Invasive Neonatal

Ventilation
Dr Badr Chaban
28/01/09
Invasive Neonatal Ventilation

 Conventional Mechanical Ventilation CMV

 Intermittent Mandatory Ventilation IMV
 Synchronized Intermittent Mandatory
Ventilation SIMV
 Assist/Control Ventilation IPPV A/C
 Pressure-Support Ventilation PSV
 Patient-Triggered Ventilation S
 Ventilatory Techniques

 Pressure-Limited Ventilation
 Pressure-Controlled Ventilation
 Volume Ventilation
 Volume Guarantee
 Pressure-Regulated Volume Control
 Volume-Assured Pressure Support
 Proportional Assist Ventilation
 Ventilatory Styles

 Conservative or “Gentle” Ventilation

 Nasopharyngeal Synchronized
 Intermittent Mandatory Ventilation
 Goals of Mechanical Ventilation

 (1) adequate pulmonary gas ex-change,

 (2) ↓ risk of lung injury,
 (3) ↓ (WOB),
 (4) optimize patient comfort.
 Ideal Mode of Ventilation

 Delivers a breath that:

 Synchronizes with the patient’s
 spontaneous respiratory effort
 Maintains adequate and consistent tidal
 volume and minute ventilation at low
 airway pressures
 Responds to rapid changes in pulmonary
 mechanics or patient demand
 Provides the lowest possible WOB
 Ideal Ventilator Design

 Achieves all the important goals of

 mechanical ventilation
 Provides a variety of modes that can
 ventilate even the most challenging
 pulmonary diseases
 Has monitoring capabilities to adequately
 assess ventilator and patient performance
 Has safety features and alarms that offer
 lung protective strategies
 Carbon Dioxide (CO2) Elimination
alveolar minute ventilation =
(tidal volume - dead space) x frequency
 Relationships among various ventilator-controlled (shaded circles) and

Carlo, W. A. et al. Pediatrics in Review 1999;20:117-126e

Copyright ©1999 American Academy of Pediatrics

 Determinants of oxygenation during pressure-limited,

Carlo, W. A. et al. Pediatrics in Review 1999;20:117-126e

Copyright ©1999 American Academy of Pediatrics

 MAP = K (PIP - PEEP) (TI/TI + TE) +
PEEP
 K is a constant determined by the flow rate
and the rate of rise of the airway pressure
curve
 COMPLIANCE

 Compliance describes the elasticity or

distensibility (eg, lungs, chest wall,
respiratory system)

 compliance = volume/ pressure

 in neonates who have normal lungs
ranges from 0.003 to 0.006 L/cm H2O
compared with compliance in neonates
who have RDS, which may be as low as
0.0005 to 0.001 L/cm H2O.
 RESISTANCE
Resistance describes the inherent
capacity of the air conducting system (eg,
airways, endotracheal tube) and tissues to
oppose airflow and is expressed as the
change in pressure per unit change in
flow:
 resistance = pressure/ flow
 Airway resistance depends on
1) radii of the airways (total cross-sectional
area),
2) length of airways,
3) flow rate,
4) density and viscosity of gas breathed.
Resistance
Δ Pressure (cm H2O)
Δ Flow (L/sec)
Normal lungs: 20-40 cm H2O/L/sec
RDS: 20-40 cm H2O/L/sec
Intubated infant: 50-150 cm
H2O/L/sec
The time constant of the respiratory system is a measure of the time necessary

