Basic modes of neonatal ventilation from clinical view

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬
"‫جميعا‬ ‫الناس‬ ‫أحيا‬ ‫فكأنما‬ ‫أحياها‬ ‫من‬ ‫و‬"
‫العظيم‬ ‫هللا‬ ‫صدق‬
(‫المائده‬)

2. PRACTICE IN NEONATAL
VENTILATION
Raafat Salama
/Arab boards in paediatricsEgyptian

3. Overview of Assisted Ventilation

4. .
The question of interest is, “How does this specific
mode work on this device and how can I best use
this tool to support my patient?”
At last count we have identified 290 names of modes on 33 ventilators in the United
States alone.
(the CareFusion Avea) offers the clinician the choice of 44
different modes

5. Avoidance of mechanical ventilation may be the best way of avoiding
ventilator-induced lung injury.
Several studies in human neonates have shown that the administration of
exogenous surfactant therapy leads to rapid improvement in oxygenation and a
decrease in the degree of support provided by mechanical ventilation.
The key concept in minimizing the need for invasive respiratory support is to
avoid heavy sedation and muscle paralysis and to maximally utilize the
patient’s spontaneous respiratory effort.

6. Suggested Indications for Mechanical Ventilation
. Inadequate/absent respiratory effort
. Excessive work of breathing (relative) -Marked retractions, severe tachypnea >100/min
-Frequent (>6 events/hr) or severe apnea requiring PPV
. High oxygen requirement -FiO2 > 0.40-0.60; labile SpO2 if PPHN is suspected
. Severe respiratory acidosis -pH <7.2 and not improving, Pco2 >65 on days 0-3, >70 beyond day 3
. Moderate or severe
respiratory distress and
contraindications for
noninvasive support
. Postoperative period
-Intestinal obstruction; intestinal perforation; recent gastrointestinal
surgery; ileus; CDH
-Residual effect of anesthetic agents; fresh abdominal incision; need for
continued muscle relaxation (e.g., fresh tracheostomy)

7. SYNCHRONIZED VENTILATION VS NON-
SYNCHRONIZED VENTILATION

8. • Without synchronization of the infant’s spontaneous effort, the irregular respiratory pattern of a
newborn baby leads to frequent asynchrony between the infant and the ventilator, sometimes resulting
in a ventilator inflation that occurs just as the infant is exhaling.
• High airway pressure, pneumothorax, poor oxygenation, and large fluctuations in intracranial pressures
leading to increased risk of intraventricular hemorrhage were the consequences of such asynchrony.
• Heavy sedation or muscle paralysis was often necessary in the past to prevent the baby from “fighting
the ventilator. These interventions resulted in greater dependence on respiratory support, lack of
respiratory muscle training, generalized edema, and inability to assess the infant’s neurologic status.

9. • Unfortunately, the two largest randomized trials of synchronized ventilation were conducted many
years ago using outdated technology (pressure trigger) and had other methodologic issues; both
failed to clearly demonstrate benefits of synchronization.
• A Cochrane meta-analysis demonstrated shorter duration of mechanical ventilation with
synchronized vs non synchronized ventilation but no effect on other important outcomes

10. TRIGGERTECHNOLOGY

11. • The ideal triggering device for newborn ventilation must be sensitive enough to be activated by a small
preterm infant but must also be relatively immune to auto- triggering.
• Flow triggering is much more sensitive than pressure triggering and is capable of detecting a patient effort of
as little as 0.2 mL/min.
susceptibility to auto-triggering:
• In the presence of a leak around the ETT.
• Leakage flow during the expiratory phase will be erroneously interpreted by the ventilator as an inspiratory
effort.
• Ventilation modes that support every patient breath and should be suspected when the ventilator rate is
>70/min with no evidence of patient inspiratory effort.

