Invasive Neonatal Ventilation
Dr Badr Chaban 28/01/09
Invasive Neonatal Ventilation
Conventional Mechanical Ventilation CMV Intermittent Mandatory Ventilation IMV Synchronized Intermittent Mandatory Ventilation SIMV Assist/Control Ventilation IPPV A/C Pressure-Support Ventilation PSV Patient-Triggered Ventilation S
Pressure-Limited Ventilation Pressure-Controlled Ventilation Volume Ventilation Volume Guarantee Pressure-Regulated Volume Control Volume-Assured Pressure Support Proportional Assist Ventilation
Conservative or “Gentle” Ventilation Nasopharyngeal Synchronized Intermittent Mandatory Ventilation
. (2) ↓ risk of lung injury. (3) ↓ (WOB).Goals of Mechanical Ventilation
adequate pulmonary gas ex-change. (4) optimize patient comfort.
Ideal Mode of Ventilation
Delivers a breath that: Synchronizes with the patient’s spontaneous respiratory effort Maintains adequate and consistent tidal volume and minute ventilation at low airway pressures Responds to rapid changes in pulmonary mechanics or patient demand Provides the lowest possible WOB
Ideal Ventilator Design
Achieves all the important goals of mechanical ventilation Provides a variety of modes that can ventilate even the most challenging pulmonary diseases Has monitoring capabilities to adequately assess ventilator and patient performance Has safety features and alarms that offer lung protective strategies
Carbon Dioxide (CO2) Elimination
alveolar minute ventilation = (tidal volume .dead space) x frequency
Relationships among various ventilator-controlled (shaded circles) and
Carlo. et al.20:117-126e
Copyright ©1999 American Academy of Pediatrics
. Pediatrics in Review 1999. A. W.
Carlo.Determinants of oxygenation during pressure-limited. Pediatrics in Review 1999. et al. W. A.20:117-126e
Copyright ©1999 American Academy of Pediatrics
PEEP) (TI/TI + TE) +
PEEP K is a constant determined by the flow rate and the rate of rise of the airway pressure curve
. MAP = K (PIP .
Compliance describes the elasticity or
distensibility (eg. lungs. chest wall. respiratory system)
. which may be as low as 0.001 L/cm H2O.003 to 0.006 L/cm H2O compared with compliance in neonates who have RDS.0005 to 0. in neonates who have normal lungs
ranges from 0.
endotracheal tube) and tissues to oppose airflow and is expressed as the change in pressure per unit change in flow: resistance = pressure/ flow
. airways. RESISTANCE
Resistance describes the inherent capacity of the air conducting system (eg.
.Airway resistance depends on
1) 2) 3) 4)
radii of the airways (total cross-sectional area). density and viscosity of gas breathed. length of airways.
Resistance Δ Pressure (cm H2O) Δ Flow (L/sec) Normal lungs: 20-40 cm H2O/L/sec RDS: 20-40 cm H2O/L/sec Intubated infant: 50-150 cm H2O/L/sec
004 L/cm H2O and a resistance of 30 cm H2O/L/s have a time constant of 0.
. the lungs of a healthy
neonate with a compliance of 0.The time constant of the respiratory system is a measure of the time necessary for the alveolar pressure to reach 63% of the change in airway pressure
time constant = resistance x compliance For example.12 seconds.
W.Carlo. A. et al.20:117-126e
. Pediatrics in Review 1999.
support ventilation (PSV) is a mode where flow cycling is used to assist every spontaneous inspiratory effort and terminate the mechanical breath as the spontaneous inspiration ends or inflation is completed
while the support pressure compensates for instrumental and disease induced loads. In some ventilators PSV can be combined with a low SIMV rate
. In the event of apnea. back-up IMV ensures ventilation.
Synchronous breath termination gives the infant greater control over the frequency and duration of inspiration.
. proportional assist ventilation reduces ventilatory pressures while maintaining or improving gas exchange. Furthermore. the ventilator can decrease the elastic or resistive work of breathing selectively. When compared with conventional and patient-triggered ventilation.PROPORTIONAL ASSIST VENTILATION PAV proportional assist ventilation matches the onset and
duration of both inspiratory and expiratory support. Thus. The magnitude of the support can be adjusted according to the patient’s needs. ventilatory support is in proportion to the volume and flow of the spontaneous breath.
real-time pulmonary graphics: Waveforms Loops Mechanics Trending
.Ideal Monitoring Features
Volume Guarantee Dräger Babylog
Pressure Regulated Volume Control and Volume Support Siemens 300 Volume Assured Pressure Support VIP BIRD Gold
Dr Badr Chaban 11/02/09
and hybrids. including (HFJV). conventional mechanical ventilation. HFOV. The rationale for HFV is that the provision of tiny gas volumes at rapid rates results in much lower alveolar pressure
HFV is a radical departure from standard. There are several types of HFV devices.
This inflates the lung to a
constant and optimal lung volume maximising the area for gas exchange and preventing alveolar collapse in the expiratory phase. MAP provides a constant distending
pressure equivalent to CPAP.
To reduce barotrauma when conventional ventilator settings are high.
