MARY A. SHORT, RNC, MSN Series Editor

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1 _ANC701-Snow.qxd 1/31/07 12:47 PM Page 8 MARY A. SHORT, RNC, MSN Series Editor A Nurse s Guide to Common Mechanical Ventilation Techniques and Modes Used in Infants Nursing Implications Timothy M. Snow, RN, NNP, 1 Debra H. Brandon, RN, PhD, CCNS 2 ABSTRACT The need for conventional mechanical ventilation (CMV) is a common one in the neonatal intensive care unit (NICU). The goals of CMV are to facilitate adequate gas exchange, minimize the risk of lung injury/damage, decrease the patient s work of breathing, and optimize the patient s comfort. Although time-cycled, pressure-limited ventilation remains the most common CMV modality, volume-cycled ventilation, assist-control ventilation, pressure-support ventilation, and pressure-control ventilation are sometimes used in the NICU. Pressure-regulated volume control, volume-guaranteed ventilation, volume-assured pressure-support ventilation, and proportional-assist ventilation are emerging hybrid modes of CMV. Although CMV is frequently life saving, it can cause complications if improperly used. Nurses are responsible for the ongoing assessment and care of infants undergoing CMV and are becoming frequently more involved in the weaning process of CMV. This article provides an overview of conventional ventilation, with a focus on common modalities, and ventilation-related nursing interventions. KEY WORDS: artificial respiration, conventional ventilation, inspiratory positive-pressure ventilation, intermittent positivepressure ventilation, mechanical ventilation, mechanical ventilator, peak inspiratory pressure, positive end-expiratory pressure, positive-pressure respiration, positive-pressure ventilation, ventilation, ventilator weaning Each year, 1 to 3 million individuals require mechanical ventilation in the United States. 1 Respiratory illnesses requiring mechanical ventilation are common occurrences within the modern neonatal intensive care (NICU). Respiratory illness, in conjunction with a rise in the preterm birth rate to 12.5% (premature infants often require mechanical ventilation) makes infants one of the largest groups of mechanically ventilated patient populations. 2 The frequent use of mechanical ventilation in the NICU necessitates that nurses and clinicians have adequate knowledge of modern mechanical ventilation and care of infants requiring this neonatal intervention. Nurses are in a unique position to have a positive effect on an infant s ventilation therapy because they maintain a continuous presence at the bedside and Address correspondence to Timothy M. Snow, 4999 NC HWY 268, Dobson, NC tsnow@wfubmc.edu or tsnow1us@yahoo.com From 1 Wake Forest University Baptist Medical Center and Brenner Children s Hospital, Winston-Salem, NC; and 2 Duke University Hospital, Durham, NC. Copyright 2007 by The National Association of Neonatal Nurses. perform related tasks, including positioning, suctioning, educating families, and in some cases, adjusting ventilator settings. 3 Even when nurses are not responsible for manipulating ventilator settings, they are responsible for collaborating with the healthcare team regarding ventilator weaning decisions. 4 Experts relate that nurses are key players in reducing the length of mechanical ventilation and should manage the process of ventilatory weaning. 5-7 Since the 1980s neonatal ventilation techniques have become increasingly complex are difficult to understand, and often the science to consistently guide best practice is lacking. 8 The goals of mechanical ventilation are to facilitate adequate gas exchange, minimize the risk of lung injury/damage, decrease the patient s work of breathing, and optimize the patient s comfort. 8 With these goals considered, it is important to emphasize that any artificial ventilation can be associated with acute or chronic respiratory tract injury. 9 These lung changes are attributed to atelectrauma, volutrauma, barotrauma, oxygen toxicity, and pulmonary/systemic inflammatory response to lung trauma (biotrauma), as defined in Table Lung injuries can lead to the development of air leaks (pneumothorax, pulmonary interstitial emphysema, pneumopericardium, pneumomediastinum) or 8 Advances in Neonatal Care Vol. 7, No. 1 pp. 8-21

2 _ANC701-Snow.qxd 1/31/07 12:47 PM Page 9 Common Mechanical Ventilation Techniques and Modes Used in Infants 9 TABLE 1. Definition of Lung Injury Mechanisms 10 Atelectrauma Barotrauma Volutrauma Oxygen toxicity Biotrauma Lung tissue injury as the result of repeated alveolar collapse Lung tissue injury as the result of the delivery of pressure Lung tissue injury as the result of alveolar and airway overdistension Lung tissue injury resulting from the oxygen-induced production of free radicals Lung tissue injury as the result of ventilator-induced inflammatory cells and chemical mediators chronic lung disease (CLD). Although air leaks and CLD may occur in any premature infant on a positivepressure device, proficient ventilator management can lessen the risk. It is essential that all clinicians are familiar with appropriate ventilator terminology (see Table 2), management, related morbidities, and the array of modern ventilatory modalities. The purpose of this article is to introduce the terminology/ classification of conventional mechanical ventilation (CMV), provide an overview of selected ventilatory modes, and review the nursing implications of caring for an infant being treated with CMV. CHARACTERISTICS OF CONVENTIONAL MECHANICAL VENTILATION Control Ventilators are classified by key variables that correlate to their clinical use. Table 2 outlines the 5 general characteristics of ventilators (control, cycling, triggering, flow pattern, and modes). 8,11-18 However, these characteristics are interdependent, and many ventilation techniques use a combination. Several manufacturers have marketed different infant ventilators (Figures 1, 2, and 3) and often have used different names for similar ventilator modalities, further complicating the process of selecting appropriate ventilator settings. Although it is important for the clinician to have an overall understanding of types of ventilation strategies, it is critical for the clinician to become competent with the type(s) of ventilator and modes of ventilation used at his/her facility. Most often, CMV is controlled using a pressurelimited or volume-controlled modality. The choice largely depends on the preference of the individual facility based on relative clinician preference and training and consistency in care. 12 However, pressure control and volume control recently have been combined in various ways and referred to as dual controlled or hybrid ventilation. Hybrid ventilation is a relatively new and promising concept that combines pressure and volume settings into a single modality. Cycling and Triggering Cycling and triggering combine to complete inhalation and exhalation during a prescribed breath. 