Neonatal Modes of Mechanical

Ventilation

Mohammed M. Tamim, MD
Consultant, NICU, Tawam Hospital
Alain, UAE

1
 Objectives
Indications of mechanical ventilation
Basics of respiratory mechanics
Modes of conventional ventilation
Modes of HFV
Indications of HFV

2
 Introduction
The primary objective of Mechanical Ventilation is to
support breathing until patient respiratory efforts are
sufficient.
First mechanical ventilation for a neonate in 1959.

One of the most important breakthroughs in the history

of neonatal care.
Mortality from RDS decreased markedly after MV.

New Morbidity developed CLD (BPD)

3
 Respiratory Failure
Hypercapnic Respiratory Failure:
Inability to remove CO2 by spontaneous breathing
Caused by hypoventilation or severe V/Q mismatch
in arterial PCO2
in pH
MV is most commonly needed for treatment

Hypoxemia
Usually the result of V/Q mismatch or RL shunt.
Diffusion abnormalities & hypoventilation (apnea)

4
 Respiratory Failure
Respiratory failure can occur because of diseases
in the lung, thorax, airway or respiratory muscle.
Indication for assisted ventilation:
Respiratory Acidosis pH < 7.2
Hypoxemia while on 100% O2

Or CPAP of 60 100%

Severe apnea

5
 Respiratory Failure
Clinical Manifestation:
Increase or decrease in respiratory rate.
Increase or decrease in respiratory effort.

Periodic breathing with increase respiratory efforts.

Apnea.

6
Neonatal Respiratory Physiology
Compliance:-
Distensible nature of lungs and chest wall.
Volume (L)
= ----------------------
Pressure (cm H2O)
Neonates have greater chest wall
compliance.( premature more than FT)
Premature infants with RDS have stiffer lungs
(poorly compliant lungs).

7
Neonatal Respiratory Physiology
Resistance:-
Property of airways and lungs to resist gas.

Pressure (cm H2O)

= --------------------------
Flow (L/sec)
Resistance in infants with normal lungs
ranges from 25 to 50 cm H2O/L/sec.
It is increased in intubated babies and ranges
from 50 to 100 cm H2O/L/sec.

8
 Resistance

Total respiratory system resistance =

chest wall R (25%)

+ airway R (55%)
+ lung tissue R (20%)

9
 Neonatal Respiratory Physiology
Time Constant:
An index of how rapidly the lungs can empty.
Time constant = Compliance X Resistance
In BPD time constant is long because of resistance.

In RDS time constant is short because of low

compliance.
Normal = 0.12-0.15 sec

10
 Time Constant
Inspiratory time must be 3-5 X time constant
One time conststant = time for alveoli to discharge
63% of its volume through the airway.
Two time constant = 84% of the volume leaves

Three time constant = 95% of volume leaves.

In RDS: require a longer I time because the lung will empty

rapidly but require more time to fill.
In CLD: decrease vent rate, which allows to lengthen the I time
and E time.

11
 Time Constant

Waldemar A. Carlo et. Al. Neoreview Dec 1999

12
Conventional Mechanical Ventilation
Mechanical ventilators achieve a pressure
gradient between the airway opening and lungs.
Ventilator for neonates are usually one of the
following types:
Pressure control Ventilators
Volume control Ventilators

13
Conventional Mechanical Ventilation
Pressure Controlled Ventilators:
A constant flow of gas pass through the ventilator.
Pressure is limited to the desired magnitude.

When expiration relief valve has been closed for the

preset period of time, the valve opens and
inspirations ceases.

14
Conventional Mechanical Ventilation
Volume Controlled Ventilators:
A preset volume of gas is delivered to the system
after which inspiration is terminated.
When this gas has been delivered by the piston
inspiration is terminated.
Infants TV (4-8 ml/kg)

Volume losses by leaks from tubing system around

the endotracheal tube.

