Neonatal Modes of Mechanical

Ventilation
Mohammed M. Tamim, MD
Consultant, NICU, Tawam Hospital
Alain, UAE

Objectives

Indications of mechanical ventilation

Basics of respiratory mechanics
Modes of conventional ventilation
Modes of HFV
Indications of HFV

Introduction
The primary objective of Mechanical Ventilation is to
support breathing until patient respiratory efforts are
sufficient.
First mechanical ventilation for a neonate in 1959.
One of the most important breakthroughs in the history
of neonatal care.
Mortality from RDS decreased markedly after MV.
New Morbidity developed CLD (BPD)

Respiratory Failure

Hypercapnic Respiratory Failure:

Inability to remove CO2 by spontaneous breathing
Caused by hypoventilation or severe V/Q mismatch
in arterial PCO2
in pH
MV is most commonly needed for treatment

Hypoxemia
Usually the result of V/Q mismatch or RL shunt.
Diffusion abnormalities & hypoventilation (apnea)

Respiratory Failure

Respiratory failure can occur because of diseases

in the lung, thorax, airway or respiratory muscle.
Indication for assisted ventilation:
Respiratory Acidosis pH < 7.2
Hypoxemia while on 100% O2
Or CPAP of 60 100%
Severe apnea

Respiratory Failure

Clinical Manifestation:
Increase or decrease in respiratory rate.
Increase or decrease in respiratory effort.
Periodic breathing with increase respiratory efforts.
Apnea.

Neonatal Respiratory Physiology

Compliance:

Distensible nature of lungs and chest wall.

Volume (L)
= ---------------------Pressure (cm H2O)

Neonates have greater chest wall

compliance.( premature more than FT)
Premature infants with RDS have stiffer lungs
(poorly compliant lungs).

Neonatal Respiratory Physiology

Resistance:

Property of airways and lungs to resist gas.

Pressure (cm H2O)

= ------------------------- Flow (L/sec)
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.
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Resistance

Total respiratory system resistance =

chest wall R (25%)
+ airway R (55%)
+ lung tissue R (20%)

Neonatal Respiratory Physiology

Time Constant:
An index of how rapidly the lungs can empty.
Time constant = Compliance X Resistance
In BPD time constant is long because of resistance.
In RDS time constant is short because of low
compliance.
Normal = 0.12-0.15 sec

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Time Constant
Inspiratory time must be 3-5 X time constant

One time conststant = time for alveoli to discharge

63% of its volume through the airway.
Two time constant = 84% of the volume leaves
Three time constant = 95% of volume leaves.
In RDS: require a longer I time because the lung will empty
rapidly but require more time to fill.
In CLD: decrease vent rate, which allows to lengthen the I time
and E time.
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Time Constant

Waldemar A. Carlo et. Al. Neoreview Dec 1999

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Conventional Mechanical Ventilation

Mechanical ventilators achieve a pressure

gradient between the airway opening and lungs.
Ventilator for neonates are usually one of the
following types:
Pressure control Ventilators
Volume control Ventilators

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Conventional Mechanical Ventilation

Pressure Controlled Ventilators:

A constant flow of gas pass through the ventilator.
Pressure is limited to the desired magnitude.
When expiration relief valve has been closed for the
preset period of time, the valve opens and
inspirations ceases.

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Conventional Mechanical Ventilation

Volume Controlled Ventilators:

A preset volume of gas is delivered to the system
after which inspiration is terminated.
When this gas has been delivered by the piston
inspiration is terminated.
Infants TV (4-8 ml/kg)
Volume losses by leaks from tubing system around
the endotracheal tube.

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Continuous Positive Airway Pressure

Important tool in management of neonates

Increase alveolar volume

Redistribution of lung water

Cons

Pros

Risk of air leak

Alveolar Volume & FRC

Over Distension

Alveolar Stability

CO2 Retention

Redistribution of lung fluids

Cardiovascular impairment

Improved V/Q matching

Compliance
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Pressure Controlled Ventilation

Ventilator Components:
1.
2.
3.

4.
5.
6.

7.
8.

