Isabella V.

Hosana, RN
Southern Isabela General Hospital
Neonatal Intensive Care Unit

BRIEF HISTORY
The introduction of mechanical ventilation in neonatal medicine begin in
1960s. It is a lifesaving therapy.
1904 Negative pressure ventilation.
1905 CPAP.
1907 Positive pressure mechanical ventilation.
1960-1970 Birth of neonatology.
1963 First baby successfully ventilated.

MECHANICAL VENTILATION
Mechanical ventilation is indicated when the patient's
spontaneous ventilation is inadequate to maintain life. It is also indicated as
prophylaxis for imminent collapse of other physiologic functions, or ineffective
gas exchange in the lungs. Because mechanical ventilation serves only to
provide assistance for breathing and does not cure a disease, the patient's
underlying condition should be correctable and should resolve over time.

Neonatal Mechanical Ventilator

MECHANISM
A pressure gradient is required for air to move from one place to another.
During natural spontaneous ventilation, inspiration results from generation
of negative intra-pleural pressure from contraction of the diaphragm and
inter-costal muscles, drawing air from the atmosphere across the airways
into the alveoli.

MECHANISM
During mechanical ventilation, inspiration results from positive pressure
created by compressed gases through the ventilator, which pushes air
across the airways into alveoli.
In both spontaneous and mechanical ventilation, exhalation results from
alveolar pressure generated by the elastic recoil of the lung and the chest
wall.

GOALS
Provide adequate oxygenation and ventilation with the most minimal
intervention possible.
Minimize the risk of lung injury.

Reduce patient work of breathing (WOB).

Optimize patient comfort.

INDICATIONS
At Birth:
Failure to establish spontaneous respiration in spite of mask.
Persistent bradycardia .
Diaphragmatic hernia.
Infant < 28 wks. gestation age or < 1kg.

Infant < 32 wks. gestation age may be intubated to receive surfactant.

INDICATIONS
In the NICU:
Respiratory failure and deterioration of blood gases

PO2 60 in FiO2 70 or PCO2 60

INDICATIONS
Others (short term indications):
To relieve respiratory distress.
General Anaesthesia: during surgeries.
To secure an airway: in patients with depressed sensorium, head injury.
To decrease systemic or myocardial oxygen consumption. eg. septic and
cardiogenic shock.
To stabilize the chest wall in children with flail chest.

ASSOCIATED RISK
Barotrauma Pulmonary barotrauma is a well-known complication of
positive-pressure mechanical ventilation. This includes pneumothorax,
subcutaneous emphysema, pneumomediastinum, and pneumoperitoneum.
Ventilator-associated lung injury Ventilator-associated lung
injury (VALI) refers to acute lung injury that occurs during mechanical
ventilation. It is clinically indistinguishable from acute lung injury or acute
respiratory distress syndrome (ALI/ARDS).

ASSOCIATED RISK
Diaphragm Controlled mechanical ventilation may lead to a rapid type
of disuse atrophy involving the diaphragmatic muscle fibers, which can
develop within the first day of mechanical ventilation. This cause of atrophy
in the diaphragm is also a cause of atrophy in all respiratory related
muscles during controlled mechanical ventilation.
Motility of mucocilia in the airways Positive pressure ventilation
appears to impair mucociliary motility in the airways. Bronchial mucus
transport was frequently impaired and associated with retention of
secretions and pneumonia.

COMPLICATIONS
Pneumothorax
Airway Injury
Alveolar Damage
Ventilator associated Pneumonia
Diaphragm Atrophy

Oxygen Toxicity

ENDOTRACHEAL TUBE SIZES

Weight of the baby

ETT size

< 1,000

2.5

1,000 2,000

> 2,000

3.5

MONITORING THE VENTILATED NEONATES

Neonates requiring mechanical ventilation require close monitoring
to optimize the respiratory support and limit the potential complications of
ventilator induced lung injury, oxygen toxicity , air leaks and nosocomial
infections.

PHYSICAL EXAMINATION
Respiratory Rate
Evidence of respiratory distress
Auscultation for equal air entry.
Ventilator patient synchrony should be observed.
Rapid shallow breathing and the presence of subcostal or intercostal
retractions in ventillated babies may suggest air hunger or increased work
of breathing.

MONITORING OXYGENATION
ABG analysis is the gold standard for monitoring the adequacy of gas
exchange
SaO2 targets of 85 - 93% is the most appropriate.

In term and near term infants who are mechanically ventilated, it is

acceptable to target SaO2 between 92 - 95 % and in children with cyanotic
CHD SaO2 between 70 - 75% are acceptable if tissue oxygenation is good.
Ventilation PaCo2 determined from an ABG is a reliable measure of
ventilation A free flowing capillary sample is an acceptable alternative
Capnography and trans -cutaneous CO2 detectors provide non invasive
alternatives to monitor ventilation.

VENTILATION
PaCO2 determined from an ABG is a reliable measure of ventilation
A free flowing capillary sample is an acceptable alternative
Capnography and trans -cutaneous CO2 detectors provide non invasive
alternatives to monitor ventilation.

CHEST RADIOGRAPHS
The findings to look for:
Position of the ETT, central lines and umbilical catheters.

Optimal positioning for ETT is approximately 1-1.5 cm above the carina.

Displacement of the tube into the esophagus is indicated by a low ETT
position.

CHEST RADIOGRAPHS
The findings to look for:
Poor aeration of the lungs and gaseous distension of the GI tract

Look for the atelectasis, flattening of the diaphragm and lung expansion
reaching the tenth rib suggests over expansion and increased risk of
pulmonary air leaks and lung injury

ENDOTRACHEAL TUBE POSITIONING

The position of ET tube should be documented in the nursing flow sheet
and checked during each assessment.
A properly placed tube should lie below the levels of clavicles at T2 level
above carina.

ENDOTRACHEAL SUCTIONING
Suction is performed only as needed based on patient assessment.
Indications are:
Visible secretions in ETT
Audible secretions or presence of rhonchi, coarse and/or decreased breath
sounds
Change in respiratory rate and /or rhythm
Oxygen desaturation or bradycardia
Changes in blood gas values
Restlessness and agitation

PREVENTION OF VENTILATOR ASSOCIATED

PNEUMONIA (VAP)
Use of new ventilator circuits for each patient.
Change of humidifiers every 5 to 7 days.
Use of close endotracheal suctioning system.
Elevation of the head of the bed to 45 degree and use of oral antiseptic
chlorhexidine may decrease the incidence of VAP.

PREVENTION OF VENTILATOR ASSOCIATED

PNEUMONIA (VAP)
Prone positioning during mechanical ventilation has been used to improve
oxygenation in severe hypoxemic respiratory failure.
Chest physiotherapy studies suggest chest physiotherapy should not be
routinely performed.

ALWAYS CHECK:
Chest movement, air entry, presence of retractions, hyper-inflated chest,
wheezing etc.
Level of ETT at lips, visible secretions in ETT, any kinking or disconnection,
any warning alarms on the ventilator.
Assess baby`s own respiratory drive: depth & rate.

ALWAYS CHECK:
Signs of baby fighting the ventilator: air hunger, asynchrony, gross
difference between ventilator and baby`s breathing rate.
Signs of pain, agitation, abnormal posturing. Abnormal heart rate, BP,
temperature.
Signs of excessive sedation

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