Ventilation Strategies in

Newborn
 Modes of Non-invasive
Ventilation
NCO2
NCPAP
SiPAP
NIPPV
 Nasal Cannula Oxygen
Indications
– Initial therapy for infants ≥ 34 weeks with TTNB or
pneumonia who have minimal respiratory distress
– Resolving BPD
– Mild AOP despite caffeine
– Post-extubation for infants who are unlikely to tolerate
NCPAP (>37 weeks)
– Infants who are weaning from NCPAP, but still have
O2 requirement
Mechanism: provides degree of CPAP
depending on flow rate
 NCPAP
Indications:
– Initial therapy for infants with RDS, TTNB or pneumonia.
– Post extubation to maintain FRC.
– BPD or evolving BPD.
– Infants with moderate to severe AOP despite caffeine.
Mechanism:
– Increases FRC by preventing alveolar collapse at end expiration
– Stents open the upper airway
Guidelines:
– Use pressures +4-8 cmH2O.
– Alternate nasal prongs and nasal mask in patients requiring
more than 1 week of therapy to change pressure points and
avoid cutaneous and mucosal breakdown.
 SiPAP
Indications:
– Initial therapy in infants with RDS, or infants
who have failed NCPAP.
– Post-extubation for infants < 28 weeks.
– Evolving or established BPD with FiO2
requirement ≥ 50% or significant respiratory
acidosis*.
– Infants with moderate to severe AOP despite
NCPAP.
 SiPAP
Mechanism:
– Provides bi-level CPAP
– Increases FRC by providing periods of high
expiratory resistance.
– CO2 removal occurs during the transition from
high to low PEEP, proportional to the P
difference.
 SiPAP
Guidelines:
– Provides bilevel CPAP and is asynchronous.
– Set CPAP to 4-6+ based on lung inflation, and
PIP +4 above CPAP.
– Set rate at 20-40 bpm
– Set Ti at 0.5 to 1.0 second
– Typical starting settings: Pressures 10/6 x 30
x Ti 1.0
– Use invasive heated humidification settings
 NIPPV
Indications:
– Initial therapy in VLBW infants with RDS or
pneumonia.
– Post-extubation for infants < 28 weeks.
– BPD or evolving BPD with FiO2 > 50% or
significant respiratory acidosis* despite
NCPAP.
– Infants with moderate to severe AOP despite
NCPAP.
 NIPPV
Mechanism:
– Increases FRC by delivery of tidal volume
breaths (similar to SIMV).
– NIPPV settings are adjusted as on SIMV.
 NIPPV
Guidelines:
– Provides collateral ventilation
– Set PEEP to 4-6+ and PIP at 16 Or 2 greater than
PIP on SIMV (max 30)
– Set rate 20-60 bpm. Higher rates are used to mimic
PSV.
– Set Ti at 0.4-0.5 depending on rate and leak.
– Set flow at 6-10 LPM (lowest flow capable of
achieving desired pressures)
– Typical starting settings: Pressures 16/6 x v 30 x Ti
0.5
– Use invasive heated humdification settings
 Invasive Ventilation
Indications for Mechanical Ventilation:
CO2 retention (PCO2 > 65 mmHg with
acidosis).
Poor oxygenation – FIO2 > 60% to
maintain sats 85-94%.
Persistent apnea or poor respiratory effort.
Significant respiratory distress.
Pressure Control/Pressure Support
Most common conventional mode used at CHRCO.
Infant receives a fixed number of TCPL SIMV breaths.
Additional breaths are supported with pressure support
ventilation (PSV).
PC and PS levels can be varied independently.
Pressure support may be used to overcome the
increased work of breathing created by the narrow lumen
of the ETT.
Since PS breaths terminate at the end of the infant’s
inspiration, there is a lower risk of air trapping due to
insufficient expiratory time during periods of tachypnea.
 PC/PS
Initial PC/PS settings
– Positive end expiratory pressure (PEEP) 5-7 cm H20
– Ti 0.25-0.4 seconds
– PC rate 20-30 (or well below the patient’s
spontaneous rate).
– PC adequate to give an exhaled Vt 4-6 mL/kg.
Remember that the PC level ordered = PIP– PEEP.
– PS adequate to give an exhaled Vt 4-6 mL/kg.
Remember that the PS level ordered = PIP– PEEP.
– Example: When PC/PS 15 is ordered in a patient
receiving a PEEP of 6, the PIP generated is 21 for
both the PC and PS breath.
Pressure Support (Automode)
Infant triggers a pressure support breath with every spontaneous
breath and therefore sets the respiratory rate of the ventilator.
A physiologic back up rate (generally 30-40 bpm) is set to provide a
minimum rate should the infant become apneic.
This mode is generally used in combination with VG.
On PSV, the Ti as well as the rate is determined by the infant. If the
infant’s spontaneous rate falls below the set rate, the infant will
receive a ventilator breath with a set Ti.
PS/VG allows for autoweaning since the level of PS is adjusted as
the infant’s lung compliance improves and the infant’s respiratory
drive adjusts the rate.
It is rare that PS/VG settings need to be changed. Adjustments are
generally limited to optimizing PEEP if the infant is spontaneously
breathing.
 TCPL
In infants, PPV is usually pressure-limited and time-cycled.
With each breath there is a peak inspiratory pressure (PIP), an end-
expiratory pressure (PEEP), and a mean airway pressure (MAP). MAP is
the average pressure over the inspiratory plus expiratory phase - “the area
under the curve”.
Increasing PEEP increases FRC and prevents atelectasis.
Prolonging the inspiratory time (Ti) allows more time for expansion of the
lungs and is useful to treat widespread atelectasis.
High inspiratory flows may injure the lungs. Flows of 5 to 7 L/min are
common.
Tidal volume is generated by the difference between PIP and PEEP. Tidal
volumes of 4-6 ml/kg are optimal.
Oxygenation is controlled by changing the FIO2 and by increasing the MAP.
Respiratory rate is altered by adjusting the inspiratory and expiratory times.
Short expiratory times lead to gas trapping within the lung. The minimum
expiratory time should not be < 0.3 seconds.
Inspiratory times are usually set at 0.3 to 0.4 sec. The expiratory time will
then be related to the respiratory rate. For example, if Ti=0.4 sec and
respiratory rate is 60, each respiratory cycle then lasts 1.0 sec, therefore,
the Te will be 0.6 sec.
 Volume Guarantee
This mode requires a flow sensor that can accurately detect
inspiratory and expiratory volumes of 2 mL or less.
With each breath there is a peak inspiratory pressure (PIP), an end-
expiratory pressure (PEEP) and a mean airway pressure (MAP).
Unlike TCPL, the PIP can vary between breaths.
Prolonging the Ti allows more time for expansion of the lungs and
allowing the tidal volume to be delivered at lower pressures.
High inspiratory flows may injure the lungs. If the flow is excessive
on VG ventilation, the excess flow is diverted from the baby causing
a loud humming noise. Flow rates 4-6 L/min.
Ventilation pressures should be monitored continuously. Changes in
ventilation pressures occur with changes in lung compliance.
Dropping ventilation pressures usually occur during lung recovery.
Rising ventilation pressures suggest worsening lung disease, air
leak or mechanical issues and require investigation.
 Volume Guarantee
Tidal volumes (Vt) of 4-6 mL/kg are optimal for infant’s > 1000
grams. Vt > 5 mL/kg are associated with increased risk of air leak
and BPD and suggests the need for high frequency ventilation.
Oxygenation is controlled by changing the FiO2 and by increasing
MAP. On VG, the latter is accomplished by increasing the PEEP.
Changes in Vt may or may not result in consistent changes in MAP
since the PIP fluctuates from breath to breath.
Respiratory rate is altered by adjusting the inspiratory and expiratory
times. Short expiratory (Te) times lead to gas trapping within the
lung. The minimum Te should not be < 0.3 seconds. Inspiratory
times are usually set at 0.3 to 0.4 sec.
VG can not be used if the infant has a large (> 40%) leak around the
ETT. In the presence of a large leak, the infant will need to be
changed to TCPL or re-intubated with a larger tube.
Pressure-Volume Curve
 Assist Control (AC)
Infant triggers a ventilator breath with every spontaneous
breath and therefore sets the respiratory rate of the
ventilator.
A physiologic back up rate (generally 30-40 bpm) is set
to provide a minimum rate should the infant become
apneic.
This mode is best used in combination with VG.
Initial AC settings
– Positive end expiratory pressure (PEEP) 5-7 cm H20
– Ti 0.25-0.4 seconds
– Back up rate 30-40
– PIP adequate to give an exhaled Vt 4-6 mL/kg
High Frequency Ventilation
There is considerable evidence that ventilation with high frequencies
and volumes which are below normal tidal volume, causes less lung
injury than does tidal ventilation.
Many animal studies have demonstrated that in diseases
characterized by atelectasis, such as respiratory distress syndrome,
high frequency oscillatory ventilation (HFOV) produces better lung
inflation and less alveolar and airway damage than does tidal
ventilation. These studies show that HFOV improves gas exchange
and reduces pulmonary injury by avoiding the large changes in
intrapulmonary pressure and volume necessitated by tidal
ventilation.
The maximum benefit from non-tidal ventilation occurs when it is
instituted before significant lung damage has been caused by tidal
ventilation, (ie shortly after birth).
 HFOV
HFOV is the preferred mode for ELBW infants and for moderate-
severe diseases which are relatively homogenous. Its role in older
infants with non-homogenous disease is less clear.
HFOV is indicated for patients with severe restrictive disease where
high PIP on conventional ventilation would place the infant at risk for
lung injury.
HFOV is effective in ventilating patients with pulmonary hypoplasia.
HFOV may be superior to conventional ventilation in VLBW infants
at high risk of developing BPD on conventional ventilation.

