Advertisement

Neonatology pp 843-864 | Cite as

Treatment of Respiratory Failure in Newborn: Mechanical Ventilation

  • Colin Morley
  • Gianluca Lista
Reference work entry

Abstract

Premature delivery is always associated with the failure of respiratory transition and a delayed achievement of an adequate functional residual capacity. For this reason preterm babies (especially the extremely low for gestational age – ELGA – infants) frequently need respiratory support. Noninvasive ventilation (NIV) is in widespread use in the management of respiratory distress even in ELGA infants without increasing neonatal mortality or neurological impairment.

The most recent meta-analysis and reviews of NIV demonstrated that NIV is a valid alternative to mechanical ventilation (MV) in the management of respiratory failure and resulted in significant reductions in the incidence of bronchopulmonary dysplasia (BPD) among surviving infants.

Nevertheless, preterm babies, mainly ELGA infants, require MV because they have unresponsive apnea, or a high and rising PaCO2, and/or a high and rising FiO2 despite treatment with continuous positive airway pressure (CPAP).

Pressure-limited ventilation continues to be the primary mode of ventilation in neonates because of its relative simplicity and ability to ventilate effectively despite large endotracheal tube (ETT) leaks.

The major disadvantage of pressure-limited ventilation is that the tidal volume (VT) varies as the baby alters its breathing pattern and with changes in lung compliance (e.g., after surfactant therapy). The consequences of such rapid improvements in compliance are inadvertent hyperventilation and lung injury from excessively large VT (volutrauma); hyperventilation may induce hypocapnia, with high risk of cerebral damage. There is strong evidence that excessive tidal volumes, rather than the ventilator pressure, are the key determinant of ventilator-induced lung injury (VILI). Inadequate (too small) VT also causes significant problems (atelectrauma): in particular inefficient gas exchange due to increased dead space to VT ratio. Therefore, in the last few years, tidal volume-targeted ventilation has become an important standard of care in neonatal and pediatric respiratory support.

There are many volume-targeted ventilation modes used in neonatal period, but volume guarantee (VG) ventilation is the most extensively studied.

The Cochrane review on volume-targeted ventilation showed significant reductions in duration of ventilation, rates of pneumothorax (PTX), and intraventricular hemorrhage (IVH) and a borderline significant reduction in the incidence of BPD in surviving infants. Also VG ventilation plus adequate PEEP, with an open lung strategy, is an alternative to high-frequency oscillatory ventilation (HFOV) in infants ventilated for severe RDS. Nevertheless in a baby with very stiff lungs, pulmonary interstitial emphysema (PIE) or PTX, the use of HFOV still remains the best ventilator approach.

To optimize ventilatory management of infants with respiratory failure and to adjust the ventilatory settings, it is important to monitor the blood gases and perform chest X-ray. As most modern ventilators have numerical and graphical displays of ventilator parameters, these should be used to guide ventilation management and reduce the risk of lung injury.

It is important to wean babes from the ventilator and extubate them as soon as possible to reduce the risk of pulmonary infections and BPD. In many cases early caffeine administration can reduce the duration of mechanical ventilation, BPD, and the occurrence of respiratory and neurological adverse outcome. It is therefore important to have a respiratory protocol that helps the neonatologist to manage both the acute and the recovery phase of respiratory failure.