11 Volume, flow, pressure, movement, or time can be manipulated to switch from inspiration to expiration (cycling) and from expiration to inhalation (triggering). Cycling in infants usually is time cycled. By manipulation of the inspiratory and expiratory time (in the time-cycled mode), the rate will inherently be set. The inspiratory time is usually set between 0.3 and 0.5 seconds. The expiratory time is increased or decreased to determine the rate. This usually is accomplished automatically by the ventilator when the rate is adjusted by the clinician. Termination sensitivity facilitates the end of a cycle when a certain percentage of peak flow has been met. It allows for the infant to control the duration of the breaths, depending on lung mechanics. The termination sensitivity is usually set so that a mechanical breath ends when the expiratory flow declines to 0% to 25% of peak flow. Termination sensitivity prevents air trapping and inversion of the inspiratory/expiratory ratio; however, this function may not work well if there is a leak around the endotracheal tube. Triggering can be accomplished by a change in flow, abdominal motion, thoracic impedance, or a drop in pressure within the tubing. Flow triggering is commonly used because of its ease of use, the ability to measure tidal volume and minute ventilation, facilitation of expiratory synchrony, decreased amount of work to trigger a breath, and rapid response time of the ventilator while using this method. Triggering by changes in flow can be set by the clinician to compensate for endotracheal tube leaks. Because the ventilator has a tendency to autocycle when endotracheal tube air leaks are present, the trigger sensitivity must be carefully adjusted. If the trigger sensitivity is too sensitive, the ventilator will autocycle when air leaks around the endotracheal tube. If the trigger sensitivity is not set high enough, an infant may not be able to trigger a ventilator breath. Flow In ventilation, flow refers to the measurement of the delivered volume of a gas per an amount of time. Flow patterns can be visualized by ventilator graphics on some models of ventilators. They may be constant, accelerating, sinusoidal, or decelerating (Figures 4, 5, 6, and 7). All methods of flow, excluding accelerating, are used in the respiratory support of the infant. Sinusoidal flow is more physiologic and is most often used in ventilating premature infants because it Advances in Neonatal Care Vol. 7, No. 1

3 _ANC701-Snow.qxd 1/31/07 12:47 PM Page Snow and Brandon TABLE 2. Common Terminology Used in Neonatal Ventilation 8,11-18 Term Definition Breath pattern Control Cycling Expiratory time Flow Frequency/rate Inspiratory time Inspired oxygen (FiO2) Mean airway pressure (MAP) Peak inspiratory pressure (PIP) Positive end-expiratory pressure (PEEP) Tidal volume (Vt) Triggering Set breath (ventilator initiated) Spontaneous breath (patient initiated) The method by which the ventilator coordinates the breath sequence. There are four general patterns used in neonatal ventilation: IMV, SIMV, AC, and PSV. How a ventilator coordinates how a breath is to be delivered. Generally, breath modes are volume controlled, pressure controlled, or dual controlled. Sequence of switching from inspiration to expiration (delivering a breath). Cycling may include time-cycled, flow-cycled, or volume-cycled breaths. Time period spent during the expiratory phase of ventilation Net movement of respiratory gases within a confined tubing or space. Flow refers to the measurement of volume over an amount of time. Flow is not well studied in infants; changes in flow probably affect arterial blood gases only minimally provided a sufficient flow is used. Number of breaths per minute. The ventilator rate affects alveolar minute ventilation, which is determined by the product of tidal volume (minus dead space ventilation) and frequency. Changes in rate primarily influence PaCO 2 (partial pressure [tension] of carbon dioxide, artery) in an inverse relationship. Thus, the higher the rate, the more CO 2 you blow off (effectively lowering the PaCO 2 ). Frequency changes alone do not significantly influence MAP or PaO 2 (arterial oxygen pressure [tension]). Time spent during the inspiratory phase of ventilation. Percent of oxygen delivered to the patient. Changes in FiO 2 alter alveolar oxygen pressure and thus oxygenation. FiO 2 and MAP both determine oxygenation. Average airway pressure delivered throughout the respiratory cycle. MAP is determined by a number of values and can be calculated with the following equation; T I MAP = K (PIP PEEP) [T I divided (T I + T E ) + PEEP Where, MAP is mean airway pressure; K is constant; PIP is peak inspiratory pressure; PEEP is positive end-expiratory pressure; T I is inspiratory time; and T E is expiratory time. Peak pressure at the end of inspiration. Changes in PIP can affect either PaO 2 (by altering mean airway pressure) or PaCO 2 (by altering tidal volume). Adequate PIP is manifested by a gentle chest rise with a delivered breath. The use of minimal PIP for effective oxygenation and ventilation should be a goal to prevent barotrauma. Constant distending pressure delivered at end expiration. PEEP helps to maintain functional residual capacity to prevent atelectasis. Increases in PEEP generally improve oxygenation. The volume of air inhaled and exhaled at each breath. Triggering is the method by which the ventilator switches from expiration to inspiration. The ventilator triggers include chest wall movement, chest wall impedance, time, pressure, and flow. Ventilator breath set by the clinician. Infant s own inherent breath. decreases sudden distention of the airway. Some experts believe sudden distention of the airways is a cause of chronic lung injury. 19 Square waveforms are sometimes used in the ventilation of newborn infants. Although square waveforms do not mimic physiologic breathing, they improve oxygenation when used in combination with slower ventilator rates and longer inspiratory times. Square waveforms are also useful with atelectasis, but overdistention of the lungs and subsequent air leaks may ensue. 12 Decelerating flow delivery may be beneficial with positive-pressure ventilation because it decreases peak inspiratory pressure while maintaining better distribution of delivered gas than does a constant flow pattern. Accelerating

