Mechanical Ventilation: Neonate (Respiratory Therapy)

ALERT

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}

OVERVIEW

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):

• Barotrauma from high ventilating pressure
• Volutrauma from large tidal volumes
• Atelectrauma from repetitive opening and closing of underinflated alveoli
• Extrapulmonary air leaks
• Nosocomial infection
• Patient–ventilator asynchrony
• Airway injury
• Oxygen toxicity

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.

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Explain the purpose for and complications of mechanical ventilation.
• Provide descriptions and explanations of the equipment and alarms.
• Discuss the need for suctioning and explain the procedure to the family.
• Discuss methods the family may use to interact with and calm their neonate.
• Explain the need for sedation while on mechanical ventilation.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the family.
3. Verify the correct patient using two identifiers.
4. Assess the family’s understanding of the reasons for and the risks and benefits of the procedure.
5. Ensure that the ventilator is connected to the appropriate oxygen and medical air outlets.
6. Ensure that the ventilator is connected to emergency (red) electrical outlets.
7. Inspect the ventilator equipment and settings.
   1. Review these set and measured parameters when using conventional ventilation: fraction of inspired oxygen (FIO₂), ventilator rate, peak inspiratory pressure (PIP), positive end-expiratory pressure (PEEP), tidal volume (VT), inspiration-to-expiration ratio, flow rate, and mean airway pressure (MAP) (Table 3).
   2. Review these parameters when using HFV: FIO₂, amplitude, frequency, and MAP (Table 3).
8. Assess and set ventilator alarms per the organization’s practice.

Preparation

1. Ensure that an appropriate-size manual ventilation bag or manual resuscitator, mask, and suction are immediately available and connected at the patient’s bedside. Test for functionality.
2. Ensure that the patient is in a developmentally and clinically appropriate position.

   Rationale: Elevating the head of the bed may reduce the risk of aspiration and the risk of intraventricular hemorrhage.

PROCEDURE

1. Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Explain the procedure to the family and ensure that they agree to treatment.
4. Ensure that the practitioner provides the appropriate sedation and pain medications.
5. Evaluate the patient’s vital signs and cardiopulmonary status, including spontaneous respiratory rate, chest expansion or vibration, and response to mechanical ventilation.
6. Auscultate the patient’s breath sounds, including upper and lower lung fields and differences in left and right lung fields, to evaluate for the equality of aeration and the presence of adventitious breath sounds.
7. Observe the chest wall vibration when HFV is in use.

   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.

8. Place the HFV on standby to assess heart sounds and manually ventilate the patient to assess breath sounds.

   Rationale: Volume and tone of HFV breath sounds affect the ability to auscultate heart sounds.

9. Examine the patient for signs and symptoms of ventilatory failure, including increased arterial partial pressure of carbon dioxide (PaCO₂) with decreasing pH, increased WOB, tachypnea, and increased retractions.
10. Examine the patient for signs and symptoms of hypoxemia, including decreased oxygen saturation, pale or cyanotic color, tachycardia or bradycardia, tachypnea, agitation, increased WOB, increased retractions, and acidosis.
11. Note the position of the ET tube, depth markings, and if a commercially available tube holder is in use.
12. Review radiographic findings, arterial blood gas (ABG) analysis, and the patient’s clinical status for indications that ventilator weaning (i.e., spontaneous breathing trial [SBT]) can be initiated.
13. Evaluate the need for suctioning.
14. Adjust ventilator settings on the basis of treatment protocols or strategies and the patient’s response in collaboration with the practitioner.

    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.

15. Suction the ET tube using the safe suction depth, preferably with an inline suction device.

    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.

    1. Suction as needed, not on a routine schedule.

       Rationale: Suctioning is not a benign procedure; therefore, it should be done only as needed to maintain airway patency and remove secretions.

