http://www.medscape.

com/viewarticle/7299
26
Device Improves Swallowing in Newborns
Jim Kling

October 04, 2010

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Related Drugs & Diseases

 Follow-up of the NICU Patient

 Transport of the Critically Ill Newborn
 Dysphagia

October 5, 2010 (San Francisco, California) — Use of a pharyngeal electrical stimulation

device (VitalStim, Empi Inc.) improves swallowing in preterm and term infants in the
neonatal intensive care unit (NICU), according to a study presented here at the American
Academy of Pediatrics 2010 National Conference and Exhibition. Neonates were also less
likely to require a gastrostomy tube when the device was employed.

Feeding problems are a common complication in infants in the NICU, noted John Patrick
Cleary, MD, a neonatologist and director of extracorporeal membrane oxygenation and
cardiovascular intensive care at the Children's Hospital of Orange County, in California, who
presented the research. Delays in feeding can prolong an infant's hospital stay and can require
insertion of a gastrostomy tube.

VitalStim electrical stimulation of the pharyngeal muscles is currently approved by the US

Food and Administration for treating dysphagia, or swallowing difficulty. There is evidence
that it improves swallowing in adults with stroke or throat cancer and in older pediatric
patients with swallowing problems. The researchers sought to study its application in
neonates.

"NICUs in general are seeing the sickest of the sick and premature babies who already have
complications. One of the major determinants of why they're in the hospital is a delay in
learning to feed, or feeding problems, or problems with safety of feeding," Dr. Cleary told
Medscape Medical News.
Infants in the study were at least 35 weeks of gestation and taking no more than 25% of
feeding volume by mouth in spite of previous dysphagia therapy. The researchers randomized
18 patients to continue standard dysphagia therapy combined with sham treatment or to
continue standard therapy with twice-daily pharyngeal electrical stimulation.

To evaluate results, the researchers used feeding volume, the Neonatal Oral–Motor
Assessment Scale, and a radiologic swallow study. Therapists, radiologists, nurses, and
treating physicians were blinded. After 2 weeks, patients in the active treatment group had a
higher percentage of feeding by mouth than those in the control group (64% vs 29%; P <
.05), and were less likely to meet the criteria for gastrostomy (1 of 9 vs 7 of 9; P < .05).
Safety of feeding also improved in the treatment group (P < .05).

"There was both statistically and clinically significant improvement in feedings. There's a
possibility that such procedures could get patients home sooner or avoid surgical gastrostomy
tubes and the problems that come with those," Dr. Cleary said.

"It's a very important study. Feeding difficulties are quite prevalent in preterm infants. Like
many areas of neonatology, we're trying to adapt adult-tested therapies in the newborn field,"
said DeWayne Pursley, MD, MPH, chief of neonatology at Beth Israel Deaconess Medical
Center and Harvard Medical School in Boston, Massachusetts, who attended the session.

The most critical question is safety, and then efficacy, according to Dr. Pursley. He doesn't
believe that the technique is ready for wide adoption. "I think [Dr. Cleary and colleagues are]
approaching that area of inquiry very carefully in trying to address both those areas. There's
quite a way to go in trying to determine if this is a therapy that can be safely and effectively
incorporated into newborn care."

The study did not receive commercial support. Dr. Cleary and Dr. Pursley have disclosed no
relevant financial relationships.

American Academy of Pediatrics (AAP) 2010 National Conference and Exhibition:

Abstract 10905. Presented October 2, 2010.
http://www.medscape.com/viewarticle/831432

New International Standards for Fetal

Growth, Newborn Size
Laurie Barclay, MD

September 10, 2014

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 Updated Birth Weight Reference Tool for Gestational Age

 Weight Gain in Pregnancy Is Key Risk Factor for Large Infants

 Air Pollution and Traffic Increase Risk for Low Birth

Weight

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Related Drugs & Diseases

 Fetal Growth Restriction

 Estimation of Fetal Weight
 Imaging in Intrauterine Growth Retardation

The first international standards for fetal growth and newborn size reflect a universally
healthy growth pattern from conception to birth, regardless of nationality or ethnic origin,
according to 2 studies published in the September 6 issue of the Lancet. Adherence to these
new standards could help prevent stunting and obesity by early recognition of deviation from
the norm.

The 2 studies, both part of the International Fetal and Newborn Growth Consortium for the
21st Century (INTERGROWTH-21st) Project, are the Fetal Growth Longitudinal Study and
the Newborn Cross-Sectional Study.

"Healthcare practitioners already have [World Health Organization] international growth

standards for children from birth up to the age of 5 that are used in 140 countries worldwide,"
Newborn Cross-Sectional Study lead author José Villar, MD, professor of perinatal medicine
at the Nuffield Department of Obstetrics and Gynaecology, University of Oxford, United
Kingdom, said in a journal news release. "Now they will have international standards for the
developing fetus and newborn too."

At present, clinicians around the world measure fetal growth and newborn size using more
than 100 different locally produced growth charts. These charts are population- and/or
region-specific, and they fail to reflect ideal growth in utero when mothers have adequate
health, nutrition, and socioeconomic status.

"With these [new] international standards, we will know when the nutrition and healthcare
needs of the developing baby are not being met," Dr. Villar said. "Across the world, this will
help identify signs of under-nutrition, stunting, wasting, and overweight at an earlier stage to
implement preventive actions to reduce long-term health problems, such as diabetes and
hypertension."

The INTERGROWTH-21st Project consists of 3 studies that gathered growth, health,

nutrition and, neurodevelopment data from less than 14 weeks and 0 days of gestation to 2
years of age in 8 diverse populations of babies born in selected urban areas in Brazil, China,
India, Italy, Kenya, Oman, the United Kingdom, and the United States. Selection criteria
included exposure to an ideal environment for healthy growth in utero, including good
nutrition, education, low levels of environmental contaminants, and access to good
healthcare, according to Aris T. Papageorghiou, MD, from the Nuffield Department of
Obstetrics and Gynaecology and the Oxford Maternal and Perinatal Health Institute, Green
Templeton College. Participants in the Fetal Growth Longitudinal Study (n = 4607)
underwent fetal ultrasound, using identical machines and measures in all countries, every 5
weeks from 14 gestational weeks to delivery. Five growth measures studied were head
circumference, biparietal diameter, occipitofrontal diameter, abdominal circumference, and
femur length.

"In one part of a city or country a fetus or newborn can be judged as small, but a healthy size
in another," senior author Stephen Kennedy, MD, professor of reproductive medicine at the
University of Oxford, said in the news release. "This can lead to inaccurate diagnosis and
ultimately unnecessary, or a lack of appropriate, treatment."

Size Standards Based on Gestational Age

The Newborn Cross-Sectional Study analyzed data from 20,486 babies born between 33 and
42 weeks' gestation to healthy mothers selected using identical criteria as in the fetal growth
study. Using identical equipment in all countries, centrally trained teams performed
anthropometric measurements within 12 hours of birth to develop new international centiles
for weight, length, and head circumference.

"These new standards allow, for the first time, international comparisons of newborn size
from 33 to 42 weeks' gestation, complementing the existing [World Health Organization]
Child Growth Standards, which start at birth but do not differentiate according to gestational
age," Dr. Villar said in the news release. "From now on, international standards can be used
worldwide to make judgments on growth and size from conception to 5 years."

The international community should endorse these new growth charts, according to Ola
Didrik Saugstad, MD, PhD, professor of pediatrics at the University of Oslo in Norway, who
wrote an accompanying comment.

These newborn growth charts "are essential to guide clinical practice and could become a
basic way to promote global child health," Dr. Saugstad writes. "[T]he charts show that
previously recorded geographical differences in fetal growth are caused mainly by different
environments."

Dr. Saugstad concludes, "[They] could become a valuable method to identify non-optimum
conditions for the newborn infant. Surveillance of a child's somatic growth against a
reference standard can assess child health and development."

Dr. Saugstad explained that early recognition of deviation from the standard could detect
stunting or overweight at birth, which might also help identify risk for adult disease and/or
obesity.

In 2012, approximately 15% of babies born worldwide (more than 20 million) had low
birthweight (<2500 g). Subsequent complications included impaired immune function, higher
risk for infant and childhood morbidity and mortality, and higher risk for diabetes and
cardiovascular disease in adulthood.

