Professional Documents
Culture Documents
Introduction
Patient-Triggered Ventilation
Continuous Mandatory Ventilation and Synchronized Intermittent
Mandatory Ventilation
Pressure Support Ventilation
Neurally Adjusted Ventilatory Assist
Pressure Control Ventilation Versus Volume-Targeted Ventilation
Lung-Protective Strategies
High-Frequency Ventilation
Closed-Loop FIO2 Control
Summary
Although the trend in the neonatal intensive care unit is to use noninvasive ventilation when-
ever possible, invasive ventilation is still often necessary for supporting pre-term neonates with
lung disease. Many different ventilation modes and ventilation strategies are available to assist
with the optimization of mechanical ventilation and prevention of ventilator-induced lung
injury. Patient-triggered ventilation is favored over machine-triggered forms of invasive ven-
tilation for improving gas exchange and patient-ventilator interaction. However, no studies
have shown that patient-triggered ventilation improves mortality or morbidity in premature
neonates. A promising new form of patient-triggered ventilation, neurally adjusted ventilatory
assist (NAVA), was recently FDA approved for invasive and noninvasive ventilation. Clinical
trials are underway to evaluate outcomes in neonates who receive NAVA. New evidence sug-
gests that volume-targeted ventilation modes (ie, volume control or pressure control with
adaptive targeting) may provide better lung protection than traditional pressure control modes.
Several volume-targeted modes that provide accurate tidal volume delivery in the face of a
large endotracheal tube leak were recently introduced to the clinical setting. There is ongoing
debate about whether neonates should be managed invasively with high-frequency ventilation
or conventional ventilation at birth. The majority of clinical trials performed to date have
compared high-frequency ventilation to pressure control modes. Future trials with premature
neonates should compare high-frequency ventilation to conventional ventilation with volume-
targeted modes. Over the last decade many new promising approaches to lung-protective
ventilation have evolved. The key to protecting the neonatal lung during mechanical ventilation
is optimizing lung volume and limiting excessive lung expansion, by applying appropriate PEEP
and using shorter inspiratory time, smaller tidal volume (4 6 mL/kg), and permissive hyper-
capnia. This paper reviews new and established neonatal ventilation modes and strategies and
evaluates their impact on neonatal outcomes. Key words: neonatal; infant; mechanical ventilation;
intensive care; noninvasive ventilation; ventilator-induced lung injury; neurally adjusted ventilatory
assist; high-frequency ventilation. [Respir Care 2011;56(9):1298 1311. 2011 Daedalus Enter-
prises]
Fig. 1. A: Machine-triggered intermittent mandatory ventilation (IMV) with inadequate patient triggering of mandatory breaths. The patient
is receiving pressure-controlled, time-cycled, continuous-flow IMV. Points A-C are unassisted spontaneous breaths. At point D the patient
begins to exhale, but before exhalation begins, a positive pressure breath is delivered, resulting in breath-stacking and patient-ventilator
asynchrony. B: Synchronized intermittent mandatory ventilation. All of the mandatory breaths are patient-triggered and delivered appro-
priately by the ventilator. (Adapted from Reference 6, with permission.)