4 _ANC701-Snow.qxd 1/31/07 12:47 PM Page 11 Common Mechanical Ventilation Techniques and Modes Used in Infants FIGURE FIGURE 2. The VIP Bird Gold (VIASYS Healthcare, Inc., Conshohoken, Pa) ventilator is designed for neonatal, infant, and pediatric patients. Photo courtesy of Stephanie Albanese, RN, NNP. The Viasys Avea (VIASYS Healthcare, Inc., Conshohoken, Pa) ventilator is a comprehensive ventilator for use in infant, pediatric, and adult patients. Photo courtesy of Stephanie Albanese, RN, NNP. flow is not used in any clinical practice because of the inherent possibility of tissue damage. an Ayre s T-Piece (Figure 8), but the infant s own spontaneous breath is not supported with peak inspiratory pressure (PIP), only proximal end-expiratory pressure (PEEP). An Ayre s T-Piece is a device that is built into all ventilators that provides a continuous flow of fresh gas to prevent the rebreathing of carbon dioxide during unsupported breathing. There are several complications that can arise from the IMV mode of ventilation. IMV is often uncomfortable for the infant because of the asynchrony that occurs when a mandatory, or forced breath is given out of synchrony with the infant s own respiratory effort.20 Asynchrony may lead to inefficient air exchange, gas trapping, air leaks, fluctuations in arterial blood pressure, and altered cerebral blood flow.8,13 To prevent or modulate these complications, sedatives and paralytics are often required; however, these drugs have their own deleterious effects.13 SIMV was created to limit these adverse effects. Synchronized intermittent mandatory ventilation (SIMV) synchronizes the ventilator s breaths with the MODES OF MECHANICAL VENTILATION There are 4 basic conventional mechanical ventilator modes in neonatal ventilation. These are intermittent mandatory ventilation (IMV), synchronized intermittent mandatory ventilation (SIMV), assist-control ventilation (ACV), and pressure-support ventilation (PSV). Volume-cycled ventilation and pressure-limited ventilation have been combined within newer ventilators to create many different types of hybrid techniques. Each mode has its own advantages and disadvantages (Table 3).8,9,12-14,20-23 Conventional Modes Intermittent mandatory ventilation (IMV) was the initial mode used in early ventilation trials. With IMV, a fresh flow of gas is present because of a device called Advances in Neonatal Care Vol. 7, No. 1

5 _ANC701-Snow.qxd 12 1/31/07 12:47 PM Page 12 Snow and Brandon FIGURE 3. The Servo-i ventilator (Siemans, Erlagen, Germany) is a comprehensive ventilator for use in infant, pediatric, and adult patients. The waves on the screen depict (from top to bottom) pressure, respiratory rate, tidal volume, and end tidal CO2. Photo courtesy of Stephanie Albanese, RN, NNP. FIGURE 4. FIGURE 5. Screens from the Viasys Avea ventilator depicting a sine wave flow pattern. Photo courtesy of Matt Brinck, RT. Screen from the Viasys Avea ventilator depicting a square flow pattern. Photo courtesy of Matt Brinck, RT.

6 _ANC701-Snow.qxd 1/31/07 12:47 PM Page 13 Common Mechanical Ventilation Techniques and Modes Used in Infants 13 FIGURE 6. FIGURE 7. Screens from the Viasys Avea ventilator depicting a decelerating flow pattern. Photo courtesy of Matt Brinck, RT. infant s own spontaneous inspiratory effort. The ventilator delivers a synchronized breath when a change in flow or a pressure drop is detected within the ventilator tubing. Ventilators commonly have an assist sensitivity control setting to permit the delivery of a ventilator breath when the infant exhibits respiratory effort. This synchronized breath increases patient comfort during mechanical ventilation because the breath is not forced atop the infant s expired breath. SIMV also increases oxygenation and decreases hypoxic episodes in comparison with IMV. 22 SIMV is commonly combined with pressure cycling, volume cycling, pressure-limited ventilation, or with PSV to provide optimal ventilation based on the infant s disease characteristics. Innovative Modes Assist-control ventilation (ACV) ventilation is similar to SIMV in that breaths are synchronized; however, every spontaneous patient breath is supported, not just a preset rate. This allows the infants to self-regulate by reducing their rate as their ventilatory status improves; this subsequently reduces barotrauma. The exception is when the breath is so small it does not trigger the ventilator. Typically a backup rate is set in case the infant has apnea. 14 This mode works well in infants who have a strong respiratory drive and are not heavily sedated. 23 This type of patient-triggered ventilation also may be useful in preterm neonates with respiratory distress syndrome (RDS). 24 Often infants determine their optimal rate of ventilation for a given illness and respiratory pathology. 12 This mode is ideal for infants who are in obvious discomfort while being mechanical ventilation. ACV can cause difficulty weaning and diaphragmatic musculature atrophy with prolonged use. Difficulty weaning occurs because the only parameters weaned by the clinician are the PIP and the PEEP. Weaning the rate will not affect the CO 2 or O 2 levels because each of the infant s spontaneous breath is supported. When The flow patterns that can be obtained with conventional mechanical ventilation. The left panel illustrates the constant square, decelerating, and the sine wave flow patterns. The ventilator used for the illustration was used on a proximal end-expiratory pressure of 5 cm while ventilating a lung model. The panel on the right represents the mean airway pressure (Paw) generated from these patterns. To simplify, on the left, the ventilator is generating a flow using a particular pattern constant (square, decelerating, and sine), and the mean airway pressure is being measured on the right. Pressure control ventilation is 1 type that uses a constant square wave flow waveform. Pressure-regulated volume control uses a decelerating flow waveform. Assist control ventilation uses a sine waveform. (Adapted from Yang & Yang, Reprinted with the expressed written consent from Chest. Yang SC, Yang, SP. Effects of inspiratory flow waveforms on lung mechanics, gas exchange, and respiratory metabolism in COPD patients during mechanical ventilation. Chest. 2002; 122: The current authors thank the publisher and authors for allowing the insertion of the flow waveforms in Figure 2 into this manuscript.) each breath is supported, the diaphragmatic musculature may atrophy because of insufficient use. This may lead to difficulty weaning because improvements in compliance may be offset by diaphragmatic muscular atrophy. It is suggested that the infant be switched to SIMV with improvement in respiratory status to circumvent these problems. 12 If an infant decompensates and fails to have spontaneous breathing, an adequate backup rate must be set, or the infant must be switched to a more appropriate mode. Advances in Neonatal Care Vol. 7, No. 1

