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A narrative review of advanced ventilator modes in the pediatric intensive care unit

Andrew G Miller1,2, Renee M Bartle1,2, Alexandra Feldman1,3

  • 1Duke University Medical Center, Durham, NC, USA.

Translational Pediatrics
|November 12, 2021
PubMed

Insights

Advanced mechanical ventilation modes like HFOV and NAVA are used for pediatric respiratory failure when conventional methods fail. Evidence for these advanced techniques is limited, necessitating further research and multicenter trials.

Area of Science:

  • Pediatric Critical Care Medicine
  • Respiratory Physiology
  • Mechanical Ventilation

Background:

  • Respiratory failure is a frequent cause for pediatric intensive care unit (PICU) admissions.
  • While conventional mechanical ventilation (CMV) suffices for most children, refractory hypoxemia or hypercapnia necessitates advanced ventilator modes.
  • This review examines current knowledge on advanced modes such as high-frequency oscillatory ventilation (HFOV), high-frequency percussive ventilation (HFPV), high-frequency jet ventilation (HFJV), airway pressure release ventilation (APRV), and neurally adjusted ventilatory assist (NAVA).

Purpose of the Study:

  • To synthesize findings from clinical, animal, and bench studies on advanced mechanical ventilation modes in pediatrics.
  • To highlight the limitations in current evidence and identify areas for future research.
  • To discuss the complexities, costs, and accessibility of advanced ventilation strategies.

Main Methods:

  • Review of clinical case series, randomized controlled trials (RCTs), animal studies, and bench research.
  • Analysis of data pertaining to the efficacy and application of various advanced ventilator modes.
  • Examination of factors influencing the clinical implementation of these technologies.

Main Results:

  • The evidence base for advanced ventilator modes is predominantly derived from single-center case series, with limited RCT data.
  • Animal and bench studies reveal the intricate mechanisms and clinical application challenges associated with different modes.
  • Proprietary nature, high cost, and limited availability at well-resourced centers can restrict the use of some advanced modes.

Conclusions:

  • Further research, including large, multicenter trials (observational, interventional, or adaptive designs like the PROSpect trial), is crucial to strengthen the evidence for advanced ventilator modes.
  • Evaluating these modes during extracorporeal membrane oxygenation (ECMO) and incorporating advanced monitoring techniques (volumetric capnography, electrical impedance tomography, transpulmonary pressure) are recommended.
  • Precise reporting of ventilator parameters and physiological variables is essential for future studies and clinical practice.

Keywords:
High-frequency ventilationairway-pressure release ventilationmechanical ventilationneurally adjusted ventilatory assist (NAVA)pediatric

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