12. • The simplest way to verify that tachypnea is caused by auto- triggering is to
briefly switch the ventilator to continuous positive airway pressure (CPAP)
mode. If auto-triggering were occurring, the patient’s respiratory rate would
immediately be less than the previous rate and usually fall briefly to zero .
• When auto-triggering is recognized, it can be mitigated by making the trigger less
sensitive.
• Automatic compensation for variable leak around the ETT as implemented on the
Dräger Babylog 8000+ .
• This approach allows the trigger sensitivity to remain at the most sensitive value without
danger of auto-triggering .
In practice:

13. BASIC SYNCHRONIZEDMODES

14. Synchronized Intermittent Mandatory Ventilation
(SIMV)
• Preset number of inflations synchronized with the infant’s spontaneous respiratory effort, if
present.
• SIMV may be pressure or volume controlled but in neonatal applications it is almost always pressure
controlled and time cycled.
• If no spontaneous effort is detected during a trigger window, a mandatory inflation will be given.
• Spontaneous breaths in excess of the set ventilator rate are not supported.

16. IN PRACTICE:
-LOW TIDAL VOLUME AND INCREASE WORK OF BREATHING DURING WEANING OF VERY SMALL
INFANT DUE TO NARROW ETT AND INCREASE RESISTANT.
-To maintain adequate alveolar minute ventilation, a relatively large VT, typically around 6
mL/kg, is thus required with the limited number of ventilator inflations.
-The selected set rate is typically lower than the infant's spontaneous breathing rate, so
additional spontaneous breaths occur without ventilator support.

17. ASSISTED CONTROL(AC)
The backup rate should be set just below the infant’s spontaneous rate, usually 30 to 40
breaths/minute
• Supports every spontaneous breath (this is the “assist” part) that is sufficient to trigger a ventilator inflation
and provides a minimum rate of ventilator inflations in case of apnea (the “control” part).
• AC is a time-cycled mode that can be pressure or volume controlled, but in neonatal applications it is
typically pressure controlled.

19. IN PRACTICE:
• AC provides more uniform VT delivery and lower work of breathing than SIMV.
• An excessively high backup rate will result in an increased number of untriggered inflations when the
ventilator backup rate kicks in before the infant has a chance to breathe .
• Backup rate that is too low will result in excessive fluctuations in minute ventilation and oxygen saturations
during periods of apnea.
In fact, the ventilator rate should
never need adjustment once the
baby is generating spontaneous
respiratory effort.

20. Pressure-Support Ventilation
• PSV is a flow- cycled and pressure-controlled continuous spontaneous ventilation mode that supports
every spontaneous breath just like AC.
• The only difference being flow cycling. Flow cycling means that an inflation is terminated when inspiratory
flow declines to a preset threshold, usually 15% of peak flow.
• Flow cycling eliminates the inspiratory hold (prolonged inflation time [TI] that keeps the lungs at peak
inflation) and thus presumably provides more optimal synchrony.
• Thus PSV automatically adjusts TI to be appropriate to the changing lung mechanics of the patient.
• Similar to AC, a backup rate will maintain a minimum inflation rate

22. IN PRACTICE:
-Changing from basic time-cycled AC to PSV usually results in a shorter TI and thus lower
mean airway pressure and therefore may lead to atelectasis, adequate positive end-
expiratory pressure (PEEP) is used to maintain mean airway pressure.
-The simple approach is to make note of the mean airway pressure on AC and then adjust
the PEEP to return to the same value after PSV is activated
• Eliminating the inspiratory hold should limit fluctuations in intrathoracic and intracranial pressure that
occur when an infant exhales against the high positive pressure during inspiratory hold.
• Adjusts TI to be appropriate to the changing lung mechanics of the patient.