7 _ANC701-Snow.qxd 1/31/07 12:47 PM Page Snow and Brandon TABLE 3. Comparing and Contrasting Common Modes of Ventilation 8-9,12-14,20-23 Ventilator Mode Definition Advantages Disadvantages Intermittent mandatory ventilation Synchronized intermittent mandatory ventilation Assist-control Pressure-support ventilation Pressure-control ventilation Pressure-regulated volume control Delivers breath at a set rate per minute regardless of patient effort. Synchronizes breaths, basing the timing on the patient s inspiratory effort. Similar to SIMV in that the breaths are synchronized but every patient breath is supported. A backup rate is often used in the event of apnea. 14 PSV provides pressure support (above PEEP) with a variable flow to assist in spontaneous breaths. 8 Similar to pressure limited, but the flow is variable so that the PIP can be met earlier in the inspiratory phase and held at a plateau pressure (square pressure waveform). Uses AC breaths to deliver a unique decelerating flow waveform. Volume controlled but breath terminates when a set pressure is met. May be useful for paralyzed infants or in those who have no/limited respiratory effort. Improves infant s comfort and lessens gas trapping, air leaks, irregular arterial and cerebral blood flow velocity. 12 Improved patient comfort. Works well in infants with a strong respiratory drive and those who are not heavily sedated. May be useful in premature infants with RDS. 14 Decreases work of breathing due to the resistance of the ET. Can be used with other modes. May improve respiratory function in young neonates. 21 Beneficial in situations in which there is an increase in the airway resistance (ie, CLD). 8 May be useful in infants with periodic breathing or apnea who are receiving low-level support. 28 May be useful during acute episodes of illness when high PIP is desired but is not an appropriate weaning mode. 8 Often uncomfortable because of asynchrony. 20 May lead to inefficiency, gas trapping, air leaks, irregular arterial blood pressure and cerebral blood flow velocity. 13,20 May still lead to asynchrony if infant s Ti is shorter than the ventilator s preset Ti. May lead to inefficiency if backup rate is insufficient. Does not work well in infants who are heavily sedated or those with a poor respiratory drive. May lead to diaphragmatic muscle atrophy and difficult weaning. 12 May make weaning more complex simply because there are multiple settings to consider. May also increase lung injury in premature neonates. 25 Difficult to use in small infants because of excessive dead space, which may result in false volume measurements and lead to autocycling and insufficient PIP. 8,11 (continued )

8 _ANC701-Snow.qxd 1/31/07 12:47 PM Page 15 Common Mechanical Ventilation Techniques and Modes Used in Infants 15 TABLE 3. Comparing and Contrasting Common Modes of Ventilation 8-9,12-14,20-23 (Continued ) Ventilator Mode Definition Advantages Disadvantages Volume-guaranteed ventilation VGV has been described as a variation of PSV in which volume, not pressure, guides the delivery of the augmented breath. 11 Results in lower breath-tobreath Vt variability than non-volume targeted modes while maintaining similar arterial blood gas values. 29 VGV has also demonstrated a gas exchange similar to that of SIMV/pressure-limited ventilation but with lower PIP. 30 Short-term use of SIMV with VGV has resulted in automatic weaning of support and enhanced spontaneous respiratory effort while maintaining gas exchange relatively unchanged in comparison with conventional SIMV. 33 A large endotracheal tube leak causes the ventilator to overestimate the delivered volume and then deliver excessive subsequent breaths. 28 May not be appropriate for premature infants weighing less than 500 g and may actually result in hypocarbia in many infants. 31,32 Recent advances in ventilator technology have made pressure-support ventilation (PSV) possible. 21 PSV provides additional pressure (above PEEP) with a variable flow and inspiratory time to assist the infant s spontaneous breaths. 8 PSV is primarily used to decrease the infant s work of breathing that is required to overcome the resistance of the endotracheal tube, the ventilator circuitry, and valves. However, it is important to remember that there is no additional decrease in the work of breathing when pressures FIGURE 8. The Ayre s T-Piece allows a continuous flow of gas through the circuit. The distal end is occluded mechanically by the ventilator to deliver breaths. The fresh gas flow through the circuit allows the infant to breath spontaneously between prescribed ventilator breaths. This schematic represents the basic concept but modern ventilators have the device built into the ventilator. greater than 10 cm H 2 O are applied. 12 PSV is often used in conjunction with other ventilator modes, such as SIMV or pressure-control ventilation. For example, a ventilator set to deliver SIMV that is time cycled and pressure limited with pressure support on a rate of 30 breaths per minute would provide 30 SIMV breaths that are pressure limited, but every breath greater than 30 would receive pressure support. Migliori et al 21 concluded that PSV (as compared with SIMV) seems to improve respiratory function in preterm neonates. Infants had decreased work of breathing and lower respiratory rates. 21 PSV can be effectively used in infants who are fatigued or for infants who are weaning from the ventilator but need to learn to reuse their respiratory musculature. 12 Infant s with CLD have air trapping and often respond well to PSV because they can control their own flow and inspiratory time. Thus, they have shorter inspiratory times and longer expiratory times. This leads to less tachypnea, improved patient synchrony, and decreased PaCO 2. Assessment of spontaneous breath effort by nurses and clinicians is essential in determining if the level of pressure support is adequate. Like pressure-limited ventilation, pressurecontrolled ventilation provides additional pressure over the PEEP. In addition, the flow is variable so the PIP can be met earlier in the inspiratory phase and held at a plateau pressure (square pressure waveform). This increases the speed of pressurization of the circuit and airway, which serves to improve gas distribution and helps to decrease airway resistance. This type of Advances in Neonatal Care Vol. 7, No. 1

