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Al Qurashi M, Al Qahtani A, Al Hindi M, Mustafa A, Ahmed A, Aga SS, Al Khotani A, Kandil H, Alallah J, Sallam A. Ventilation practices in the neonatal intensive care units in Saudi Arabia, survey of the utilization of volume-targeted ventilation among practicing neonatologists. J Neonatal Perinatal Med 2024:NPM240054. [PMID: 38875048 DOI: 10.3233/npm-240054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2024]
Abstract
OBJECTIVE To assess the current practice in using volume-targeted ventilation among neonatologists working at the Neonatal Intensive Care Units (NICU) of Saudi Arabia. METHODS The questionnaire was provided electronically to 153 practicing Neonatologists working in 39 NICUs. The survey's results were received and statistically analyzed. RESULTS One hundred nineteen (119) responses were received with, a 78% response rate. Volume Targeted Ventilation (VTV) was used routinely by 67.2%, whereas 21.8% still use only pressure control (PC)/pressure limited (PL) mode. During the acute phase of ventilation support, Assist Control was the most popular synchronized mode, whereas Synchronized Intermittent Mandatory Ventilation (SIMV) with pressure support (PS) or PSV were the two most common modes during the weaning phase, 31.8%, and 31% respectively. The majority of the neonatologists used a tidal volume of 4 ml/kg as the lowest and 6 ml/kg as the highest. The major reasons for not implementing VTV were the limited availability of ventilator devices that have an option of VTV, followed by lack of experience. CONCLUSION VTV is the predominant ventilation practice approach among neonatologists working in the KSA. Limited availability and lack of experience in using are the main challenges. Efforts to equip NICUs with the most advanced ventilation technology, enhance practitioners' experience and sufficient training in its use are warranted.
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Affiliation(s)
- M Al Qurashi
- Department of Pediatrics, King Abdulaziz Medical City-Jeddah, Ministry of National Guard Health Affairs (MNGHA), Saudi Arabia
- College of Medicine-Jeddah, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), Saudi Arabia
- King Abdullah International Medical Research Centre (KAIMRC), Ministry of National Guard Health Affairs (MNGHA), Saudi Arabia
| | - A Al Qahtani
- College of Medicine-Jeddah, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), Saudi Arabia
- Department of Educational Technology, College of Medicine-Jeddah, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), Saudi Arabia
| | - M Al Hindi
- Department of Pediatrics, King Abdulaziz Medical City-Jeddah, Ministry of National Guard Health Affairs (MNGHA), Saudi Arabia
- College of Medicine-Jeddah, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), Saudi Arabia
- King Abdullah International Medical Research Centre (KAIMRC), Ministry of National Guard Health Affairs (MNGHA), Saudi Arabia
| | - A Mustafa
- Department of Pediatrics, King Abdulaziz Medical City-Jeddah, Ministry of National Guard Health Affairs (MNGHA), Saudi Arabia
- College of Medicine-Jeddah, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), Saudi Arabia
- King Abdullah International Medical Research Centre (KAIMRC), Ministry of National Guard Health Affairs (MNGHA), Saudi Arabia
| | - A Ahmed
- Department of Pediatrics, King Abdulaziz Medical City-Jeddah, Ministry of National Guard Health Affairs (MNGHA), Saudi Arabia
- College of Medicine-Jeddah, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), Saudi Arabia
- King Abdullah International Medical Research Centre (KAIMRC), Ministry of National Guard Health Affairs (MNGHA), Saudi Arabia
| | - S S Aga
- College of Medicine-Jeddah, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), Saudi Arabia
- Department of Basic Medical Sciences, College of Medicine-Jeddah, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), Saudi Arabia
- King Abdullah International Medical Research Centre (KAIMRC), Ministry of National Guard Health Affairs (MNGHA), Saudi Arabia
| | - A Al Khotani
- Department of Pediatrics, College of Medicine, Um Al Qura University, Makkah, Saudi Arabia
| | - H Kandil
- Department of Pediatrics, King Abdulaziz Medical City-Jeddah, Ministry of National Guard Health Affairs (MNGHA), Saudi Arabia
- College of Medicine-Jeddah, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), Saudi Arabia
- King Abdullah International Medical Research Centre (KAIMRC), Ministry of National Guard Health Affairs (MNGHA), Saudi Arabia
