Mechanical Ventilation of the Newborn
I Indications for Mechanical Ventilation of the Newborn Generally Fall into the Following Categories
A Severe oxygenation deficit from
B Ventilatory failure with elevated Pco2 and significant respiratory acidosis
C Congenital anomalies (see Chapter 27)
D Need for surfactant administration (modified from the AARC Practice Guidelines on Surfactant Administration, 1994)
II Goals of Mechanical Ventilation
A Provide adequate ventilation
B Provide adequate oxygenation
III Complications of Mechanical Ventilation in the Newborn
A Ventilator-induced lung disease
G Abdominal distention (gastric air)
A Manual ventilation (BMV) of the neonate
a. Non–self-inflating bag connected to an oxygen source
b. Self-inflating bag with oxygen reservoir and PEEP device connected to an oxygen source
2. Position mask on infant’s face
a. Cover nares, mouth, and tip of chin with mask
b. Avoid contact with infant’s eyes
c. Hold mask with thumb and index or middle finger on the rim of the mask
d. Keep infant’s chin forward with fourth and fifth fingers
e. Position head midline with neck slightly extended to optimize airway position
f. Apply gentle downward pressure to mask to create seal
g. Squeeze bag, and observe chest movement
h. If no chest movement reassess the following
i. Ventilate at a rate of approximately 30 to 50 breaths/min
A Unlike the adult airway cuffed ETTs are generally not needed to provide mechanical ventilation to neonates.
B The cricoid cartilage is the narrowest point in the neonatal airway.
C Appropriately sized uncuffed ETTs are adequate to provide mechanical ventilation and reduce airway complications associated with cuffed tubes.
D Approximate ETT sizes for gestational ages and weights are listed in Table 28-1.
TABLE 28-1
ETT and Suction Catheter Sizes for Various Gestational Ages and Weights
| Gestational Age (wk) | Weight (kg) | ETT Size (mm ID) | Suction Catheter Size (French) |
| <28 | <1 | 2.5 | 5 |
| 28-34 | 1-2 | 3.0 | 6 or 8 |
| 34-38 | 2-3 | 3.5 | 8 |
| >38 | >3 | 3.5-4.0 | 8 or 10 |
1. Laryngoscope with bulbs and batteries
3. Size-appropriate ETTs (see Table 28-1)
5. Resuscitation bag and size-appropriate mask
6. Suction canister and suction regulator
1. Establish adequate Spo2 with oxygen, or use BMV if apneic.
2. Position infant on a flat surface with head midline and neck slightly extended.
3. Turn on laryngoscope light, and hold laryngoscope in left hand.
4. Slide the laryngoscope blade over the right side of the tongue.
5. Advance the blade to the tip of the vallecula.
6. Lift the tongue out of the way to expose the pharyngeal area.
8. Suction if necessary to improve view of larynx.
9. Hold the ETT in your right hand, and insert it through the vocal cords as they open.
10. Insert tube until vocal cord guide on ETT is at the level of the vocal cords.
a. Estimated distance to insert ETT according to gestational age and weight is outlined in Table 28-2.
TABLE 28-2
Approximate Distance from Infant’s Lip to Tip of a Properly Inserted Oral ETT
| Weight in Kilogram | Centimeter Mark at Lip |
| <1 | 6.5 |
| 1 | 7 |
| 2 | 8 |
| 3 | 9 |
| 4 | 10 |
11. Stabilize the tube with one hand, and remove laryngoscope.
12. If stylet was used withdraw it from the tube, keeping a firm hold on the ETT.
13. Note landmark on tube associated with infant’s lip or nare if nasal tube is used.
1. Deliver positive pressure breath.
3. Auscultate the chest, and confirm bilateral breath sounds.
4. Auscultate over stomach to ensure no air entry.
5. Obtain chest radiograph to evaluate ETT position.
6. Position head midline in neutral position before chest radiograph.
7. Chest radiograph should indicate ETT approximately 1 cm above the carina.
VI Types of Neonatal Mechanical Ventilators
A The condition necessitating mechanical ventilation and the goals of support should be considered when selecting the type of ventilator, ventilator mode, and settings.
B Neonatal ventilators are generally classified as conventional or high frequency.
C Approaches to conventional and high frequency ventilation are outlined below. (A detailed description of high frequency ventilation is presented in Chapter 42.)
D Neonatal conventional ventilation
1. Neonates requiring mechanical ventilation are most often ventilated using pressure-limited ventilation.
2. Pressure-limited ventilation is accomplished by setting a peak inspiratory pressure (PIP) that the ventilator targets during each mechanical breath.
3. Pressure-limited ventilation can be accomplished using any of the following modes.
a. Synchronized intermittent mandatory ventilation (SIMV) (Figure 28-1)
(1) Mandatory mechanical rate is set (range generally 15 to 40 breaths/min).
(2) Minimum PEEP is set (3 to 8 cm H2O).
(3) Every mechanical breath starts from the preset PEEP level to a preset inspiratory pressure (generally between 15 and 25 cm H2O). Total peak pressure should be less than 30 cm H2O.
(4) The difference between PEEP and the inspiratory pressure target should result in a Vt of 5 to 7 ml/kg.
(5) Inspiratory time is operator controlled on all mandatory breaths (normally set between 0.3 and 0.5 second).
(6) Continuous flow of gas is available for all nonmechanical (spontaneous) breaths (normally set between 6 and 10 L/min).
(7) Spontaneous breaths are not supported with positive pressure >PEEP level.
(8) Pressure support may be applied during spontaneous breaths.
b. Assist control (AC) (Figure 28-2)
(1) Minimum mandatory mechanical rate is set (range, 20 to 40 breaths/min).
(2) Minimum PEEP is set (3 to 8 cm H2O).
(3) Every patient effort triggers a pressure-targeted breath.
(4) The difference between PEEP and the pressure target should result in a Vt of 5 to 7 ml/kg.
(5) Inspiratory time is operator controlled for all breaths (0.3 to 0.5 second).
c. Pressure support (PS) (Figure 28-3)
(2) Rate controlled by patient.
(3) Minimum PEEP is set (3 to 8 cm H2O).
