Objectives - Introduction to MV - Challenges in newborn ventilation - Non-invasive ventilation - Invasive ventilation

1. BASICS OF NEONATAL VENTILATION
Instructor:
Mr. Gokul Krishna G BSRT MSRT (NPRC)
Assistant Professor
Department of Respiratory Therapy
Batterjee Medical college, Jeddah, KSA

2. CONTENTS
ü INDICATIONS
ü SETTINGS
ü TROUBLE SHOOTING
ü COMPLICATIONS
ü WEANING

3. Respiratory
depression
Surfactant
deficiency
Fluid filled
lungs
C-section
absence of
labour
Limited
muscle
strength
Limited ability to
establish FRC
Compliant
chest wall
Preterm ˂ 37 Weeks
Term 37-42 Weeks
Post term ˃ 42 Weeks

4. Techniques of assisted ventilation
There are two approaches :
Non-invasive ventilation
• Continuous positive airway pressure
• Heated high flow nasal cannula
Invasive ventilation
• Conventional ventilation
• High frequency ventilation

5. Continuous Positive Airway Pressure
(CPAP)
• Most common ventilation modality in newborns.
• Recruits the alveoli and keep it opens the lung at the level of FRC
• Keeps it open at minimum constant pressure
• Controlled PEEP is recommended in newborns who need more than
normal resuscitation at birth but are breathing spontaneously.

7. Heated High Flow Nasal Cannula
(HHFNC)
• HHFNC allows the delivery of
oxygen or a mixture of oxygen
and air at flow rates higher
than the insp flow of neonates
• Washout of nasopharyngeal
dead space
• Proven benefits in post
Extubation in term infants.

10. INVASIVE VENTILATION
DRAGGER BABYLOG 8000 PLUS
SLE 5000

11. Ventilator Settings
• Mode of ventilation
• Fraction of inspired oxygen (FIO2)
• Tidal Volume (TV)
• Peak Inspiratory Pressure (PIP) or Pressure control (PC)
• Positive End Expiratory Pressure (PEEP)
• Respiratory rate (RR)

12. Modes Of Ventilation
• Pressure Control Ventilation (PC)
• Volume Guaranteed Ventilation (VG) – Dual Control Mode
• Synchronized Intermittent Mandatory Ventilation (SIMV)
• Pressure Support Ventilation (PSV)
• High Frequency Ventilation (HFV)
SIMV+ PC – common mode

13. VENTILATOR PARAMETERS RANGE
FIO2 0.21- 1.0
Flow 3-120 L/min
Respiratory Rate 1-150 bpm
Tidal volume 1-1000 ml/kg
PIP 0-60 cmH20
PEEP/CPAP 0-60 cmH2O
Trigger Level -10 - +60 cmH2O

16. IMPROVING OXYGENATION
Flow
PIP or PC
FiO2
Mean
airway
pressure
PEEP
I:E ratio
Oxygenation

17. IMPROVING VENTILATION
RR
TE
Minute
Ventilation
TV or PC
Ventilation
Flow
PEEP

19. Oxygen Saturation Target
INFANTS
Arterial oxygen level
(PaO2 mmHg)
Oxygen saturation range
(SPO2 %)
Preterm < 32 Weeks 50-70 88-92
Preterm ≥ 32 Weeks 60-80 90-95
Term & Post Term 60-80 90-95

20. Ventilator Troubleshooting
• To reduce cuff associated
injury
• High chance of
endotracheal tube leak
causing ventilator
dyssynchrony.
Uncuffed Endotracheal Tube

21. Ventilator Troubleshooting cont.
• Deterioration of vital signs
• Ventilatory alarm
• Chest wall movement
21
“DOPE”
D- Displacement of ETT
O- Obstruction
P- Pneumothorax
E- Equipment failure

22. Complications of Mechanical Ventilation
• Alveolar over distention is a primary cause of complications
encountered during mechanical ventilation and is a result of:
– Volutrauma (Large tidal volumes)
– Atelectrauma (Repetitive opening and closing of the
terminal lung units at low lung volumes)
– Barotrauma (High ventilating pressures)
22

23. Cardiovascular complications
–Reduced cardiac output
Oxygen toxicity
–High FIO2 levels that have been applied for an extended period may
result in tissue injury that alters lung function and gas distribution
–Retinopathy of prematurity
Hypoventilation, hyperventilation
–Disconnection from the ventilator and unplanned extubation
–High impedance to inflation
–“Operator error” in establishing ventilation
23

24. When to decide weaning ?
Primary illness
resolved??
Hemodynamic stability?
Oxygenation status ? Neuromuscular status
Respiratory muscle
strength
Acid –base balance?
ü.
ü.
ü.
ü.
ü. ü.

25. WEANING STRATEGY
Assess the weaning readiness
Setting should be reduced in small
increment in every 4- 6 hours:
PIP: 2-3 cm H2O
FiO2: 5-10% (Reduce FiO2 to 80%
before
PEEP: 1 cmH2O; Rate: 5-10/min; I time:
0.3-0.4 seconds
“Weaning should be attempted throughout the day, not just during rounds”

26. Weaning Dilemma’s
ü No weaning protocol is 100% accurate in predicting successful
weaning and extubation – Physician dependent
ü Weaning too slowly may be more dangerous than weaning too
fast, as it may result in excessive lung injury and hypocarbia
ü Early weaning will facilitate parental bonding and
developmentally appropriate care.

27. Surfactant Therapy
• Exogenous surfactant replacement therapy has been
established as an appropriate preventive and lung protective
therapy for prematurity*.
*AAP committee on Fetus and Newborn March 1999,pp 684-685
Prophylactic
Vs
Rescue
INSURE
Vs
MIST

28. Chronic Lung Disease (CLD)/ BPD
Fetal Lung
Development
Postnatal Lung Growth And
Development
Pulmonary
Outcome
Initiation
Of
Breathing
Mechanical
Ventilation
Oxygen Infection
Preterm
Labour
Preterm
Delivery
CANNALICULAR STAGE
SACCULAR STAGE
ALVEOLAR STAGE

29. “Lung Protective /Optimal /Gentle
Ventilation”
Optimal is the tidal volume that creates a homogeneous delivery
of each breath to the open lung units without creating
volutrauma
“Optimize FRC”
• Intrapulmonary shunt is decreased
• Lung volume effects on cardiac output are minimized
• Oxygen delivery is optimized

30. Summary
• Mechanical ventilation is only a supportive care therapy always
consider the risk Vs benefits before initiation.
• Not just pressure excessive volume also causes ventilator
Induced lung injury *volume guaranteed mode of ventilation.
• Cautious use of FiO2 especially in preterm neonates.
• Initiate weaning as soon as possible ; not too fast or too slow
• Practice gentle or optimal ventilation establishing the FRC.

31. References:
• Perinatal And Pediatric Respiratory Care 3rd Edition Brian K.
Walsh
• Assisted ventilation of the neonate 5th edition; Goldsmith and
Karotkin

32. THANK YOU
“ What is important is not how the lung open but
do get it open and keep it open”

33. QUESTIONS??