9 _ANC701-Snow.qxd 1/31/07 12:47 PM Page Snow and Brandon ventilation may be beneficial in situations in which there is an increase in the airway resistance (ie, CLD). 8 However, pressure control also may increase lung injury in premature neonates. 25 Injury may be associated with the flow-related increased mean airway pressure (MAP) that exists with this ventilator modality (as compared with pressure-limited ventilation or volume ventilation). Pressure-controlled ventilation and pressure-limited ventilation require close patient assessment because rapid changes in compliance can result in large changes in Vt. The variable volumes that occur during changes in compliance or airway resistance may give rise to hypo- or hyperinflation. 8 A decrease in lung compliance leads to a decrease in Vt (and vice versa). Nurses have an essential role in observing and minimizing large compliance changes through observing the Vt, assessing lung excursion, and performing supportive care techniques, such as frequent turning and endotracheal tube suctioning as needed. Pressure-regulated volume control (PRVC) is a mode of ventilation on the Siemens Servo 300A Ventilator (Siemens, Erlangen, Germany). PRVC uses AC breaths to deliver a unique decelerating flow waveform. Lung compliance is assessed over several (usually 4) learning breaths. 8 The ventilator delivers the 4 breaths and modifies the pressure to attain the prescribed Vt. Subsequently, the breaths are both pressure and volume regulated. 11 This mode may be useful during acute episodes of illness when high PIP is desired but is not an appropriate weaning mode. 8 With this type of ventilation, the potential exists for development of hyperventilation if the infant becomes tachypneic. PRVC often is difficult to use in small infants because the Vt is measured at the ventilator (versus at the proximal endotracheal tube); thus, the dead space within the ventilator circuit may result in false volume measurements and lead to autocycling and insufficient PIP. 8,11 In addition, there is conflicting data about the efficacy of this mode of ventilation. Piotrowski et al 26 reported that PRVC can be used safely in infants and may contribute to a lower incidence of complications such as air leaks and intraventricular hemorrhage. However, a study by D Angio et al 27 failed to find any advantage to PRVC over SIMV in the treatment of premature newborns with RDS who have received surfactant therapy. Volume-guaranteed ventilation (VGV) is a hybrid mode that supplies a pressure-limited breath at a fixed flow rate in addition to a clinician-selected Vt. The ventilator adjusts the pressure based upon the average expired volume on a number of previous infant breaths. 8 Thus, the infant s expired volume is used as a basis for determining future Vt. This feature differentiates VGV from other volume modalities. VGV is currently available only on the Dräger Babylog 8000 (Dräger Medical, Lübeck, Germany). It can be used with SIMV, ACV, and PSV. With SIMV and ACV, the inspiratory time is set by the clinician. When VGV is used with PSV the inspiratory time is determined by the infant. VGV has been described as a variation of PSV in which volume, not pressure, guides the delivery of the augmented breath. 11 This can be problematic if the volume lost from around the endotracheal tube is too excessive. A large endotracheal tube leak causes the ventilator to overestimate the delivered volume and then deliver excessive subsequent breaths. 28 Overall, VGV results in lower breath-to-breath Vt variability than do the non volume-targeted modes while maintaining similar arterial blood gas values. 29 VGV has also demonstrated a gas exchange similar to that of SIMV/pressure-limited ventilation but with lower PIP. 30 This strategy may not be appropriate for premature infants weighing less than 500 g and may actually result in hypocarbia in many infants. 31,32 VGV is useful in infants with periodic breathing or apnea who are on low-level support. 28 In these infants, the shallow breaths occurring before an apneic phase are supported sufficiently with a guaranteed Vt to avoid hypercarbia or hypoxia, thus preventing bradycardia or decompensation. Short-term use of SIMV with VGV has resulted in automatic weaning of support and enhanced spontaneous respiratory effort while maintaining gas exchange relatively unchanged in comparison with conventional SIMV. 33 Additional study of VGV may give rise to guaranteed minute ventilation (minute ventilation is the volume of gas delivered into the lungs per minute), wherein a desired minute ventilation is designated and the ventilator delivers a mixture of Vt and frequency to provide the desired minute ventilation. 22 DISCUSSION The evolution of the modern NICU has provided great opportunity for ventilator innovations. Established premodern techniques, such as volume-cycled ventilation and pressure-limited ventilation, have been combined within newer ventilators to create many different types of hybrid techniques. Pressure-Limited Ventilation Pressure-limited ventilation (time-cycled, pressurelimited ventilation) is the most commonly used modality in infants. It can be delivered using IMV, SIMV, PSV, or ACV. Settings that are commonly manipulated by clinicians include the rate, PEEP, PIP, and inspiratory time. These parameters are manipulated to achieve desired changes in an infant s blood gas or clinical condition (Table 4). This modality is designed to minimize barotrauma. The ventilator delivers a volume of gas until a preset PIP has been met. Pressurelimited ventilators offer several advantages compared with volume ventilation, including their simple design and ease of operation. Novice clinicians such as house

