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Review Article

Mechanical Ventilation in Newborn Infants: Clinical Practice Guidelines

of the Saudi Neonatology Society
Fahad Nasser Al Hazzani, Saleh Al Alaiyan, Khalid Al Hussein1, Saad Al Saedi2, Khalid Al Faleh3, Fahad Al Harbi4,
Zakariya Al‑Salam5, Sameer Yaseen Al Abdi6, Aziza S Al Harbi7, Abbas Al Omran8, Mahasen Azzouz9

Department of Pediatrics, Mechanical ventilation is one of the most common therapies in the neonatal

Abstract
King Faisal Specialist
Hospital and Research
intensive care unit (NICU), it is an area where technical complexity overlap
Centre, Riyadh, 1Department individual preferences due to lack of extensive scientific evidence. Our aim is
of Pediatrics, Security to provide clinical practice guidelines for conventional mechanical ventilation of
Forces Hospital, Riyadh, newborn infants, utilizing the best available scientific evidence and to address
2
Department of Pediatrics, the controversies. These guidelines are meant to help the clinician in managing
Faculty of Medicine, King
ventilated newborn infants; it should not replace clinical judgment.
Abdulaziz University, Jeddah,
3
Department of Pediatrics,
College of Medicine, King
Saud University, Riyadh,
4
Department of Pediatrics,
Neonatal Intensive Care Unit,
Al Takhassusi Hospital, Dr.
Suliman Al Habib Medical
Group, Riyadh, Saudi Arabia,
5
Department of Pediatrics and
Neonatology, Oasis Hospital,
Al Ain, Unite Arab Emirates,
6
Department of Pediatrics,
King Abdulaziz Hospital,
Ministry of National Guard,
Al Ahsa, 7Department of
Pediatrics, Madina Maternity
and Children Hospital,
Al‑Madinah Al‑Munawarah,
8
Department of Pediatrics,
AlMana Genereal Hospital,
Al Ahsa, 9Department of
Pediatrics, Maternity and
Children Hospital, Jeddah, Keywords: Infant, mechanical ventilation, newborn, preterm, very low birth
Saudi Arabia weight infants

Introduction evidence for many aspects of mechanical ventilation in

M echanical ventilation is one of the most common
therapies in the neonatal Intensive Care Unit and
is associated with increased morbidity and mortality. The
management of infants receiving mechanical ventilation
remains largely dependent on individual preferences.
Mechanical ventilation is a complex and highly
specialized area of neonatology, made more complicated
by the availability of many different modes, techniques,
and devices. In the face of a lack of clear scientific
Access this article online
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preterm infants, achieving consensus may not be easy.[1]
The development and implementation of mechanical
ventilation protocols are well supported in the
adult literature and have been recommended by
Address for correspondence: Dr. Fahad Nasser Al Hazzani,
Department of Pediatrics, King Faisal Specialist Hospital and
Research Centre, Riyadh, Saudi Arabia.
E‑mail: fhazzani@kfshrc.edu.sa
This is an open access article distributed under the terms of the Creative Commons
Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak,
and build upon the work non-commercially, as long as the author is credited and the new
creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

How to cite this article: Al Hazzani FN, Al Hussein K, Al Alaiyan S,

DOI: Al Saedi S, Al Faleh K, Al Harbi F, et al. Mechanical ventilation in newborn
10.4103/jcn.JCN_131_16 infants: Clinical practice guidelines of the Saudi Neonatology Society. J
Clin Neonatol 2017;6:57-63.

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Al Hazzani, et al.: Mechanical ventilation in newborn infants