15
Continuous Positive Airway Pressure
Important tool in management of neonates
Increase alveolar volume
Redistribution of lung water

Cons Pros
Risk of air leak Alveolar Volume & FRC
Over Distension Alveolar Stability
CO2 Retention Redistribution of lung fluids
Cardiovascular impairment Improved V/Q matching
Compliance
16
 Pressure Controlled Ventilation
Ventilator Components:
1. Gas mixer.
2. Inspiratory expiratory time adjustment
3. Expiratory relief valve to limit the peak inspiratory
pressure
4. Pressure gauge to measure applied pressure
5. Humidification or nebulization
6. Positive end expiratory pressure to maintain functional
residual capacity.
7. Exhalation assist to reduce the end expiratory pressure
8. Alarms
17
 Pressure Controlled Ventilation
Peak Inspiratory Pressure (PIP):
Changes in PIP affect both PaO2 & PaCO2 by altering
the MAP.
Increase in PIP:
Increase in PaO2
Decrease in PaCO2

A high PIP should be used cautiously because it may

increase the risk of volutrauma air leak and BPD
Common mistake large babies need higher PIP
requirement is strongly determined by compliance

18
 Pressure Controlled Ventilation
Positive End Expiratory Pros Cons
Pressure
Alveolar volume Increased Risk for
Adequate PEEP prevents & FRC air leaks
alveolar collapse and maintain
Alveolar stability Overdistention
lung volume at end of
expiration.
Redistribution of CO2 retention
Improve V/Q matching lung water
Very high PEEP reduce Improved V/Q Cardiovascular
venous return cardiac matching impairment
output decrease oxygen Decreased
transport increase Compliance
pulmonary vascular resistance

19
 Pressure Controlled Ventilation
Rate: PROS CONS
Change in rate alter alveolar
minute ventilation Air leak Gas trapping
High rate low TV is
strongly preferred Volutrauma Generalized
atelectasis
Rate change alone with
constant I:E ratio do not CVS side effects Maldistribution of
alter MAP gas

Any change in inspiratory Risk of resistance

Pulmonary edema
time that accompany
change in rate will alter
MAP
20
 Pressure Controlled Ventilation
Inspiratory Expiratory Ratio:-
in I:E ratio lead to in MAP
Long inspiratory time:
Pros:
Increased oxygenation
May improve gas distribution
Cons
Gas trapping
Increased risk of volutrauma and air leak
Impaired venous return
Increased pulmonary vascular resistance

21
 Pressure Controlled Ventilation
Inspiratory Expiratory Ratio:
Short Inspiratory time:
Pros:
Faster weaning
Decreased risk for pneumothorax
Allows use of higher ventilator
Cons:
Insufficient tidal volume
May need high flow rate

22
Inspiratory & Expiratory Time

23
Mean Airway Pressure

24
 Pressure Controlled Ventilation
FIO2:
Changes alter Alveolar Oxygen Pressure

Flow:
Not well studied in infants
Minimal effects on ABG

In general 8-12 LPM

High Flow is needed with short inspiratory time to

achieve adequate TV.
25
 Oxygenation
Depends largely on the FIO2
Oxygenation increase linearly with increase in
MAP.
MAP is a measure of the average pressure to
which the lungs are exposed.

26
 Carbon Dioxide Elimination
Depends largely on the amount of gas that passes in
and out of the alveoli Minute Ventilation.
Minute Ventilation = TV X Rate
Any increase in TV or Rate will eliminate CO2.
TV may be increased by in PIP or in PEEP

27
Tidal Volume

28
 Alternative Modalities of MV
Technology advances including improvement in
flow delivery systems, breath termination criteria,
stability of PEEP, air leak compensation,
prevention of pressure overshoot and triggering
system led to development of new modalities of
mechanical ventilation:
Patient Triggered Ventilation (PTV)
Proportional Assist Ventilation
Tracheal Gas Insufflation

29
 Patient Triggered Ventilation
Modified CMV
Neonate is able to initiate ventilatory breath by:
Abdominal motion
Chest wall impedance

Airway flow

Great degree of synchronacy between patient

and ventilator

30
 Patient Triggered Ventilation
Modes:
Synchronized Intermttent Mandatory Ventilation
(SIMV):
Preset rate that is triggered, other patient breath is not
assisted.
Assist Control Mode (A/C):
All breath initiated by patient is triggered.
Weaning accomplished by reducing PIP.

31
 Patient Triggered Ventilation
Advantages:
Reduction in cerebral blood flow variability
(Renie et al 1987)
Shorter time on ventilator
(Visveshwara et al 1999)
Improved oxygenation with SIMV
(Cleary et al 1995)
No difference between SIMV & A/C in length of
weaning.
(chon et al 1994)
32
 Proportional Assist Ventilation
Synchronize onset & duration of both
inspiratory and expiratory support.
Ventilatory support is in proportion to the
volume and flow of the spontaneous breath.
It will reduce ventilatory pressure while
maintaining or improving gas exchange.

