The document describes 3 case scenarios involving newborn infants with respiratory issues. Case 1 involves a term newborn not crying after birth who is not responding to positive pressure ventilation. Case 2 involves a preterm infant admitted to the NICU with respiratory distress. Case 3 involves a preterm infant with symmetrical IUGR who develops repeated apnea while on CPAP support. The document asks what the problem is in each case. It then discusses troubleshooting positive pressure ventilation and various problems that can occur, such as air leaks, obstruction, equipment issues, and abnormal blood gases. Management strategies for different problems are provided.

1. Case Scenario: 1
• D/O sayeda , Term (38wks), AGA(3000gm) delivery by
NVD not crying after drying ,suction and
stimulation.Then start positive pressure ventilation- bag
mask ventilation but chest not inflate..?
What is the problem ?

2. Case Scenario: 2
• D/O Tahmina, inborn, got admitted in NICU at 15 min of
her age due to prematurity (30weeks), LBW(1270g) and
respiratory distress soon after birth.
• On arrival baby was normothermic, euglycemic, reflex &
activities were good, but having respiratory distress in
the form of tachypnea, nasal flaring, chest retraction
and grunting. DOWNE’s Score – 05.Baby put on CPAP but
sign of respiratory distress not disappear.
What may be the problems ?

3. Case Scenario: 3
• D/O Mukta, Preterm (32wks) VLBW(1300gm) with symmetrical
IUGR with suspected EONS
• At Postnatal age 48 hours, baby developed repeated apnea with
supplemental O2. So, baby was put on CPAP.
• At 103 hours of age, despite of high setup on CPAP, baby
developed repeated apnea and desaturation with poor
respiratory drive,so baby put on MV .Intially MV working well
then baby developed hypoxia and B/L air entry in lungs was
absent.
What problem was
there?

4. Mechanical ventilation in neonates
Basics of neonatal ventilation
Different Modes of neonatal mechanical ventilation
Initiation of neonatal MV
Pulmonary graphics
Disease specific ventilation
Complications , VAP
• High frequency ventilation
• Weaning strategy
• Troubleshooting of positive pressure ventilation
4

5. Troubleshooting of positive
pressure ventilation

6. Outline
• Introduction
• Devices of positive pressure ventilation(PPV)
• Troubleshooting and its possible
Management
• Take home message

7. Introduction
Positive pressure ventilation is a form of respiratory therapy
that involves the delivery of air or a mixture of oxygen combined
with other gases by positive pressure into the lungs.

8. Introduction cont.
• Positive-pressure ventilation can be provided through
1. a face mask or
2.an endotracheal tube
either with a mechanical ventilator or with one of the three
commonly used manual resuscitators:
1.the self-inflating bag,
2.the flow-inflating (“anesthesia”)bag, and
3. T-piece resuscitator.
Assisted Ventilation of the Neonate 6th edition

9. Assisted Ventilation of the Neonate 6th edition

10. Assisted Ventilation of the Neonate 6th edition

11. Commonly used PPV in our NICU
• Self inflating bag(Bag mask ventilation)
Management of birth asphyxia
Approximately 10% of newborns require some assistance to
begin breathing at birth; about 1%
needs extensive resuscitative measures to survive.
• Initial steps: Put the baby on mother’s abdomen
• Dry thoroughly ( if amniotic fluid is clear)
• Remove the wet cloth
• Keep warm: Management protocol of newborn, NICU, BSMMU, January 2016

12. • Assess Crying/Breathing while drying:
• Breathing Well: Crying or breathing quietly & regularly
• Not breathing well: Not breathing at all or gasping
• Bag musk ventilation (BMV):
• If the baby is not breathing well after suction & stimulation
• Cut the umbilical cord to separate from mother
• Shift the baby to the area for ventilation
• Start PPV within one minute of birth

13. If chest does not rise with BMV
• Troubleshooting of BMV---

14. Troubleshooting of BMV---
• Clear airway (if necessary)
• Selection of appropriate size masks

15. Troubleshooting of BMV---
• Position yourself at the bedside
• Position the baby’s head
• Applying and sealing mask on the face

16. Troubleshooting of BMV---
• After starting BMV
Take ventilation corrective measures for effective ventilation at any time if
chest does not
rise with squeezing:
 Repositioning
Check the mouth, oropharynx, and nose for secretions; suction the mouth
and nose (if necessary)
Reapplying mask with mouth open and ensuring better seal
Providing harder squeeze (Lock pop-off valve if necessary)

17. Other problems of BMV
• Over-ventilating and hyperventilating. Giving too much volume
or going too fast could push air into the stomach, resulting in
gastric insufflation. This could lead to vomiting and subsequent
airway obstruction or aspiration.