. pulmonary interstitial emphysema) 3. Rescue
following failure of conventional ventilation (PPHN. 2. Air leak syndromes (pneumothorax. MAS).Indications for high frequency ventilation include
cycles per second) MAP Mean airway pressure (cmH2O) Amplitude delta P or power is the variation around the MAP Oxygenation is dependent on MAP and FiO2
Frequency High frequency ventilation rate (Hz.
Ventilation is dependent on amplitude and
to lesser degree frequency.
Thus when using HFV CO2 elimination
and oxygenation are independent.
Making adjustments once established on HFV Poor Over Oxygenatio Oxygenatio n n Increase Decrease FiO2 FiO2 Increase Decrease MAP MAP (1-2cmH2O) (1-2cmH2O) Under Ventilation Increase Amplitude Decrease Frequency (1-2Hz) if Amplitude Maximal Over Ventilation Decrease Amplitude Increase Frequency (1-2Hz) if Amplitude Minimal
since most newborns are obligate nasal breathers. and head boxes. It soon became apparent that it could also be applied nasally. Use of nasal CPAP also obviated face masks. the mouth acts as a pressure relief valve if the applied pressure is too high. At the same time. applied CPAP in RDS. face chambers. Although the first application of CPAP was through the endotracheal tube.Continuous Positive Airway Pressure
Gregory et al in 1971.
and enhancing surfactant release.
pattern of breathing in preterm
. decreasing obstructive apnea. This may be attributed to reducing thoracic distortion and stabilizing the chest wall. splinting the airway and the diaphragm.Advantages of CPAP
The second is an interface to connect the circuit to the airway. Newer devices use fluidics to reduce expiratory resistance and decrease the WOB. which must be warmed and humidified. Binasal tubes or prongs are the most commonly used. The third component is a device to generate positive pressure. The first is a circuit to provide a continuous flow of inspired gas.
.CPAP delivery systems contain 3 major components.
Recent trials using nCPAP from birth in 25 to 28 week infants describe more customised strategies: in the COIN trial, 27-28 week infants breathing at birth benefit the most from nCPAP.
Fewer infants received oxygen on day 28; they had fewer days of ventilation and no increase in morbidities despite having more pneumothoraces.
The suggests that intubation with early surfactant administration followed by nCPAP mostly benefits to 25-26 week infants. Thus, nCPAP is feasible from birth. The overall strategy should take into account infants' gestational age, maturation and behaviour in the delivery room.
Hascoet et la Dec 2008
• It is uncommon (<5%).
Abdominal Distension from • This is benign Swallowing • Easily reduced with gastric drainage or aspiration Air Nasal obstruction
• From improper prong placement or inadequate airway care
. • Usually occurs in acute phase. • It is not a contraindication to the use of CPAP. • It usually results from the underlying disease process rather than positive pressure alone.Complication
Nasal Septal Erosion or Necrosis Pneumothorax
• This is preventable when using appropriate sized prongs that are correctly positioned.
Neonatal nasal intermittent positive pressure ventilation (NIPPV) provides non-invasive respiratory support to premature infants who may otherwise require endotracheal intubation and ventilation.
NIPPV is the augmentation of continuous positive airway pressure (CPAP) with superimposed inflations. to a set peak pressure
Sep 2007. increasing tidal and minute volume.
. Dis. Child. Hypotheses include: increasing pharyngeal dilation improving the respiratory drive inducing Head’s paradoxical reflex increasing mean airway pressure allowing recruitment of alveoli increasing functional residual capacity.HOW DOES NIPPV WORK
the mechanism of action of NIPPV remains uncertain.F418. 92: F414 .
Arch. Fetal Neonatal Ed..
defined as mechanical inflation commencing within 100 ms of the onset of inspiration.
Synchronisation. uses a capsule to detect abdominal movement at the start of inspiration.
4-0.WHAT VENTILATOR SETTINGS SHOULD WE USE DURING NIPPV?
PEEP 3-6 cm H2O PIP 8-21 cm H2o R 10-30 /m iT 0.6 s Flow 8-10 l/m up to 15 l/m
NON-INVASIVE SYNCHRONISED MECHANICAL VENTILATION
Synchronisation techniques enabled
delivery of (N-A/C) (N-SIMV) N A/C N PSV N PAS
. while N-A/C reduced breathing effort and improved ventilation. In comparison to nasal continuous positive
airway pressure (NCPAP). N-SIMV reduced chest wall distortion in preterm infants following extubation.
These data also showed a tendency towards reduced oxygen dependency among infants extubated to N-SIMV .Three randomised trials have shown the consistent efficacy of N-SIMV in the post-extubation period as indicated by better respiratory evolution and lower extubation failure. These reports suggest that reduced apnea is responsible in part for these effects and that infants with worse lung mechanics are likely to benefit more from N-SIMV.
Eduardo Bancalari miami
. there are few data on the use of non-invasive synchronised ventilation to avoid earlier use of invasive ventilation.
Data from physiological and clinical trials indicate that non-invasive synchronised ventilation has important benefits. the use of non-invasive synchronised ventilation is uncommon.In summary. perhaps because few such ventilators are available. More importantly. Despite this evidence.
PEEP 5 PIP up to 20 10-40 iT 0.25-1s Flow depend on the leak