Effects of Volume-Guaranteed Synchronized Intermittent Mandatory Ventilation

in Preterm Infants Recovering From Respiratory Failure

Carmen M. Herrera, Tilo Gerhardt, Nelson Claure, Ruth Everett, Gabriel Musante,
Carlos Thomas and Eduardo Bancalari
Pediatrics 2002;110;529
DOI: 10.1542/peds.110.3.529

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 Effects of Volume-Guaranteed Synchronized Intermittent Mandatory
Ventilation in Preterm Infants Recovering From Respiratory Failure
Carmen M. Herrera, MD; Tilo Gerhardt, MD; Nelson Claure, MS; Ruth Everett, RN; Gabriel Musante, MD;
Carlos Thomas, MD; and Eduardo Bancalari, MD
ABSTRACT. Objective. Volume guarantee (synchro-
nized intermittent mandatory ventilation [SIMV]ⴙVG)
is a novel mode of SIMV for automatic adjustment of the
peak inspiratory pressure to ensure a minimum set me-
chanical tidal volume (VT mech). The objective of this
study was to compare the effects of SIMVⴙVG with
conventional SIMV on ventilation and gas exchange in a
group of very low birth weight infants recovering from
acute respiratory failure.
Methods. Nine infants were initially studied during 2
consecutive 60-minute ventilatory modalities of conven-
tional SIMV (ventilator settings by clinical team) and
SIMVⴙVG 4.5 (VT mech set at 4.5 mL/kg) in random order.
Eight additional infants were studied during the same
ventilatory modalities plus 1 additional epoch consisting
of SIMVⴙVG 3.0 (VT mech set at 3.0 mL/kg).
Results. Peak inspiratory pressure was significantly
lower during SIMVⴙVG 3.0. Mean airway pressure,
VT mech, number of large VT mech (>7 mL/kg), and me-
chanical minute ventilation (VⴕE) were reduced during
SIMVⴙVG 4.5 compared with SIMV and were further
reduced during SIMVⴙVG 3.0. Spontaneous VⴕE in-
creased during SIMVⴙVG 4.5 and was even higher dur-
ing SIMVⴙVG 3.0. The resulting total VⴕE was higher
during both SIMVⴙVG modes compared with SIMV.
Arterial oxygen saturation by pulse oximetry, transcuta-
neous carbon dioxide tension, and fraction of inspired
oxygen did not differ significantly, although transcuta-
neous carbon dioxide tension increased slightly during
SIMVⴙVG 3.0.
Conclusions. The short-term use of SIMVⴙVG re-
sulted in automatic weaning of the mechanical support
and enhancement of the spontaneous respiratory effort
while maintaining gas exchange relatively unchanged in
comparison to conventional SIMV. Pediatrics 2002;110:
529 –533; mechanical ventilation, patient triggered venti-
lation, weaning.
ABBREVIATIONS. VLBW, very low birth weight; SIMV, synchro-
nized intermittent mandatory ventilation; PIP, peak inspiratory
pressure; VG, volume guarantee ventilation; VT mech, mechanical
tidal volume; PEEP, positive end-expiratory pressure; Fio2, frac-
tion of inspired oxygen; Spo2, arterial oxygen saturation by pulse
oximetry; TcPco2, transcutaneous carbon dioxide tension; MAP,
mean airway pressure; SD, standard deviation; V⬘E spont, sponta-
neous minute ventilation; V⬘E mech, mechanical minute ventilation;
V⬘E tot, total minute ventilation (mechanical ⫹ spontaneous); IMV,
From the Division of Neonatology, Department of Pediatrics, University of
Miami School of Medicine, Miami, Florida.
Received for publication Aug 8, 2001; accepted Mar 14, 2002.
Reprint requests to (E.B.) Division of Neonatology, Department of Pediat-
rics, University of Miami School of Medicine, Box 06960 R-131, Miami, FL
33101. E-mail: ebancalari@miami.edu
PEDIATRICS (ISSN 0031 4005). Copyright © 2002 by the American Acad-
emy of Pediatrics.
PEDIATRICS Vol. 110 No. 3 September 2002
Downloaded from pediatrics.aappublications.org at Pennsylvania State Univ on March 3, 2014
intermittent mandatory ventilation; VT spont , spontaneous tidal
volume.
D
espite a substantial decrease in mortality
from initial respiratory failure in very low
birth weight (VLBW) infants during the past
2 decades, significant morbidities associated with
mechanical ventilation still occur frequently.1 There
is no consensus regarding an optimal ventilatory
strategy for the support of the preterm newborn.