18. Other problems of BMV
• Barotrauma — Pulmonary barotrauma is a well-known
complication of positive pressure ventilation.
• Consequences include
1. pneumothorax,
2.subcutaneous emphysema,
3.pneumomediastinum.

19. Smaller facemasks for positive pressure ventilation in preterm
infants: A randomised trial
Eoin O’Currain , Joyce E. O’Shea d, Lorraine McGrory e, Louise S. Owena, Omar Kamlin , Jennifer
A. Dawson, Peter G. Davis , Marta Thio
R E S U S C I T A T I O N 1 3 4 ( 2 0 1 9 ) 9 1 – 9 8
Received 5 September 2018; Received in revised form 18 October 2018; Accepted 10 December
2018
Conclusions: Using a smaller mask to administer PPV to preterm
infants did not reduce facemask leak. Facemask leak and
physiological instability are high in preterm infants receiving PPV,
in particular in those ≤26 weeks’ gestation. Factors other than
size may need to be improved when designing facemasks for this
population and future research should investigate the influence of
mask malleability, shape rim and hold on the quality of facemask
ventilation.

20. Airway Obstruction During Mask Ventilation of
Very Low Birth Weight Infants During Neonatal Resuscitation
Neil N. Finer, MD, Wade Rich, BSHS, RRT, Casey Wang, MD, Tina Leone,
Md
Pediatrics 2009;123:865–869
• CONCLUSIONS
Airway obstruction, as detected by the use of a colorimetric
carbon dioxide detector, occurs in the majority of
the VLBW infants who require ventilation with a face
mask during resuscitation after delivery. The use of this
simple device can alert the resuscitation team to this situation and
facilitate
maneuvers that can re-establish a patent airway.

21. NEXT PART…

22. Most widely used CPAP is Bubble CPAP
Indications: Presence of good respiratory drive is pre requisite of CPAP
support.
- Respiratory disorder (RDS, MAS, Pneumonia, PPHN)
- Apnea of prematurity
- Disorder causing excessive lung fluid
(TTN, PDA, CCF,Hydrops fetalis ect.)
- Laryngo/tracheo/bronchomalacia
- After extubation

23. CPAP Failure
• Presence of retraction/grunt despite giving optimum
CPAP
• Recurrent or severe apnea (significant apnea means 3
apnea/ hour or that requiring bag & mask ventilation)
• Significant bradycardia
• PO2 < 50 in FiO2 >0.60
• PCO2 > 60 or PH < 7.25

24. Troubleshooting in CPAP
SPO2-low
Chest retraction-+++
B/L air entry poor
Bubbling absent in machine
???
leak

25. Action should be taken
• Replace the circuit

26. Troubleshooting in CPAP
SPO2-low
Chest retraction-+++
B/L air entry poor
Bubbling present in machine
???
obstruction

27. Action should be taken
Cause:
Most commonly by mucous secretion
Action: proper suction ensure

28. Troubleshooting in CPAP
SPO2-Normal
Chest retraction-+++
B/L air entry good
Bubbling present in machine
???
Metabolic acidosis

29. Action should be taken
Common causes: Action
1. Hypoxia Due to any cause mx accordingly
2. Hypothermia Maintain temperature
2. Hypoglycemia Maintain glycemic control by feed or IVF
4. Infection By appropriate antibiotics

30. Troubleshooting in CPAP
SPO2-low
Chest retraction-+/nil
B/L air entry good
Bubbling present in machine
???
PPHN/CHD

31. Troubleshooting in CPAP
SPO2-low
Chest retraction-+++
B/L air entry poor
Bubbling present in machine
???
Lung disease

32. • Bubble CPAP versus Ventilator CPAP in Preterm Neonates
with Early Onset Respiratory Distress—A Randomized Controlled Trial
by Amit Tagare, Sandeep Kadam, Umesh Vaidya,Anand Pandit, and Sanjay Patole
Division of Neonatology, Department of Pediatrics, KEM Hospital, Pune 411011, India
Centre for Neonatal Research and Education, King Edward Memorial Hospital for Women,
University of Western Australia, Perth, Western Australia
Correspondence: Sandeep Kadam, Division of Neonatology, Department of Pediatrics KEM
Hospital,
Rasta Peth, Pune 41101
JOURNAL OF TROPICAL PEDIATRICS, VOL. 59, NO. 2, 2013
• Conclusion: BCPAP has higher success rate than VCPAP for managing preterm neonates
with early
onset respiratory distress, with comparable safety.