23. -LEAK AROUND THE ETT MAY AFFECT FLOW CYCLING .FLOW CYCLING WILL NOT OCCUR WHEN
LEAKAGE FLOW IS GREATER THAN THE THRESHOLD FOR INFLATION TERMINATION.
-FOR THIS REASON THE USER MUST STILL SET A TI LIMIT, WHICH SHOULD BE ABOUT 50% LONGER
THAN THE BASELINE SPONTANEOUS INSPIRATORY TIME, TO ALLOW THE INFANT AN
OPPORTUNITY TO RECEIVE A LONGER TI WHEN HE OR SHE TAKES A LONGER, DEEPER
SPONTANEOUS BREATH.
Because of the risk of failure to flow cycle due to leak, some devices allow the user to
manually set the termination criteria (i.e., the percentage of peak flow that will
terminate an inflation) up to as much as 25% to 50% of peak flow.
Dräger ventilators, which automatically compensates for leakage flow and maintains
effective inflation termination even in the face of very large ETT leak(leak-adapted
pressure support ).

24. • In most devices PSV can also be used to support spontaneous breathing between
low-rate SIMVs, to overcome the problems associated with inadequate
spontaneous respiratory effort and high ETT resistance.
• Adding PSV to SIMV has been shown to increase minute ventilation and reduce
tachypnea, increase the VT of spontaneous breaths and lead to more rapid
weaning from mechanical ventilation.

25. • PSV can also be used as a fully spontaneous mode, which lacks a backup rate and depends instead on an
“apnea ventilation” setting that kicks in after a user-preset period of apnea.

26. • When used to support spontaneous breaths between SIMV or with CPAP, PSV does not come with a backup
mandatory rate, so a reliable spontaneous respiratory effort is required.
• When used with SIMV, PSV can be thought of as a pressure boost given for each spontaneous breath, lasting
only as long as there is inspiratory flow.
• While this approach is effective, it adds complexity and does not appear to have any advantage over either PSV
used alone or AC with appropriate settings, as long as atelectasis is avoided by avoiding heavy sedation and
using an adequate level of PEEP.
• Withdrawal of support for PSV as a primary mode is accomplished in the same way as for AC. When used in
conjunction with SIMV, both the inflation rate and the PSV level should be lowered, again adding a level of
unnecessary complexity.

27. CHOICE OF ASSISTED
VENTILATION MODES

28. SIMValone should be avoided in small preterm infants when the inflation rate is <30.
but
Is a reasonable choice when apnea is the primary indication for respiratory support or in larger infants who are
able to generate adequate spontaneous VT.
Modes that support every spontaneous breath (A/C)are preferable in small preterm infants.
PSVtheoretically results in more optimal synchronization than AC so should
probably be the preferred mode in most situations.
The exception would be extremely small infants with RDS during the
first few days of life . We therefore avoid PSV in infants of <800 g during the first 3 to 4
days of life.

29. Tidal Volume-Targeted Ventilation

30. • PC, time-cycled, continuous-flow ventilation has been the standard of care in neonatal ventilation for more than
30 years because early attempts at VC ventilation in small preterm neonates were unsuccessful with the devices
available at the time.
• Advantages of PC ventilation are the ability to directly control the inflation pressure and time and to ventilate
despite large leaks around the uncuffed endotracheal tubes used with neonates.
• Pressure by itself, without generating excessively large tidal volume, is not the main cause of lung
injury.
Thirty percent (30% )of ventilated infants had at least one blood gas with PaCO2 < 25 torr during the first day of
life .
• Hyperventilation remains a common problem with pressure-limited ventilation, especially early in the clinical
course when the baby starts breathing, lung compliance changes rapidly in response to clearing of lung fluid,
surfactant is administered, and lung volume is optimized.

32. • When VT is the primary control variable, inflation pressure will fall as lung compliance and patient inspiratory
effort improve, resulting in real-time weaning of pressure, in contrast to intermittent manual lowering of pressure
in response to blood gases.
• Two meta-analyses that included a combination of several different modalities of VC and targeted ventilation
documented a number of advantages of VC/VTV, compared to pressure-limited ventilation, including significant
decrease in the combined outcome of death or bronchopulmonary dysplasia (BPD), lower rate of
pneumothorax, less hypocarbia, decreased risk of severe intraventricular hemorrhage/ periventricular
leukomalacia, and significantly shorter duration of mechanical ventilation.