The mechanical support required by ventilator-
dependent preterm infants varies from minute to
minute because of the spontaneous changes in in-
spiratory effort and sudden changes in respiratory
compliance and resistance associated with breath-
holding and active expiration.2 Slower changes in
lung mechanics can occur with development or res-
olution of atelectasis, pulmonary edema, and accu-
mulation of secretions in the airway. During syn-
chronized intermittent mandatory ventilation
(SIMV), these varying conditions are met with a con-
stant peak inspiratory pressure (PIP) regardless of
the tidal volume achieved. The PIP is chosen to pro-
vide stability of gas exchange throughout these
changing conditions, and, therefore, pressure set-
tings are usually higher than those required. This
increases the risks of ventilator-induced lung inju-
ry3–7 and may result in hypocarbia, which inhibits
the infant’s own inspiratory drive and may be asso-
ciated with pulmonary and neurologic complica-
tions.8,9
Volume guarantee (SIMV⫹VG) is a novel mode of
synchronized, time-cycled, pressure-limited ventila-
tion, developed to maintain a minimal preset me-
chanical tidal volume (VT mech) by microprocessor-
controlled PIP adjustments. The automatic PIP
adjustments during SIMV⫹VG are determined by
the difference between set and exhaled VT mech.
The proposed mechanism by which SIMV⫹VG
may benefit mechanically ventilated preterm infants
is by ensuring a tidal volume close to a physiologic
level, which would result in a more efficient use of
their spontaneous inspiratory effort. Downregula-
tion of PIP when VT mech remains at or above the
physiologic level releases the infant’s own respira-
tory drive from the suppression caused by superim-
posed ventilation and averts overinflation pressures
that increase the risk of baro- and volutrauma. In
addition, prevention of excessively low tidal vol-
umes, attributable to sudden deterioration in the me-
529
chanical characteristics of the respiratory system, can
preserve alveolar gas exchange and prevent atelecta-
sis.10 –12
The objective of this study was to assess the effects
of SIMV⫹VG on ventilator-generated airway pres-
sure, minute ventilation, oxygenation, and ventila-
tion in relation to conventional SIMV in a group of
stable preterm VLBW infants in the recovery phase
of acute respiratory failure. We hypothesized that
guaranteeing a VT mech within the normal range of
spontaneously breathing VLBW preterm infants
would allow reduction in PIP while maintaining ad-
equate ventilation and oxygenation.
METHODS
Study Population
Mechanically ventilated, clinically stable infants who were ap-
propriate for gestational age, had birth weights between 600 g and
1200 g, and were at least 48 hours of age at the time of the study
were considered eligible. Exclusion criteria included severe con-
genital anomalies, perinatal asphyxia, sepsis, symptomatic patent
ductus arteriosus, severe intraventricular hemorrhage (grades
3– 4), sedation, and patient deemed to be clinically unstable by the
attending neonatologist.
The study was approved by the University of Miami School of
Medicine, Subcommittee for the Protection of Human Subjects.
Patients were enrolled after written informed consent was ob-
tained from the parents.
Study Protocol
Initially, infants were studied during 2 consecutive 60-minute
epochs of conventional SIMV and SIMV⫹VG at a target VT mech of
4.5 mL/kg (SIMV⫹VG 4.5) in random order. Ventilator settings of
PIP, positive end-expiratory pressure (PEEP), mechanical inspira-
tory time, and rate during SIMV were those selected by the clinical
team before the study. During SIMV⫹VG, all ventilator settings
were the same except for PIP, which was set at 10 cm H2O above
the clinical setting and was used to limit the delivered PIP during
VG.
An interim evaluation of the results from the first 9 patients
showed evidence that, the majority of the time, VT mech was larger
than that during spontaneous breaths, preventing the infants from
increasing their respiratory contribution. Therefore, to explore
further the effect of VT mech on PIP, we studied 8 additional infants
while they underwent the same ventilatory modalities of conven-
tional SIMV and SIMV⫹VG 4.5 plus 1 additional epoch consisting
of SIMV⫹VG 3.0 (VT mech set at 3.0 mL/kg) also in random order.
Ventilator settings of mechanical rate, inspiratory time, and PEEP
were left unchanged during both SIMV⫹VG periods.
Randomization was determined using sealed envelopes. The
infants were studied in their incubators in the prone position.