for the alveolar pressure to reach 63% of the change in airway pressure

 time constant = resistance x compliance

 For example, the lungs of a healthy

neonate with a compliance of 0.004 L/cm
H2O and a resistance of 30 cm H2O/L/s
have a time constant of 0.12 seconds.
Carlo, W. A. et al. Pediatrics in Review 1999;20:117-126e
CMV
IMV
SIMV
SIMV+VG
IPPV
SIPPV A/C
SIPPV+VG
 PSV
 Pressure support ventilation (PSV) is
a mode where flow cycling is used to
assist every spontaneous inspiratory
effort and terminate the mechanical
breath as the spontaneous
inspiration ends or inflation is
completed
 Synchronous breath termination gives the
infant greater control over the frequency and
duration of inspiration,
 while the support pressure compensates for
instrumental and disease induced loads.
 In the event of apnea, back-up IMV ensures
ventilation.
 In some ventilators PSV can be combined
with a low SIMV rate
 PROPORTIONAL ASSIST
VENTILATION
PAV
 proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support.
Furthermore, ventilatory support is in proportion to the
volume and flow of the spontaneous breath. Thus, the
ventilator can decrease the elastic or resistive work of
breathing selectively. The magnitude of the support can
be adjusted according to the patient’s needs. When
compared with conventional and patient-triggered
ventilation, proportional assist ventilation reduces
ventilatory pressures while maintaining or improving gas
exchange.
 Ideal Monitoring Features

 Proximal airway monitoring,

 real-time pulmonary graphics:
 Waveforms
 Loops
 Mechanics
 Trending
 Volume Guarantee
 Dräger Babylog
 Pressure Regulated Volume
 Control and Volume Support
 Siemens 300
 Volume Assured Pressure Support
 VIP BIRD Gold
Neonatal Ventilation
Dr Badr Chaban
11/02/09
 High-Frequency Ventilation

HFV is a radical departure from

standard, conventional mechanical
ventilation.
There are several types of HFV
devices, including (HFJV), HFOV, and
hybrids.
The rationale for HFV is that the
provision of tiny gas volumes at rapid
rates results in much lower alveolar
pressure
 MAP provides a constant distending
pressure equivalent to CPAP.

 This inflates the lung to aconstant and

optimal lung volume maximising the area
for gas exchange and preventing alveolar
collapse in the expiratory phase. 
 Indications for high frequency
ventilation include
1. Rescue following failure of
conventional ventilation (PPHN,
MAS).
2. Air leak syndromes (pneumothorax,
pulmonary interstitial emphysema)
3. To reduce barotrauma when
conventional ventilator settings are
high.
 Terminology

Frequency
 High frequency ventilation rate (Hz,
cycles per second)
MAP
 Mean airway pressure (cmH2O)

Amplitude
 delta P or power is the variation
around the MAP
Oxygenation is dependent on MAP and
FiO2
 Ventilation is dependent on amplitude and
to lesser degree frequency.

 Thus when using HFV CO2 elimination

and oxygenation are independent.
Making adjustments once established on HFV

Poor Over
Under Over
Oxygenatio Oxygenatio
Ventilation Ventilation
n n
Increase Decrease Increase Decrease
FiO2 FiO2 Amplitude Amplitude
Decrease Increase
Increase Decrease Frequency Frequency
MAP MAP  (1-2Hz)  (1-2Hz)
(1-2cmH2O) (1-2cmH2O) if if
Amplitude Amplitude
Maximal Minimal
 Continuous Positive Airway
Pressure
 Gregory et al in 1971. applied CPAP in RDS.
 Although the first application of CPAP was
through the endotracheal tube.
 It soon became apparent that it could also be
applied nasally, since most newborns are
obligate nasal breathers.
 At the same time, the mouth acts as a pressure
relief valve if the applied pressure is too high.
 Use of nasal CPAP also obviated face masks,
face chambers, and head boxes.
 Advantages of CPAP
 regular pattern of breathing in preterm
infants.
 This may be attributed to reducing thoracic
distortion
 and stabilizing the chest wall, splinting the
airway and
 the diaphragm, decreasing obstructive
apnea, and enhancing
 surfactant release.
CPAP delivery systems contain 3 major components.

The first is a circuit to provide a continuous flow of

inspired gas, which must be warmed and humidified.

The second is an interface to connect the circuit to the airway.

