Documente Academic
Documente Profesional
Documente Cultură
Division of Neonatal-Perinatal
Medicine, University of Michigan Health
System, Ann Arbor, Michigan, USA;
b
The James Cook University Hospital,
Middlesbrough, UK
Introduction
402
Ventilatory modes
Intermittent mandatory ventilation or intermittent
positive pressure ventilation (IPPV) is a ventilator
mode that functions independently of spontaneous
patient effort. Mechanical breaths are programmed
according to a frequency and limit variable, chosen
by the clinician, and the patient is free to breathe
spontaneously between mechanical breaths, supported by PEEP. However, because the patient and
ventilator function independently, there is a significant probability of dyssynchrony [3]. The patient
and ventilator may be out of phase, resulting in an
infant who struggles or fights mechanical ventilation. This can result in inconsistent tidal volume
delivery, increased work of breathing, inefficient
gas exchange, barotrauma and thoracic airleaks [4],
and even disturbances in cerebral perfusion associated with the development of intraventricular
haemorrhage in preterm infants [5].
Newer modes of neonatal mechanical ventilation
have addressed patient-ventilator dyssynchrony
[6,7]. Synchronized intermittent mandatory ventilation (SIMV) attempts to link the onset of mechanically delivered breaths to the onset of spontaneous
breathing by the patient. The ventilator rate is
chosen by the clinician, but mandatory breaths are
held within a timing window until initiation of a
patient breath to which it is then synchronized. As
with IMV or IPPV, the patient is free to breathe
between mechanical breaths and is supported by
PEEP. This mode of ventilation is a major advance
from IMV, but there is still the problem of dyssynchrony if the patients own inspiratory time is
shorter than that chosen by the clinician for the
ventilator. Pressure support ventilation (PSV), a
mode which is flow-cycled and pressure-limited,
can be added to SIMV to support spontaneous
breathing and provide an inspiratory pressure
boost to overcome the imposed work of breathing
created by narrow lumen endotracheal tubes, ventilator circuit dead space, and the demand valve [8].
Pressure support breaths are patient-triggered and
may either be flow- or time-cycled.
The most recent mode of mechanical ventilation
introduced into the neonatal intensive care unit is
assist/control ventilation (A/C), also referred to as
patient-triggered ventilation (PTV) [1,2,7]. In this
ventilatory mode, all spontaneous breaths which
403
Limit
Flow
Ends (cycles)
TCPL
PC
PS
Pressure
Continuous set
Set or flow
Pressure
Variable
Set
Pressure
Variable
Flow
TCPL, Time cycled pressure limited; PC, pressure control; PS, pressure
support.
Volume-targeted ventilation
The development of microprocessor-based ventilator technology and sophisticated neonatal
transducers has enabled the reintroduction of
volume-targeted ventilation in neonatal intensive
care [11,12]. The distinguishing features of pressure
and volume-targeted modes and their perceived
advantages and disadvantages are summarized in
Tables 2 and 3. Volume ventilation involves selecting a targeted tidal volume to be delivered to the
patient while allowing the pressure required to
deliver that volume to be variable. When patient
compliance is low, pressure will be high, but as
404
Pressure-limited
Volume-controlled
Pressure
Volume
Patient or machine
Pressure
Time or flow
Variable
Constant
Patient or machine
Flow
Volume or flow
Constant
Variable
Ramp-descending
IMV, SIMV, A/C, PSV
Square
IMV, SIMV, A/C, PSV
IMV, Intermittent mandatory ventilation; SIMV, synchronized intermittent mandatory ventilation; A/C, assist-control; PSV,
pressure support ventilation.
