Best Practices Clinical

Guidelines for Mechanical

Ventilation in Neonates
Mammady Al maghayreh
Date: October 17-19, 2011
Venue: Pr. Rahma Hospital/Auditourium
Introduction

It is an invasive life-support procedure with many
effects on the cardiopulmonary system
The goal is to optimize both gas exchange and
clinical status at minimum FiO2 and ventilator
pressure. The ventilator strategy employed to
accomplish this goal depends in part on the infant
disease process.
Conventional positive pressure ventilation remains
the mainstay of assisted ventilation in neonates
despite the development of new ventilatory
techniques.

2
Physiologic functions of the lung
Ventilation
The movement of air between the atmosphere and the
respiratory portion of the lungs
Perfusion
The flow of blood through the lungs
Diffusion
The transfer of gases between the air-filled spaces in the
lungs and the blood.


Ventilation
Depends on
the conducting airways:
Nasopharynx and oropharynx
Larynx
Tracheobronchial tree
Open Alveoli
Function:
Moves air in and out of the lung, warms and humidifes.
Airways do not participate in gas exchange.
Lung Compliance

The ease with which lungs can be expanded
Specifically, the measure of the change in lung
volume that occurs with a given change in
transpulmonary pressure
Determined by two main factors
Distensibility of the lung tissue and
surrounding thoracic cage
Surface tension of the alveoli
Pulmonary Mechanics during Assisted Ventilation




Compliance (ml/cmH
2
O) =Distensible nature of lungs
and chest wall. = Change in volume (ml) X change in
pressure (cmH
2
O)
Neonates have greater chest wall
Compliance
Premature infants with RDS have stiffer lungs
(poorly compliant lungs).
Neonatal lung
Normal 0.003-0.006 L/cm H
2
O
with RDS 0.0005-0.001 L/cm H
2
O
Resistance
10
Resistance (cmH
2
O/L/sec)= Property of airways and lungs to
resist gas. = Change in pressure (cmH
2
O) X Change in flow
(L/sec)
Time constant of the respiratory system = Resistance x
Compliance
Resistance in infants with normal lungs ranges from 25 to
50 cm H2O/L/sec.
It is increased in intubated babies and ranges from 50 to
100 cm H2O/L/sec.
Pulmonary mechanics
Time constant
The time taken for the airway pressure (and
volume) changes to equilibrate throughout the
lung is proportional to the compliance and
resistance of the respiratory system

Time constant = Compliance x Resistance

12
Pulmonary mechanics







Almost full equilibration: 3-5 time constants



100
80
60
40
20
0
1 2 3 4 5
Time constants




C
h
a
n
g
e


i
n

p
r
e
s
s
u
r
e

(
%
)

63
86
95
98
99
14
Time Constant
Inspiratory time must be 3-5 X time
constant
1) One time conststant = time for alveoli
to discharge 63% of its volume through
the airway.
2) Two time constant = 84% of the volume
leaves
3) Three time constant = 95% of volume
leaves.
Lung Mechanics Differ in Different Disease States
Disease Compliance
ml/cm H
2
O
Resistance
(cm/H2O/
ml/s)
Time
Constant(s)
FRC
(ml/kg)
V/Q
Matching
Work
Normal
Term
4-6 20-40 0.25 30 --- ---
RDS Decreased Decreased Decreased Decreased Decreased Increased
Meconium
Aspiration
Decreased Increased Increased Increased Decreased Increased
BPD
Increased/
Decreased
Increased Increased Increased Decreased Increased
Air leak Decreased Increased Increased Increased Decreased Increased
VLBW
apnea
Decreased Decreased Decreased Decreased Decreased Increased
15
Basic Ventilator Parameters
FiO
2

Fractional concentration of
inspired oxygen
delivered expressed as a
% (21-100)
Breath Rate (f)
The number of times over a
one minute period
inspiration is initiated
(bpm)

Tidal volume (V
T
)
The amount of gas that is
delivered during
inspiration expressed in
mls or Liters. Inspired or
exhaled.
Flow
The velocity of gas flow or
volume of gas per
minute


Phase Variables
Trigger (start)- begins inspiratory flow
Cycling (end)- ends inspiratory flow
Limiting (continue)- places a maximum value on
a control variable
pressure
volume
flow
time
Breath Type Only Two (for now)!
Mandatory
Ventilator does the work
Ventilator controls start and stop
Spontaneous
Patient takes on work
Patient controls start and stop
Trigger Variable-
Start of a Breath
Time - control ventilation
Pressure - patient assisted
Flow - patient assisted
Volume - patient assisted
Manual - operator control
The Control Variable-
Inspiratory Breath Delivery
Flow (volume) controlled
pressure may vary
Pressure controlled
flow and volume may vary
Time controlled (HFOV)
pressure, flow, volume may vary
Inspiratory - delivery limits
Maximum value that can be reached but will not end
the breath-
Volume
Flow
Pressure

Expiratory - baseline
Positive End Expiratory Pressure
Expiratory Retard
Negative End Expiratory Pressure
Expiratory Hold
Time Limited Exhalation
PEEP
Definition
Positive end expiratory pressure
Application of a constant, positive pressure such that at end
exhalation, airway pressure does not return to a 0
baseline

Used with other mechanical ventilation modes such as
A/C, SIMV, or PCV

Referred to as CPAP when applied to spontaneous
breaths
PEEP
Increases functional residual capacity (FRC) and
improves oxygenation
Recruits collapsed alveoli
Splints and distends patent alveoli
Redistributes lung fluid from alveoli to perivascular
space
5 cm
H
2
O
PEEP
Gas Exchange during Assisted
Ventilation
Carbon Dioxide (CO
2
)
Diffuses rapidly from the blood into the alveoli.
Its elimination depends largely on alveolar
ventilation.
Minute alveolar ventilation= (Tidal volume
Dead space) x Frequency.
Tidal volume is determined by the pressure
gradient between inspiration and expiration.
25
CPAP
Definition
Continuous positive airway pressure
Application of constant positive pressure
throughout the spontaneous ventilatory cycle

No mechanical inspiratory assistance is
provided
Requires active spontaneous respiratory drive

Same physiologic effects as PEEP
Gas Exchange during Assisted
Ventilation (cont.)
Carbon Dioxide (CO
2
) - (cont.)
Inspiratory duration may partially determine the
tidal volume
Tidal volume can be decreased by shortening the
inspiratory time.
Changes in ventilator frequency have a strong
effect on CO2 elimination
27
Oxygen
Oxygen exchange depends on matching
perfusion with ventilation.
Oxygenation is determined by the mean airway
pressure applied.
Paw = (PIP PEEP) [Ti/ (Ti +Te)] + PEEP


28
Gas Exchange during Assisted
Ventilation (cont.)
Mean airway pressure will be augmented by
increasing any of the following:
Inspiratory flow
PIP
I:E ratio
PEEP
Frequency (or rate) by shortening Te

29
Gas Exchange during Assisted
Ventilation (cont.)
The effect of mean airway pressure on oxygenation
is related to:
Optimizing the lung volume
Preventing atelectasis and consequently
improving ventilation perfusion relationships.

30
Gas Exchange during Assisted
Ventilation (cont.)
Conventional Neonatal Ventilator

31
Volume-Cycled Ventilators

Less used to ventilate neonates
Deliver a fixed volume irrespective of pressure
Flow and I:E ratio determine the tidal volume
Does not work well for RDS patient
32
Pressure-Limited, Time-Cycled
Peak inspiratory pressure, and inspiratory timing
are selected
Continuous flow of fresh heated humidified gas
It allows the infant to make spontaneous
respiratory efforts
Fighting neonates may face air leak syndrome

33
Patient Triggered Ventilation
Neonate is able to initiate ventilatory breath by:
1) Abdominal motion
2) Chest wall impedance
3) Airway flow
4) Great degree of synchronacy between patient and
ventilator
34
PatientTriggered Ventilators (PTV)

The patient is able to initiate ventilator breaths by
1) Abdominal motion
2) Chest wall impedance
3) Airway flow
4) Great degree of synchronacy between patient and ventilator

Triggering the ventilator setting detector
The system support the patient if it didn't breath
improved tidal volume and blood gases
It can be Synchronized (SIMV) or Assisted/ control (A/C) modes
Weaning is by reducing the PIP
Cerebral blood flow is controlled
Reduce the duration of ventilation and ease weaning
35
Troubleshooting Changes in Tidal Volume
during Pressure Ventilation of the Neonate

Tidal Volume
Change
Possible Cues Solutions
Increase Increased compliance,
decreased resistance,
decreased PEEP, increased
inspiratory time, decreased
leak.
Reduce peak inspiratory
pressure.
Decrease Decreased compliance,
increased resistance,
decreased peak inspiratory
pressure, increased PEEP,
decreased inspiratory time,
increased leak.
Suction airway
Administer surfactant.
Increase inspiratory pressure,
performing a transillumination
to check for pneumothorax,
obtaining chest radiography,
and check tube positioning.
36
Indications for Mechanical
Ventilation
Absolute indications
Severe hypoxemia with a PaO2 less than 50mm
Hg despite FiO2 of 0.8
Respiratory acidosis with pH of less than 7.20 to
7:25 or PaCO2 above 60mm Hg.
Severe prolonged apnea

37

USAID-Funded Health Systems
Strengthening II Project 38
Relative indications
Frequent intermittent apnea unresponsive to
drug therapy
Early treatment when use of mechanical
ventilation is anticipated because of deteriorating
gas exchange
Relieving work of breathing in an infant with
signs of respiratory difficulty
Initiation of exogenous surfactant therapy in
infants with RDS

39
Indications for Mechanical
Ventilation (cont.)
Volume vs
Pressure Control Ventilation
Volume Ventilation

Volume delivery constant
Inspiratory pressure
varies
Inspiratory flow constant
Inspiratory time
determined by set flow
and V
T
Pressure Ventilation

Volume delivery varies
Inspiratory pressure
constant
Inspiratory flow varies
Inspiratory time set by
clinician
The Effects of Ventilator Setting
Changes on Blood Gases

Effects on Blood Gas Tensions
Ventilator setting changes PaCO
2
PaO
2

Increase PIP Decrease Increase
Increase PEEP Increase Increase
Increase Frequency Decrease Increase
Increase I:E Ratio ------ Increase
Increase FiO
2
------ Increase
Increase Flow Decrease Increase
41
Starting Ventilator Settings

Guidelines for Endotracheal Tube Size
Infant Weight (gm) Endotracheal Tube
Internal Diameter
< 1,000 2.5mm
1,000-2,000 3.0mm
2,000-3,000 3.5mm
> 3,000 3.5 - 4.00mm
42
Initial Settings for mechanical ventilation
Setting Instructions for Use
Peak inspiratory pressure (PIP) As needed to provide tidal volume of
5-7ml/kg.
Positive end-expiratory pressure
(PEEP)
3-5cm H
2
O
Rate 40- 60/minute.
Inspiratory time 0.3- 0.4 seconds
Fractional inspired oxygen
concentration (FiO
2
)
maintain SpO

(88-93%)
Flow 8-12L/minute.
43
Starting Ventilator Settings (cont.)

The subsequent settings for mechanical ventilation
Subsequent Settings PEEP PIP
Low PaO
2
, low PaCO
2
Increase
Low PaO
2
, high PaCO
2
Increase
High PaO
2
, high PaCO
2
Decrease
High PaO
2
, low PaCO
2
Decrease
44
Starting Ventilator Settings (cont.)

