Neonatal mechanical ventilation is the life-saving process of providing ventilatory support to newborns with respiratory distress. It involves the use of a specialized mechanical ventilator to assist infants with ventilation and oxygenation.
In this article, we will provide an overview of neonatal mechanical ventilation, including its goals, indications, and more.
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What is Neonatal Mechanical Ventilation?
Neonatal mechanical ventilation is the process of delivering positive pressure to an infant’s lungs for breathing support. It is indicated when a neonate’s own respiratory efforts are insufficient to maintain life.
Providing ventilatory support to newborns is different than in adults because neonates are anatomically different. Their lungs are much smaller, which equates to smaller tidal volumes.
Additionally, the pressure needed to ventilate a neonate’s lungs is much lower than in adults.
The differences in pulmonary mechanics between neonates and adults require special considerations when providing mechanical ventilatory support.
The primary goals of neonatal mechanical ventilation include:
- To improve ventilation
- To improve oxygenation
- To improve lung mechanics
- To decrease work of breathing
- To prevent lung injuries
Positive-pressure ventilation helps to improve ventilation by increasing the amount of air that enters the lungs. This, in turn, decreases the infant’s workload, which reduces their work of breathing.
An increased FiO2 can be administered to improve the infant’s oxygenation. In addition, positive pressure improves lung volumes and compliance by helping the lungs expand.
Mechanical ventilation is indicated in newborns to help maintain adequate ventilation and oxygenation.
Some specific examples of when an infant may require ventilatory support include:
- Ventilatory failure
- Severe hypoxemia
- Extreme prematurity
- Poor muscle tone
- Unresponsive to stimulus
- Low Apgar score
- When surfactant replacement therapy is needed
- Meconium present at birth
Each of these indications represents a situation in which the newborn’s respiratory efforts are insufficient. Therefore, mechanical ventilation is required to sustain life.
Neonatal Ventilator Modes
There are several modes of mechanical ventilation that can be used in neonates, including the following:
- Pressure-controlled ventilation
- Volume-controlled ventilation
- Pressure-support ventilation
- Volume-support ventilation
- Airway pressure release ventilation
- Dual-controlled mode
- Neurally adjusted ventilator assist (NAVA)
- High-frequency positive-pressure ventilation (HFPPV)
- High-frequency jet ventilation (HFJV)
- High-frequency oscillatory ventilation (HFOV)
Each neonatal ventilator mode has its own unique advantages and disadvantages, depending on the individual needs of the infant.
Neonatal Mechanical Ventilation Practice Questions:
1. What are the indications for neonatal mechanical ventilation?
Ventilator failure and oxygenation failure.
2. What is
A PaCO2 less than 60 and a pH less than 7.24.
3. What is oxygenation failure in neonates?
PaO2 less than 50 on 80-100% oxygen, or
4. How can we treat oxygenation failure?
Infant Respiratory Distress Syndrome (RDS).
6. What are the steps for the initiation of CPAP?
Obtain baseline ABG values & vital signs. Decide on
7. More mature and larger infants with fewer secretions and stable pulmonary conditions can have CPAP effectively applied how?
Above the glottis by nasal prongs or a nasopharyngeal tube.
8. What is required for less mature and smaller infants who need suctioning and have an unstable pulmonary condition?
9. When is CPAP usually started?
4-5 cmH2O with FiO2 kept at the previously set level and flow rates of 5-10 L/min.
10. In general, the PaO2 should be kept between what?
PaO2 between 60-70
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11. How do we increase CPAP if PaO2 is too low and patients’ vital signs are acceptable?
Increments of 2 cmH2o.
12. What is the maximum CPAP level in a neonate?
13. What is the maximum CPAP level in an infant?
14. What is the indication of a sudden decrease in the CPAP level to zero?
A disconnection at the patient or somewhere in the breathing circuit.
15. What does it mean if the CPAP level decreases more than 2 cmH2O during inspiration?
The flow is inadequate and should be increased.
16. What should be reduced if the infant is breathing > 50% oxygen while on CPAP?
Reduce the oxygen before decreasing CPAP to decrease the effects of oxygen toxicity.
17. What should be decreased if the infant is breathing 50% oxygen or less and has unstable vital signs or pulmonary barotrauma?
18. When evaluation of the neonates ABGs and vital signs indicates the need for mechanical ventilation, most neonatal patients require what?
Time-triggered, pressure limited, time cycled mechanical ventilation. This mode of conventional ventilation can deliver rates up to 150/min. If higher rates are needed, a mode of HFV must be used.
19. Volume cycled ventilation can be used on an infant that
More than 10 kg (22lb).
20. What is the typical tidal volume goal for a neonatal patient?
4-6 mL/kg in neonates and 6-8ml/kg in pediatrics.
