This document discusses neonatal mechanical ventilation. It begins by introducing mechanical ventilation and its importance in improving neonatal survival since the 1960s. It then discusses the benefits of mechanical ventilation in improving gas exchange and decreasing work of breathing. Various indications for ventilation are provided. Common conditions requiring ventilation are also listed. The document goes on to describe different types of ventilators and modes, how to initiate a breath, and studies comparing different modes. It concludes by discussing parameters for conventional ventilation like PIP, PEEP, flow rates, and methods for controlling oxygenation and ventilation.

1. Neonatal Mechanical Ventilation

2. Introduction:
• Introduction in 1960’s one of major inventions
in Neonatology.
• Along with Antenatal steroids and Surfactant
replacement ,ventilation played imp role in
increasing neonatal survival.
• Although life saving it may cause BPD.

3. Benefits of MV:
• Improve Gas exchange, by lung recruitment to
improve V/Q matching.
• Decrease WOB
• CO2 removal in babies with respiratory
depression and apnea.

4. Indications for Ventilation:
• Respiratory Acidosis,pH<7.2 and PaCO2> 60
mm Hg.
• Hypoxia PaO2<50 mmHg.
• Recurrent Apnea.
• Downes score> 7.

5. Common Conditions:
• RDS
• Apnea of Prematurity.
• Septicemia-Pneumonia
• Post operative recovery.
• PPHN
• MAS
• Congenital pulmonary or cardiac
anomalies(CDH).

6. Types of :
• CMV: Exchange of gas in bulk similar to tidal volume
Initiation of breath-Ventilator (CMV or IMV)
Patient
Tidal volume regulation- PC
VC
Breath is terminated- Volume
Time .
Flow regulated.
• HFV: small volume of gas at extremely rapid rate(300-
1500)
290 Modes on 33 Ventilators .
One ventilator- Care fusion Avea ,offers choice of 44 different modes

7. Initiation of Breath:
 Synchronised Ventilation:(Patient triggered)
-SIMV
-A/C Ventilation
-Pressure support ventilation(PSV)
-NAVA
 CMV or IMV.
Increase in death rate using SIMV(RR-1.19)
No difference in air leak,IVH,BPD,extubation failure
Shorter duration of Ventilation in SIMV(Mean difference -35 hrs)

8. Assist Control SIMV

9. SIMV Mode:

11. PSV +SIMV vs SIMV
PSV+SIMV REDUCES WOB & INCREASES Minute Ventilation.
LESS LIKELY TO REQUIRE MV @ 28 DAYS
COMPLICATION RATES NO DIFFERENCE

12. Flow Sensor and Modes:

13. NAVA
Observational studies have shown better synchrony, less PIP and
sedation with similar ABG
Further research needed to determine effects on outcome

14. Modes in our Ventilator:
SLE 5000 GE CARESCAPE

15. Modality:
• Pressure limited :
PC-SIMV
PC-A/C
PC-PSV
• Volume targeted
VC
VG
PRVC

16. Pressure Limited Ventilation:
• TCPL ventilators are MC used Neonatal
ventilators.
• Amount of pressure during inspiration is
set(PIP).
• TV delivered depends on PIP,Ti,Compliance
and synchrony.

17. Pressure control Waveform:

18. Pressure Limited Ventilation(TCPL):
Advantages
• Relatively easy to use and less
costly.
• Continues flow of gas in circuit
allows for spontaneous
breathing.
• PIP and MAP can be adjusted
to optimize gas exchange and
minimize lung injury
Disadvantages
• Variation in TV from breath
to breath
• Increased WOB during
spontaneous breaths
• Poor synchrony decreased
O2,increase CO2,de TV,de
MV(overcome with
synchronization)

19. Volume Targeted Ventilation:
• Provides consistent TV resulting in less lung
injury.
• In 2011,volume targeted ventilation had
replaced pressure limited ventilation in 25 of
50 neonatal tertiary units.
• Volume control & Volume Guarantee

20. Volume Controlled Ventilation:
• Set TV (4-6ml/kg) is delivered by variation in
PIP.
• RR and max Ti are set.
• Measure TV delivered to circuit ,No
compensation for ET tube leaks

21. Volume Control Waveform:

22. Volume guarntee(VG):
• Modified pressure targeted ventilation.
• Addition of microprocessor that adjusts the
pressure to ensure Targeted Tidal Volume(TTV).
• TV,Ti,Max PIP is set
• Flow sensor senses ex TV to adjust pressure for
next few breaths.

