Mechanical ventilation can be associated with acute or chronic respiratory tract injury, such as atelectrauma, volutrauma, barotrauma, oxygen toxicity, and a pulmonary or systemic inflammatory response to lung trauma.
Avoid an irregular respiratory pattern by using an optimum lung volume characterized by using a patient-triggered synchronized ventilation modality.undefined#ref1">1 Irregular respiratory patterns in neonates can lead to asynchrony with the ventilator, resulting in high airway pressure, poor oxygenation, and fluctuation in intracranial pressure when the ventilator breath occurs just after the neonate exhales. Lung protective ventilation strategies can minimize ventilator-induced lung injury.2
Mechanical ventilation is most commonly required for the extremely low-birth-weight or critically ill neonate. The goals of mechanical ventilation are to facilitate adequate gas exchange, minimize the risk of lung injury, decrease the patient’s work of breathing (WOB), and optimize the patient’s comfort.
There are several basic conventional modes of mechanical ventilation for neonates: synchronized intermittent mandatory ventilation, assist-control ventilation, and pressure-support ventilation. Two modes of ventilation are available for the neonatal population: volume-targeted ventilation and neurally adjusted ventilator assist (NAVA). Volume-targeted ventilation provides a continuous flow of gas throughout inspiration, producing the characteristic “square wave” of flow versus time. Peak pressure and volume delivery occur at the end of inspiration, resulting in slower and more uniform lung inflation. The pressure is varied to deliver the desired volume of gas. NAVA is a mode of ventilation designed to improve patient-ventilator interaction by interpreting a neural signal from the diaphragm to trigger a supported breath. Neurally triggered breaths may reduce trigger delay, ventilator response times, and WOB. These various modes of mechanical ventilation are best classified on the basis of three factors: how each breath is initiated, gas flow during the ventilator breath, and how the breath ends (Table 1).
In addition to the basic conventional modes of mechanical ventilation, there are other high-frequency ventilation (HFV) modes: high-frequency oscillatory ventilation (HFOV) and high-frequency jet ventilation (HFJV). HFV uses small tidal volumes (VTs) and delivers high rates. HFOV’s advantage over conventional mechanical ventilation is the ability to deliver sub-VT breaths at high frequencies. Indications for using HFOV include severe lung disease that is unresponsive to conventional ventilation, pulmonary air leaks, and pulmonary hypoplasia. HFJV is most effective with disorders in which the major problem is carbon dioxide elimination because it can be achieved more readily at a lower peak and mean airway pressure than with HFOV. Severe atelectatic disorders, such as respiratory distress syndrome, and obstructive disorders, such as meconium aspiration syndrome, have been shown to respond to HFJV. The appropriate ventilator mode to be used is based on the individual patient’s clinical condition, disease process, and response to previous ventilatory support (Table 2).
Rationale: Elevating the head of the bed may reduce the risk of aspiration and the risk of intraventricular hemorrhage.
Rationale: Chest wall vibration is an indicator of lung compliance, airway patency, and effectiveness of ventilator settings. A sudden decrease in chest wall vibration may indicate a plugged endotracheal (ET) tube or a pneumothorax.
Rationale: Volume and tone of HFV breath sounds affect the ability to auscultate heart sounds.
Rationale: Changes in lung compliance may occur, resulting in the need for more or less ventilator support.
Keep in mind that the goal is to wean the patient from the ventilator as soon as possible to minimize lung injury.
Rationale: Using the safe suction depth ensures that the suction catheter is not inserted beyond the end of the ET tube, protecting the soft tissue of the carina from injury.
Rationale: Suctioning is not a benign procedure; therefore, it should be done only as needed to maintain airway patency and remove secretions.
Rationale: An alarm may be associated with the need for suctioning or the need to drain water from the tubing, or it may indicate that the ventilator tubing has been disconnected.
Walsh, B.K., Chatburn, R.L. (2019). Chapter 17: Invasive mechanical ventilation of the neonate and pediatric patient. In B.K. Walsh (Ed.), Neonatal and pediatric respiratory care (5th ed., pp. 301-337). St. Louis: Elsevier.
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