Gas mixer.
Inspiratory expiratory time adjustment
Expiratory relief valve to limit the peak inspiratory
pressure
Pressure gauge to measure applied pressure
Humidification or nebulization
Positive end expiratory pressure to maintain functional
residual capacity.
Exhalation assist to reduce the end expiratory pressure
Alarms
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Pressure Controlled Ventilation

Peak Inspiratory Pressure (PIP):
Changes in PIP affect both PaO2 & PaCO2 by altering
the MAP.
Increase in PIP:

Increase in PaO2
Decrease in PaCO2

A high PIP should be used cautiously because it may

increase the risk of volutrauma air leak and BPD
Common mistake large babies need higher PIP
requirement is strongly determined by compliance

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Pressure Controlled Ventilation

Positive End Expiratory

Pressure

Adequate PEEP prevents

alveolar collapse and maintain
lung volume at end of
expiration.
Improve V/Q matching
Very high PEEP reduce
venous return cardiac
output decrease oxygen
transport increase
pulmonary vascular resistance

Pros

Cons

Alveolar volume
& FRC

Increased Risk for

air leaks

Alveolar stability

Overdistention

Redistribution of
lung water

CO2 retention

Improved V/Q
matching

Cardiovascular
impairment
Decreased
Compliance

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Pressure Controlled Ventilation

Rate:

Change in rate alter alveolar

minute ventilation
High rate low TV is
strongly preferred
Rate change alone with
constant I:E ratio do not
alter MAP
Any change in inspiratory
time that accompany
change in rate will alter
MAP

PROS

CONS

Air leak

Gas trapping

Volutrauma

Generalized
atelectasis

CVS side effects Maldistribution of

gas
Risk of
Pulmonary edema

resistance

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Pressure Controlled Ventilation

Inspiratory Expiratory Ratio: in I:E ratio lead to in MAP

Long inspiratory time:

Pros:

Increased oxygenation
May improve gas distribution

Cons

Gas trapping
Increased risk of volutrauma and air leak
Impaired venous return
Increased pulmonary vascular resistance
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Pressure Controlled Ventilation

Inspiratory Expiratory Ratio:

Short Inspiratory time:

Pros:

Faster weaning
Decreased risk for pneumothorax
Allows use of higher ventilator

Cons:

Insufficient tidal volume

May need high flow rate

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Inspiratory & Expiratory Time

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Mean Airway Pressure

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Pressure Controlled Ventilation

FIO2:

Changes alter Alveolar Oxygen Pressure

Flow:
Not well studied in infants
Minimal effects on ABG
In general 8-12 LPM
High Flow is needed with short inspiratory time to
achieve adequate TV.

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Oxygenation

Depends largely on the FIO2

Oxygenation increase linearly with increase in
MAP.
MAP is a measure of the average pressure to
which the lungs are exposed.

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Carbon Dioxide Elimination

Depends largely on the amount of gas that passes in

and out of the alveoli Minute Ventilation.
Minute Ventilation = TV X Rate
Any increase in TV or Rate will eliminate CO2.
TV may be increased by in PIP or in PEEP

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Tidal Volume

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Alternative Modalities of MV

Technology advances including improvement in

flow delivery systems, breath termination criteria,
stability of PEEP, air leak compensation,
prevention of pressure overshoot and triggering
system led to development of new modalities of
mechanical ventilation:
Patient Triggered Ventilation (PTV)
Proportional Assist Ventilation
Tracheal Gas Insufflation
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Patient Triggered Ventilation

Modified CMV
Neonate is able to initiate ventilatory breath by:
Abdominal motion
Chest wall impedance
Airway flow

Great degree of synchronacy between patient

and ventilator

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Patient Triggered Ventilation

Modes:

Synchronized Intermttent Mandatory Ventilation

(SIMV):

Preset rate that is triggered, other patient breath is not

assisted.

Assist Control Mode (A/C):

All breath initiated by patient is triggered.
Weaning accomplished by reducing PIP.

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Patient Triggered Ventilation

Advantages:

Reduction in cerebral blood flow variability

(Renie et al 1987)

Shorter time on ventilator

(Visveshwara et al 1999)

Improved oxygenation with SIMV

(Cleary et al 1995)

No difference between SIMV & A/C in length of

weaning.
(chon et al 1994)
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Proportional Assist Ventilation

Synchronize onset & duration of both

inspiratory and expiratory support.
Ventilatory support is in proportion to the
volume and flow of the spontaneous breath.
It will reduce ventilatory pressure while
maintaining or improving gas exchange.

