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NNC Module: Basics of Mechanical Ventilation in Neonates
Learning Objectives Slide 1
Learning Objectives Learning Objectives (cont.)(cont.)
7. Apply initial ventilator settings.
8. Adjust ventilator settings to improve oxygenation and ventilation as indicated
9. Monitor the neonate during mechanical ventilation.
10. Detect any deterioration during mechanical ventilation and identify its causes.
NNC Module: Basics of Mechanical Ventilation in Neonates
Learning Objectives Slide 2
Learning Objectives Learning Objectives (cont.)(cont.)
11. Apply paralysis and sedation as needed.
12. Recognize how to wean the neonate from assisted ventilation.
13. Apply physiotherapy and suction to the neonate as indicated.
14. Detect complications that may occur during mechanical ventilation.
NNC Module: Basics of Mechanical Ventilation in Neonates
Introduction Slide 3
IntroductionIntroduction
Mechanical ventilation is an invasive life-support procedure with many effects on the cardiopulmonary system.
The goal is to optimize both gas exchange and clinical status at minimum FiO2 and ventilator pressure. The ventilator strategy employed to accomplish this goal depends in part on the infant disease process.
NNC Module: Basics of Mechanical Ventilation in Neonates
Indications of Mechanical Ventilation Slide 4
Indications of Mechanical Indications of Mechanical Ventilation Ventilation
Absolute indicationsAbsolute indications
If any of the following is present:If any of the following is present:
1. Severe hypoxemia with PaO2 less than 50 mmHg despite FiO2 of 0.8.
2. Respiratory acidosis with pH of less than 7.20 to 7.25, or PaCO2 above 60 mmHg.
3. Severe prolonged apnea.
NNC Module: Basics of Mechanical Ventilation in Neonates
Indications of Mechanical Ventilation Slide 5
Indications of Mechanical Indications of Mechanical Ventilation Ventilation (cont.)(cont.)
Relative indicationsRelative indications1. Frequent intermittent apnea
unresponsive to drug therapy.2. Early treatment when use of mechanical
ventilation is anticipated because of deteriorating gas exchange.
3. Relieving work of breathing in an infant with signs of respiratory difficulty.
4. Initiation of exogenous surfactant therapy in infants with RDS.
NNC Module: Basics of Mechanical Ventilation in Neonates
Effects of Ventilator Setting Changes on Blood Gases Slide 6
Effects of Ventilator Setting Changes on Effects of Ventilator Setting Changes on Blood GasesBlood Gases
EffectEffectVentilator Ventilator setting setting changeschanges
PaCO2PaCO2 PaO2PaO2
Increase PIPIncrease PIP Decrease Increase
Increase PEEPIncrease PEEP Increase Increase
Increase rateIncrease rate Decrease Increase
Increase I:E Increase I:E ratioratio
------- Increase
Increase FiO2Increase FiO2 ------- Increase
Increase flowIncrease flow Decrease Increase
NNC Module: Basics of Mechanical Ventilation in Neonates
Starting Ventilator Setting Slide 7
Starting Ventilator Starting Ventilator SettingSetting
Intubate infant with an endotracheal tube according to body weight.
During intubation, infants require fractional inspired oxygen FiO2 that is 10% higher than what they were receiving before mechanical ventilation.
NNC Module: Basics of Mechanical Ventilation in Neonates
Guidelines for Endotracheal Tube Size Slide 8
Guidelines for Endotracheal Guidelines for Endotracheal Tube SizeTube Size
Infant weight(gm)Infant weight(gm) Endotracheal tube Endotracheal tube internal diameterinternal diameter
< 1,000gm 2.5mm
1,000 - 2,000 3.0mm
2,000 - 3,000 3.5mm
> 3,000 3.5 - 4.00mm
NNC Module: Basics of Mechanical Ventilation in Neonates
Initial Setting of Mechanical Ventilation Slide 9
Initial Setting of Mechanical Initial Setting of Mechanical VentilationVentilation
PIP is determined by hearing good breath sounds and good lung expansion.
FiO2 is determined according to patient need.
Ti should not be prolonged because of risk of alveolar over-distention. Start with 0.25 seconds and do not exceed 0.5 seconds (unless there are special indications).
Respirator rate should not ordinarily exceed 80 breaths/min to allow sufficient time for exhalation.
