Comparison of Three Non-invasive Ventilation Interfaces in Preterm and Term Neonates: A Retrospective Cohort Study

Summary

This study of 187 preterm and term neonates demonstrates that systematic rotation between nasal prongs and masks reduces moderate-to-severe nasal injuries by 60% without compromising respiratory efficacy. This strategy also improves oxygenation and shortens the duration of continuous positive airway pressure compared with continuous interface use.

Abstract

Non-invasive ventilation (NIV) is the primary mode of support for neonatal respiratory distress; however, nasal injury remains a frequent complication. The optimal interface strategy for minimizing nasal injury while maintaining respiratory efficacy remains uncertain. This retrospective cohort study of 187 neonates compared three interface strategies: nasal prongs (n = 63), nasal mask (n = 61), and an alternating prongs/mask protocol (n = 63). Primary outcomes included NIV failure and nasal injury severity. NIV failure rates were comparable across groups (p = 0.72); however, the alternating group demonstrated a significant reduction in moderate-to-severe nasal injury (9.5%) compared with continuous prongs (23.8%, p = 0.03) and continuous masks (18.0%, p = 0.19). Furthermore, the alternating strategy was associated with significantly improved oxygenation and shorter median durations of continuous positive airway pressure (CPAP) (15 vs. 18 vs. 20 h, p = 0.04). Systematic interface rotation every 2–4 h minimizes iatrogenic injury without compromising efficacy and should be integrated into standard neonatal care.

Introduction

Nasal injury remains a significant iatrogenic complication of neonatal non-invasive ventilation (NIV), with incidence rates reported as high as 90%¹. Non-invasive ventilation has revolutionized neonatal respiratory care over the past two decades and has become the preferred initial approach for respiratory support in preterm and term infants^2,3. The shift from invasive mechanical ventilation to NIV strategies has been driven by compelling evidence demonstrating reduced rates of bronchopulmonary dysplasia, shorter hospitalizations, and improved neurodevelopmental outcomes⁴. Current guidelines from the American Academy of Pediatrics and the European Consensus Guidelines recommend continuous positive airway pressure (CPAP) as first-line therapy for respiratory distress syndrome, with NIV failure rates ranging from 25%–40%, depending on gestational age and underlying pathology^5,6.

Despite these advances, the optimal interface for NIV delivery remains controversial. Recent systematic reviews have failed to demonstrate clear superiority of any single interface type, although individual studies suggest potential benefits of specific approaches in selected populations^7,8. The heterogeneity in study designs, patient populations, and outcome measures has limited the ability to draw definitive conclusions regarding interface selection.

Nasal prongs are widely used for their reliable pressure delivery; however, their rigid structure often creates concentrated pressure points at the nasal septum and the columella^9,10,11. In contrast, nasal masks distribute pressure over a larger area but may introduce challenges such as increased gas leak and pressure variability^12,13,14,15.

The concept of interface rotation aims to combine the advantages of both systems. Early investigations suggest that systematic rotation protocols can reduce injury rates^16,17. This study addresses the lack of direct comparisons across a broad cohort of preterm and term neonates, particularly highlighting extremely low birth-weight infants, who are at the highest risk due to skin fragility and the need for prolonged NIV duration^18,19,20. By evaluating these strategies, this research provides a framework for proactive interface management, guiding clinical decision-making to balance respiratory efficacy with the prevention of iatrogenic injury. It is hypothesized that the underlying physiological mechanisms involve a reduction in localized inflammatory cascades and optimization of tissue perfusion; however, these mechanisms require further validation²¹.

This study aimed to compare the incidence and severity of nasal injuries among three interface strategies; evaluate the impact on respiratory parameters and inflammatory markers; test whether interface rotation improves gas exchange via varied mechanical stimuli; and identify predictors of NIV success across different interface approaches.

Protocol

This study was performed in accordance with the principles of the Declaration of Helsinki. Ethical approval was granted by the Institutional Review Board of the First Affiliated Hospital of Xiamen University (Approval No. [2025] KYLSZ (049)) prior to data collection. De-identified data extraction forms were used to maintain patient confidentiality. Given the retrospective nature of this study, the ethics committee waived the requirement for written informed consent.