tures are never used in clinical practice. Thus, the sea- ability to initiate mandatory ventilator breaths based on
soned clinician is left wondering if the costs and risks of their own intrinsic respiratory efforts during patient-trig-
novel ventilators and ventilation modes outweigh the clin- gered ventilation include:
ical benefit to patients. This paper will address many of the
past and recent advances in neonatal ventilators and man- Lower and more consistent ventilator pressure and less
agement strategies, review outcomes data related to these fluctuation in intracranial pressure
advances, and explore some of the more promising ap- Increased patient comfort with less sedation, which may
proaches to neonatal ventilation that are on the horizon. facilitate ventilator weaning
Flow Quick response time, highly sensitive, noninvasive Affected by leaks, added dead space and weight
Pressure No added dead space or weight, noninvasive Longer trigger delay, lower sensitivity
Diaphragm electromyogram (neurally Fastest response time, not affected by leaks, Probe positioning more difficult, probe cost,
adjusted ventilatory assist) highly sensitive invasive
Bernstein, 1994 13
PC-IMV vs PC-SIMV PC-SIMV provided larger (P 0.01), more consistent (P .001) tidal volumes than
PC-IMV in neonates
Cleary, 199514 PC-IMV vs PC-SIMV PC-SIMV provided greater oxygenation (P 0.01) and ventilation (P .05) than
PC-IMV in neonates
Jarreau, 199615 PC-IMV vs PC-SIMV PC-SIMV provided lower work of breathing than PC-IMV (P .05) in neonates
Smith, 199716 PC-IMV vs PC-SIMV PC-SIMV provided lower respiratory rate than PC-IMV (P .01) in neonates
used in conjunction with SIMV. PSV is classified as a true in infants with high airway resistance (ie, chronic lung
form of pressure control continuous spontaneous ventila- disease), who are prone to developing gas trapping. In a
tion, but because it appears on just about all ventilators, we case report, Nicks et al25 observed lower airway pressure
will use the term PSV instead of the lesser-known term and improved VT and compliance when a neonate with
pressure control continuous spontaneous ventilation, to BPD was transitioned from PC-SIMV to PSV. This re-
avoid confusion. PSV differs from PC-CMV in that every sulted in the ability to promptly wean and extubate the
breath is patient triggered and cycled (by means of a flow- patient from mechanical ventilation.
cycle criterion). In PSV the patient controls the start of PSV has evolved to employ adaptive targeting: for
inspiration, the start of expiration, the inspiratory time, the example, volume support (on the Servo-i ventilator,
breathing frequency, and the minute volume, so the patient Maquet, Solna, Sweden) or pressure support volume guar-
has complete control of the breath, which enhances patient antee (on the VN500, Drager, Lubeck, Germany), which
comfort and patient-ventilator synchrony.22 It is important is a mode that automatically adjusts the inspiratory pres-
to note that to use PSV the neonate must have sufficient sure to maintain a minimum pre-set VT target. Nafday
respiratory drive. While newer PSV modes have an apnea et al,26 in a small, unblinded RCT with 34 premature ne-
backup mode, it takes time for the ventilator to sense onates with RDS, compared pressure support volume guar-
apnea before mandatory backup breaths are delivered. Pa- antee to PC-SIMV as the initial ventilation mode after
tients with persistent and frequent apnea may be better surfactant-replacement therapy. There was a faster reduc-
served by PC-CMV or PC-SIMV. A large ETT leak can tion in mean airway pressure in the PC-SIMV group, and
also pose a problem for PSV, because the leak may not only a reduced need for arterial blood gas analysis in the
allow the patient to flow-cycle to exhalation. Most venti- pressure-support-volume-guarantee group, which is prob-
lators have added secondary time-cycling criteria to pro- ably related to better control and maintenance of the VT.
vide appropriate breath-termination when flow-cycling can- Olsen et al27 investigated short-term clinical effects of
not be achieved during PSV. pressure support volume guarantee versus PC-SIMV in a
Pre-term neonates use frequent sighs to recruit and main- crossover trial with 14 pre-term neonates recovering from
tain end-expiratory lung volume and maintain oxygen- RDS. The pressure-support-volume-guarantee group had
ation.23 It has been speculated that PSV may better enable higher respiratory rate, larger minute ventilation, and lower
a ventilated neonate to establish a breathing pattern that end-expiratory lung volume, and required higher mean
includes sighs.24 PSV may be particularly useful in pa- airway pressure. Olsen et al speculated that deterioration
tients who are difficult to manage with a fixed inspiratory in lung recruitment was partly due to shorter inspiratory
time and respiratory rate (eg, PC-CMV). This is especially time during pressure support volume guarantee.
