1. NNC Module: Basics of Mechanical Ventilation in Neonates
Learning Objectives Slide 1
Learning ObjectivesLearning Objectives (cont.)(cont.)
7. Apply initial ventilator settings.
8. Adjust ventilator settings to improve
oxygenation and ventilation as
indicated
9. Monitor the neonate during mechanical
ventilation.
10. Detect any deterioration during
mechanical ventilation and identify its
causes.

2. NNC Module: Basics of Mechanical Ventilation in Neonates
Learning Objectives Slide 2
Learning ObjectivesLearning Objectives (cont.)(cont.)
11. Apply paralysis and sedation as needed.
12. Recognize how to wean the neonate
from assisted ventilation.
13. Apply physiotherapy and suction to the
neonate as indicated.
14. Detect complications that may occur
during mechanical ventilation.

3. NNC Module: Basics of Mechanical Ventilation in Neonates
Introduction Slide 3
IntroductionIntroduction
 Mechanical ventilation is an invasive life-
support procedure with many effects on
the cardiopulmonary system.
 The goal is to optimize both gas exchange
and clinical status at minimum FiO2 and
ventilator pressure. The ventilator strategy
employed to accomplish this goal depends
in part on the infant disease process.

4. NNC Module: Basics of Mechanical Ventilation in Neonates
Indications of Mechanical Ventilation Slide 4
Indications of MechanicalIndications of Mechanical
VentilationVentilation
Absolute indicationsAbsolute indications
If any of the following is present:If any of the following is present:
1. Severe hypoxemia with PaO2 less than
50 mmHg despite FiO2 of 0.8.
2. Respiratory acidosis with pH of less than
7.20 to 7.25, or PaCO2 above 60 mmHg.
3. Severe prolonged apnea.

5. NNC Module: Basics of Mechanical Ventilation in Neonates
Indications of Mechanical Ventilation Slide 5
Indications of MechanicalIndications of Mechanical
VentilationVentilation (cont.)(cont.)
Relative indicationsRelative indications
1. Frequent intermittent apnea unresponsive to
drug therapy.
2. Early treatment when use of mechanical
ventilation is anticipated because of
deteriorating gas exchange.
3. Relieving work of breathing in an infant with
signs of respiratory difficulty.
4. Initiation of exogenous surfactant therapy in
infants with RDS.

6. NNC Module: Basics of Mechanical Ventilation in Neonates
Effects of Ventilator Setting Changes on Blood Gases Slide 6
Effects of Ventilator Setting Changes onEffects of Ventilator Setting Changes on
Blood GasesBlood Gases
EffectEffect
VentilatorVentilator
setting changessetting changes
PaCO2PaCO2 PaO2PaO2
Increase PIPIncrease PIP Decrease Increase
Increase PEEPIncrease PEEP Increase Increase
Increase rateIncrease rate Decrease Increase
Increase I:EIncrease I:E
ratioratio
------- Increase
Increase FiO2Increase FiO2 ------- Increase
Increase flowIncrease flow Decrease Increase

7. NNC Module: Basics of Mechanical Ventilation in Neonates
Starting Ventilator Setting Slide 7
Starting Ventilator SettingStarting Ventilator Setting
 Intubate infant with an endotracheal tube
according to body weight.
 During intubation, infants require fractional
inspired oxygen FiO2 that is 10% higher
than what they were receiving before
mechanical ventilation.

8. NNC Module: Basics of Mechanical Ventilation in Neonates
Guidelines for Endotracheal Tube Size Slide 8
Guidelines for Endotracheal TubeGuidelines for Endotracheal Tube
SizeSize
Infant weight(gm)Infant weight(gm) Endotracheal tubeEndotracheal tube
internal diameterinternal diameter
< 1,000gm 2.5mm
1,000 - 2,000 3.0mm
2,000 - 3,000 3.5mm
> 3,000 3.5 - 4.00mm

9. NNC Module: Basics of Mechanical Ventilation in Neonates
Initial Setting of Mechanical Ventilation Slide 9
Initial Setting of MechanicalInitial Setting of Mechanical
VentilationVentilation
 PIP is determined by hearing good breath
sounds and good lung expansion.
 FiO2 is determined according to patient need.
 Ti should not be prolonged because of risk of
alveolar over-distention. Start with 0.25 seconds
and do not exceed 0.5 seconds (unless there
are special indications).
 Respirator rate should not ordinarily exceed 80
breaths/min to allow sufficient time for
exhalation.