33
 Tracheal Gas Insufflation
Reduce anatomical dead space in alveolar
minute ventilation
Gas is delivered to the distal part of the
endotracheal tube
Result in decrease in PCO2 and PIP
Still under study

34
 Preparation for MV
Establishment of artificial airway
Tracheal intubation oral vs. nasal
Examine and continue assessing your patient
Use a manometer when bagging
Follow HgB O2 saturation continually & ABGs
Insure that nebulization is adequate
Understand the effect of every ventilator knob
Select ventilator sitting that is appropriate for your patient

35
 Suggested CMV Sittings
Normal Lungs HMD

PIP 12-16 18-25

PEEP 2-3 4-5

Rate / min 20 20-40

Inspiratory Time 0.5 0.6

FIO2 0.21 0.3 0.4 1.0

36
 High Frequency Ventilation
Definition:
Ventilation at a high rate at least 2 4 times the
natural breathing rate, using a small TV that is less
than anatomic dead space:
Types:
High Frequency Jet Ventilator (HFJV)
Up to 600 breath / min
High Frequency Flow Interrupter (HFFI)
Up to 1200 breath / min
High Frequency Oscillatory Ventilator (HFOV)
Up to 3000 / min
37
 High Frequency Ventilation
Introduction
The respiratory insufficiency remains one of the major causes of
neonatal mortality.
Intensification of conventional ventilation with higher rates and
airway pressures leads to an increased incidence of barotrauma.
Either ECMO or high-frequency oscillatory ventilation might
resolve such desperate situations.
Since HFOV was first described by Lunkenheimer in the early
seventies this method of ventilation has been further developed
and is now applied the world over.

38
 Definition

There are three distinguishing characteristics of

high-frequency oscillatory ventilation:
The frequency range from 5 to 50 Hz (300 to 3000
bpm)
active inspiration and active expiration
Tidal volumes: about the size of the deadspace
volume

39
High Frequency Ventilation

40
 Commercial ventilators

Various technical principles are used to generate oscillating

ventilation patterns.

The so-called "true" oscillators provide active inspiration and

active expiration with sinusoidal waveforms:
Piston oscillators move a column of gas rapidly back and forth in
the breathing circuit with a piston pump.
Its size determines the stroke volume, which is therefore fairly
constant. A bias flow system supplies fresh gas

41
The "flow-interrupters" chop up the gas flow into the patient circuit
at a high rate, thus causing pressure oscillations. Their power,
however, depends also on the respiratory mechanics of the patient

42
 Commercial ventilators
Other devices (e.g. Sensormedics 3100A)
generate oscillations with a large loudspeaker
membrane and are suitable also beyond the
neonatal period.
As with the piston oscillators, a bias flow system
supplies fresh gas.
However, this device cannot combine
conventional and HFO ventilation.

43
 The InfantStar interrupts the inspiratory gas flow with
a valve bank. Some authors regard this device as a jet
ventilator because of its principle of operation.

The Babylog 8000 delivers a high inspiratory

continuous flow (max 30 l/min) and generates
oscillations by rapidly switching the expiratory valve.
Active expiration is provided with a jet Venturi
system.

44
 Characteristic parameters and
control variables of HFV

Three parameters determine oscillatory ventilation:

Firstly, there is the mean airway pressure (MAP):
around which the pressure oscillates.
Secondly, the oscillatory volume: which results
from the pressure swings and essentially
determines the effectiveness of this type of
mechanical ventilation.
Thirdly, the oscillatory frequency: the number of
cycles per unit of time.
45
46
 Mean Airway Pressure (MAP)

The Babylog 8000 uses a PEEP/CPAP-servo-control system to

adjust MAP. In the CPAP ventilation mode, MAP equals the set
PEEP/CPAP level.
When conventional IMV ventilation cycles are superimposed,
MAP also depends on both the peak inspiratory pressure (PIP)
and the frequency.
MAP in HFV should be about the same as in the
preceding conventional ventilation, depending on the underlying
disease, and should be higher than pulmonary opening pressure.
In prematures with RDS this opening threshold is approximately
12 mbar .

47
 Mean Airway Pressure (MAP)
The crucial physiologic effect of such continuously
applied (inflation) pressure is the opening of atelectatic
lung areas, resulting in marked recruitment of lung
volume.

Intermittent application of additional sigh manoeuvres

can further enhance this effect.

Opening of atelectases reduces ventilation-perfusion

mismatch and thus intrapulmonary right-to-left
shunting.

48
 Mean Airway Pressure (MAP)
Therefore MAP is the crucial parameter to
control oxygenation.

By way of the PEEP/CPAP-servo-control

system the mean airway pressure with the
Babylog 8000 can be set in the range from 3 to
25 mbar.