References

  1. Abubakar K, Keszler M (2005) Effect of volume guarantee combined with assist/control vs synchronized intermittent mandatory ventilation. J Perinatol 25(10):638–642CrossRefGoogle Scholar
  2. Ammari A et al (2005) Variables associated with the early failure of nasal CPAP in very low birth weight infants. J Pediatr 147(3):341–347CrossRefGoogle Scholar
  3. Attar MA, Donn SM (2002) Mechanisms of ventilator-induced lung injury in premature infants. Semin Neonatol 7(5):353–360CrossRefGoogle Scholar
  4. Aziz HF et al (1999) The pediatric disposable end-tidal carbon dioxide detector role in endotracheal intubation in newborns. J Perinatol 19(2):110–113CrossRefGoogle Scholar
  5. Bamat N et al. (2012) Positive end expiratory pressure for preterm infants requiring conventional mechanical ventilation for respiratory distress syndrome or bronchopulmonary dysplasia. Cochrane Database Syst Rev CD004500.pub2Google Scholar
  6. Beck J et al (2009) Patient-ventilator interaction during neurally adjusted ventilatory assist in very low birth weight infants. Pediatr Res 65(6):663–668CrossRefGoogle Scholar
  7. Bellu R et al (2009) Opioids for neonates receiving mechanical ventilation. A systematic review and meta-Analysis. Arch Dis Child Fetal Neonatal Ed 95(4):F241–F251CrossRefGoogle Scholar
  8. Bhandari V et al (2005) Morphine administration and short-term pulmonary outcomes among ventilated preterm infants. Pediatrics 116(2):352–359CrossRefGoogle Scholar
  9. Bjorklund LJ et al (1997) Manual ventilation with a few large breaths at birth compromises the therapeutic effect of subsequent surfactant replacement in immature lambs. Pediatr Res 42(3):348–355CrossRefGoogle Scholar
  10. Carlo WA et al (1987) Control of laryngeal muscle activity in preterm infants. Pediatr Res 22(1):87–91CrossRefGoogle Scholar
  11. Castoldi F et al (2011) Lung recruitment maneuver during volume guarantee ventilation of preterm infants with acute respiratory distress syndrome. Am J Perinatol 28(7):521–528CrossRefGoogle Scholar
  12. Cools F, Offringa M (2005) Neuromuscular paralysis for newborn infants receiving mechanical ventilation. Cochrane Database Syst Rev (2): p CD002773Google Scholar
  13. Dargaville PA, Tingay DG (2012) Lung protective ventilation in extremely preterm infants. J Paediatr Child Health 48:740–746CrossRefGoogle Scholar
  14. Davis P et al (1998) Randomised controlled trial of nasal continuous positive airway pressure in the extubation of infants weighing 600 to 1250 g. Arch Dis Child Fetal Neonatal Ed 78:F1–F4CrossRefGoogle Scholar
  15. De Jaegere A et al (2006) Lung recruitment using oxygenation during open lung high-frequency ventilation in preterm infants. Am J Respir Crit Care Med 174:639–645CrossRefGoogle Scholar
  16. Donn SM, Sinha SK (2003) Can mechanical ventilation strategies reduce chronic lung disease? Semin Neonatol 8(6):441–448CrossRefGoogle Scholar
  17. Greenough A et al (1986) Fighting the ventilator–are fast rates an effective alternative to paralysis? Early Hum Dev 13(2):189–194CrossRefGoogle Scholar
  18. Herrera CM et al (2002) Effects of volume-guaranteed synchronized intermittent mandatory ventilation in preterm infants recovering from respiratory failure. Pediatrics 110(3):529–533CrossRefGoogle Scholar
  19. Hoellering AB et al (2008) Lung volume and cardiorespiratory changes during open and closed endotracheal suction in ventilated newborn infants. Arch Dis Child Fetal Neonatal Ed 93(6):F436–F441CrossRefGoogle Scholar
  20. Hummler H, Schuze A (2009) New and alternative modes of mechanical ventilation in neonates. Semin Fetal Neonatal Med 14(1):42–48CrossRefGoogle Scholar
  21. Kamlin CO et al (2005) Colorimetric end-tidal carbon dioxide detectors in the delivery room: strengths and limitations. A case report. J Pediatr 147(4):547–548CrossRefGoogle Scholar
  22. Kamlin CO et al (2006) Predicting successful extubation of very low birthweight infants. Arch Dis Child Fetal Neonatal Ed 91(3):F180–F183CrossRefGoogle Scholar
  23. Keszler M, Abubakar K (2004) Volume guarantee: stability of tidal volume and incidence of hypocarbia. Pediatr Pulmonol 38(3):240–245CrossRefGoogle Scholar
  24. Lane B et al (2004) Duration of intubation attempts during neonatal resuscitation. J Pediatr 145(1):67–70CrossRefGoogle Scholar
  25. McCallion N et al (2005) Volume-targeted versus pressure-limited ventilation in the neonate. Cochrane Database Syst Rev (3): CD003666Google Scholar
  26. McCallion N et al (2005b) Volume guarantee ventilation, interrupted expiration, and expiratory braking. Arch Dis Child 90(8):865–870CrossRefGoogle Scholar
  27. McCallion N et al (2008) Neonatal volume guarantee ventilation: effects of spontaneous breathing, triggered and untriggered inflations. Arch Dis Child Fetal Neonatal Ed 93(1):F36–F39CrossRefGoogle Scholar
  28. Monkman S, Kirpalani H (2003) PEEP – a “cheap” and effective lung protection. Pediatr Resp Rev 4(1):15–20CrossRefGoogle Scholar