The Bill & Melinda Gates Foundation funded these studies. Dr. Papageorghiou has received
personal fees from Intelligent Ultrasound and nonfinancial support from Philips Ultrasound.
One coauthor has received a subcontract for the INTERGROWTH-21st Project from Oxford
University. Another coauthor has received personal fees from Intelligent Ultrasound and
grants and nonfinancial support from Philips Ultrasound. The other authors have disclosed
no relevant financial relationships.

Lancet. 2014;384:833-835, 857-879. Fetal Growth Longitudinal Study abstract, Newborn

Cross-Sectional Study abstract, Comment extract
http://www.medscape.com/viewarticle/840942

Simple Intervention Reduces Infant

Mortality
Diana Phillips

March 05, 2015

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Editors' Recommendations

 Nepal's Miracle Gel Saves Newborns From Infection

 Chlorhexidine Cleansing of Umbilical Cord

 Antiseptic Reduces Cord Infection and Neonatal Mortality

Related Drugs & Diseases

 Evaluation of Fetal Death

 Use of Vital Statistics in Obstetrics
 Omphalitis

The use of chlorhexidine as a cleansing agent on the skin or umbilical cord stumps of babies
born outside of a hospital is a cost-effective option for reducing the risk for newborn
infection and death, a study has shown. The low-cost broad-spectrum antiseptic agent, which
is active against common organisms causing perinatal infections, could help reduce infant
mortality in developing countries by 12% and reduce omphalitis (umbilical cord stump
infection) by 50%, according to the authors of a systematic literature review published March
4 in the Cochrane Database of Systematic Reviews.

To evaluate the efficacy of neonatal skin or cord care with 4% chlorhexidine vs routine care
or no treatment for the prevention of infections in infants born in hospital and community
settings, Anju Sinha, PhD, from the Division of Reproductive and Child Health, Indian
Council of Medical Research in Ansari Nagar, and colleagues systematically screened the
literature for cluster and individual patient randomized controlled trials, identifying seven
hospital-based and five community-based studies that met the inclusion criteria.

The studies included in the analyses were conducted in low-, middle-, and high-income
countries in Southeast Asia (seven studies), Africa (two studies), Europe (two studies), and
South America (one study) and involved a total of 87,046 neonates and 13,613 pregnant
women, the authors report.

Of the 12 trials, the five carried out in community settings (including home births) involving
72,030 newborns provided the highest-quality evidence, the authors write. Four of the studies
included maternal vaginal wash with chlorhexidine in addition to neonatal skin and cord care.

The results of meta-analyses by setting showed chlorhexidine cord and skin care reduced the
newborn infection rate by 23% in hospital-based studies, reduced neonatal mortality by 12%
in community-based studies, and reduced the incidence of umbilical cord stump infection
(omphalitis) by 52% in the community setting. In the meta-analysis of the studies using
maternal vaginal wash in addition to neonatal skin or cord care, nonsignificant effects on
infection rates were noted.

"Our review findings indicate that there is high-quality evidence that the risk of omphalitis
and neonatal mortality is lower with chlorhexidine intervention compared with usual care in
the community setting," the authors write.

"There is some uncertainty as to the effect of chlorhexidine applied to the umbilical cords of
newborns in hospital settings on neonatal mortality. The quality of evidence for the effects on
infection [is] moderate for cord application and low for application to skin," they add.

Regarding maternal vaginal chlorhexidine compared with usual care, the intervention
"probably leads to no difference in neonatal mortality in hospital settings," they conclude.

Results from ongoing studies in Africa will help substantiate the evidence around
chlorhexidine, according to the authors, who note that additional research is needed to
ascertain optimum frequency of application.

The authors have disclosed no relevant financial relationships.

Cochrane Database Syst Rev. 2015;3:CD007835.

http://emedicine.medscape.com/article/979268-overview

Assisted Ventilation of the Newborn

 Author: Massimo Bellettato, MD; Chief Editor: Ted Rosenkrantz, MD more...

Updated: Jan 28, 2015

 Overview
 Impaired Gas Exchange
 Pulmonary Mechanics
 Physiologic Control of Breathing
 Ventilatory Approaches
 Pathophysiology-Based Ventilatory Strategies
 Ventilatory Strategies for Preventing Lung Injury
 Strategies Based on Alternative Modes of Ventilation
 Benefits and Drawbacks of Specific Ventilatory Strategies
 Show All

Multimedia Library
Tables

References

Overview

This article reviews assisted ventilation of the newborn, highlighting the concepts of
pulmonary mechanics, gas exchange, respiration control, and lung injury that can be used to
enhance conventional mechanical ventilation (CMV) so as to improve survival and reduce
adverse effects. Sound application of these concepts is necessary to optimize mechanical
ventilation.

See the video of assisted ventilation of the newborn, below.

Assisted ventilation newborn –Intubation and meconium aspiration. Video courtesy of Therese
Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.

Hypercapnia is usually caused by severe ventilation/perfusion (V/Q) mismatch or

hypoventilation. Over the past 30-40 years, the availability of improved ventilatory support
has led to a substantial proportion in the survival rate for preterm infants. CMV is being used
on smaller and more ill infants for longer durations.

The primary objective of assisted ventilation is to support breathing until the patient's
respiratory efforts are sufficient. Ventilation may be required during immediate care of the
infant who is depressed or apneic or during prolonged periods of respiratory failure treatment.
Improved survival rates due to advances in neonatal care have resulted in an increased
number of infants at risk for chronic lung disease.
Although the etiology of lung injury is multifactorial, animal and clinical data indicate that
lung injury is affected, in large part, by the ventilatory strategies used. Optimal ventilatory
strategies provide the best possible gas exchange, with minimal or no lung injury or other
adverse effects. The use of pathophysiology-based ventilatory strategies, strategies to prevent
lung injury, and alternative modes of ventilation should yield further improvements in
neonatal outcomes.

Impaired Gas Exchange

Newborns are vulnerable to impaired gas exchange because of their high metabolic rate,
propensity for decreased functional residual capacity (FRC), decreased lung compliance,
increased resistance, and potential for right-to-left shunts through the ductus arteriosus,
foramen ovale, or both. Thus, impaired gas exchange is common in newborns. Hypercapnia
and hypoxemia may coexist, though some disorders may affect gas exchange differentially.

Hypercapnia

Optimal V/Q matching occurs when the ratio of the volume of gas to the volume of blood
entering the lungs approximates 1. Pulmonary venoarterial shunts and alveolar
hypoventilation result in V/Q mismatch, which is probably the most important mechanism of
gas exchange impairment in infants with respiratory failure due to various causes, including
respiratory distress syndrome (RDS). Hypoventilation is frequently seen in infants with apnea
of prematurity.

The effect of assisted ventilation on hypercapnia strongly depends on the mechanism of gas-
exchange impairment. Hypercapnia secondary to severe V/Q mismatch may be treatable with
conventional mechanical ventilation (CMV) or may require high-frequency ventilation
(HFV). Hypercapnia secondary to hypoventilation is usually easily managed with CMV.

Carbon dioxide normally diffuses readily from the blood into the alveoli. Elimination of
carbon dioxide from the alveoli is directly proportional to alveolar minute ventilation (see the
image below), which is determined by the product of tidal volume (minus dead-space
ventilation) and frequency as follows:

Alveolar minute ventilation = (tidal volume – dead space) × frequency

 Relations between ventilator-
controlled variables (shaded circles) and pulmonary mechanics (unshaded circles) that determine
minute ventilation during pressure-limited time-cycled ventilation. Relations between circles joined
by solid lines are described by simple mathematical equations. Dashed lines represent relations that
cannot be calculated precisely without considering other variable such as pulmonary mechanics.
Thus, simple mathematical equations determine time constant of lungs, pressure gradient, and
inspiratory time. In turn, these determine delivered tidal volume, which, when multiplied by the
respiratory frequency, provides minute ventilation. Alveolar ventilation can be calculated from
product of tidal volume and frequency when dead space is subtracted from former. Image adapted
from Chatburn RL, Lough MD.