NNC Module: Basics of Mechanical Ventilation in Neonates
Initial Setting of Mechanical Ventilation Slide 10
Initial Setting of Mechanical Initial Setting of Mechanical Ventilation (cont.)Ventilation (cont.)
Initial settingsInitial settings
Fio2Fio2 As indicatedAs indicated
Systemic flowSystemic flow 8-10l/min8-10l/min
RateRate 60 breaths / min60 breaths / min
Ti/TeTi/Te 1:1.25 - 1:41:1.25 - 1:4
PIPPIP 18 - 22cm H2018 - 22cm H20
Good breath Good breath soundssounds
PEEPPEEP 3 - 5cm H203 - 5cm H20
NNC Module: Basics of Mechanical Ventilation in Neonates
Subsequent Settings of Mechanical Ventilation Slide 11
Subsequent Settings of Subsequent Settings of Mechanical VentilationMechanical Ventilation
Measure arterial blood gases half an hour after the initial setting and adjust the setting accordingly. (Table)
Although it is tempting to try to lower PaCO2 by increasing the respiratory rate rather than by adjusting ventilatory pressure, data suggest that this can not be without risk.
NNC Module: Basics of Mechanical Ventilation in Neonates
Subsequent Settings of Mechanical Ventilation Slide 12
Subsequent Settings of Mechanical Subsequent Settings of Mechanical VentilationVentilation (cont.) (cont.)
Subsequent Subsequent settingssettings
PEEPPEEP PIPPIP
Low PaO2 ,Low PaO2 ,
Low PaCo2Low PaCo2Increase
Low PaO2 ,Low PaO2 ,
High PaCo2High PaCo2Increase
High PaO2 ,High PaO2 ,
High PaCo2High PaCo2Decrease
High PaO2 ,High PaO2 ,
Low PaCo2Low PaCo2Decrease
NNC Module: Basics of Mechanical Ventilation in Neonates
Monitoring The Infant during Mechanical Ventilation Slide 13
Monitoring The Infant Monitoring The Infant during Mechanical during Mechanical
VentilationVentilation Obtain an initial blood gas within 15-30
minutes of starting mechanical ventilation.• Obtain a blood gas within 15-30 minutes of Obtain a blood gas within 15-30 minutes of
any change in ventilator settings. any change in ventilator settings.
• Obtain a blood gas every 6 hours unless a Obtain a blood gas every 6 hours unless a sudden change in the infant's condition sudden change in the infant's condition occurs. occurs.
• Continuous monitoring of the O2 saturation Continuous monitoring of the O2 saturation
level as well as the HR and RR is necessary.level as well as the HR and RR is necessary.
NNC Module: Basics of Mechanical Ventilation in Neonates
Deterioration during Mechanical Ventilation Slide 14
Deterioration during Deterioration during Mechanical VentilationMechanical Ventilation
Sudden clinical deteriorationSudden clinical deterioration Mechanical or electrical ventilator
failure. Disconnected tube or leaking
connection. Endotracheal tube displacement or
blockage. Pneumothorax.
NNC Module: Basics of Mechanical Ventilation in Neonates
Deterioration during Mechanical Ventilation Slide 15
Deterioration during Deterioration during Mechanical VentilationMechanical Ventilation
(cont.)(cont.)Gradual deteriorationGradual deterioration Inappropriate ventilator setting. Intraventricular hemorrhage. Baby fighting against ventilator. PDA. Anemia. Infection.
NNC Module: Basics of Mechanical Ventilation in Neonates
Paralysis and Sedation Slide 16
Paralysis and Sedation Paralysis and Sedation (cont.)(cont.)
Sedation is useful when agitation interferes with ventilatory support and when infants fight the ventilator.
Phenobarbital decreases the variability in mean arterial pressure and intracranial pressure associated with endotracheal suctioning.
NNC Module: Basics of Mechanical Ventilation in Neonates
Weaning Slide 17
WeaningWeaning When the patient is stable, FiO2 and PIP
are weaned first. Decrease PIP as tolerated and as chest rise
diminishes. When PIP is around 20, attention is
directed to FiO2 and then to the respiratory rate alternating with each other, in response to assessment of chest excursion, blood gas results, and oxygen saturation.
