After the Breathing Tube Comes Out: What a New Study Found About Two Gentle Ways to Help Preemies Breathe

A look at new research comparing two common breathing-support methods used in the NICU right after a premature baby is taken off a ventilator

Why This Question Matters to Families

When a premature baby comes off a breathing machine, doctors usually switch to one of two gentle nose-based breathing aids. A new study found that one of these, NIPPV, was linked to slightly lower heart-pumping measurements than the other, NCPAP, in the first day afterward — though every baby stayed stable and all measurements were within the normal range. It is the first study to look closely at this question.

For families, the bigger picture matters as much as that one finding. Neonatal intensive care units (NICUs) rely on nasal breathing support of this kind every day, and both methods studied here remain standard, well-established parts of routine preemie care. This is not a warning story; it is a story about researchers measuring, carefully and for the first time, something that had never been closely tracked before in real premature babies right after their breathing tube comes out, so that NICU teams can watch a little more attentively going forward.

The Two Breathing-Support Methods Being Compared

After a premature baby's breathing tube is removed, most NICUs use one of two nose-based breathing support systems to help the baby avoid needing to go back on the ventilator. The first, called nasal continuous positive airway pressure (NCPAP), gently pushes one steady stream of air pressure into the baby's nose the whole time, keeping the tiny air sacs in the lungs propped open. The second, called nasal intermittent positive pressure ventilation (NIPPV), does something similar but adds extra rhythmic "puffs" of higher pressure on top of that steady baseline, a bit like giving the baby's lungs periodic gentle boosts. Both are considered safe, well-established tools, and choosing between them has traditionally come down to one main question: which one gives this particular baby the best chance of not needing to go back on the ventilator.

The Study: Measuring the Heart, Not Just the Lungs

A team of researchers led by Dr. Chougula, working at a tertiary (specialized, high-level) neonatal unit at Bharati Vidyapeeth Medical College and Hospital in Pune, India ([1]), decided to ask a different question: does the extra pressure used in NIPPV change how hard the heart has to work, or how much blood it pumps, in the hours right after a baby comes off the breathing machine? To find out, the researchers enrolled 60 premature babies (born between about 26 and 37 weeks of pregnancy) who had needed a breathing machine and were now ready to be taken off it. By random assignment — like a coin flip, so neither the babies nor the assignment process could be biased — 30 babies were placed on NIPPV and 30 on NCPAP after their breathing tubes came out.

The researchers then used a bedside heart ultrasound, called an echocardiogram, to look at the babies' hearts twice: once in the first several hours after extubation (coming off the breathing machine) and again about a day later. An echocardiogram is a painless, non-invasive scan, the same basic technology used to check a baby's heart during pregnancy, and it let the team measure something called cardiac output — essentially, how much blood the heart's left and right sides are pumping out with each beat, a direct measure of how well the heart is doing its job.

What the Researchers Found

The study found that babies on NIPPV had somewhat lower cardiac output — meaning their hearts were pumping a bit less blood — than babies on NCPAP, both in the first several hours after coming off the breathing machine and again about a day later. This difference showed up on both sides of the heart, and it tracked closely with how much average air pressure each baby's NIPPV machine was actually delivering: babies receiving higher NIPPV pressure tended to show a bigger dip in cardiac output. When the researchers looked more closely, they found that some of the difference seen in the first few hours seemed to be explained by how sick a baby already was going into the comparison, but the larger difference seen a day later held up even after accounting for that.

Here is the most important part for families to understand: even though the NIPPV babies' hearts were pumping somewhat less blood than the NCPAP babies' hearts, every single measurement in both groups stayed within the normal, healthy range for a premature baby. No baby in either group showed any sign of poor circulation. None needed extra fluids or heart-supporting medication. None had a drop in blood pressure serious enough to require treatment. The researchers were explicit about this: this was a real, measurable difference on ultrasound, not a sign that any baby was in trouble.

The study also found, as a side observation, that babies on NIPPV tended to need non-invasive breathing support for longer overall (a median of about two weeks) than babies on NCPAP (about five days) — a reminder that the two groups of babies were not simply interchangeable, and that NIPPV is often chosen for babies whose lungs need more help to begin with. The researchers also noticed an interesting pattern over time: in the NCPAP group, the heart's pumping actually rose above its pre-extubation level in the first few hours and stayed elevated the next day, almost as if the heart were working a little harder to adjust to breathing on its own; in the NIPPV group, the heart's output held steady at first and only dipped by the one-day mark. Neither pattern is inherently better or worse — they simply describe two different, and both entirely survivable, ways a newborn heart can respond to coming off a ventilator.

A Little History: Why Nobody Had Looked at This Before

Doctors have been comparing NIPPV and NCPAP for premature babies coming off ventilators for close to two decades, and the question they have almost always asked is the same one: which method better keeps a baby from needing to go back on the breathing machine? A major trial published in 2013 ([2]), and two large research reviews published in 2023 that pooled results from many smaller studies ([3], [4]), all found that NIPPV modestly lowers the chance a baby will need to be reintubated, compared with NCPAP, though it does not appear to change longer-term outcomes like chronic lung disease. What none of that research closely examined was what either method does to a baby's heart specifically in the vulnerable hours right after extubation, in the real world, in babies who had just come off a ventilator. A couple of small earlier studies had peeked at the heart during NIPPV use ([5], [6]), but only in babies who were already stable and only for very brief stretches of half an hour to an hour — nothing that could show what happens hour by hour, right after a baby's breathing tube comes out, until this study.