inspiratory pressure assist is a product of the EAdi signal Pressure Control Ventilation Versus
and the pre-set NAVA level.33 NAVA has been available Volume-Targeted Ventilation
as an invasive mode on the Servo i ventilator for nearly
2 years, and was recently FDA approved for NIV. Initial attempts at ventilating pre-term infants with vol-
Beck et al33 studied 7 premature neonates (2529 weeks ume ventilators were often unsuccessful and were quickly
gestational age) with resolving lung disease and who were abandoned with the introduction of neonatal pressure ven-
ready to be extubated. In the first phase of the study, a tilators. Today pressure control ventilation is widely used
NAVA catheter was placed, and airway pressure and EAdi in neonates. Aside from being able to trigger pressure
were measured during a 60-min period on a conventional control breaths based on changes in flow or pressure, pres-
ventilator. The neonates were then placed on invasive sure control may offer some other subtle but clinically
NAVA at a level that provided airway pressure similar to important differences. Historically, infant ventilators gen-
that of conventional ventilation. Following a short period erated inspiratory pressure by directing a pre-set continu-
of NAVA, the neonates were extubated and supported ous flow through a pressure-relief valve. Depending on
with NAVA via a single nasal prong and at NAVA level how the flow was set, inspiratory flow could be almost
similar to that at which they were extubated. No PEEP was anything from constant flow (essentially volume control)
used because of excessive leak during NAVA. NAVA with a triangular pressure waveform, to an exponential
resulted in lower mean airway pressure (P .002) and a decay with a sharply rectangular pressure waveform. Cur-
higher oxygen requirement (P .003) than did the other rent ventilators used with infants use sophisticated pres-
testing conditions, due to poor pressure transmission from sure control systems to generate either a rectangular pres-
the leak. Interestingly, NAVA (without PEEP) resulted in sure waveform or one that has a variable pressure rise. The
a lower neural respiratory rate (P .004), less breath- unifying feature between the old and new ventilators is
cycling delay, and better correlation between EAdi and that with a rectangular pressure waveform, inspiratory flow
airway pressure (P .001) than did invasive ventilation. is dependent on patient mechanics, including inspiratory
This short-term study identified NAVA as a reasonable demand.
way to support spontaneously breathing premature neo- Variable flow during pressure control is useful because
nates following, and potentially prior to, intubation. patient flow demand is often variable and flow from the
Breatnach et al34 compared NAVA to PSV in 16 ven- demand valve is delivered in response to large airway
tilated infants and children (age range 2 d to 4 years, mean leaks and during active patient efforts to maintain inspira-
9.7 months, weight range 2.4 13.7 kg, mean 6.2 kg). NAVA tory pressure constant. While intra-breath flow response is
improved patient-ventilator synchrony and lowered the sufficient in the majority of patients, some neonates may
peak inspiratory pressure, compared to PSV. The current require more aggressive gas delivery during pressure con-
data on NAVA are preliminary, but the initial studies ap- trol. Some ventilators can provide a pre-set continuous
pear to be positive, especially in terms of improved ven- flow as an alternative to variable flow during pressure
tilator-patient synchrony. NAVA does seem to have the control, and some patients may be more comfortable on
ability to trigger and cycle breaths during NIV, even in the continuous flow because higher flow may be available at
presence of large leaks. the onset of patient inspiration.35
NAVA requires that the patient is breathing spontane- Since pressure is constant during pressure control, the
ously. Premature neonates who are apneic may not be able VT delivery can vary with changes in lung mechanics and
to be supported by NAVA, even with a backup ventilation respiratory effort, which can cause rapid and large changes
mode. In the study by Beck et al,33 premature neonates in VT (eg, after surfactant-replacement therapy) if the in-
were supported with a prototype Servo 300 ventilator (Ma- spiratory pressure setting is not immediately weaned. Ex-
quet, Solna Sweden), and NAVA is now commercially cessive VT increases the risk of ventilator-induced lung
available only on the Servo-i ventilator. NAVA is inva- injury (VILI) and profound hypocarbia. There is compel-
sive, relatively expensive, and requires frequent bedside ling evidence that short-term exposure to volutrauma dur-
attendance. Future studies with larger numbers of neonates ing mechanical ventilation initiates lung inflammation in
are needed to assess outcomes with NAVA as a standard premature infants, even after only a few minutes of manual
NIV approach for neonates with lung disease. There is also resuscitation.36
concern about the cost of the NAVA esophageal catheters, Ventilation for 15 min with a VT of 15 mL/kg injures
their proper placement, and their propensity to be acciden- the pre-term lung.36 As few as 3 over-distending breaths at
tally dislodged, especially in the NICU population of small birth compromised the therapeutic effect of subsequent
infants. Although many of the difficulties associated with surfactant replacement in an animal model of prematu-
flow sensors at the airway might be bypassed with this rity.36 Hyperventilation and the consequent hypocarbia
new EAdi method, new issues such as proper sensor place- can cause long-term neurological sequelae, cystic brain
ment and higher cost might develop instead. lesion, and periventricular leukomalacia.37,38 Conversely,
if the pressure control level is not increased due to wors- tion is whether one mode performs better than another
ening lung mechanics and consequent hypoventilation, then when considering the ability to maintain VT in the face
the patient can become profoundly hypercarbic, which may of large leaks and with changes in lung mechanics and
increase the risk of developing intraventricular hemor- respiratory effort.