the American College of Chest Physician and the
American College of Critical Care Medicine.[2] In
neonates, only one single‑center retrospective study
evaluated the impact of a ventilation protocol on the
respiratory outcomes of preterm infants born with birth
weight <1250 g.[3] In that center, the implementation of a
respiratory therapist‑driven protocol was associated with
earlier extubation, decreased rate of extubation failure,
and shorter duration mechanical ventilation, without any
reported side effect.
Objectives
• To provide clinical practice guidelines for
conventional mechanical ventilation of newborn
infants, utilizing the best available scientific evidence
• To address the controversial issue related to
mechanical ventilation.
Scope of the Guidelines
• The guidelines address the conventional mechanical
ventilation of newborn infants for various disease
processes in preterm and term infants
• Other forms of ventilation such as high‑frequency
oscillatory ventilation and noninvasive ventilation
will be covered in a separate clinical practice
guidelines
• Delivery room care is covered by separate clinical
guidelines
• Guidelines are meant to help the clinician in
managing ventilated infants; it should not replace
clinical judgment
• The guidelines do not endorse the use of any
commercial device or any specific type of ventilator.
 List of Abbreviations
The following explains the terminology used in the
guidelines:
• PIP: Peak inspiratory pressure
• PEEP: Positive end-expiratory pressure
• MAP: Mean airway pressure
• VT: Tidal volume
• RR: Respiratory rate
• Ti: Inspiratory times
• Te: Expiratory time
• AC: Assist‑control mode
• IMV: Intermittent mandatory ventilation
• SIMV: Synchronized intermittent mandatory
ventilation
• PLV: Pressure‑limited ventilation
• PC: Pressure control mode
• PS: Pressure support mode
• VTV: Volume‑targeted ventilation
• VC: Volume control mode
• VG: Volume guarantee mode
• PRVC: Pressure‑regulated volume control mode
• ETT: Endotracheal tube
• RDS: Respiratory distress syndrome
• PPHN: Persistent pulmonary hypertension of the
newborn.
Choice of Basic Synchronized Ventilation
Mode
The three basic synchronization modes are
assist/control (AC), pressure support ventilation (PSV), or
synchronized intermittent mandatory ventilation (SIMV).
AC results in more even tidal volume  (VT), lower work
of breathing, and more rapid weaning from mechanical
ventilation compared to SIMV. PSV provides more
complete synchronization because it is flow cycled, thus
avoiding inspiratory hold, but may result in very short
inspiratory time  (Ti) and rapid respiratory rate in very
small infants in the first few days of life when time
constants are very short. Because the short Ti results in
relatively low mean airway pressure  (MAP), adequate
positive end-expiratory pressure  (PEEP)  must be used
with PSV to avoid atelectasis.[1]
During weaning process in AC mode, reduction in
ventilator rate has no impact on minute ventilation if the
infant breathes above the control rate; primary weaning
parameter is peak inspiratory pressure  (PIP) or VT. It
is preferable to switch to SIMV mode during weaning
process or to SIMV combined with PSV.
In AC mode, the Ti is fixed; this can lead to a very short
expiratory time at high respiratory rates with resultant
incomplete expiration and air trapping (auto‑PEEP).
Volume Preset Ventilator versus Pressure
preset Ventilators
Volume preset ventilators deliver the same VT of gas
with each breath, regardless of the inflating pressure
that is needed. Pressure preset ventilators, in contrast,
are designed to deliver a volume of gas with each
breath until a preset limiting pressure designated by the
physician is reached. The remainder of volume in the
unit is then released into the atmosphere. As a result,
the VT that is delivered to the patient by pressure preset
ventilators with each breath may be variable, but the
peak pressure delivered to the airway remains constant.[4]
The Choice of Volume‑targeted versus
Pressure‑limited Ventilation
Pressure‑limited ventilation  (PLV) became the standard
of care early in the history of neonatal respiratory support
because of its ease of use and ability to cope with large