Optimizing HFOV settings:

– Inspiratory time (Tinsp) 33%
– Mean airway pressure (Paw) at least 20% greater than patient was
receiving on conventional ventilation.
– Frequency 6-10 Hertz, depending on patient size
– Amplitude (deltaP) adjusted based on physical examination (wiggle)
and/or TCM for CO2.
 HFJV
HFJV is indicated for management of patients with PIE or broncho-pleural
fistula. The short Tinsp of HFJV minimizes air leak and promotes healing of
PIE or BP fistula.
HFJV can be used effectively for any restrictive disease (e.g. RDS,
pneumonia).
HFJV provides excellent ventilation in patients with pulmonary hypoplasia.
HFJV may be superior to HFOV or conventional ventilation in some patients
with chronic lung disease and air trapping.

Initial HFJV settings:

– HFJV inspiratory time ( Tinsp) 0.02 sec
– HFJV rate 240-480 breaths/min (4-8 Hz) – use lower frequency with PIE or
hyperinflation
– PEEP 6-8. Maintaining adequate PEEP is important for success with HFJV
– HFJV PIP set 1-2 cm H20 below monitored CV
– Conventional rate 0-5 breaths/min (rate 0-3 if PIE or hyperinflation, 3-5 if
atelectasis is a problem)
– Conventional inspiratory time (Tinsp) 0.3-0.5 sec
– Conventional PIP 2-5 cm H2O less than HFJV PIP
Complications of Ventilation
Vent failure
Pulmonary over-expansion
Pneumothorax
Pneumomediastinum
Right mainstem