Neonatal Ventilation Made Easy

Neonatal Ventilation
Made Easy
Neonatal Ventilation
Made Easy
Sujoy Chakravarty
MBBS, MRCPCH (UK), DCH (Lon)
Visiting Paediatrician and Neonatologist

Jain Hospital, Howrah
Woodlands Medical Centre, Kolkata
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Neonatal Ventilation Made Easy

2007, Sujoy Chakravarty
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First Edition: 2007
ISBN 81-8448-165-9
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd, Sector 60, Noida
dedicated to
Soumil and
Swapnil
Foreword
It is a pride and pleasure for me to introduce Dr Sujoy
Chakravarty, my ex-student for his outstanding and
challenging contribution in writing this book on neonatal
ventilation. This book is intended for postgraduate trainees,
junior doctors and medical personnel involved in level I, II,
and III care of children in neonatal resuscitation unit.
Respiratory distress and/or failure is the common cause
of pulmonary arrest in neonates which may be due to
hypoventilation, diffusion mismatch, intrapulmonary
shunting. All these disturbances may finally lead to
respiratory arrest calling for ventilatory support. The two
forms of ventilation practiced in NICU arepressure
controlled and volume controlled typesboth discussed
in this book. The author has also discussed some common
pulmonary and extra pulmonary conditions frequently
encountered in daily neonatal practice.
I again congratulate this young doctor for his sound
knowledge and expertise with a bold attempt in discussing
neonatal ventilation in a concise and yet such user friendly
form. I sincerely wish this book will be of true help to all
concerned and hope he will go a long way in Pediatric
Academy.
Prof (Dr) Manas Mukherjee
Ex-President Indian Academy of Pediatrics
Ex-Head of the Department of Pediatrics,
NRS Medical College, Kolkata
Preface
This book is an effort to share my minimal knowledge
and experience with all my colleagues involved in
neonatal care and in particular with all the junior doctors.
I had my share of running around from one ventilated
baby to another, of running blood gases, and of headscratching with the results. The dilemma to call or not to
call your senior! (Better ask for help in these cases!). A
baby collapses on a ventilator! Of course shout for help
but as a junior doctor I felt it is extremely stressful, if you
are not sure what exactly you are supposed to do
particularly when you are the first port of call. There is no
substitute for hands on experience, but I hope this book
will be your constant companion and aid particularly in
hours when you need urgent help. The book will also be
helpful for aspiring Neonatologists who will be working
in India and abroad. This is not a substitute for a proper
textbook, which should be consulted at the earliest
opportunity.
Sujoy Chakravarty
Acknowledgements
I would like to thank my parents, my family for their
constant inspiration and support. Also I would like to
thank all my teachers and colleagues in neonatal units
from whom I have learnt the ABC of Neonatology. My
special thanks to Dr Rashmi Gandhi without whose help
this book would not have seen the light of the day.
I would like to extend my sincere thanks to the
publishers, and in particular to Mr Sabyasachi Hazra and
Mr Sandip Gupta for their tireless work and tenacity in
getting this book published.
Contents
1. Newborn Life Support .............................................. 1
2. Formulas Commonly Used in NICU ..................... 5
3. Acid-Base Balance ...................................................... 7
4. Continuous Positive Airway Pressure (CPAP) .... 11
5. Positive Pressure Ventilation
Introduction and Terminologies ............................ 17
6. Different Modes of Positive Pressure
Ventilation ................................................................. 23
7. Ventilatory Adjustments According to
Blood Gas Changes .................................................. 27
8. Volume Controlled Ventilation .............................. 31
9. High Frequency Ventilation ................................... 35
10. Nitric Oxide ............................................................... 41
11. Extra Corporeal Membrane Oxygenation
(ECMO) ....................................................................... 45
12. Respiratory Distress Syndrome ............................. 49
13. Chronic Lung Disease .............................................. 53
14. Meconium Aspiration Syndrome .......................... 55
15. Transient Tachypnoea of Newborn ...................... 57
16. Collapse of a Baby on Ventilator ........................... 59
17. Necrotising Enterocolitis ......................................... 63
xiv
NEONATAL VENTILATION MADE EASY
18. Jaundice ...................................................................... 65

19. Neonatal FeedingDifficulties ............................. 69
20. Neonatal VomitingCommon Causes ................ 71
21. Anaemia in Neonates .............................................. 73
22. Hypoxic Ischaemic Encephalopathy (HIE) .......... 75
23. Intraventricular Haemorrhage and Periventricular
Leucomalacia ............................................................ 77
24. Persistent Pulmonary Hypertension of the
Newborn (Persistent Foetal Circulation) .............. 79
25. Sepsis in Neonates ................................................... 81
26. Tit-Bits ........................................................................ 85
27. Neonatal Formulary (Commonly used
Medications) .............................................................. 89
Index ............................................................................ 91
Chapter 1
Newborn Life
Support
The care of the newborn in the first few minutes after birth
is extremely crucial with regards to the subsequent flow
of events. The foetus was in a nice and warm atmosphere
inside the womb requiring no effort to breathe and not
having to worry about its nutrition as well. As soon as the
cord is severed the newborn baby has to find ways of
independent existence.
RESUSCITATION AT BIRTH
Preparation
It is always useful to reach for the delivery with a few minutes
to spare (absolute necessity for preterm labours). A brief
maternal history is to be taken and all equipments (the
overhead heater, the laryngoscope, the suction apparatus,
appropriate masks, proper size ET tube) to be checked.
Few dry towels should always be available.
Collecting the Baby
After the baby is born and cord is clamped the baby should
be collected in a dry and clean towel. In case of extreme
prematurity, babies are put in a plastic bag immediately
after birth to minimize further chances of heat loss.
In the Resuscitaire
1. Start the clock.
2. Dry the baby and transfer to a fresh and warm towel.
3. Keeping the baby covered feel or listen for the heart beat.
(Heart rate can be felt by palpating the umbilical cord)
Also assess the respiratory effort, colour and tone of the
baby.
4. If the heart rate is > 100 and regular, all the baby might
need is gentle stimulation and the doctors patience.
NEWBORN LIFE SUPPORT
5. If the heart rate is slow (< 80), the baby will need
stimulation by inflation breaths with a mask. Before doing
that it is important to check for the patency of the airway.
Blind suction is strongly discouraged. Sometimes
simple airway opening manoeuvres, e.g. head tilt and
chin lift or jaw thrust might do the trick and the
condition of the baby might improve.
6. If these doesnt work and after airway is reassessed
5 inflation breaths are given and each breath should ideally
last for about 2 seconds. These breaths are given with
the aim to displace as much lung fluids as possible.
The inflation breaths should measure about 30 cm H2O
pressure. The important point to note here is the chest
movement with the inflation breaths. If the chest is not
moving then airway needs to be reassessed again. If the chest
rises with each breath, the baby is examined after the
5 breaths. If by this time the heart rate has improved
and the baby is making spontaneous efforts to breathe,
masterly inactivity is what might be needed at this
stage. If heart rate has improved but the breathing is
still not satisfactory, ventilation breaths might be
needed till the baby establishes regular and
spontaneous breathing. The ventilation breaths are of
much shorter duration compared to the inflation breaths.
7. If above methods have failed and the baby is still bradycardiac
with a very poor tone, the baby needs intubation for a definite
and a secure airway. If intubation is difficult (not possible
within 30 seconds, i.e. one attempt) revert to bag and mask
ventilation and ask for help. (According to Scandinavian
studies 1 in 500 babies only need intubation). Once
the ET tube is in place and secured continue ventilation
and reassess the heart rate. If the heart rate is still low
start cardiac compression ( 3:1 ) with one hand or two hand
technique. If there is no improvement in heart rate
recheck the position of the ET tube (see for chest

movement and listen for air entry).
8. If the tube is in place continue ventilation and cardiac
massage. Consider adrenaline (0.1 ml/kg 1: 10,000)
at this stage.
IMPORTANT POINTS TO REMEMBER
1. Always ensure that the baby is kept warm and dry.
2. Follow ABC (airway, breathing, circulation) in order.
It is completely irrelevant to sort out circulation
without establishing the airway.
3. Always reassess after a manoeuvre. Start from airway.
4. If there is presence of meconium and the baby is
screaming, it indicates open airway. Floppy baby
with meconium demands a look inside the oral cavity.
Suctioning is mandatory if meconium is present
below the vocal cords and if thick particulate meconium is seen inside oral cavity before administering
any inflation breaths.
5. Oropharyngeal airway can be sometimes be useful
prior to proceeding to the stage of intubation, (provided
you find one in the resuscitation trolley).
6. The only drugs used in newborn resuscitation are
adrenaline and 10% dextrose (2.5 ml/kg). If the mother
has received pethidine prior to delivery sometimes a
dose of naloxone (IM) is given to the baby, if needed
though its precise role in resuscitation is debatable.
7. A fluid bolus of normal saline (10 ml/kg) is only needed
if there is definite evidence of maternal blood loss, e.g.
antepartum haemorrhage.
8. Consider stopping resuscitation, if there is no
functional circulation established by the end of
15 minutes of resuscitation.
9. Dont forget the parents.
10. Swallow your pride and ask for help without delay.
Chapter 2
Formulas
Commonly Used in NICU
1. Size of ET tubeGestation/10 (a baby of 25 weeks

