Educative power point presentation for trainees or fellow in pediatrics / neonatology/ post graduate students in pediatrics or neonatology .

1. Neonatal Clinical Guidelines for
Mechanical Ventilation
Dr Isha Deshmukh
Asst Prof – Pediatrics
BJGMC , Pune

2. Introduction
• Mechanical ventilation is a complex and highly specialized area of
neonatology, made more complicated by the availability of many different
modes, techniques, and devices.
Objectives:
1. To provide clinical practice guidelines for conventional mechanical
ventilation of newborn infants, utilizing the best available scientific evidence.
2. To address the controversial issue related to mechanical ventilation.

3. Scope of Guidelines
• The guidelines address the conventional mechanical ventilation of newborn infants
for various disease processes in preterm and term infants.
• Other forms of ventilation such as high-frequency oscillatory ventilation and
noninvasive ventilation will be covered in a separate clinical practice guidelines.
• Delivery room care is covered by separate clinical guidelines.
• Guidelines are meant to help the clinician in managing ventilated infants; it should
not replace clinical judgment.
• The guidelines do not endorse the use of any commercial device or any specific
type of ventilator.

4. Choice of Basic Synchronized Ventilation
mode
• The three basic synchronization modes are assist/control (AC), pressure support
ventilation (PSV), or synchronized intermittent mandatory ventilation (SIMV).
• AC results in more even tidal volume (VT), lower work of breathing, and more
rapid weaning from mechanical ventilation compared to SIMV.
• PSV provides more complete synchronization because it is flow cycled, thus
avoiding inspiratory hold, but may result in very short inspiratory time (Ti) and
rapid respiratory rate in very small infants in the first few days of life when time
constants are very short.

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• Because the short Ti results in relatively low mean airway pressure (MAP),
adequate positive end-expiratory pressure (PEEP) must be used with PSV to
avoid atelectasis.

6. Volume Preset Ventilator Vs Pressure
Preset Ventilators
• Volume preset ventilators deliver the same VT of gas with each breath, regardless
of the inflating pressure that is needed.
• Pressure preset ventilators, in contrast, are designed to deliver a volume of gas with
each breath until a preset limiting pressure designated by the physician is reached.
• The remainder of volume in the unit is then released into the atmosphere.
• As a result, the VT that is delivered to the patient by pressure preset ventilators with
each breath may be variable, but the peak pressure delivered to the airway remains
constant.

7. The Choice of Volume-targeted versus
Pressure-limited Ventilation
• The main disadvantage of PLV is the risk of volutrauma and inadvertent over
ventilation when lung compliance improves as often happens soon after birth when
lung fluid is cleared, surfactant is administered and optimal lung volume is achieved.
• Volume-controlled (VC) ventilation as implemented on available universal
ventilators (neonatal to adult population) controls the VT delivered into the
proximal end of the ventilator circuit, not the VT delivered to the patient.
• The loss of volume to compression of gas in the circuit and humidifier and to ETT
leak may be 75% or more of the total, making standard VC ventilation difficult to
use effectively in small newborn infants.

8. Volume Guarantee (VG)
• Volume guarantee (VG) is one of the several modes of volume-targeted
pressure-limited ventilation.
• These modes control delivered VT indirectly by adjusting either the inflation
time (volume limit) or inflation pressure (VG) to target a user-selected target
VT.
• The PIP for the next breath is adjusted based on the difference between the
target and measured exhaled VT from previous breaths.

9. Pressure-regulated volume control
• PIP is automatically regulated to deliver a set volume in the A/C mode.
• In preterm infants, pressure-regulated volume control may be limited by the
accuracy of internally measured volumes.

10. Targeted tidal volume mode
• In the targeted tidal volume (TTV) mode, a ventilator delivers gas of a set
VT.
• During TTV, an inspiratory pressure and an Ti are adjusted so that a VT of
each breath will reach the target Vte.

11. Suggested Settings for Volume Guarantee
Ventilation
• The following settings are recommended when using
VG ventilation:
• VT target should be 4–6 cc/kg.
• Pressure limit: 20–22 cm of water for small infants and 25–28 cm of water
for large infants.

12. Selecting Optimal Positive End-expiratory
Pressure
• PEEP should be set in proportion to the current oxygen requirement because
hypoxemia is usually a reflection of ventilation–perfusion mismatch due to
atelectasis and low lung volume.
• PEEP should be set in proportion to the current oxygen requirement because
hypoxemia is usually a reflection of ventilation–perfusion mismatch due to
atelectasis and low lung volume.
• Using high PEEP may lead to lung hyperinflation, air leak pneumothorax, decrease
cardiac venous return, as well as higher PaCO2 (as VT will be lower).