21. What is a rule to estimate the depth of intubation?
Add six to the body weight in kilograms. As always, request a chest x-ray to verify proper tube placement after intubation.
22. Because delivered volumes are so small when volume ventilating infants and small pediatric patients, what must be taken into account?
The tubing compression factor.
23. What factor allows us to consider the volume that is lost within the circuit?
24. How do you calculate compressible volume?
TC factor x delta P = compressible volume (ml/cmH2O) PIP-PEEP= delta P.
25. What is the corrected tidal volume formula?
Set VT-compressible volume (AKA effective tidal volume).
26. What are the indications for mechanical ventilation?
Respiratory failure, neurologic, and pulmonary conditions.
27. What is considered respiratory failure in neonates?
PaO2 less than 50
28. What are the neurologic reasons for mechanical ventilation?
Complete apnea, apneic periods leading to hypoxemia and bradycardia, ICH (intracranial hemorrhage), and drug depression.
29. What are the pulmonary conditions for mechanical ventilation?
Respiratory distress syndrome (RDS), diffuse pneumonia, pulmonary edema, meconium aspiration, diaphragmatic hernia, prophylactic use, cyanotic congenital cardiac defect, persistent pulmonary hypertension of the neonate, and post op after major thoracic or abdominal surgery.
30. The greatest challenge presented in the care of the critically ill infant on mechanical ventilation is to provide adequate gas exchange without causing oxygen toxicity due to what?
A high FiO2 or pulmonary barotrauma.
31. It is commonly held that giving more than 50% oxygen for more than how many hours will increase the risk of pulmonary oxygen toxicity in the neonate?
Giving 50% oxygen for more than 48-72 hours.
32. What will occur if you give the neonate more than 80% oxygen?
The poorly ventilated alveoli will have all the oxygen absorbed leading to denitrogenating absorption atelectasis.
33. You should keep the PaO2 below 80 mmHg to reduce the risk of what?
The risk of ROP.
34. What do you want to set first on the ventilator?
35. How do we set PIP on mechanical ventilation for an infant?
Set it initially at 20-25 cmH2O and it may be increased to 35-45 cmH2O.
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36. Infants with decreased compliance (IRDS) need higher PIP. What should you set it at?
37. For infants with increased RAW and normal lung compliance, you should set the PIP at what?
<20 cm H2O.
38. In preemies, the PIP should be set how?
Less than gestational age.
39. What can you adjust to control the PaCO2?
40. What should be the rate be set at for term infants?
41. What should the rate of infants with decreased compliance be set at?
30-60 but may be increased up to 150.
42. What should the rate be set at for infants with increased RAW and normal lung compliance?
43. Rate is most commonly used to adjust PaCO2 after what is set appropriately?
44. Use higher rates and lower PIPs to treat restrictive pulmonary disorders and decrease the risk of what?
45. When do we use lower rates aside from infants with normal lungs?
Use lower rates on those who are neurologically compromised.
46. What setting on the ventilator is set third for neonates?
I-time. Set is for at least 0.4 seconds.
47. What should the I-time be set at for a term infant?
48. The i-time for infants with decreased compliance should be set between what?
49. The i-time for infants with increased RAW and normal compliance should be set between what?
50. After you adjust primary settings for a neonate, you can proceed to set what?
The Flow, FIO2 & PEEP, and Mode.
51. The flow should be set between what for a neonate?
52. If pressure manometer needle swings into negative range during inspiration, increase the flow, but be careful because too much flow leads to what?
53. The FiO2 for a neonate on mechanical ventilation should be set at what?
40% but can be increased if necessary.
54. The PEEP for a neonate on mechanical ventilation should be set at what?
It should be set between 2-4 with a range of 2-10 cm H2O.
55. What mode should be preferred in neonates?
Intermittent Mandatory Ventilation (IMV).
56. Although MAS is a common cause of increased RAW, it is also seen in infants with?
Excessive airway secretions and bronchospasm.
57. The meconium or other obstruction causes of uneven airflow results in what?
Hypoxemia, air trapping, auto-PEEP, and increased risk of barotrauma and volutrauma.
58. What are 2 key clinical goals in treating neonates with increased RAW?
Minimize turbulence during inspiration by reducing the inspiratory flow as much as possible, and give long enough expiratory time to prevent air trapping.
59. In general, the inspiratory flow and respiratory rates are kept?
Relatively long with an I:E ratio favoring a long time for complete exhalation.
60. What is the formula for time constants?
TC (secs)= CS x Raw.
61. It will take 3 time constants to exhale to 95% of the delivered volume and how many time constants to exhale completely?
62. Infants with normal compliance and increased resistance have long time constants, and as a result are at risk for what?
Air trapping and auto peep.