gestation needs a 2.5 mm size tube).
2. Length of ET tube6 + weight of baby.
3. Umbilical artery catheterBirth weight (in kg) 3 +
9 cm.
For term babies a length of 16-17 cm suffice. For
preterms 10-12 cm should be sufficient.
4. Umbilical venous catheter1.5 Birth weight (in kg)
+ 5.5 cm.
For term babies a length of 10 cm suffice. For preterms
5 cm should be sufficient.
5. Half correction of bicarbonate0.3 weight (in kg)
base deficit (over 2 hours).
6. Dilutional (Partial) exchange transfusion(Desired
HB-Current HB) Blood volume/Current
Haematocrit.
7. Blood transfusion (Packed cells)15 ml/kg or (Desired
Hb-Current Hb) weight 4.
8. Sodium requirement for neonates3 mmol/kg (Add
in 500 ml of 10% Dextrose).
9. Potassium requirement2 mmol/kg (Add in 500 ml
of 10% Dextrose).
10. Calcium requirement1 mmol/kg (Add in 500 ml
of 10% Dextrose).
Accepted position of catheters:
UVCT-9
UACT6-T10
Long line tip (upper arms)T3
Long line tip (lower limbs) T9-T10
Chapter 3
Acid-Base
Balance
The understanding of acid-base balance and interpretation

of blood gases is of prime importance in managing
ventilated neonates. Minimal changes in the ventilation
can produce significant alteration in the acid-base status
in the neonates, which can either be detrimental or
beneficial.
NORMAL ARTERIAL BLOOD GAS VALUES
pH
pO2
pCO2
Bicarbonate
Base excess
:
:
:
:
:
7.35-7.45
10.6-14 kPa
4.7-6 kPa
23-33 mmol/L
+/- 2-3 mmol/L (Metabolic acidosis
is associated with a base excess below
5 mmol/L and metabolic alkalosis
with a base excess above +5 mmol/L
Lactic acid : < 1 mmol/L
Acid-base
abnormality
Primary
disturbance
Effect on
pH
Base
excess
Respiratory
acidosis
Increased
pCO2
Decreased
Negative Increased
HCO3
Metabolic
acidosis
Decreased
HCO3
Decreased
Negative Decreased
pCO2
Respiratory
alkalosis
Decreased
pCO2
Raised
Positive
Decreased
HCO 3
Metabolic
alkalosis
Increased
HCO3
Increased
Positive
Increased
pCO2
Compensatory
response
In general metabolic disturbances are compensated

acutely by changes in ventilation and chronically by renal
responses.
ACID-BASE BALANCE
Respiratory disturbances are compensated by renal

tubular secretion of hydrogen ion.
Steps in Interpreting Blood Gas
1. First look at the pH whether it is acidotic or alkalotic.
2. Then check the pCO2 and the bicarbonatewhether
it is respiratory or metabolic.
3. Check pO2.
4. Next look at the base excessfor the degree of acidosis
or alkalosis.
5. Finally check the lactic acid.
Blood Gas Analysis
1. Arterial blood gas measurement: This is the gold standard in
monitoring the baby on the ventilator. Generally,
indwelling arterial catheters are used when multiple
sampling is necessary over a longer duration of period.
2. Continuous blood gas analysis (Neotrend): This method
is useful for rapid and continuous evaluation of
changes in the clinical status of the baby. It gives a
continuous monitoring of pO2, pCO2 and pH. It also
minimizes the volume of blood sampling in the
newborns.
3. Capillary blood gas analysis: It is relatively easy to obtain
and with the free flow of blood it provides a good estimate
of pCO2, but it is traumatic to the heel and can give
inaccurate results if the extremities are not well perfused.
4. Venous blood gas analysis: This is the least preferred method
used for monitoring blood gases in ventilated babies.
Venous pCO2 is usually 6-10 mm of Hg higher than
arterial or capillary values.
10
5. Transcutaneous monitoring of pCO2 : In this method

electrodes are placed on the babys skin and give a
continuous reading of pCO2, but there are chances of
skin burns and inaccurate measurements.
SCENARIOS
1. pH: 7.25, pO2: 9.0, pCO2: 7.1, HCO3: 25, BE: 2, Lactate:
1.2.
Interpretation: This is an example of respiratory
acidosis. The pH is acidic and pCO2 is increased.
2. pH: 7.28, pO2: 8, pCO2: 5.3, HCO3: 17, BE: -7, Lactate:
2.2.
Interpretation: Those is an example of metabolic
acidosis. The pH is acidic with a low bicarbonate and
elevated base excess and lactic acid.
3. pH: 7.47, pO2: 8, pCO2: 3.2, HCO3: 23, BE: +2, Lactate:
1.0.
Interpretation: This is an example of respiratory
alkalosis. The pH is alkaline and pCO2 is decreased.
4. pH: 7.48, pO2: 9, pCO2: 5.4, HCO3: 34, BE: +7, Lactate:
1.0.
Interpretation: This is an example of metabolic alkalosis.
The pH is alkaline with raised bicarbonate.
5. pH: 7.36, pO2: 2.2, pCO2: 4.9, HCO3: 24, BE: +2, Lactate:
2.5.
Interpretation: This is an example of gas of a hypoxic
neonate. This type of blood gas can be suggestive of
congenital cyanotic heart disease.
6. pH: 7.36, pO2: 8.2, pCO2: 7.0, HCO3: 34, BE: -2, Lactate:
1.2.
Interpretation: This is an example of compensated
respiratory acidosis. The pH is in the normal range
though the pCO2 is increased. An increased bicarbonate
level compensates the respiratory acidotic component.
Chapter 4
Continuous
Positive Airway Pressure
(CPAP)
12
DEFINITION
Continuous Positive Airway Pressure (CPAP) is a form of
non-invasive ventilation in which positive pressure is applied
to the airways both during inspiration and expiration.
BACKGROUND
In early 1970s the use of CPAP was described in premature
babies with respiratory distress. Due to reported incidence
of increased air leaks, gastric distension and also because
of the introduction of more advanced ventilation CPAP fell
out of favour in the 1980s and 1990s. But, because of its
non-invasive nature there has been renewal of interest in
this form of ventilation.
METHODS OF DELIVERING CPAP
1.
2.
3.
4.
Nasal prongs (most common)

Nasal masks
Nasal cannula
Face mask.
DEVICES
1. Infant flow driver: It is a variable flow positive CPAP
device.
2. Bubble CPAP: In bubble CPAP a source of blended gas
is administered to the baby via a nasal prongs and the
distal end of the tube is immersed in fluid to a depth
of the desired level of PEEP.
MECHANISM OF ACTION OF CPAP
The main way CPAP acts is by generating PEEP (positive end
expiratory pressure), which is the pressure, needed to keep the
alveoli open at the end of expiration. Before the advent of
CONTINUOUS POSITIVE AIRWAY PRESSURE
13
CPAP, end expiratory pressures would drop to zero at the

end of delivering PIP (positive inspiratory pressure), which
literally means the collapse of alveoli. By holding the alveoli
open at the end of expiration CPAP ensures adequate gas
exchange and also less pressure is needed to inflate the
lungs in inspiration (it is easier to inflate a already partially
inflated balloon rather than a balloon which is completely
deflated). In babies who are grunting (breathing against a
partially closed glottis) they effectively try to generate CPAP
thereby preventing the collapse of alveoli and thereby their
lungs.
There are mainly two schools of thought regarding the
amount of PEEP needed in newbornsthe low pressure
group and the high pressure group. Generally, a PEEP of
4-6 cm H2O pressure is adequate for premature newborns.
But pressures as high as 9-10 cm has been used which
might accentuate possibilities of air-leaks and abdominal
distension causing more respiratory distress and reduce
lung compliance.
When a baby is already on CPAP and needs to come
out of it, the weaning is done as a gradual process. If the
pressures are set quite high, it needs to be decreased
gradually over hours or days depending on how well the
baby tolerates the weaning process. If the PEEP is already
at 4 cm H2O, the weaning mode is time cycled allowing
the baby to come off CPAP for brief periods and increasing
the duration off CPAP gradually as tolerated by the baby.
Indications for CPAP Use
1.
2.
3.
4.
5.
Babies born with immature lungs