Tidal volume is the volume of gas inhaled (or exhaled) with each breath; frequency is the
number of breaths per minute; and dead space is the part of the tidal volume not involved in
gas exchange (eg, the volume of the conducting airways) and is relatively constant. Thus,
increases in either tidal volume or frequency increase alveolar ventilation and decrease the
arterial partial pressure of carbon dioxide (Pa CO2).

Because dead-space ventilation is constant, changes in tidal volume appear to be more

effective in altering carbon dioxide elimination than frequency changes are. For example, a
50% increase in tidal volume (eg, 6-9 mL/kg) with a constant dead space (eg, 3 mL/kg)
doubles alveolar ventilation (3-6 mL/kg × frequency). In contrast, a 50% increase in
frequency increases alveolar ventilation by 50% because dead-space ventilation (dead space
× frequency) increases when frequency is increased.

Although increases in minute ventilation achieved via larger tidal volumes are more effective
in increasing alveolar ventilation, the use of relatively small tidal volumes and high
frequencies is usually preferred to minimize volutrauma.

Hypoxemia

Hypoxemia is usually the result of V/Q mismatch or right-to-left shunting, though diffusion
abnormalities and hypoventilation (eg, apnea) may also decrease oxygenation. V/Q mismatch
is a major cause of hypoxemia in infants with RDS and other causes of respiratory failure.
V/Q mismatch is usually caused by poor ventilation of alveoli relative to their perfusion.
Shunting can be intracardiac (eg, congenital cyanotic heart disease), extracardiac (eg,
pulmonary or via a patent ductus arteriosus), or both.

Diffusion abnormalities typical of interstitial lung disease and other diseases that affect the
alveolar-capillary interface are not major mechanisms of severe hypoxemia in neonates.
Hypoventilation usually causes mild hypoxemia unless severe hypercapnia develops.

During CMV, oxygenation (see the image below) is largely determined by the fraction of
inspired oxygen (FI O2) and the mean airway pressure (MAP).

Determinants of oxygenation during

pressure-limited time-cycled ventilation. Shaded circles represent ventilator-controlled variables.
Solid lines represent simple mathematical relations that determine mean airway pressure and
oxygenation, whereas dashed lines represent relations that cannot be quantified in simple
mathematical way. Image adapted from Carlo WA, Greenough A, Chatburn RL.

MAP is the average airway pressure during the respiratory cycle and can be calculated by
dividing the area under the airway pressure curve by the duration of the cycle. The formula
includes the constant determined by the flow rate and the rate of rise of the airway pressure
curve (K), peak inspiratory pressure (PIP), positive end-expiratory pressure (PEEP),
inspiratory time (TI), and expiratory time (TE), as follows:

Table. MAP (Open Table in a new window)

TI

MAP = K (PIP – PEEP) + PEEP

--------
 TI + T E

This equation indicates that MAP increases with increasing PIP, PEEP, ratio of TI to TI + TE,
and flow (which increases K by creating a squarer waveform).

The mechanism by which increases in MAP generally improve oxygenation appears to

involve increased lung volume and improved V/Q matching. Although a direct relation
between MAP and oxygenation is observed, some exceptions are found. For the same change
in MAP, increases in PIP and PEEP enhance oxygenation more than changes in the ratio of TI
to TE (I:E ratio).

Increases in PEEP are not as effective once optimal inflation is reached and may not improve
oxygenation at all. In fact, an excessive MAP may cause overdistention of alveoli, leading to
air trapping and right-to-left shunting of blood in the lungs.

If a very high MAP is transmitted to the intrathoracic structures, as may occur when lung
compliance is near normal, cardiac output may decrease; thus, even with adequate
oxygenation of blood, systemic oxygen transport (arterial oxygen content × cardiac output)
may decrease.

Unlike other causes of hypoxemia, shunting is usually unresponsive to oxygen

supplementation. Hypoxemia due to V/Q mismatch can be difficult to manage but may be
resolved if an increase in airway pressure reexpands atelectatic alveoli. Hypoxemia due to
impaired diffusion or hypoventilation usually responds to oxygen supplementation and
assisted ventilation.

Blood oxygen content largely depends on oxygen saturation and hemoglobin level.
Accordingly, it is common practice to give packed red blood cells (RBCs) to infants with
anemia (hemoglobin level < 7-10 mg/dL) who are receiving assisted ventilation. Oxygen
delivery also depends on oxygen unloading at the tissue level, which is strongly determined
by the oxygen dissociation curve. Acidosis, increases in 2,3-diphosphoglycerate, and adult
hemoglobin levels reduce oxygen affinity to hemoglobin and, thus, favor oxygen delivery to
the tissues.

Pulmonary Mechanics

The interaction between the ventilator and the infant largely depends on the mechanical
properties of the respiratory system.

Pressure gradient

A pressure gradient between the airway opening and the alveoli must be present to drive the
flow of gases during both inspiration and expiration. The necessary pressure gradient can be
calculated from the following equation:
Pressure = volume compliance + resistance × flow

Compliance

Compliance describes the elasticity or distensibility of the respiratory structures (eg, alveoli,
chest wall, and pulmonary parenchyma) and is calculated from the change in volume per unit
change in pressure as follows:

Compliance = Δvolume/Δpressure

Thus, the higher the compliance, the larger the delivered volume per unit change in pressure.
Normally, the chest wall is compliant in newborns and does not impose a substantial elastic
load as compared with the lungs. The range of total respiratory system compliance (lungs +
chest wall) in newborns with healthy lungs is 0.003-0.006 L/cm H2 O, whereas compliance in
babies with respiratory distress syndrome (RDS) may be as low as 0.0005-0.001 L/cm H2 O.

Resistance

Resistance describes the inherent capacity of the air conducting system (eg, airways,
endotracheal tube [ETT]) and tissues) to oppose airflow. It is expressed as the change in
pressure per unit change in flow as follows:

Resistance = Δpressure/Δflow

Airway resistance depends on the following 4 variables:

 Radii of the airways (total cross-sectional area)

 Lengths of the airways
 Flow rate
 Density and viscosity of gas

Unless bronchospasm, mucosal edema, or interstitial edema decrease their lumina, distal
airways normally contribute less than proximal airways to airway resistance because of their
larger cross-sectional area. Small ETTs that may contribute significantly to airway resistance
are also important, especially when high flow rates that may lead to turbulent flow are used.
The range of values for total airway plus tissue respiratory resistance for healthy newborns is
20-40 cm H2 O/L/s; in intubated newborns, this range is 50-150 cm H2 O/L/s.

Time constant

Compliance and resistance can be used to describe the time necessary for an instantaneous or
step change in airway pressure to equilibrate throughout the lungs. The time constant of the
respiratory system is a measure of the time necessary for the alveolar pressure to reach 63%
of the change in airway pressure, which can be calculated as follows:

Time constant = resistance × compliance

Thus, the time constant of the respiratory system is proportional to compliance and
resistance. For example, the lungs of a healthy newborn with a compliance of 0.004 L/cm H2
O and a resistance of 30 cm H2 O/L/s have a time constant of 0.12 seconds. When a longer
time is allowed for equilibration, a higher percentage of airway pressure equilibrates
throughout the lungs. The longer the duration of the inspiratory (or expiratory) time allowed
for equilibration, the higher the percentage of equilibration.

For practical purposes, delivery of pressure and volume is complete (95-99%) after 3-5 time
constants. A time constant of 0.12 seconds indicates a need for an inspiratory or expiratory
phase of 0.36-0.6 seconds. In contrast, lungs with decreased compliance (eg, in RDS) have
shorter time constants. Lungs with shorter time constants complete inflation and deflation
faster than normal lungs do.

The clinical application of the concept of time constant is clear: Very short inspiratory times
may lead to incomplete delivery of tidal volume, resulting in lower peak inspiratory pressure
(PIP) and mean arterial pressure (MAP) and leading to hypercapnia and hypoxemia (see the
image below).