| | - J Alallah
- Department of Pediatrics, King Abdulaziz Medical City-Jeddah, Ministry of National Guard Health Affairs (MNGHA), Saudi Arabia
- College of Medicine-Jeddah, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), Saudi Arabia
- King Abdullah International Medical Research Centre (KAIMRC), Ministry of National Guard Health Affairs (MNGHA), Saudi Arabia
| | - A Sallam
- Department of Pediatrics, King Abdulaziz Medical City-Jeddah, Ministry of National Guard Health Affairs (MNGHA), Saudi Arabia
- College of Medicine-Jeddah, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), Saudi Arabia
- King Abdullah International Medical Research Centre (KAIMRC), Ministry of National Guard Health Affairs (MNGHA), Saudi Arabia
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Keszler M, Abubakar MK. Volume-targeted ventilation. Semin Perinatol 2024; 48:151886. [PMID: 38553330 DOI: 10.1016/j.semperi.2024.151886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
Despite strong evidence of important benefits of volume-targeted ventilation, many high-risk extremely preterm infants continue to receive traditional pressure-controlled ventilation in the United States and elesewhere. Reluctance to abandon one's comfort zone, lack of suitable equipment and a lack of understanding of the subtleties of volume-targeted ventilation appear to contribute to the relatively slow uptake of volume-targeted ventilation. This review will underscore the benefits of using tidal volume as the primary control variable, to improve clinicians' understanding of the way volume-targeted ventilation interacts with the awake, breathing infant and to provide information about evidence-based tidal volume targets in various circmstances. Focus on underlying lung pathophysiology, individualized ventilator settings and tidal volume targets are essential to successful use of this approach thereby improving important clinical outcomes.
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Affiliation(s)
- Martin Keszler
- Emeritus Professor of Pediatrics, Alpert Medical School of Brown University, Department of Pediatrics, Women & Infants Hospital of Rhode Island, 101 Dudley Street, Providence RI 02905, USA.
| | - M Kabir Abubakar
- Professor of Clinical Pediatrics, Georgetown University School of Medicine, Chief of Neonatology, MedStar Medical Group, Chief, Division of Neonatal Perinal Medicine, MedStar Georgetown University Hospital, 3800 Reservoir Road, Washington DC, 20007, USA.
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Tang J, Gong L, Xiong T, Chen C, Tian K, Wang A, Huang Y, Liu W, Zhou R, Zhu J, Mu D. Volume-targeted ventilation vs pressure-controlled ventilation for very low birthweight infants: a protocol of a randomized controlled trial. Trials 2023; 24:536. [PMID: 37587501 PMCID: PMC10428577 DOI: 10.1186/s13063-023-07564-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 08/03/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Mechanical ventilation (MV) is essential in the management of critically ill neonates, especially preterm infants. However, inappropriate or prolonged use of invasive MV may result in ventilator-associated lung injury. A systemic review comparing pressure control ventilation (PCV) with volume-targeted ventilation mode (VTV) approved that VTV reduces the incidence of death or bronchopulmonary dysplasia (BPD) in neonates; however, this study did not analyze subgroups of very low birthweight (VLBW) infants. Therefore, the aim of this study was to compare the use of VTV and PCV in VLBW infants and to provide clinical evidence for reducing mortality and complications of MV in VLBW infants. METHOD A single-center randomized controlled trial will be performed. All eligible infants will be randomized and assigned to either VTV or PCV group with 1:1 ratio using sealed envelopes. Death or BPD at 36 weeks' postmenstrual age will be used as the primary outcome. Secondary outcomes include BPD, death, length of invasive MV, noninvasive mechanical ventilation, and oxygen use, length of hospital stay, failure of conventional MV, rate of using high-frequency oscillatory ventilation (HFOV) as rescue therapy, rate of reintubation within 48 h, and hospital expenses. DISCUSSION Systemic review suggested that VTV decreases the incidence of death or BPD in neonates compared to PLV; however, this study did not specifically analyze subgroups of VLBW infants. We designed this single-center randomized controlled trials (RCT) to add a significant contribution regarding the benefits of VTV for VLBW patients.