As a weaning mode of ventilation
Atelectasis
Apnoea of prematurity
Obstructive apnoea.
14
Recent trials have shown the beneficial use of CPAP in

babies with extreme prematurity but more studies are
needed to validate these findings.
Contraindications of CPAP Use
1. Persistent and profound apnoeas and bradycardias in
spite of being on NCPAP.
2. Congenital malformations, e.g. congenital diaphragmatic hernia, choanal atresia, etc.
3. Respiratory failure.
Hazards of CPAP Use
1. Air trapping.
2. Air-leaks (Pneumothorax, pulmonary interstitial
emphysema).
3. CO2 retention.
4. Gastric distension (orogastric tube might help).
5. Local trauma to the nostrils from nasal prongs.
6. Noisy.
GENERAL GUIDELINES FOR CPAP
1. Respiratory distress in newborn baby (grunting, chest
recessions, etc.).
2. Increasing oxygen requirement (about 40%, if oxygen
requirement is more than 60% or there is increasing
hypercapniaconsider ventilation).
3. Initial PEEP is usually set at 4-6 cm of water.
Threshold for Intubation
Preterm infants with respiratory distress should be
considered for intubation and surfactant treatment if:
1. Early chest X-ray is consistent with RDS.
CONTINUOUS POSITIVE AIRWAY PRESSURE
15
2. Despite adequate CPAP FiO2 requirement > than 60 per

cent.
3. A lower threshold may be used for intubation and
surfactant for infants < 30 weeks gestation at high-risk
of RDS and increasing oxygen requirements, particularly if the X-ray is consistent with RDS.
NASAL VENTILATION
This mode of ventilation has been tried but with variable
success. It has been used as a weaning mode of ventilation,
and also in treating apnoea of prematurity. To date there
is no concrete medical evidence to suggest its definite role
in ventilation though it is still used in some UK centres.
Chapter 5
Positive Pressure
VentilationIntroduction
and Terminologies
18
INTRODUCTION
Positive pressure ventilation is mainly of two types:
1. Volume controlled ventilatorsdelivers the same amount
of tidal volume irrespective of pressure.
2. Pressure controlled ventilatorsdelivers variable amount
of tidal volume depending upon the preset pressure.
Advantages of Pressure Controlled Ventilators
1. Simple design and lower cost.
2. Is simple to operate.
3. As the same pressure is delivered with each breath,
even with changes in lung compliance over-distension
of the lung is less likely.
VENTILATOR CONTROLS
Peak Inspiratory Pressure (PIP)
It is the main factor used to deliver tidal volume. In most
modern ventilators the physician can directly adjust PIP. It
can also be manipulated by changing the flow rate or the I/E
ratio. The initial levels of PIP are selected depending on
the infants weight, gestational age, lung compliance and
airway resistance. As a basic principle the lowest level of
PIP that adequately ventilates a neonate should be used. In most
instances PIP of 20-24 cm H2O is adequate to ventilate a
newborn.
Use of high pressures may be associated with side effects
like bronchopulmonary dysplasia and pulmonary air leaks. On
the other hand uses of low pressures run the risk of the
baby receiving insufficient ventilation (Table 5.1).
POSITIVE PRESSURE VENTILATION
19
Table 5.1: Advantages and disadvantages of low PIP

Low PIP (< 20 cm H 2O)
Advantages
1.
2.
Fewer side effectsBPD, PAL

Normal lung development
proceed rapidly
Adverse effects
1. Insufficient ventilation
2. Generalised atelectasis may
occur
Positive End-Expiratory Pressure (PEEP)

The use of PEEP has been documented since early 1970s.
PEEP is continuous distending pressure, which prevent alveolar
collapse at the end of expiration. In most modern ventilators,
like PIP the physician can directly adjust the PEEP as well.
PEEP can be altered by changing expiratory time or if the
airway resistance changes. The initial levels of PEEP
depend on the weight of the baby, the pathophysiology
of the disease process, and also on the aim of the treatment.
The benefits of PEEP are:
a. Stabilization and recruitment of lung volume.
b. Improvement in lung compliance.
c. Improvement in ventilation-perfusion matching in
the lungs.
In most instances the level of PEEP used is 4-7 cm of
H 2O. Levels above 8 cm of H2 O are associated with
increased risk of pulmonary air leaks, abdominal
distension and reduction of cardiac output. Pressures
below 4 cm may be too low to maintain adequate lung
volume.
Rate
CO2 elimination depends mainly on the amount of gas
that passes in and out of the alveoli. The total amount of
gas that passes in and out of the lungs is called minute
20
ventilation. Respiratory rate is one of the primary

determinants of minute ventilation (MV) in mechanical
ventilation (MV = RR tidal volume).
In most instances the rate used is between 40 to
60 breaths per minute, but the adjustment in rate
might depend on the weight of the baby, type of the
respiratory disease and on the clinical response. This
rate mimics the normal respiratory rate of the baby
and will effectively treat most neonatal lung diseases.
Rates < 40/minute might be associated with increase
PIP and its adverse effects, and rates > 60/minute may
cause hypocapnia and inadvertent PEEP.
Fraction of Inspired Oxygen
Oxygen is probably the most commonly used drug in the
neonatal intensive care, but it can act as a double edged
sword, if not used with caution. Inadequate O2 administration
can lead to hypoxemia and consequently to severe neurologic
injury. On the other hand high oxygen concentration has been
implicated as one of the precipitating factors for retinopathy of
prematurity and bronchopulmonary dysplasia.
The oxygen that is delivered to the neonate during
ventilation is in a humidified form. Humidification prevents
bronchospasm and airway injury in newborns.
Inspiratory to Expiratory Ratio
I:E is an important variable in the ventilatory management
in babies. The normal I: E is 1:1- 1:3. In most instances the
Ti (inspiration time) is selected along with the rate and
the I: E is automatically set. In general a starting Ti of 0.3
to 0.4 seconds is used. This ratio mimics the natural
breathing pattern of the baby. Increasing Ti increases the
mean airway pressure without increasing the PIP.
POSITIVE PRESSURE VENTILATION
21
If I: E is inversed (> 1 : 1) it may result in air trapping,

pulmonary interstitial emphysema and also impaired
venous return to the heart, but it may also be used to
recruit more alveoli in presence of atelectasis thereby
improving the oxygenation.
A prolonged I: E (< 1 : 3) may be useful in conditions
such as meconium aspiration syndrome, but a low
inspiratory time can also result in decrease in tidal volume
and increase risk of intraventricular haemorrhage.
Mean Airway Pressure (MAP)
MAP is the measure of the average pressure to which the
lungs are exposed during the respiratory cycle.
Oxygenation increases linearly with increase in MAP. The
ventilator variables which increase MAP are:
a. PIP
b. PEEP
c. I : E
d. Flow
e. Rate
MAP as low as 5 cm H2O may be sufficient in babies
with normal lungs whereas pressure as high as 20 cm H2O
may be necessary in newborns with RDS.
LIMITATION OF MAP
1. Increases in PIP and PEEP are more effective in
enhancing oxygenation as compared to increases in
I : E.
2. Very high MAP may cause lung over distension, right to
left intrapulmonary shunting, or decreased cardiac output.
3. Long Ti increases risk of air leaks.
22
Wave Forms
The two commonly used waveforms in neonatal ventilation
are sine and square.
The sine wave breathing resembles normal spontaneous respiration of infants. There is gradual increase
in inspiratory pressure, which may be helpful in many
neonatal lung diseases.
The square wave breathing improves oxygenation
when used with low rates and longer Ti. It provides a
higher MAP compared to sine wave breathing for identical
PIP. If longer Ti is used it can impede venous return to the
heart and cardiac output may decrease.
Flow Rate
Flow rate is an important determinant of the ability of the
ventilator to deliver expected levels of PIP to the baby.
Minimum flow of at least twice the babys minute
ventilation is usually required but in practise the operating
range can be much higher. (Normal neonatal minute
ventilation ranges from 0.2-1 L/minute).
Chapter 6
Different Modes of
Positive Pressure
Ventilation
24
There are various modes of positive pressure ventilation

