MECHANICAL VENTILATION

Types of ventilation — Ventilators used in the NICU can be divided into two categories
based on how minute ventilation is provided.

1. Conventional mechanical ventilation (CMV)

- Involves intermittent exchange of bulk volumes of gas, which are similar in volume to
physiologic tidal volume, within the airway tree.
- The minute ventilation is the product of frequency of breaths and tidal volume.
- Delivery of conventional ventilation varies by:
a. How the breath is initiated (ventilator or patient-triggered),
b. How the delivered tidal volume is regulated (eg, pressure or volume control)
c. How the breath is terminated (eg, volume, time, or flow-regulated)
d. Rate of ventilation
2. High frequency ventilation (HFV)
- Is based upon the delivery of small volumes of respiratory gas, which are equal to or
smaller than the anatomic dead space, at an extremely rapid rate (300 to 1500 breaths
per minute).

Mechanical Ventilator Setting

Conventional
 Rate = Set of ventilator breath per minute
 PIP = Peak Inspiratory Pressure opens the alveoli.
High PIP is a major contributor to barotrauma in the lung.
 PEEP = Positive end expiratory pressure prevents the alveoli from
collapsing during exhalation; thereby, maintains adequate
functional residual capacity (FRC) - the volume of gas that
remains in the lungs after a normal expiration.
- It also aid in recruiting atelectasis for gas exchange, improving
compliance & improving ventilation-perfusion of the lung.
 MAP = Mean Airway pressure recruit alveolar unit.
- Oxygenation is directly proportional to MAP and I:E ratio.
lower MAP- lower oxygenation
higher MAP – higher oxygenation.
- MAP also optimizes lung volume.
 Venous return and cardiac output is compromised when MAP is
abnormally high
 I:E ratio = Inspiratory Time – Expiratory Time ratio which is
between 1:1.5 or 1:2. Long inspiratory times may
contribute to excessive alveolar distention in compliant
lungs.
 VG = Volume Guarantee provides assisted tidal ventilation (Vt)
from breath to breath.
- Vt is the volume of air that moves in & out of the lungs with each
single breath.(4-6 ml/kg)
 PS = Pressure Support provides breath-by-breath pressure
support by means of a positive pressure wave
synchronized with the inspiratory effort of the patient, both
patient-initiated and patient-terminated.
 HFOV –High Frequency Oscillation Ventilation
- A method of mechanical ventilation that employs supra-
physiological breathing rates (faster rates) and tidal volumes
frequently lower than dead space.
- HFOV has been described as “CPAP with a wiggle”.
This reflects the two physical goals:
 CPAP: Sustained inflation and recruitment of lung
volume by the application of distending
pressure (mean airway pressure [MAP]) to
achieve oxygenation.
 Wiggle: Alveolar ventilation and CO2 removal by
the imposition of an oscillating pressure
waveform on the MAP at an adjustable
frequency (Hz) and an adjustable amplitude
(delta P).
- The low tidal volume allows the primary goals of ventilation,
oxygenation and CO2 removal, to be achieved without the costs of
pressure-induced lung injury.

SETTING
 Frequency = the rate measured in hertz (cycles per second)
i.e. 10Hz = 10 cycles/sec = 600 cycles/min
 Amplitude = delta P or power is the variation around the
MAP
- A rough representation of the volume of gas flow in
each high frequency pulse or "breath."
- Adjust amplitude until you achieve vigorous chest
wall vibrations.
 MAP = Mean airway pressure.
- MAP becomes approximately equal to the PEEP
- MAP provides a constant distending pressure equivalent to
CPAP.
- MAP inflates the lung to a constant and optimal lung volume
maximizing the area for gas exchange and preventing alveolar
collapse in the expiratory phase.
- If starting immediately on HFOV - use a MAP of ≈ 8-10 cm in
neonates
- If switching from CMV, the initial MAP should be either 2-4
cm above the MAP on CMV or the same as on the CMV.
- If lung is not hyper-inflated (flattened diaphragm) or is below
optimal lung volume around 9-10 ribs then increase MAP by
1-2 cm every 20-30 min until adequate oxygenation is achieved
or lung starts to become over-inflated.

Points to remember in HFOV

 Oxygenation is dependent on MAP and FiO2.

 CO2 elimination is dependent on amplitude and to a lesser degree the
frequency
 Raising the delta P of oscillation (amplitude) and vice versa may increase
ventilation. Decreasing the frequency increases CO2 removal (opposite to
CMV).
Common Ventilation Modes used in NICU and the major differences

1. AC/PC = Assist Control/Pressure Control

- The Rate, PIP, PEEP are set. FiO2 is based on O2 saturation
- Every ventilator and spontaneous breathe are provided with the set PIP and
PEEP

2. AC/PC VG = Assist Control/Pressure Control

Volume Guarantee
- The Rate, PEEP, tidal volume (Vt), maximum PIP (P max) are set. FiO2 is based
on O2 saturation
- Both ventilator and spontaneous breathe are provided with the set tidal
volume.
- The PIP varies. It depends upon the airway resistance and the lung compliance of
the patient.

3. AC/PC SIMV PS = Assist Control/Pressure Control

Pressure Support
Synchronized Intermittent Mandatory Ventilation
 The ventilator is synchronized with the baby’s
respiratory cycle. The baby & the ventilator work in
tandem. Baby does not trigger ventilator breath.
The patient trigger spontaneous breaths at a
rate and volume determined by the patient.
- The Rate, PIP, PEEP, PS are set. FiO2 is based on O2 saturation
- Each ventilator breath are provided with the set PIP and PEEP
- During spontaneous breathing, the vent provides the set pressure support and
the patient generates his own PIP.

4. AC/PC SIMV VG PS = Assist Control/Pressure Control

Synchronized Intermittent Mandatory Ventilation
Volume Guarantee
Pressure Support
- The Rate, PEEP, tidal volume (Vt), maximum PIP (P max) are set.
FiO2 is based on O2 saturation
- Each ventilator breath is provided with the set tidal volume.
- During spontaneous breathing, the vent provides the set pressure support and
the patient generates his own tidal volume.
Safety check for vented patients

 Vent settings are correctly displayed

 At what level the ETT taped at the lips
 MSCD = in-line and open suction measurement is updated and visible
 Self-inflating and anesthesia bag are properly attached, checked and functioning

VAP prevention

 A continuously closed, in-line suctioning system

 Oral care every 3 to 4 hours or with every care. Use sterile water.
 Good hand washing and glove use prior to ETT care
 Suctioned mouth prior to the nose. If multiuse suction catheters or devices are used
for oral and nasal suctioning, they should be rinsed well and place in a clean, non-
sealed plastic bag when not in use. Water used for rinsing oral suction should be
labeled with date and time.
 Elevate head at an angle of 15-30 degrees to prevent micro aspiration of both
gastrointestinal contents and oral secretions.
 Hand hygiene must be meticulous before handling respiratory equipment or
performing any type of airway care.

When to use CV and HFOV

 CV is the initial mode use. Setting is adjusted based on the blood gas result
 At present HFOV is only indicated as a rescue therapy in case of:
- Failure of conventional ventilation in patient with MAS, RDS
- Air leak syndromes like Pneumothorax, PIE
- Reduce barotrauma when conventional ventilator settings are high