NNC Module: Basics of Mechanical Ventilation in Neonates
Weaning Slide 18
Weaning Weaning (cont.)(cont.) As frequency is decreased, Te should
be prolonged. For larger infants, weaning to
endotracheal CPAP may begin when PIP has been stable between 15-18 cmH2O, and FiO2 is less than 0.4.
The infant can be weaned to oxygen hood when he/she requires less than 4 cmH2O of end expiratory pressure.
NNC Module: Basics of Mechanical Ventilation in Neonates
Weaning Slide 19
Weaning Weaning (cont.)(cont.) For infants weighing less than 1,750 gm,
when PIP is less than 15 cmH2O and FiO2 is less than 0.3, start to decrease the respiratory rate gradually to 15-20 breaths/min and then wean directly to nasal CPAP if available.
In most infants, when ventilator frequency of approximately 15 breaths per minute is tolerated, endotracheal CPAP may be tried for a short period before extubation.
NNC Module: Basics of Mechanical Ventilation in Neonates
Weaning Slide 20
Weaning Weaning (cont.)(cont.) Atelectasis after extubation is common in
preterm infants recovering from RDS. Use of nasal CPAP may prevent atelectasis.
Steroids are not routine before extubation, but if there was prolonged intubation or previous failed attempts of extubation, a short course of steroids may facilitate extubation.
If strider caused by laryngeal edema develops after extubation, racemic epinephrine aerosols and steroids may be helpful.
NNC Module: Basics of Mechanical Ventilation in Neonates
Physiotherapy and Suctioning Slide 21
Physiotherapy and Physiotherapy and SuctioningSuctioning
Tracheal suctioning and chest physiotherapy should be minimized in infants with HMD in the first few days after birth because their secretions are scant.
Physiotherapy and suctioning should be done to prevent the development of atelectasis, especially in premature infants. However, some infants show acute deterioration of blood gases.
NNC Module: Basics of Mechanical Ventilation in Neonates
Complications of Mechanical Ventilation Slide 22
Complications of Mechanical Complications of Mechanical VentilationVentilation
Endotracheal tube complications Endotracheal tube complications and and
tracheal lesionstracheal lesions Accidental displacement of the
endotracheal tube into main stem bronchus, hypopharynx, or esophagus.
Accidental extubation. Obstruction of endotracheal tube.
NNC Module: Basics of Mechanical Ventilation in Neonates
Complications of Mechanical Ventilation Slide 23
Complications of Complications of Mechanical Ventilation Mechanical Ventilation
(cont.) (cont.) Airway injuryAirway injury Subglottic stenosis. Edema of the cords after extubation
(may result in hoarseness and stridor). Prolonged use of orotracheal
intubation associated with palatal groove formation.
Necrotizing tracheobronchitis.
NNC Module: Basics of Mechanical Ventilation in Neonates
Complications of Mechanical Ventilation Slide 24
Complications of Complications of Mechanical Ventilation Mechanical Ventilation
(cont.)(cont.)
InfectionInfectionPneumonia and systemic infections with Staphylococcus epidermidis, Candida organism, gram-negative organisms, and Staphylococcus aureus.
NNC Module: Basics of Mechanical Ventilation in Neonates
Complications of Mechanical Ventilation Slide 25
Complications of Complications of Mechanical Ventilation Mechanical Ventilation
(cont.)(cont.)Chronic lung disease / Oxygen Chronic lung disease / Oxygen
toxicitytoxicity Bronchopulmonary dysplasia (BPD),
related to increased airway pressure and changes in lung volume.
Other contributing factors are oxygen toxicity, anatomic and physiologic immaturity, and individual susceptibility.
NNC Module: Basics of Mechanical Ventilation in Neonates
Complications of Mechanical Ventilation Slide 26
Complications of Complications of Mechanical Ventilation Mechanical Ventilation
(cont.)(cont.)Air leakAir leakPneumothorax, pulmonary interstitial emphysema (PIE), and pneumomediastinum directly related to increased airway pressure occurring frequently at MAP >14 cmH2O.
NNC Module: Basics of Mechanical Ventilation in Neonates
Complications of Mechanical Ventilation Slide 27
Complications of Complications of Mechanical Ventilation Mechanical Ventilation
(cont.)(cont.)MiscellaneousMiscellaneous Intraventricular hemorrhage. Decreased cardiac output. Feeding intolerance