10 _ANC701-Snow.qxd 1/31/07 12:47 PM Page 17 Common Mechanical Ventilation Techniques and Modes Used in Infants 17 TABLE 4. Common Ventilator Adjustments and the Resultant PaCO 2 /PaO 2 Expected Change 20 Parameter PaCO 2 Change PaO 2 Change Increase in FiO 2 No Change Increase in rate Increase in peak inspiratory pressure Increase in proximal end-expiratory pressure Increase in tidal volume Note that these changes are only what is expected. With some changes the result may be paradoxical. For instance, extremely high rates may not allow a sufficient time for exhalation. The PaCO 2 may subsequently rise because it is not being eliminated. PaCO 2, partial (tension) of carbon dioxide, artery PaO 2, arterial oxygen pressure (tension) staff and new nurse practitioners can learn the modality in a short period. 12 More importantly, pressurelimited ventilation allows for the monitoring and control of PIP. This is important because the delivery of excessive PIP has been implicated as a cause of air leaks and CLD in premature infants. 34 Close monitoring of the infant s clinical status permits timely weaning of the PIP as compliance improves, thereby preventing lung injury. Alternatively, when compliance worsens, the same PIP will be delivered despite declining Vt. Normal Vt for an infant should be 4 to 6 ml/kg. Nurses must monitor Vt levels closely and know how to rapidly troubleshoot reasons for changes in Vt and for patient decompensation (ie, kinked tubing, secretions, pneumothorax). Nurses must be aware of what a certain ventilator should do. For example, increasing the rate should decrease the PaCO 2 (Table 4). Volume-Cycled Ventilation Volume ventilation is a method of ventilation meant to prevent the detrimental effects of volutrauma. A volume ventilator does this by varying the delivered pressure while delivering a set volume (milliliters per kilogram), thus preventing overdistention of the lungs by volume. This mode is time cycled and can be delivered using IMV, SIMV, PSV, or ACV. Settings commonly manipulated by clinicians (in SIMV-volume mode or IMV-volume mode) include rate, Vt, PEEP, and inspiratory time. Volume ventilation also allows for a stable minute volume (minute ventilation is defined as Vt in ml ventilator frequency) that is independent of lung compliance. As an infant s compliance improves, the PIP required to deliver the set volume will automatically decrease. This functions as a form of automatic weaning mode in neonates. 8 This autoweaning occurs because the PIP is reduced as compliance improves. This is especially useful during rapid compliance changes that often occur during RDS or after surfactant instillation. 8 There are a few inherent disadvantages in volumecycled ventilation. There is some loss of volume via the uncuffed endotracheal tubes. This is the major reason pressure ventilation predominates in the care of infants. The prescribed Vt that leaves the ventilator and the Vt measured at the proximal endotracheal tube may not be the same volume that is delivered to the proximal airway because of an air leak. There is also a built-in loss of volume because of circuit tubing size and compliance, humidification, and pulmonary compliance. 28 Volume ventilation also has a slower rise to peak pressure and can have an uneven gas distribution within the lung parenchyma. 8 Infants may also breath out of synchrony because of the fixed inspiratory flow that occurs with volume ventilation. In this situation, the infant s flow differs from the ventilator flow and results in flow starvation and increased work of breathing. 28 Finally, with volume ventilation, if the infant has periods of decreased compliance or increased resistance, barotrauma may occur secondary to the high level of PIP required to deliver the set Vt. Thus, nurses must monitor PIP levels closely during volume ventilation. PIP levels are displayed on the ventilator. Visually assessing chest rise frequently is essential in ensuring proper ventilation of the neonate. Volume ventilation has been shown by several studies to be an effective mode of ventilation for neonatal patients. 32,35,36,37-39 One study reported that volume ventilation may decrease the acute inflammatory response (via reducing cytokines) in premature infants with RDS. 36 Cytokines are thought to have a role in the pathogenesis of CLD. 10 Thus, volume ventilation theoretically could decrease the incidence of CLD. When compared with pressure-cycled ventilation, volume ventilation appears to reduce the duration of CMV and rates of pneumothorax and severe intraventricular hemorrhage. 35 However, the possibility exists that different types of volume-targeted strategies may have different safety and efficacy profiles. 37 With regard to hypoxemic episodes, volume ventilation (when compared with pressure-limited ventilation) has been shown to shorten the duration of hypoxemic episodes but not to reduce their frequency. 38 NURSING IMPLICATIONS Care of the infant receiving mechanical ventilation includes routine safety checks, ongoing assessment Advances in Neonatal Care Vol. 7, No. 1

11 _ANC701-Snow.qxd 1/31/07 12:47 PM Page Snow and Brandon and monitoring, and quick response to improvement or deterioration in respiratory status (Table 5) Daily care of these infants is dependent upon the nurse s knowledge of the mode of ventilation and the current respiratory goals, including acceptable arterial (ABG) or venous (VBG) blood gas values for the infant s disease and stage of illness. Respiratory goals for individual infants must be developed in collaboration with the healthcare team depending upon the infant s respiratory disease (ie, pneumonia, respiratory distress syndrome, meconium aspiration) and stage of the illness (ie, early, late). For example, a 2-day-old term infant with meconium aspiration may require a higher PaO 2 and a lower CO 2 than would the same infant at 10 days of age. Safety Checks Safety checks for infants on the ventilator should be incorporated with other routine safety practices (Table 5). Ventilator safety checks should be conducted at the beginning of each caregiving shift, hourly, and with any deterioration in infant status. These checks should include ensuring that the infant s current ventilator orders match the current settings. In addition, all monitor alarms should be on, and the endotracheal tube should be well secured to prevent accidental extubation. All safety checks should be documented per unit standards. Ongoing Assessment Assessment of the infant receiving mechanical ventilation should include the establishment of baseline respiratory status and any changes from that baseline. Most of the assessment is consistent with a typical assessment of the respiratory system, including color, capillary refill, breath sounds, vital signs, secretions, and comfort/pain (Table 5). Ongoing assessment is essential to determine if the infant appears comfortable with the ventilator support that is being delivered. Most infants will have a combination of spontaneous and mechanically delivered breaths, and asynchrony with the ventilator may cause discomfort. Infants who are not adequately ventilated may breathe on top of the ventilator or against the ventilator breaths. Infants may have decreased inspiratory effort if they are in pain after surgery. Unilateral absence of chest movement may indicate a pneumothorax, diaphragmatic hernia, phrenic nerve palsy, or possible surgical removal of part of the lung, such as in the infant with a congenital cystic adenomatoid malformation. 