#PAGE_PARAMS# #ADS_HEAD_SCRIPTS# #MICRODATA#

Basic principles of mechanical ventilation in immature newborns and used ventilation modes


Authors: R. Plavka
Authors‘ workplace: Klinika gynekologie, porodnictví a neonatologie, 1. LF UK a VFN, Praha
Published in: Čes-slov Neonat 2023; 29 (2): 108-120.
Category: Contributions on respiratory problems of preterm newborns

Overview

The chapter reflects, in a modified form, European recommendations that are standardized in the workplace in writing. Although the mechanisms of lung injury due to mechanical ventilation have universal effects on lung tissue, in premature newborns, they have specific impacts due to the fetal stage of lung development and frequently present fetal inflammatory responses. One of the fundamental principles of protecting immature lungs during mechanical ventilation is to maintain the lungs in a relatively homogeneous state without adverse effects on circulation. From this perspective, the parameters used can be divided into less and more injurious ones. Dynamic changes in lung volume are more injurious than static ones. During conventional mechanical ventilation modes, we adhere to the use of physiological tidal volumes and achieve their even distribution by optimizing the positive end-expiratory pressure level. At the same time, we prefer conventional modes that allow for the highest degree of synchronization with the patient's own breathing effort or even proportional support throughout the patient's entire respiratory cycle. For severe forms of respiratory failure and extremely premature infants < 26 weeks of gestation, we electively indicate high frequency oscillatory ventilation with the assumption of reducing the impact of shear forces in the canalicular-saccular developmental stage of the lungs. During mechanical ventilation, we prefer the prone position, which we consider a protective factor facilitating the even distribution of gas in the lungs. The chapter also deals with the use of inhaled nitric oxide in premature newborns with a history of severe oligohydramnios of various etiologies and maternal preeclampsia, where a reduction in endogenous nitric oxid can be expected in the adaptation phase after birth. The use of postnatal steroids, their choice, and dosage are related to the diagnosis and postnatal age of extremely premature newborns, not only on mechanical ventilation.

Keywords:

mechanical ventilation, lung injury, homogeneous ventilation, synchronized, proportional ventilation, inhaled nitric oxide, postnatal steroids