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Al Hazzani, et al.: Mechanical ventilation in newborn infants
leaks around uncuffed endotracheal tubes  (ETTs). The
main disadvantage of PLV is the risk of volutrauma
and inadvertent over ventilation when lung compliance
improves as often happens soon after birth when lung
fluid is cleared, surfactant is administered and optimal
lung volume is achieved. Volume‑controlled  (VC)
ventilation as implemented on available universal
ventilators (neonatal to adult population) controls the VT
delivered into the proximal end of the ventilator circuit,
not the VT delivered to the patient. The loss of volume
to compression of gas in the circuit and humidifier and
to ETT leak may be 75% or more of the total, making
standard VC ventilation difficult to use effectively in
small newborn infants.
Volume guarantee  (VG) is one of the several modes
of volume‑targeted pressure‑limited ventilation. These
modes control delivered VT indirectly by adjusting
either the inflation time  (volume limit) or inflation
pressure  (VG) to target a user‑selected target VT. In
VG, the microprocessor compares exhaled VT of the
previous breath to the desired target and adjusts the
working pressure up or down to achieve the target VT.
Thus, inflation pressure is reduced continuously, in real
time, rather than intermittently in response to blood gas
measurement.[1]
It is very important to know that VG ventilation does
not work properly in the presence of significant ETT
leak; in such case, a pressure‑limited mode should be
used.
A recent Cochrane review demonstrated that the use of
volume‑targeted ventilation  (VTV) modes as compared
to PLV resulted in a reduction in the combined outcome
of death or bronchopulmonary dysplasia  (BPD),
pneumothorax, days of ventilation, hypocarbia, and the
combined outcome of periventricular leukomalacia or
grade 3–4 intraventricular hemorrhage.[5]
Technical Issues with Volume‑targeted
Ventilation
In the presence of large leak around the ETT, then
VTV might not work properly. In case of major tube
leakage, the actual VT in the patient’s lungs can  (as
in other ventilation modes also) be larger than the VT
measured on the expiratory side. Then, the inspiratory
and expiratory tidal volumes are different.
It is important to understand that different mechanical
ventilators use different mechanisms to deliver target
volume and to compensate for the leak.
The clinician should refer to the ventilator manual to
understand the followings:
Journal of Clinical Neonatology  ¦  Volume 6  ¦  Issue 2  ¦  April-June 2017
• Where is the VT measured? Measuring VT at the tip
of ETT is more accurate than measuring VT at the
ventilator box (which will include the circuit volume)
• Does the ventilator measure the Inspiratory tidal
volume (VTi) or expiratory tidal volume (VTe); in
some ventilators using the neonate patient category,
the VT measured on the expiratory side is taken as
a basis for the control. While in the pediatric patient
category, the VTi is used
• What is the mechanism by which the ventilator
compensates for the leak? Most modern ventilators
provide the option of using a leak compensation
algorithm to offset this problem. Some ventilators
can compensate for 15%–20% of the leak while
others may compensate up to 50% of the leak
• What is the volume of flow sensor used? Flow sensor
represents a part of the dead space; standard neonatal
flow sensor is about 0.9 ml (generally <1.3 ml). Long
ETT contributes to the dead space also; ETT can be
cut short to decrease such dead space
• What is the scale used for flow sensor trigger
sensitivity? This could be an arbitrary scale from 1
to 10. 1 is the most sensitive setting, corresponds
to a flow trigger at 0.2 L/min with no minimum
volume required, or the trigger sensitivity could be a
set value in liter per minutes and the most sensitive
setting (0.2 L/min).[6]
Modalities of Volume‑targeted Ventilation
Volume guarantees ventilation
This modality consists of automatic adjustments to
PIP aimed at maintaining the measured exhaled VT
at a target level to compensate for changes in lung
mechanics and spontaneous breathing effort. The PIP
for the next breath is adjusted based on the difference
between the target and measured exhaled VT from
previous breaths. Proximal measurements of exhaled VT
help in circumventing the effects of inspiratory leaks
and gas compression in the circuit.[7]
Pressure‑regulated volume control
In this modality, PIP is automatically regulated to
deliver a set volume in the A/C mode. A  diagnostic
VC breath is used to calculate respiratory compliance.
Subsequently, PIP is adjusted stepwise based on volume
measurements obtained by internal flow sensors during
the inspiratory phase of prior breaths. In preterm infants,
pressure‑regulated volume control may be limited by the
accuracy of internally measured volumes. Although circuit
compliance compensation methods appear to be effective,
these have not been tested in small preterm infants.
Furthermore, measurements of inspired volume may
overestimate VT in the presence of leaks around the ETT.[7]
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Al Hazzani, et al.: Mechanical ventilation in newborn infants
Targeted tidal volume mode
In the targeted tidal volume  (TTV) mode, a ventilator
delivers gas of a set VT. During TTV, an inspiratory
pressure and an Ti are adjusted so that a VT of each breath
will reach the target VTe. In some older ventilators,
the target was not VTe but VTi and a significant gap
often occurred between the setting and VTe when there
was a leakage. In newer ventilators, a function of leak
compensation within a range of 0%–20% is added in the
TTVplus mode. While there is a leak, a unit increases an
VTi up to 20% and compensates the leak.
Suggested Settings for Volume Guarantee
Ventilation
Inflation pressure limit should initially be set 3–5  cm
H2O above the level estimated to be sufficient to achieve
a normal VT. If the target VT cannot be reached with this
setting, the pressure limit is increased until the desired
VT is generated. It is important to make sure that the
ETT is not kinked, is in the main stem bronchus or
obstructed on the carina. Significant volutrauma and/or
air leak could result from failure to recognize single‑lung
intubation. Pressure limit is subsequently adjusted to
be about 20% above the current working pressure and
adjusted periodically as lung compliance improves and
working pressure comes down. If the ventilator is unable
to reach the target VT with the set inflation pressure
limit, an alarm will sound. This serves as an early
warning system that should prompt an evaluation of the
reason for this change.
The following settings are recommended when using
VG ventilation:
• VT target should be 4–6 cc/kg
• Pressure limit: 20–22  cm H2O for small infants and
25–28 cm H2O for large infants.
Selecting Optimal Positive End‑expiratory
Pressure
PEEP should be set in proportion to the current oxygen
requirement because hypoxemia is usually a reflection
of ventilation–perfusion mismatch due to atelectasis and
low lung volume. Therefore, using a PEEP of 5 cm H2O
for all infants with respiratory distress syndrome  (RDS)
is not optimal for oxygenation and lung recruitment.[1]
Using high PEEP may lead to lung hyperinflation, air
leak, pneumothorax, decrease cardiac venous return, as
well as higher PaCO2  (as VT  will be lower). Using low
PEEP may lead to lung hypoinflation, lung collapse, and
increase requirement for FiO2.
We recommend starting with a PEEP of 5–6  cm H2O.
PEEP should be increased gradually up to 8  cm H2O if
60 Journal of Clinical Neonatology ¦ Volume 6 ¦ Issue 2 ¦ April-June 2017
the FiO2 is more than 0.30  and/or there is evidence of
low lung volume on chest X‑ray.
Pressure‑targeted Modalities
Pressure‑targeted modalities are characterized by limiting
the amount of pressure that can be delivered during
inspiration. The clinician sets the maximum pressure,
and the ventilator does not exceed this level. The
volume of gas delivered to the infant varies according
to lung compliance and the degree of synchronization
between the infant and the ventilator. If compliance
is low, less volume is delivered than if compliance
is high. In intermittent mandatory ventilation, VT
fluctuates depending on whether the infant is breathing
with the ventilator or against it. There are three main
pressure‑targeted modalities: Pressure limited ventilation
(PLV), pressure control ventilation  (PCV), and PSV,
which is also a mode [Table 1].
All three are pressure limited. Some devices allow both
PLV and PCV to be time or flow cycled. PSV is flow
cycled but time limited. Inspiratory flow during PLV is
continuous and is set by the clinician. During both PCV
and PSV, inspiratory flow is variable and is related to
lung mechanics and patient effort. It accelerates rapidly
early in inspiration, then decelerates quickly, producing
a characteristic waveform.
PCV was recently introduced into neonatal ventilators.
It differs from PLV primarily in the manner in which
flow is regulated. This produces a waveform that
accelerates then decelerates rapidly. A  rapid rise in flow
early in inspiration leads to earlier pressurization of the
ventilator circuit and delivery of gas to the infant early
in inspiration. Intuitively, this should be beneficial in
disease states characterized by homogeneity and the need
for a higher opening pressure, such as RDS. Variable flow
should be advantageous when resistance is high, such as
when a small ETT is used. The relative novelty of PCV
has thus far precluded adequate comparison to PLV.[8]
As discussed previously, VTV is better for preterm
infants than pressure‑targeted ventilation (except if there
is a major ETT leak).
Pressure Support Ventilation
PSV is used mainly as a weaning mode.
Table 1: Comparison of pressure target modalities
Parameter Pressure limited Pressure Pressure support
control
Limit Pressure Pressure Pressure
Flow Continuous, fixed Variable Variable
Cycle Time or flow Time or flow Flow (time limited)
Breath type Mechanical Mechanical Spontaneous
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Al Hazzani, et al.: Mechanical ventilation in newborn infants

