Mechanical Ventilation: Neonate (Respiratory Therapy)
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Mechanical ventilation can be injurious to immature and underdeveloped lungs. Use lung protective ventilation strategies to minimize ventilator-induced lung injury (VILI).undefined#ref1">1,2
Mechanical ventilation is commonly used for neonates that may be extremely low birth weight or have immature and underdeveloped lungs (Table 1). The risk for needing intubation and mechanical ventilation increases inversely to gestational age.5 VILI may be caused by low lung volumes (atelectrauma), high lung volumes (volutrauma), and high pressures (barotrauma). Trauma from mechanical ventilation may result in risk to the neonate that may be life-threatening or lead to long-lasting complications.
The goals of mechanical ventilation are to ensure adequate gas exchange, decrease work of breathing (WOB), and minimize the risk of VILI, while keeping the patient as comfortable as possible.1 In general, the basic types of ventilation used for neonates are conventional ventilation (CV) and high-frequency ventilation (HFV). CV uses a mechanical ventilator using ventilatory frequencies and tidal volumes that achieve required minute ventilation, whereas HFV provides preset ventilatory frequencies at higher rates and tidal volumes less than or equal to dead space volume.4 During CV, the ventilator may initiate a breath, the patient may initiate a breath, or there may be a combination of the two patterns.1 During CV, the breath delivered may be controlled by a set or targeted volume, pressure, or time setting. Regardless of the type of mechanical ventilator used or the type of breaths delivered to the patient, it is important that the respiratory therapist (RT) monitors the neonate carefully to optimize safety and comfort, and to ensure that the duration of mechanical ventilation is minimized as much as possible.
Although mechanical ventilation may be necessary for the neonate, it does come with risk of complications. The most common complications include (Table 2):
Methods that optimize oxygenation and ventilation and lung protective ventilation strategies to minimize harmful side effects from mechanical ventilation can limit the risk of VILI.2 Oxygen use should be initiated at the lowest possible setting to maintain oxygenation and adjusted based on continuous monitoring of blood gases and peripheral oxygen saturation (SpO2). Lung protective ventilation strategies, such as volume-targeted ventilation, low ventilating pressures, optimal positive end-expiratory pressure (PEEP), and mechanical ventilator modes that promote patient–ventilator synchrony, should be used to minimize the risk of complications and optimize mechanical ventilation liberation as soon as possible.6 Monitoring SpO2, capnography (end-tidal carbon dioxide [ETCO2]), volume and pressure values, and ventilator graphics may help the RT respond quickly to changes in oxygenation, ventilator, or patient–ventilator synchrony by changing mechanical ventilation parameters. Care of the patient receiving mechanical ventilation should focus on both the patient and the equipment. The patient–ventilator system should have humidification, the ventilator circuit should be clean, and the ventilator settings and function should be checked and always maintained to facilitate changes in the patient’s condition. The patient should be positioned for comfort and safety, suctioned when secretions are present, and the artificial airway always maintained securely to prevent inadvertent extubation. The patient should be monitored regularly for readiness to wean from mechanical ventilation as soon as possible to minimize the risk of VILI or other complications associated with mechanical ventilation.
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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.
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.
Clinical Review: Justin J. Milici, MSN, RN, CEN, CPEN, CPN, TCRN, CCRN, FAEN
Published: February 2024
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