13. Strategies to titrate PEEP
• Starting with a PEEP of 5–6 cm H2O.
• PEEP should be increased gradually up to 8 cm H2O if the FiO2 is more
than 0.30 and/or there is evidence of low lung volume on chest X-ray.

14. Pressure-targeted Modalities
• Pressure-targeted modalities are characterized by limiting the amount of
pressure that can be delivered during inspiration.
• There are three main pressure-targeted modalities:
1.Pressure limited ventilation (PLV)
2.Pressure control ventilation (PCV)
3. PSV which is also a mode.

15. Comparison of Pressure Target Modalities
Parameter Pressure Limited Pressure Control Pressure Support
Limit Pressure Pressure Pressure
Flow Continuous Variable Variable
Cycle Time or Flow Time or flow Flow
Breath Type Mechanical Mechanical Spontaneous

16. Pressure Support Ventilation
• Pressure support (PS) is a patient-triggered, pressure-limited, flow-cycled mode of
ventilation designed to assist an infant’s spontaneous effort with an inspiratory
pressure “boost.”
• PS can be used in conjunction with other modes, such as SIMV, or it can be applied
independently.
• To set an appropriate PS level, select a value between the difference of PIP and
PEEP, for example, if PIP is 18, PEEP is 6, then give a PS between 6 and 11 cm
H2O
• Assessment of work of breathing, blood gas, and chest X-ray should be used to
choose the most appropriate level.

17. Setting Inspiratory Time
• An Ti as long as 3–5 times constants (a measure of how rapidly gas can get
in and out of the lungs) allows relatively complete inspiration.
• PSV is preferred in most infants, with the exception of those <1 kg during
the first 2–3 days of life when their time constants are very short.
• During PSV, the maximum Ti should be set at about 0.4 s in preterm infants,
longer in term infants, and those with increased airway resistance.

18. Setting the Respiratory Rate
• In SIMV mode: Use a high rate, especially in premature infant with RDS.
• In A/C or PSV mode: Use backup rate of 30–40, so there is enough room
for the infant to trigger the ventilator.
• If SIMV is used at a low rate, then it is advisable to add PSV to decrease the
work of breathing.

19. Suggested Initial Respiratory settings for
Common Neonatal Disorders
Initial Strategy :
Preterm Infant Less than 1 week:
1. Rate 40-60/min 2. PEEP 5-6 cm H2O 3. PIP 12-20 cm H2O
4. Ti 0.3-0.35 s 5. VT 4-6 CC/kg
Blood Gas Targets:
• pH 7.25-7.35
• PaO2 40-60 mmHg
• PaCO2 45-55 mmHg (avoid PaCO2 <35 mmHg as it decreases brain perfusion)
• SO2 91%-95%

20. • Preterm >1 week: Keep same settings as Preterm <1 week plus:-
1. Increase Ti to 0.35-0.45 s
2. Increase VT by 0.5 CC
Blood Gas Targets:
1. PaCO2 50-70 mmHg

21. Meconium aspiration syndrome (without PPHN)
Initial Strategy :
1.Rate 40-60/min
2.PEEP 4-6 cm H2O (adjust based on chest X-ray and clinical situation)
3.PIP 15-25 cm H2O
4.Ti 0.4-0.5 s (long expiratory time is needed)
5.VT 4-6 CC/kg
Blood Gas Targets: 1. pH 7.3-7.4
2. PaO2 60-80 mmHg
3. PaCO2 40-50 mmHg
4. SO2 92%-96%

22. PPHN
Initial Strategy :
1. Rate 40-60/min
2. PEEP 5-8 cm H2O
3. PIP 15-25 cm H2O
4. Ti 0.35-0.45 s
5. VT 4-6 CC/kg
Blood Gas Targets:
pH 7.3-7.4
PaO2 60-80 mm Hg
PaCO2 40-50 mm Hg
SO2 94%-98%

23. Desired blood gas goal and corresponding
ventilator parameter changes
Desired Goal PIP PEEP Rate i:E Ratio Flow
Decrease
PaCO2
Increase Decrease Increase rate same increase
Increase
PaCO2
Decrease increase OR
Same
Reduce rate same increase
Decrease PaO2 Reduce Reduce constant reduce increase
Increase PaO2 Increase Increase Increase/ same Increase

24. Parameters for Extubation
• In a preterm infant, extubation should be attempted when:
1. FiO2 is <0.35
2. PaCO2 is <55 mm Hg
3.Ventilator rate is 15–20
4. MAP <8 cm H2O
5. Adequate spontaneous respiratory effort without excessive work of breathing on the
current settings
6. Methylxanthines are already started.

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THANK YOU FOR YOUR PATIENT LISTENING
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Reference : AAP Guidelines For mechanical
ventilation of neonates.