Mechanical ventilation in neonates
- Eric C Eichenwald, MD
Eric C Eichenwald, MD
- Professor of Pediatrics
- University of Texas Health Science Center
The introduction of mechanical ventilation in the 1960s was one of the major new interventions in neonatology, which provided lifesaving support for infants with respiratory failure. Along with other technologic advancements, such as the administration of antepartum corticosteroids and replacement surfactant therapy, mechanical ventilation has led to improved neonatal survival, especially for preterm infants born less than 30 weeks gestation with immature lung function. (See "Incidence and mortality of the preterm infant".)
Although mechanical ventilation can be lifesaving, it may cause chronic lung injury resulting in bronchopulmonary dysplasia (BPD), a major complication of prematurity. As a result, continued efforts have been focused upon development of new technology, including the use of early continuous positive airway pressure (CPAP) in preterm infants at risk for neonatal respiratory distress syndrome (RDS) and strategies for neonatal ventilator care to maintain adequate gas exchange but minimize lung damage. (See "Pathogenesis and clinical features of bronchopulmonary dysplasia" and "Prevention and treatment of respiratory distress syndrome in preterm infants", section on 'Nasal continuous positive airway pressure'.)
Neonatal ventilator care, including the different types of mechanical ventilation and their advantages and disadvantages, will be reviewed here.
Benefits — The principal benefits of neonatal mechanical ventilation during respiratory failure are as follows:
●Improve gas exchange, primarily by lung recruitment to improve ventilation/perfusion (V/Q) matching (see "Physiologic and pathophysiologic consequences of mechanical ventilation", section on 'Reduced shunt')
- Cullen AB, Cooke PH, Driska SP, et al. The impact of mechanical ventilation on immature airway smooth muscle: functional, structural, histological, and molecular correlates. Biol Neonate 2006; 90:17.
- Donn SM, Sinha SK. Minimising ventilator induced lung injury in preterm infants. Arch Dis Child Fetal Neonatal Ed 2006; 91:F226.
- Bernstein G, Mannino FL, Heldt GP, et al. Randomized multicenter trial comparing synchronized and conventional intermittent mandatory ventilation in neonates. J Pediatr 1996; 128:453.
- Firme SR, McEvoy CT, Alconcel C, et al. Episodes of hypoxemia during synchronized intermittent mandatory ventilation in ventilator-dependent very low birth weight infants. Pediatr Pulmonol 2005; 40:9.
- Donn SM, Nicks JJ, Becker MA. Flow-synchronized ventilation of preterm infants with respiratory distress syndrome. J Perinatol 1994; 14:90.
- Baumer JH. International randomised controlled trial of patient triggered ventilation in neonatal respiratory distress syndrome. Arch Dis Child Fetal Neonatal Ed 2000; 82:F5.
- Beresford MW, Shaw NJ, Manning D. Randomised controlled trial of patient triggered and conventional fast rate ventilation in neonatal respiratory distress syndrome. Arch Dis Child Fetal Neonatal Ed 2000; 82:F14.
- Greenough A, Dimitriou G, Prendergast M, Milner AD. Synchronized mechanical ventilation for respiratory support in newborn infants. Cochrane Database Syst Rev 2008; :CD000456.
- Cleary JP, Bernstein G, Mannino FL, Heldt GP. Improved oxygenation during synchronized intermittent mandatory ventilation in neonates with respiratory distress syndrome: a randomized, crossover study. J Pediatr 1995; 126:407.
- Ramanathan R, Sardesai S. Lung protective ventilatory strategies in very low birth weight infants. J Perinatol 2008; 28 Suppl 1:S41.
- Claure N, Bancalari E. New modes of mechanical ventilation in the preterm newborn: evidence of benefit. Arch Dis Child Fetal Neonatal Ed 2007; 92:F508.
- Osorio W, Claure N, D'Ugard C, et al. Effects of pressure support during an acute reduction of synchronized intermittent mandatory ventilation in preterm infants. J Perinatol 2005; 25:412.