that are in practice and though each mode has its own
merits and demerits, at the end of the day it comes down
to the clinicians choice and experience. The types used
can be broadly divided into two main categories
asynchronized and synchronized. Due to reasons described
later asynchronized type of ventilation has fallen out of
favour.
Intermittent Mandatory Ventilation (IMV)
This is asynchronized form of mechanical ventilation. Here
the ventilator delivers a minimum number breaths per
minute with which the baby has to be ventilated. The babies
can still breathe independently between ventilators
delivered breaths, but there can be asynchrony between
the two. Asynchronized ventilation can result in variable tidal
volume, lung over distension, air leaks and intraventricular
haemorrhage. To minimize the asynchronized ventilation
the baby should be adequately sedated and paralysed.
Synchronized Intermittent
Mandatory Ventilation (SIMV)
It is improvement over IMV in achieving the synchronized
mode of ventilation. This form of ventilation delivers
intermittent positive pressure breaths at a fixed rate in
synchrony with the babys inspiratory effort. Here the clinician
presets a ventilator backup rate (e.g. 30/minute). This
implies that the ventilator is going to deliver 30 mandatory
breaths to the baby per minute irrespective of the babys
own respiratory effort. If the baby is breathing at a rate
higher than the preset rate (e.g. 40/minute) 30 of these
breaths will be synchronized and supported by the
ventilator. The remaining 10 breaths are the babys own
effort only and may or may not be effective breaths.
DIFFERENT MODES OF PP VENTILATION
25
The advantage of this mode of ventilation is that there

is lesser need for sedation and paralysis and is often used
as a weaning mode.
Synchronized Intermittent Positive Pressure
Ventilation (SIPPV)/Assist Control (A/C)
In this mode each spontaneous breath that exceed trigger
threshold will result in the delivery of a completely
supported mechanical breath. If the baby does not breathe
or if the breath fails to exceed the trigger threshold a
mechanical breath will be provided by the ventilator at a
rate preset by the clinician. For example, if the clinician
sets the rate of 30/minute it will imply that the baby will
be receiving 30 guaranteed breaths from the ventilator. If
the baby is breathing at a rate higher than this for example,
40/minute then this will imply that all the 40 breaths will
be supported by the ventilator and the will effectively be
breathing at a rate of 40/minute. Weaning in this form of
ventilation is generally by reduction of PIP as compared to
SIMV where rate is the weaning parameter.
The advantage of this mode of ventilation is that it
requires minimal amount of patient effort and also has
the safety of a guaranteed backup rate (all breaths are
supported by the ventilator and hence effective).
Chapter 7
Ventilatory Adjustments
According to
Blood Gas Changes
28
1. To increase pO2:
a. Increase PIP
b. Increase PEEP
c. Increase I/E ratio
d. Increase flow.
2. To decrease pCO2:
a. Decrease PIP
b. Decrease PEEP
c. Increase rate
d. Decrease flow.
3. To increase pCO2:
a. Increase PIP
b. Decrease rate
c. Increase PEEP.
SCENARIOS
Always remember DOPE before any intervention
(Displaced tube, Obstructed tube, Pneumothorax,
Equipment failure).
1. Baby on ventilator with high pCO2, acceptable pO2
( FiO250%, RR40/m, IT0.35 sec, P22/4). Initial
likely ventilator adjustment to be made Increase rate.
2. Baby on ventilator with low pCO2, acceptable pCO2
(FiO2 80%, RR40/min, P22/4, IT0.35 sec). Initial
likely ventilator adjustment to be made Decrease rate/
Increase PIP.
3. Baby on ventilator with low pCO2, acceptable pO2
(FiO2 50%, RR40/m, P26/4, IT0.35 sec). Initial
likely ventilator adjustment to be made Decrease rate.
4. Baby on ventilator with high pCO2, acceptable pO2
likely ventilator adjustment Decrease PIP.
VENTILATORY ADJUSTMENTS ACCORDING TO BGC
29
5. Baby on ventilator with low pCO2, acceptable pCO2

likely ventilator adjustmentIncrease FiO2.
Answers
1.
2.
3.
4.
5.
Increase rate.
Increase FiO2/Increase pressure (PIP)think PPHN!
Decrease rate.
Decrease PIP.
Increase FiO2.
WEANING OF VENTILATION
It should be tried when the concentration of inspired
oxygen is 40 percent or less. The PIP is gradually reduced
along with the ventilator rate to allow the baby to breathe
on his/her own. When the rate is weaned to around 10/
minute or less the baby is extubated to CPAP with a PEEP
of 4-6 cm of H2O. The infant should not be stressed before
weaning and usually is kept nil by mouth for 6-8 hours.
A loading dose of caffeine citrate is also administered 12 to
24 hours prior to extubation.
Chapter 8
Volume Controlled
Ventilation
32
INTRODUCTION
The age old concept of pressure related trauma
(barotrauma) is gradually being replaced by the understanding that it is the over distention and stretching of the
lungs (volume-trauma), which is, more damaging to the
alveoli. The repeated stretching of the lungs cause a
shearing stress which might lead to air-leak syndromes.
Why is Tidal Volume Important?
The normal tidal volume in babies is5-8 ml/kg. Volumes
greater than 8 ml/kg will cause over distension.
Tidal volume less than total dead space (inadequate)
will produce insufficient exchange of alveolar gases.
Large tidal volume may produce alveolar over distention
and shear stress damage.
Lung over stretching and over distention are significant
in causing lung injury.
Extreme over distention may lead to impaired venous return
and subsequent cardiac compromise.
Volume Controlled Ventilation
The characteristic feature of this mode of ventilation is
that the ventilator delivers a specific volume of gas to the
baby irrespective of changes in pressure. In this the clinician
sets the tidal volume, frequency (therefore the minute volume)
and inspiratory and expiratory times are set by default. The
most significant advantage of this mode of ventilation is
that even in the face of rapidly changing lung compliance
the actual tidal volume delivered to the patient remains constant.
This is in contrast to pressure-limited ventilators where
pressures are preset but there is no guaranteed tidal
volume delivered. On the other hand because of the
endotracheal tube leaks and poor lung compliance measurement
VOLUME CONTROLLED VENTILATION
33
of delivered tidal volumes can be erroneous at times. The chances

of endotracheal tube leaks are high because uncuffed ETT
are used in babies as a standard practise. Also the tidal
volume that is delivered is measured more near the
ventilator than the baby which again increases the risk of
erroneous measurement of tidal volumes.
There are various types of volume-targeted ventilation.
Volume-Assured Pressure Support (VAPS)
This modality combines the advantages of pressure and
volume ventilation on a breath to breath basis and can be
used with other pressure support ventilation or by itself
in babies with reliable respiratory drive. The clinician
presets the volume to be delivered. As long as the
delivered volume exceeds the preset level the breath
behaves as a pressure support breath. If the preset volume
is not achieved during the course of breathing inspiratory
time will be prolonged till the desired volume is reached.
Pressure-Regulated Volume-Controlled (PRVC)
This form of ventilation has the features of volume and
pressure control. The clinician sets a target tidal volume
and the maximum pressure level. The first delivered
breath is at 5 cm water pressure, which is also used to
calculate the lung compliance. The next three breaths are
delivered at three quarters of the calculated pressure
needed to deliver the targeted tidal volume. After this
pressure is increased by 3 cm of water each breath until
target volume is delivered.
Volume-Guaranteed Pressure-Limited
In this mode of ventilation the clinician presets the tidal
volume and the maximum pressure. The pressure set is
34
usually 15-20 per cent above the peak pressure needed to

constantly deliver the target tidal volume. The volume
guarantee is based on the expired tidal volume of the
preceding eight breaths. The volume guarantee can only
be used in association with SIMV and Assist Control.
WEANING OF VENTILATION
Most babies can be extubated when they are able to
maintain the target tidal volume with delivered PIP of
less than 10-12 cm of H2O and FiO2 less than 35 per cent
and show a good sustained respiratory effort.
Chapter 9
High Frequency
Ventilation
36
INTRODUCTION
This is a form of ventilation that uses small tidal volumes
with very rapid ventilator rates. Lunkenheimer first reported
this method of ventilating babies in the early 1970s. Since
then there has been lot of advancement in this regard and
currently is used extensively worldwide for ventilating
newborns.
The exact mechanism by which HFV works is still not
very clear, but facilitated diffusion is thought to be one of the
major mechanisms for gas exchange. Generally, if the tidal
volume is extremely low, particularly, if lower than the
anatomical dead space, chances of effective alveolar
ventilation is minimal. But, even with such low volume
there is still effective gas exchange in HFV mode of
ventilation.
TERMINOLOGIES USED
1. Mean Airway Pressure (MAP): This is the point about
which oscillation occurs and directly affects oxygenation
as with all other forms of ventilation. It opens up the
atelectatic areas of the lung and thereby minimizes
ventilation-perfusion mismatch and intrapulmonary
right-to-left shunting.
2. Amplitude: Also referred to as delta p. This influences
the CO2 elimination and indicates the size of the swings
(chest bounce) about the MAP. This is also one of the
determinants of the oscillatory volume.
3. Frequency: This is measured in Hertz (1 hertz = 60
breaths/minute) and influences both the oscillatory
volume and the amplitude. Generally frequencies of
around 10 Hz are used in newborns. As the frequency
decreases the volume and amplitude increase resulting
in a drop in pCO2.
HIGH FREQUENCY VENTILATION
37
4. Oscillatory volume: This results from pressure swings