49
50
 Amplitude oscillatory volume

The term amplitude has stood for pressure amplitude.

In the end, however, ventilation does not depend on
the pressure amplitude but on the oscillatory volume.
as a setting parameter the amplitude is one of the
determinants of oscillatory volume.
The oscillatory volume exponentially influences CO2
elimination
During HFV volumes similar to the deadspace
volume (about 2 to 2.5 ml/kg) should be the target.

51
 Amplitude oscillatory volume
In any HF ventilator, the oscillatory volume depends
characteristically on the oscillatory frequency.

Normally, lower frequencies permit higher volumes.

Even small changes in resistance and/or compliance of

the respiratory system, e.g. by secretion in the airways,
or through the use of a different breathing circuit or ET
tube, can change the oscillatory volume and thus the
effectiveness of HFV.

52
 Amplitude oscillatory volume
The amplitudes and oscillatory volumes vary also with MAP.
Especially at MAP below 8 mbar oscillatory volumes
are markedly reduced.

The oscillation amplitude is adjustable as a percentage from 0 to

100%, where 100% means the highest possible amplitude under
the given circumstances of MAP and frequency settings as well
as the characteristics of the respiratory system (breathing circuit,
connectors, ET tube and airways)

53
Amplitude oscillatory volume

54
55
Oscillation amplitude and flow as functions of MAP
and frequency with the Babylog 8000:

a) Start: FHFO = 10 Hz, MAP 6 mbar, VTHFO = 4,6 ml

b) Increase in MAP: FHFO = 10 Hz, MAP 12 mbar, VTHFO = 5,8 ml

c) Decrease in frequency: FHFO = 7 Hz, MAP 12 mbar, VTHFO = 8,5 ml

56
 Oscillatory frequency

The oscillatory frequency, measured in units of

Hertz influences the oscillatory volume and the
amplitude depending on the ventilator type
used.

57
 Oscillatory frequency
The choice of an optimal oscillatory frequency is
currently subject of controversial discussion.

With the Babylog 8000 frequencies of 10 Hz and

below have been found to be favourable because
then the internal programming permits high
flow rates and in consequence high oscillatory
volumes.

58
Oscillatory frequency

59
 The gas transport coefficient DCO2

In conventional ventilation the product of tidal volume

and frequency, known as minute volume or minute
ventilation.
Different study groups have found that CO2
elimination in HFO correlates well with VT2 x f
VT and f stand for oscillatory volume and frequency,
respectively.
This parameter is called gas transport coefficient,
DCO2 is measured and displayed by the Babylog 8000.
An increase in DCO2 will decrease pCO2.

60
the clinical relevance of the gas transport
coefficient

61
 HFV: Indications 1

When conventional ventilation fails

reduced compliance
RDS/ARDS
airleak
meconium aspiration
BPD
pneumonia
atelectases
lung hypoplasia
Other:
PPHN

62
 Indications 2

When conventional ventilation fails

Prematures
relative: PIP > 22 mbar

absolute: PIP > 25 mbar

Newborns
relative: PIP > 25 mbar

absolute: PIP > 28 mbar

63
 Combining HFV and IMV, and
sustained inflation

Oscillatory ventilation on its own can be used in the

CPAP mode, or with superimposed IMV strokes,
usually at a rate of 3 to 5 strokes per minute.

The benefit of the IMV breaths is probably due to the

opening of uninflated lung units to achieve further
volume recruitment.
Sometimes very long inspiratory times (15 to 30 s) are
suggested for these sustained inflations (SI).

64
 Combining HFV and IMV, and
sustained inflation

By applying them about every 20 minutes compliance

and oxygenation have been improved and atelectases
prevented. Especially after volume loss by deflation
during suctioning
Prevention of atelectases, which might occur under
HFV with insufficient MAP is the primary benefit
of combining HFV and IMV.
HFV superimposed to a normal IMV can markedly
improve CO2 washout (flushing the deadspace by
HFV) at lower peak pressures than in conventional
ventilation.
65
Effect of a sigh manoeuvres through sustained inflation (SI):
prior to the SI the intrapulmonary volume equals V1 at the MAP level (point
a); the SI manoeuvres temporarily increases pressure and lung volume
according to the pressure-volume curve; when the pressure has returned
to the previous MAP level, pulmonary volume remains on a higher level, V2
(point b), because the decrease in pressure occurred on the expiratory
limb of the PV loop.

66
HFV: Start

67
68
69
70
Strategies for various lung diseases

71
72
73
74
75