Mechanical Ventilation: Neonatal Time-Triggered, Pressure-Limited, and Time-Cycled (Respiratory Therapy)

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ALERT

Neonates on mechanical ventilation are at high risk for complications like pneumonia, respiratory distress syndrome (RDS), sepsis, bronchopulmonary dysplasia (BPD) or ventilator-induced lung injury (VILI) from volutrauma, barotrauma, or atelectrauma, and retinopathy of prematurity (ROP) from excessive arterial oxygen levels.

OVERVIEW

Time-triggered, pressure-limited, and time-cycled ventilation (TCPLV) is a conventional mode of mechanical ventilation commonly used in neonates. The trigger is what starts the breath, and the cycle is what ends the breath. In this mode, breaths are initiated at set time intervals independent of the infant’s effort (time-triggered), and gas flow may be continuous or a set parameter that determines how quickly the preset pressure limit or peak inspiratory pressure (PIP) is reached on the pressure waveform. Once the pressure limit is reached, excess flow is diverted away from the patient. Each breath ends after a preset inspiratory time (TI; time-cycled), regardless of the volume delivered. Tidal volume (VT) varies depending on lung compliance, airway resistance, and the set pressure limit.

TCPLV is indicated for a range of neonatal conditions, including apnea of prematurity, RDS, air leak syndromes, and congenital lung or cardiac anomalies.^{undefined#ref1">1,2} The primary goal is to support oxygenation and ventilation while minimizing lung injury through lung-protective strategies. Safety, comfort, and timely liberation from mechanical ventilation are overarching goals.²

Initial ventilator settings should be individualized based on gestational age, underlying pathology, and the infant’s clinical response to manual or transport ventilation.¹ Continuous clinical evaluation, waveform analysis, and blood gas monitoring are essential for guiding adjustments. The TI is typically set 0.25 to 0.4 seconds^1,2 for preterm infants and should be fine-tuned using flow-time curve analysis. Proper adjustment ensures complete inspiratory flow without prolonging inspiration unnecessarily, which could lead to patient–ventilator asynchrony or air leak syndromes.

PIP or pressure limit should be set to achieve visible chest rise and adequate breath sounds, targeting a VT of 4 to 6 mL/kg.^1,2 While there is no universally optimal PIP strategy, infants with poor lung compliance may require higher pressures, which can be adjusted downward as compliance improves. Importantly, PIP alone is not inherently injurious unless it results in excessive VT. Typical PIP values range from 18 to 25 cm H₂O.² High and low VT alarms quickly detect changes in lung compliance.

Positive end-expiratory pressure (PEEP) is another critical setting, with initial values typically ranging from 3 to 7 cm H₂O.^1,2 This supports alveolar stability and is a key component of lung-protective ventilation. Expiratory time (TE) may be set directly or derived from the respiratory rate and TI. An initial rate of 30 to 50 breaths per minute is common.

Positioning of mechanically ventilated neonates should be carefully managed to reduce the risk of ventilator-associated event (VAE). Rotating among supine, prone, and lateral positions is recommended. Elevating the head of the bed can be achieved using reverse Trendelenburg positioning. Due to the weight of the ventilator circuit, caregivers must take extra precautions to maintain endotracheal (ET) tube stability during repositioning to minimize the risk of unplanned extubation.²

SUPPLIES

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EDUCATION

• Give developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, preferred learning style, and overall neurologic and psychosocial state.
• Explain the purpose and possible complications of mechanical ventilation.
• Describe and explain the equipment and alarms.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Determine if the family has health literacy needs or require tools or assistance to effectively communicate. Be sure these needs can be met without compromising safety.
2. Review the family’s previous experience and knowledge of mechanical ventilation and understanding of the care to be provided.
3. Assess the need for invasive mechanical ventilation.
4. Assess the patient’s vital signs, breath sounds, and ET tube placement on the chest x-ray; ensure ET tube is secured properly.

