Basic Ventilation

Basic principles of Mechanical
Ventilation :
What a Pediatrician and
Neonatologist should know ?
Risma Kerina Kaban

Objectives
1. Concept of optimal ventilation
2. Pulmonary mechanics; compliance; resistance;
and time constant
3. Pathophysiologic mechanism responsible for
hypoxemia
4. Oxygenation during assisted ventilation
5. Pathophysiologic mechanisms responsible for
hypercapnia
6. CO2 elimination during assisted ventilation
INTRODUCTION
• Ventilation-Induced Lung Injury (VILI) caused by

mechanical ventilation contributes to significant
morbidity and mortality in neonates
• The goal of mechanical ventilation is to oxygenate

the baby and to remove carbon dioxide and to
minimize damage to the lung
VENTILATION
OPTIMAL
normal arterial normal carbon

oxygenation dioxide excretion
PCO2
PO2 → 50-80 mmHg
35-45 mmHg
SpO2 →88-92%
60 mmHg (when pH > 7,25)
Concept of optimal ventilation
“Safe Window”
Ensure adequate
pulmonary gas exchange
Minimize lung injury
With invasive or non-invasive

ventilation.
Based on patient underlying

pathophysiology (individualized). Goldsmith, J.P. & Karotkin, E.H. & Keszler, Martin & Suresh, G.K.. (2016).
Assisted Ventilation of the Neonate: An Evidence-Based Approach to
Newborn Respiratory Care: Sixth Edition.
Optimal ventilation
Oxygenation
• The lowest possible FiO2 to reach targeted O2
saturation.
• Adequate PEEP/ MAP
CO2 removal
• The lowest effective PIP → depends on the
compliance.
• Respiratory rate → depends on the resistance,
avoid gas trapping.
Mechanical Ventilation
I. Pulmonary mechanics
• The mechanical properties of the lungs is a
determinant of the interaction between the
ventilator and the infant
• A pressure gradient between the airway opening

and alveoli drives the flow of gas
• The pressure gradient necessary for adequate

ventilation is largely determined by the
compliance and resistance
Carlo W, Ambalavanan N, Chatburn R. Basic Principles of Mechanical Ventilation. In: Sinha SK, Donn
SM, editors. Manual of neonatal respiratory care. Armonk, NY: Futura Publishing Co; 2000:73–86.
II. Compliance
• Describes the elasticity or distensibility of the
lungs or respiratory system (lungs plus the
chest wall)
Infants with normal lungs

= 3-5 mL/cm /kg
Infants with RDS

= 0.1 to 1 mL/cm/kg
Clinical Relevance
A lung which is surfactant deficient as in RDS is stiff and cannot be

distended easily and hence has low compliance
A lung which has hyperinflated areas as in Bronchopulmonary
Displasia (BPD) can be easily distended and hence is described to
gave high compliance
Goldsmith, J.P. & Karotkin, E.H. & Keszler, Martin & Suresh, G.K.. (2016).
Assisted Ventilation of the Neonate: An Evidence-Based Approach to
Newborn Respiratory Care: Sixth Edition.
III. Resistance
• Describes the ability of the gas conducting parts of the
lungs or respiratory system (lungs plus chest wall) to
resist airflow.
Infants with normal lungs = 25-50 cm /L/s5
• Resistance is not markedly altered in infants with RDS or

other acute pulmonary disorders, but can be increased to
100 cm /L/s or more by small endotracheal tubes.
• Influenced by :
• Length
• Diameter
• Branches of lung and the characteristic of lung surface
• Type of flow (laminar or turbulent)
Risk Factors of Resistance
Physiological Mechanical
Small airway Flow sensor

Bronchial spasm Ett size
PIE Flow
Corpus alienum / obstruction Water in tube
Excess secretion Expiration valve of the
Trakeo bronkial malasia ventilator
Clinical Relevance
High airway resistance lungs need longer
inspiratory and expiratory time to inflate and deflate
11
IV. Time constant
➢ a measure of the time necessary for the alveolar
pressure (or volume) to reach 63% of a change in
airway pressure (or volume)
Time constant = Compliance × Resistance
Example :
lung compliance 2 mL/cm(0.002 L/ cm ) and a
resistance of 40 cm /L/s
→ Time constant = 0.002 L/cm × 40 cm /L/s

= 0.080 s.
Carlo W, Ambalavanan N, Chatburn R. Basic Principles of Mechanical Ventilation. In: Sinha SK, Donn SM, editors. Manual of
neonatal respiratory care. Armonk, NY: Futura Publishing Co; 2000:73–86.
…Time constant
Carlo W, Ambalavanan N, Chatburn R. Basic Principles of Mechanical Ventilation. In: Sinha SK, Donn SM, editors. Manual of
neonatal respiratory care. Armonk, NY: Futura Publishing Co; 2000:73–86.
…Time constant
A duration of inspiration or expiration equivalent to
3–5 time constants is required for a relatively
complete inspiration or expiration
inspiratory and expiratory duration should be 0.24–