rhage.39,40 Prolonged ventilation at low inspiratory pres- In a recent survey by the NeoVent group, NICUs in 21
sure and low lung volume can also cause atelectrauma and European countries responded regarding 535 pre-term ne-
VILI.41 Recently improved volume monitoring capabili- onates.44 The respondents ventilated pre-term neonates with
ties, lung mechanics measurements, and system alarms conventional ventilation 85% of the time, and with high-
can better guide clinicians in ventilator adjustments. frequency ventilation (HFV) 15% of the time. During con-
The term volume-targeted ventilation is commonly ventional ventilation the preferred mode was patient-trig-
used in the neonatal ventilation literature to describe breath gered pressure control (79%), and VT was monitored almost
types that achieve a minimum VT by using either volume exclusively at the proximal airway. Only 11% of the re-
control or adaptive pressure control (also known as dual- spondents used modes that use a volume-targeted strategy,
control). The concept of volume-targeted ventilation is not including volume control or adaptive pressure control. In
new, but its progression has been hampered by technolog- the United States there have been no surveys designed to
ical limitations of ventilators, preventing its application in assess the prevalent ventilation modes used for neonates,
infants. Improvements in signal processing, servo control, but based on anecdotal reports it is likely that they are
and volume monitoring have made volume- targeted ven- similar to those practiced in Europe. Based on the recent
tilation a reality for even the smallest of patients. Most of Cochrane review43 it is unclear why more clinicians are
the currently available neonatal-capable ventilators allow not choosing volume-targeted over pressure control strat-
setting the VT as low as 23 mL and, remarkably, with egies in neonates as an initial form of support for conven-
great precision and accuracy. Sinha and colleagues first tional ventilation. One notion may be that previous at-
introduced this clinical approach in a RCT of volume con- tempts at neonatal volume-targeted ventilation were made
trol versus pressure control (targeted at 5 8 mL/kg) as an with adult and pediatric volume-cycled ventilators, during
initial management strategy in pre-term neonates with the mid-1970s, and those approaches often caused severe
RDS.42 The volume-control group had a significantly BPD or death. Another likely reason is that some of vol-
shorter duration of ventilation (P .001) and a trend ume-targeted modes are cumbersome to operate and thus
toward a lower incidence for BPD (P .09) than the cause clinicians to resort to pressure control. The accuracy
pressure-control group. and precision of delivered VT with this method remains
Adaptive pressure control involves volume-targeted controversial in smaller infants, especially if the lung com-
breaths that automatically adjust inspiratory pressure based pliance is less than that of the ventilator circuit.45,46 It must
on VT measurements to target a minimum inspiratory or be noted that all measurements, irrespective of source, are
expiratory VT. The VT measurements are obtained, during affected by ETT leaks, humidification, ventilator circuit
inhalation or exhalation, by a flow sensor at the patient compliance, and airway secretions. Some centers remove
Y-piece or at the ventilator exhalation valve. patients from volume-targeted ventilation if the ETT leak
A 2010 Cochrane review43 of 12 RCTs, including 9 par- is 30% or re-intubate with a larger ETT to eliminate the
allel trials (with 629 infants) and 3 crossover trials (with leak, so a volume-targeted mode can be used. It is unclear
64 infants), compared volume-targeted ventilation to pres- what the best practice is and whether the risks of reintu-
sure control during mechanical ventilation. The volume- bation with a larger ETT outweigh the benefits of imple-
targeted modes reduced the combined outcome of death or menting these modes.
