30 min). Main outcome measures included tolerance, ventilation pressure, Edi and patient-ventilator synchrony.

RESULTS

Twenty infants born at 28.0±1.0 weeks were included. NeuroPAP was well tolerated and could be delivered during 100% of planned period. During NeuroPAP, the PEEP was continuously adjusted proportionally to tonic diaphragm Edi, although the average PEEP value was similar to the set minimal pressure. During NeuroPAP, 83 (78-86)% breaths were well synchronised vs 9 (6-12)% breaths during NIPPV (p<0.001).

CONCLUSIONS

NeuroPAP is feasible and well tolerated in stable preterm infants, and it allows transient adaptation in PEEP in response to tonic diaphragm electrical activity changes. Further studies are warranted to determine the impact of these findings on clinical outcomes.

TRIAL REGISTRATION NUMBER

NCT02480205.

A Review on Non-invasive Respiratory Support for Management of Respiratory Distress in Extremely Preterm Infants

Majority of extremely preterm infants require positive pressure ventilatory support at the time of delivery or during the transitional period. Most of these infants present with respiratory distress (RD) and continue to require significant respiratory support in the neonatal intensive care unit (NICU). Bronchopulmonary dysplasia (BPD) remains as one of the major morbidities among survivors of the extremely preterm infants. BPD is associated with long-term adverse pulmonary and neurological outcomes. Invasive mechanical ventilation (IMV) and supplemental oxygen are two major risk factors for the development of BPD. Non-invasive ventilation (NIV) has been shown to decrease the need for IMV and reduce the risk of BPD when compared to IMV. This article reviews respiratory management with current NIV support strategies in extremely preterm infants both in delivery room as well as in the NICU and discusses the evidence to support commonly used NIV modes including nasal continuous positive airway pressure (NCPAP), nasal intermittent positive pressure ventilation (NIPPV), bi-level positive pressure (BI-PAP), high flow nasal cannula (HFNC), and newer NIV strategies currently being studied including, nasal high frequency ventilation (NHFV) and non-invasive neutrally adjusted ventilatory assist (NIV-NAVA). Randomized, clinical trials have shown that early NIPPV is superior to NCPAP to decrease the need for intubation and IMV in preterm infants with RD. It is also important to understand that selection of the device used to deliver NIPPV has a significant impact on its success. Ventilator generated NIPPV results in significantly lower rates of extubation failures when compared to Bi-PAP. Future studies should address synchronized NIPPV including NIV-NAVA and early rescue use of NHFV in the respiratory management of extremely preterm infants.