Ventilation Management DHFOV - Risma

6/27/2019
VENTILATION MANAGEMENT:
What We Can Do Better
From Delivery Room to NICU
Risma Kerina Kaban
Kamajaya Mulyana
Neonatology Division
Child Health Department
Faculty of Medicine University of Indonesia
Cipto Mangunkusumo Hospital
Introduction
• The proper management of respiratory distress
syndrome (RDS) in the delivery room (DR) is a
crucial step, especially for preterm infants.
• “Supporting transition” rather than

“resuscitation” is the preferred term in RDS
management.
• Providing optimal respiratory support is crucial

to improve tissue oxygenation & guarantee
normal gas exchange.
2 RDS Management in DR. IntechOpen. 2018
Ped Respiratory Reviews. 23. 2017
1
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Monitoring & Lung Protective Ventilation
• Pulse Oximetry,
• End-tidal CO2 (EtCO2),
• Blood Gases, Monitoring
• Near-Infrared Spectroscopy (NIRS)
• Chest X-Ray
RDS
Lung Protective Strategies?

• NCPAP 1 2 3
• NIPPV
• nHFO
NIV Failure Intubation
• HFNC CMV
INSURE
Success Surfactant MV
(LISA, MIST) HFV
Weaning Extubation
3
Non-Invasive Ventilation During Transfer to NICU
Baby requiring non-invasive respiratory support following birth
All Gestational Age
Single prong (ETT) CPAP
• via Neopuff® infant T-Piece Resuscitator

• via Hamilton® transport ventilator (non-humidified)
NICU
Binasal CPAP (bubble) HFNC

via Hudson prongs
4
Cipto Mangunkusumo Hospital Guideline
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……NIV During Transfer to NICU

Baby requiring non-invasive respiratory support following birth
< 30 weeks Gestation? ≥ 30 weeks
Binasal CPAP Single prong (ETT) CPAP
(via Hudson prongs with humidified (via humidified Stefan circuit on transport cot)
Stefan circuit on transport cot)
NICU NICU
Provide binasal CPAP (bubble) Continue single prong
as per medical order CPAP in NICU cot
≥ 30 % Is ongoing respiratory support required?
Oxygen requirement? YES NO
< 30 %
Trial off respiratory support
Commence nasal high flow as per medical order
5
The Royal Women’s Hospital. Policy, Guideline and Procedure Manual. 2017
Current Common Ventilation Management
• HFNC
• CPAP
• NIPPV
• CMV
• HFOV
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Monitoring During Neonatal Transition

1. Respiratory Functioning
Monitoring (RFM)
2. End-tidal CO2 (EtCO2)
3. Peripheral Oxygen saturation
(SaO2)
4. Near-infrared spectroscopy
(NIRS)
The Respiratory Functioning Monitoring (RFM) can show in real-time information

about pulse oximetry and the main respiratory data.
7
RDS Management in DR. IntechOpen. 2018
Signals recorded by an RFM during stabilization of a preterm infant in the DR
Pmask
Flow
Vte
SpO2
Pulse
Rate
The signal of pressures delivered during mask PPV is indicated as Pmask, expired tidal Volume
calculation (VTe), flow signal, pulse rate, and oxygen saturation (SpO2) are recorded concurrently.
Pulse rate and SpO2 raise in this example is clearly related to raise in peak pressures during mask
PPV with a following increase in VTe.
8
RDS Management in DR. IntechOpen. 2018
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Infants < 32 weeks of GA receiving mask resuscitation with RFM

(airway pressure, flow, and VT waves)
1 2
RFM visible group, n=26 RFM masked group, n=23
Primary outcomes :
Mask leak, PIP, VTe
9
J Pediatr;160:377-81. 2012
……RFM in the DR
DR Interventions
RFMs in the Visible & Masked Groups

Using an RFM was
associated with
significantly less mask
leak, more adjustments of
mask position & airway
pressure, and a lower rate
*The first 40 inflations were analyzed for each infant.
of excessive VT
10
J Pediatr;160:377-81. 2012
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Patient-Triggered Synchronized Ventilation

Synchronization of spontaneous breathing efforts with inflations
provided by the ventilator are better than non synchronized
ventilation:
- Consistent VT
- Improved oxygenation
- Less sedation
- Less air leak
- Shorter duration of ventilation
Graseby Abdominal
Flow/Volume-triggered
Pneumatic Capsule
Modes of Synchronization
Pressure-triggered NAVA
Neurally Adjusted Ventilatory Assist (NAVA)