chronic lung disease (risk ratio [RR] 0.73, 95% CI 0.57 to Adaptive pressure control modes appear to show great
0.93, NNT [number needed to treat] 8, 95% CI 5 to 33), promise for volume-targeted ventilation in this technically
pneumothorax (RR 0.46, 95% CI 0.25 to 0.84, NNT 17, challenging group of patients. Several ventilator manufac-
95% CI 10 to 100), ventilation days (mean difference turers have incorporated advanced algorithms that can re-
2.36 d, 95% CI 3.9 to 0.8), hypocarbia (typical RR liably deliver the pre-set VT despite a large ETT leak. In
0.56, 95% CI 0.33 to 0.96), NNT 4, 95% CI 2 to 25), one example, the ventilator continuously measures proxi-
and the combined outcome of periventricular leukoma- mal flow and airway pressure, calculates the inspiratory
lacia or grade 3 4 intraventricular hemorrhage (typical and expiratory leak, and adjusts the inspiratory pressure
RR 0.48, 95% CI 0.28 to 0.84, NNT 11, 95% CI 7 to based on an estimated volume delivered to the patient
50). The neonates were supported with various volume- (Fig. 4). As volume-targeted strategies become more prev-
targeted ventilation modes, including volume control alent in the NICU, hopefully these new features will help
and adaptive pressure control modes. The major ques- provide better lung protection in the future.
piration is passive, and therefore HFJV may be used with fewer air leaks, fewer surgical ligations of patent ductus
lower mean airway pressure than HFOV without risk of arteriosus, and less retinopathy of prematurity ( stage 2).
airway collapse on exhalation, although insufficient expi- For infants with pulmonary interstitial emphysema,
ratory time can still cause air trapping during HFJV. HFJV is more effective than high-rate conventional ven-
In a Cochrane meta-analysis of 17 RCTs, with a total of tilation, and associated with lower mortality in the smallest
3,652 patients, there was no difference in 28-day mortality infants and a quicker time to resolution.67 In a 1998 meta-
in premature neonates supported by conventional ventila- analysis68 of elective HFJV versus conventional ventila-
tion versus HFV.64 The effect of HFV and conventional tion, HFJV was associated with less BPD at 36 weeks
ventilation on BPD was inconsistent across the studies, postmenstrual age in survivors (RR 0.58, 95% CI 0.34 to
and there was a borderline significance favoring HFV. 0.98, relative difference 0.138, 95% CI 0.268 to
Some subgroups had significantly less BPD with HFV, but 0.007), NNT 7 (95% CI 4 to 90). The overall analysis
only when surfactant was not administered. Piston-driven found that elective HFJV benefited pulmonary outcomes.
oscillators, when conventional ventilation strategies were Many of the trials reviewed compared HFV only to pres-
not lung-protective, when randomization occurred at sure control ventilation. Future trials of open-lung HFV
2 6 hours of age, and when the inspiratory/expiratory ra- versus conventional ventilation should include volume-
tio was 1:2, were used for HFOV. The rate of retinopathy targeted ventilation modes with small VT (4 6 mL/kg),
of prematurity was lower, overall, and pulmonary air leaks rapid respiratory rate, short inspiratory time, and permis-
were more frequent in the HFOV group. The rates of grade sive hypercapnia.
3 or 4 intraventricular hemorrhage and periventricular leu-
komalacia were higher in the HFOV groups that used a Closed-Loop FIO2 Control
high-volume strategy. One trial found an adverse effect on
long- term neurodevelopment with HFOV, but the other 5 Premature infants often need supplemental oxygen for
extended periods. Retinopathy of prematurity can be caused
trials that reported this outcome did not. It is important to
by excessive FIO2, and BPD has been attributed partly to
note that several different forms of HFV were used, rou-
high FIO2.69 The optimal oxygen saturation is still under
tine monitoring of arterial blood gases were not performed
investigation. Manual control of FIO2 during mechanical
in all patients, and many of the neonates were managed
ventilation can be difficult and time-consuming. Automated
with lower-mean-airway-pressure approaches during HFV.
(closed-loop) regulation of FIO2 is a new concept that is
These factors may account for many of the observed dif-
awaiting FDA approval for use in one neonatal ventilator.
ferences.
The clinician sets the target SpO2 range on the ventilator,
In a Cochrane meta-analysis of HFOV versus conven-
and the ventilator titrates FIO2 based on the SpO2.
tional ventilation for near-term and term infants with se-
In a study of 16 pre-term infants (24.9 1.4 weeks)
vere pulmonary dysfunction, 2 trials met the review crite- with frequent hypoxemia episodes, the percent of time
ria. 65 One involved the elective use of HFOV and within the target SpO2 range was greater with automated
randomized 118 infants. The other used HFOV as a rescue FIO2 control (58 10% vs 42 9%, P .001).70 Auto-
therapy in 81 infants. Neither trial found lower mortality at mated oxygen control also reduced hyperoxemia and FIO2.
28 days. There was no difference in air leak, BPD, or Theoretically, automated FIO2 control could decrease the
intracranial injury. In the elective HFOV study there was frequency of hypoxic and hyperoxic episodes in infants
no difference in ventilator days or hospital days. In the receiving mechanical ventilation, and reduce clinician time
rescue HFOV study there was no difference in the need for and the risk of morbidities associated with supplemental
extracorporeal membrane oxygenation. Based on the prior oxygen (retinopathy of prematurity and BPD). Closed-
review, it was stated: There is no clear evidence that loop control is a promising approach, and may be available
elective HFOV offers important advantages over conven- in the near future.
tional ventilation when used as the initial ventilation strat-
egy to treat pre-term infants with acute pulmonary dys- Summary
function.65
In 2010 a systematic review and meta-analysis used Although the trend in the neonatal NICU is to use NIV
individual patient data from 12 RCTs (n 3,229 patients) whenever possible, invasive ventilation is often necessary
to compare outcomes in pre-term infants who received in pre-term neonates with lung disease. Many different
HFOV (higher mean airway pressure) versus conventional ventilation modes and ventilation strategies are available
ventilation.66 There were no differences in BPD, mortality, to optimize mechanical ventilation and prevent VILI.
or neurological insult. However, when randomization oc- Patient-triggered ventilation is favored over machine-
curred earlier (within 4 h), HFOV was associated with less triggered forms of invasive ventilation for improving gas
death and less chronic lung disease (P .01), and with exchange and patient-ventilator interaction. However, no
studies have shown that patient-triggered ventilation im- 8. Cools F, Offringa M. Neuromuscular paralysis for newborn infants
proves mortality or morbidity in premature neonates. A receiving mechanical ventilation. Cochrane Database Syst Rev 2005;
(2):CD002773.
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nates. New evidence suggests that volume-targeted venti- sure and airflow triggering systems using a single type of neonatal
ventilator. Acta Paediatr 2001;90(4):445-447.
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133.
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Discussion useful data. It boils down to the per- Walsh: You didnt mention any-
son driving the ventilator. I would thing about extubation readiness test-
Rogers:* As a point of disclosure, much rather have Rich [Branson] driv- ing or what pressure you think is ap-
Im the high-frequency product man- ing a conventional ventilator than propriate to extubate from.
ager for CareFusion. Its important to someone whos never seen a high-
realize that the meta-analysis that com- frequency device driving it. Just intu- Brown: It depends what part of the
pared HFOV to conventional ventila- itively, I think high-frequency does country youre from. I think theres
tion looked at all the RCTs, which yield better results. Alison Froese an east-coast/west-coast thing going
included a couple of trials done very pointed out that one good thing HFV on, which I see when I collaborate
early in the history of HFV, primarily has done is show us how to use con- with people further east than me. I
the HiFO Trial1 and the UKOS trial,2 ventional ventilators better. dont think anybody really knows the
both of which had serious flaws, in- right answer. My experience is that
cluding lack of a strict protocol and 1. Clark RH, Gerstmann DR, Null DM Jr, de- the sooner you try, the more likely
clinical trial oversight, and disparate Lemos RA. Prospective randomized com- youll get them off faster, and I think
high-frequency devices. We must look parison of high-frequency oscillatory and the adult evidence bears that out, and
at the type of high-frequency device, conventional ventilation in respiratory dis- thats how we ended up with sponta-
tress syndrome. Pediatrics 1992;89(1):5-12.
rather than combining all high- neous breathing trials, which we cant
2. Johnson AH, Peacock JL, Greenough A,
frequency devices. In the recent Co- Marlow N, Limb ES, Marston L, Calvert
do in the NICU, but just force people
chrane meta-analysis,3 for piston- SA; United Kingdom Oscillation Study to come off the ventilator sooner. The
driven high-frequency ventilators the Group. High-frequency oscillatory ventila- east-coast numbers are a lot higher than
incidence of intraventricular hemor- tion for the prevention of chronic lung dis- the west-coast numbers. On the west
rhage and retinopathy of prematurity ease of prematurity. N Engl J Med 2002; coast theyll go down to a ventilator
347(9):633-642.
were lower for piston HFOV than for rate of 12 breaths a minute. As for
3. Cools F, Henderson-Smart DJ, Offringa M,
conventional ventilation. Askie LM. Elective high-frequency oscil-
pressure, I think it should be tidal-
Regarding future studies, its latory ventilation versus conventional ven- volume-based and what the baby can
much easier to justify putting a tilation for acute pulmonary dysfunction in do on his own, and come up with a
patient on HFOV, and in the pedi- pre-term infants. Cochrane Database Syst combination with the ventilator.
atric realm using a mean airway pres- Rev 2009;(3):CD000104.
sure of 25 or 30 cm H2O, than on Walsh: Im not sure that the NICU
conventional ventilation at a similar Brown: I agree. I spent many years doesnt have it right. Theyre not do-
PEEP. How many times have you using high-frequency in pediatric and ing all these fancy ventilation modes,
seen a PEEP of 20 or 30 cm H2O neonatal ICUs. If it wasnt working because it probably doesnt matter. Its
in neonatal or pediatric patients? for us, I dont think wed keep using something weve continuously ex-
Having a more comparative group it, so theres something there, but plored in the pediatric and adult world,
between conventional and high- sometimes its hard to find in the stud- but I wonder if theyre actually more
frequency is good for getting more ies. As for whether we can design the evidence-based than the rest of the pe-
right study, sometimes I think we cant. diatric ICUs.
Its difficult when all the studies are
* Mark Rogers RRT, CareFusion, San Diego, combined like that to really see the Brown: I kind of agree with you.
California. facts about the individual devices. Its funny that, if youre around long
enough, everything comes back havent even shown that simple things I found it very interesting that in
around, I distinctly remember stand- like patient-ventilator synchrony make that meta-analysis table you showed,
ing at the bedside in the pediatric ICU a difference. We have to look at what of outcomes in infants supported with
trying to explain to an intensivist why are the most clinically relevant end volume-targeted versus pressure con-
he needed to learn pressure-support points? For me as a neonatologist, its trol ventilation, that the majority of
ventilation and he said, Ive never mortality and chronic lung disease. We the babies supported with volume-tar-
needed it before, so why do I need it havent shown any differences. geted ventilation received volume-
now? It was a good argument and Some trials have found that maybe control, and not one of the new-fangled
maybe we dont need those modes at were a little bit better on duration of dual-control modes. My concern is that
all. Though I have seen good things ventilation, and maybe fewer air leaks, the technology is changing so rapidly
with babies with really bad chronic but in general were not doing better. that data obtained from older studies
lung disease on a mode such as adap- In our National Institute of Child that used older technologies do not
tive support ventilation; Ive seen their Health and Human Development spon- extrapolate to the newer modes.
comfort improve dramatically and sored neonatal network, which does a Last week one manufacturer told me
seen them get off the ventilator when lot of our clinical trials, clearly the that they were servo-controlling in-
they couldnt get off it before. So site that has the lowest BPD rate is spiratory pressure based on exhaled
maybe theres some use for some of Columbia [University Medical Cen- VT, and the next week another venti-
those things. I dont want to throw ter], in New York, and their main lator manufacturer tells me that theyre
them all out. I agree with you that method of mechanical ventilation is trying to target VT based on a theo-
were going back to some simpler IMV, 1970s-style ventilation. retical delivered VT with a 90% ETT
things. leak. This is great technology but how
1. Courtney SE, Durand DJ, Asselin JM,
Hudak ML, Aschner JL, Shoemaker CT;
can we all keep up and who will fund
Walsh: But you said that continu-
Neonatal Ventilation Study Group. High a large enough RCT to determine if
ous mandatory ventilation produces
frequency oscillatory ventilation versus theyre better than what were using
less WOB. Maybe youre right, maybe conventional mechanical ventilation for now?
its causing more lung damage because very-low-birth-weight infants. N Engl
were over-supporting them when we J Med 2002;347(9):643-652.
Brown: No, if weve not gotten any-
shouldnt be.
Brown: I agree, and I pointed out where near that in the adult world,
that there were no BPD or mortality were never going to get near it in the
Brown: I agree. I kind of have two
differences. Patient-triggered volume- neonatal world. Im not even advocat-
separate goals: one is to decrease
targeted ventilation makes sense. ing that we do. I think its nice to have
WOB, and the other one is to not cause
more damage. Maybe sometimes those There is evidence that volume target- some things available that might work
are in competition with each other. ing is safer. Im not wholeheartedly for particularly difficult babies, but I
embracing anything beyond that, but I dont think its what we need for most
Wiswell: Ill be the contrarian. do think its interesting that we havent of the babies most of the time. When
Youve expressed bewilderment about even embraced those things in some I was reading the studies, I thought it
why we havent come around in neo- places. Columbia is special because was very interesting that a lot of them
natology. Ive been doing this for over the physician in that unit is so special, used volume-controlled square-wave-
30 years. The biggest change in ven- and that expertise makes a difference. form flow versus decelerating flow.
tilation came about 40 years ago with Doing what you do best is the most
the advent of IMV and the first Baby- important thing, obviously. Cheifetz: You discussed various
Bird ventilator. We have yet to show ventilation strategies, including the
that anything else is better. I was in- DiBlasi: Perhaps its not that we open-lung approach. For the purposes
volved in San Antonio in the mid- should be doing the right thing, but of your presentation, you maintained
1980s ventilating premature baboons, that we should be doing the same thing, your discussion of mode and strategy/
and in the first human baby trials, and because we dont really know what is approach as separate entities. But what
Ive been involved in high-frequency the right thing to do. Rather than us- is most important? Does the specific
trials including the one by Courtney ing four different ventilation modes ventilator mode really matter? Or is
et al a couple years ago, which found with two different ventilators and the approach/strategy the key issue,
maybe its a little bit better.1 switching between the two, I think that regardless of the mode? What are the
I think it makes sense to use pa- following a standardized ventilation outcome data to support mode versus
tient-triggered and volume-limited management protocol might change ventilation strategy in neonates? In pe-
ventilation, but Im a realist. We outcomes. diatrics there are no data to support
one mode over another in terms of the place in the NICU. It drives me that accurate. Im not sure its accu-
outcome in acute-lung-injury and crazy to see over 25 mL being used in rate below 3 or even 5 mL with the
ARDS patients. In my opinion the key a 4-kg baby. technology we have, or if we can mea-
is an open-lung, low-VT strategy, re- sure it. And theres a lot of variability.
gardless of the specific ventilation DiBlasi: Is it the machine or the Rather than propagating more modes,
mode. baby? I think we need to study in detail what
we have now, and what were actually
Brown: Strategy. The only evidence Brown: Its the machine.
capable of doing. With volume-
we have is strategy. Open lung is im-
targeting I see CO2 run all over the
portant, and we need more evidence Myers: Regarding volume-targeting
I want to restate the question: is it the place, despite no changes in settings.
in the NICU, but thats probably some
of the high-frequency success. Thats baby or is it the technology? Babies
why I think high-frequency ventila- have such rapidly changing lung com- Brown: I agree, I dont think modes
tion often does better. Theres some pliance with what we know best, which are the answer at all. We definitely need
evidence that volume-targeting is im- is RDS, and its all over the board. to do better with what we have now.
portant. I kind of beat up on the fact Im not convinced the technology is We still have to control the pressure;
that were still using pressure ventila- there yet. With a 400 or 500 gram Im certainly not advocating that we sim-
tion in the NICU, because I think vol- newborn, how do you target 3 or 5 mL/ ply target the volume and let the ma-
ume-targeting is important and the ev- kg? Thats about 1.52 mL, and Im chine run away with it and trust that
idence is there. I see volumes all over not sure the ventilation technology is completely. I dont advocate that at all.