44 Ongoing assessment should include use of accessory muscles, which may indicate hypoventilation or a malpositioned endotracheal tube. Infants with enlarged livers, abdominal ascites, or abdominal disorders such as gastroschisis also may have increased work of breathing because of pressure placed on the diaphragm. In addition, pressure on the diaphragm may be caused by large amounts of air in the stomach. Air leaks may require placement of an orogastric tube for stomach decompression. Some nurseries place orogastric tubes as standard of care, whereas others place them only if stomach decompression is necessary (ie, during and after resuscitation). Monitoring ABG or VBG, including assessment for metabolic and respiratory acidosis, is also essential to daily care of the infant requiring mechanical ventilation. With the knowledge of the respiratory goals for the infant, providers can determine from the blood gases if weaning is possible. Ventilator Weaning The goal is to wean the infant from the ventilator as soon as possible because of the potential for lung damage and complications with longer mechanical ventilation exposure. An infant who is considered medically stable (ie, resolution of acute insult, appropriate nutrition for stage of illness), has spontaneous respirations, and has blood gases that would permit weaning based upon the infant s respiratory goals, is generally considered a candidate for weaning from conventional mechanical ventilation. However, the method of weaning is dependent upon the stage of an infant s illness (acute vs chronic) and provider preference. In general, factors that are most toxic to the lungs (ie, oxygen and pressure) are weaned first, and small frequent changes in ventilator parameters are preferred to large changes. 12,44 Changing 1 ventilator setting at a time (rate or PIP) is recommended to permit evaluation of tolerance decreases in different parameters. In addition, evaluation of blood gases generally is done after most changes and before additional changes in ventilator settings. 45 End tidal CO 2 and transcutaneous CO 2 monitors are also useful to trend weaning tolerance. 46 Infant Deterioration Infant deterioration during mechanical ventilation can develop slowly or suddenly. The cause of the deterioration may be worsening of the infant s underlying respiratory disease, new disease processes such as sepsis, or complications related to mechanical ventilation. Deterioration in an infant may be as simple as disconnected oxygen tubing or a major complication, such as an air leak. To minimize consequences for the infant, the cause of the clinical deterioration must be identified and quickly managed. A minimum of 2 healthcare providers should be at the bedside to quickly manage deterioration. When deterioration occurs, both the infant and ventilator should be assessed (Table 5). This assessment should begin with visual inspection of the infant and ventilator and then move to auscultation. Unfortunately, complications that contribute to infant deterioration may be associated with sudden deterioration in one circumstance and slow deterioration in another circumstance and may be related to the infant s fragility or reserve.

12 _ANC701-Snow.qxd 1/31/07 2:21 PM Page 19 Common Mechanical Ventilation Techniques and Modes Used in Infants 19 TABLE 5. Care Issues for the Ventilated Infant Ventilator/Respiratory Issue Safety checks Intervention Ongoing assessment/care Assess 41 Potential for weaning Clinical deterioration Ventilator orders match current settings Ventilator, pulse oximetry, cardiorespiratory monitor alarms on Connected to oxygen Plugged into emergency electrical outlet Machine is cycling (check flow loops if available, chest rise in synchrony with the ventilator) Temperature 36 C to 37 C and 70% humidity with visible condensation of ventilator circuit 40,42 Water collected in ventilator tubing should be emptied; ensure placement of tubing so water will not empty into endotracheal tube No kink in ventilator tubing Endotracheal tube (ETT) in appropriate position with adequate fixation: Well secured (tape or device) No tension on ETT from ventilator tubing Identify and document centimeter mark at infant s lip This mark to be noted when appropriate tube placement is confirmed by x-ray). 41,43 Color cyanosis, pink, mottled, pallor Capillary refill Respiratory effort increased (use of accessory muscles with retractions of chest wall during inspiration) or decreased (with pain) Chest excursion present, symmetrical, synchrony with ventilator Respiratory rate, rhythm, spontaneous, synchrony with ventilator Breath sounds equal without adventitious sounds, grunting, or air leak Apical heart sounds Normal vital signs, including blood pressure Color of secretions during suctioning Comfort level Monitor blood gases per orders or unit guidelines Position nested with head in midline in relation to the trunk and head in neutral extension Change body position every 2 to 3 hours as tolerated, maintaining the position described above; repositioning may require 2 persons Suction as needed; suctioning may require 2 persons Continuous monitoring of oxygen saturation using pulse oximeter Retape (secure) endotracheal tube as needed (alternate corner of mouth in which tube is placed with each securing event) Educate family to ongoing mechanical ventilation needs Medically stable (ie, appropriate hematologic, nutritional, cardiovascular status for stage of illness) Excessive chest excursion Flow loops Overexpansion on chest x-ray Abnormal ABGs (hypocarbia, hyperoxia, respiratory alkalosis) Perform safety checks as listed above Assess Apnea, bradycardia, desaturation Blood gases (respiratory acidosis, metabolic acidosis, hypoxia, hypercarbia) Shift in apical heart sounds Diminished or asymmetrical breath sounds New/different adventitious breath sounds Asynchrony with ventilator Advances in Neonatal Care Vol. 7, No. 1