Effects of incomplete inspiration (A) or

incomplete expiration (B) on gas exchange. Incomplete inspiration leads to decreases in tidal volume
and mean airway pressure. Hypercapnia and hypoxemia may result. Incomplete expiration may lead
to decreases in compliance and tidal volume and increase in mean airway pressure. Hypercapnia
with decrease in arterial oxygen tension may result. However, gas trapping and its resulting increase
in mean airway pressure may decrease venous return, decreasing cardiac output and impairing
oxygen delivery. Image adapted from Carlo WA, Greenough A, Chatburn RL.

Similarly, insufficient expiratory time may lead to increases in FRC and inadvertent PEEP,
which is evidence of gas trapping.

Gas trapping

A short expiratory time, a prolonged time constant, or an elevated tidal volume can result in
gas trapping. Gas trapping may decrease compliance and impair cardiac output. Gas trapping
during mechanical ventilation may manifest as decreased tidal volume, CO2 retention, or lung
hyperexpansion. Although arterial partial pressure of oxygen (Pa O2) may be adequate during
gas trapping, venous return to the heart and cardiac output may be impaired; thus, oxygen
delivery can be decreased.

Clinical situations that may suggest the presence of gas trapping include the following:

 Use of a short expiratory time (eg, high ventilatory rates)

 A prolonged time constant (eg, high resistance)
 Lung overexpansion on radiography
 Decreased thoracic movement despite high PIP
 Impaired cardiovascular function (ie, increased central venous pressure, decreased systemic
blood pressure, metabolic acidosis, peripheral edema, decreased urinary output)

Values of compliance and resistance differ throughout inspiration and expiration; thus, a
single time constant cannot be assumed. Furthermore, with heterogeneous lung diseases such
as bronchopulmonary dysplasia (BPD), different lung regions may have different time
constants because of varying compliances and resistances, and these differences partly
account for the coexistence of atelectasis and hyperexpansion.

Chest wall motion

A technique to estimate the time constant that may be helpful in everyday clinical practice is
the use of chest wall motion as a semiquantitative estimate of tidal volume. At the bedside,
chest wall motion can be measured with appropriately placed heart rate/respiration leads such
as are used for routine clinical monitoring (see the image below). Careful visual assessment
of chest wall motion can also suffice.

Estimation of optimal inspiratory

and expiratory times on basis of chest wall motion. Image adapted from Ambalavanan N, Carlo WA.

The shape of the inspiratory and expiratory phases can be analyzed. A rapid rise in
inspiratory chest wall motion (or volume) with a plateau indicates complete inspiration. A
rise without a plateau indicates incomplete inspiration. In this situation, prolongation of the
inspiratory time results in more inspiratory chest wall motion and tidal volume delivery. An
inspiratory plateau indicates that inspiratory time may be too long; shortening inspiratory
time does not decrease inspiratory chest wall motion or tidal volume delivery and does not
eliminate the plateau.

A short expiratory time leads to gas trapping. If gas trapping results from a short expiratory
time, lengthening expiration improves ventilation. However, a very prolonged expiratory
time does not improve ventilation. Indeed, in the absence of gas trapping, shortening
expiratory time allows the provision of more breaths per minute, which improves ventilation.

Physiologic Control of Breathing

For a better understanding of the interaction between the ventilator and the baby's respiratory
system, it is a necessary to consider certain important physiologic aspects of the control of
breathing. The respiratory drive is servocontrolled by the brain. This serves to minimize
variations in arterial blood gas values and pH despite physiologic changes in the efficiency of
gas exchange and moment-to-moment differences in oxygen consumption and carbon dioxide
production.

Ventilation is maintained by intrinsic fine adjustments in tidal volume and respiratory rate
that minimize the work of breathing. These adjustments are accomplished by motor neurons
in the central nervous system (CNS) that receive input largely from chemoreceptors and
mechanoreceptors to regulate inspiratory and expiratory muscles. These 2 components of
respiratory control provide feedback to the brain that allows continuous adjustment of
ventilation. Mechanical ventilation results in changes in chemoreceptor and mechanoreceptor
stimulation.

Chemoreceptors

When arterial partial pressure of carbon dioxide (Pa CO2) changes, ventilation is largely
adjusted by the activity of chemoreceptors in the brainstem. An increase in Pa CO2 increases
respiratory drive. Because the chemoreceptors most likely sense the hydrogen ion
concentration (pH), metabolic acidosis and metabolic alkalosis have strong effects on
respiratory drive that are somewhat independent of Pa CO2 values.

Most changes in ventilation and respiratory drive produced by arterial partial pressure of
oxygen (Pa O2) changes depend on the peripheral chemoreceptors, which include the carotid
bodies and, to a lesser extent, the aortic bodies. In newborns, acute hypoxia produces a
transient increase in ventilation that disappears quickly. Moderate or profound respiratory
depression can be observed after a couple of minutes of hypoxia, and this decline in
respiratory drive is an important cause of hypoventilation, apnea, or both.

Mechanoreceptors

Particularly during neonatal life and infancy, it is important also to consider the role of
mechanoreceptors in the regulation of breathing. Stretch receptors in airway smooth muscles
respond to tidal volume changes. For example, immediately after inflation, a brief period of
decreased or absent respiratory effort can be detected. This is called the Hering-Breuer
inflation reflex; it is usually observed in newborns during conventional ventilation, when a
large enough tidal volume is delivered.

The presence of the Hering-Breuer inflation reflex is a clinical indication that a relatively
good tidal volume is delivered, and the reflex is absent if the ventilator tidal volume is very
small (eg, if the endotracheal tube [ETT] becomes plugged). The Hering-Breuer reflex is also
time-related (eg, a longer inspiration tends to stimulate the reflex more). Thus, for the same
tidal volume, a breath with a longer inspiratory time elicits a stronger Hering-Breuer reflex
and a longer respiratory pause.

At slow ventilator rates, large tidal volumes stimulate augmented inspirations (Head's
paradoxical reflex). This reflex demonstrates improved lung compliance, and its occurrence
is increased by methylxanthine administration. This reflex may be one of the mechanisms
through which methylxanthines facilitate weaning from mechanical ventilation.

Mechanoreceptors also are altered by changes in functional residual capacity (FRC). An

increase in FRC leads to a longer expiratory time because the next inspiratory effort is
delayed. High continuous distending pressure (continuous positive airway pressure [CPAP]
or positive end-expiratory pressure [PEEP]) can prolong expiratory time and even decrease
the respiratory rate because of the intercostal phrenic inhibitory and Hering-Breuer reflexes.
During weaning from a ventilator, a high PEEP may decrease the spontaneous respiratory
rate.

Other components of the mechanoreceptor system are the juxtamedullary (J) receptors. These
receptors are located in the interstitium of the alveolar wall and are stimulated by interstitial
edema and fibrosis, as well as by pulmonary capillary engorgement (eg, congestive heart
failure). Stimulation of the J receptors increases respiratory rate and may explain the rapid
shallow breathing frequently observed in patients with these conditions.

Another reflex that affects breathing is the baroreflex. Arterial hypertension can lead to reflex
hypoventilation, apnea, or both through aortic and carotid sinus baroreceptors. Conversely, a
decrease in blood pressure may result in hyperventilation.

Ventilatory Approaches
Continuous positive airway pressure

Continuous positive airway pressure (CPAP) has been an important tool in the treatment of
newborns with respiratory distress syndrome (RDS). The mechanisms by which CPAP
produces its beneficial effects include increased alveolar volumes, alveolar recruitment and
stability, and redistribution of lung water, resulting in an improvement in
ventilation/perfusion (V/Q) matching. However, high CPAP levels may lead to adverse
effects.

The use of CPAP instead of assisted ventilation may be a strategy for minimizing ventilator-
associated lung injury. Several retrospective studies suggest that the decreased need for
ventilator support with the use of CPAP may allow lung inflation to be maintained but may
prevent volutrauma due to alveolar overdistention, atelectasis, or both. However, 3
multicenter randomized controlled trials including a total of 459 preterm infants reported that
prophylactic CPAP did not decrease the incidence or severity of RDS or its complications.[1]
Once the diagnosis of RDS is established, administration of CPAP decreases oxygen
requirements, decreases the need for mechanical ventilation, and may reduce mortality.
However, the incidence of air leaks is increased among infants who receive CPAP.