What This Means for Families

If your baby is placed on NIPPV after coming off a breathing machine, this research does not suggest anything is wrong or unsafe about that choice. NIPPV remains a well-established, effective tool, refined over many years of engineering and clinical use ([7]), and doctors continue to choose it specifically because, for many babies, it lowers the chance of needing to go back on the ventilator. What this study adds is new information that may lead your baby's medical team to keep an especially close eye on things like blood pressure and circulation during the first day on NIPPV, using the same careful, standardized bedside heart-ultrasound techniques that neonatal teams are trained to follow ([8]) — something NICU teams already do routinely for every baby, regardless of which breathing support they are on. It is also worth knowing that the exact fit of the small nasal tubing used for either method can affect how much pressure actually reaches a baby's airway ([9]), which is one reason your care team checks and adjusts the fit regularly. Think of all of this less as a new worry and more as a new piece of the puzzle that helps your baby's care team fine-tune their attention, particularly for the smallest, most premature babies, who made up a larger share of the NIPPV group in this particular study.

What Researchers Are Working On Next

Because this study was done at a single hospital with 60 babies, the next natural step is a larger study across multiple hospitals, to see whether the same pattern holds true more broadly and in more diverse groups of babies. Researchers will also want to know whether this heart-pumping difference, small and within-normal as it was here, ever connects to anything a family or doctor would notice clinically — such as feeding, growth, or how long a baby stays in the NICU — or whether it simply reflects a normal physiological adjustment that fades without consequence. Another open question is whether findings like these might eventually lead NICU teams to fine-tune exactly how much extra pressure they use with NIPPV, once a baby's breathing has stabilized enough that less pressure is needed. Researchers are also working, separately, on better ways to predict ahead of time which babies are most likely to need to go back on the breathing machine at all ([10]), so that both the respiratory and, now, the heart side of this decision can eventually be tailored to each baby. For now, this study's main contribution is simply that, for the first time, someone measured this carefully — and found reassuring news alongside a new detail worth watching.

References

  1. Chougula PV, Deshpande S, Nagpal R, Lakshminrusimha S, Kolkur K, Kaur A, Sohane A, Suryawanshi P. Hemodynamic effects of nasal intermittent positive pressure ventilation versus nasal continuous positive airway pressure in preterm neonates following extubation: a randomized controlled trial. BMC Pediatrics. 2026;26:762. doi:10.1186/s12887-026-07122-9 ↩
  2. Kirpalani H, Millar D, Lemyre B, Yoder BA, Chiu A, Roberts RS; NIPPV Study Group. A Trial Comparing Noninvasive Ventilation Strategies in Preterm Infants. New England Journal of Medicine. 2013;369(7):611-620. doi:10.1056/NEJMoa1214533 ↩
  3. Lemyre B, Deguise M-O, Benson P, Kirpalani H, De Paoli AG, Davis PG. Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for preterm neonates after extubation. Cochrane Database of Systematic Reviews. 2023;2023(7):CD003212. doi:10.1002/14651858.CD003212.pub4 ↩
  4. Lemyre B, Deguise M-O, Benson P, Kirpalani H, Ekhaguere OA, Davis PG. Early nasal intermittent positive pressure ventilation (NIPPV) versus early nasal continuous positive airway pressure (NCPAP) for preterm infants. Cochrane Database of Systematic Reviews. 2023;2023(7):CD005384. doi:10.1002/14651858.CD005384.pub3 ↩
  5. Chang H-Y, Cheng K-S, Liu Y-P, Li S-T, Lin C-Y, Lee H-C, Lee C-H, Hung H-F. Hemodynamic Effects of Nasal Intermittent Positive Pressure Ventilation in Preterm Infants. Medicine. 2016;95(6):e2780. doi:10.1097/MD.0000000000002780 ↩
  6. Mukerji A, Abdul Wahab MG, Razak A, Rempel E, Patel W, Mondal T, Beck J. High CPAP vs. NIPPV in preterm neonates — a physiological cross-over study. Journal of Perinatology. 2021;41(7):1690-1696. doi:10.1038/s41372-021-01122-6 ↩
  7. Owen LS, Manley BJ. Nasal intermittent positive pressure ventilation in preterm infants: Equipment, evidence, and synchronization. Seminars in Fetal and Neonatal Medicine. 2016;21(3):146-153. doi:10.1016/j.siny.2016.01.003 ↩
  8. de Boode WP, Singh Y, Gupta S, Austin T, Bohlin K, Dempsey E, Groves A, Eriksen BH, van Laere D, Molnar Z, Nestaas E, Rogerson S, Schubert U, Tissot C, van der Lee R, van Overmeire B, El-Khuffash A. Recommendations for neonatologist performed echocardiography in Europe: Consensus Statement endorsed by European Society for Paediatric Research (ESPR) and European Society for Neonatology (ESN). Pediatric Research. 2016;80(4):465-471. doi:10.1038/pr.2016.126 ↩
  9. Borg U, Aviano J, Ginani M, Li K. Evaluation of Common Nasal Cannulas in Neonatal Noninvasive Ventilation (NIV) Using a Novel Neonatal Nasal Model. Medical Devices: Evidence and Research. 2022;15:307-315. doi:10.2147/MDER.S374418 ↩
  10. Calegari LH, Goyal M, Dutta S, Mukerji A. Predictors and Outcomes of Extubation Failure in Preterm Neonates: A Systematic Review. Pediatrics. 2025;155(2):e2024068677. doi:10.1542/peds.2024-068677 ↩