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Affiliation(s)
- Jun Tang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Renmin South Road #16, Wuhou District, Chengdu, China
| | - Lingyue Gong
- West China Second University Hospital, Sichuan University, Renmin South Road #20, Wuhou District, Chengdu, China
| | - Tao Xiong
- West China Second University Hospital, Sichuan University, Renmin South Road #20, Wuhou District, Chengdu, China
| | - Chao Chen
- West China Second University Hospital, Sichuan University, Renmin South Road #20, Wuhou District, Chengdu, China
| | - Ke Tian
- West China Second University Hospital, Sichuan University, Renmin South Road #20, Wuhou District, Chengdu, China
| | - Aoyu Wang
- West China Second University Hospital, Sichuan University, Renmin South Road #20, Wuhou District, Chengdu, China
| | - Yi Huang
- West China Second University Hospital, Sichuan University, Renmin South Road #20, Wuhou District, Chengdu, China
| | - Wenli Liu
- West China Second University Hospital, Sichuan University, Renmin South Road #20, Wuhou District, Chengdu, China
| | - Rong Zhou
- West China Second University Hospital, Sichuan University, Renmin South Road #20, Wuhou District, Chengdu, China
| | - Jun Zhu
- West China Second University Hospital, Sichuan University, Renmin South Road #20, Wuhou District, Chengdu, China
| | - Dezhi Mu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Renmin South Road #16, Wuhou District, Chengdu, China
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Ganguly A, Makkar A, Sekar K. Volume Targeted Ventilation and High Frequency Ventilation as the Primary Modes of Respiratory Support for ELBW Babies: What Does the Evidence Say? Front Pediatr 2020; 8:27. [PMID: 32117833 PMCID: PMC7025474 DOI: 10.3389/fped.2020.00027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 01/20/2020] [Indexed: 12/01/2022] Open
Abstract
Respiratory management of the extremely low birth weight (ELBW) newborn has evolved over time. Although non-invasive ventilation is being increasingly used for respiratory support in these ELBW infants, invasive ventilation still remains the primary mode in this population. Current ventilators are microprocessor driven and have revolutionized the respiratory support for these neonates synchronizing the baby's breath to ventilator breaths. High frequency ventilators with the delivery of tidal volumes less than the dead space have been introduced to minimize barotrauma and chronic lung disease. Despite these advances, the incidence of chronic lung disease has not decreased. There is still controversy regarding which mode is ideal as the primary mode of ventilation in ELBW infants. The most common modes seem to be pressure targeted conventional ventilation, volume targeted conventional ventilation and high frequency ventilation which includes high frequency oscillatory ventilation, high frequency jet ventilation and high frequency flow interrupter. In recent years, several randomized controlled trials and meta-analyses have compared volume vs. pressure targeted ventilation and high frequency ventilation. While volume targeted ventilation and high frequency ventilation does show promise, substantial practice variability among different centers persists. In this review, we weighed the evidence for each mode and evaluated which modes show promise as the primary support of ventilation in ELBW babies.
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Affiliation(s)
- Abhrajit Ganguly
- Section of Neonatal-Perinatal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Abhishek Makkar
- Section of Neonatal-Perinatal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Krishnamurthy Sekar
- Section of Neonatal-Perinatal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
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Ventilating on the Go: Do We Know What Is Best? Pediatr Crit Care Med 2019; 20:1194-1195. [PMID: 31804440 DOI: 10.1097/pcc.0000000000002146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Wong S, Wang H, Tepper R, Sokol GM, Rose R. Expired Tidal Volume Variation in Extremely Low Birth Weight and Very Low Birth Weight Infants on Volume-Targeted Ventilation. J Pediatr 2019; 207:248-251.e1. [PMID: 30770195 DOI: 10.1016/j.jpeds.2018.12.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 10/12/2018] [Accepted: 12/21/2018] [Indexed: 10/27/2022]
Abstract
In a prospective study we describe the delivery of small tidal volumes to extremely low birth weight (ELBW) and very low birth weight (VLBW) infants using a volume-targeted ventilation mode (VTV). Tidal volume delivery was consistent for both ELBW and VLBW infants independent of gestational age, birth weight, and the target volume.
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Affiliation(s)
- Samuel Wong
- Section of Neonatology, Indiana University, Indianapolis, Indiana.
| | - Honglang Wang
- Department of Mathematical Sciences, Indiana University-Purdue University, Indianapolis, Indiana
| | - Robert Tepper
- Wells Center for Pediatric Research, Indiana University, Indianapolis, Indiana
| | - Gregory M Sokol
- Section of Neonatology, Indiana University, Indianapolis, Indiana
| | - Rebecca Rose
- Section of Neonatology, Indiana University, Indianapolis, Indiana
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Keszler M. Volume-targeted ventilation: one size does not fit all. Evidence-based recommendations for successful use. Arch Dis Child Fetal Neonatal Ed 2019; 104:F108-F112. [PMID: 30068668 DOI: 10.1136/archdischild-2017-314734] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/03/2018] [Accepted: 07/04/2018] [Indexed: 12/14/2022]
Abstract
Despite level 1 evidence for important benefits of volume-targeted ventilation (VTV), many vulnerable extremely preterm infants continue to be exposed to traditional pressure-controlled ventilation. Lack of suitable equipment and a lack of appreciation of the fact that 'one size does NOT fit all' appear to contribute to the slow uptake of VTV. This review attempts to improve clinicians' understanding of the way VTV works and to provide essential information about evidence-based tidal volume (VT) targets. Focus on underlying lung pathophysiology, individualised ventilator settings and VTtargets are keys to successful use of VTV thereby improving important clinical outcomes.