The optimal time to start CPAP may depend on the severity of RDS. Early CPAP (ie, when
arterial partial pressure of oxygen [Pa O2] is less than 50 mm Hg on a fraction of inspired
oxygen [FI O2] of 0.40 or more) decreases the subsequent need for mechanical ventilation and
duration of ventilatory assistance in newborns with RDS.

Initiate CPAP in newborns with RDS when Pa O2 is less than 50 mm Hg on an FI O2 of 0.40

or more. Studies performed to determine whether CPAP facilitates successful extubation have
not yielded consistent results. CPAP and nasal intermittent mandatory ventilation (compared
with nasal CPAP) reduce extubation failure in small trials and can be an alternative to
reintubation.

Synchronizing ventilatory support during nasal intermittent mandatory ventilation can be

difficult with newer ventilators that rely on inspiratory flow to trigger the ventilator in
relation to inspiratory leak through the nasal prongs. Because the leakage varies, using a fixed
flow level to trigger inspiration is difficult. Nasal intermittent mandatory ventilation is used
in about 50% of English neonatal intensive care units (ICUs).[2] Although isolated
gastrointestinal (GI) problems have been reported, no significant increase in GI side effects
have been noted.

A combination of a sustained inflation and early CPAP may be an effective and potentially
less injurious way of recruiting the lung in very premature neonates at birth. This attempt to
avoid intubation and mechanical ventilation may reduce lung injury and bronchopulmonary
disease (BPD) in preterm infants. Sustained inflation and early nasal CPAP at birth seems
justified in extremely preterm infants at risk for RDS, providing that early surfactant rescue is
given if required.

In a large randomized, controlled study of infants born at 25-28 weeks’ gestation, early nasal
CPAP did not significantly reduce the rate of death or BPD when compared with
intubation.[3] Although the CPAP group had a higher incidence of pneumothorax (9% vs 3%),
fewer infants received oxygen at 28 days (51% vs 63%), and the infants had fewer days of
ventilation.

Only limited data are available regarding the practical aspects of CPAP delivery, including
the best way of providing the positive airway pressure (ie, bubble CPAP, infant flow driver
CPAP, or ventilator CPAP), optimal pressures, need for intermittent breaths, and patient
interfaces. Success with CPAP is likely to be center-dependent.

The optimal method of weaning infants from CPAP is unclear. The 2 most common weaning
methods are (1) reducing pressure and (2) reducing the time spent on CPAP each day. In a
randomized trial, weaning by pressure was shown to be associated with significantly greater
weaning success in infants born at 23-31 weeks' gestation.[4]

A comparison study found that in preterm babies with RDS, bilevel nasal CPAP has
advantages over nasal CPAP.[5] Lista et al reported that babies treated with bilevel nasal
CPAP had better respiratory outcomes, earlier discharge, and the same changes in cytokine
levels.
A study to investigate if postresuscitation care (PRC) is indicated for all infants who receive
positive pressure ventilation (PPV) at birth concludes that neonates who receive PPV at birth
for as little as one minute still need close monitoring as part of their postresuscitation care.[6,
7]

Conventional mechanical ventilation

The ventilator, the blood gas values, the mechanical characteristics of the respiratory system,
and the infant's spontaneous respiratory efforts are interrelated in a complex fashion.
Although attention is often focused on the effect of ventilator setting changes on blood gases,
these changes may also alter pulmonary mechanics either acutely (eg, changes in positive
end-expiratory pressure [PEEP] affect compliance) or chronically (by predisposing to lung
injury). They may also affect spontaneous breathing (eg, high PEEP decreases respiratory
rate).

An understanding of the basic pathophysiology of the underlying respiratory disorder is

therefore essential to optimize the ventilatory strategy. The aim should be to achieve adequate
gas exchange without injuring the lungs; the ultimate goal is a healthy child without chronic
lung disease.

A review of the major ventilatory parameters that can be adjusted on a pressure-limited time-
cycled ventilator (the type of ventilator most commonly used for conventional mechanical
ventilation [CMV]) is useful. These concepts are also applicable to volume ventilators.

Peak inspiratory pressure

Changes in peak inspiratory pressure (PIP) affect both Pa O2, by altering mean arterial
pressure (MAP), and Pa CO2, by affecting tidal volume and thus alveolar ventilation.
Therefore, an increase in PIP improves oxygenation and decreases Pa CO2. Use of a high PIP
may increase the risk of volutrauma with resultant air leaks and BPD; thus, exercise caution
when using high levels of PIP. The level of PIP required in an infant depends largely on the
compliance of the respiratory system.

A useful clinical indicator of adequate PIP is a gentle chest rise with every breath; this should
be little more than the chest expansion with spontaneous breathing. The absence of breath
sounds may indicate inadequate PIP (or a blocked or displaced endotracheal tube [ETT], or
even ventilator malfunction), but their presence is not helpful in determining optimal PIP.
Adventitious sounds (eg, crackles) often indicate disorders of lung parenchyma associated
with poor compliance (requiring higher PIP); wheezes often indicate increased resistance
(affecting the time constant).

Always use the minimum effective PIP. Frequently change PIP in the presence of changing
pulmonary mechanics (eg, after the administration of surfactant in the management of RDS).
Babies with chronic lung disease often have nonhomogeneous lung disease, leading to
varying compliance throughout different regions of the lung and, therefore, differing
requirements for PIP. This partially accounts for the coexistence of atelectasis and
hyperinflation in the same lung.

Positive end-expiratory pressure

Adequate PEEP helps prevent alveolar collapse, maintains lung volume at end-expiration,
and improves V/Q matching. Increases in PEEP usually increase oxygenation associated with
increases in MAP.

However, in infants with RDS, an excessive PEEP may not further improve oxygenation and
may in fact decrease venous return, cardiac output, and oxygen transport. High levels of
PEEP also may decrease pulmonary perfusion by increasing pulmonary vascular resistance.
By reducing the difference between PIP and PEEP, an elevation of PEEP may decrease tidal
volume and increase Pa CO2.

Although both PIP and PEEP increase MAP and may improve oxygenation, they usually
have opposite effects on Pa CO2. Generally, older infants with chronic lung disease tolerate
higher levels of PEEP without carbon dioxide retention and with improvements in
oxygenation. PEEP also has a variable effect on lung compliance and may affect the PIP
required.

With RDS, compliance improves with low levels of PEEP, followed by declining compliance
at higher levels of PEEP. A minimum PEEP of 4-5 cm H2 O is recommended, in that
endotracheal intubation eliminates the active maintenance of functional residual capacity
(FRC) accomplished with vocal cord adduction and closure of the glottis.

Rate

Changes in frequency alter alveolar minute ventilation and thus Pa CO2. Increases in rate
(and, therefore, increases in alveolar minute ventilation) decrease Pa CO2 proportionally;
decreases in rate increase Pa CO2. Frequency changes alone (with a constant inspiratory-to-
expiratory [I:E] ratio) usually do not alter MAP or substantially affect Pa O2. Any changes in
inspiratory time that accompany frequency adjustments may change the airway pressure
waveform and thereby alter MAP and oxygenation.

Generally, a high-rate, low-tidal-volume strategy is preferred. However, if a very short

expiratory time is used, expiration may be incomplete. Gas trapped in the lungs can increase
FRC, decreasing lung compliance. Tidal volume falls as inspiratory time is reduced beyond a
critical level, depending on the time constant. Thus, above a certain rate during pressure-
limited ventilation, minute ventilation is not a linear function of frequency. Alveolar
ventilation may fall with higher rates as tidal volume decreases and approaches the volume of
the anatomic dead space.

Inspiratory and expiratory times

The effects of changes in inspiratory and expiratory times on gas exchange are influenced
strongly by the relations of these times to the inspiratory and expiratory time constants,
respectively. An inspiratory time 3-5 times longer than the time constant of the respiratory
system allows relatively complete inspiration. A long inspiratory time increases the risk of
pneumothorax. Shortening inspiratory time is advantageous during weaning.

In a randomized trial, limitation of inspiratory time to 0.5 second, instead of 1 second,

resulted in a significantly shorter duration of weaning. In contrast, patients with chronic lung
disease may have a prolonged time constant. In these patients, a longer inspiratory time
(closer to 0.8 second) may result in improved tidal volume and better carbon dioxide
elimination.