Inclusion criteria. Neonates admitted to the facility between 2020 and 2024 were eligible for inclusion if they had a gestational age of ≥24 weeks, required non-invasive ventilation (NIV) within the first 72 h of life, and exhibited respiratory distress identified by clinical signs, including a respiratory rate >60 breaths/min, grunting, or a Silverman–Anderson score ≥3. The study intentionally included extremely preterm infants (24 weeks) and extremely low birth-weight infants (<1,000 g) to reflect the full clinical scope of NIV application.

Exclusion criteria. Infants with major craniofacial anomalies or those requiring immediate intubation were excluded.

1. Subject screening and preparation

The electronic medical database was searched for neonates admitted between 2020 and 2024 with a gestational age of ≥24 weeks who required non-invasive ventilation (NIV) within the first 72 hours of life. Respiratory distress was identified based on clinical signs, including a respiratory rate >60/min, grunting, or a Silverman–Anderson score ≥3. Infants with major craniofacial anomalies or those requiring immediate intubation were excluded. The inclusion of extremely preterm infants (24 weeks) and extremely low birth-weight infants (<1,000 g) was intentional to reflect the full clinical scope of NIV application in the unit.

2. Non-invasive ventilation interface application

The appropriate interface size was determined using a calibrated measuring guide to assess the nasal columellar distance and nostril diameter. The skin was cleaned and dried, followed by application of a thin hydrocolloid barrier. The barrier was cut into an ‘H-shape’ for nasal prongs or a ‘reverse heart-shape’ for nasal masks. The interface was then placed and secured with the fixation system, with Velcro straps adjusted to allow one finger-breadth of space to prevent excessive pressure.

Interface rotation was performed every 2–4 h for the alternating group. The timing within this interval was individualized based on clinical judgment and synchronized with routine clustered care to minimize unnecessary handling and physiological instability. This approach prioritized infant comfort, stability during handling, and the preservation of nasal skin integrity, as assessed at visual checkpoints.

During each interface switch, a 5-min pressure-relief period was provided by delivering oxygen via a low-flow cannula positioned 1–2 cm above the nares.

3. Visual checkpoints and monitoring

Visual checkpoints ensured that nasal prongs did not contact the base of the nose and that the nasal mask did not impinge on the eyes. Patients were monitored for clinical stabilization, including a reduction in respiratory rate and maintenance of oxygen saturation between 91%–95%. Blood gas samples were obtained at baseline and at 2, 6, 12, and 24 h after initiation to measure pH (potential of hydrogen), partial pressure of arterial oxygen (PaO₂), and partial pressure of arterial carbon dioxide (PaCO₂). Primary outcomes included NIV failure (intubation within 72 h) and nasal injury severity.

4. Post-procedural data analysis

All statistical analyses were performed after completion of clinical data collection to maintain procedural flow. Categorical and continuous variables were entered into statistical software for analysis. The normality of continuous data was assessed using the Shapiro–Wilk test. Clinical outcomes were compared across the three interface groups using ANOVA, the Kruskal–Wallis test, or the chi-square test, as appropriate. The Bonferroni correction was applied for multiple comparisons of secondary outcomes (blood gas parameters and inflammatory markers) to adjust the significance threshold. Multivariable logistic regression was used to identify independent predictors of nasal injury, adjusting for birth weight and CPAP duration.

Results

Baseline characteristics and demographics

The study cohort comprised 187 neonates with a median gestational age of 33+2 weeks (interquartile range [IQR]: 29+4 to 34+5) and a mean birth weight of 881.1 ± 525.7 g (range: 580–2050 g). The inclusion of extremely preterm infants (<28 weeks) and very low birth weight infants (<1,500 g) reflects the broad clinical application of NIV in the neonatal intensive care unit.

Baseline characteristics, inclu...

Discussion

This study provides compelling evidence that systematic interface rotation significantly reduces nasal injury in preterm and term neonates receiving NIV support without compromising respiratory efficacy. The 60% relative reduction in moderate-to-severe nasal injuries with the alternating protocol represents a clinically meaningful improvement that could substantially impact neonatal comfort and parental satisfaction. The findings align with and extend previous work by demonstrating that the benefits of rotation persist a...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
DuoDERM Extra Thin	Convatec	NA	Hydrocolloid barrier for skin protection
fabian Therapy Evolution	Vyaire Medical	NA	Neonatal ventilator used for NIV delivery
MR850 Heated Humidifier	Fisher & Paykel	NA	Maintains gas temperature and humidity
R version 4.2.1	R Foundation for Statistical Computing	NA	Statistical analysis software