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Tracheal Gas Insufflation

Reduce anatomical dead space in alveolar

minute ventilation
Gas is delivered to the distal part of the
endotracheal tube
Result in decrease in PCO2 and PIP
Still under study

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Preparation for MV

Establishment of artificial airway

Tracheal intubation oral vs. nasal
Examine and continue assessing your patient
Use a manometer when bagging
Follow HgB O2 saturation continually & ABGs
Insure that nebulization is adequate
Understand the effect of every ventilator knob
Select ventilator sitting that is appropriate for your patient

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Suggested CMV Sittings

Normal Lungs

HMD

12-16

18-25

PEEP

2-3

4-5

Rate / min

20

20-40

Inspiratory Time

0.5

0.6

0.21 0.3

0.4 1.0

PIP

FIO2

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High Frequency Ventilation

Definition:

Ventilation at a high rate at least 2 4 times the

natural breathing rate, using a small TV that is less
than anatomic dead space:

Types:

High Frequency Jet Ventilator (HFJV)

High Frequency Flow Interrupter (HFFI)

Up to 600 breath / min

Up to 1200 breath / min

High Frequency Oscillatory Ventilator (HFOV)

Up to 3000 / min
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High Frequency Ventilation

Introduction
The respiratory insufficiency remains one of the major causes of
neonatal mortality.
Intensification of conventional ventilation with higher rates and
airway pressures leads to an increased incidence of barotrauma.
Either ECMO or high-frequency oscillatory ventilation might
resolve such desperate situations.
Since HFOV was first described by Lunkenheimer in the early
seventies this method of ventilation has been further developed
and is now applied the world over.

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Definition
There are three distinguishing characteristics of
high-frequency oscillatory ventilation:

The frequency range from 5 to 50 Hz (300 to 3000

bpm)

active inspiration and active expiration

Tidal volumes: about the size of the deadspace
volume

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High Frequency Ventilation

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Commercial ventilators
Various technical principles are used to generate oscillating
ventilation patterns.
The so-called "true" oscillators provide active inspiration and
active expiration with sinusoidal waveforms:
Piston oscillators move a column of gas rapidly back and forth in
the breathing circuit with a piston pump.
Its size determines the stroke volume, which is therefore fairly
constant. A bias flow system supplies fresh gas

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The "flow-interrupters" chop up the gas flow into the patient circuit
at a high rate, thus causing pressure oscillations. Their power,
however, depends also on the respiratory mechanics of the patient

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Commercial ventilators

Other devices (e.g. Sensormedics 3100A)

generate oscillations with a large loudspeaker
membrane and are suitable also beyond the
neonatal period.
As with the piston oscillators, a bias flow system
supplies fresh gas.
However, this device cannot combine
conventional and HFO ventilation.
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The InfantStar interrupts the inspiratory gas flow with

a valve bank. Some authors regard this device as a jet
ventilator because of its principle of operation.

The Babylog 8000 delivers a high inspiratory

continuous flow (max 30 l/min) and generates
oscillations by rapidly switching the expiratory valve.
Active expiration is provided with a jet Venturi
system.

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Characteristic parameters and

control variables of HFV
Three parameters determine oscillatory ventilation:
Firstly, there is the mean airway pressure (MAP):
around which the pressure oscillates.
Secondly, the oscillatory volume: which results
from the pressure swings and essentially
determines the effectiveness of this type of
mechanical ventilation.
Thirdly, the oscillatory frequency: the number of
cycles per unit of time.
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Mean Airway Pressure (MAP)

The Babylog 8000 uses a PEEP/CPAP-servo-control system to

adjust MAP. In the CPAP ventilation mode, MAP equals the set
PEEP/CPAP level.
When conventional IMV ventilation cycles are superimposed,
MAP also depends on both the peak inspiratory pressure (PIP)
and the frequency.
MAP in HFV should be about the same as in the
preceding conventional ventilation, depending on the underlying
disease, and should be higher than pulmonary opening pressure.
In prematures with RDS this opening threshold is approximately
12 mbar .
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Mean Airway Pressure (MAP)

The crucial physiologic effect of such continuously

applied (inflation) pressure is the opening of atelectatic
lung areas, resulting in marked recruitment of lung
volume.

Intermittent application of additional sigh manoeuvres

can further enhance this effect.

Opening of atelectases reduces ventilation-perfusion

mismatch and thus intrapulmonary right-to-left
shunting.
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Mean Airway Pressure (MAP)

Therefore MAP is the crucial parameter to

control oxygenation.

By way of the PEEP/CPAP-servo-control

system the mean airway pressure with the
Babylog 8000 can be set in the range from 3 to
25 mbar.

