The Predictors and Outcomes of Early Noninvasive Positive Pressure Ventilation Failure in Very Preterm Infants: A Prospective Study

Abstract

Objective

Limited data exist on predicting nasal intermittent positive pressure ventilation (NIPPV) failure in very preterm infants. This study aimed to identify factors predicting NIPPV failure, focusing on the fraction of inspired oxygen (FiO₂), and evaluating associated outcomes.

Study Design

This prospective observational study included infants with gestational ages between 23^0/7 and 31^6/7 weeks, who were managed with NIPPV as the initial respiratory support. Infants were categorized as either successfully managed with NIPPV (NIPPV-S) or failed and required intubation within the first 72 hours of life (NIPPV-F). Predictors of NIPPV failure and clinical outcomes were evaluated. ROC curve analysis was used to determine FiO₂ thresholds in the first and second hours of life. Demographic, perinatal, and respiratory parameters were analyzed using univariate and multivariate logistic regression models.

Results

Of the 397 infants, 121 (30.5%) failed NIPPV and required intubation. Multivariate analysis revealed that FiO₂ in the first hour, FiO₂ in the second hour, and mean airway pressure were independent predictors of NIPPV failure. The optimal FiO₂ threshold was 0.32 (sensitivity, 79% and specificity, 50%) for the first hour and 0.31 (sensitivity, 75% and specificity, 55%) for the second hour of life. NIPPV failure was associated with an increased risk of pneumothorax (adjusted odds ratio [aOR]: 16.83; 95% confidence interval [CI]: 2.05–138.45; p < 0.001), BPD (aOR: 2.61; 95% CI: 1.47–4.62; p < 0.001), and mortality (aOR: 2.37; 95% CI: 1.32–4.23; p < 0.001).

Conclusion

FiO₂ is a valuable predictor of NIPPV success in the early hours of life. NIPPV failure, predicted by a FiO₂ exceeding 0.30 within the first 2 hours of life, is associated with adverse neonatal outcomes.

Key Points

• FiO₂ > 0.30 in first 2 hours predicts NIPPV failure in very preterm infants.

• Early NIPPV failure is linked to increased risks of BPD, pneumothorax, and death.

• FiO₂ and MAP are independent predictors of NIPPV failure.

Keywords

FiO₂ threshold - noninvasive ventilation - preterm infant

Ethical Approval

This study was approved by the Institutional Review Board of our tertiary center. (Ankara Bilkent City Hospital Ethics Committee number 1, ethics approval number E1–20–1250).

Clinical Trial

This study is registered with ClinicalTrial.gov (identifier: NCT05260424; https://clinicaltrials.gov/study/NCT05260424 ).

Patient Consent

Written informed consent was obtained from all the participants included in this study, and no identifying information from any participant was included.

Authors' Contributions

M.S.A. and F.N.S. were responsible for the data collection and analysis. M.S.A. wrote the manuscript, performed the planning of the method, and is responsible for the overall content (as a guarantor). F.N.S. reviewed and revised the manuscript accordingly. I.C.A. recorded the data and E.A.D. and A.K.C. performed statistical analysis of the data.

Publication History

Received: 12 February 2025

Accepted: 29 May 2025

Article published online:
16 June 2025

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