Preparation

1. Gather equipment, including a ventilator with neonatal-size circuit, humidification device, filters (if needed), manual resuscitation bag with appropriate-size mask, and closed-suction device.
2. Before initiating the mechanical ventilator, check the microprocessor or ventilation system to ensure calibration per manufacturer’s instructions.
   1. Verify compliance of the ventilator circuit with the humidification device and filters (if needed).
   2. Document the completed ventilation system test. Include pass or fail, date, initials or signature, and credentials.
3. Verify the authorized practitioner’s order for the initiation of mechanical ventilation.

PROCEDURE

1. Clean hands and put on appropriate personal protective equipment (PPE) based on the risk of exposure to body fluids or infection precautions.
2. Verify the correct patient using two identifiers.
3. Explain the procedure to the family and ensure that they agree to treatment.
4. Set the TI. Begin with 0.25 to 0.4 seconds,^1,2 depending on the gestational age and underlying clinical condition.

   Monitor the inspiratory to expiratory (I:E) ratio to maintain greater than 1:1.^1,2

5. Set the initial respiratory rate or set the TE to achieve the desired rate. Begin with 30 to 50 breaths per minute.
6. Set the PIP. Begin with 18 to 25 cm H₂O.²

   Rationale: A useful clinical indicator of adequate PIP is a gentle chest rise with every breath and adequate breath sounds.

   Use the lowest possible PIP to achieve Vt of 4 to 6 mL/kg^1,2 and adequate gas exchange to minimize lung injury.

7. Set the PEEP. Begin with 3 to 7 cm H₂O,^1,2 depending on underlying clinical condition.

   PEEP is adjusted to improve oxygenation, lung function, or lung compliance.

8. Set the flow rate so that the PIP rises normally during the breath cycle on the pressure waveform.
9. Set the fraction of inspired oxygen (FIO₂).
10. Ensure that all ventilator alarms are on and set appropriately for the patient’s individual settings.
11. Discard supplies, remove PPE, and clean hands.
12. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Regularly perform a check of ventilator settings, alarms, and measured parameters.
2. Maintain the humidification device and circuit temperature to avoid excessive condensation in the ventilator circuit.
3. Assess the patient’s overall level of comfort and patient–ventilator synchrony.
4. To minimize alveolar derecruitment, consider using a closed-suction device to minimize the number of times the patient is disconnected from the ventilator.

EXPECTED OUTCOMES

• Improved oxygenation
• Improved ventilation
• Patient-ventilator synchrony and comfort
• Liberation from mechanical ventilation

UNEXPECTED OUTCOMES

• Alveolar overdistention on chest x-ray
• Worsening oxygenation
• Worsening ventilation
• Patient-ventilator asynchrony
• VILI
• VAE

DOCUMENTATION

• Cardiorespiratory assessment
• Ventilator settings
  • Mode of ventilation
  • Set TI
  • Set respiratory rate or set TE
  • Set PIP
  • Set PEEP
  • Set flow rate
  • Set FIO₂
• Monitored settings
  • Exhaled VT
  • Exhaled minute volume
  • Total respiratory rate
  • I:E ratio
  • PIP
  • Mean airway pressure (MAP)
• Education
• Patient tolerance
• Unexpected outcomes and related interventions

REFERENCES

1. Keszler, M. (2022). Chapter 19: Overview of assisted ventilation. In M. Keszler, K.S. Gautham (Eds.), Goldsmith’s assisted ventilation of the neonate: An evidence-based approach to newborn respiratory care (7th ed., pp. 221-231). St. Louis: Elsevier.
2. Walsh, B.K. (2023). Chapter 14: Invasive mechanical ventilation of the neonate. In B.K. Walsh (Ed.), Neonatal and pediatric respiratory care (6th ed., pp. 227-259). Philadelphia: Elsevier.

ADDITIONAL READINGS

Sammour, I.A.K., DiBlasi, R. (2025). Chapter 54: Neonatal and pediatric respiratory care. In J.K. Stoller and others (Eds.), Egan’s fundamentals of respiratory care (13th ed., pp. 1208-1250). St. Louis: Elsevier.

Clinical Review: Jennifer Elenbaas, MA, BS, RRT, AE-C

Published: October 2025