Mechanical Ventilator
A Draeger Babylog 8000 plus, a timed-cycled, continuous-flow,
pressure-limited, flow-triggered neonatal ventilator, with expira-
tory tidal volume targeting (Software version 3; Draeger, Inc,
Lubeck, Germany), was used for all ventilation modes. The flow
sensor, a hot wire anemometer (direction sensitive), was calibrated
before each study. According to the manufacturer’s instructions,
the ventilator undergoes an internal calibration procedure while
both ends of the sensor are occluded. The ventilator airflow and
airway pressure output signals were also internally calibrated.
The same ventilator unit was used to ventilate all infants during
the 3 modes. The reported relative volume error of this device is
⫺5.3 ⫾ 1.1% for volumes ⬍10 mL.13
During SIMV⫹VG, the ventilator compares the measured ex-
haled VT mech to the target guaranteed level set by the operator.
After each mechanical breath, the necessary pressure for the sub-
sequent mechanical breath is calculated using a proprietary algo-
rithm based on such comparison. For achieving a relatively
smooth transition from the initial tidal volume to the target vol-
ume, only a portion (⫾3 cm H2O) of the pressure difference is
added to the pressure on the next breath. As a safety feature, if
530 VOLUME-GUARANTEED VENTILATION IN PRETERM INFANTS
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total inspiratory VT mech exceeds 150% of the set tidal volume, then
the ventilator expiratory valve opens, ending the mechanical in-
spiration. The automatic adjustments of PIP are kept within a
preset range defined by an upper limit of PIP and the PEEP. In this
study, the PIP limit was set 10 cm H2O above the PIP that was
used during the conventional SIMV mode.
Measurements
The following parameters were measured throughout the en-
tire study period: Airflow and airway pressure signals were ob-
tained from the ventilator’s analog output, and tidal volume was
obtained by digital integration of airflow signal. Fraction of in-
spired oxygen (Fio2) was measured using an oxygen analyzer
(VTI oxygen analyzer; Vascular Technology, Inc, Chelmsford,
MA). Arterial oxygen saturation was monitored continuously by
pulse oximetry (Spo2; Novametrix 520 A; Novametrix Medical
Systems Inc, Wallingford, CT). Transcutaneous carbon dioxide
tension (TcPco2) was measured with a Transcend Shuttle (Sensor-
medics, CA) or TCM3 (Radiometer, Copenhagen, Denmark). All
signals were digitized at a rate of 100 Hz and recorded on disk
using data acquisition software (DATAQ Instruments, Inc, Akron,
OH).
Data Processing and Statistical Analysis
Computerized analysis was performed during the last 45 min-
utes of each 60-minute epoch of conventional SIMV, SIMV⫹VG
4.5, and SIMV⫹VG 3.0. The first 15 minutes of each epoch was
considered a stabilization period.
PIP, mean airway pressure (MAP), and the number of ventila-
tor-generated breaths were obtained from the airway pressure
signal. The tidal volume resulting from the combined ventilator
positive pressure plus the infant’s inspiratory effort during syn-
chronous breaths was counted as a mechanical breath. An effec-
tive mechanical breath was defined as any mechanical breath
delivered with positive inspiratory pressure above the PEEP level.
The mechanical rate refers to the number of effective mechanical
breaths occurring every minute.
The number of effective mechanical breaths and VT mech coef-
ficient of variation were calculated for each epoch. The number of
effective mechanical breaths with VT mech ⬎7 mL/kg was calcu-
lated for each mode and reported as a percentage of the total
number of mechanical breaths. Spontaneous breaths were defined
as those generated by the infant’s spontaneous respiratory effort
without any positive pressure generated by the ventilator above
the PEEP level.
The mean and standard deviation (SD) of all individual breaths
were obtained for each infant during each ventilatory mode. The
reported data represent the mean and SD of all infants’ mean
values.
For each infant, the spontaneous (V⬘E spont) and mechanical
(V⬘E mech) components of the total expiratory minute ventilation
(V⬘E tot) were derived from the number and tidal volumes of spon-
taneous and mechanical breaths for every minute, and the mean
and SDs were calculated for each epoch. The average Fio2, Spo2,
and TcPco2 were obtained for each 45-minute epoch.
Within-subjects comparisons were done using 1-way repeated
measures analysis of variance. P ⬍ .05 was considered statistically
significant.