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Affiliation(s)
- Martin Keszler
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Providence, RI 02905, USA
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Hunt K, Dassios T, Ali K, Greenough A. Volume targeting levels and work of breathing in infants with evolving or established bronchopulmonary dysplasia. Arch Dis Child Fetal Neonatal Ed 2019; 104:F46-F49. [PMID: 29305407 DOI: 10.1136/archdischild-2017-314308] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 12/11/2017] [Accepted: 12/13/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To assess the work of breathing at different levels of volume targeting in prematurely born infants with evolving or established bronchopulmonary dysplasia (BPD). DESIGN Randomised crossover study. SETTING Tertiary neonatal intensive care unit. PATIENTS Eighteen infants born at <32 weeks gestation who remained ventilated at or beyond 1 week after birth, that is, they had evolving or established BPD. INTERVENTIONS Infants received ventilation at volume targeting levels of 4, 5, 6 and 7 mL/kg each for 20 minutes, the levels were delivered in random order. Baseline ventilation (without volume targeting) was delivered for 20 minutes between each epoch of volume-targeting. MAIN OUTCOME MEASURES Pressure-time product of the diaphragm (PTPdi), a measure of the work of breathing, at different levels of volume targeting. RESULTS The 18 infants had a median gestational age of 26 (range 24-30) weeks and were studied at a median of 18 (range 7-60) days. The mean PTPdi was higher at 4 mL/kg than at baseline, 5 mL/kg, 6 mL/kg and 7 mL/kg (all P≤0.001). The mean PTPdi was higher at 5 mL/kg than at 6 mL/kg (P=0.008) and 7 mL/kg (P<0.001) and higher at 6 mL/kg than 7 mL/kg (P=0.003). Only at 7 mL/kg was the PTPdi significantly lower than at baseline (P=0.001). CONCLUSIONS Only a tidal volume target of 7 mL/kg reduced the work of breathing below the baseline and may be more appropriate for infants with evolving or established BPD who remained ventilator dependent at or beyond 7 days of age.
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Affiliation(s)
- Katie Hunt
- MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK.,Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Theodore Dassios
- Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Kamal Ali
- Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK.,Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
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Klingenberg C, Wheeler KI, McCallion N, Morley CJ, Davis PG. Volume-targeted versus pressure-limited ventilation in neonates. Cochrane Database Syst Rev 2017; 10:CD003666. [PMID: 29039883 PMCID: PMC6485452 DOI: 10.1002/14651858.cd003666.pub4] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Damage caused by lung overdistension (volutrauma) has been implicated in the development of bronchopulmonary dysplasia (BPD). Modern neonatal ventilation modes can target a set tidal volume as an alternative to traditional pressure-limited ventilation (PLV) using a fixed inflation pressure. Volume-targeted ventilation (VTV) aims to produce a more stable tidal volume in order to reduce lung damage and stabilise the partial pressure of carbon dioxide (pCO2). OBJECTIVES To determine whether VTV compared with PLV leads to reduced rates of death and death or BPD in newborn infants and to determine whether use of VTV affected outcomes including air leak, cranial ultrasound findings and neurodevelopment. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 12), MEDLINE via PubMed (1966 to 13 January 2017), Embase (1980 to 13 January 2017) and CINAHL (1982 to 13 January 2017). We also searched clinical trials databases, conference proceedings and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. We contacted the principal investigators of studies to obtain supplementary information. SELECTION CRITERIA Randomised and quasi-randomised trials comparing VTV versus PLV in infants of less than 44 weeks' postmenstrual age and reporting clinically relevant outcomes. DATA COLLECTION AND ANALYSIS We assessed risk of bias for each trial using Cochrane methodology. We evaluated quality of evidence for each outcome using GRADE criteria. We tabulated