Pressure support (PS) is a patient‑triggered, pressure‑limited,
flow‑cycled mode of ventilation designed to assist an
infant’s spontaneous effort with an inspiratory pressure
“boost.” PS can be used in conjunction with other modes,
such as SIMV, or it can be applied independently.[9] Most
neonatal pressure–support systems are flow triggered. It
is important to recognize that in PSV, the Ti is set by the
infant (not the ventilator). The clinician can control the max
Ti to avoid long inspiration.
To set an appropriate PS level, select a value between
the difference of PIP and PEEP, for example, if PIP is
18, PEEP is 6, then give a PS between 6 and 11 cm H2O;
assessment of work of breathing, blood gas, and chest
X‑ray should be used to choose the most appropriate
level.
Different ventilators display the PS value differently;
some ventilators display the “actual value” of PS while
other ventilators display the PS value “above PEEP.”
Setting Inspiratory Time
An Ti as long as 3–5  times constants  (a measure
of how rapidly gas can get in and out of the lungs)
allows relatively complete inspiration. Selection of
Ti with AC should reflect the infant’s time constants.
Small preterm infants with RDS have very short time
constants and should be ventilated with Ti of 0.35 s
or less. Larger infants or those with increased airway
resistance  (e.g.,  chronic lung disease or meconium
aspiration) have longer time constants and require longer
Ti up to 0.5 s. PSV is a flow‑cycled mode that results in
automatic adjustment of effective Ti in response to the
infant’s changing lung mechanics. PSV is preferred in
most infants, with the exception of those  <1  kg during
the first 2–3  days of life when their time constants are
very short. During PSV, the maximum Ti should be set
at about 0.4 s in preterm infants, longer in term infants,
and those with increased airway resistance.
Setting the Respiratory Rate
In SIMV mode: Use a high rate, especially in premature
infant with RDS. In A/C or PSV mode: Use backup
rate of 30–40, so there is enough room for the infant to
trigger the ventilator.
If SIMV is used at a low rate, then it is advisable to
add PSV to decrease the work of breathing. Additional
settings are provided in the appendix.
Suggested Blood Gas Targets
Suggested initial ventilatory settings and blood gas
targets are summarized in Table 2.
Extubation
It is important to recognize that extubation is a critical
transitional time, and many infants can experience