0.4 s
The time constant will be :

➢ shorter if compliance is decreased (e.g., in
patients with RDS) or if resistance is decreased
➢ longer if compliance is high (e.g., big infants
with normal lungs) or if resistance is high (e.g.,
infants with chronic lung disease)
…Time constant
➢ Patients with a short time constant ventilate well

with short inspiratory and expiratory times and high
ventilatory frequency
➢ patients with a long time constant require longer

inspiratory and expiratory times and slower rates
➢ If inspiratory time is too short (i.e., a duration

shorter than approximately 3–5 time constants),
there will be a decrease in tidal volume delivery and
mean airway pressure (Fig. 8.2 )
Carlo W, Ambalavanan N, Chatburn R. Basic Principles of Mechanical Ventilation. In: Sinha SK, Donn SM,
editors. Manual of neonatal respiratory care. Armonk, NY: Futura Publishing Co; 2000:73–86.
…Time constant
➢ If expiratory time is too short (i.e., a duration shorter
than approximately 3–5 time constants), there will be
gas trapping and inadvertent positive end expiratory
pressure (PEEP)
Fig. 8.4 Effects of various ventilation-perfusion ratios on blood gas tensions
(a) Direct venoarterial shunting (VA/Q = 0). (b) Alveolus with a low VA/Q ratio.(c) Normal
alveolus. (d) Underperfused alveolus with high VA/Q ratio
Krauss AN: Ventilation-perfusion relationships in neonates. In Thibeault DW, Gregory GA [eds]:
Neonatal Pulmonary Care, 2nd ed. Norwalk, CT, Appleton-Century-Crofts, 1986, p 127
V. Hypoxemia
a. Ventilation–perfusion (V/Q) mismatch
is an important cause of hypoxemia in newborns
Supplemental oxygen can largely overcome the
hypoxemia resulting from V/Q mismatch
b. Shunt
is a common cause of hypoxemia in newborns
A shunt may be physiologic, intracardiac (e.g., PPHN,
congenital cyanotic heart disease), or pulmonary (e.g.,
atelectasis)
It can be thought of as a V/Q = 0 and supplemental oxygen
cannot reverse the hypoxemia.
Carlo W, Ambalavanan N, Chatburn R. Basic Principles of Mechanical Ventilation. In: Sinha SK, Donn SM,
editors. Manual of neonatal respiratory care. Armonk, NY: Futura Publishing Co; 2000:73–86.
… Hypoxemia
c. Hypoventilation
results from a decrease in tidal volume or
respiratory rate
It can be thought of as low V/Q and
supplemental oxygen can overcome the
hypoxemia easily
Causes of hypoventilation include:
depression of respiratory drive, weakness
of the respiratory muscles, restrictive
lung disease, and airway obstruction.
… Hypoxemia
d. Diffusion limitation
Diffusion limitation is an uncommon cause of
hypoxemia, even in the presence of lung
disease
Diffusion limitation occurs when mixed
venous blood does not equilibrate with
alveolar gas.
Supplemental oxygen can overcome
hypoxemia secondary to diffusion
limitation.
Oxygenation factors
Increase the oxygen uptake :
A. Increasing FiO2
B. Optimizing lung volume
• Optimizing ventilation (V) to perfusion (P)
matching and increasing the surface area for gas
exchange by increasing Mean Airway Pressure
(MAP)
C. Maximizing pulmonary blood flow
(preventing left-to-right shunt)
Chakkarapani AA, Adappa R, Mohammad Ali SK, Gupta S, Soni NB, Chicoine L, et al. “Current concepts of mechanical ventilation
in neonates” – Part 1: Basics. International Journal of Pediatrics and Adolescent Medicine. 2020 Mar 1;7(1):15–20.
VI. Oxygenation during assisted ventilation
Basic Mechanism of Gas Transport
in Neonatal Mechanical Ventilation
Tidal Volume
The amount of gas inspired in a single spontaneous
breath or delivered through an endotracheal tube
during single mechanical inflation
TV : 4-6 ml/kg
Minute Ventilation (MV) :
Tidal Volume (ml) x Respiratory Rate/min
MV → 0,2-0,3 L/min in Healthy neonates
Clinical Relevance
Using VTV (Volume Target Ventilation)
TV approx. 4-6 ml/kg
Alarm limit MV 10-20% above and below the

limit of 0,2-0,3 L/min/kg
Anatomic dead space
The portion of the incoming TV that fails to

arrive at the level of the respiratory
bronchioles and alveoli but instead remains in
the conducting airways occupying the space
• Approx. 1.5 ml/kg