33. • Common problem we faced during MV handling

34. Troubleshooting in MV
Acute deterioration: Consider “DOPE” and large IVH
Acute deterioration
Displaced tube
Obstructed
tube
Pneumothorax
Equipment
failure
34

35. Acute deterioration of ventilated newborn
Tube displaced
Air entry in stomach
Abdominal distension
Check Baby
Check Ventilator
Disconnect from ventilator
and Start bag- ET tube
ventilation
Unequal
sound
Change ET Tube
No air entry
Tube in oropharynx
Complete
tube block
Tube dislodged
No air entry
↓ Breath sound
↓ Air entry
No chest movement
Pneumo
thorax

36. Acute deterioration of ventilated newborn
Poor saturation
PDA , Sepsis , PPHN , IVH
Worsening lung disease
Partial tube block
Faulty O2 supply
With same pressure
Improving saturation
Normal breath sound
Adequate chest movement Check Baby
Check Ventilator
Disconnect from ventilator
and Start bag- ET tube
ventilation
More pressure

37. Pulmonary Graphics
Graphical representation of Pressure, Flow and Volume.
Waveforms:
Pressure waveforms
Flow waveforms
Volume waveforms
Loops:
Pressure-Volume loop
Flow-Volume loop

38. Ventilatory Waveform

39. Pressure Limit waveforms

40. Volume Limit waveform

41. Abnormal Waveforms

42. Abnormal wave form
Air Leak

43. Abnormal wave form

44. Abnormal wave form

45. Abnormal wave form
Accidental Extubation

46. Abnormal wave form

47. Ventilatory Loops

48. Loops in mechanical ventilator

49. Normal Pressure-Volume Loops

50. Pressure volume loops
lung complance change

51. Abnormal pressure-volume Loops

52. Abnormal pressure-volume Loops

53. Abnormal pressure-volume Loops

54. Normal Flow-Volume Loop

55. Abnormal Flow-Volume Loops

56. Abnormal Flow-Volume Loops

57. Abnormal Flow-Volume Loops
Resistance pattern/Airway obstruction

58. Abnormal Flow-Volume Loops

59. Abnormal Flow-Volume Loops
abnormal flow

60. Abnormal Flow-Volume Loops
Secretion/Water in the inspiratory or expiratory limb

61. Problem Possible Cause Suggested Action
Low VT alarm
-not volume
reaching target
Recurrent alarms Decreased compliance:
• Atelectasis Evaluate breath sounds
• Pneumothorax/PIE Evaluate chest rise
• ETT obstructed on tracheal wall or carina Reposition patient and/or ETT
• Abdominal distention Assess overall condition
Assisted Ventilation of the Neonate 6th edition

62. Problem Possible Cause Suggested Action
Low VT alarm
-not volume
reaching target
Recurrent alarms Increased resistance :
• Airway secretions Evaluate brearh sounds
• Partial kinking of ETT Examine ETT, circuit
• Bronchospasm Listen to patient, examine flow waveform
Assisted Ventilation of the Neonate 6th edition

63. Problem Possible Cause Suggested Action
Low VT alarm
-not volume
reaching target
Recurrent alarms
• Large ETT leak Check for ETT leak on the ventilator display.
Assisted Ventilation of the Neonate 6th edition

64. Problem Possible Cause Suggested Action
• Ventilator is not
generating any PIP
• Tubing disconnection Check for leak, disconnection
• VT is too low for the infant’s physiologic need Reevaluate VT setting.
Assisted Ventilation of the Neonate 6th edition

65. problem Possible Cause Suggested Action
• Persistently low
PaCO2
• Metabolic acidosis Consider pH, not just PaCO2; the respiratory
control center responds to
pH and respiratory compensation for a base
deficit is normal.
• Agitation Ensure optimal positioning, comfort.
Provide sedation if necessary.
Assisted Ventilation of the Neonate 6th edition

66. problem Possible Cause Suggested Action
• Tachypnea,
• increased WOB
• VT set too low Insufficient support leads to
tachypnea and retractions.
Reassess appropriateness of VT setting.
• Agitation as above
Assisted Ventilation of the Neonate 6th edition

