BASICS OF NEONATAL VENTILATION

Dr Abid Ali Rizvi

Why do we ventilate neonates?

Oxygenation CO2 elimination Overwhelming Work of Breathing Poor respiratory drive Others: Transport of sick baby, pre-op etc.

Applied Mechanics

Flow of gas PIP minus PEEP Compliance [C] Tidal Volume [TV] TV x Rate = Minute volume Mean Airway Pressure [Paw] Time Constant = [C] x [Raw] Dead Space [VD] Right to Left Shunting Work of Breathing [WOB] Endotracheal Leak and Airway Resistance [Raw]

Generates the inflating pressure. Creates a pressure gradient [DP]. Dictate the PIP and PEEP required. Is proportional to the DP size. Quantifies the CO2 removal. Quantifies the adequacy of alveolar recruitment & oxygenation. Decides optimum Ti and Te

Start here:

A pressure gradient between the airway opening (mouth) and the alveoli must be present to drive the flow of gases during both inspiration and expiration. Peak Inspiratory Pressure [PIP]: Opens the alveoli. Positive End Expiratory Pressure [PEEP]: Prevents the alveoli from collapsing during exhalation; thereby maintains adequate Functional Residual Capacity [FRC].

Components of the inflating pressure

Mean Airway Pressure = area under the Pressure Time Curve Pressure (cm of H2O) PIP

PEEP

PIP wave form is shaped by the gas flow rate during inspiration.

Compliance

Compliance describes the elasticity or distensibility of the respiratory structures (alveoli, chest wall, and pulmonary parenchyma). A measure of the ease of expansion of the lungs and thorax. Compliance = volume pressure Low Compliance means Stiff lungs [as in Hyaline Membrane Disease]. It will need higher pressure gradient for pushing air inside.

Elastance [E] :Recoil Tendency

Elastance is reciprocal of compliance [C]. It measures the ease with which a distended structure return back to its original size. E=1/C Alveoli with low compliance are difficult to inflate, but their elastance is high, so they deflate easily. Such alveolar units are prone to atelectasis during expiration.

Compliance

Airway resistance

Airway resistance is the opposition to gas flow. Ratio of driving pressure to the rate of air flow. ET is the most important contributor of Raw Airway resistance depends on:
Radii

of the airways (total cross-sectional area) Lengths of the airways Flow Type: Laminar or Turbulent Density and viscosity of gas

Airway resistance

ET resistance increases with flow

Time Constant [Kt] = C x Raw

One time constant of a respiratory system is defined as the time required by the alveoli to empty 63% of its tidal volume through the airways into the mouth/ventilator circuit. At the end of three [Kt ] 95% of the tidal volume is emptied. Airway diameter during inspiration: Raw . Therefore inspiratory [Kt ] are ~ half of the expiratory [Kt ].

% filling and emptying of alveoli after every Time Constant.

Time Constant [Kt] = C x Raw

Stiff alveoli (eg HMD) have very short [Kt ], so small Ti is sufficient to fill them, and they will empty quickly also. Conditions with high Raw ( eg MAS, BPD) have long expiratory time constant, so they will empty adequately with longer Te, and will be slow to fill too. It is also dependent on the patient`s size. Every thing being equal, larger infants have longer time constant than the extremely premature ones. Therefore premature neonate will have normal breathing faster than a term AGA newborn.

Anatomic Dead Space

Anatomic dead space:

The

total volume of the conducting airways from the nose or mouth down to the level of the terminal bronchioles. This volume does not participate in the gas exchange. Extrathoracic : 2-2.5 ml/kg in neonates. Intrathoracic : 1.03 ml/kg, age independent.

Intrapulmonary RL shunting [ V/Q ]

Alveolar Dead Space [Collapsed alveoli]

Instrumental dead space

In babies <1000 g, the extra dead space may slightly increase PaCO2 levels. The advantages of using flow sensors for monitoring, volume targeting and flow triggering, outweigh the small effect on PaCO2. Instrumental dead space imposes a ventilatory burden during SIMV weaning in small preterm infants.

Work of Breathing

Work = Pressure x Volume Work against Elastic Recoil Work against Resistance
Airway

Metabolic cost of WOB in spont. breathing in normal lungs is 1-2% of total O2 consumption, but can increase to >30% in ventilated baby with premature lungs.

resistance: Mainly the narrow ET Tissue resistance Viscous forces within tissues as they slide over each other.

2 Components of WOB: Elastic and Resistive Resp. Rate Dependency

Imposed work of breathing [WOB]

ET, circuit tubing, ventilator exhalation valve, all increase the resistance against which the baby must breathe while on ventilator. This leads to increased O2 consumption and exhaustion of respiratory muscles.

Techniques to counter the Imposed WOB:

Avoid

narrow ET if possible. [Poiseuille's equation R . L (Radius)4] Pressure Support for the spontaneous breaths. Adequate PEEP in expiration: [Maximum WOB is for re-opening a collapsed alveoli] Optimize the lung volume:
lung volume: Airway resistance is high, so WOB . Over-distended Lungs: Compliance is low, so WOB .
Low

Synchronization Good

of ventilator and baby`s cycling.

nutrition. Early extubation ASAP.

