Volume Guarantee Ventilation:

New Paradigm in Neonatal Ventilation

Martin Keszler, MD, FAAP
Professor of Pediatrics
Brown University
Women and Infants Hospital
Providence, RI

Respiratory Support in Neonatology:

State-of-the-Art 2013

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PSV

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Unique Challenges in NB Ventilation

Children Small Adults!

Newborns Small Children!
Transitional circulation
Compliant chest wall, stiff lungs
Unfavorable chest wall mechanics
Limited muscle strength and endurance
Immature respiratory control
Rapid RR, short time constants
Small trachea, high ETT resistance
Uncuffed ETT
Location of flow sensor

Need for a specialty Neonatal Ventilator

Volume or Pressure Ventilation?

BP 200
Bourns LS104

Volume vs. Pressure Ventilation

Volume Ventilation
- Controls the set flow rate
- Cycles when set volume is
delivered
- Pressure rises passively

Pressure Ventilation
- Controls the set pressure
- Cycles when set time or flow is
reached
- Volume depends on compliance

Volume vs. Pressure Ventilation

Volume Ventilation
- Controls the set flow rate
- Cycles when set volume is
delivered
- Pressure rises passively

Pressure Ventilation
- Controls the set pressure
- Cycles when set time or flow is
reached
- Volume depends on compliance

Limitations of Volume - Controlled

Ventilation in Newborns
Tubing System and Humidifier
.
V
Vent

Flow
Sensor

CT
Humid

Actual tidal volume is influenced by:

1) Ratio of circuit compliance to
respiratory system compliance
1
VTLung = VT set *
CT
1+
CRS

Leak

CCRS
RS

Respiratory
System

2) compressible volume of the circuit, including humidifier

Pressure-limited IMV
Continuous flow

PEEP
valve

Spont.
breath

Patient

Expiration

Continuous flow

Pressure
limit

Leak

Patient

Inflation

Why Volume-Targeted
Ventilation?

Volutrauma not Barotrauma

Inadvertent hyperventilation is common

Hypocapnia is bad for the brain and the

lungs

Adult-type volume controlled ventilation

doesnt work well in NB

Effect of Pressure v. Volume on Lung Injury

Hernandez, et al, J Appl Physiol 1989
Capillary
filtration
Capillary
coefficient:
filtration
measure of
coefficient:
acute of
lung
measure
injury
acute
lung
injury

Peak Inflation Pressure (cm H2O)

PIP is Excessive Relative to Compliance!

E
I

!!
VT

FRC

Ventilator-Induced Lung Injury:

Volutrauma, not Barotrauma
Rodents ventilated
with 3 modes:
- High pressure
(45 cm H2O),
high volume
- Low (negative)
pressure, high
volume
- High pressure
(45 cm H2O), low
volume (strapped
chest & abdomen)

Qwl/BW
(mL/kg)

DLW/BW
(g/kg)

*
10
8

Albumin space
(%)

1.2

100

80

0.9

60

6
0.6

40

2
0

0.3

20

*P<0.01.
Dreyfuss D et al. Am Rev Respir Dis. 1988;137:1159-1164.

Volutrauma

Both High and Low PCO2 Increase Risk of IVH

Fabres, et al, Pediatrics 2007

Modalities of Volume -Targeted Ventilation

Manufacturer

Model

Modality

Maquet

Servo 300, Servo-i

PRVC, VC, VS

Viasys

VIP Bird Gold

VAPS, VC

Viasys

Bear Cub 750

Volume Limit

Hamilton

Galileo

Carefusion

Avea

Adaptive Pressure
Ventilation, VC
VAPS + VL
VC, VG

P. Bennett

840

Volume Ventilation
Plus

Draeger

Babylog 8000 +,
Babylog VN 500

VG
VG, VC

Volume Guarantee
Principles of Operation
The PIP (working
pressure) is servoregulated within preset
limits (pressure limit)
to achieve VT that is
set by the user.
Regulation of PIP is in
response to exhaled VT
to minimize artifact
due to ETT leak.
Breath terminates if
130% of TVT reached.
Separate algorithm for
spontaneous and
machine breaths.

Pressure limit
Working
Pressure

VT = VT set by user

Pressure Limit
Working
Pressure

PRESSURE

Target tidal volume

VOLUME

Benefits of VG
Maintenance

of (relatively) constant tidal volume

Prevention of volutrauma and hypocapnia due to:
Surfactant administration
Lung volume recruitment
Clearance of lung fluid
Automatic lowering of pressure support level
during weaning
Compensation for variable respiratory drive
stabilization of tidal volume and minute
ventilation due to changes of respiratory
drive (periodic breathing)

The benefits of VTV can not be

realized without ensuring that the
tidal volume is evenly distributed
throughout an open lung!!!