Table 2: Suggested Initial Ventilatory Strategies for Common Neonatal Respiratory Disorders
Disease Initial strategy Blood gas targets
Preterm infant
<1 week Rate 40-60/min pH 7.25-7.35
PEEP 5-6 cm H2O PaO2 40-60 mmHg
PIP 12-20 cm H2O PaCO2 45-55 mmHg (avoid PaCO2 <35 mmHg
Ti 0.3-0.35 s as it decreases brain perfusion)
VT 4-6 CC/kg SO2 91%-95%
>1 week Same as above but Same as above except
Increase Ti to 0.35-0.45 s PaCO2 50-70 mmHg
Increase VT by 0.5 CC
Meconium aspiration Rate 40-60/min pH 7.3-7.4
syndrome (without PPHN) PEEP 4-6 cm H2O (adjust based on chest PaO2 60-80 mmHg
X‑ray and clinical situation) PaCO2 40-50 mmHg
PIP 15-25 cm H2O SO2 92%-96%
Ti 0.4-0.5 s (long expiratory time is needed)
VT 4-6 CC/kg
PPHN Rate 40-60/min pH 7.3-7.4
PEEP 5-8 cm H2O PaO2 60-80 mm Hg
PIP 15-25 cm H2O PaCO2 40-50 mm Hg
Ti 0.35-0.45 s SO2 94%-98%
VT 4-6 CC/kg
PPHN – Persistent pulmonary hypertension of the newborn; PIP – Peak inspiratory pressure; PEEP – Peak end‑expiratory pressure VT – Tidal
volume; Ti – Inspiratory times

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Al Hazzani, et al.: Mechanical ventilation in newborn infants