RESULTS
Seventeen mechanically ventilated, clinically sta-
ble, VLBW preterm infants were included in the
study. These infants weighed 854 g (655–1140 g) at
birth (mean [range]), were born at 27 weeks of ges-
tation (24 –31 weeks), and were 5 days old (2–9 days)
at the time of the study. Of the 17 infants, 8 had
perinatal respiratory depression without significant
lung disease. Nine infants were recovering from re-
spiratory distress syndrome, and they all received
surfactant therapy within the first 6 hours of life.
Seven infants were boys, 15 were exposed to antena-
tal steroids; 12 mothers received magnesium sulfate
before delivery. Their mechanical ventilatory sup-
port consisted of an SIMV rate of 16 breaths/min
(10 –20 breaths/min), PIP of 15 cm H2O (13–20 cm
H2O), PEEP of 4 cm H2O (3–5 cm H2O), and Fio2 of
0.22 (0.21– 0.30).
There was a significant reduction in PIP during
SIMV⫹VG 3.0 compared with both SIMV⫹VG 4.5
and SIMV periods. There was a small but not signif-
icant reduction in PIP during SIMV⫹VG 4.5 in com-
parison with conventional SIMV (Table 1).
Downregulation of PIP to PEEP level when spon-
taneously generated tidal volumes were sufficiently
large (at or above the VT mech set) during SIMV⫹VG
resulted in a lower number of effective mechanical
breaths delivered when compared with conventional
SIMV. Therefore, during SIMV⫹VG, the effective
mechanical rate was often lower than the one set at
the ventilator. A significant reduction of the effective
mechanical rate was observed with SIMV⫹VG 3.0
compared with SIMV and SIMV⫹VG 4.5 (Table 1).
The combined reduction in PIP and number of
breaths generated by the ventilator resulted in a
lower MAP during SIMV⫹VG modes compared
with SIMV and was lower during SIMV⫹VG 3.0 in
comparison with SIMV⫹VG 4.5 (Table 1).
As expected, the reduction in the mechanical sup-
port affected the ventilation in these infants. V⬘E tot
was higher during both SIMV⫹VG modes compared
with conventional SIMV, but its mechanical compo-
nent was lower during SIMV⫹VG. This reduction in
V⬘E mech was more pronounced with SIMV⫹VG 3.0.
The reduction in V⬘E mech during SIMV⫹VG was
accompanied by a proportional increase in VE spont,
thus increasing the contribution of the spontaneous
component on V⬘E tot (Fig 1).
The increase in V⬘E spont observed at both levels of
SIMV⫹VG with respect to SIMV resulted from a
combined increase in spontaneous tidal volume (VT
spont) and spontaneous respiratory rate (ie, unsup-
ported breaths generated by the infant). Further-
more, there was a greater increase in spontaneous
respiratory rate during SIMV⫹VG 3.0 than during
SIMV⫹VG 4.5. This increase in the spontaneous re-
spiratory rate resulted in a significant increase in the
total respiratory rate (Table 1).
The driving pressures generated by the ventilator
alone or combined with the spontaneous inspiratory
effort during synchronous breaths resulted in a
TABLE 1. Mechanical Support, Ventilation, and Oxygenation
SIMV
PIP (cmH2O) 15.4 ⫾ 1.7
MAP (cmH2O) 5.3 ⫾ 1.4
VT mech (mL/kg) 5.9 ⫾ 0.8
VT mech ⬎ 7 mL/kg (%) 16 ⫾ 12
VT spont (mL/kg) 2.5 ⫾ 0.6
Mechanical rate (breaths/min)‡ 16 ⫾ 3
Spontaneous rate (breaths/min) 41 ⫾ 15
Total rate (breaths/min) 57 ⫾ 12
Fio2 0.23 ⫾ 0.024
Spo2 (%) 94 ⫾ 2.1
TcPco2 (mmHg) 46.8 ⫾ 11.5
Mean ⫾ SD.
* P ⬍ .05 versus SIMV.
† P ⬍ .05 versus SIMV ⫹ VG 4.5.
‡ Refers to effective mechanical rate.
Downloaded from pediatrics.aappublications.org at Pennsylvania State Univ on March 3, 2014
smaller VT mech delivered during SIMV⫹VG than
during conventional SIMV. This was more evident
during SIMV⫹VG 3.0. This reduction in VT mech dur-
ing SIMV⫹VG resulted in a lower incidence of me-
chanical breaths with excessive tidal volumes (⬎7
mL/kg) during both SIMV⫹VG modes when com-
pared with SIMV (Table 1). There was a significantly
greater coefficient of variation (%) in VT mech during
SIMV⫹VG 3.0 (41 ⫾ 7) when compared with con-
ventional SIMV (27 ⫾ 7) and SIMV⫹VG 4.5 (31 ⫾ 7).