Inspiratory-to-expiratory ratio

The major effect of an increase in the I:E ratio is an increased MAP and thus improved
oxygenation. However, when corrected for MAP, changes in the I:E ratio are not as effective
in increasing oxygenation as are changes in PIP or PEEP. A reversed (inverse) I:E ratio (ie,
with the inspiratory time longer than the expiratory time) as high as 4:1 has been
demonstrated to be effective in increasing Pa O2; however, adverse effects may occur.

Although it is possible that reversing the I:E ratio might decrease the incidence of BPD, a
large, well-controlled, randomized trial found that reversed I:E ratios only reduced the
duration of a high FI O2 and PEEP exposure and did not yield any differences in morbidity or
mortality. Changes in the I:E ratio usually do not alter tidal volume unless inspiratory and
expiratory times become relatively too short. Thus, carbon dioxide elimination is usually not
altered by changes in the I:E ratio.

Fraction of inspired oxygen

Changes in FI O2 alter alveolar oxygen pressure and thus oxygenation. Because F I O2 and
MAP both determine oxygenation, they can be balanced as follows:

 During increasing support, first increase F I O 2 to approximately 0.6-0.7, when additional

increases in MAP are warranted
 During weaning, first decrease F I O 2 to approximately 0.4-0.7 before reducing MAP;
maintenance of an appropriate MAP may allow a substantial reduction in F I O 2

Reduce MAP before a very low FI O2 is reached because a higher incidence of air leaks has
been observed if the patient is not weaned from distending pressures earlier.

Flow

Although changes in flow have not been well studied in infants, they probably impact arterial
blood gas values minimally as long as a sufficient flow rate is employed. Flow rates of 5-12
L/min are sufficient in most newborns, depending on the mechanical ventilator and ETT
being used. To maintain an adequate tidal volume, high flow rates are needed when
inspiratory time is shortened.

Pathophysiology-Based Ventilatory Strategies

Respiratory distress syndrome

Respiratory distress syndrome (RDS) is characterized by low compliance and low functional
residual capacity (FRC). An optimal conventional ventilation strategy may include
conservative indications for conventional ventilation, the lowest peak inspiratory pressure
(PIP) and tidal volume that will be effective, modest positive end-expiratory pressure (PEEP;
4-5 cm H2 O), permissive hypercapnia (arterial partial pressure of carbon dioxide [Pa CO2]
45-60 mm Hg), judicious use of sedation or paralysis, and aggressive weaning.
Chronic lung disease

Bronchopulmonary disease (BPD) usually has heterogeneous time constants among lung
areas. Resistance may be increased markedly, and frequent exacerbations may occur. A
higher PEEP (4-6 cm H2 O) is often used, and longer inspiratory and expiratory times with
low rates are preferred. Hypercarbia with compensated respiratory acidosis is often tolerated
to prevent lung injury secondary to aggressive mechanical ventilation.

Persistent pulmonary hypertension of the newborn

Persistent pulmonary hypertension of the newborn may be primary or associated with

aspiration syndrome, prolonged intrauterine hypoxia, congenital diaphragmatic hernia, or
other causes. Ventilatory treatment of infants is often controversial and may vary widely from
one center to another.

In general, adjust the fraction of inspired oxygen (FI O2) to maintain the arterial partial
pressure of oxygen (Pa O2) at 80-100 mm Hg to minimize hypoxia-mediated pulmonary
vasoconstriction; adjust ventilatory rates and pressures to maintain an arterial pH of 7.45-7.55
(sometimes combined with bicarbonate infusion).

Take care to keep Pa CO2 from falling below 30 mm Hg; extremely low Pa CO2 values can
cause cerebral vasoconstriction and subsequent neurologic injury. Addition of inhaled nitric
oxide to mechanical ventilation reduces the need for extracorporeal membrane oxygenation.

Ventilatory Strategies for Preventing Lung Injury

There is substantial evidence to suggest that lung injury is partially dependent on the
particular ventilatory strategies used. Ventilator-associated lung injury has traditionally been
believed to result from the use of high pressures (hence the term barotrauma). However,
laboratory-based and clinical research has raised questions about this purported mechanism.

Experimentally, investigators have used high and low volumes and pressures in an attempt to
determine whether volume or pressure is the major culprit responsible for lung injury in the
immature animal. These studies consistently demonstrate that markers of lung injury
(pulmonary edema, epithelial injury, and hyaline membrane formation) are present with the
use of high volumes and low pressures but not with the use of low volumes and high
pressures. Thus, many investigators and clinicians prefer the term volutrauma to the more
classic term barotrauma.

Lung injury is also caused by repeated collapse (atelectasis) and reopening of the alveoli,
which occurs with very low end-expiratory pressures. The heterogeneity of lung tissue
involvement in many respiratory diseases predisposes some parts of the lung to volutrauma.
Oxidant injury may be another serious cause of lung injury. Immature and developing lungs
are particularly susceptible to acquired injury.

The increased risk of impaired cerebral blood flow autoregulation and intracranial
hemorrhage in neonates with hypercapnia is concerning. However, hypercapnic acidosis
increases cerebral oxygen delivery, and the carbon dioxide – induced alterations in cerebral
blood flow appear to be reversible.
A retrospective study of 849 infants who weighted 1250 g or less revealed that severe
hypocapnia, severe hypercapnia, and wide fluctuations in arterial partial pressure of carbon
dioxide (P a CO2) were associated with an increased risk of hemorrhage.[8] The randomized,
controlled trials of permissive hypercapnia in neonates have not reported an increase in
intracranial hemorrhage.[9]

Hypercapnia may play a role in the development of retinopathy of prematurity (ROP) through
retinal vessel vasodilation, increased oxygenation, and subsequent formation of oxygen-
derived free radicals. However, randomized trials in neonates that tested for the presence of
ROP or long-term visual outcomes reported no differences between control groups and
hypercapnia groups.[10]

Permissive hypercapnia

Permissive hypercapnia, or controlled mechanical hypoventilation, is a strategy for the

treatment of patients receiving ventilatory assistance. When using this strategy, prioritize the
prevention or limitation of overventilation rather than the maintenance of normal blood gases
and the high alveolar ventilation that is frequently used. Respiratory acidosis and alveolar
hypoventilation may be an acceptable price for the prevention of pulmonary volutrauma.

Experimental data show that therapeutic hypercapnia reduces lung and brain injury and
attenuates hypoxic brain injury in newborn rats.[11] In preterm lambs, hypercapnia is
associated with improved compliance and lung volume.

A multicenter trial of 841 adult patients with acute respiratory distress syndrome (RDS)
revealed that low tidal volume and hypercapnia yielded a large reduction in mortality (from
40% to 31%) in the gentle ventilation group.

Three trials in preterm infants have attempted to minimize lung injury by tolerating
hypercapnia and reducing tidal volume and minute ventilation. A small pilot randomized trial
revealed that permissive hypercapnia (target P a CO2, 45-55 mm Hg) during the first 4 days in
infants who weighed 601-1250 g resulted in greater number of infants weaned from
mechanical ventilation.[9] A second small trial did not confirm the potential benefits of
permissive hypercapnia.

A multicenter trial of infants weighing less than 1000 g reported that permissive hypercapnia
(target P a CO2, >50 mm Hg) during the first 10 days of life led to a trend toward reduced
bronchopulmonary disease (BPD) or death at a postconceptional age (PCA) of 36 weeks
(68% vs 63%). Furthermore, permissive hypercapnia reduced the severity of BPD, as
evidenced by a decreased need for ventilator support (from 16% to 1%) at 36 weeks' PCA.

Hypercapnia was well tolerated and no apparent side effects were reported in a study of
infants with persistent pulmonary hypertension who were managed with P a CO2 values of up
to 60 mm Hg. In nonrandomized studies, infants with congenital diaphragmatic hernia also
appear to benefit from permissive hypercapnia.[12, 13]

A gentle ventilator strategy consisting of small tidal volumes, higher rates, and permissive
hypercapnia may reduce BPD in very premature infants. However, extreme hypercapnia may
be associated with an increased risk of intracranial hemorrhage.[14] Thus, avoiding large
fluctuations in P a CO 2 values may be imperative. The optimal P a CO 2 goal in clinical
practice has not been determined.