- Guthrie SO, Lynn C, Lafleur BJ, et al. A crossover analysis of mandatory minute ventilation compared to synchronized intermittent mandatory ventilation in neonates. J Perinatol 2005; 25:643.
- Reyes ZC, Claure N, Tauscher MK, et al. Randomized, controlled trial comparing synchronized intermittent mandatory ventilation and synchronized intermittent mandatory ventilation plus pressure support in preterm infants. Pediatrics 2006; 118:1409.
- Beck J, Reilly M, Grasselli G, et al. Patient-ventilator interaction during neurally adjusted ventilatory assist in low birth weight infants. Pediatr Res 2009; 65:663.
- Lee J, Kim HS, Sohn JA, et al. Randomized crossover study of neurally adjusted ventilatory assist in preterm infants. J Pediatr 2012; 161:808.
- Stein H, Firestone K. Application of neurally adjusted ventilatory assist in neonates. Semin Fetal Neonatal Med 2014; 19:60.
- Keszler M, Abubakar K. Volume guarantee: stability of tidal volume and incidence of hypocarbia. Pediatr Pulmonol 2004; 38:240.
- Bolivar JM, Gerhardt T, Gonzalez A, et al. Mechanisms for episodes of hypoxemia in preterm infants undergoing mechanical ventilation. J Pediatr 1995; 127:767.
- Dreyfuss D, Soler P, Basset G, Saumon G. High inflation pressure pulmonary edema. Respective effects of high airway pressure, high tidal volume, and positive end-expiratory pressure. Am Rev Respir Dis 1988; 137:1159.
- Hernandez LA, Peevy KJ, Moise AA, Parker JC. Chest wall restriction limits high airway pressure-induced lung injury in young rabbits. J Appl Physiol (1985) 1989; 66:2364.
- Dreyfuss D, Saumon G. Ventilator-induced lung injury: lessons from experimental studies. Am J Respir Crit Care Med 1998; 157:294.
- Klingenberg C, Wheeler KI, Owen LS, et al. An international survey of volume-targeted neonatal ventilation. Arch Dis Child Fetal Neonatal Ed 2011; 96:F146.
- McCallion N, Davis PG, Morley CJ. Volume-targeted versus pressure-limited ventilation in the neonate. Cochrane Database Syst Rev 2005; :CD003666.
- Grover A, Field D. Volume-targeted ventilation in the neonate: time to change? Arch Dis Child Fetal Neonatal Ed 2008; 93:F7.
- Herrera CM, Gerhardt T, Claure N, et al. Effects of volume-guaranteed synchronized intermittent mandatory ventilation in preterm infants recovering from respiratory failure. Pediatrics 2002; 110:529.
- McCallion N, Lau R, Morley CJ, Dargaville PA. Neonatal volume guarantee ventilation: effects of spontaneous breathing, triggered and untriggered inflations. Arch Dis Child Fetal Neonatal Ed 2008; 93:F36.
- Wheeler K, Klingenberg C, McCallion N, et al. Volume-targeted versus pressure-limited ventilation in the neonate. Cochrane Database Syst Rev 2010; :CD003666.
- Wheeler KI, Klingenberg C, Morley CJ, Davis PG. Volume-targeted versus pressure-limited ventilation for preterm infants: a systematic review and meta-analysis. Neonatology 2011; 100:219.
- Davis PG, Morley CJ. Volume control: a logical solution to volutrauma? J Pediatr 2006; 149:290.
- Sharma A, Milner AD, Greenough A. Performance of neonatal ventilators in volume targeted ventilation mode. Acta Paediatr 2007; 96:176.
- Lista G, Castoldi F, Fontana P, et al. Lung inflammation in preterm infants with respiratory distress syndrome: effects of ventilation with different tidal volumes. Pediatr Pulmonol 2006; 41:357.
- Yoder BA, Siler-Khodr T, Winter VT, Coalson JJ. High-frequency oscillatory ventilation: effects on lung function, mechanics, and airway cytokines in the immature baboon model for neonatal chronic lung disease. Am J Respir Crit Care Med 2000; 162:1867.