• A minimally invasive technology
• NAVA uses electrical activity of the diaphragm (EAdi):
- To trigger onset of inflation
- To modulate inflation pressure in proportion to the infant’s diaphragmatic activity.
- To cycle into expiration when diaphragmatic activity waves.
NAVA during variable spontaneous respiratory drive
The Newborn Lung. Ch 16. 2019

Rev Bras Ter Intensiva. 2017;29(4):408-413
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……NAVA
EAdi
catheter
Esophageal
wall
Diaphragm
Stomach
Blue lines
Adequate
positioning

……NAVA
Maximum electrical activity of the Proportional increase in airway

diaphragm, showing phasic activity of the pressure in response to the
diaphragm, and minimal electrical activity corresponding increase in
of the diaphragm, or tonic activity. electrical activity of the diaphragm.

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23 infants were studied, with median (range) GA at birth 27 weeks (24–41

wk), BW 780 g (490–3,610 g), and 7 days old (1–87 d old)
Patient ventilator asynchrony was lower during NAVA (18.3%

compared with SIMV Baseline Settings (BL) (46.5% ±11.7%; p < 0.05) &
± 6.3%)
SIMV adjusted settings (ADJ) (45.8% ± 9.4%; p < 0.05) Pediatr Crit Care Med. 2017
……SIMVBL VS SIMVADJ VS NAVA
Central apnea, defined as a flat

electrical activity of the
diaphragm more than 5 seconds,
was significantly reduced during
NAVA compared with both SIMV
periods.
The frequency & duration of

central apneas were consistently
lower during NAVA than during
SIMVBL & SIMVADJ (p=0,011)
Pediatr Crit Care Med. 2017
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Prospective Randomized Crossover Trial

15 infants, BW 790 (IQR 675-1215) g, GA 27 ⁺¹ (IQR 26⁺º– 28⁺²) weeks
NAVA-SNIPPV PS
NAVA allows improving patient-

ventilator synchrony in preterm
infants during non-invasive nasal
ventilation by reducing trigger delay
& the number of asynchrony events.
17
Lee, J. et al. Am J of Resp and Crit Care Med;191:A1187. 2015
8 ELBW infants (BW < 1000 g, GA 24-30 weeks)
SNIPPV NIPPV
• n=7 • n=8
• BW 725.71±141.73 g • BW 790.62±58.25 g
• GA 26(25;27) weeks • GA 26(25;27) weeks
Primary outcome :
The need for mechanical ventilation utilizing an endotracheal tube (MVET) at 7
days of life did not differ significantly.
Secondary outcome :
The incidence of BPD was significantly higher in both groups.
Trial with additional sample size is needed to be analyzed in the future

18
Amatya, S., et al. Am J of Resp and Crit Care Med;199:A1891. 2019
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Which Ventilation Mode Should I Use?
AC-VG
if conventional MV is used, targeted
tidal volume ventilation should be
employed. The default initial mode of
conventional ventilation at the RWH
SIMV
(occasionally with VG + Pressure PSV
Support) may be indicated in may be indicated in infants with
some infants with low CO2 but variable compliance (i.e. evolving
are not able to be extubated (i.e. or established BPD) and Ti
severe HIE, airway obstruction)
19
Volume Targeted Ventilation

(VTV)
• Purpose : to ventilate the lungs with an appropriate tidal
volume (VT)
• ↓ variability of VT
• avoiding high VT  ↓ volutrauma
• ↓ VT fluctuations
• ↓ variations in minute volume
• more stable PaCo2 and less hypocarbia  ↓ fluctuation
in cerebral blood flow and ↓ risk of brain injury
• Avoiding a very low VT  ↓ risks of atelectotrauma &
hypercarbia
Klingenberg C et al. J Perinatol. 2011,1–11
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VG ( Volume Guarantee ) Setting
Target VT Based on Various Clinical Situations
23
Adjusting Settings during VG-ventilation
24
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Escalating Respiratory Support

Following clinical assessment & CXR, HFOV should be considered when a baby:
• requires a high MAP (e.g. >12 cm H2O), or