Low-tidal-volume ventilation

Strategies for conventional mechanical ventilation (CMV) in infants should focus on

prevention of overdistention, use of relatively small tidal volumes, maintenance of adequate
functional residual capacity (FRC), and use of sufficient inspiratory and expiratory times.

Because high maximal lung volume appears to correlate best with lung injury, selection of an
appropriate peak inspiratory pressure (PIP) and FRC (or operating lung volume) is critical for
the prevention of lung injury during pressure-limited ventilation. With the recognition that
large tidal volumes lead to lung injury, relatively small tidal volumes are now recommended.

Studies in healthy infants report tidal volume ranges of 5-8 mL/kg, whereas infants with RDS
have tidal volumes of 3-6 mL/kg. In infants with severe pulmonary disease, ventilation with
small tidal volumes may be preferable because lung heterogeneity and unexpanded alveoli
lead to overdistention and injury of the most compliant alveoli if a normal tidal volume is
used. Maintenance of an adequate FRC is also necessary.

Strategies Based on Alternative Modes of Ventilation

Technological advances have resulted in better ventilators and more effective ventilatory
strategies. Patient-triggered ventilation (PTV), synchronized intermittent mandatory
ventilation (SIMV), volume-targeted ventilation, and other newer ventilator modes are
increasingly used in newborns. High-frequency ventilation (HFV) is another mode of
ventilation that may reduce lung injury and may improve pulmonary outcomes, though
available studies fail to demonstrate consistent benefits.

Patient-triggered ventilation

The ventilators most frequently used in newborns are time-triggered at a preset frequency;
however, because of the available bias flow, they also allow the patient to take spontaneous
breaths.

In contrast, PTV (also referred to as assist-control ventilation) uses spontaneous respiratory

effort to trigger the ventilator. During PTV, changes in airway flow or pressure, chest wall or
abdominal movements, or esophageal pressure are used as an indicator of the onset of the
inspiratory effort. Once the ventilator detects inspiratory effort, it delivers a ventilator breath
at predetermined settings (for peak inspiratory pressure [PIP], inspiratory duration, flow).

Although PTV has been observed to yield improved oxygenation, it may occasionally have to
be discontinued in some very immature infants because of weak respiratory efforts. A backup
(control) rate may be used to reduce this problem. Despite the short-term benefit noted, large
randomized, controlled trials report that PTV does not improve long-term outcomes in infants
with respiratory distress syndrome (RDS), though it may reduce the cost of care.[15, 16]

A meta-analysis of randomized trials demonstrated no significant differences between

ventilation modes with respect to the rates of bronchopulmonary disease (BPD), severe
intracranial hemorrhage, air leaks, or death.[17] PTV was associated with a shorter duration of
ventilation, but only in infants recovering from respiratory distress, not in infants in the acute
stages of distress.

Synchronized intermittent mandatory ventilation

SIMV achieves synchrony between the patient and the ventilator breaths. Synchrony easily
occurs in most newborns because strong respiratory reflexes during early life elicit relaxation
of respiratory muscles at the end of lung inflation. Furthermore, inspiratory efforts usually
start when lung volume is decreased at the end of exhalation.

Synchrony may be achieved by nearly matching the ventilator frequency to the spontaneous
respiratory rate or by simply ventilating at relatively high rates (60-120 breaths/min).
Triggering systems can be used to achieve synchronization when synchrony does not occur
with these maneuvers. SIMV is as effective as conventional mechanical ventilation (CMV);
however, no major benefits were observed in a large randomized, controlled trial.

Proportional assist ventilation

Unless they are flow-cycled, both PTV and SIMV are designed to synchronize only the onset
of inspiratory support. In contrast, proportional assist ventilation (PAV) is designed to match
the onset and duration of both inspiratory and expiratory support. Ventilatory support is
provided in proportion to the volume or flow of the spontaneous breath. Thus, the ventilator
can selectively decrease the elastic or resistive work of breathing. The magnitude of the
support can be adjusted according to the patient's needs.

In comparison with CMV and PTV, PAV may reduce ventilatory pressures while maintaining
or improving gas exchange and may have advantages when used as for weaning. Randomized
clinical trials are needed to determine whether PAV has any major advantages over CMV.

Volume-targeted ventilation

Volume-targeted ventilators self-adjust in an attempt to maintain the tidal volume set by the
clinician. This approach may be effective in maintaining tidal volume despite changes in
respiratory mechanics. Modern neonatal ventilators, which have very sensitive and accurate
flow sensors, make adjustments to PIP or inflation time from one inflation to the next in an
effort to deliver the set volume. Although little information is available regarding the optimal
tidal volume for preterm infants, the typical volume target is 4-6 mL/kg.

A meta-analysis of trials in preterm infants reported no differences in mortality between

volume-targeted and pressure-limited groups but found some clinically important benefits of
volume-targeting, including reductions in the duration of intermittent positive pressure
ventilation and the incidence of pneumothorax, and severe intraventricular hemorrhage.[18]

In one randomized study, volume targeting plus SIMV was more effective than SIMV alone
in maintaining a desirable arterial partial pressure of carbon dioxide (Pa CO2) in infants born
at more than 25 weeks' gestation.[19]
Volume-targeted ventilation may be particularly helpful in patients with heterogeneous lung
disease because the differing time constants throughout the lung parenchyma when pressure-
limited ventilation is used may result in suboptimal tidal volume delivery. Low volume-
targeted levels increase the work of breathing during volume-targeted ventilation. During
weaning, a volume-targeted level of 6 mL/kg could be used in place of a lower level to avoid
an increase in the work of breathing.[20]

Tracheal gas insufflation

The added dead space provided by the endotracheal tube (ETT) and the ventilator circuit
connected to the machine contribute to the anatomic dead space, reducing alveolar minute
ventilation and leading to decreased carbon dioxide elimination. In smaller infants or infants
with increasingly severe pulmonary disease, dead space becomes the largest proportion of the
tidal volume.

With tracheal gas insufflation (TGS), gas delivered to the distal part of the ETT during
exhalation washes out this dead space and the accompanying carbon dioxide. TGS results in a
decrease in Pa CO2, PIP, or both. If TGS is proved safe and effective, it may be useful in
reducing tidal volume and the accompanying volutrauma, particularly in very premature
infants and infants with greatly decreased lung compliance.

High-frequency ventilation

HFV may improve blood gas values because in addition to the gas transport by convection,
other mechanisms of gas exchange (variable velocity profiles of gas during inspiration and
exhalation, gas exchange between parallel lung units, and increased turbulence and
diffusion)may become active at high frequencies.

The various forms of HFV have been extensively used in newborns. High-frequency positive-
pressure ventilators use standard ventilators modified with low-compliance tubing and
connectors. Thus, an adequate tidal volume may be delivered despite very short inspiratory
times.

High-frequency jet ventilation (HFJV) is characterized by the delivery of gases from a high-
pressure source through a small-bore injector cannula. The fast flow of gas from the cannula
may produce areas of relative negative pressure that entrain gases from their surroundings.

High-frequency flow interruption (HFFI) also delivers small tidal volumes by interrupting the
flow of the pressure source; however, unlike HFJV, HFFI does not use an injector cannula.

High-frequency oscillatory ventilation (HFOV) delivers very small volumes (even smaller
than the dead space) at extremely high frequencies. HFOV is unique in that exhalation is
generated actively, whereas in other forms of HFV, exhalation is passive.

HFOV, HFFI, and HFJV have been evaluated in many randomized controlled trials,
including trials of more than 3000 preterm infants.[21, 22, 23, 24, 25] Although the trial results have
been heterogeneous, meta-analysis reveals no clear evidence that HFV is superior to
conventional ventilation as the initial mode of ventilatory support. There may be a small
reduction in the rate of chronic lung disease with HFOV, but the effect is inconsistent across
trials and, overall, of borderline significance.[26] Trends toward reductions in mortality and
BPD have been reported, despite a significant increase in air leaks with HFOV.