- Cools F, Askie LM, Offringa M, et al. Elective high-frequency oscillatory versus conventional ventilation in preterm infants: a systematic review and meta-analysis of individual patients' data. Lancet 2010; 375:2082.
- Elective high-frequency oscillatory ventilation versus conventional ventilation for acute pulmonary dysfunction in preterm infants. Neonatology 2013; 103:7.
- Cools F, Henderson-Smart DJ, Offringa M, Askie LM. Elective high frequency oscillatory ventilation versus conventional ventilation for acute pulmonary dysfunction in preterm infants. Cochrane Database Syst Rev 2009; :CD000104.
- Cools F, Offringa M, Askie LM. Elective high frequency oscillatory ventilation versus conventional ventilation for acute pulmonary dysfunction in preterm infants. Cochrane Database Syst Rev 2015; 3:CD000104.
- Zivanovic S, Peacock J, Alcazar-Paris M, et al. Late outcomes of a randomized trial of high-frequency oscillation in neonates. N Engl J Med 2014; 370:1121.
- Wiswell TE, Graziani LJ, Kornhauser MS, et al. High-frequency jet ventilation in the early management of respiratory distress syndrome is associated with a greater risk for adverse outcomes. Pediatrics 1996; 98:1035.
- Rojas-Reyes MX, Orrego-Rojas PA. Rescue high-frequency jet ventilation versus conventional ventilation for severe pulmonary dysfunction in preterm infants. Cochrane Database Syst Rev 2015; 10:CD000437.
- Randomized study of high-frequency oscillatory ventilation in infants with severe respiratory distress syndrome. HiFO Study Group. J Pediatr 1993; 122:609.
- Keszler M, Donn SM, Bucciarelli RL, et al. Multicenter controlled trial comparing high-frequency jet ventilation and conventional mechanical ventilation in newborn infants with pulmonary interstitial emphysema. J Pediatr 1991; 119:85.
- Lemyre B, Davis PG, De Paoli AG, Kirpalani H. Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for preterm neonates after extubation. Cochrane Database Syst Rev 2014; 9:CD003212.
- Kirpalani H, Millar D, Lemyre B, et al. A trial comparing noninvasive ventilation strategies in preterm infants. N Engl J Med 2013; 369:611.
- Bhandari V. Nasal intermittent positive pressure ventilation in the newborn: review of literature and evidence-based guidelines. J Perinatol 2010; 30:505.
- Cummings JJ, Polin RA, Committee on Fetus and Newborn, American Academy of Pediatrics. Noninvasive Respiratory Support. Pediatrics 2016; 137.
- Davis PG, Lemyre B, de Paoli AG. Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for preterm neonates after extubation. Cochrane Database Syst Rev 2001; :CD003212.
- De Paoli AG, Davis PG, Lemyre B. Nasal continuous positive airway pressure versus nasal intermittent positive pressure ventilation for preterm neonates: a systematic review and meta-analysis. Acta Paediatr 2003; 92:70.
- Khalaf MN, Brodsky N, Hurley J, Bhandari V. A prospective randomized, controlled trial comparing synchronized nasal intermittent positive pressure ventilation versus nasal continuous positive airway pressure as modes of extubation. Pediatrics 2001; 108:13.
- Salvo V, Lista G, Lupo E, et al. Noninvasive ventilation strategies for early treatment of RDS in preterm infants: an RCT. Pediatrics 2015; 135:444.
- Indications for ventilation
- Types of ventilation
- CONVENTIONAL VENTILATION
- Types of conventional ventilators
- Ventilatory mode: Initiation of breath
- - Synchronized (patient-triggered) ventilation
- Modality: Pressure-limited or volume-targeted ventilation
- - Pressure-limited ventilation
- Advantages and disadvantages
- - Volume-targeted ventilation
- Advantages and disadvantages
- - Comparison between pressure- and volume-controlled ventilation
- HIGH-FREQUENCY VENTILATION
- Elective HFOV versus conventional ventilation
- Elective HFJV versus conventional ventilation
- Rescue HFV versus conventional ventilation
- NONINVASIVE MECHANICAL VENTILATION
- OUR APPROACH
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS