Conventional Ventilation strategies

IMV (Intermittent Mandatory Ventilation) and SIMV (Synchronised Intermittent Mandatory Ventilation) will be discussed below Definition: Pressure-limited, time-cycled, continuous flow ventilation Advantages: good control of pressures independent control of inspiratory and exspiratory time relatively simple logic of ventilatory settings Disadvantages: poor control of tidal volumes the system does not respond to changes in lung compliance risk of air leak in case of asynchronous spontaneous breathing Synchronization For IMV, you preset PIP, PEEP, Ti and rate. The ventilator will then deliver regular positive-pressure breaths. It does not synchronize with patients spontaneous breaths. Interference between artificial and spontaneous breaths may enhance barotrauma /volutrauma. So, IMV is now only appropriate for patients who do not breath spontaneously, for example paralyzed infants. For SIMV, you preset the same settings as for IMV. However, in this case the machine uses a trigger mechanism to recognize the initiation of a patient s breath and synchronizes the artificial breaths with the spontaneous ones. So, the breaths delivered by machine are not quite regular and there is less interference between the patients and the machines breaths. The synchronized ventilation was proved to reduce the risk of air leak and lung injury, reduces the need of sedation and should be preferred toICMV wherever the patient exhibits their spontaneous respiratory efforts. There are various types of trigger mechanisms. The Drager 8000 ventilator uses the flow-generated trigger. Indications Inadequate gas exchange due to respiratory, cardiac or central reasons Neonatal conditions requiring intubation and artificial ventilation Common Rare Neuromuscular RDS maternal myasthenia gravis TTN myotonia congenita CLD muscular dystrophy Apnea of prematurity Sepsis Upper airway obstruction Asphyxia Pierre-Robin MAS laryngitis Seizures Lower airway obstruction PPHN tracheomalatia Congenital heart defect bronchomalatia vascular ring

Clinical parameters used for indication of CMV/SIMV FiO2 more than 60% required to maintain adequate saturations (minimum 85% in premature babies) 2. PCO2 more than 8.0 kPa (not in compensated cases of permissive hypercapnia in CLD ) 3. pH less than 7.20 from respiratory reasons 4. loss of central respiratory drive Risks of CMV/SIMV Barotrauma/volutrauma Positive pressure ventilation causes airway injury. The higher the pressures used the higher the risk of airway damage. However, it was recently found that tidal volumes delivered by the ventilator correlate even better with the severity of airway trauma. Possible adverse effects of positive pressure ventilation: enhances progress of RDS causes air-leaks may cause overexpansion/emphysema important in pathogenesis of CLD hypocapnia increases the risk of white matter injury Artificial ventilation should only be used where clearly indicated and discontinued as soon as becomes unnecessary Ventilatory parameters, Ventilatory settings PIP PEEP MAP Ti Te TV peak inspiratory pressure positive end-exspiratory pressure mean airway pressure inspiratory time exspiratory time tidal volume 1.

Initial settings Flow rate 6-8 l/min PIP the lowest possible to elicit good chest movements, usually 12 20 cmH2O PEEP 4 6 cmH2O TI 0.35 0.4 s Rate 50 60/min in RDS and when pCO2 is increased 40 45/min in the absence of lung disease and stable pCO2 FiO2 adjust to maintain saturations 87 92% in premature babies < 35 weeks 90 95% in more mature babies 95-100% in PPHN

How is the gas exchange influenced by ventilatory settings Oxygenation depends primarily on MAP MAP may be increased by increasing PIP, PEEP or Ti or reducing Te Carbon dioxide wash-out depends primarily on alveolar ventilation Alveolar ventilation may be increased by increasing ventilatory rate or tidal volume Tidal volume may be increased by increasing PIP and, sometimes, by reducing PEEP How to respond to suboptimal gases Aim To improve oxygenation Action Increase FiO2 Increase PIP Increase PEEP Increase Ti Repeat surfactant ? Optimize sedation Consider HFO Consider suctioning ETT Optimize sedation Increase rate Increase PIP Reduce PEEP Risks Oxygen toxicity Barotrauma/volutrauma May increase pCO2 Volutrauma Hypocapnia

To improve CO2 clearance

Barotrauma/volutrauma

Sedation for CMV/SIMV Babies may require analgesia/sedation for CMV/SIMV. Inadequate sedation increases barotrauma/volutrauma and causes unnecessary stress 10 40 mcg/kg/hr 30 60 mcg/kg/hr 0.5 - 2.0 mcg/kg/hr Risks intestinal motility blood pressure Muscle rigidity

Morphine sulphate Midazolam Fentanyl

Guidance on frequency of blood gas monitoring After initiation of the ventilation Once the baby gets stable After significant change of the settings After switch to HFO Within 30 minutes Usually 8 hourly to 12 hourly more often if needed clinically By two hours By 30 minutes (risk of hypocapnia!)

What to do if a baby on a ventilator suddenly deteriorates Perform prompt clinical examination Resuscitate as necessary Check for cause - the tube dislodged?, obstructed? pneumothorax auscultation, cold light, XR - the ventilator circuit OK? pulmonary haemorrhage ? IVH ? - sepsis ?

Ventilatory strategies for specific neonatal respiratory conditions PIE/Pneumothorax consider switch to HFO in bilateral PIE.. In case you decide to continue SIMV, minimize PIP, PEEP and Ti and use higher rate as required. MAS consider switch to HFO if condition is homogenous. In case you decide to continue SIMV, use longer Ti and adequate PIP and PEEP. Good sedation is essential, paralysis might be necessary. The baby might require NO or even.ECMO. PPHN It is primarily problem of circulation. Severe cases require intubation and ventilation. However, excessively high PIP should be avoided as the positivepressure ventilation cannot improve the right-to left shunting. Use appropriate sedation or paralysis. Consider HFO. Avoid hypocapnia, aim for pCO2 5.0 5.5 kPa. Aim for saturation 95-100% whenever possible. Use alkalinisation with bicarbonate up to > 7.4. Start NO and consider ECMO if NO fails.

Weaning For elective extubation wean the ventilatory settings: Pressures to 12 18 cmH2O Rate to 20 25/min Fi02 21 30% Reduce/ stop any sedation Start caffeine where appropriate (premature babies less than 34 weeks.)

Elective extubation Make sure the baby has a working i.v. line. Start caffeine ( in premature babies). Suction the ETT. Stop feeding and make sure the stomach is empty. Extubate. Use CPAP as needed.

Check for stridor

Ivan Peychl, May 2008. Reviewed Vimal Vasu September 2011 Sources: Neonatal Unit Handbook, Kings College Hospital, 2005 Neonatal Unit Guidelines, Guy s and St. Thomas Hospital, 2006 Manual of Neonatal Care, Cloherty et al., 5th ed., 2004