Lung protective ventilatory strategies in very low birth weight infants

Abstract

Respiratory distress syndrome (RDS) is the most common respiratory diagnosis in preterm infants. Surfactant therapy and mechanical ventilation using conventional or high-frequency ventilation have been the standard of care in the management of RDS. Bronchopulmonary dysplasia (BPD) continues to remain as a major morbidity in very low birth weight infants despite these treatments. There is no significant difference in pulmonary outcome when an optimal lung volume strategy is used with conventional or high-frequency ventilation. Lung injury is directly related to the duration of invasive ventilation via the endotracheal tube. Studies using noninvasive ventilation, such as nasal continuous positive airway pressure and noninvasive positive pressure ventilation, have shown to decrease postextubation failures as well as a trend toward reduced risk of BPD. Lung protective ventilatory strategy may involve noninvasive ventilation as a primary therapy or following surfactant administration in very preterm infants with RDS. Initial steps in the management of preterm infants may also include sustained inflation to establish functional residual capacity, followed by noninvasive ventilation to minimize lung injury and subsequent development of BPD.

High-Frequency Oscillatory Ventilation Versus Synchronized Intermittent Mandatory Ventilation Plus Pressure Support in Preterm Infants With Severe Respiratory Distress Syndrome

“…30 Despite the effectiveness of surfactant treatment in cases of RDS, BPD remains an important adverse outcome in preterm infants, and its incidence has been directly related to the duration of invasive ventilation. 31 For this reason, pressure support ventilation and volume guarantee are 2 new neonatal ventilation techniques that have been developed to avoid overdistention and atelectasis. 32 This noninvasive ventilation strategy combines nasal CPAP with a method of selective surfactant administration, and has shown results similar to prophylactic surfactant treatment.…”

Mechanical Ventilation of the Premature Neonate

“…Invasive mechanical ventilation, although often necessary for supporting neonates with lung disease, has been implicated as a major cause of lung injury and inflammation, and is now considered a primary risk factor for neonates developing bronchopulmonary dysplasia (BPD). 3,4 As such, institutions with better outcomes appear to be taking a different approach to mechanical ventilation. Assuming a neonate has an acceptable respiratory effort, even the smallest and youngest of these patients are now being supported noninvasively using gentler forms of mechanical respiratory support (eg, continuous positive airway pressure).…”

Bubble and ventilator-derived nasal continuous positive airway pressure in premature infants: work of breathing and gas exchange

“…[4][5][6][7] It is still a widely held belief that the delivered mean intraprong pressure during B-NCPAP may be estimated by the submersion depth of the expiratory tubing and is independent of the flow rate. 8 However, the bubbling in a B-NCPAP system causes variability in the delivered mean B-NCPAP pressure, and has been shown to be dependent on the bias flow rate. 6 We have previously shown in both a lung model and in premature infants that pressure delivered to the nasal prongs in a B-NCPAP system is greater than the immersion depth of the expiratory tubing, even at the lowest flow that causes gentle continuous bubbling.…”