Non-Homogenous Aeration in RDS

Atelectotrauma

Recruitment/ derecruitment injury

Ventilated
Stable

Expiration

Ventilated
Unstable

Unventilated

Shear
forces

Inspiration

Adequate PIP, Adequate PEEP

Good oxygenation, low FiO2, minimal lung injury

VT

CCP

FRC

COP

CCP = critical closing pressure; COP = critical opening pressure

OLC Prevents Lung Injury

VG Reduces Markers of Lung Inflammation

Lista, et al 2005 & 2006

Two prospective randomized trials

A/C vs. A/C + VG

BAL on days 1,3,5

VG @ 5 mL/kg reduced proinflammatory cytokine levels and

decreased duration of ventilation

VG @ 3 mL/kg increased proinflammatory cytokine levels

Low PEEP (3-4 cm H2O)

Patient-Ventilator Interactions

Proportion of Values Outside the

Target Range
60%

A/C
A/C+VG

50%

40%

30%
20%
10%
0%
VT>6/kg
p < 0.001

PaCO2<35
Keszler, et al. Ped Pulmonol 04

Spontaneous Hyperventilation and VG

VT (ml)

PIP (cm H2O)

18
16
14
12
10
8
6
4
2
0

18
16
14
12
10
8
6

PIP
PIP limit
PEEP
VT
Set VT

4
2
0
1

9 10 11 12 13 14 15

Breath #

Note the large VT, generated by the infant, while the PIP
drops near the PEEP level as the ventilator in VG mode
responds appropriately to the large VT by reducing PIP.

A/C + VG vs. SIMV + VG

Hypothesis: VG is more efficient with A/C

12 NB 26 + 2.4 wk GA, BW 679 + 138 g

Study age 27 + 18 d, wt 887 + 138 g
Crossover design, four alternating 2 hour periods
VT set at 5 ml/kg, rate at 30/min in both groups
All other settings same in both modes
SPO2, HR, VT , PIP, RR, MV downloaded
continuously (Lufu3)

VG Combined with A/C v. SIMV

Variance of VT and SpO2
12

A/C + VG

10

SIMV + VG

6
4

2
0
VT variance

* P < 0.001

SpO2 variance

Abubakar, et al, J Perinatol 2005

VG Combined with A/C v. SIMV

Ventilator Variables Mechanical Inflations
18

A/C + VG
SIMV + VG

16
14
12
10
8
6
4
2
0

# P < 0.005

PIP

VT

MV (L/min x 10)

Abubakar, et al, J Perinatol 2005

Synchronized Ventilation: The Magnitude of

VT is the result of the combined effort of
ventilator and patient!
Trans-pulmonary pressure

Tidal
Volume

Patients
Pleural
Pressure

Machine
Generated
Pressure

VG Combined with A/C v. SIMV

Cardio-Respiratory Variables
180
160

A/C + VG

SIMV + VG

140
120

100
80
60

40
20
0

* P < 0.001

HR

RR

SpO2

Abubakar,et al, J Perinatol 2005

Normal Response of VG

Problem 2o Irregular Resp Effort

Working
Pressure

PRESSURE

FLOW
Target tidal volume

VOLUME

Transpulmonary Pressure

Spontaneous
effort

Transpulmonary Pressure

Separate Algorithm
Working
Pressure
PRESSURE

FLOW

Target tidal volume

VOLUME

Cochrane Review: Duration of MV

Wheeler, et al 2010

Cochrane Review: Death or BPD @ 36 wk

Wheeler, et al 2010

Cochrane Review: Pneumothorax

Wheeler, et al 2010

Systematic Review:
Severe IVH / PVL
Morley 2012

Summary of VG Studies

When compared to PLV, VG results in:

Same or lower PIP 1,2,3
More stable VT 1,3
Less hypocapnia 3
Faster recovery from forced exhalation episodes3
Works better with A/C than SIMV 4
Faster recovery from suctioning 4
Pro-inflammatory cytokines decreased @ 5 ml/kg5
Faster weaning from mechanical ventilation5
Higher VT needed in RLBW* infants 6
Higher VT needed with advancing post-natal age 3
1 Herrera et al, 2 Cheema, et al, 3 Keszler, et al, 4 Abubakar, et al, 5 Lista, et al
6 Montazami, et al

* RLBW = Ridiculously low birth weight infant (<600g)

One size does NOT fit all!