Binasal tubes or prongs are the most commonly used.
Newer devices use fluidics to reduce expiratory resistance
and decrease the WOB.

The third component is a device to

generate positive pressure.
 COIN trial
Recent trials using nCPAP from birth in 25
to 28 week infants describe more
customised strategies: in the COIN trial,
27-28 week infants breathing at birth
benefit the most from nCPAP.
Fewer infants received oxygen on day 28;
they had fewer days of ventilation and no
increase in morbidities despite having
more pneumothoraces.
 REVE trial
The suggests that intubation with early
surfactant administration followed by
nCPAP mostly benefits to 25-26 week
infants. Thus, nCPAP is feasible from
birth.
The overall strategy should take into
account infants' gestational age,
maturation and behaviour in the delivery
room.
Hascoet et la Dec 2008
 Complication
Nasal Septal
Erosion or • This is preventable when using appropriate sized
Necrosis prongs that are correctly positioned.
Pneumothorax
• Usually occurs in acute phase.
• It is uncommon (<5%).
• It usually results from the underlying disease
process rather than positive pressure alone.
• It is not a contraindication to the use of CPAP.
Abdominal Distension
from • This is benign
Swallowing • Easily reduced with gastric drainage or aspiration
Air

Nasal
obstruction • From improper prong placement or inadequate
airway care
 NIPPV
Neonatal nasal intermittent positive pressure
ventilation (NIPPV) provides non-invasive
respiratory support to premature infants
who may otherwise require endotracheal
intubation and ventilation.
NIPPV is the augmentation of continuous
positive airway pressure (CPAP) with
superimposed inflations, to a set peak
pressure
 HOW DOES NIPPV WORK
 the mechanism of action of NIPPV remains uncertain. Hypotheses
include:
 increasing pharyngeal dilation

 improving the respiratory drive

 inducing Head’s paradoxical reflex

 increasing mean airway pressure allowing recruitment of alveoli

 increasing functional residual capacity;

 increasing tidal and minute volume.

Arch. Dis. Child. Fetal Neonatal Ed., Sep 2007; 92: F414 - F418.
 SNIPPV
Synchronisation, defined as mechanical
inflation commencing within 100 ms of the
onset of inspiration, uses a capsule to
detect abdominal movement at the start of
inspiration.
 WHAT VENTILATOR SETTINGS SHOULD WE USE
DURING NIPPV?

PEEP 3-6 cm H2O

PIP 8-21 cm H2o
R 10-30 /m
iT 0.4-0.6 s
Flow 8-10 l/m up to 15 l/m
 NON-INVASIVE SYNCHRONISED MECHANICAL
VENTILATION

 Synchronisation techniques enabled

delivery of
 (N-A/C)
 (N-SIMV)
 N A/C
 N PSV
 N PAS
 In comparison to nasal continuous positive
airway pressure (NCPAP), N-SIMV
reduced chest wall distortion in preterm
infants following extubation, while N-A/C
reduced breathing effort and improved
ventilation.
Three randomised trials have shown the consistent efficacy
of N-SIMV in the post-extubation period as indicated by
better respiratory evolution and lower extubation failure.
These reports suggest that reduced apnea is responsible
in part for these effects and that infants with worse lung
mechanics are likely to benefit more from N-SIMV.
These data also showed a tendency towards reduced
oxygen dependency among infants extubated to N-SIMV
.

Eduardo Bancalari miami

 In summary,
Data from physiological and clinical trials indicate
that non-invasive synchronised ventilation has
important benefits.
Despite this evidence, the use of non-invasive
synchronised ventilation is uncommon, perhaps
because few such ventilators are available.
More importantly, there are few data on the use of
non-invasive synchronised ventilation to avoid
earlier use of invasive ventilation.
 S.NCPAP setting
PEEP 5
PIP up to 20
10-40
iT 0.25-1s
Flow depend on the leak
Thank you