and essentially determines the effectiveness of CO2 removal.
The target oscillatory volume is usually around
2-2.5 ml/kg. The volume is directly proportional to the
amplitude and related inversely to the frequency.
5. Gas transport coefficient (DCO2): CO2 elimination in
HFV correlates well with (Oscillatory volume) 2
frequency. This is called the gas transport coefficient
and measures the effectiveness of CO2 removal. An
increase in DCO2 will result in decrease in pCO2.
Types of High Frequency Ventilators
High Frequency Positive Pressure Ventilators (HFPPV)
This refers to mechanical ventilators operating at rates
between 60-150 breaths/minute. This has been used in
clinical trails to treat severe air leaks and lung diseases
unresponsive to conventional ventilation. In most cases
HFPPV requires no special equipment, all that is needed is to
turn the rate up in a conventional mechanical ventilator. But,
because standard ventilators are not generally designed with
such high frequencies in mind, minute ventilation decreases
significantly at higher rates. Inadequate gas delivery during
inspiration and air trapping during expiration are also the
major factors limiting the use of HFPPV.
High Frequency Jet Ventilators (HFJV)
This mode of ventilation involves delivering of
pressurized gas in small aliquots into the upper airway
through a jet injector. It is used in tandem with the
conventional ventilator that provides PEEP and
background conventional breaths (Sigh breaths), which
helps to prevent atelectasis. HFJV uses passive exhalation
relying on the elastic recoil of the lung to help drive the
38
exhaled gases. The frequency used in this mode varies from

150-600 breaths per minute. Studies have demonstrated
the superiority of HFJV to conventional ventilation in
resolving pulmonary interstitial emphysema. Also there is
no evidence to suggest a link between the use of HFJV and
chronic lung disease in infants.
High Frequency Oscillatory Ventilation (HFOV)
In this mode of ventilation piston pumps are used that
operate at rates ranging from 400-2400 breaths/minute.
During HFOV inspiration and expiration are both active.
It applies continuous distending pressure to maintain an
elevated lung volume and small tidal volumes are
superimposed at a rapid rate. Pressure oscillations
produce tiny tidal volumes, which are again determined
by the amplitude of the airway pressure oscillation. Sigh
breaths are not used with HFOV.
INDICATION OF HIGH FREQUENCY VENTILATION
1. It can be used as a primary mode of ventilation in
extreme prematurity.
2. As a rescue therapy for infants failing conventional
ventilation.
a. Reduced compliance
b. RDS
c. Air leaks
d. Hypoplastic lungs
e. Meconium aspiration
f. Atelectasis.
3. Primary pulmonary hypertension of newborn.
4. Babies with established PIE.
5. Diaphragmatic hernia.
HIGH FREQUENCY VENTILATION
39
The only relative contraindication for the use of HFV is

pulmonary obstruction.
ADVANTAGES OF HFV
1. Achieves adequate ventilation while avoiding large
swings in lung volume.
2. There is more alveolar recruitment and improvement
in ventilation perfusion matching because of the high
MAP used.
Complications
1. Irritation: Babies require more sedation to avoid
irritation by HFV.
2. Hemodynamics: High MAP can jeopardies venous
return and cardiac output and also increase pulmonary
vascular resistance.
3. Intracranial haemorrhage (debatable).
4. Over inflation: With higher frequencies there is a
possibility of lung over inflation specially with
obstructive airway disease (e.g. meconium aspiration).
Management Strategies of Babies on HFV
Problems
Suggested management
High pO 2
Decrease FiO2
Decrease MAP gradually
Low pO2
Increase MAP
Increase FiO 2?
Apply sigh manoeuvre
High pCO 2
Decrease frequency
Increase amplitude
Increase MAP
40
Low pCO 2
Increase frequency
Decrease amplitude
Decrease MAP
Over inflation
Decrease MAP
Decrease frequency?
Discontinue HFV
Hypotension
Give colloid
Give dopamine/dobutamine
Reduce MAP
Chapter 10
Nitric Oxide
42
INTRODUCTION
In 1992, Science magazine named Nitric oxide as the
molecule of the year for its potential as a revolutionary
medical gas therapy. Nitric oxide is a highly diffusible,
colourless gas with a sharp and sweet odour. The NO
molecule is a free radical making it able to react with other
molecules.
Mechanism of Action of NO
NO is produced endogenously as the direct result of the
enzyme nitric oxide synthase which oxidises the nitrogen
atoms of L-arginine.
NO diffuses into the pulmonary vascular smooth
muscles and it activates the soluble form of guanylate
cyclase and thereby increasing the second messenger
cyclic guanosine monophosphate which results in
pulmonary vasodilation. NO is a very potent short acting
vasodilator with a half-life of 3-5 seconds. Once, it combines
with haemoglobin it is quickly inactivated. This results in
the formation of methaemoglobin, inorganic nitrate and
nitrite, which are then renally excreted.
Functions of NO
1. Pulmonary vasodilatation.
2. Kills bacteria and tumour cells in white cells.
3. Acts as a synaptic transmitter in the brain and the spinal
cord.
4. Releases adrenaline from the adrenal medulla.
5. Stimulates gut peristalsis.
6. Inhibits clotting.
Why NO?
NO has the unique ability to achieve potent and sustained
pulmonary vasodilation without decreasing the systemic vascular
NITRIC OXIDE
43
resistance. This ability of NO to selectively lower pulmonary

vascular resistance and decrease the extra-pulmonary
arteriovenous admixture justifies its use for the immediate
improvement and oxygenation in babies with persistent
pulmonary hypertension. It also improves oxygenation by
redirecting blood from poorly aerated lung regions to betteraerated air spaces.
INDICATIONS
1. Persistent pulmonary hypertension of the neonate
(PPHN) (extrapulmonary right to left shunt).
2. Atelectasis, alveolar filling with meconium or blood
(intrapulmonary right to
left
shunt).
3. Meconium aspiration (V/Q mismatch).
4. Pulmonary interstitial emphysema (V/Q mismatch).

TREATMENT STRATEGIES
Infants who have hypoxemic respiratory failure with evidence of
PPHN and requiring mechanical ventilation with high FiO2 are
suitable candidates for inhaled NO therapy. The most common
criterion, which is generally used for starting NO, is the
oxygenation index (OI). OI is calculated as:
OI =
MAP (cm H2O) FiO2 100

Postductal paO2 mmHg (kPa 7.5)
NO is usually started at OI values of > 25.