Fio2, Spo2, and TcPco2 did not differ significantly
among the 3 different ventilatory modalities (Table
1).
DISCUSSION
Microprocessor technology present in the new
generation of neonatal ventilators allows for precise
control of pressure, volume, rate, and inspiratory
time. This technology renders itself useful for the
automatic control of these parameters, thereby pro-
viding gentler mechanical ventilatory support to pre-
term infants by preventing the delivery of excessive
pressure or tidal volume while providing the sup-
port needed to maintain adequate lung volume and
gas exchange.
In this group of preterm newborns, using
SIMV⫹VG to guarantee the delivery of VT mech in the
range of that spontaneously generated by the infant
was associated with a reduction in mechanical sup-
port to a level significantly lower than that chosen by
the clinical team for conventional SIMV. Despite the
reduction in the mechanical ventilatory support,
Fio2, Spo2, and TcPco2 were not significantly differ-
ent between SIMV and SIMV⫹VG.
The reduction in PIP observed during SIMV⫹VG
4.5 was similar to that reported in a recent publica-
tion,14 but in the present study, a more striking re-
duction was observed only during SIMV⫹VG 3.0. In
that study, PIP limit during VG was set at the same
level used for conventional ventilation, whereas in
the present study, PIP was limited to 10 cm H2O
above the clinical setting. This higher PIP limit did
not have a significant influence on the results of the
present study, which included infants in relatively
stable condition. However, it may have significant
effects in a population of infants who present with
dynamic changes in lung compliance and resistance.2
SIMV⫹VG 4.5 SIMV⫹VG 3.0
14.2 ⫾ 2.4 11.7 ⫾ 2.9*†
4.9 ⫾ 1.3* 4.4 ⫾ 0.53*†
4.8 ⫾ 0.4* 4.2 ⫾ 0.6*†
6 ⫾ 4* 4 ⫾ 3*
3.3 ⫾ 0.7* 3.6 ⫾ 0.5*
15 ⫾ 3 12 ⫾ 4*†
46 ⫾ 11* 51 ⫾ 10*†
61 ⫾ 9* 63 ⫾ 8*†
0.23 ⫾ 0.023 0.23 ⫾ 0.018
94 ⫾ 2.4 95 ⫾ 1.5
48.2 ⫾ 13.4 52.0 ⫾ 11.0
ARTICLES 531
Fig 1. V⬘E tot, V⬘E mech, and V⬘E spont, during conventional SIMV, SIMV⫹VG 4.5, and SIMV⫹VG 3.0 (mean ⫾ SD). V⬘E tot was higher,
whereas its mechanical component was lower during SIMV⫹VG when compared with conventional SIMV. *P ⬍ .05 versus SIMV; #P ⬍
.05 versus SIMV⫹VG 4.5.
No adverse effects were observed during
SIMV⫹VG when tidal volume target values in the
physiologic range and a pressure limit of 10 cm H2O
above the PIP used clinically were used. No exces-
sive pressures or tidal volumes were recorded, and
episodes of low arterial saturation and bradycardia
did not increase in number.
Although this group of infants was already receiv-
ing a relatively low level of mechanical support dur-
ing SIMV, automatic weaning further stimulated the
infants’ respiratory drive, resulting in an increase in
VT spont and spontaneous respiratory rate during
SIMV⫹VG. The enhanced respiratory drive is re-
flected in the increased spontaneous component of
V⬘E tot.
These results suggest that VLBW infants fre-
quently require less ventilatory support than that
provided clinically and that they are able to increase
their inspiratory effort when challenged. A lower
level of mechanical support should reduce the risks
of baro- and volutrauma, as shown by a reduction in
the incidence of breaths with excessive tidal volumes
during SIMV⫹VG.
A similar reduction in mechanical support could
be obtained by decreasing PIP during conventional
SIMV. This maneuver, however, may result in a
VT mech that fluctuates over time, particularly in the
lower ranges of PIP, where VT mech has a greater
spontaneous inspiratory effort component that is
characterized by its variability in preterm infants.
Therefore, a reduction in PIP during SIMV may re-
quire more frequent monitoring to prevent delivery
of a VT mech less than or close to the anatomic dead
space. This could result in insufficient gas exchange
and progressive lung collapse.