Monitoring the infant during mechanical ventilation
First blood gas after 15-30 mins
Blood gas after 15-30 mins of every change
Regularly blood gas every 6 hrs
Continuous vital sings monitoring
45
Starting Ventilator Settings (cont.)
Deterioration during Mechanical
Ventilation
Sudden clinical deterioration
Mechanical or electrical ventilator failure
Disconnected tube or leaking connection
Endotracheal tube displacement or blockage
Pneumothorax
46
Deterioration during Mechanical
Ventilation (cont.)
Gradual deterioration
Inappropriate ventilator setting
Intraventricular hemorrhage
Baby fighting against the ventilator
PDA
Anemia
Infection
47
Paralysis and Sedation

The use of neuromuscular blockade is not routinely
indicated
Sedation is restricted to cases when agitation
interferes with ventilatory support and when
infants fight the ventilator.
It is necessary to increase ventilator pressure after
initiation of neuromuscular blockade.


48
Weaning
When the patient is stable, FiO2 and PIP are
weaned first.
Decrease PIP as tolerated and as chest rise
diminishes.
When PIP is around 20, attention is directed to FiO2
and then to the respiratory rate alternating with
each other
As frequency is decreased, Te should be prolonged
For larger infants, endotracheal CPAP when PIP 15-
18 cm H2O and FiO2 40%


49
Weaning (cont.)
The infant can be weaned to oxygen hood when
PEEP is 4cm H2O
For less than 1.750gm, when PIP is less than 15cm
and FiO2 30% decrease respiratory rate to 15-20/
min then to nasal CPAP
In most infants, when ventilator frequency of
approximately 15 breaths per minute is tolerated,
endotracheal CPAP may be tried for a short period
of time before extubation.

50
Weaning (cont.)
Atelectasis after extubation is common in preterm
infants recovering from RDS.
Use of nasal CPAP may prevent atelectasis.
Steroids are not routine before extubation, but if
there was prolonged intubation or previous failed
attempts of extubation, a short course of steroids
may facilitate extubation.
If strider developed epinephrine aerosols and
steroids may be helpful
51
Complications of Mechanical
Ventilation

Endotracheal tube complications and tracheal
lesions
Airway injury
Air leak
Chronic lung disease/Oxygen toxicity
Intraventricular hemorrhage
Decreased cardiac output
Feeding intolerance

52
Pulmonary Hygiene
Chest physiotherapy

Suction
53
Goals of Pulmonary Hygiene
Maintain a patent airway by clearing secretions
Promote optimal pulmonary oxygenation and
ventilation
Prevent pulmonary infection from accumulated
secretions
Facilitate removal of pulmonary debris
54
Chest Physiotherapy Indication
Intubated neonates:
Chest physiotherapy should only be applied if it is
clearly indicated.
No CPT after surfactant administration
CPT in early RDS increases incidence of
intraventricular hemorrhage
Post-extubation
Chronic lung disease of prematurity

55
Physiotherapy and surgery
After abdominal or cardiac surgery
Postoperative physiotherapy should never be
routine but should be used judiciously.
56
Chest Physiotherapy Indication (cont.)
Chest Physiotherapy Technique
Positioning

Vibration
57
When It Is Indicated
During intubation and ventilation
Post ex-tubation
Premature with chronic lung disease
After abdominal and chest surgery


58
Suction
Methods of suctioning:
Open
Closed
Catheter suction ca be:
Deep
Shallow
Suctioning should be performed under strict sterile
preparation
59
Suction Procedure
Shallow suction is recommended to prevent trauma
Deep suction may cause apnea and vagal
stimulation
Duration of suction should be 15 seconds
60
Follow-up Care

Hyper-oxygenation for at least 1 min especially for
hypoxemic infants
Hyperventilation should not be routinely used.
The patient should be monitored for adverse
reactions
61
Indications

Secretions in peripheral airways should not be
directly removed by endotracheal suctioning
Suctioning should be performed only when
clinically indicated
To remove accumulated pulmonary secretions
To maintain the patency and integrity of the
artificial airway
62
Signs of Increased Pulmonary
Secretions
Increased peak inspiratory pressure during volume-
controlled mechanical ventilation
Decreased tidal volume during pressure-controlled
ventilation
Deterioration of oxygen saturation and/or arterial
blood gas values
Visible secretions in the airway
Acute respiratory distress
Suspected aspiration of gastric or upper-airway
secretions
The need to obtain a sputum specimen