Sources
  1. Jobe AH, Bancalari E. Bronchopulmonary dysplasia. Am J Respir Crit Care Med 2001; 163(7): 1723–1729.
  2. Webb HH, Tierney DF. Experimental pulmonary edema due to intermittent positive pressure ventilation with high inflation pressures. Protection by positive end-expiratory pressure. Am Rev Respir Dis 1974; 110(5): 556–565.
  3. Dreyfuss D, Soler P, Basset G, et al. High inflation pressure pulmonary edema. Respective effects of high airway pressure, high tidal volume, and positive end-expiratory pressure. Am Rev Respir Dis 1988; 137(5): 1159–1164.
  4. Dreyfuss D, Saumon G. Role of tidal volume, FRC, and end-inspiratory volume in the development of pulmonary edema following mechanical ventilation. Am Rev Respir Dis 1993; 148(5): 1194–1203.
  5. Wada K, Jobe AH, Ikegami M. Tidal volume effects on surfaktant treatment responses with the initiation of ventilation in preterm lambs. J Appl Physiol 1997; 83(4): 1054–1061.
  6. Dreyfuss D, Saumon G. Ventilator-induced lung injury: lessons from experimental studies. Am J Respir Crit Care Med 1998; 157(1): 294–323.
  7. Taskar V, John J, Evander E, et al. Surfactant dysfunction makes lungs vunerable to repetitive collapse and reexpansion. Am J Respir Crit Care Med 1997; 155(1): 313–320.
  8. Gattinoni L, Carlesso E, Caironi P. Stress and strain within the lung. Curr Opin Crit Care 2012; 18(1): 42–47.
  9. Sud S, Friedrich JO, Adhikari NKJ, et al. Effect of prone positioning during mechanical ventilation on mortality among patients with acute respiratory distress syndrome: a systematic review and meta-analysis. CMAJ 2014, 186(10): E381–E390.
  10. Adams EW, Counsell SJ, Joseph V, et al. Magnetic resonance imaging of lung water content and distribution in term and preterm infants. Am J Respir Crit Care Med 2002; 166(3): 397–402.
  11. Pandit PB, Pyon KH, Courtney SE, et al. Lung resistance and elastance in spontaneously breathing preterm infants: effects of breathing pattern and demographics. J Appl Physiol 2000; 88(3): 997–1005.
  12. Ancora G, Lago P, Garetti E, et al. Evidence-based clinical guidelines on analgesia and sedation in newborn infants undergoing assisted ventilation and endotracheal intubation. Acta Paediatr 2019; 108(2): 208–217.
  13. Bellù R, Romantsik O, Nava C, et al. Opioids for newborn infants receiving mechanical ventilation. Cochrane Database Syst Rev 2021; 3(3): CD013732.
  14. Chawla S, Natarajan G, Shankaran S, et al.; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Markers of successful extubation in extremely preterm infants, and morbidity after failed extubation. J Pediatr 2017; 189: 113–119.e2.
  15. Danan C, Durrmeyer X, Brochard L, et al. A randomized trial of delayed extubation for the reduction of reintubation in extremely preterm infants. Pediatr Pulmonol 2008; 43(2): 117–124.
  16. Shalish W, Kanbar L, Kovacs L, et al. Assessment of extubation readiness using spontaneous breathing trials in extremely preterm neonates. JAMA Pediatr 2020; 174(2): 178–185.
  17. Gupta D, Greenberg RG, Sharma A, et al. A predictive model for extubation readiness in extremely preterm infants. J Perinatol 2019; 39(12): 1663–1669.
  18. Cools F, Offringa M, Askie LM. Elective high frequency oscillatory ventilation versus conventional ventilation for acute pulmonary dysfunction in preterm infants. Cochrane Database Syst Rev 2015; 2015(3): CD000104.
  19. Blazek EV, East CE, Jauncey-Cooke J, et al. Lung recruitment maneuvers for reducing mortality and respiratory morbidity in mechanically ventilated neonates. Cochrane Database Syst Rev. 2021 Mar 30; 3(3): CD009969.
  20. Meyers M, Rodrigues N, Ari A. High-frequency oscillatory ventilation: a narrative review. Can J Respir Ther 2019; 55: 40–46.
  21. Pillow J (ed.). High-frequency oscillatory ventilation: theory and practical applications [online]. Lübeck: Drägerwerk AG & Co. KGaA, 2016: 9102693 [cit. 2023-09-20]. Dostupné z: https://www.draeger. com/Content/Documents/Content/hfov-bk-9102693-en.pdf.
  22. De Jaegere AP, Deurloo EE, van Rijn RR, et al. Individualized lung recruitment during high–frequency ventilation in preterm infants is not associated with lung hyperinflation and air leaks. Eur J Pediatr 2016; 175(8): 1085–1090.
  23. Iscan B, Duman N, Tuzun F, et al. Impact of volume guarantee on high-frequency oscillatory ventilation in preterm infants: a randomized crossover clinical trial. Neonatology 2015; 108(4): 277–282.
  24. Solís-García G, González-Pacheco N, Ramos-Navarro C, et al. Target volume-guarantee in high-frequency oscillatory ventilation for preterm respiratory distress syndrome: low volumes and high frequencies lead to adequate ventilation. Pediatr Pulmonol 2021; 56(8): 2597–2603.
  25. Ramos-Navarro C, González-Pacheco N, Rodríguez-Sánchez de la Blanca A, et al. Effect of a new respiratory care bundle on bronchopulmonary dysplasia in preterm neonates. Eur J Pediatr 2020; 179(12): 1833–1842.
  26. Unal S, Ergenekon E, Aktas S, et al. Effects of volume guaranteed ventilation combined with two different modes in preterm infants. Respir Care 2017; 62(12): 1525–1532.
  27. Wheeler CR, Smallwood CD. 2019 year in review: neonatal respiratory support. Respir Care 2020; 65(5): 693–704.
  28. Sindelar R, Mc Kinney RL, Wallstrom L, Keszler M. Proportional assist and neurally adjusted ventilation. Pediatr Pulmonol 2021; 56: 1841–1849.
  29. Andrade LB, Ghedini RG, Dias AS, et al. Neurally adjusted ventilatory assist in pediatrics: why, when, and how? Rev Bras Ter Intensiva 2017; 29(4): 408–413.