• Larger in extremely low birth weight
(ELBW) infants than in more mature infants
Alveolar dead space
A portion of VT may be delivered to unperfused
or underperfused alveoli
Physiologic dead space (VDS)

Alveolar + Anatomic dead space =
physiologic dead space (VDS)
Waste Ventilation = VDS/TV

The proportion of tidal gas delivered that is not
involved in actual gas exchange
Clinical Relevance
As a 24-weeks old, 600 gr preterm infant
would gave a larger dead space, usually
start at 5 ml/kg tidal volume when
compared to a term baby at 4 ml/kg at
the start of volume ventilation
VII. Hypercapnia
▪ The pathophysiologic mechanisms responsible for
hypercapnia : V/Q mismatch, shunt, hypoventilation,
and increased physiologic dead space
▪ The physiologic dead space results in part from areas

of inefficient gas exchange because of low perfusion
(wasted ventilation)
▪ Physiologic dead space includes ventilation to

conducting airways and alveolar spaces not perfused
(i.e., anatomical dead space)
Ventilation
A. Process of CO2 removal from the lung
B. Retention of CO2
• Respiratory acidosis
• ↓ pH
C. Aggressive clearance of CO2 (very low
CO2 level)
• Harmful → ↓ cerebral blood flow
• Brain ischemia
VIII. CO2 elimination during assisted ventilation
CONCLUSION
❖Concepts of optimal ventilation are ensure
adequate gas exchange (prevent hypoxemia
and hypercapnia) and minimize lung injury
❖Mechanism responsible for hypoxemia are

ventilation-perfusion mismatch, shunt,
hypoventilation and diffusion limitation
❖Mechanism responsible for hypercapnia are

V/Q mismatch, shunt, hypoventilation, and
increased physiologic dead space
Thank you…
QUIZ
34
ARE YOU VENTILATING NEONATES ?
1. Yes, routinely
2. Yes, occasionally
3. Very rarely
4. Never have I done so far
35
Quiz
Case : 1 day old baby, 30-weeks gestational age,
BW 1250 gr, ventilated on SIPPV
Pressure : 20/5 PROBLEM ?
FiO2 : 50% 1. Low MV
RR : 60x/m 2. High pCO2
MV : 0.15 L/m 3. Low pO2
Saturation 85% 4. All of the above
ABG : pH 7,2
pO2 30 Solution ?
pCO2 70 3. ↑ PEEP
1. ↑ RR
HCO3 25 4. ↓ PEEP
2. ↑ PiP
BE -5 5. ↑ Flow
Quiz
Case : 3 days old baby, 26-weeks gestational age,
BW 700 gr, ventilated on SIPPV
Pressure : 20/5 PROBLEM ?
FiO2 : 35% 1. High pCO2
RR : 40x/m 2. Low pH
3. Normal pO2
MV : 0.15 L/m
4. All of the above
Saturation 90%
ABG : pH 7,1 Solution ?
pO2 50 3. ↑ PiP
1. ↑ FiO2
4. ↑ PEEP
pCO2 75 2. ↑ RR
5. ↑ Flow
BE -5

Basic Ventilation

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Basic Ventilation

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Basic principles of Mechanical

Risma Kerina Kaban

• Ventilation-Induced Lung Injury (VILI) caused by

• The goal of mechanical ventilation is to oxygenate

normal arterial normal carbon

Minimize lung injury

With invasive or non-invasive

Based on patient underlying

• A pressure gradient between the airway opening

• The pressure gradient necessary for adequate

Infants with normal lungs

Infants with RDS

A lung which is surfactant deficient as in RDS is stiff and cannot be

Infants with normal lungs = 25-50 cm /L/s5

• Resistance is not markedly altered in infants with RDS or

Small airway Flow sensor

Time constant = Compliance × Resistance

→ Time constant = 0.002 L/cm × 40 cm /L/s

inspiratory and expiratory duration should be 0.24–

The time constant will be :

➢ Patients with a short time constant ventilate well

➢ patients with a long time constant require longer

➢ If inspiratory time is too short (i.e., a duration

MV → 0,2-0,3 L/min in Healthy neonates

TV approx. 4-6 ml/kg

Alarm limit MV 10-20% above and below the

The portion of the incoming TV that fails to

• Approx. 1.5 ml/kg

Physiologic dead space (VDS)

Waste Ventilation = VDS/TV

▪ The physiologic dead space results in part from areas

▪ Physiologic dead space includes ventilation to

❖Mechanism responsible for hypoxemia are

❖Mechanism responsible for hypercapnia are

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