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Amplitude oscillatory volume

The term amplitude has stood for pressure amplitude.

In the end, however, ventilation does not depend on
the pressure amplitude but on the oscillatory volume.
as a setting parameter the amplitude is one of the
determinants of oscillatory volume.
The oscillatory volume exponentially influences CO2
elimination
During HFV volumes similar to the deadspace
volume (about 2 to 2.5 ml/kg) should be the target.
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Amplitude oscillatory volume

In any HF ventilator, the oscillatory volume depends

characteristically on the oscillatory frequency.

Normally, lower frequencies permit higher volumes.

Even small changes in resistance and/or compliance of

the respiratory system, e.g. by secretion in the airways,
or through the use of a different breathing circuit or ET
tube, can change the oscillatory volume and thus the
effectiveness of HFV.
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Amplitude oscillatory volume

The amplitudes and oscillatory volumes vary also with MAP.

Especially at MAP below 8 mbar oscillatory volumes
are markedly reduced.

The oscillation amplitude is adjustable as a percentage from 0 to

100%, where 100% means the highest possible amplitude under
the given circumstances of MAP and frequency settings as well
as the characteristics of the respiratory system (breathing circuit,
connectors, ET tube and airways)

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Amplitude oscillatory volume

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Oscillation amplitude and flow as functions of MAP

and frequency with the Babylog 8000:

a) Start:

FHFO = 10 Hz, MAP 6 mbar, VTHFO = 4,6 ml

b) Increase in MAP: FHFO = 10 Hz, MAP 12 mbar, VTHFO = 5,8 ml

c) Decrease in frequency: FHFO = 7 Hz, MAP 12 mbar, VTHFO = 8,5 ml

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Oscillatory frequency

The oscillatory frequency, measured in units of

Hertz influences the oscillatory volume and the
amplitude depending on the ventilator type
used.

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Oscillatory frequency

The choice of an optimal oscillatory frequency is

currently subject of controversial discussion.

With the Babylog 8000 frequencies of 10 Hz and

below have been found to be favourable because
then the internal programming permits high
flow rates and in consequence high oscillatory
volumes.
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Oscillatory frequency

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The gas transport coefficient DCO2

In conventional ventilation the product of tidal volume

and frequency, known as minute volume or minute
ventilation.
Different study groups have found that CO2
elimination in HFO correlates well with VT2 x f
VT and f stand for oscillatory volume and frequency,
respectively.
This parameter is called gas transport coefficient,
DCO2 is measured and displayed by the Babylog 8000.
An increase in DCO2 will decrease pCO2.
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the clinical relevance of the gas transport

coefficient

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HFV: Indications 1

When conventional ventilation fails

reduced compliance
RDS/ARDS
airleak
meconium aspiration
BPD
pneumonia
atelectases
lung hypoplasia
Other:
PPHN
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Indications 2
When conventional ventilation fails
Prematures
relative: PIP > 22 mbar
absolute: PIP > 25 mbar
Newborns
relative: PIP > 25 mbar
absolute: PIP > 28 mbar
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Combining HFV and IMV, and

sustained inflation

Oscillatory ventilation on its own can be used in the

CPAP mode, or with superimposed IMV strokes,
usually at a rate of 3 to 5 strokes per minute.

The benefit of the IMV breaths is probably due to the

opening of uninflated lung units to achieve further
volume recruitment.
Sometimes very long inspiratory times (15 to 30 s) are
suggested for these sustained inflations (SI).

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Combining HFV and IMV, and

sustained inflation

By applying them about every 20 minutes compliance

and oxygenation have been improved and atelectases
prevented. Especially after volume loss by deflation
during suctioning
Prevention of atelectases, which might occur under
HFV with insufficient MAP is the primary benefit
of combining HFV and IMV.
HFV superimposed to a normal IMV can markedly
improve CO2 washout (flushing the deadspace by
HFV) at lower peak pressures than in conventional
ventilation.
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Effect of a sigh manoeuvres through sustained inflation (SI):

prior to the SI the intrapulmonary volume equals V1 at the MAP level (point
a); the SI manoeuvres temporarily increases pressure and lung volume
according to the pressure-volume curve; when the pressure has returned
to the previous MAP level, pulmonary volume remains on a higher level, V2
(point b), because the decrease in pressure occurred on the expiratory
limb of the PV loop.

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HFV: Start

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Strategies for various lung diseases

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