Mean Airway Pressure [MAP/Paw]

Contributing parameters {PIP, PEEP, Ti, Flow, Rate} Important for the: MAP= (PIP-PEEP) x [Ti (Ti+Te)] + PEEP Recruitment of alveolar units:
Oxygenation is directly proportional to MAP. Surfactant preservation.

Optimization of Lung volume:

Airway resistance is high at low lung volumes. Compliance is poor at high (over-distended) lung volume. Pulmonary vascular resistance is high at low lung volume

Venous return and Cardiac output is compromised when MAP is abnormally high.

Mean Airway Pressure [MAP/Paw]

Safety & Efficiency of ventilation is best in this Lung Volume & Paw range.

Lung Volume

Mean Airway Pressure

Importance of PEEP

Presence of ET in the glottis disables the braking action of the vocal cords during expiration, which would normally prevent the collapse of alveoli. It is easy to expand an already open alveoli, rather than opening a fully collapsed one. FRV provides a means of oxygenation of pulmonary blood flow during expiration. PEEP split opens the floppy airways of preterm neonate, thereby preventing their collapse during expiration; so helps in reducing the airway resistance in expiration.

Modes of Neonatal Ventilation Classified by three factors:

Breath initiation:
Controlled

or Synchronized with the patient`s effort.

Gas flow control during the breath delivery:

Pressure

limited or Volume limited

Breath is termination:
Time

cycled (fixed inspiratory time) or Flow cycled (matching with the patient`s own Ti)

Hybrid modes mix multiple techniques from above.

CMV & IMV: by definition

Continuous Mandatory Ventilation: Used most often in the paralyzed or apneic patients. The ventilator rate is set faster than the patient's own breathing rate. Intermittent Mandatory Ventilation: The ventilator rate is lower (less than 30 bpm), therefore the patient gets chance to breathe spontaneously between two controlled breaths. In both CMV and IMV, breaths are delivered regardless of the patient's effort. Synchronization is not intended in both.

Poor Synchronization causes:

Baby fighting with the ventilator. Increased WOB Abnormally high intra-thoracic and intra-pulmonary pressure surges. Decreased venous return. Increased intracranial pressure. Barotrauma Sub-optimal training of muscles in weaning.

Synchronized ventilation modes

1.

2.

Nomenclature is a mess. Heart of synchronized ventilation is the breath sensor attached between the ventilator tubing & ET. Pressure sensor Flow sensor
1. 2.

Pneumotachograph Hot wire anemometer

3.

Hybrid

Limitations of flow sensors

ET leak: expiratory TV may be underestimated. Less than the expected expiratory tidal volume due to ET leak is registered as a negative flow ( same as baby`s breath initiation). This artifact falsely triggers a ventilator breath in the middle of the baby`s expiration: [AUTOCYCLING], ventilator can end up with very high auto triggered rate. Imposing 1 mL of dead space, may increase the work of breathing in very tiny preterm.

Assist Control [A/C] Patient Triggered Ventilation [PTV]

Every breath of baby that the flow sensor detects is supported with PIP/PEEP Ventilator rate therefore belongs to baby. Ti is fixed by the physician. Backup rate [20-30/min] is set by physician in case of apnea or flow sensor failure. Weaning is done by decreasing the PIP. If baby is excessively tachypneic, the A/C mode may deliver abnormally high ventilator breaths, causing hypocapnea.

A/C: Green parts at beginning of flow

curve is the patient`s effort

Synchronized Intermittent Mandatory Vent. [SIMV]

SIMV was developed as a result of the problem of high respiratory rates associated with PTV. SIMV delivers the preset pressure and rate while allowing the patient to breathe spontaneously in between ventilator breaths. Each ventilator breath is delivered in synchrony with the patients breaths, yet the patient is allowed to completely control the spontaneous breaths. Work of breathing and respiratory muscle fatigue increase with low parameter SIMV.

SIMV breaths: Green spontaneous;

Blue ventilator

Volume Targeted Ventilation [VTV] Targeted Tidal Volume [TTV] Ventilation Volume Guarantee [VG]

Physician selects a desired tidal volume (app. 5-6 mL/kg) for the baby. The ventilator then delivers the desired tidal volume at the lowest feasible PIP and Ti according to changes in Raw, C and baby`s effort. Main benefits of TTV: Reduction in volutrauma and barotrauma. A stable Tidal Volume avoiding swings in pCO2. Ventilation is at the lowest possible parameters. Ability to self wean.

Pressure Support Ventilation [PSV]

Peak Expiratory Flow

PSV with SIMV

Effect of various parameters on oxygenation and ventilation.

In brief: Always Check:

Chest movement, air entry, presence of retractions, hyper-inflated chest, wheezing etc. Level of ET at lips, visible secretions in ET, any kinking or disconnection, any warning alarms on the ventilator. Assess baby`s own respiratory drive: depth & rate. Signs of baby fighting the ventilator: air hunger, asynchrony, gross difference between ventilator and baby`s breathing rate. Signs of pain, agitation, abnormal posturing. Abnormal heart rate, BP, temperature. Signs of excessive sedation.