10. NNC Module: Basics of Mechanical Ventilation in Neonates
Initial Setting of Mechanical Ventilation Slide 10
Initial Setting of MechanicalInitial Setting of Mechanical
Ventilation (cont.)Ventilation (cont.)
Initial settingsInitial settings
Fio2Fio2 As indicatedAs indicated
Systemic flowSystemic flow 8-10l/min8-10l/min
RateRate 60 breaths / min60 breaths / min
Ti/TeTi/Te 1:1.25 - 1:41:1.25 - 1:4
PIPPIP 18 - 22cm H2018 - 22cm H20
Good breath soundsGood breath sounds
PEEPPEEP 3 - 5cm H203 - 5cm H20

11. NNC Module: Basics of Mechanical Ventilation in Neonates
Subsequent Settings of Mechanical Ventilation Slide 11
Subsequent Settings ofSubsequent Settings of
Mechanical VentilationMechanical Ventilation
 Measure arterial blood gases half an hour after
the initial setting and adjust the setting
accordingly. (Table)
 Although it is tempting to try to lower PaCO2 by
increasing the respiratory rate rather than by
adjusting ventilatory pressure, data suggest that
this can not be without risk.

12. NNC Module: Basics of Mechanical Ventilation in Neonates
Subsequent Settings of Mechanical Ventilation Slide 12
Subsequent Settings of MechanicalSubsequent Settings of Mechanical
VentilationVentilation (cont.)(cont.)
SubsequentSubsequent
settingssettings
PEEPPEEP PIPPIP
Low PaO2 ,Low PaO2 ,
Low PaCo2Low PaCo2
Increase
Low PaO2 ,Low PaO2 ,
High PaCo2High PaCo2
Increase
High PaO2 ,High PaO2 ,
High PaCo2High PaCo2
Decrease
High PaO2 ,High PaO2 ,
Low PaCo2Low PaCo2
Decrease

13. NNC Module: Basics of Mechanical Ventilation in Neonates
Monitoring The Infant during Mechanical Ventilation Slide 13
Monitoring The Infant duringMonitoring The Infant during
Mechanical VentilationMechanical Ventilation
 Obtain an initial blood gas within 15-30
minutes of starting mechanical ventilation.
• Obtain a blood gas within 15-30 minutesObtain a blood gas within 15-30 minutes
of any change in ventilator settings.of any change in ventilator settings.
• Obtain a blood gas every 6 hours unlessObtain a blood gas every 6 hours unless
a sudden change in the infant's conditiona sudden change in the infant's condition
occurs.occurs.
• Continuous monitoring of the O2Continuous monitoring of the O2
saturation level as well as the HR and RRsaturation level as well as the HR and RR
is necessary.is necessary.

14. NNC Module: Basics of Mechanical Ventilation in Neonates
Deterioration during Mechanical Ventilation Slide 14
Deterioration duringDeterioration during
Mechanical VentilationMechanical Ventilation
Sudden clinical deteriorationSudden clinical deterioration
 Mechanical or electrical ventilator failure.
 Disconnected tube or leaking connection.
 Endotracheal tube displacement or
blockage.
 Pneumothorax.

15. NNC Module: Basics of Mechanical Ventilation in Neonates
Deterioration during Mechanical Ventilation Slide 15
Deterioration duringDeterioration during
Mechanical VentilationMechanical Ventilation (cont.)(cont.)
Gradual deteriorationGradual deterioration
 Inappropriate ventilator setting.
 Intraventricular hemorrhage.
 Baby fighting against ventilator.
 PDA.
 Anemia.
 Infection.

16. NNC Module: Basics of Mechanical Ventilation in Neonates
Paralysis and Sedation Slide 16
Paralysis and SedationParalysis and Sedation
(cont.)(cont.)
 Sedation is useful when agitation
interferes with ventilatory support and
when infants fight the ventilator.
 Phenobarbital decreases the variability in
mean arterial pressure and intracranial
pressure associated with endotracheal
suctioning.

17. NNC Module: Basics of Mechanical Ventilation in Neonates
Weaning Slide 17
WeaningWeaning
 When the patient is stable, FiO2 and PIP are
weaned first.
 Decrease PIP as tolerated and as chest rise
diminishes.
 When PIP is around 20, attention is directed to
FiO2 and then to the respiratory rate alternating
with each other, in response to assessment of
chest excursion, blood gas results, and oxygen
saturation.