63. You should adjust the FiO2 to keep the PaO2 in a safe range for neonates. What is the preferred range?
64. Increasing I-time can lead to inverse I:E ratios when needed to produce an adequate PaO2, however, care must be taken to ensure that the tidal volume is fully exhaled to avoid auto-PEEP. As lung compliance improves, the I-time should be decreased for what two reasons?
(1) The alveolar pressure is more readily transmitted throughout the lungs and may decrease venous return to the heart, resulting in decreased cardiac output. (2) The more normal lungs are more prone to barotrauma or volutrauma.
65. Excessive PEEP may cause a decreased venous return to the heart and decreased cardiac output. It also may cause barotrauma resulting in what?
PIE, Pneumothorax, or Pneumomediastinum.
66. What are the basic equipment and supplies needed for intubation?
A laryngoscope, and appropriately sized laryngoscope blade with light and an endotracheal tube.
67. When should intubation and surfactant therapy be considered in a neonate?
If the infant with RDS is having recurrent apnea, persistent respiratory acidosis, or low PaO2 on > 50% with N-CPAP.
68. What is the primary mode of neonatal mechanical ventilation?
69. Pressure controlled ventilation generates sufficient flow and delivers variable tidal volumes by what?
A preset pressure.
70. Ventilation can also be achieved by using a preset volume in what?
Volume controlled ventilation.
71. What is used to deliver tidal volumes in pressure-limited ventilation?
A preset Peak Inspiratory pressure.
72. In pressure limited ventilation, the volume is variable depending on what?
The changing compliance and airflow resistance characteristics of the infant.
73. What has gained popularity because the volume is preset using variable pressures?
74. What initial tidal volume should be used for infants on volume limited ventilation?
75. The smaller the infant the higher the incidence of what?
76. What is High-Frequency Ventilation (HFV)?
A mode that delivers small tidal volumes at very high rates with low pressure to reduce the risk of barotrauma.
77. When is high-frequency ventilation used?
It is used when conventional ventilation fails.
78. HFV appears to be more useful in treating what?
RDS and pneumonia
79. HFV is categorized by what?
It is in the frequency of ventilation and the method of which the tidal volume is delivered.
80. HFV rates range from what?
150-1800 cycles per minute.
81. 1 Hertz equals what?
60 cycles or breaths /min or 1 cycle (breath) per second.
82. HFPPV has been found to improve what?
The incidence of pneumothoraxes and asynchrony reduced.
83. HFPPV is indicated for what?
Hypoxemia or hypercapnia when conventional methods fail.
84. What is the clinical use for HFPPV?
In cases of severely none compliant lungs an increase in rate to increase minute volume, which allowed the tidal volume is smaller with lower PIP.
85. What are the hazards of using HFPPV?
As the rate increases, Maximum Allowable Working Pressure (MAWP) increases with the increased risk of barotrauma, cardiac changes, and intracranial bleeding. Also, suctioning becomes problematic as even brief removal from ventilation can cause severe hypoxemia and hypercapnia.
86. What are the indications for High-Frequency Jet Ventilation (HFJV)?
Severe pulmonary disease complicated by air leaks, pulmonary interstitial emphysema, pulmonary hypoplasia, restrictive lung disease and persistent pulmonary HTN.
87. HFJV delivers what?
High-pressure pulse of gas to airway thru special adaptor on ETT or special ETT.
88. HFJV is used with conventional ventilation which provided what?
Sighs which stimulates surfactant production and treats micro atelectasis, PEEP, and it provides a continuous flow of gas to airway for entrainment by the jet ventilation.
89. What are the hazards of HFJV?
Tracheal and large airways damage leading to necrotizing tracheobronchitis due to the gas bullets on the wall of these airways. Gas trapping, hyperinflation, obstruction of the airway with secretions, hypotension and inflammatory injury to
90. To offset
A special catheter which exits inside the ETT or thru a triple lumen ETT.
91. Why is auscultation difficult during HFJV?
It is due to constant vibration and noise produced by the ventilator.
92. A decreased compliance and pneumothorax is indicated with what??
Decreased chest wall vibrations, increased CO2 and decreased O2.
93. A decreased PaO2 is seen with what?
Micro atelectasis and hyperinflation.
94. What must be monitored during HFJV?
Fluid, electrolyte and neurological status.
95. What does piston pump produce in HFOV?
The oscillatory waves that deliver the gas to the lungs.
96. What are the indications for HFOV?
Failure of conventional ventilation, severe RDS, congenital diaphragmatic hernia,
Diffuse alveolar disease, non-homogeneous lung disease, air leaks
97. The release of what appears to decrease due to HFOV?
Inflammatory chemical mediators in the lung, resulting in less lung injury than seen in conventional ventilation.
98. How is the incidence and severity of bronchopulmonary dysplasia affected when HFOV is used with surfactant replacement therapy during the first hours of life?
It is reduced.
99. Because HFOV does not oxygenate as well as other methods, this causes what to occur?
High PEEP levels are often used.