23. Volume Guarantee waveform:

24. Controlling Volume ,a better mode?
• Costly and needs more expertise.
• Lower rate of death and BPD(RR-0.73).
• Reduced rate of Air leak(RR-0.46),days of
ventilation,Hypocarbia and neurologic
injury(RR-0.48)

25. Volume targeted ventilation with either SIMV
or A/C using modified TCPL ventilators with TTV
of 4-6ml/kg with permissive hypercarbia should
be initial mode of ventilation

26. Ventilator settings and strategies:

27. Parameters in Conventional ventilation:
• Mode of ventilation
• PIP
• PEEP
• Flow
• Inspiratory time(Ti)
• Fio2
• Rate.
• Trigger
• Tidal Volume(TTV)
• I:E ratio

28. Setting PIP:
• PIP is the primary factor used to deliver tidal
volume
• PIP required mainly depends on the
compliance of lungs
• Useful clinical indicator of adequate PIP is
gentle chest rise with every vent breath.
• If compliance is normal, initiate with 12-14 If
abnormal, check chest rise on hand ventilation

29. Setting PIP:
Insufficient PIP
• Insufficient ventilation
• Decreased oxygenation
• Generalized atelectasis
High PIP
• Increased barotraumas (air
leaks)
• Increased BPD
• Impede venous return/
cardiac output

30. Setting PEEP:
• Adequate PEEP improves FRC & V/Q mismatch
• PEEP levels between 3 – 6 improve
oxygenation & well tolerated

31. Setting PEEP:
• Choices are between 3 - 6
• If FRC is expected to be:
normal: 3
moderately reduced: 4
severly reduced: 5 – 6
• Low PEEP-Atelectotrauma
Co2 retention due to V/Q mismatch
• High PEEP-Decrease lung compliance
Impede venous return/ shock
Pulmonary air leaks

32. • RR is one of the primary determinants of MV,
thus CO2 elimination
• No conclusive evidence for appropriate RR
• In SIMV mode ventilatory rate may not affect
ABG as much as anticipated
• Choices are between 20 to 60
• Considerations are:
- work of breathing
- Is there asynchrony: need for overdrive?
- pressure requirement ?

33. Setting FiO2:
• Choices are between 21-100%
• Target is Pa02 of 50-70 mm Hg with Spo2 of
88-95%.
• If lung compliance is good start with 21-25%
• Other lung conditions start with FiO2 50%

34. • Very rapid rate may cause insufficient
inspiratory time and decreased tidal volume
• May lead to inadvertent PEEP and gas
trapping due to inadequate expiration
• CO2 retention, impaired cardiac output
High RR
• Low RR

35. Setting Ti:
• The respiratory system time constant
determines optimal Ti & Te
• Ideal Ti = 3 x time constant
• An Ti of 0.3 – 0.4 sec is commonly used
• In conditions like MAS – shorter Ti (0.25sec)
• In severe ARDS / Pulmonary hemorrhage
prolonged Ti (0.5 sec)

36. Setting Flow:
• Adequate flow rate is required for the
ventilator to deliver the desired PIP &
waveform
• Minimum flow rate of about 3 times the
infants MV
• Flows of 4 -10 L/min are sufficient for most
infants

37. Mean Airway
Pressure:

38. How to Increase MAP
• 1. Increase inspiratory flow
rate
• 2. Increase peak inspiratory
pressure
• 3. Increase inspiratory time
• 4. Increase PEEP

39. Increasing Oxygenation:

40. Increasing Ventilation(PaCO2)