Volume targeted
Advantages
Disadvantages
compliance improves, the ventilator will automatically wean peak inspiratory pressure to deliver the
same tidal volume, and thus it may be more
effective in states characterized by rapidly changing compliance such as following the administration of surfactant. Volume ventilation involves
a constant flow rate. It assures a guaranteed tidal
volume delivery, although it is important that the
volume of delivered gas be measured as close to
the airway as possible. It is also important to know
the compliance of the ventilator circuit itself, as
there is compressible volume loss to the circuit
and this will increase as pulmonary compliance
decreases. Volume-targeted ventilation is not
affected by lung impedance nor rapidly changing
pulmonary mechanics. Its major advantage is a
Monitoring
In addition to the advances in ventilator and sensor
technology, neonatal clinicians now have the
ability to monitor ventilator performance and ventilator patient interaction on a breath-to-breath
basis, utilizing real-time displays of pulmonary
mechanics, waveforms, or numerical data [13]. An
ideal monitor is one capable of measuring and
displaying airway graphics with a proximal monitor. This should include flow, pressure, and volume
waveforms; pressure-volume and flow-volume
loops; calculation of pulmonary mechanics; and
trending of data. The importance of proximal
monitoring was recently demonstrated. With infant
circuits, tidal volume measurements at the airway
were only 56% of that measured at the machine
because of compressible volume loss [14]. A small
discrepancy in delivered tidal volume could have a
huge impact on an extremely low birth weight
baby.
Monitoring also enables the customization of
ventilator settings based on the response of the
individual patient. It allows for determination of
optimal positive end expiratory pressure, detection
of overinflation, determination of gas trapping,
and many other subtle features which have the
potential for causing injury.
405
Volume assured pressure support (VAPS) is available on the VIP BIRD Gold Infant/Pediatric ventilator [11]. This is a hybrid mode of ventilation,
which combines the best features of pressurelimited and volume-targeted ventilation. The ventilator delivers a breath to a set pressure limit. If the
targeted volume has not been delivered to the
patient at this pressure, the breath will be prolonged to guarantee delivery of tidal volume. Peak
inspiratory pressure and inspiratory time are
increased and the guaranteed volume is provided
on the current breath without the need for previous
breath averaging. VAPS maybe thought of as
variable flow volume ventilation. It involves a
decelerating but non-limited variable flow rate in
order to achieve guaranteed tidal volume delivery.
The ventilator continuously measures the flow and
pressure, and calculates the delivered volume. It can
406
Table 4. Commonly available neonatal ventilators which provide volume targeted modes of ventilation
Ventilator
Available modes
Features
Volume control
Combination modes
VAPS
Volume control
Combination modes
PRVC
Volume support
Combination mode
Volume guaranteed pressure-limited
Flow cycling
Variable orifice sensor
Proximal airway sensor
Flow triggering
Conclusions
The newer modes in the forms of mechanical
ventilation for the newborn combine the best
features of volume and pressure ventilation. These
modes and forms have been shown to reduce
the work of breathing and to improve patients
synchrony and comfort.
Much more clinical investigation is necessary to
define the best indications and applications of these
407
9
10
11
12
13
References
1 Sinha SK, Donn SM. Advances in neonatal conventional
ventilation. Arch Dis Child 1996; 75: F135140.
2 Donn SM, Sinha SK. Newer modes of mechanical ventilation for the neonate. Curr Opin Pediatr 2001; 13:
99103.
3 Donn SM, Nicks JJ, Becker MA. Flow-synchronized
ventilation of preterm infants with respiratory distress
syndrome. J Perinatol 1994; 14: 9094.
4 Lipscomb AP, Thorburn RJ, Reynolds EO, et al.
Pneumothorax and cerebral hemorrhage in preterm
infants. Lancet 1981; 1: 414416.
5 Perlman JM, Goodman S, Kreusser KL, Volpe JJ.
Reduction in intraventricular hemorrhage by elimination
of fluctuating cerebral blood flow velocity in preterm
infants with respiratory distress syndrome. N Engl J Med
1985; 312: 13531357.
6 Bernstein G, Mannino F, Heldt GP, et al. Randomized
multicenter trial comparing synchronized and conventional intermittent mandatory ventilation in neonates. J
Pediatr 1996; 128: 453463.
7 Greenough A. Update on patient-triggered ventilation.
Clin Perinatol 2001; 28: 533546.
8 Sinha SK, Donn SM. Pressure support ventilation. In:
Sinha SK, Donn SM (eds) Manual of Neonatal Respiratory
14
15
16
17
18
19