mortality, rates of BPD, short-term clinical outcomes and long-term developmental outcomes. STATISTICS for categorical outcomes, we calculated typical estimates for risk ratios (RR), risk differences (RD) and number needed to treat for an additional beneficial outcome (NNTB). For continuous variables, we calculated typical estimates for mean differences (MD). We used 95% confidence intervals (CI) and assumed a fixed-effect model for meta-analysis. MAIN RESULTS Twenty randomised trials met our inclusion criteria; 16 parallel trials (977 infants) and four cross-over trials (88 infants). No studies were blinded and the quality of evidence for outcomes assessed varied from moderate to low.We found no difference in the primary outcome, death before hospital discharge, between VTV modes versus PLV modes (typical RR 0.75, 95% CI 0.53 to 1.07; low quality evidence). However, there was moderate quality evidence that the use of VTV modes resulted in a reduction in the primary outcome, death or BPD at 36 weeks' gestation (typical RR 0.73, 95% CI 0.59 to 0.89; typical NNTB 8, 95% CI 5 to 20) and the following secondary outcomes: rates of pneumothorax (typical RR 0.52, 95% CI 0.31 to 0.87; typical NNTB 20, 95% CI 11 to 100), mean days of mechanical ventilation (MD -1.35 days, 95% CI -1.83 to -0.86), rates of hypocarbia (typical RR 0.49, 95% CI 0.33 to 0.72; typical NNTB 3, 95% CI 2 to 5), rates of grade 3 or 4 intraventricular haemorrhage (typical RR 0.53, 95% CI 0.37 to 0.77; typical NNTB 11, 95% CI 7 to 25) and the combined outcome of periventricular leukomalacia with or without grade 3 or 4 intraventricular haemorrhage (typical RR 0.47, 95% CI 0.27 to 0.80; typical NNTB 11, 95% CI 7 to 33). VTV modes were not associated with any increased adverse outcomes. AUTHORS' CONCLUSIONS Infants ventilated using VTV modes had reduced rates of death or BPD, pneumothoraces, hypocarbia, severe cranial ultrasound pathologies and duration of ventilation compared with infants ventilated using PLV modes. Further studies are needed to identify whether VTV modes improve neurodevelopmental outcomes and to compare and refine VTV strategies.
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Affiliation(s)
- Claus Klingenberg
- University Hospital of North NorwayDepartment of PediatricsTromsøNorwayN‐9038
- UiT The Arctic University of NorwayPaediatric Research GroupTromsøNorway
| | - Kevin I Wheeler
- Royal Children's Hospital MelbourneDepartment of Neonatology50 Flemington RoadParkville, MelbourneVictoriaAustralia3052
- Murdoch Childrens Research InstituteParkvilleVictoriaAustralia
| | - Naomi McCallion
- Rotunda HospitalDepartment of PaediatricsParnell SquareDublinIreland
- Royal College of Surgeons in IrelandDepartment of PaediatricsDublin 2Ireland
| | - Colin J Morley
- University of CambridgeDepartment of Obstetrics and GynecologyCambridgeUK
| | - Peter G Davis
- The Royal Women's HospitalNewborn Research Centre and Neonatal ServicesMelbourneAustralia
- Murdoch Childrens Research InstituteMelbourneAustralia
- University of MelbourneDepartment of Obstetrics and GynecologyMelbourneAustralia
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Reiterer F, Schwaberger B, Freidl T, Schmölzer G, Pichler G, Urlesberger B. Lung-protective ventilatory strategies in intubated preterm neonates with RDS. Paediatr Respir Rev 2017; 23:89-96. [PMID: 27876355 DOI: 10.1016/j.prrv.2016.10.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 10/20/2016] [Indexed: 11/16/2022]
Abstract
This article provides a narrative review of lung-protective ventilatory strategies (LPVS) in intubated preterm infants with RDS. A description of strategies is followed by results on short-and long-term respiratory and neurodevelopmental outcomes. Strategies will include patient-triggered or synchronized ventilation, volume targeted ventilation, the technique of intubation, surfactant administration and rapid extubation to NCPAP (INSURE), the open lung concept, strategies of high-frequency ventilation, and permissive hypercapnia. Based on this review single recommendations on optimal LPVS cannot be made. Combinations of several strategies, individually applied, most probably minimize or avoid potential serious respiratory and cerebral complications like bronchopulmonary dysplasia and cerebral palsy.