33. NEONATAL TIDAL VOLUME-TARGETED VENTILATION
VOLUME GUARANTEE
PRESSURE-REGULATED VOLUME CONTROL SERVO-i ventilator
VOLUME VENTILATION PLUS
VOLUME-TARGETED VENTILATION
TARGETED TIDAL VOLUME
VOLUME LIMIT Older-generation pressure-limited ventilators
SLE 4000 and SLE 5000
Hamilton G5
Bennett 840
Dräger Babylog 8000+

34. VOLUME GUARANTEE
• VG may be combined with any of the basic ventilator modes (continuous mandatory ventilation, assist/control
[AC], synchronized intermittent mandatory ventilation [SIMV], pressure support ventilation).
• The operator chooses a target VT and a pressure limit up to which the ventilator operating pressure (working
pressure) may be adjusted.
• The microprocessor compares the exhaled VT of the previous inflation and adjusts the working pressure up or
down to target the set VT .
• VG has been shown to be more effective when used with AC than with SIMV, probably because all inflations are
subject to volume targeting.

35. VOLUME GUARANTEE on the Dräger Babylog 8000+

36. In practice:
• The smallest infants require a slightly larger VT/kg because of the proportionally larger fixed dead space of the
flow sensor.
• Infants with pulmonary conditions that lead to increased alveolar dead space (e.g., meconium aspiration
syndrome or BPD) also require relatively larger VT.
• SIMV requires a larger VT to deliver the same alveolar minute ventilation, because fewer breaths are supported
and volume targeted.
• It should be clearly understood that the physiologic VT required by the patient does
not decrease (over time it may actually increase).
• What goes down is the pressure required to achieve that VT because of improved compliance of
the respiratory system and the infant breathing more effectively.

37. Clinical Guidelines for Volume-Targeted Ventilation
Initiation of VTV :
• Implement VTV as soon as feasible.
• If using SIMV + PSV, be aware that only the SIMV inflations are volume guaranteed.
• Select backup rate about 10 breaths below spontaneous breathing rate: 30/min for term, 40/min for preterm infants.
• Select PEEP appropriate to the infant’s diagnosis, current condition, and FiO2 .
• Ensure that flow sensor is calibrated and functioning properly .
• Select target VT:
-4.5 mL/kg for typical preterm infant with RDS.
-5-6 mL/kg if <700 g.
-5-6 mL/kg if MAS, air-trapping.
-6 mL/kg if >2 weeks.
• Set PIP limit 3-5 cm H2O above expected PIP need:-
-If VT target not met, ensure ETT is in good position, then increase PIP limit if needed .
Confirm adequacy of support by observing chest rise, auscultating breath sounds, and monitoring SpO2 and obtaining
blood gas .
- If converting from PC to VTV, match the VT generated by PC mode if PaCO2 was satisfactory and increase PIP limit by 3-5
cm H2O.
• Choose basic mode of synchronized ventilation: PC-AC or PC-PSV is preferred.

38. Subsequent Adjustment :
• Once range of working PIP is known, set PIP limit 25%-30% above upper end of the range.
• Record and present on rounds range of working PIP as well as PIP limit • If indicated, adjust VT in steps of ∼0.5
mL/kg.
• Base VT adjustments on pH, not PaCO2; do not lower VT target if pH is not alkalotic.
• Lower PIP limit as needed to keep it 25%-30% above upper end of the range of PIP.
• Assess patient’s respiratory rate, comfort, oxygen requirement, and working pressure, not just blood gas.
Increase VT if necessary to achieve adequate support .
• Always verify appropriateness of support by clinical assessment, especially if large increase in support appears
to be needed .
• Use birth weight initially to determine VT target and remember to adjust for weight gain if the baby remains
ventilated.