    2. Observe and document the characteristics of secretions.
16. Discard supplies, remove PPE, and perform hand hygiene.
17. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Assess the patient and review the ventilator parameters per the organization’s practice.
2. Confirm the activation of all alarms per the organization’s practice.
3. Monitor and document oxygen saturation per the organization’s practice.
4. Monitor blood gases as indicated. ABGs are obtained within 30 minutes³ after initiation of assisted ventilation, after significant changes in ventilation settings, and with changes in the patient’s condition per the organization’s practice. Correlate ABG results with ETCO₂.
5. Provide oral care per the organization’s practice.
6. Confirm ET tube stability and centimeter marking at the gumline or lip line once per shift and as needed.
7. Respond immediately to ventilator alarms and watch for changes and fluctuations in prescribed settings, which may indicate water in the tubing or the need for suctioning.

   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.

8. Monitor for signs of unplanned extubation, including sudden deterioration in clinical status, abdominal distention, crying, decreased chest wall movement, breath sounds in the abdomen, agitation, cyanosis, or bradycardia.
9. Observe the patient for signs and symptoms of pain. If pain is suspected, report it to the authorized practitioner.
10. Assess the patient’s readiness for weaning and extubation.

EXPECTED OUTCOMES

• Adequate oxygenation and ventilation
• Maintenance of adequate pH and PaCO₂
• Oxygenation and ventilation without lung injury
• Hemodynamic stability
• Proper placement of ET tube
• Mobilization and removal of secretions
• Weaning from and termination of mechanical ventilation as soon as patient is physiologically ready

UNEXPECTED OUTCOMES

• Inadequate ventilation and oxygenation (hypoxemia, hypercarbia, acidosis, alkalosis)
• Lung overinflation (air-leak syndrome)
• Acute lung injury (barotrauma, volutrauma, or progression of lung disease)
• Atelectasis
• Hemodynamic instability
• Unplanned extubation or malposition of ET tube
• Ventilator-associated events (VAE) or ventilator-associated conditions (VAC)
• ET tube obstruction
• Inadequately managed pain and agitation due to presence of ET tube or hypoxemia

DOCUMENTATION

• Cardiopulmonary assessment
  • Vital signs
  • Lung sounds
  • WOB
  • Capillary or arterial blood gases
  • Pulse oximetry
  • ETCO₂
• Confirmation of placement of ET tube by radiograph and any changes made following radiograph
• ET tube centimeter mark at the teeth or gums
• ET tube size
• ET tube type: cuffed or uncuffed
• Date, time, and response to initiation of ventilator assistance
• Conventional ventilator settings, if appropriate, including FIO₂, mode, VT, PIP, rate, and PEEP
• HFV settings, if appropriate, including inspiratory time, hertz (hz), FIO₂, amplitude, frequency, and MAP
• Timing of suctioning
• Characteristics of ET tube secretions
• Patient’s response to suctioning
• Assessment of breath sounds after suctioning
• Additional interventions and patient’s response
• Comfort assessment and any specific interventions provided
• Education
• Unexpected outcomes and related interventions

REFERENCES

1. Kacmarek, R.M. (2021). Chapter 49: Initiating and adjusting invasive ventilatory support. In R.M. Kacmarek, J.K. Stoller, A.J. Heuer (Eds.), Egan’s fundamentals of respiratory care (12th ed., pp. 1072-1104). St. Louis: Elsevier.
2. Thekkeveedu, R.K. and others. (2022). Ventilation-induced lung injury (VILI) in neonates: Evidence-based concepts and lung-protective strategies. Journal of Clinical Medicine, 11(3), 557. doi:10.3390/jcm11030557
3. Walsh, B.K. (2023). Chapter 7: Invasive blood gas analysis in the neonate. In B.K. Walsh (Ed.), Neonatal and pediatric respiratory care (6th ed., pp. 82-95). Philadelphia: Elsevier.
4. 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.
5. Wheeler, C.R., Smallwood, C.D. (2020). 2019 Year in review: Neonatal respiratory support. Respiratory Care, 65(5), 693-704. doi:10.4187/respcare.07720
6. Williams, E.E., Greenough, A. (2021). Lung protection during mechanical ventilation in the premature infant. Clinics in Perinatology, 48(4), 869-880. doi:10.1016/j.clp.2021.08.006

Clinical Review: Justin J. Milici, MSN, RN, CEN, CPEN, CPN, TCRN, CCRN, FAEN

Published: February 2024