Dose
The starting dose for NO varies among different units,
but usually a maximum concentration of 40 ppm (parts
per million) is used. In most instances a dose of 20 ppm will
suffice.
44
Duration of Treatment
In NOVO trial recommends that an increase of 3 kPa in
paO2 above baseline should be considered as an evidence
of a clinical response. If no response is seen within 15-30
minutes of using the highest dose then cessation of therapy
should be considered. In most studies the typical duration
of NO treatment has been less than 5 days. If required longer
than 5 days then investigations into other causes of pulmonary
hypertension should be considered.
WEANING
Continued weaning for inhaled NO should be tried daily
in infants in whom a clinical response is seen. When very
low levels of NO are reached (5 ppm) further reduction
in dose should be very gradual and may take several days.
PATIENT MONITORING
1. Methaemoglobin: It should be measured 8-12 hourly.
Levels above 4-5 per cent may be considered an
indication to reduce NO concentrations and levels
above 7-8 per cent may be an indication to stop NO
therapy. Methaemoglobinaemia is uncommon if lower
doses of NO are used (< 20 ppm).
2. Clotting profile (because of the effect of NO on platelet
function)
3. Environmental levels of NO and NO2 should be
monitored in the relevant clinical areas.
Side-effects of NO
1. Bleeding problems including intracranial haemorrhage.
2. Methaemoglobinaemia.
Chapter 11
Extra Corporeal
Membrane Oxygenation
(ECMO)
46
This is a device of placing babies on heart-lung bypass. It

is used to support infants with severe respiratory and/or
cardiac failure not responding to conventional ventilatory
support. It is being used more frequently now with
increasing rate of success.
PROCEDURE
A venoarterial or a venovenous bypass is set up through
a semipermeable silicone membrane that provides
oxygenation and removal of carbon dioxide. In the
venoarterial bypass two large bore perfusion cannulas are
usedone is placed in the right atrium via the right
internal jugular vein and the other into the common
carotid artery so that the tip is at the origin of the
innominate artery from the aortic arch. In the venovenous type a double lumen cannula is placed in the right
heart.
SELECTION CRITERIA
There are various criteria used to select a baby for ECMO
therapy. The commonly used ones are:
1. Oxygenation index > 40
2. Unresponsive to conventional treatmentincreasing
oxygen requirement, persistent metabolic acidosis or
very high PIP (> 38 cm) requirement.
Indications
1. Severe case of meconium aspiration syndrome.
2. Congenital diaphragmatic herniabefore and after
repair.
3. Severe neonatal pneumonia.
EXTRA CORPOREAL MEMBRANE OXYGENATION
47
Contraindications
1. Weight < 2000 gm.
2. Gestational age < 35 weeks.
3. Severe pulmonary haemorrhage, gastrointestinal
haemorrhage or intraventricular haemorrhage (Gr II
and greater).
4. Lethal genetic condition.
5. Nontreatable congenital cardiac malformation or
disease.
ADVANTAGE OF ECMO
It helps to avoid the barotrauma of high inspired oxygen
concentration associated with ventilation and gives the
lungs the required time to heal by rendering them almost
non-functioning. All newborn babies receiving ECMO do
have a endotracheal tube in place with minimal mechanical ventilation.
The ECMO is generally successful in treating the
pulmonary hypertension along with the right to left
shunting in the above mentioned group of babies.
Monitoring a Baby on ECMO
The following parameters need vigilant monitoring:
1. FBC
2. Urea and electrolytes
3. Clotting
4. Liver function test
5. Blood culture
6. Endotracheal tube culture
7. Cranial ultrasound.
Side-effects
1. Increased chances if intracranial haemorrhage.
2. Auditory abnormalities
Chapter 12
Respiratory Distress
Syndrome
50
Respiratory Distress Syndrome (RDS) equates to lung

disease in newborn due to surfactant deficiency but some
Neonatologists prefer the terms surfactant deficiency lung
disease or hyaline membrane lung disease.
AETIOLOGY
Deficiency of surfactant in the lungs.
Predisposing Factors
1.
2.
3.
4.
Prematurity
Males
Race-Black babies tend to suffer less from RDS
Maternal diabetes.
Clinical Features
1.
2.
3.
4.
5.
Chest recessions
Tachypnoea
Expiratory grunting
Bradycardia (severe RDS)
Hypotension.
Prevention of RDS
1. Prevention of prematurity (Neonatologists might be
made redundant though!).
2. Antenatal steroidseven a single dose of steroid 12
hours before delivery makes the prognosis better. Two
doses of antenatal steroids are usually given, but
multiple doses have been used though benefit of that
is not very clear.
3. Prophylactic surfactantThe use of surfactant within
the first few minutes of birth has been shown to
improve the oxygenation and also reduces morbidity.
RESPIRATORY DISTRESS SYNDROME
51
INVESTIGATION
Chest radiography Fine diffuse granular shadowing of both
lung fields with air bronchogram (the classical finding).
Treatment
1.
2.
3.
4.
Ventilationif necessary
Fluid balance
Nutrition
Antibiotics (as it is hard to differentiate RDS from early
onset sepsis)
5. Surfactant therapy.
Complications
1.
2.
3.
4.
Air leaks
Intraventricular haemorrhage
Chronic lung disease
PDA ( the incidence of symptomatic PDA increases, if
there is fluid retention).
Chapter 13
Chronic Lung
Disease
54
DEFINITION
Oxygen dependency after 28 days of age with characteristic chest X-ray changes.
AETIOLOGY
1. Volutrauma.
2. Prematurity/surfactant deficiency.
3. Airleaks.
4. PDA.
5. O2 toxicity.
6. Chorioamnionitis.
MANAGEMENT
1. VentilatoryMaintaining steady tidal volume and
ventilating at lower pressure helps.
2. Oxygen therapy.
3. Prompt treatment of chest infections.
4. Blood transfusion.
5. Nutrition.
6. DrugsDiuretics, bronchodilators, corticosteroids.
7. Specialist team for home O2 therapy.
PROPHYLAXIS
1. Antenatal steroids.
2. Avoidance of aggressive respiratory support in initial
stages.
3. Vitamin E.
4. Strict fluid management.
Complications
1. Aspiration pneumonia.
2. Gastro-oesophageal reflux.
3. Right heart failure.
4. Cor pulmonale.
Chapter 14
Meconium Aspiration
Syndrome
56
Meconium Aspiration Syndrome (MAS) occurs as a result

of inhalation of meconium antepartum, intrapartum or
immediate postpartum.
PROPHYLAXIS
Airway suctioning in time (before delivering the inflation
breaths in presence of thick meconium) can effectively
reduce the incidence of MAS. There is no need to suction
airway if the baby cries spontaneously after birth even in
presence of meconium staining unless meconium is visible
below the cords or it is particulate type.
Effect on the Baby
1.
2.
3.
4.
Hypoxia
Acidosis
Raised pulmonary artery pressure
PPHN.
Treatment
1.
2.
3.
4.
5.
Oxygen
VentilationIPPV, ECMO
Pulmonary vasodilatorsNitrous oxide, Tolazoline
Antibiotics
Fluid balance and acid-base homeostasis.
Complications
1.
2.
3.
4.
Airleaks
PPHN
HIE
Renal failure.
Chapter 15
Transient Tachypnoea
of Newborn
58
This is probably the most common cause of respiratory

distress in neonates born by caesarean section. The reason
for this condition is likely to be the delayed absorption of
lung fluid, which can often be visualised in the X-ray.
Treatment is supportive. The close differential for this
condition in term babies is sepsis while in premature ones
surfactant deficiency should be thought of as well.
Chapter 16
Collapse of a Baby
on Ventilator
60
This is a common scenario one encounters while working

in intensive care unit. Along with ABC of resuscitation,
the mnemonic to remember here is:
Ddisplaced tube
OObstructed tube
PPneumothorax
EEquipment failure
The primary approach to a baby who has collapsed on
ventilator remains the same as in resuscitationABC. Quite
often, if the baby is not adequately paralysed and/or the
ET tube is not properly secured there is always the
possibility of the tube getting dislodged. In this situation
the tube needs to be changed.
In certain instances, if the endotracheal tube has been
in place for long there is always an increased chance of
the tube getting blocked by secretions and thereby
obstructing the airway. Similar problems might occur, if
a narrow diameter ET tube is used. In these circumstances,
tracheal toileting may suffice or else might need a tube
change.
Pneumothoraces can be spontaneous, but more often
it is iatrogenic caused by inadvertent high pressures
during ventilation. After checking the position and the
patency of the tube, a cold light examination of the chest
is to be done to rule out any airleak. A chest X-ray should
be arranged though in case of a tension pneumothorax
intervention is urgent without waiting for a X-ray. A
tension pneumothorax needs urgent intercostal drainage
with a needle. Later as in case of a simple pneumothorax
a proper chest drain can be inserted.
Equipment failures are a common cause of collapse of
a ventilated baby. The ventilatory circuit must be
thoroughly checked before making exotic diagnoses for
the collapse!
COLLAPSE OF A BABY ON VENTILATOR
61
In premature babies it is also very useful to do a cranial

ultrasound as intracerebral bleed can lead to a similar
scenario. Also remember sepsis as a cause for collapse
and it is worth checking the blood sugar as well.
Chapter 17
Necrotising
Enterocolitis
64
This condition commonly encountered in premature