39. Weaning
• When pH is low enough to ensure respiratory drive, weaning is automatic; do not lower target VT to wean,
unless patient is alkalotic.
• Withhold or reduce sedation/analgesia .
• Do not reduce VT below 3.5-4 mL/kg.
• Consider raising PEEP to maintain adequate distending pressure as PIP
comes down.
• Avoid using SIMV and do not wean backup rate on PC-AC or PC-PSV.
• Observe the graphic display to detect excessive periodic breathing or apnea.

40. Extubation:
• Consider extubation if inflation pressure is ≤12-15 cm H2O with satisfactory blood gas.
• Readiness for extubation can be assessed using the SBT.
• Caffeine should always be used prior to extubation of preterm infants ≤32 weeks.
• Distending pressure with CPAP, NIPPV, or HHHFNC should always be used for at least 24 hr post extubation.

41. Mechanical Ventilation: Disease-Specific
Strategies

42. RESPIRATORY DISTRESS SYNDROME
• The best evidence base for management of RDS includes initial management with noninvasive modes of
respiratory support .
• High-frequency oscillatory ventilation (HFOV) as the initial mode of support for those infants that require
mechanical ventilation for neonatal RDS, at any gestational age considered in many centers.
• There is also good evidence to support the use of a volume-targeted rather than pressure-limited approach to
conventional mechanical ventilation in RDS.
Conventional Ventilation (Volume-Targeted, SIMV + PS, or A/C)
Volume target (VT) 4-6 mL/kg
Rate 30-60 bpm
I-time 0.30-0.35 seconds
PEEP 5-8 cm H2O
PS to achieve ∼¾ set VT

43. MECONIUM ASPIRATION SYNDROME
• The key to management includes recognition of the predominant underlying pulmonary pathophysiology.
• While the majority of infants with MAS do not require ventilator support, those infants that do are usually
quite ill and often have a mixed pattern of both over- and underinflated lung segments, as well as severe
persistent pulmonary hypertension of the newborn (PPHN).
• Most commonly use HFOV the initial management of MAS or volume-targeted SIMV-conventional
ventilation
Pressure-controlled
PIP to move chest
lower I-time ≤.3
PEEP 4-6 cm H2O
PS ∼⅔ set PIP
Volume-targeted
VT 5-6 mL/kg
limit rate to ≤30
PEEP 4-6 cm H2O
PS to achieve ∼¾ set VT
• Irrespective of the ventilatory approach used, frequent clinical, radiographic, and laboratory assessments are
indicated to optimize gas exchange .

44. CONGENITAL DIAPHRAGMATIC HERNIA
• The existence of a specific set of guidelines targeting early neonatal care of CDH infants is associated with
improved center-specific survival.
• Despite the absence of a clear evidence base, there is general agreement that immediate surgical repair of the
diaphragmatic defect is not only unnecessary but probably detrimental . However, specific indications for
optimal timing of repair remain unclear.
• Gentle approach to ventilator support has been associated with reported improvements in morbidity and
mortality.
• HFOV as the initial mode of support for all infants with CDH in many centers.
Recommended Initial Ventilator Settings for Neonates with Congenital Diaphragmatic Hernia (SIMV-A/C )
Max PIP ≤25 cm H2O
PEEP 4-6 cm H2O
VT 4-5 mL/kg
Frequency 40-60 bpm
I-time 0.3 seconds
FiO2 <0.50
SpO2 Preductal
First hour >80%
Goal 92%-98%
“Tolerated” >90%
PaCO2 Goal 45-55 mm Hg
“Tolerated” <65 mm Hg
Chest X-ray 9-10 rib inflation
contralateral lung

