Clinical Implications Of Both Therapies Health And Social Care Essay

Statistically different or not all the studies had a common finding. They all showed NIPPV (nasal intermittent positive pressure ventilation) to provide better successful extubation rates, when compared with NCPAP (nasal continuous positive airway pressure). The results also included several variables, such as birth weight, gestational age at birth and surfactant administration. All the studies did, however, avoid including those infants, which had other problems, other than RDS (respiratory distress syndrome). Clinical implications comparing both interventions may be seen in the following table, 5.1.

Implication of NCPAP

Implications of NIPPV

No need for frequent arterial gas monitoring

Need for frequent arterial gas monitoring

No need for indwelling umbilical/arterial line

Definite need for indwelling umbilical/arterial line

Reduced infection liability

Arterial line present- increases liability to infections

Lower costing to buy and run

Higher costs due to sophisticated machinery

Staff needs training

Staff needs training

Table 5.1 Clinical Implications Of Both Therapies

Recommendations for Education

Local protocols and guidelines should be updated according to this new research, as well as being uploaded and updated on KURA (Intranet or Hospitals in Malta). This will be used as a form of guidance for practitioners, when dealing with the care of preterm infants with RDS, thus offering a standard of care. The guidelines must also include precautionary measures; to monitor potential complications, for example IVH (intra ventricular haemorrhage). They must also include how to use the different ventilators, keep the lines clean, attach the tubing to the infant using different prongs and in general how to care for the infant as a whole.

Seminars and classes are required for the hospital board to approve the study and the guidelines. Health care professionals must be included in the seminars, as they can bring their first hand experience into the lectures and can raise valid arguments. Therefore the lectures must be open to discussion so as to allow everyone to communicate and discuss their views. The professionals must also be included, so as to be involved in the decisions made on their care to the patient. The professionals involved must include all those working in NPICU (Neonatal and Paediatric Intensive Care Unit); consultants, paediatricians and nurses, also nurses and doctors wishing to expand their knowledge on neonatal treatment, student nurses and doctors who may be assigned to work in that setting.

Recommendations for Research

Until December 2012, when the research was carried out for this study, there were no local studies carried out with regard to the PICO question, comparing the successful extubation rates when infants are placed on NCPAP or NIPPV. Sufficient evidence from the Internet on international studies including all the above factors provided solid grounds for the results achieved. Also it is recommended that local RCTs (randomised controlled trials) should take place locally so as to ensure that the guidelines are safe to enforce in Malta. When comparing the two forms of therapies, as well analysing the rates of successful extubation, other secondary results must be taken into consideration, such as length of hospitalisation or complications like IVH, BPD (bronchopulmonary dysplasia) and abdominal perforation.

Recommendations for Management

As discussed previously the studies all lean towards preferring NIPPV as a form of treatment in preterm infants suffering from RDS. However, most studies did use surfactant therapy, either prophylactically or as rescue treatment when failing extubation. A recommendation is that in low birth weight infants especially, and those infants born below 30 weeks gestational age be given surfactant therapy prophylactically so as to aid their final outcome. It is also recommended that low birth weight infants, and those born before 30weeks gestation be placed on NIPPV so they can be managed better and more effectively immediately after birth, and if managing well can then be extubated to NCPAP.

In the studies analysed there were no serious adverse effects when using either treatment. However it is important that all health care professionals involved in the care of the infants on ventilator therapy should be well accustomed to the ventilators and be taught how to use them efficiently so as to provide maximum support. The position of the tubing in the infant must be done well so as to ensure that the air is not entering the stomach instead of the lungs. Thus abdominal girth should be measured daily, if not more often depending on the circumstances.


According to local protocols (see Appendix 4), the infant is intubated on birth, if suffering RDS, and given surfactant. The infant will then be normally extubated onto a form of CPAP and managed until they can be eventually extubated onto oxygen supplements or oxygen is removed completely. In some cases the infant may be extubated onto IMV (intermittent mandatory ventilation), which is a form of NIPPV though less sophisticated, and managed this way until stable enough to be extubated onto CPAP and then onto oxygen and eventually onto air. In essence the protocol does follow the results of this study, however it does not state in the guidelines exactly at what stage, or what requirements, are needed to extubate to either IMV (NIPPV in the case of the study) or to CPAP.

