Assisted Ventilation in

the Newborn
Oxygenation
Ventilation
 Time Constant
time required to allow pressure and volume
equilibration of the lung
product of compliance and resistance
setting the expiratory time at less than 3 to 5
times the length of the time constant will
increase the risk of gas trapping and
potentially inadvertent PEEP and alveolar
rupture
 Types of Ventilation
Conventional Mechanical Ventilation
ventilator or patient-triggered
pressure or volume control
volume, time, or flow-regulated
rate of ventilation.
High frequency ventilation
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)
Classification of Mechanical Ventilators
 Control Variables
When pressure is controlled, volume will
fluctuate according to the compliance of the
lungs
when volume is controlled, pressure will
fluctuate as a function of compliance
Intermittent Mandatory Ventilation
Delivers mechanical breaths at a rate set by
the clinician
Breaths are provided at regular intervals and
are not influenced by spontaneous breathing
 SIMV
Provides mechanical breaths, which are set by the
clinician, in synchrony with the onset of
spontaneous breaths that meet the preset
inspiratory flow by the infant within a timing
window.
The selected set rate is typically lower than the
infant’s spontaneous breathing rate so additional
spontaneous breaths occur without ventilator
support.
Positive end-expiratory pressure is provided for
every breath.
Synchronization is thought to lower peak
inspiratory pressure (PIP), leading to
potentially less air leak and lung injury, and
reduce the need for sedatives, thereby
shortening the weaning process from the
ventilator.
Ventilators that provide synchronization
measure inspiratory flow, pressure change, or
movement, and when a preset value is
reached, a breath is initiated
Synchronized modalities include:
Synchronized IMV (SIMV)
Assist/Control (A/C) ventilation
Pressure support ventilation (PSV)
 Assist/Control Ventilation
ventilator delivers a mechanical breath each time
the patient’s inspiratory effort exceeds the preset
threshold criterion.
provides the safety of a guaranteed minimal
mechanical breath rate (the control rate, set by the
operator) in case no patient effort occurs or is
detected.
The clinician also sets a minimum mandatory
ventilator rate to maintain adequate minute
ventilation should the spontaneous respiratory
rate fall below the minimum selected rate.
 Pressure Support Ventilation
developed to help intubated patients overcome
the imposed work of breathing created by the
narrow lumen (high resistance) endotracheal tube,
circuit dead space.
PSV is used in conjunction with SIMV to support
spontaneous breathing between SIMV breaths
with something more substantial than PEEP.
It appears that it is most commonly used as a
weaning strategy with low rate SIMV.
 PSV
similar to A/C mode in that each spontaneous
patient breath that exceeds a preset trigger
results in a ventilator support breath.
the patient determines the rate and pattern
of breathing
Continuous Positive Airway Pressure
 Physiology
Prevents collapse of alveoli at end expiration
Decreases work of breathing in accordance
with LaPlace’s Law
CPAP helps maintain functional residual
capacity (FRC) and facilitates gas exchange
CPAP maintains upper airway stability
Augment stretch receptors and decrease
diaphragmatic fatigue
 Physiology
CPAP is a form of continuous distending
pressure (CDP)
CPAP is positive pressure applied to
spontaneously breathing infants
Distending pressure applied to a mechanically
ventilated infant is positive end-expiratory
pressure (PEEP)
 Complications of CPAP
Excessive CPAP may contribute to lung
overinflation
Increase intrathoracic pressure and decrease
venous return and cardiac output
High CPAP setting may result in carbon dioxide
retention and impaired gas exchange
Soft tissue injury to nasal mucosa, septum, and
philtrum
Gastric distention
 Administration of CPAP
Nasal interfaces
Indwelling Endotracheal Tube
 Methods of Generating CPAP
High-Flow Nasal Cannula CPAP
Bubble or Underwater CPAP
 Bubble CPAP (BCPAP)
Blended gas is heated and humidified
Air delivered through a low-resistance nasal
prong cannula
Effective and inexpensive option to provide
respiratory support to premature babies
 High-Flow Nasal Cannula
Flow of gas in excess of 2L/min through a
nasal cannula provides some degree of CPAP
Highly variable depending on the leak on nose
or the mouth
 Practical Problems of NCPAP
Nasal prongs rarely fit tightly into the nostrils
resulting in gas leak and inability to maintain
baseline pressure
Nasal trauma
Non-Invasive Nasal Ventilation
NIPPV
SNIPPV
SiPAP
 Conventional Ventilation
Time-cycled, pressure-limited (TCPL)
is the most commonly used ventilator in
neonates.
provide a continuous flow of warmed, humidified
gas through the breathing circuit, allowing the
patient to breathe spontaneously at any time.
 NAVA
uses electrical activity from the diaphragm
(EAdi), recorded by a specialized nasogastric
tube in the lower esophagus, to synchronize
mechanical ventilator breaths.
NAVA can be delivered as a component of
noninvasive nasal intermittent positive
pressure ventilation (NIPPV) without
endotracheal intubation and appears effective
even in the presence of large air leaks.
High Frequency Ventilation (HFV)
High frequency ventilation (HFV) delivers
small volumes of gas, which are equal to or
smaller than anatomic dead space, at an
extremely rapid rate (300 to 1500 breaths per
minute)
Non-Invasive Mechanical Ventilation
Neonatal nasal intermittent positive pressure
ventilation (NIPPV) provides noninvasive
respiratory support to preterm infants who
otherwise would require endotracheal
intubation and ventilation