18. NNC Module: Basics of Mechanical Ventilation in Neonates
Weaning Slide 18
WeaningWeaning (cont.)(cont.)
 As frequency is decreased, Te should be
prolonged.
 For larger infants, weaning to endotracheal
CPAP may begin when PIP has been stable
between 15-18 cmH2O, and FiO2 is less
than 0.4.
 The infant can be weaned to oxygen hood
when he/she requires less than 4 cmH2O of
end expiratory pressure.

19. NNC Module: Basics of Mechanical Ventilation in Neonates
Weaning Slide 19
WeaningWeaning (cont.)(cont.)
 For infants weighing less than 1,750 gm, when
PIP is less than 15 cmH2O and FiO2 is less than
0.3, start to decrease the respiratory rate
gradually to 15-20 breaths/min and then wean
directly to nasal CPAP if available.
 In most infants, when ventilator frequency of
approximately 15 breaths per minute is
tolerated, endotracheal CPAP may be tried for a
short period before extubation.

20. NNC Module: Basics of Mechanical Ventilation in Neonates
Weaning Slide 20
WeaningWeaning (cont.)(cont.)
 Atelectasis after extubation is common in
preterm infants recovering from RDS. Use of
nasal CPAP may prevent atelectasis.
 Steroids are not routine before extubation, but if
there was prolonged intubation or previous failed
attempts of extubation, a short course of steroids
may facilitate extubation.
 If strider caused by laryngeal edema develops
after extubation, racemic epinephrine aerosols
and steroids may be helpful.

21. NNC Module: Basics of Mechanical Ventilation in Neonates
Physiotherapy and Suctioning Slide 21
Physiotherapy andPhysiotherapy and
SuctioningSuctioning
 Tracheal suctioning and chest physiotherapy
should be minimized in infants with HMD in
the first few days after birth because their
secretions are scant.
 Physiotherapy and suctioning should be done
to prevent the development of atelectasis,
especially in premature infants. However,
some infants show acute deterioration of
blood gases.

22. NNC Module: Basics of Mechanical Ventilation in Neonates
Complications of Mechanical Ventilation Slide 22
Complications of MechanicalComplications of Mechanical
VentilationVentilation
Endotracheal tube complications andEndotracheal tube complications and
tracheal lesionstracheal lesions
 Accidental displacement of the
endotracheal tube into main stem
bronchus, hypopharynx, or esophagus.
 Accidental extubation.
 Obstruction of endotracheal tube.

23. NNC Module: Basics of Mechanical Ventilation in Neonates
Complications of Mechanical Ventilation Slide 23
Complications of MechanicalComplications of Mechanical
VentilationVentilation (cont.)(cont.)
Airway injuryAirway injury
 Subglottic stenosis.
 Edema of the cords after extubation (may
result in hoarseness and stridor).
 Prolonged use of orotracheal intubation
associated with palatal groove formation.
 Necrotizing tracheobronchitis.

24. NNC Module: Basics of Mechanical Ventilation in Neonates
Complications of Mechanical Ventilation Slide 24
Complications of MechanicalComplications of Mechanical
VentilationVentilation (cont.)(cont.)
InfectionInfection
Pneumonia and systemic infections with
Staphylococcus epidermidis, Candida
organism, gram-negative organisms, and
Staphylococcus aureus.

25. NNC Module: Basics of Mechanical Ventilation in Neonates
Complications of Mechanical Ventilation Slide 25
Complications of MechanicalComplications of Mechanical
VentilationVentilation (cont.)(cont.)
Chronic lung disease / OxygenChronic lung disease / Oxygen
toxicitytoxicity
 Bronchopulmonary dysplasia (BPD), related
to increased airway pressure and changes in
lung volume.
 Other contributing factors are oxygen toxicity,
anatomic and physiologic immaturity, and
individual susceptibility.

26. NNC Module: Basics of Mechanical Ventilation in Neonates
Complications of Mechanical Ventilation Slide 26
Complications of MechanicalComplications of Mechanical
VentilationVentilation (cont.)(cont.)
Air leakAir leak
Pneumothorax, pulmonary interstitial
emphysema (PIE), and
pneumomediastinum directly related to
increased airway pressure occurring
frequently at MAP >14 cmH2O.

27. NNC Module: Basics of Mechanical Ventilation in Neonates
Complications of Mechanical Ventilation Slide 27
Complications of MechanicalComplications of Mechanical
VentilationVentilation (cont.)(cont.)
MiscellaneousMiscellaneous
 Intraventricular hemorrhage.
 Decreased cardiac output.
 Feeding intolerance