It is best that the guidelines will be clarified with regards to the recommendations and implications from this chapter.

: Conclusion


In the previous chapter clinical implications and recommendations were given in relation to the PICO question at hand and with regard to the local situation. In this chapter one will find an overview of the entire study and in another section will find the strengths and limitations observed in the study.

General Overview

RDS (respiratory distress syndrome) is a common problem in infants born prematurely, especially under 32 weeks gestation, when the lungs would not have developed properly. The purpose of this study was to address the PICO question at hand through evidence; on "Which provides better extubation success rates in neonates, NCPAP (nasal continuous positive airway pressure) or NIPPV (nasal intermittent positive pressure ventilation)?". From the evidence one could then understand the best practice to adopt when treating the affected infants.

In the literature review the PICO question was broken up into keywords and evaluated to find articles, which addressed all the components of the question; the Population affected, the Intervention and Comparison needed to treat the infants, and the overall Outcome that was being judged. Inclusion and exclusion criteria were set up and applied to the articles found, ensuring a more refined collection of studies. This refining yielded three RCT’s (randomised controlled trials), two systematic reviews and a review. The CASP (Critical Appraisal Skills Programme) tools, see Appendix 2, were then used to appraise the literature found in chapter 2. This helped identify if the trials addressed a focussed issue, whether the infants were randomised in the study, any possibility of bias, if each group was treated equally, the outcomes and whether the results may be applied to the local population.

The findings were then analysed depending on the results they yielded, determining which were statistically different. Although not each study did show statistical significance, an overall result showed that NIPPV did provide better rates for successful extubation. Secondary finding analysis, such as length of hospitalisation and complications such as IVH (intraventricular haemorrhage) and BPD (bronchopulmonary dysplasia) were also taken into account, though little to no difference was shown between the two groups, and none showed statistical difference. Recommendations with regard to the local situation were suggested, along with the implications to clinical practice, brought about from the evidence shown from the studies analysed.

Strengths and Limitations

Each study has its strengths and limitations. In this particular study a major strength was that all the literature reviewed correctly appraised the objectives needed to carry out the study. This means that all the articles contained the components of the PICO question being analysed. Also all articles involved infants with the same baseline characteristics and did not include any infants suffering from more than the physiological problem at hand, RDS. All articles followed their own approved protocols, ensuring safe practice at all times.

Limitations in this dissertation included not having a large enough population size in each study. All authors suggested, in the discussion part, to conduct more studies involving a larger number of infants to yield more concrete results. Implications were based only on those articles read, thus some form of bias may be present. The use of surfactant was different in all studies, whether as a prophylactic, or as rescue or not at all. Thus may also alter results slightly. Different views on treating younger gestation ages were also viewed in the articles obtained. Thus a better understanding could be made either focussing on one age group, or obtaining more generalised studies. Cross-over from one intervention to the next was allowed in some studies, but not in the rest. Although these results were not included in the final results a more standardised approach should be formed.

Another limitation this study faced was that NIPPV is a relatively new form of ventilator treatment. In fact, the literature available online was limited to the last decade, give or take a few years. Thus the only few good quality studies which were available, and appropriate to answer this research question were then used, resulting in 6 studies.

Although all the results did indicate the same results, there were no local studies to compare it with. Thus local studies must be made to see the way the Maltese population will react to the different therapies. The infants involved were followed up with various texts. However any possible long term effects were not documented and this may need to be seen into.

Being new to research analysis some important points may have been missed in the critical appraisal conducted for this study. To combat this every effort has been put in place to utilise any existing knowledge, evidence and research. The CASP tools (Appendix 2) were used to implement an in-depth analysis to be able to reach the correct conclusion.


Having had previous work experience in NPICU (Neonatal and Paediatric Intensive Care Unit), the results obtained from the search process and the recommendations evolved from it, provide positive, realistic and achievable outcomes, which can be implemented locally. Although limitations were identified in this study, they still do not impair the outcomes found and the evidence provides sound support for the recommendations given.

This dissertation enforced positive critical thinking, starting from the moment the PICO question was chosen, till it was addressed and a title was established. The articles were then critically analysed for their methodology and findings.