NEONATAL VENTILATION: LATEST UPDATE

Dr Robin Saggers

NEONATAL VENTILATION: LATEST UPDATES

CONFLICT OF INTEREST

• No affiliation to any respiratory care companies

• Neonatal Fellow – I am no expert!

OUTLINE

• History

• Goals and safety

• Indications and common conditions

• Types of ventilation & settings

• Synchronization (SIMV, A/C)

• Modes (Pressure vs volume)

• Meta analysis 2016

• Meta analysis 2017

• Recommendations and best practice

HIS

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NMR 1953 - 2018

4th gen. ventilators

Steroids

Surfactant

1st gen. ventilators

1940s and 1950sPositive pressureOnly volume controlNo PEEP

2nd gen. ventilators

1970sPEEP introducedIMVBasic alarms1972Antepartum steroid use1980Surfactant used as treatment for RDS

MicroprocessorsMany modes availableAll the bells and whistles

TYPES OF VENTILATION

• Non-invasive ventilation (NCPAP, HFNC, NIPPV)

• Conventional mechanical ventilation (CMV/IPPV)• Intermittent exchange of bulk volumes of gas

• High frequency ventilation (HFV)• Small volumes of respiratory gas

• At extremely rapid rate

INDICATIONS

• Respiratory failure• Type 1 – failure of oxygenation

• PaO2 <50mmHg despite oxygen supplementation

• Or when FiO2 exceeds 40 % on nCPAP

• Type 2 – failure of ventilation (pH <7.2 and PaCO2 >60 – 65 mmHg)

• Recurrent apnoeas

• To relieve work of breathing

COMMON CONDITIONS

Respiratory distress syndrome

Apnoea due to prematurity or perinatal depression

Infection – Sepsis and/or pneumonia

Postoperative recovery

Persistent pulmonary hypertension

Meconium aspiration syndrome

Congenital pulmonary and cardiac abnormalities

Hypoxic-ischaemic encephalopathy

VENTILATOR INDUCED LUNG INJURY

• Atelectrauma• Volutrauma• Biotrauma

• Cystic PVL• IVH

Van Kaam AH, Rimensberger PC: Lung-protective ventilation strategies in neonatology: What do we know – What do we need to know? Crit Care Med 2007; 35:925-931

OPEN LUNG APPROACH

• Searches for optimal lung volume

• More even distribution of the applied tidal volume

• Reducing the risk of local alveolar overdistension

• Limiting tidal volume

• Applying PEEP

• Combined with a recruitment manoevre to reopen already collapsed alveoli

Van Kaam AH, Rimensberger PC: Lung-protective ventilation strategies in neonatology: What do we know – What do we need to know? Crit Care Med 2007; 35:925-931

LUNG PROTECTIVE VENTILATION

• Optimizing lung volume

• Limiting excessive lung expansion

• Appropriate PEEP

• Using shorter IT (0,35 – 0,5 secs)

• Smaller tidal volume (4 – 6 mL/kg)

• Permissive hypercapnia

SETTINGS

SYNCHRONIZED VENTILATION

• Patient-triggered

• May improve patient comfort

• Reported to lower MAP and reduce need for sedatives (Bernstein 1996)

• Some benefit over non-synchronized ventilation in neonates• Fewer periods of low oxygen saturation

• Less variability in exhaled tidal volume (Firme 2005, Donn 1994, Baumer 2000, Beresford 2000, Cleary 1995)

PRESSURE-TARGETED VENTILATION

• PC-A/C

• PC-SIMV

• PC-PSV

VOLUME-TARGETED VENTILATION

• VC-A/C

• VC-SIMV

• VG

• PRVC

PRESSURE-REGULATED VOLUME

CONTROL / VOLUME GUARANTEE

• Clinician selects: • Expiratory tidal volume target• IT• Maximum inspiratory pressure limit (Pmax)

• Machine measures:• Inspired tidal volume • Expired tidal volume

• Inspiratory pressure (uses exhaled tidal volume reference) adjusted until the targeted tidal volume is achieved, using lowest possible pressure

• Lung compliance incr → inspiratory pressure decr

• Spontaneous respiratory effort incr → “self-weaning”

Modified pressure-targeted ventilatory mode

MODES

PROS CONS

Pressure• Easy to use• Less costly

• Variation of tidal volume from breath to breath

Volume• More consistent tidal

volume• Less injury

• Expense• Experience

COCHRANE REVIEW 2016

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• No difference in:• Overall outcome

• Mortality rate

• Incidence of BPD

• Synchronization may be useful in the subgroup of <28 weeks GA• shortens the period of

ventilation (patients more susceptible to VALI)

Ramanathan R: Optimal ventilatory strategies and surfactant to protect the preterm lungs.Neonatology. 2008;93(4):302-8

Claure N, Bancalari E: New modes of mechanical ventilation in the preterm newborn: evidence of benefit. Arch Dis Child Fetal Neonatal Ed. 2007 Nov;92(6):F508-12

COCHRANE REVIEW 2017

COCHRANE REVIEW

2017

BPD AND

DEATH

COCHRANE REVIEW

2017

BPD ONLY

PRIMARY OUTCOMES

VTV vs PLVRisk Ratio

NNTB

Death before discharge

No difference 0.75

Death or BPD at 36 weeks

VTV reduced risk

0.73 8

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SECONDARY OUTCOMES

VTV vs PLV Relative Risk NNTB

Mean days VTV reduced stay -1.35

Pneumothorax VTV reduced risk 0.52 20

Hypocarbia VTV reduced risk 0.49 3

Severe IVH or PVL VTV reduced risk 0.47 11

PVL VTV reduced risk 0.45

Severe IVH VTV reduced risk 0.53 11

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• VTV not associated with any increased adverse outcomes

RECOMMENDATIONS

Eichenwald EC, Martin R, Kim MS. Mechanical ventilation in neonates. UpToDate 2019

Sweet DG, et al. European Consensus Guidelines on the Management of Respiratory Distress Syndrome – 2019 Update. Neonatology 2019

RECOMMENDATIONS CONT.

Eichenwald EC, Martin R, Kim MS. Mechanical ventilation in neonates. UpToDate 2019

RECOMMENDATIONS CONT.

Eichenwald EC, Martin R, Kim MS. Mechanical ventilation in neonates. UpToDate 2019

PRACTICALLY SPEAKING

• Limited access to VG ventilation

• Limited comfort with VC ventilation

• Disappearing flow sensors

• Use the mode with which one is most comfortable

• Have a unit wide policy

• Ongoing education

FUTURE

• Adaptive support ventilation / closed loop monitoring

• NAVA trigger mechanism

• nIPPV

• Optimal PEEP

• Recruitment manoeuvres in neonates

THANK YOU!

SLIDE SORTER

• Why

• Outline

• Goals

• History

• Indications

• Common conditions

• Types

• VILI

• Open lung

• Lung protection

• Settings

• P vs V graph

• Synchronization

• Pressure targeted

• Modes table comparison

• Volume targeted

• VG / PRVC

• VG pic

• Cochrane 2016

• Meta 2016 - 1

• Meta 2016 - 2

• Meta 2016 - 3

• Meta 2016 - 4 - pic

• Cochrane 2017

• Meta 2017 -1

• Meta 2017 - 2

• Meta 2017 -primary

• Meta 2017 -secondary

• Recommend 1

• Recommend 2

• Recommend 3

• Practical

• Future

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