In addition, trends toward increasing rates of grade 3 and 4 intraventricular hemorrhage and
of periventricular leukomalacia have been seen; however, a subgroup meta-analysis of all
trials using optimized respiratory care, including high use of antenatal steroids, surfactant
replacement, lung volume recruitment, and a high rate of conventional ventilation, yielded
inconsistent results.

The heterogeneity of the results of trials comparing HFV with CMV in preterm infants may
be due to differences in ventilatory strategies. Long-term outcome studies do not show HFV
to have any significant advantages over conventional ventilation. The use of HFJV in preterm
infants with pulmonary interstitial emphysema has led to more frequent and faster resolution
of pulmonary interstitial emphysema but not to reductions in mortality or other adverse
outcomes.

In the United Kingdom Oscillation Study (UKOS), a randomized trial involving a population
of infants born at less than 28 weeks' gestation, the initial mode of ventilation had no impact
on respiratory or neurodevelopmental morbidity at age 2 years.[27] HFOV and CMV appeared
to be equally effective for the early treatment of RDS. Follow-up assessments of UKOS
survivors demonstrated no significant differences in lung function results or in respiratory
outcome at 2 years of corrected age.

Benefits and Drawbacks of Specific Ventilatory Strategies

The benefits of using continuous positive airway pressure (CPAP) or high positive end-
expiratory pressure (PEEP) in infants with respiratory distress syndrome (RDS) are as
follows:

 Increased alveolar volume and functional residual capacity (FRC)

 Alveolar recruitment
 Alveolar stability
 Redistribution of lung water
 Improved ventilation/perfusion (V/Q) matching

The drawbacks of using CPAP or high PEEP in infants with RDS are as follows:

 Increased risk of air leaks

 Overdistention
 Carbon dioxide retention
 Cardiovascular impairment
 Decreased compliance
 Possible increase in pulmonary vascular resistance

The benefits of using a high rate and low tidal volume (low peak inspiratory pressure [PIP])
are as follows:

 Decreased air leaks

 Decreased volutrauma
 Decreased cardiovascular adverse effects
  Decreased risk of pulmonary edema

The drawbacks of using a high rate and low tidal volume (low PIP) are as follows:

 Gas trapping or inadvertent PEEP

 Generalized atelectasis
 Maldistribution of gas
 Increased resistance

The benefits of using a high inspiratory-to-expiratory (I:E) ratio or long inspiratory time are
as follows:

 Increased oxygenation
 Potentially improved gas distribution in lungs with atelectasis

The drawbacks of using a high I:E ratio or long inspiratory time are as follows:

 Gas trapping and inadvertent PEEP

 Increased risk of volutrauma and air leaks
 Impaired venous return
 Increased pulmonary vascular resistance

The benefits of permissive hypercapnia in neonates are as follows:

 Decreased volutrauma and lung injury

 Decreased duration of mechanical ventilation
 Reduced alveolar ventilation
 Reduced side effects of hypocapnia
 Increased oxygen unloading

The drawbacks of permissive hypercapnia in neonates are as follows:

 Cerebral vasodilation
 Hypoxemia
 Hyperkalemia
 Decreased oxygen uptake by hemoglobin
 Increased pulmonary vascular resistance

The benefits of using a short inspiratory time are as follows:

 Faster weaning
 Decreased risk of pneumothorax
 Possibility of using a higher ventilator rate

The drawbacks of using a short inspiratory time are as follows:

 Insufficient tidal volume

 Potential need for high flow rates
http://emedicine.medscape.com/article/2172591-overview

APGAR Score

The Apgar score is used as a part of early assessment of a newborn.[1]

A score of 0, 1, or 2 is assigned to each of the 5 physical signs at 1 and 5 minutes after birth.
The maximum score that can be assigned is 10. Scores ranging from 7-10 are considered
normal. If the 5-minute Apgar score is abnormal (< 7), appropriate measures should be taken.
Apgar scores should be assigned every 5 minutes until the infant is stabilized.

Heart rate

 2 points = ≥100 beats/min

 1 point = < 100 beats/min
 0 points = Absent

Respirations

 2 points = Regular breathing/strong cry

 1 point = Irregular/weak/slow breathing/gasping
 0 points = Absent

Muscle tone and movement

 2 points = Good flexion/action motion

 1 point = Some flexion
 0 points = None/limp

Skin color / oxygenation

 2 points = Body and extremities pink

 1 point = Blue at extremities; pink body
 0 points = Completely blue

Reflex irritability to tactile stimulation

 2 points = Cry/cough/sneeze
 1 point = Grimace/feeble cry when stimulated
 0 points = Silence; no response to stimulation
http://www.medscape.com/viewarticle/824654

Mothers Can Hold Newborns Before

Umbilical Cord Is Clamped: Study
By Kathryn Doyle

May 06, 2014

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NEW YORK (Reuters Health) - Newborn babies don't need to be held down around their
mother's vagina while the last of the placental blood makes its way through the umbilical
cord, according to a new study.

Waiting a couple of minutes after a baby is born to clamp and cut the umbilical cord is
generally considered a good idea, and some authorities have recommended holding the
newborn level with the vagina so gravity can help draw extra blood from the placenta.

But babies held that way didn't seem to get any more placental blood than babies held in their
mother's arms instead, the new study found.

"The fantasy that gravity plays a role was based on very old studies," Dr. Nestor E. Vain told
Reuters Health.

Vain worked on the study at the Foundation for Maternal and Child Health in Buenos Aires,
Argentina.

The uterus continues to contract after the baby is born, and those contractions are what push
blood through the umbilical cord, not gravity, he said.

Between 2011 and 2012, Vain and his team recruited about 400 women in labor at three
hospitals in Argentina. With hospital cooperation, half of their babies were held at the level
of the vagina after birth and the other half were placed on their mother's abdomen or chest for
two minutes before the umbilical cord was clamped.

The babies were weighed immediately after birth and again after the cords were clamped.

Based on their weights, babies in both groups seemed to gain about the same amount of blood
regardless of where they were held, according to results published April 17 in The Lancet. In
the abdomen/chest group, babies gained an average of 53 grams, or about a tenth of a pound,
compared to 56 grams in the vagina-level group.

"At any time during pregnancy in the last trimester, one third of the fetal blood in the baby is
circulating in the placenta, which is where the baby's blood goes to get oxygen and sugar
from the maternal blood and eliminate carbon dioxide like the kidney of an adult," Vain said.

That blood needs to get to the baby before the cord is clamped or cut, he said. Waiting one to
four minutes to clamp decreases the baby's risk of iron-deficiency anemia and
neurodevelopmental problems, which are a concern in Western as well as developing
countries, he said.

"In preterm infants, we know that more blood improves baby's blood pressure, reduces the
need for blood transfusions, reduces the risk for having intracranial bleeding, and helps in the
smooth transition between fetal and neonatal cardiovascular adaptation," said Dr. Tonse N.K.
Raju.

Raju, from the Eunice Kennedy Shriver National Institute of Child Health and Human
Development at the National Institutes of Health in Bethesda, Maryland, wrote an editorial
accompanying the study.

Most doctors know that delaying clamping the cord is important, but recommendations that a
doctor or nurse hold the baby down low for gravity's sake mean it doesn't always happen,
Vain said.

"Two minutes, that's a long time to stay holding a baby who is kicking, screaming and
slippery," he said.

Hopefully delayed cord clamping will happen more often now that researchers know giving
the baby to its mother, which has other benefits, is okay, he said.

"Many studies have shown that infant-and-mother attachment and bonding improves by
direct physical contact soon after birth between mom and her infant," Raju told Reuters
Health in an email. "More importantly, keeping the infant on mom's chest helps the infant to
immediately begin to latch on to mom's nipple, begin sucking, and establish early on a
successful pattern for breastfeeding," he said.

Latching on helps release more of the hormone oxytocin, which can help contract the now-
empty uterus and deliver the placenta, he added.

"Many believe that this is the evolutionary basis for a relatively long umbilical cord," Raju
said. "That is, this enables the mom to grab her newly born baby, put the baby on her chest to
help the baby to begin to suckle, which has a dual advantage of helping the delivery of the
placenta."

SOURCE: http://bit.ly/1juRt2z and http://bit.ly/1kFkS8i

Lancet 2014.