VT in infants with MAS

Sharma, et al PAS 2011

Relationship of Birthweight and VT

Montazami,et al, Ped Pulmonol 2009
6.5

VT (ml/kg)

RLBW *

ELBW

5.5
5
4.5
4
3.5
3
0.3

0.4

0.5

*RLBW = Ridiculously LBW

R= -0.563 p<0.001

0.6
Weight (kg)

0.7

0.8

0.9

Conventional Physiology
Anatomical dead-space = 2mL/kg. Instrumental dead-space is fixed.
Anatomical + Instrumental dead-space = 3mL in a typical 1 kg infant
Anatomical + Instrumental dead-space = 2.5mL in a typical 0.5 kg infant
Alveolar ventilation = tidal volume dead-space volume) x RR
Alveolar ventilation = X

VT = 5mL , DS=3mL

Alveolar ventilation
= 0.5 X

VT = 4mL , DS=3mL

Alveolar ventilation
=0

VT = 3mL , DS=3mL

Time to Eliminate CO2 from Test Lung

Seconds

500
450
400
350
300
250
200
150
100
50
0
DS + 2

DS+ 1

DS

DS -0.5

DS - 1

Volume
Volume above orTidal
below
dead (ml)
space (mL)

Keszler, et al. ADC FN 2012

DS -1.5

Gas Flow Through Narrow ETT

Fresh gas inflow spikes through DS gas

Mixing when flow abruptly stops

Exhaled gas spikes through mixed DS gas

Hendersons Experiment 1915

Relationship of Post-Natal
Age and VT (mL/Kg)

VT (mL/kg)

Day 1-2
n = 251

Day 5-7
n = 185

5.15 + 0.6

5.24 + 0.7

Day 14-17 Day 18-21

n = 216
n = 176
5.63 + 1.0

6.07 + 1.4

PCO2 (torr) 44.0 + 5.4 46.3 + 5.2 53.9 + 7.3

53.9 + 6.2

Keszler,et al, Arch Dis Child 09

VG-Clinical Caveats
VG should be implemented early.
Initial target VT is 4 - 5 mL/kg during the acute
phase of the illness.
Larger VT is needed in ELBW infants, those with
MAS and older infants with chronic lung disease!
PIP limit should be set 25% above the working PIP
and adjusted as needed.
PIP will default to the limit if sensor is out or when giving
a manual breath!
Mainstem bronchus intubation can result in volutrauma
If the low VT alarm sounds repeatedly, increase the
pressure limit AND INVESTIGATE THE CAUSE

Corrected VT

Herber-Jonat, Ped Crit Care Med 2008

VG Clinical Guidelines: Weaning

If target VT is set at low normal (usually 4 mL/kg in first
few days, higher later on) and PaCO2 is allowed to rise
to the mid - high 40s (pH <7.35), weaning occurs
automatically (self-weaning).
If VT is set too high and/or the pH is too high, the baby
will not have a respiratory drive and will not self-wean.
Avoid oversedation during the weaning phase!
If significant oxygen requirement persists, PEEP may
need to be increased to maintain mean airway pressure
as PIP is automatically lowered.
Most infants can be extubated when they consistently
maintain VT at or above the target value with working
PIP < 10-12 cm H2O (< 12-15 cm H2O in infants > 1 kg)
with FiO2 < 0.35 and good sustained respiratory effort.

Work of Breathing @ Different VT target

Patel, et al Pediatrics 2009

VG-SIMV: Minute Ventilation

Herrera, et al, Pediatr 2002
ml/kg/min

250
200
150

Total
Mech

100

Spont

50
0
SIMV

SIMV+VG4.5 SIMV+VG3

Whats Next?

Define optimal settings/weaning in BPD

Randomized trial to show the impact of VG in

the immediate post-intubation period

Comparison with other volume-targeted

modes
Long-term studies with important clinical
endpoints: BPD, duration of mech. vent.

Thank You

mkeszler@WIHRI.org

Troubleshooting

There will be more alarms (interactive mode,

gives useful information, pay attention to it)
Avoid excessive alarms (they get ignored!
Common causes:
- Limits are too tight (most often pressure limit)
- Excessive ETT leak (change ETT if leak > 40%
(Less of a problem with the VN 500)

- Forced exhalation episodes

- Agitation
Excessive noise
handling
lack of boundaries

VG vs NAVA

Extreme Periodic Breathing

Owen, et al, ADC 2010

Interrupted Exhalation

SIMV: Uneven VT
(Osorio, et al. J Perinat Apr 05)

7
6

ml/kg

5
4
3
2
1
0
SIMV

SIMV+PS3
VT SIMV

SIMV
VT spont

SIMV+PS6

MV and Anatomical Dead Space

in ELBW Infants

As gas is delivered under pressure

to the newborn lung, the airway
expands in proportion to its
compliance.1
Over time, elasticity is lost and
airway becomes larger than
normal.
Preterm infants who are mechanically
ventilated have larger tracheal widths
than nonventilated neonates (Figure)2

5.0

4.0

Tracheal Width, mm

3.0

2.0

Ventilated

1.0

Non-ventilated

750

1,000

1,250

Study Weight, g

1. Greenspan JS, et al. Neonatal Netw. 2006;25:159-166.

2. Bhutani VK, et al. Am J Dis Child. 1986;140:449-452.

1,500