Neonatal mechanical ventilation

Neonatal mechanical ventilation is a cornerstone in the management of respiratory failure in newborns (NBs), particularly in preterm infants, in whom pulmonary and neurologic increases their vulnerability to ventilation-induced lung injury. At present, the primary objective of respiratory support is to ensure adequate ventilation while minimizing lung and brain injury through lung-protective strategies and careful oxygen titration. Noninvasive ventilation (NIV) is currently the first-line approach for both initial respiratory support and post-extubation care, as it reduces the need for invasive ventilation and the incidence of ventilator-induced lung injury. Multiple modalities and devices are available, and their selection should be individualized according to the underlying disease, gestational age, and clinical response. The selection of the appropriate interface and ventilatory settings and patient-ventilator synchronization are of utmost importance. Noninvasive ventilation failure should be preceded by systematic optimization and requires well-defined criteria for timely therapeutic escalation. Conventional mechanical ventilation continues to be necessary in more severe cases. Its use should be synchronized and volume-targeted whenever possible, as this strategy has been shown to reduce major complications such as pneumothorax, intraventricular hemorrhage, and the composite outcome of death or bronchopulmonary dysplasia. High-frequency oscillatory ventilation serves as a rescue strategy in refractory cases and selected clinical condition, relying on the maintenance of lung recruitment with extremely low tidal volumes. Finally, ventilatory management of the most common neonatal respiratory conditions-such as respiratory distress syndrome, meconium aspiration syndrome, air leak syndrome, and bronchopulmonary dysplasia-requires a dynamic, individualized approach focused on lung protection from the earliest hours of life.