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Affiliation(s)
- F Reiterer
- Division of Neonatology, Department of Pediatrics and Adolescence Medicine, Medical University Graz, Austria.
| | - B Schwaberger
- Division of Neonatology, Department of Pediatrics and Adolescence Medicine, Medical University Graz, Austria
| | - T Freidl
- Division of Neonatology, Department of Pediatrics and Adolescence Medicine, Medical University Graz, Austria
| | - G Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada; Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - G Pichler
- Division of Neonatology, Department of Pediatrics and Adolescence Medicine, Medical University Graz, Austria
| | - B Urlesberger
- Division of Neonatology, Department of Pediatrics and Adolescence Medicine, Medical University Graz, Austria
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11
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Owen LS, Manley BJ, Davis PG, Doyle LW. The evolution of modern respiratory care for preterm infants. Lancet 2017; 389:1649-1659. [PMID: 28443559 DOI: 10.1016/s0140-6736(17)30312-4] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 11/27/2016] [Accepted: 12/19/2016] [Indexed: 10/19/2022]
Abstract
Preterm birth rates are rising, and many preterm infants have breathing difficulty after birth. Treatments for infants with prolonged breathing difficulty include oxygen therapy, exogenous surfactant, various modes of respiratory support, and postnatal corticosteroids. In this Series paper, we review the history of neonatal respiratory care and its effect on long-term outcomes, and we outline the future direction of the research field. The delivery and monitoring of oxygen therapy remains controversial, despite being in use for more than 50 years. Exogenous surfactant replacement has been used for 25 years and has dramatically reduced mortality and morbidity, but more research on when and how it is administered is needed. Methods and techniques of neonatal respiratory support are evolving. Clinicians are moving away from routine intubation and ventilation, and new modes of non-invasive support are being investigated. Postnatal corticosteroids have a limited role in infants with evolving bronchopulmonary dysplasia, but more research is needed to identify the best timing, type, dose, and method of administration. Despite advances in neonatal care in the past 50 years, bronchopulmonary dysplasia, with all its adverse short-term and long-term consequences, is still a serious problem in neonatal care. The challenge remains to support breathing in preterm infants, with special attention to risk factors in the subpopulation of infants that are at highest risk of bronchopulmonary dysplasia, without damaging their lungs or adversely affecting their long-term health.
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Affiliation(s)
- Louise S Owen
- Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia; Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia.
| | - Brett J Manley
- Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia; Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia
| | - Peter G Davis
- Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia; Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Lex W Doyle
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
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12
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Hurley EH, Keszler M. Effect of inspiratory flow rate on the efficiency of carbon dioxide removal at tidal volumes below instrumental dead space. Arch Dis Child Fetal Neonatal Ed 2017; 102:F126-F130. [PMID: 27515984 DOI: 10.1136/archdischild-2015-309636] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 05/12/2016] [Accepted: 06/14/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The ability to ventilate babies with tidal volumes (VTs) below dead space has been demonstrated both in vivo and in vitro, though it appears to violate classical respiratory physiology. We hypothesised that this phenomenon is made possible by rapid flow of gas that penetrates the dead space allowing fresh gas to reach the lungs and that the magnitude of this phenomenon is affected by flow rate or how rapidly air flows through the endotracheal tube. METHODS We conducted two bench experiments. First, we measured the time needed for complete CO2 washout from a test lung to assess how fixed VT but different inflation flow rates affect ventilation. For the second experiment, we infused carbon dioxide at a low rate into the test lung, varied the inflation flow rate and adjusted the VT to maintain stable end tidal carbon dioxide (ETCO2). RESULTS At all tested VTs, lower flow rate increased the time it took for CO2 to washout from the test lung. The effect was most pronounced for VTs below dead space. The CO2 steady-state experiment showed that ETCO2 increased when the flow rate decreased. Ventilating with a slower flow rate required a nearly 20% increase in VT for the same effective alveolar ventilation. CONCLUSIONS Inflation flow rate affects the efficiency of CO2 removal with low VT. Our results are relevant for providers using volume-controlled ventilation or other modes that use low inflation flow rates because the VT required for normocapnia will be higher than published values that were generated using pressure-limited ventilation modes with high inflation flows.