neonates increases mortality and morbidity rates in NICUs
considerably.
1. Prematurity.
2. Absent or reversed end-diastolic flow.
3. Early introduction of feeds in high-risk cases.
Clinical Findings
1. Blood stained stool.
2. Abdominal distension.
3. Vomiting/large NG aspirates.
4. Apnoea.
5. Feed intolerance.
Pathogenesis
Ischaemic necrosis and inflammation of the gut. Whether
this condition is a direct result of a bacterial infection is a
matter of controversy.
Diagnosis
1. Raised inflammatory markers in blood.
2. Abdominal X-ray:
a. Pneumatosis intestinalis
b. Portal vein gas
c. Pneumoperitoneum.
Treatment
1. Nil by mouth.
2. Antibiotics (Benzylpenicillin, Gentamicin, Metronidazole or Cefotaxime and Metronidazole.
3. Surgery (Resection of the necrotic bowel) in cases of
bowel perforation.
Chapter 18
Jaundice
66
Mild unconjugated hyperbilirubinaemia is common in

newborns, but conjugated hyperbilirubinaemia implies
serious underlying pathology (always check color of stools
in jaundice-white in conjugated type).
PHYSIOLOGIC JAUNDICE
Usually starts by 2nd to 4th day of life and resolves by a
week. It happens probably due to increased breakdown of
foetal red blood cells and thereby raised bilirubin
production.
BREAST MILK JAUNDICE
This happens usually by 5th to 7th day and can persist as
long as 2-3 weeks. The cause for this condition is unclear
but glucuronidase might have a role to play. If breast-feeding
is continued in the face of jaundice, the bilirubin decreases
gradually. Cessation of breast-feeding reduces hyperbilirubinaemia drastically.
First Day Jaundice
This is always pathological. Common causes are:
1. Sepsis.
2. Blood Group incompatibility.
3. Haematological disorders, e.g. G6PD deficiency,
Hereditary spherocytosis, etc.
4. Hypothyroidism (a cause for prolonged jaundice).
Treatment
Phototherapy and Exchange Transfusion
Phototherapy usually acts by converting the bilirubin to
lumirubin, which is excreted by the kidneys. There is no
JAUNDICE
67
agreed level at which phototherapy should be started. But

generally accepted figures are:
24-48 hrs 15 mg/dl
48-72 hrs 20 mg/dl
> 72 hrs 20-25 mg/dl
These figures are applicable for term babies. For
premature babies phototherapy is initiated at much lower
levels.
Chapter 19
Neonatal Feeding
Difficulties
70
Feeding a newborn baby is an art, which has to be acquired

with patience. Poor suck is a worrying sign and can be
the first indication of an unwell baby.
Common problem checklist of a breast-feeding baby:
1. Positioning of the baby.
2. Are the size of nipples to large or too small for the
baby.
3. Any cracked nipples.
4. Evidence of mastitis.
Checklist for bottle-fed babies:
1. Positioning of the bottle.
2. Size of the nipple.
3. Size of the teat.
4. Milk to water ratio.
Chapter 20
Neonatal Vomiting
Common Causes
72
NEONATAL VOMITINGCOMMON CAUSES

1.
2.
3.
4.
Sepsis (UTI)
Gastro-oesophageal reflux
Over feeding
Lack of burping after feeds.
Chapter 21
Anaemia in
Neonates
74
COMMON CAUSES
1.
2.
3.
4.
5.
Transplacental haemorrhage.
Haemolytic disease of newborn.
Maternal APH prior to delivery.
Anaemia of prematurity.
Repeated phlebotomy in neonatal units.
POLYCYTHAEMIA IN NEONATES
Common Causes
1.
2.
3.
4.
5.
Twin to twin transfusion.

Infant of diabetic mother.
Trisomy-21.
Hypothyroidism.
Delayed clamping of cord.
Treatment
Treatment for symptomatic polycythaemia is dilutional
partial exchange transfusion with normal saline. The
formula used is:
Volume of exchange =
Blood volume (Observed Desired Haematocrit)
Observed Haematocrit
Chapter 22
Hypoxic Ischaemic
Encephalopathy (HIE)
76
This is an important cause of neonatal mortality and of

cerebral palsy or learning difficulty in later life. HIE causes
permanent damage to CNS cells.
The three stages of HIE are:
1. Stage 1 Hyper alert baby with normal tone and
posture.
2. Stage 2 baby with hypotonia.
3. Stage 3 Stuporous and flaccid baby with decerebrate posture.
Treatment
Therapy is supportive. Procedures like total body
hypothermia (TBHT) or local cranial cooling are under
trial.
Chapter 23
Intraventricular
Haemorrhage and
Periventricular
Leucomalacia
78
Intraventricular haemorrhage (IVH) may result from

trauma, asphyxia, etc. IVH occurs in the subependymal
germinal matrix, which is the site of embryonic neurons
and immature blood vessels.
Common predisposing conditions for IVH:
1. Prematurity
2. Pneumothorax
3. HIE
4. Increased or decreased cerebral blood flow due to any
reason.
The pathogenesis of periventricular leucomalacia (PVL)
is still evolving, but it is thought to be as a result of disturbance in regulation of cerebral blood flow compounded
with maternal or foetal infection. The chances of PVL are
high in infants with IVH. PVL is responsible for adverse
neurodevelopmental outcome in infants.
Diagnosis
Serial cranial ultrasound is the mainstay of diagnosing
IVH and PVL. But more advanced imaging techniques
like MRI or CT may be required particularly for
diagnosing PVL which is characterized by focal necrotic
lesions in periventricular white matter or more extensive
white matter damage.
Treatment
Treatment is supportive. Antenatal administrations of
corticosteroids reduce both IVH and PVL. Indomethacin
has been used prophylactically to reduce the incidence of
severe IVH but is not universally practised. A DRIFT study
is being practised in UK (Bristol) which aims at removing
pooled blood in brain in IVH and thereby reducing needs
of a V-P shunt in later stages.
Chapter 24
Persistent Pulmonary
Hypertension of the
Newborn (Persistent
Foetal Circulation)
80
This condition happens when there is persistence of foetal

circulatory pattern of right to left shunting through
Foramen ovale and PDA. This is due to high pulmonary
vascular resistance.
1.
2.
3.
4.
Perinatal asphyxia.
Neonatal sepsis.
Meconium aspiration syndrome.
Polycythaemia.
Diagnosis
There is universal hypoxia with no or minimal response
to 100 percent O2. Echocardiogram with Doppler studies
is usually diagnostic.
Differential Diagnosis
Congenital cyanotic heart disease.
Treatment
1.
2.
3.
4.
VentilationHFV
Tolazoline
Nitric oxide
ECMO.
Chapter 25
Sepsis in Neonates
82
MOST COMMON ORGANISMS

1.
2.
3.
4.
Streptococcus (Group B)
E. coli
Listeria Monocytogenes
Staphylococcal epidermidis (in babies with central lines
in situ).
Manifestations
1.
2.
3.
4.
5.
Apnoea
Feed intolerance
Desaturating episodes
Not well
Worried nurse.
Investigations
1.
2.
3.
4.
Blood for FBC, culture, CRP

Chest X-ray
Urine for M/C/S
Lumbar puncture.
Predisposing Factors for Sepsis

1. Prolonged rupture of membranes (dribbling for > 18
hours though most units will consider > 24 hours to
be significant).
2. Maternal pyrexia in labour (temperature > 38C).
3. Previous baby had proven sepsis after birth.
Treatment
Different units have their own guidelines regarding when
and how to treat. Gestational age of the baby should also
be taken into consideration. Benzylpenicillin/Gentamicin
or Ampicillin/Gentamicin is a reasonable choice to start
SEPSIS IN NEONATES
83
with. Gentamicin can be substituted by Cefotaxime.