63
Complications

Decrease in dynamic lung compliance and functional
residual capacity
Atelectasis
Hypoxia/hypoxemia
Tissue trauma
Bronchoconstriction/bronchospasm
Increased microbial colonization
Changes in cerebral blood flow and increased
intracranial pressure
Hypertension or hypotension
Cardiac dysrhythmias

64
Assessment of Outcome

Improvement in appearance of ventilator graphics
and breath sounds
Decreased need for ventilation support
Improvement in arterial blood gas values or
saturation
Removal of pulmonary secretions

65
The following should be monitored prior to, during,
and after the procedure:
Breath sounds
Oxygen saturation
Pulse rate
Skin color
Respiratory rate and pattern
Sputum characteristics: color, volume,
consistency, and odor
Ventilator

66
Monitoring during suction (cont.)

Recommendations
Endotracheal suctioning should be performed only
when secretions are present and not routinely. (1C)
Pre-oxygenation should be considered if the patient
has a clinically important reduction in oxygen
saturation with suctioning. (2B)
Performing suctioning without disconnecting the
patient from the ventilator (2B)
Use of shallow suction (2B)
67
Routine use of normal saline instillation prior to
endotracheal suction should not be performed. (2C)
A suction catheter is used that occludes less than
70% of the lumen of the ETT in infants. (2C)
The duration of the suctioning event be limited to
less than 15 seconds. (2C)


68
Recommendations (cont.)
High Frequency Ventilation
(HFV)

Rescue following failure of conventional
ventilation (PPHN, Meconium).2,3
Air leak syndromes (pneumothorax,
pulmonary interstitial emphysema) 4
To reduce barotrauma when conventional
ventilator settings are high
F
r
e
q
u
e
n
c
y

High frequency ventilation rate (Hz, cycles per second)
M
A
P

Mean airway pressure (cmH
2
O)
A
m
p
l
i
t
u
d
e

delta P or power is the variation around the MAP
O
x
y
g
e
n
a
t
i
o
n

i
s

d
e
p
e
n
d
e
n
t

o
n

M
A
P

a
n
d

F
i
O
2


MAP provides a constant distending pressure equivalent to
CPAP.
This inflates the lung to a constant and optimal lung volume
maximising the area for gas exchange and preventing alveolar
collapse in the expiratory phase.
Ventilation is dependent on amplitude and to lesser degree
frequency.
Thus when using HFV CO
2
elimination and oxygenation are
independent
The clinician sets

The amplitude .
Frequency of the pressure wave generated by the
ventilator piston or diaphragm
Mean airway pressure (MAP)
Inspiratory time.
Fractional inspired concentration (FiO
2
)
USAID-Funded Health Systems
Strengthening II Project 71
Optimal lung volume strategy
(aim to maximise recruitment of alveoli).
Set MAP 2-3 cmH2O above the MAP on
conventional ventilation
MAP in 1-2 cmH2O steps until oxygenation
improves
Set frequency to 10 Hz


73
HFV
Low volume strategy
(aim to minimise lung trauma)
Set MAP equal to the MAP on
conventional ventilation
Set frequency to 10 Hz
Adjust amplitude to get an adequate chest
wall vibration.
Making adjustments once established on HFV

Poor
Oxygenation
Over
Oxygenation
Under
Ventilation
Over
Ventilation
Increase
FiO
2

Decrease
FiO
2

Increase
Amplitude
Decrease
Amplitude
Increase
MAP
(1-2cmH
2
O)
Decrease
MAP
(1-2cmH
2
O)
Decrease
Frequency
(1-2Hz)
if Amplitude
Maximal
Increase
Frequency
(1-2Hz)
if Amplitude
Minimal