13 _ANC701-Snow.qxd 1/31/07 12:47 PM Page Snow and Brandon For example, a pneumothorax may cause a sudden deterioration in an infant (apnea, bradycardia, hypoxia, absent breath sounds on the affected side, shift in the apical pulse away from the affected side), or the deterioration may occur over time (diminished breath sounds, worsening ABGs, hypotension). Common complications of mechanical ventilation include: 1. Plugged endotracheal tube or airway obstruction 2. Malpositioned endotracheal tube (right or left mainstem bronchus) 3. Accidental extubation 4. Pneumothorax 5. Pneumomediastinum 6. Pneumopericardium 7. Malfunctioning equipment (ie, ventilator, disconnected oxygen tubing) 8. Pneumonia 9. Pulmonary hemorrhage Many of the safety checks (ie, centimeter mark at secured location) and routine care of the ventilated infant are aimed at prevention or early identification of complications associated with mechanical ventilation. Mishaps with the endotracheal tube, including accidental extubation, are common complications during mechanical ventilation. Numerous methods of securing tubes are used, including taping, metal and plastic bows, and commercial devices. 39 Regardless of the method that is used to secure the tube, frequent monitoring of the tube will permit early identification of poorly secured tubes. Loosening of the tape around the endotracheal tube may permit dislodgement as the infant moves spontaneously or during caregiving. CONCLUSION Optimal ventilation of the newborn consists of maximizing ventilation during the acute phases of respiratory illness while preventing and minimizing the future negative consequences of invasive ventilation techniques. Different modalities of ventilation can be used in the face of evolving lung pathology. Nurses and clinicians must be both active and proactive when choosing and adjusting ventilator modalities. Diligence includes continual assessment of infants and early identification and management of complications associated with CMV. Time-cycled pressure-limited ventilation remains the most utilized mode of ventilation within modern NICUs. Other modalities are sometimes used based on provider experience and certain disease characteristics. The provider should always consider the individual infant, disease process, and clinical status when implementing a particular mode of ventilation. Clark stated, The most important issue is not the specific mode of ventilation, or the ventilator used, but rather a matching of a ventilator strategy to the patient s underlying physiology. 10 Various invasive ventilation techniques should be compared with other noninvasive techniques (ie, continuous nasal positive airway pressure or nasal intermittent positive-pressure ventilation). Future research should attempt to clarify whether noninvasive ventilation actually promotes better outcomes in this population of infants. If effective, less invasive forms of ventilation may prove to be optimal for this delicate population of patients. Future research also should compare established techniques (ie, volumeor pressure-limited ventilation) with newer hybrid techniques when providing ventilation to newborns. This would help to determine which CMV mode would be useful in various clinical situations. Becoming familiar with the basic terminology, modalities, and nursing interventions is essential for nurses and other providers who function in the modern NICU. In conclusion, while discussing mechanical ventilation of premature infants, a question of whether ventilation is an art or a science often surfaces. 28 One can argue this statement from either perspective. However, it is quite clear that understanding the science is essential in performing the art. References 1. MacIntyre NR. Mechanical ventilation: the next 50 years. Respir Care. 1998;43: Centers for Disease Control. Preliminary births for 2004: Infant and Maternal Health Available at: pubs/pubd/hestats/prelimbirths04/prelimbirths04health.htm. Accessed: May 12, Fulbrook P, Delaney N, Rigby J, et al. Developing a network protocol: nurseled weaning from ventilation. The World of Critical Care Nursing. 2003;3: Taylor F. A comparative study examining the decision-making processes of medical and nursing staff in weaning patients from mechanical ventilation. Intensive Crit Care Nurs. 2006;22(5): De D. Clinical skills: a care plan approach to nurse-led extubation. Br J Nurs. 2004;13: Marelich GP, Murin S, Battistella F, et al. Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilator-associated pneumonia. Chest. 2000;118: Webster J. Nurse-led weaning from ventilation and extubation in the paediatric cardiothoracic intensive care unit. Nurs Crit Care. 2000;5: Donn SM, Sinha SK. Invasive and noninvasive neonatal mechanical ventilation. Respir Care. 2003;48: ; discussion, Henderson-Smart DJ, Wilkinson A, Raynes-Greenow CH. Mechanical ventilation for infants with respiratory failure due to pulmonary disease. The Cochrane Database of Systematic Reviews, Issue 4. Available at: CD002770/frame.html. Accessed: June 23, Clark RH, Gerstmann DR, Jobe AH, Moffitt ST, Slutsky AS, Yoder BA. Lung injury in neonates: causes, strategies for prevention, and long-term consequences. J Pediatr. 2001;139: MacIntyre NR. Principles of Mechanical Ventilation. In Murray JF, Nadel JA, Mason RJ, Boushey HA, eds. Murray & Nadel; Textbook of Respiratory Medicine. 3rd ed. Philadelphia, PA: WB Saunders; 2000: Spitzer AR, Greenspan JS, Fox WW. Positive Pressure Ventilation: Pressure Limited and Time Cycle Ventilators. In Goldsmith JP, Karotkin EH, eds. Assisted Ventilation of the Neonate. 4th ed. Philadelphia, PA: WB Saunders; 2003: Carlo, WA, Waldemar AC, Martin RJ, Fanaroff AA. Assisted Ventilation and Complications of Respiratory Distress. In Fanaroff AA, Martin RJ, eds. Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant. 7th ed. St. Louis, MO: Mosby, Inc.; 2002: Johnson HD. Trauma, Burns, and Common Critical Care Emergencies. In Johns Hopkins Hospital, Robertson J, Shilkofski N, eds. The Harriet Lane Handbook: A Manual for Pediatric House Officers. 17th ed. St. Louis, MO: Mosby Inc.; 2005:

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