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Affiliation(s)
- Edward H Hurley
- Department of Pediatrics, Women and Infants, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Martin Keszler
- Department of Pediatrics, Women and Infants, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Jain D, Claure N, D'Ugard C, Bello J, Bancalari E. Volume Guarantee Ventilation: Effect on Preterm Infants with Frequent Hypoxemia Episodes. Neonatology 2016; 110:129-34. [PMID: 27088487 DOI: 10.1159/000444844] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 02/18/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Preterm infants on mechanical ventilation have spontaneous hypoxemia episodes (HE) triggered by decreases in lung volume and tidal volume (VT). Volume guarantee (VG) is a mode where the ventilator peak pressure is adjusted to keep the exhaled VT at a target level. The effect of VG on HE under routine clinical conditions has not been fully evaluated. OBJECTIVE To evaluate the effect of VG on HE in preterm infants in comparison to pressure control (PC) ventilation under routine clinical conditions. METHODS Twenty-four mechanically ventilated preterm infants with ≥4 HE of arterial oxygen saturation (SpO2) <75% over 8 h were enrolled. They were studied over 2 consecutive 24-hour periods of VG and PC, in random order. RESULTS While the frequency of HE (SpO2 <85% for ≥20 s) did not differ, their duration was reduced during VG. The frequency or duration of severe HE (SpO2 <75% for ≥20 s) did not differ between PC and VG. The proportion of time in severe hypoxemia (SpO2 <75%) during VG did not differ from PC [median: 4.4 (IQR 2.9-5.0) vs. 5.0% (IQR 3.9-6.9), p = 0.44]. The fraction of inspired oxygen (FiO2) was lower during VG compared to PC. CONCLUSION The use of VG during routine clinical conditions resulted in a modest reduction in the duration of HE (SpO2 <85%) and FiO2 compared to PC. The use of VG did not reduce the more severe HE.
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Affiliation(s)
- Deepak Jain
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Fla., USA
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14
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Shalish W, Anna GMS. The use of mechanical ventilation protocols in Canadian neonatal intensive care units. Paediatr Child Health 2015; 20:e13-9. [PMID: 26038643 DOI: 10.1093/pch/20.4.e13] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2015] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To identify the proportion of Canadian neonatal intensive care units with existing mechanical ventilation protocols and to determine the characteristics and respiratory care practices of units that have adopted such protocols. METHODS A structured survey including 36 questions about mechanical ventilation protocols and respiratory care practices was mailed to the medical directors of all tertiary care neonatal units in Canada and circulated between December 2012 and March 2013. RESULTS Twenty-four of 32 units responded to the survey (75%). Of the respondents, 91% were medical directors and 71% worked in university hospitals. Nine units (38%) had at least one type of mechanical ventilation protocol, most commonly for the acute and weaning phases. Units with pre-existing protocols were more commonly university-affiliated and had higher ratios of ventilated patients to physicians or respiratory therapists, although this did not reach statistical significance. The presence of a mechanical ventilation protocol was highly correlated with the coexistence of a protocol for noninvasive ventilation (P<0.001, OR 4.5 [95% CI 1.3 to 15.3]). There were overall wide variations in ventilation practices across units. However, units with mechanical ventilation protocols were significantly more likely to extubate neonates from the assist control mode (P=0.039, OR 8.25 [95% CI 1.2 to 59]). CONCLUSION Despite the lack of compelling evidence to support their use in neonates, a considerable number of Canadian neonatal intensive care units have adopted mechanical ventilation protocols. More research is needed to better understand their role in reducing unnecessary variations in practice and improving short- and long-term outcomes.
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Affiliation(s)
- Wissam Shalish
- Division of Neonatology, Montreal Children's Hospital, McGill University, Montreal, Quebec
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15
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Abstract
Neonatal ventilation is an integral component of care delivered in the neonatal unit. The aim of any ventilation strategy is to support the neonate's respiratory system during compromise while limiting any long-term damage to the lungs. Understanding the principles behind neonatal ventilation is essential so that health professionals caring for sick neonates and families have the necessary knowledge to understand best practice. Given the range of existing ventilation modes and parameters available, these require explanation and clarification in the context of current evidence. Many factors can influence clinical decision making on both an individual level and within the wider perspective of neonatal care.
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16
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Respiratory support practices in infants born at term in the United Kingdom. Eur J Pediatr 2012; 171:1633-8. [PMID: 22821075 DOI: 10.1007/s00431-012-1784-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 06/15/2012] [Indexed: 10/28/2022]
Abstract
Infants born at term requiring mechanical ventilation suffer significant mortality and morbidity, yet few studies have tried to identify the optimum respiratory support for such infants. We, therefore, hypothesised that practice would vary, particularly between different levels of neonatal care provision. The lead clinicians of all 212 UK neonatal units were asked to complete an electronic web-based survey regarding respiratory support practices for term-born infants. Survey questions included the level of neonatal care provided, number of term-born infants ventilated per annum, initial and rescue ventilation modes and whether surfactant or inhaled nitric oxide (NO) were used. The overall response rate was 82 %. A greater proportion of neonatal intensive care units (NICUs) compared to local neonatal units (LNUs) stated that they used volume-targeting, particularly for infants with RDS (p = 0.0006) or congenital pneumonia (p = 0.0005). High-frequency oscillatory ventilation was stated as initial mode by a greater proportion of NICUs compared to LNUs and special care units (SCUs), particularly for respiratory distress syndrome (p < 0.0001) or persistent pulmonary hypertension of the newborn (p < 0.001). Continuous mandatory ventilation was stated to be the rescue mode by a greater proportion of LNUs/SCUs compared to NICUs (p < 0.0001). Surfactant was stated to be most commonly given for respiratory distress syndrome (79 % of units) and MAS (61 % of units); surfactant use was lowest in SCUs (p < 0.0001); inhaled NO was infrequently used by LNUs and SCUs. Conclusions There was considerable variation in respiratory support practices for term-born infants, particularly between different levels of neonatal care provision.