100. Combined with evidence that HFOV causes hyperinflation of the alveoli, high PEEP levels compromise what?
Cardiac output and lead to
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101. What is dual control ventilation?
It is a breath type that combines the useful feature of volume-controlled ventilation and pressure-controlled ventilation.
102. What is liquid ventilation?
It is to use liquid rather than gas to inflate the lungs, resulting in a more equal distribution of ventilation which could prevent damage to the lung tissue.
103. What is extracorporeal membrane oxygenation (ECMO)?
Oxygenation of blood outside the body through a membrane oxygenator.
104. What are the pathologies that may be considered for ECMO?
Persistent pulmonary hypertension, meconium aspiration syndrome, sepsis, and congenital
105. ECMO is not recommended for which infants?
Infants that are less than 34 weeks of gestational age, weighing less than 2000g, and those having evidence of ICH.
106. What is the reason why patients with ICH are not candidates for ECMO?
The need for systemic heparinization during the procedure.
107. What must a candidate of ECMO have?
A reversible lung disease and free of significant cardiac disease.
108. What are the most common complications of ECMO?
They are related to bleeding from heparinization.
109. What is the high incidence during ECMO?
Intracranial hemorrhage, pulmonary edema, and pulmonary hemorrhage.
110. What are the complications of ECMO?
Pump failure, rupture of tubing, failure of membrane failure and difficulties with cannulation.
111. What are the physiological objectives for neonatal and pediatric mechanical ventilation?
Decrease VILI, decrease work of breathing, to optimize lung volume, improve oxygenation and manipulate alveolar ventilation.
112. What is the importance of mean airway pressure in neonates?
It is the average pressure exerted on airway and lungs from the beginning of inspiration until the beginning of next inspiration. It’s an important tool to monitor babies oxygenation, babies are very much affected by increases with MAP ( increased MAP can lead to hemorrhaging.
113. What is the definition of opening pressure?
The lower inflection point, to open an alveolus a certain amount of pressure must be applied to alveoli.
114. What are the normal values for compliance in newborns?
About 2.5 – 5 ml/cmH2o,
115. What are the normal values for resistance in newborns?
About 20 -30 cmH2o/L/sec in a spontaneously breathing neonate; basically driving pressure needed to move gases through at a constant flow rate.
116. What are the factors that increase airway resistance in a neonate?
Bronchospasm, airway secretions, edema of airway walls, inflammation, ET tube or trach tubes.
117. What are the partial ventilatory support modes for neonates?
CPAP, PSV, and SIMV.
118. What are the methods of application of CPAP for neonates and peds?
Neonates: nasal pharyngeal or nasal prongs. Pediatrics: nasal or full face mask.
119. What are the indications for CPAP in neonates?
Respiratory rate greater than 30% of normal, paradoxical chest wall movement, grunting, nasal flaring and cyanosis, CO2 less than 60 and pH greater than 7.25.
120. What are the contraindications for CPAP in neonates?
Prolonged apnea, untreated pneumothorax, hemodynamically unstable, unilateral pulmonary problem, mouth/face abnormalities or post-surgery.
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121. What are the hazards of CPAP in neonates?
It can make PPHN worse, increased ICP, decreased cardiac output, may be ineffective if the neonate weighs less than 1,000-1,200 grams.
122. What are the CPAP settings for infants?
In a perfect world, they would be: 4-6 cmH2O starting point, flow rate of 8LPM (5cmcpap), higher FiO2 initially (wean down ASAP) increased levels by increments of 1 or2 cm, levels of 8-9 begin to show need for mechanical ventilation, and level of 12 cmH2o is the maximum pressure attainable.
123. When should you initiate CPAP weaning?
When the patient is stable, no incidents of apnea, acceptable ABGs and chest x-ray, decrease FiO2 1% at a time (until 0.4 maybe 0.6), then pressure increments of 1-2 cm H2O until 2-3 cmH2O are reached.
124. What is the most useful blade type for the intubation of neonates and peds?
The Miller blade (straight blade) is most useful.
125. What are the suctioning parameters for neonates?
Suction level for neonates: -60 to -80 larger infants and children : -80 to -100. One minute of preoxygenation is required.
Neonatal mechanical ventilation is a life-saving intervention for infants with respiratory distress. It involves the use of a specialized mechanical ventilator to assist with ventilation and oxygenation.
There are several different modes of neonatal mechanical ventilation, each with its own unique advantages and disadvantages. The goals of neonatal mechanical ventilation include improving ventilation, oxygenation, lung mechanics, and decreasing the work of breathing.
Respiratory therapists are involved in the maintenance and care of neonates requiring mechanical ventilation. That explains why this is such an important topic to learn and understand.
We have a similar guide that covers the basics of adult mechanical ventilation. I think you’ll find it helpful. Thanks for reading!
John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.
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