  29. Morley CJ et al (2008) Nasal CPAP or intubation at birth for very preterm infants. N Engl J Med 358(7):700–708CrossRefGoogle Scholar
  30. Mrozek JD et al (2000) Randomized controlled trial of volume-targeted synchronized ventilation and conventional intermittent mandatory ventilation following initial exogenous surfactant therapy. Pediatr Pulmonol 29(1):11–18CrossRefGoogle Scholar
  31. O’Donnell CP et al (2006) Endotracheal intubation attempts during neonatal resuscitation: success rates, duration, and adverse effects. Pediatrics 117(1):e16–e21CrossRefGoogle Scholar
  32. Okumura A et al (2001) Hypocarbia in preterm infants with periventricular leukomalacia: the relation between hypocarbia and mechanical ventilation. Pediatrics 107(3):469–475CrossRefGoogle Scholar
  33. Osorio W et al (2005) Effects of pressure support during an acute reduction of synchronized intermittent mandatory ventilation in preterm infants. J Perinatol 25(6):412–416CrossRefGoogle Scholar
  34. Patel DS et al (2009) Work of breathing and different levels of volume-targeted ventilation. Pediatrics 123(4):e679–e684CrossRefGoogle Scholar
  35. Pellicano A et al (2009) Comparison of four methods of lung volume recruitment during high frequency oscillatory ventilation. Intensive Care Med 35(11):1990–1998CrossRefGoogle Scholar
  36. Peng WS et al (2014) Volume-targeted ventilation is more suitable than pressure-limited ventilation for preterm infants: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 99:F158–F165CrossRefGoogle Scholar
  37. Reyes ZC et al (2006) Randomized, controlled trial comparing synchronized intermittent mandatory ventilation and synchronized intermittent mandatory ventilation plus pressure support in preterm infants. Pediatrics 118(4):1409–1417CrossRefGoogle Scholar
  38. Schmidt B et al (2006) Caffeine therapy for apnea of prematurity. N Engl J Med 354(20):2112–2121CrossRefGoogle Scholar
  39. Schmidt B et al (2007) Long-term effects of caffeine therapy for apnea of prematurity. N Engl J Med 357(19):1893–1902CrossRefGoogle Scholar
  40. Schmolzer GM et al (2010) Respiratory monitoring of neonatal resuscitation. Arch Dis Child Fetal Neonatal Ed 95(4):F295–F303CrossRefGoogle Scholar
  41. Schulze A (2007) Respiratory gas conditioning and humidification. Clin Perinatol 34(1):19–33CrossRefGoogle Scholar
  42. Singh J et al (2007) Volume-targeted ventilation of newborns. Clin Perinatol 34:9–1053CrossRefGoogle Scholar
  43. South M, Morley CJ (1986a) Synchronous mechanical ventilation of the neonate. Arch Dis Child 61(12):1190–1195CrossRefGoogle Scholar
  44. South M, Morley CJ (1986b) Monitoring spontaneous respiration in the ventilated neonate. Arch Dis Child 61(3):291–294CrossRefGoogle Scholar
  45. South M, Morley CJ (1986c) Ventilator settings and active expiration. Arch Dis Child 61:310–311CrossRefGoogle Scholar
  46. South M, Morley CJ (1992) Respiratory timing in intubated neonates with respiratory distress syndrome. Arch Dis Child 67(4):446–448CrossRefGoogle Scholar
  47. South M et al (1987) Expiratory muscle activity in preterm babies. Arch Dis Child 62(8):825–829CrossRefGoogle Scholar
  48. South M et al (1988) A simple technique for recording the electromyogram of the external abdominal oblique muscle in the newborn. Early Hum Dev 16(1):55–60CrossRefGoogle Scholar
  49. Stein H et al (2013) Prospective crossover comparison between NAVA and pressure control ventilation in premature neonates less than 1500 grams. J Perinatol 33(6):452–456CrossRefGoogle Scholar
  50. Swingle HM et al (1984) New approach to management of unilateral tension pulmonary interstitial emphysema in premature infants. Pediatrics 74(3):354–357PubMedPubMedCentralGoogle Scholar
  51. Thome U et al (1998) The effect of positive end expiratory pressure, peak inspiratory pressure, and inspiratory time on functional residual capacity in mechanically ventilated preterm infants. Eur J Pediatr 157(10):831–837CrossRefGoogle Scholar
  52. Tingay DG et al (2007) Effects of open endotracheal suction on lung volume in infants receiving HFOV. Intensive Care Med 33(4):689–693CrossRefGoogle Scholar
  53. Wheeler KI et al (2009a) Assist control volume guarantee ventilation during surfactant administration. Arch Dis Child Fetal Neonatal Ed 94(5):F336–F338CrossRefGoogle Scholar
  54. Wheeler KI et al (2009b) Volume-guarantee ventilation: pressure may decrease during obstructed flow. Arch Dis Child Fetal Neonatal Ed 94(2):F84–F86CrossRefGoogle Scholar
  55. Wheeler KK et al (2010) Volume-targeted or pressure-limited ventilation in the neonate. Cochrane Database Syst Rev 11:CD003666Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Dept Obstetrics and GynecologyUniversity of Cambridge at Rosie Maternity HospitalCambridgeUK
  2. 2.Neonatology and Neonatal Intensive Care UnitOspedale dei Bambini V. BuzziMilanItaly

Personalised recommendations