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Abstract
The lungs of an extremely preterm infant ≤28 weeks gestation are structurally and biochemically immature and vulnerable to injury from positive pressure ventilation. A lung protective approach to respiratory support is vital, aiming to ventilate an open lung, using the lowest pressure settings that maintain recruitment and oxygenation and avoiding hyperinflation with each tidal breath. For infants with severe respiratory distress syndrome and persistent atelectasis, lung protective ventilation requires recruitment using stepwise pressure increments, followed by reduction in ventilator pressures in search of an optimal point at which to maintain ventilation. Several studies, including a single randomised controlled trial, have found this lung protective strategy to be more effectively administered using high-frequency oscillatory ventilation rather than conventional ventilation. Many extremely preterm infants have minimal atelectasis and low oxygen requirements in the first days of life, and the ventilatory approach in this case should be one of avoidance of factors including overdistension that are known to contribute to later pulmonary deterioration. From a practical perspective, this means setting positive end-expiratory pressure at the lowest value that maintains oxygenation and restricting tidal volume using a volume-targeted mode of ventilation.
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Affiliation(s)
- Peter A Dargaville
- Department of Paediatrics, Royal Hobart Hospital and University of Tasmania, Hobart, Tasmania, Australia.
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Wheeler KI, Morley CJ, Hooper SB, Davis PG. Lower back-up rates improve ventilator triggering during assist-control ventilation: a randomized crossover trial. J Perinatol 2012; 32:111-6. [PMID: 21637192 DOI: 10.1038/jp.2011.73] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The objective of this study is to compare the effects of back-up ventilation rates (BURs) on triggered inflations and patient cardiorespiratory stability during assist-control/volume guarantee ventilation (AC/VG). STUDY DESIGN This study is a randomized crossover trial conducted in a neonatal unit in an Australian tertiary NICU. In all, 26 stable preterm infants on AC/VG ventilation were studied at BUR settings of 30, 40 and 50 min(-1). Inflation rate, triggering and cardiorespiratory measures of patient stability were compared during 20 min epochs with 10 min washout periods. RESULT The 26 infants studied were median (inter-quartile range) gestational age 27 (26, 30) weeks, birth weight 0.84 (0.75, 1.14) kg and FiO(2) 0.24 (0.21, 0.31) and age 6 (4, 19) days. At BURs of 30, 40 and 50, the proportions of inflations, which were triggered, were mean (s.d.) 85% (11), 75% (19) and 61% (25); P<0.01 for all comparisons. Total delivered inflation rates were 56 (8), 58 (9) and 62 (8) min(-1), respectively. Cardiorespiratory parameters did not vary between the settings. CONCLUSION Using a lower BUR allows greater triggering of ventilator inflations. Cardiorespiratory parameters including CO(2) levels were stable at all rates.
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Affiliation(s)
- K I Wheeler
- Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia.
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Abstract
A recent systematic review and meta-analysis shows that volume-targeted ventilation (VTV) compared with pressure-limited ventilation (PLV) reduce death and bronchopulmonary dysplasia, pneumothorax, hypocarbia and severe cranial ultrasound abnormalities. In this paper, we present published research and our experience with volume guarantee (VG) ventilation, a VTV mode available on the Dräger Babylog 8000plus and VN500 ventilators. The VG algorithm measures the expired tidal volume (V(T)) for each inflation and adjusts the peak inflating pressure for the next inflation to deliver a V(T) set by the clinician. The advantage of controlling expired V(T) is that this is less influenced by endotracheal tube leak than inspired V(T). VG ventilation can be used with an endotracheal tube leak up to ∼50%. Initial set V(T) for infants with respiratory distress syndrome should be 4.0 to 5.0 ml kg(-1). The set V(T) should be adjusted to maintain normocapnoea. Setting the peak inflating pressure limit well above the working pressure is important to enable the ventilator to deliver the set V(T), and to avoid frequent alarms. This paper provides a practical guide on how to use VG ventilation.
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