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Ventilatory management in extremely low birth weight infants
1Department of Pediatrics, The Hospital for Sick Children, The University of Toronto. shaun.morris@utoronto.ca
Insights
Optimizing mechanical ventilation after surfactant therapy in premature infants significantly reduces chronic lung disease. Adjusting ventilator settings like lower pressures and using synchronous intermittent mandatory ventilation improves outcomes for neonates.
Area of Science:
- Neonatology
- Pediatric Pulmonology
- Critical Care Medicine
Background:
- Mechanical ventilation improves survival in premature infants but increases the risk of ventilator-induced lung injury (VILI) and chronic lung disease (CLD).
- High-frequency ventilation (HFV) has shown promise in reducing VILI and CLD in very low birth weight infants.
- Understanding optimal ventilator strategies for conventional mechanical ventilation (CMV) is crucial for minimizing CLD in neonates, especially after surfactant administration.
Purpose of the Study:
- To investigate whether optimizing lung volumes on CMV can minimize CLD in neonates.
- To evaluate the impact of evolving ventilatory strategies on mortality and CLD incidence in extremely low birth weight infants.
Main Methods:
- Retrospective review of medical charts of 51 extremely low birth weight infants from two distinct epochs (1990-1991 and 1999-2000).
- Analysis of ventilatory strategies, including peak inspiratory pressure (PIP), mean airway pressure (MAP), and mode of ventilation (e.g., synchronous intermittent mandatory ventilation - SIMV).
- Comparison of outcomes (mortality and CLD rates) between different eras and in relation to surfactant therapy and ventilation management.
Main Results:
- Surfactant therapy improved pulmonary compliance but necessitated adjustments in ventilatory management to prevent lung damage.
- In the pre-surfactant era, mortality was 30% and CLD was 40%. Post-surfactant, mortality decreased to 18%, but CLD increased to 78%.
- In the most recent era, with 10 years of experience, mortality was 17% and CLD was 21%, associated with lower PIP/MAP and increased SIMV use in the first 24 hours post-surfactant.
Conclusions:
- Ventilator strategies, particularly in the immediate period following surfactant administration, significantly impact long-term morbidity in premature infants.
- Lowering peak inspiratory pressure and mean airway pressure, alongside increased use of synchronous intermittent mandatory ventilation, is associated with improved outcomes.
- Further research is needed to optimize conventional ventilation modes for protecting the immature lung and managing lung volumes effectively.
Abstract:
The improvement in survival in premature infants associated with the evolution of mechanical ventilation has been accompanied by an increase in ventilator induced lung injury. High frequency ventilation has been shown to reduce the incidence of ventilator induced lung injury and hence chronic lung disease in the very low birth weight infant. The evolution in understanding how to best use high frequency ventilation in this population has prompted us to ask whether similar strategies to optimize lung volumes on conventional mechanical ventilation can minimize chronic lung disease in the neonate. We retrospectively reviewed the medical charts of 51 extremely low birth weight infants born in Kingston, Ontario in two epochs, 1990 to 1991 and 1999 to 2000, for ventilatory strategy and outcome. From our review, it is clear that surfactant therapy rapidly changes lung mechanics by improving pulmonary compliance and that lung damage may result if there are not changes in the ventilatory management to reflect the altered compliance. Early ventilation strategies during the apparently stable "honeymoon period" in a patient with respiratory distress syndrome (RDS) has significant implications on long term morbidity. In the era prior to the use of surfactant, 30% of infants died and 40% developed chronic lung disease (CLD). Immediately following the use of surfactant , mortality was reduced to 18%, however, the incidence of CLD increased to 78%. In the most recent era, following 10 years of experience with surfactant and mechanical ventilation, morbidity was 17% and CLD 21%. This study demonstrates that a particularly crucial time is in the immediate period following surfactant administration. The use of lower peak inspiratory pressure (PIP) and mean airway pressure (MAP) over the first 24 hours and an increase in the use of synchronous intermittent mandatory ventilation (SIMV) was associated with an improved outcome. The challenge remaining is to determine how to best utilize a conventional mode of ventilation to best optimize lung volume and protect the immature lung.
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