The respiratory drive of VLBW infants has an in-
trinsic instability2,15; thus, shifting the ventilation to a
larger V⬘E spont component during SIMV⫹VG led to
increased variability in VT mech. Most of the variabil-
ity in VT mech during SIMV⫹VG resulted from the
variability of the infant inspiratory effort during syn-
532 VOLUME-GUARANTEED VENTILATION IN PRETERM INFANTS
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chronized mechanical breaths, but it may also be
secondary to a delayed response by the ventilator’s
algorithm that adjusts PIP in subsequent breaths af-
ter a change in VT mech. The delay in the response is
larger at lower SIMV rates, which in the face of
rapidly changing conditions could augment the vari-
ability in VT mech.
The most appropriate setting for VT mech during
SIMV⫹VG or even SIMV for different clinical condi-
tions and its long-term implications still remain to be
determined. In this study, a significant decrease in
PIP was obtained only with SIMV⫹VG when the
VT mech was set at approximately 50% of the VT mech
delivered during SIMV. However, the smaller
VT mech may result in lower alveolar ventilation in
infants with a relatively large anatomic dead space,
thus requiring them to increase V⬘E tot beyond the
levels observed during SIMV to compensate for in-
creased dead space ventilation. Conversely, setting
too high a guaranteed VT mech during SIMV⫹VG
may override the infant’s inspiratory effort, allowing
the ventilator to take over ventilation and thereby
inhibiting the infant’s own respiratory drive.
In the present study, the increase in V⬘E tot during
VG in comparison with SIMV was generated by an
increase in both VT spont and respiratory rate. In con-
trast to the results reported by Cheema and Ahluwa-
lia ,14 the observed compensatory increase in V⬘E spont
exceeded the reduction in V⬘E mech.
Our results show that it was necessary to guaran-
tee a relatively low VT mech during SIMV⫹VG 3.0 to
reduce significantly the mechanical support. This,
however, was accompanied by an upward trend in
TcPco2, suggesting that not all infants were able to
maintain adequate ventilation when the support was
reduced to those levels. The increasing values of
TcPco2 observed during the SIMV⫹VG modes, es-
pecially with SIMV⫹VG 3.0, although not statisti-
cally different, could reach significance with a larger
sample size. Furthermore, our findings are based on
a relatively short study period, which may change
when the support is reduced for longer periods of
time.
In the present study, we sought to investigate the
short-term effects of SIMV⫹VG in infants requiring
relatively low levels of mechanical support. These
results suggest that SIMV⫹VG may be a useful tool
for the optimization of the mechanical support, but
additional investigation is required to determine the
effects of this modality when used for longer periods
of time and in different clinical conditions. Whether
SIMV⫹VG facilitates weaning and reduces the risk
of baro- and volutrauma and associated morbidities
during long-term use could be determined only with
a randomized clinical trial.
ACKNOWLEDGMENT
This study was supported by the University of Miami Project:
New Born.
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Increased incidence of sighs (augmented inspiratory efforts) during
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neonates. Pediatr Pulmonol. 1997;24:195–203

SMOKE GETS IN YOUR. . . ? COLON?

“The notion of reviving victims of drowning accidents with tobacco smoke

enemas seems, to say the least, a little odd. But to 18th century physicians, this
approach was entirely rational. The mainstay of treating the ‘apparently dead’ was
warmth and stimulation. Rubbing the skin was one method of stimulation, but
injecting tobacco smoke into the rectum was generally thought more powerful. . . .
Resuscitation kits. . .were produced from the middle of the 18th century onwards.
They consist of bellows, tubing, nasal or tracheal airways, rectal pipes, and medi-
caments of various kinds. Although, to our eyes, blowing air into the lungs was
vastly preferable to blowing smoke into the rectum, in part at least, these therapies
were considered interchangeable, each a stimulus of sorts.”

Lawrence G. Tobacco smoke enemas. Lancet. 2002;359:203

Noted by JFL, MD

ARTICLES 533
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Effects of Volume-Guaranteed Synchronized Intermittent Mandatory Ventilation
in Preterm Infants Recovering From Respiratory Failure
Carmen M. Herrera, Tilo Gerhardt, Nelson Claure, Ruth Everett, Gabriel Musante,
Carlos Thomas and Eduardo Bancalari
Pediatrics 2002;110;529
DOI: 10.1542/peds.110.3.529
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

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