67. Troubleshooting of ABG

68. Adjustment of ventilator settings
PaO₂ PaCO₂ Parameters to be changed
Low High ↑ PIP, that will ↑ MAP, ↑ Rate
Low Normal ↑ FiO₂, ↑ MAP but maintain PIP (↑ PEEP or ↑
Ti )
Low Low PPHN, Sepsis, Over ventilation. ↑ FiO₂, ↑ MAP
Normal High ↑ Rate, ↓ PEEP, Keep MAP constant
Normal Low ↓ Rate, maintain MAP
High High Check Mechanical problem-↓ PEEP, ↓ Ti, ↓
FiO₂, ↑ Rate,
High Normal ↓ FiO₂,↓ MAP (usually ↓ PIP)
High Low ↓Pressure, ↓ Rate, ↓ FiO₂
Normal Normal Plan to Wean
Rennie and Roberton’s Textbook of Neonatology
Fifth edition

69. Indications of HFV
1.When conventional ventilation fails
– reduced compliance,RDS/ARDS,meconium aspiration ,BPD
,pneumonia,atelectasis, lung hypoplasia
Other: PPHN
2.Primary mode of ventilation in extreme prematurity.
3.Air leak syndromes (pneumothorax, PIE)
4.Congenital diaphragmatic hernia.
Assisted ventiltion of the neonate, Goldsmith 6th edition
Dragger manuals – high frequency ventilation basics and
practical application

70.  MAP: 2-5mbar above MAP of CMV
 Frequency: 10 Hz
 Amplitude: 50- 100% watch thorax
vibrations
 Volume: about 2 to 2.5 ml/kg
 Fi02:100%
Start HFV

71. Troubleshooting and adjustment during HFOV
Hypoxia Hyperoxia Hypercapnia Hypocapnia
Increase Fi02 Decrease Fi02 Increase Amplitude Decrease
Ampiltude
Increase MAP (1-2
cm H20)
Decrease MAP(1-2
cm H20)
Decrease
Frequency (1-2 cm
H20) if MAP max
Increase
Frequency(1-2 cm
H20) if MAP max

72. Common problems in PPV and its possible management

73. Ventilator-induced lung injury (VILI)
Ventilator-induced lung injury (VILI) results from
injury to the blood-gas barrier caused by mechanical
ventilation.
Common VILI are:
Barotrauma
Volutrauma
Atelectrauma
Biotrauma
73

74. Barotrauma
Slutsky, Chest, 1999

75. Abnormal wave form
Air Leak

76. Abnormal pressure-volume Loops

78. Management
Acute decompression with needle thoracostomy
followed by water seal drainage.
Prevention
Optimizing ventilator settings by using low tidal volume and
low plateau pressures provides a mortality benefit.
In view of the deleterious effects of alveolar overdistention,
limiting plateau pressures to less than 30 cm H2O while
balancing other ventilator settings .
The average tidal volume used for mechanical ventilation has
decreased over time. It is clearly not> 6 mL/kg.
78

79. Volutrauma
Pulmonary volutrauma:
Volutrauma is essentially damage to the lung caused
by over distention by a mechanical ventilator set for
an excessively high tidal volume .
This may result in increased epithelial and
microvascular permeability, thus, allowing fluid
filtration into the alveoli (pulmonary edema).
 Volutrauma is separate from pulmonary barotrauma
because the mechanism of injury is excessive volume
(volutrauma), instead of pressure (barotrauma).
79

80. Volutrauma

81. Abnormal pressure-volume Loops

82. Mx of volutrauma
Minimizing volutrauma has mainly been associated with reducing
tidal volume during mechanical ventilation.

83. Atelectrauma:
 The repetitive opening and collapse of alveoli plays a
pivotal role in VILI, which was known as atelectrauma.
Atelectrauma
83

84. Management
Minimizing Atelectrauma: is based on two principles
First, already collapsed alveoli/ saccules need to be reopened or
recruited by applying sufficient inflation pressure.
Second, after recruitment, sufficient(end-expiratory) airway pressure
should be applied to stabilize the lung volume and prevent
subsequent collapse during expiration.

85. Biotrauma:
 MV-induced inflammatory response may contribute
to the development of multiple system organ
dysfunction including respiratory failure in ventilated
patients.
 MV is able to trigger the release of numerous
proinflammatory mediators that may induce lung
injury and impair pulmonary function.
 High VT ventilation increases interleukin (IL)-1β, IL-6,
IL-8, tumor-necrosis factor (TNF)-α etc.
Biotrauma
85

86. Biotrauma
• This biological form of trauma is known as biotrauma.

87. Troubleshooting of positive pressure ventilation is common
We should 1st think simple ways and search it‫׳‬s solution
For our patient safety never overlook any alarm or troubleshooting of
PPV
Take home messages
87