Table 3: Desired blood gas goal and corresponding 7. Use the lowest effective PIP to maintain adequate
ventilator parameter changes gas exchange and avoid volutrauma
Desired goal PIP PEEP Rate I:E ratio Flow 8. PEEP should be set at 5–6  cm H2O. If the FiO2 is
Decrease PaCO2 ↑ ↓ ↑ ‑ ±↑ more than 0.30  and/or if there is evidence of low
Increase PaCO2 ↓ ↑ ↓ ‑ ±↑ lung volume on chest X‑ray, then the PEEP should
Decrease PaO2 ↓ ↓ ‑ ↓ ±↑ be increased gradually up to 8 cm
Increase PaO2 ↑ ↑ ‑ ↑ ±↑ 9. A short Ti of 0.35 s or less should be used for
PIP – Peak inspiratory pressure; PEEP – Peak end‑expiratory pressure; preterm infants. A  longer Ti  (up to 0.5 s) should be
↑ – Increase; ↓ – Decrease used for infants with increased airway resistance
significant problems during this process. Therefore, for such as: BPD or meconium aspiration syndrome
the extreme preterm infant, we recommend the presence 10. Suggested initial ventilatory strategies for common
of senior staff experienced in intubation. neonatal respiratory disorders are provided in
In a preterm infant, extubation should be attempted Table 2.
when: Financial support and sponsorship
• FiO2 is <0.35 Nil.
• PaCO2 is <55 mm Hg
• Ventilator rate is 15–20 Conflicts of interest
• MAP <8 cm H2O There are no conflicts of interest.
• Adequate spontaneous respiratory effort without
excessive work of breathing on the current settings References
• Methylxanthines are already started. 1. Sant’Anna GM, Keszler M. Developing a neonatal unit ventilation
protocol for the preterm baby. Early Hum Dev 2012;88:925‑9.
Summary of Recommendations 2. Blackwood  B, Alderdice  F, Burns  K, Cardwell  C, Lavery  G,
O’Halloran P. Use of weaning protocols for reducing duration of
1. Mechanical ventilation should be managed by a mechanical ventilation in critically ill adult patients: Cochrane
skilled clinician with good expertise in the care of systematic review and meta‑analysis. BMJ 2011;342:c7237.
newborn infants 3. Hermeto  F, Bottino  MN, Vaillancourt  K, Sant’Anna  GM.
2. The principles of neonatal resuscitation program Implementation of a respiratory therapist‑driven protocol for
neonatal ventilation: Impact on the premature population.
should be followed in relation to equipment, ETT Pediatrics 2009;123:e907‑16.
size, and stabilization 4. Spitzer  AR, Clark  RH. Positive‑pressure ventilation in the
3. Clinicians should be familiar with the specific type treatment of neonatal lung disease. In: Assisted Ventilation of the
of mechanical ventilators that are used in their units. Neonate. 5th ed. St. Louis, MO: Elsevier Inc.; 2011.
The knowledge should include and not limited to 5. Wheeler K, Klingenberg C, McCallion N, Morley CJ, Davis PG.
the modes of ventilation and the algorithms used for Volume‑targeted versus pressure‑limited ventilation in the
neonate. Cochrane Database Syst Rev 2010;11:CD003666.
leak compensation. The ventilator manual should be
6. Klingenberg  C, Wheeler  KI, Davis  PG, Morley  CJ. A  practical
reviewed carefully before use guide to neonatal volume guarantee ventilation. J  Perinatol
4. VTV is superior to PLV in preterm infants  (in the 2011;31:575‑85.
absence of large ETT leak) 7. Claure N, Bancalari E. New modalities of mechanical ventilation
5. VG ventilation mode is available in most neonatal in the newborn. In: Newborn Lung, Neonatology: Questions and
ventilators. Suggested initial settings are: Controversies Series. Philadelphia, PA: Elsevier Inc.; 2008.
8. Donn  SM, Sinha  SK. Assisted ventilation and its complications.
• VT target should be 4‑6 cc/kg
Fanaroff and Martin’s Neonatal‑Perinatal Medicine. 9th  ed. St.
• Pressure limit: 20–22 cm H2O for a small infant and Louis: Elsevier Inc.; 2011.
25–28 cm H2O for a large infant 9. Donn  SM, Becker  MA, Nicks  JJ. Special ventilation techniques
6. In the presence of large ETT leak, PLV should be I: Patient‑triggered ventilation In: Assisted Ventilation of the
used Neonate. 5th ed. St. Louis: Elsevier Inc.; 2011.