45. BRONCHOPULMONARY DYSPLASIA
• Defining Bronchopulmonary Dysplasia—Modification of National Institutes of Health Consensus Conference
Criteria.
Gestational Age–Birth <32 weeks
≥32 weeks
Assessment age 36 weeks’ PMA, or D/C to home >28 but <56 days’ postnatal age, or D/C to home
Mild In room air In room air
Moderate FiO2 >21% but <30% FiO2 >21% but <30% at 56 days
Severe FiO2 >30% ± NIV FiO2 >30% ± NIV at 56 days
Severe–chronic Need for ventilator support Need for ventilator support at 56 days’ age
Suggested Approaches to Mechanical Ventilation for Infants Diagnosed with Bronchopulmonary Dysplasia
(BPD) Based on Relative Severity of BPD
Mild/Moderate BPD Chronic–Severe BPD
Tidal volume (VT) 5-8 mL/kg VT: May need 6-10 mL/kg due to increased dead space
I-time 0.35-0.45 seconds I-time: 0.4-0.6 seconds
PEEP to “optimize” lung inflation PEEP: Quite variable; often 8-10
Rate 20-40 based on infant effort Rate: 20-30 bpm
Target PaCO2: 45-60
Pressure support ∼¾ VT
SpO2 goals: 92%-98%SpO2 goals: 88%-98% based on GA
Target PaCO2: 50-60

46. Tracheostomy with chronic–severe BPD
• The reported rate of tracheostomy in populations of very preterm infants at high risk for BPD is
around 3% to 5%.
• The optimal time to move toward tracheostomy is unclear at this time in terms of postnatal age
and/or duration of mechanical ventilation.
• Most infants have been ventilator dependent for more than 2 to 3 months before tracheostomy is
considered.
• In practice we tend to delay tracheostomy unless we have evidence for earlier development of trachea/
bronchomalacia, but there appear to be developmental and other benefits to earlier tracheostomy.
• In one of these studies tracheostomy after 120 days was associated with worse neurodevelopmental outcome.

47. Weaning from Mechanical Ventilation

48. • Weaning and extubation at the earliest possible time are among the a priori goals of mechanical respiratory
support.
• Therefore, as soon as the patient’s condition stabilizes and the underlying respiratory disorder that led to
the initiation of ventilation begins to improve, weaning should be initiated.
• A retrospective study of infants of ≤1000 g and ≤28 weeks demonstrated a seventeenfold increase in the risk
of any BPD in infants ventilated for >7 days, compared to those extubated on days 1 to 3.
Some important concepts that should be kept in mind to facilitate weaning include the following
(1) Weaning too slowly may be more dangerous than weaning too fast, as it may result in excessive lung injury
and hypocarbia.
(2) Weaning should be attempted throughout the day, not just during rounds.
(3) When gas exchange is satisfactory and the work of breathing is not excessive, weaning should be attempted.
(4) Volume-targeted ventilation effectively addresses concepts 1 to 3 by lowering inflation pressure in real
time in response to improving lung mechanics and patient effort.

49. With SIMV, weaning is accomplished by reducing both peak inflation pressure (PIP) and the ventilator rate.
• The rate should not be reduced much until PIP has been reduced to relatively low values (<20 cm H2O)
that indicate improved lung compliance.
• In small preterm infants, it is advisable to add pressure support (PS) when SIMV rate is reduced
below 30/ minute.
• If SIMV is used without PS, the rate should not be reduced below 15 inflations/minute.
• There are no studies to inform the best method of weaning from SIMV + PS. It seems reasonable to reduce
the SIMV rate gradually to 10 while also reducing the PIP as necessary to maintain PS at a level sufficient to
achieve acceptable VT for the spontaneous breaths, typically 4-5 ml/kg.
With A/C or PS ventilation Weaning is accomplished by lowering the PIP and gradually transferring
the work of breathing to the infant.
• For a brief period of several hours just prior to extubation, it may be reasonable to reduce the backup rate
to 20 inflations/minute to better recognize any inconsistent respiratory effort that may have been masked
by a higher backup rate.