Supportive care is essential.
POINTS TO REMEMBER
1. Sepsis can cause either hypo- or hyperglycaemia.
2. Sepsis can cause either thrombocytopenia or thrombocytosis.
3. Restrict fluid to two-third maintenance in case of
SIADH.
Differential Diagnosis
1. Surfactant deficiency respiratory distress.
2. Transient tachypnoea of newborn.
3. Total anomalous pulmonary venous drainage.
Chapter 26
Tit-Bits
86
TIT-BITS
1. Three common differentials for an unwell neonate:
a. Sepsis
b. Cardiac
c. Metabolic.
2. Fluid therapy in neonates:
a. D-160 ml/kg/d
b. D-290 ml/kg/d
c. D-3120 ml/kg/d
d. D-4150 ml/kg/d
e. D-5180 ml/kg/d
Fluid therapy started a day ahead in IUGR babies.
3. The mechanism of Rh incompatibility and alloimmune
thrombocytopenia are identical (for details refer to
Robertons Textbook of Neonatology).
4. Baby collapses on D-3 or D-4Think duct dependent
heart problems.
5. Most common cause of organic heart murmur in
neonates:
a PDA
b. Pulmonary stenosis
c. VSD
6. Routine investigations for heart murmur:
a. Chest X-ray
b. ECG
c. Echocardiogram (gives the definitive answer
provided the expertise is present).
7. Weight along with length, OFC and mid-arm circumference is a better indicator of the childs nutritional
status than just weight alone.
8. Baby born to a mother with diabetesremember to
start feeds early to prevent hypoglycaemia. Also
remember hypocalcaemia and cardiomyopathy.
TIT-BITS
87
9. Neonate vomiting and crying after feedsthink about

gastroesophageal reflux. Treatmentpostural,
Gaviscon, Ranitidine, Omeprazole, Nissens fundoplication (a graded approach).
10. Remember UTI in neonates. Antenatal renal pelvic
dilation of > 10 mm demands Trimethoprim
prophylaxis after birth followed by postnatal renal
ultrasound scans the timings of which is again
dictated by the degree of dilatation. Usually scans
before D-3 may be less informative.
Chapter 27
Neonatal Formulary
(Commonly Used
Medications)
90
Adrenaline (IV)10 g/kg (0.1 ml/kg of 1 in 10,000).

Adrenaline (ET)100 g/kg (0.1 ml/kg of 1 in 1000).
Atropine sulphate (IV)15 g/kg slowly.
Benzylpenicillin (IV)25 mg/kg twice daily.
Caffeine citrate (IV/PO)20 mg/kg loading dose
followed by 5 mg/kg maintenance.
Calcium gluconate (Infusion)0.5 mmol/kg over
24 hours for maintenance therapy.
Cefotaxime (IV)50 mg/kg twice to thrice a day.
Chloral hydrate (PO/PR)25 mg/kg.
Dobutamine (IV infusioncontinuous)5-15 g/kg/
min (to be diluted in 5% Dextrose or 0.9% NaCl).
Dopamine (IV continuous infusion)5-20 mcg/kg/
min (to be diluted in 5% Dextrose or 0.9% NaCl).
Frusemide (IV/PO)1 mg/kg.
Gentamicin (IV)4-5 mg/kg every 24 to 36 hourly
depending on the gestational age.
Indomethacin200 g/kg for 3 days (for PDA closure).
Midazolam (IV)100 g/kg single dose.
Morphine sulphate (IV infusion)5-20 g/kg/hour (to
be diluted in 5% Dextrose or 0.9% NaCl).
Nystatin (PO)1 ml 4 times a day.
Pancuronium (IV bolus)100 g/kg.
Paracetamol (PO)10-15 mg/kg (can be repeated
4-6 times).
Surfactant (natural)100-200 mg/kg depending on
source.
Teicoplanin (IV)16 mg/kg loading dose followed by
8 mg/kg maintenance.
Trimethoprim (PO)2 mg/kg for UTI prophylaxis.
Index
A
Acid-base balance 7
Anaemia in neonates 73
F
Formulas commonly used in
NICU 5
B
Blood gas analysis 9
arterial blood gas
measurement 9
capillary blood gas analysis 9
continuous blood gas
analysis 9
transcutaneous
monitoring of pCO2 10
venous blood gas analysis 9
G
General guidelines for CPAP 14
increasing oxygen
requirement 14
initial PEEP 14
respiratory distress in
newborn baby 14
C
Chronic lung disease 53
aetiology 54
complications 54
management 54
prophylaxis 54
Collapse of a baby on ventilator 59
Continuous positive airway
pressure (CPAP) 11
contraindication 14
indications 13
mechanism of action 12
methods of delivering 12
E
Extracorporeal membrane
oxygenation (ECMO) 45
advantage 47
contraindications 47
indications 46
procedure 46
side effects 47
H
High frequency ventilators 37
advantages 39
complications 39
indication 38
types 37
Hypoxic ischaemic
encephalopathy (HIE) 75
treatment 76
I
Intraventricular
haemorrhage and
periventricular
leucomalacia 77
diagnosis 78
treatment 78
J
Jaundice 65
breast milk jaundice 66
physiologic jaundice 66
treatment 66
L
Limitation of MAP 21
flow rate 22
waveforms 22
92

M
Management strategies of
babies on HFV 39
Meconium aspiration
syndrome 55
complications 56
effect on the baby 56
prophylaxis 56
treatment 56
N
Nasal ventilation 15
Necrotising enterocolitis 63
clinical findings 64
diagnosis 64
pathogenesis 64
predisposing factors 64
treatment 64
Neonatal feeding 69
Neonatal vomiting 72
Nitric oxide 41
functions 42
indications 43
mechanism 42
patient monitoring 44
side effects 44
treatment strategies 43
Normal arterial blood gas
values 8
P
Persistent pulmonary
hypertention of the
newborn 79
diagnosis 80
differential diagnosis 80
treatment 80
Polycythaemia in neonates 74
common causes 74
treatment 74
Positive pressure ventilation 18

advantages 18
types 18
Positive pressure ventilation 24
R
Respiratory distress
syndrome 49
aetiology 50
clinical features 50
prevention 50
investigation 51
complications 51
treatment 51
Resuscitation at birth 2
S
Sepsis in neonates 81
investigations 82
manifestations 82
most common organisms 82
treatment 82
T
Terminologies used in HFV 36
Threshold for intubation 14
Tit-bits 86
Transient tachypnoea of
newborn 57
V
Ventilator controls 18
Ventilatory adjustments 27
Volume controlled ventilation 31
Volume-targeted ventilation 33
types 33
W
Weaning of ventilation 29, 34

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Neonatal Ventilation

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Visiting Paediatrician and Neonatologist

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

Neonatal Ventilation Made Easy

NEONATAL VENTILATION MADE EASY

18. Jaundice ...................................................................... 65

NEONATAL VENTILATION MADE EASY

NEWBORN LIFE SUPPORT

NEONATAL VENTILATION MADE EASY

recheck the position of the ET tube (see for chest

NEONATAL VENTILATION MADE EASY

1. Size of ET tubeGestation/10 (a baby of 25 weeks

NEONATAL VENTILATION MADE EASY

The understanding of acid-base balance and interpretation

In general metabolic disturbances are compensated

Respiratory disturbances are compensated by renal

NEONATAL VENTILATION MADE EASY

5. Transcutaneous monitoring of pCO2 : In this method

NEONATAL VENTILATION MADE EASY

Nasal prongs (most common)

CONTINUOUS POSITIVE AIRWAY PRESSURE

CPAP, end expiratory pressures would drop to zero at the

Babies born with immature lungs

NEONATAL VENTILATION MADE EASY

Recent trials have shown the beneficial use of CPAP in

CONTINUOUS POSITIVE AIRWAY PRESSURE

2. Despite adequate CPAP FiO2 requirement > than 60 per

NEONATAL VENTILATION MADE EASY

POSITIVE PRESSURE VENTILATION

Table 5.1: Advantages and disadvantages of low PIP

Fewer side effectsBPD, PAL

Positive End-Expiratory Pressure (PEEP)

NEONATAL VENTILATION MADE EASY

ventilation. Respiratory rate is one of the primary

POSITIVE PRESSURE VENTILATION

If I: E is inversed (> 1 : 1) it may result in air trapping,

NEONATAL VENTILATION MADE EASY

NEONATAL VENTILATION MADE EASY

There are various modes of positive pressure ventilation

DIFFERENT MODES OF PP VENTILATION

The advantage of this mode of ventilation is that there

NEONATAL VENTILATION MADE EASY

VENTILATORY ADJUSTMENTS ACCORDING TO BGC

5. Baby on ventilator with low pCO2, acceptable pCO2

NEONATAL VENTILATION MADE EASY

VOLUME CONTROLLED VENTILATION

of delivered tidal volumes can be erroneous at times. The chances

NEONATAL VENTILATION MADE EASY

usually 15-20 per cent above the peak pressure needed to

NEONATAL VENTILATION MADE EASY

HIGH FREQUENCY VENTILATION

4. Oscillatory volume: This results from pressure swings

NEONATAL VENTILATION MADE EASY

exhaled gases. The frequency used in this mode varies from

HIGH FREQUENCY VENTILATION

The only relative contraindication for the use of HFV is

NEONATAL VENTILATION MADE EASY

NEONATAL VENTILATION MADE EASY

resistance. This ability of NO to selectively lower pulmonary

3. Meconium aspiration (V/Q mismatch).

4. Pulmonary interstitial emphysema (V/Q mismatch).

MAP (cm H2O) FiO2 100

NO is usually started at OI values of > 25.