  30. Beck J, Sinderby C. Neurally adjusted ventilatory assist in newborns. Clin Perinatol 2021; 48(4): 783–811.
  31. Hunt KA, Dassios T, Greenough A. Proportional assist ventilation (PAV) versus neurally adjusted ventilator assist (NAVA): effect on oxygenation in infants with evolving or established bronchopulmonary dysplasia. Eur J Pediatr 2020; 179(6): 901–908.
  32. Kallio M, Koskela U, Peltoniemi O, et al. Neurally adjusted ventilatory assist (NAVA) in preterm newborn infants with respiratory distress syndrome: a randomized controlled trial. Eur J Pediatr 2016; 175(9): 1175–1183.
  33. Aikio O, Metsola J, Vuolteenaho R, et al. Transient defect in nitric oxide generation after rupture of fetal membranes and responsiveness to inhaled nitric oxide in very preterm infants with hypoxic respiratory failure. J Pediatr 2012; 161(3): 397–403.e1.
  34. Barrington KJ, Finer N, Pennaforte T, et al. Inhaled nitric oxide for respiratory failure in preterm infants. Cochrane Database Syst Rev 2017; 2017(1): CD000509.
  35. Chandrasekharan P, Kozielski R, Kumar VHS, et al. Early use of inhaled nitric oxide in preterm infants: is there a rationale for selective approach? Am J Perinatol 2017; 34(5): 428–440.
  36. Chandrasekharan P, Lakshminrusimha S, Abman SH. When to say no to inhaled nitric oxide in neonates? Semin Fetal Neonatal Med 2021; 26(2): 101200.
  37. Cotten CM. Pulmonary hypoplasia. Semin Fetal Neonatal Med 2017; 22(4): 250–255.
  38. Ellsworth KR, Ellsworth MA, Weaver AL, et al. Association of early inhaled nitric oxide with the survival of preterm neonates with pulmonary hypoplasia. JAMA Pediatr 2018; 172(7): e180761.
  39. Garrido F, Gonzalez-Caballero JL, Lomax R, et al. The immediate efficacy of inhaled nitric oxide treatment in preterm infants with acute respiratory failure during neonatal transport. Acta Paediatr 2020; 109(2): 309–313.
  40. Hansmann G, Sallmon H, Roehr CC, et al.; European Pediatric Pulmonary Vascular Disease Network (EPPVDN). Pulmonary hypertension in bronchopulmonary dysplasia. Pediatr Res 2021; 89(3): 446–455.
  41. Manja V, Guyatt G, Lakshminrusimha S, e t al. Factors influencing decision making in neonatology: inhaled nitric oxide in preterm infants. J Perinatol 2019; 39(1): 86–94.
  42. Shiraishi J, Kusuda S, Cho K, et al. Standardization of nitric oxide inhalation in extremely preterm infants in Japan. Pediatr Int 2019; 61(2): 152–157.
  43. Subhedar NV, Jawad S, Oughham K, et al.; UK Neonatal Collaborative. Increase in the use of inhaled nitric oxide in neonatal intensive care units in England: a retrospective population study. BMJ Paediatr Open 2021; 5(1): e000897.
  44. Chock VY, Van Meurs KP, Hintz SR, et al.; NICHD Neonatal Research Network. Inhaled nitric oxide for preterm premature rupture of membranes, oligohydramnios, and pulmonary hypoplasia. Am J Perinatol 2009; 26(4): 317–322.
  45. Alison M, Tilea B, Toumazi A, et al.; PREMILOC Trial Group. Prophylactic hydrocortisone in extremely preterm infants and brain MRI abnormality. Arch Dis Child Fetal Neonatal Ed 2020; 105(5): 520–525.
  46. Baud O, Watterberg KL. Prophylactic postnatal corticosteroids: early hydrocortisone. Semin Fetal Neonatal Med 2019; 24(3): 202–206.
  47. Doyle LW, Cheong JL, Ehrenkranz RA, et al.; Cochrane Neonatal Group. Late (> 7 days) systemic postnatal corticosteroids for prevention of bronchopulmonary dysplasia in preterm infants. Cochrane Database Syst Rev 2017; 2017(10): CD001145.
  48. Fontijn JR, Bassler D. Early systemic steroids in preventing bronchopulmonary dysplasia: are we moving closer to a benefit-risk-adapted treatment strategy? J Pediatr 2021; 234: 12–13.
  49. Hansen TP, Oschman A, Pallotto EK, et al. Using quality improvement to implement consensus guidelines for postnatal steroid treatment of preterm infants with developing bronchopulmonary dysplasia. J Perinatol 2021; 41(4): 891–897.
  50. Htun ZT, Schulz EV, Desai RK, et al. Postnatal steroid management in preterm infants with evolving bronchopulmonary dysplasia. J Perinatol 2021; 41: 1783–1796.
  51. Marr BL, Mettelman BB, Gross S. Randomized trial of 42-day compared with 9-day courses of dexamethasone for the treatment of evolving bronchopulmonary dysplasia in extremely preterm infants. J Pediatr 2019; 211: 20–26.e1.
  52. Morris IP, Goel N, Chakraborty M. Efficacy and safety of systemic hydrocortisone for the prevention of bronchopulmonary dysplasia in preterm infants: a systematic review and meta-analysis. Eur J Pediatr 2019; 178(8): 1171–1184.
  53. Onland W, Cools F, Kroon A, et al.; STOP-BPD Study Group. Effect of hydrocortisone therapy initiated 7 to 14 days after birth on mortality or bronchopulmonary dysplasia among very preterm infants receiving mechanical ventilation a randomized clinical trial. JAMA 2019; 321(4): 354–363.
  54. Rousseau C, Guichard M, Saliba E, et al. Duration of mechanical ventilation is more critical for brain growth than postnatal hydrocortisone in extremely preterm infants. Eur J Pediatr 2021; 180(11): 3307–3315.
  55. Shaffer ML, Baud O, Lacaze-Masmonteil T, et al. Effect of prophylaxis for early adrenal insufficiency using low–dose hydrocortisone in very preterm infants: an individual patient data meta–analysis. J Pediatr 2019; 207: 136–142.e5.
  56. Singhi S, Johnston M. Recent advances in perinatal neuroprotection. Version 1. F1000Res 2019; 8(F1000 Faculty Rev): 2031.
Labels
Neonatology Neonatal Nurse
Topics Journals
Login
Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.

Login

Don‘t have an account?  Create new account

#ADS_BOTTOM_SCRIPTS#