50. Ventilatory Settings at Which Extubation Should Be Considered in Infants
≤2 Weeks of Age.
Conventional Ventilation (AC, SIMV, PSV)
• SIMV:
PIP ≤16 cm H2O
PEEP ≤6 cm H2O
rate ≤20
FiO2 ≤0.30
• AC/PSV, BW <1000 g:
MAP ≤7 cm H2O
FiO2 ≤0.30
• AC/PSV, BW >1000 g:
MAP ≤8 cm
FiO2 ≤0.30

51. Clinical Assessment: Spontaneous Breathing Trials
Trials of endotracheal (ET) CPAP before extubation on assess extubation readiness.
• Several early trials done more than 20 years ago used ET CPAP trials ranging from 6 to 24 hours; a meta-
analysis of those studies concluded that preterm infants should be extubated directly from low ventilatory
settings without a trial of ET CPAP.
BUT The basic principle of an SBT as used today is to test the patient’s capacity to sustain adequate ventilation
and oxygenation during a brief loading challenge before removal of the endotracheal tube.
In neonates, this challenge is usually done by leaving the patient to breathe through the
endotracheal tube with PEEP but no other support for 3 to 10 minutes.
• In a prospective observational study, a 3-minute SBT was shown to identify suitability for extubation in
very low birth-weight infants with high accuracy.

52. POSTEXTUBATION MANAGEMENT
• The use of CPAP following extubation of preterm infants has been shown to reduce extubation failure.
• The rationale for the use of distending pressure is the excessively compliant rib cage of the ELBW infant, which
is unable to maintain adequate functional residual capacity.
• The preterm infant normally uses grunting as a means to generate an internal distending pressure, but after
being intubated for some time, the infant’s vocal cords are edematous, preventing effective grunting.
• The most commonly used types are CPAP, nasal intermittent positive-pressure ventilation, and heated
humidified high-flow nasal cannula therapy.

53. Adjunctive Therapiespostextubation
Caffeine:
• A Cochrane meta-analysis documented a relative risk of failed extubation of infants exposed to
methylxanthines before extubation.
• Thus in preterm infants at risk of apnea of prematurity, caffeine should virtually always be administered prior to
extubation, if it has not been initiated previously.
-The optimal dose to achieve successful extubation may be higher than the standard dose used for apnea
20 mg/kg/day dosing
Nebulized Racemic Epinephrine:
• Nebulized racemic epinephrine is commonly used to treat acute airway edema for postextubation stridor in
newborn infants.
• Although short-term studies support its use a Cochrane meta-analysis last updated in 2010 failed to
identify any randomized studies that evaluated important clinical outcomes.

54. Postnatal Corticosteroids for the Prevention and Treatment of Postextubation Stridor
• Two studies examined the use of systemic steroids for the prevention of postextubation stridor in newborn
infants.
• A meta-analysis revealed that the results were heterogeneous, with no overall statistically significant
reduction in postextubation stridor.
• A study that selected high-risk neonates treated with multiple doses of steroids around the time of
extubation showed a significant reduction in stridor.
• Because corticosteroids have important side effects, it is prudent to reserve such therapy for infants who
have been intubated for prolonged periods, who have a history of traumatic or multiple endotracheal
intubations, or who previously failed extubation owing to subglottic edema.

55. Chest Physiotherapy
ACTIVE RESPIRATORY PHYSIOTHERAPY, CHEST WALL PERCUSSION AND VIBRATION FOLLOWED BY
OROPHARYNGEAL SUCTIONING, DURING THE PERIEXTUBATION PERIOD.
-FREQUENT CHEST PHYSIOTHERAPY PERFORMED EVERY 1 TO 2 HOURS WAS ASSOCIATION WITH A
REDUCTION IN THE NEED FOR REINTUBATION WITHIN THE FIRST 24 HOURS POST EXTUBATION.
-THERE WAS NO DECREASE IN THE INCIDENCE OF POSTEXTUBATION LOBAR COLLAPSE AND
INFORMATION TO ADEQUATELY ASSESS IMPORTANT SHORT- AND LONGER TERM OUTCOMES,
ADVERSE EFFECTS.
• Caution is required when interpreting any possible positive effects of this therapy.

56. CONCLUSION
“A MODE OF VENTILATION
IS ONLY
AS GOOD AS THE OPERATOR WHO
APPLIED IT”

57. THANK YOU