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Al Hazzani, et al.: Mechanical ventilation in newborn infants
Appendix
Cycling
In conventional positive‑pressure ventilators, the cycling
process determines the method by which the inspiratory
phase is initiated and terminated. Volume‑preset
ventilators are cycled when a preset volume is attained.
Most standard pressure‑preset ventilators are regulated
by either an electrical timer  (time‑cycled) or by a
pneumatic timer (pressure‑cycled). The pneumatic‑cycled
ventilators have a small chamber in which pressure
increases to a preset level and subsequently closes the
inspiratory valve.
Trigger sensitivity
Most neonatal pressure‑support systems are flow triggered.
The infant initiates an inspiratory effort that results in an
acceleration of airway flow. The trigger sensitivity is set
by the clinician to the lowest possible level that avoids
autocycling.[9] Optimal level depends on gestational age
and work of breathing, for small infant <750 g select low
trigger, for example, 0.5 (if minimum is 0.2, maximum is
5) or 1  (if minimum is 1, maximum is 10). If the infant
has average respiratory rate, for example, 60–70 select 2
or 3, If the infant is tachypnic, select high trigger as 4
or even 5, especially if he/she is on A/C mode to avoid
air leak.
Trigger delay
Trigger delay, also referred to as the system response
time, is the interval between signal detection and the rise
in pressure at the proximal airway. For a system to work
well, trigger delay must be minimal. As an example, an
infant whose own inspiratory time is 0.2 s  (200 msec)
will already be halfway through the inspiratory phase
if the trigger delay is longer than 100 msec. Thus,
the longer the trigger delay, the higher the work of
breathing.
Termination sensitivity (or expiratory trigger)
Termination sensitivity is a ventilator control that the
clinician can set to terminate a ventilator breath at a
specific percentage of peak flow during expiration.
Termination sensitivity is an effective way to limit
prolongation of the inspiratory phase of the ventilatory
cycle. By setting a termination sensitivity of 5%–10%,
inspiration will cease when inspiratory flow decreases
to 5%–10% of peak flow. A  termination sensitivity
of 5%–10% will usually limit inspiration to 0.2–0.3 s
during neonatal mechanical ventilation. In practice, it
is preferable to simply set the desired inspiratory time
Journal of Clinical Neonatology  ¦  Volume 6  ¦  Issue 2  ¦  April-June 2017
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directly on the ventilator and turn off the termination
sensitivity control.[9]
Heating and humidification
Administration of poorly humidified oxygen may result
in bronchospasm and airway injury in neonates. It is
important that inspired gasses are delivered at or near
body temperature  (37°C) to reduce the risk of airway
problems. When warming and humidifying any gas
administered to infant, excessive humidification may get
into the circuit and produce “rainout,” or the formation
of droplets that can drip into the airway. A  heating wire
within the ventilator circuitry can reduce the severity of
this problem.
Flow rate
An adequate flow rate is required for the ventilator to
deliver the desired PIP and waveform. As long as a
sufficient flow is used, there is minimal effect of flow
rate on gas exchange. High flows may be required
when TIs are short, to maintain tidal volume delivery.
A  minimum flow rate of about three times the infant’s
minute ventilation  (typically 0.2–1 L/min) is usually
required, and flows of 6–10  L/min are sufficient for
most neonates when using most standard conventional
ventilators.
1. Inadequate flow may contribute to air hunger,
asynchrony, and increased work of breathing
2. Excessive flow may contribute to turbulence,
inefficient gas exchange, hyperinflation, and
inadvertent PEEP.
Mean airway pressure
MAP is increased by increasing the following variable:
PEEP, PIP, Ti, and flow  (PEEP is the most effective
variable in increasing MAP if Ti is less than expiratory
time [Te]).
MAP = (PIP − PEEP) × Ti/Ti + Te + PEEP
Oxygen index
Oxygen index (OI) = MAP × FiO2/PaO2  ×  100
OI  >20 means severe hypoxic respiratory disease; other
interventions such as HFO ± iNO are needed rather than
just escalating conventional ventilation settings which
can end with lung damage.
Ventilatory adjustment
Table  3 demonstrates the effect of ventilatory variables
adjustment on blood gas values.
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