• remains poorly oxygenated despite high FiO2 and increased PEEP, or
• remains acidotic/hypercapnic despite high set VT (6-8 ml/kg), or is unable to
achieve thei set VT even with Pmax ≥ 30-35 cmH2O, or
• has had significant pulmonary haemorrhage, or
• has an air leak syndrome such as pulmonary interstitial emphysema
Early change to HFOV may be more lung protective in these scenarios.
Nasal High Frequency Oscilatory Ventilation

(nHFOV)
• nHFOV is a non-invasive ventilation mode that applies

an oscillatory pressure waveform to the airways using
a nasal interface.
• During nHFOV, spontaneous breathing is maintained

and oscillation is given along with changes in airway
pressure.
• The transmission of actual oscillations to the alveoli

tends to be minimal compared to invasive modes
because the risk of leak is unavoidable.
De Luca, D. Arch Dis Child Fetal Neonatal Ed 10(1136). 2016
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nHFOV Operational
• The binasal short prongs interface is technically feasible and can provide
effective ventilation.
• Nasal masks are as effective as binasal short prongs in providing CPAP.
• Nasal-mask-nHFOV has been used in clinical practice and is suitable for nHFOV.
Suggested parameters boundaries for NHFOV use in two clinical scenarios
A total of 8 RCTs involving 463 patients were included.
The meta-analysis:
- lower risk of intubation (relative risk = 0.50, 95% confidence interval of 0.36 to 0.70)
- more effective clearance of CO2 (weighted mean difference = − 4.61, 95%
confidence interval of − 7.94 to − 1.28) in the nHFOV group than in the nCPAP/BP-
CPAP group.
• nHFOV, as respiratory support in preterm infants, significantly remove CO2

and reduce the risk of intubation compared with nCPAP/BP-CPAP.
• The appropriate parameter settings for different types of noninvasive high-
frequency ventilators, the effect of nHFOV in extremely preterm infants,
and the long-term safety of nHFOV need to be assessed in large trials.
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High-Frequency Oscillatory Ventilation

with Volume Guarantee
( HFOV-VG )
• During HFOV, the same pressure amplitude & frequency can result
in different chest oscillations & tidal volume (VT) due to changes in
lung mechanics & patient–ventilator interactions.
• During HFOV-VG, the clinician can set a target high-frequency tidal

volume (VThf) & the ventilator will automatically adjust the
amplitude pressure to deliver the set VThf.
• Using HFOV-VG reduces fluctuations of VThf & the variability of

partial pressure of carbon dioxide (pCO2).
• Carbon dioxide diffusion coefficient (DCO2) is considered to be the

best predictor of CO2 elimination during HFOV. An optimal DCO2 &
VT have not yet been established due to much individual variance.
29 Arch Dis Child Fetal Neonatal;0:F1–F6. 2018
Yonsei Med J, Jan;59(1):101-106. 2018
Lung Recruitment
30
Neo Guidelines. King Edward Memorial Hospital. 2019
15
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……Lung Recruitment
31
Commencing HFOV from CMV

1. Read MAP on CMV.
2. Set MAP as ordered (usually 2-3 cmH2O above

conventional MAP if using an I:E ratio of 1:2 for hyaline
membrane disease/diffuse atelectasis).
- May require lung opening/recruitment manoeuvres
once started on infant.
3. Set oscillatory frequency as ordered according to patient

age and disease pathology (usually between 8-15 Hz).
- Increase amplitude until infant’s chest wall is visibly
vibrating (rough starting place x 1.5-2 MAP depending
on frequency – higher amplitude at higher frequency).
32
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…… HFOV from CMV
4. Where possible place TcM for TcpCO2 monitoring.
5. Assess lung inflation with a chest X-ray 30 to 60

minutes after commencing HFO. Optimal lung
inflation correlates with obtaining an 8 to 9
posterior rib level expansion (8-8.5 ribs for
extreme preterm, 8.5 – 9 ribs for more mature
infants).
33
Commencing HFOV with VG

(If Already on HFOV)
1. Start HFOV without VG based on above guide.
2. Must start TcM monitoring and check accuracy prior to
starting.
3. Once a steady state has been reached with stable TcpCO2
in target range then:
• Record the VT and amplitude that is being given by
ventilator.
• Set VG at the VT provided by the ventilator.
• Set amplitude limit ~20% above the amplitude currently
used.
4. If ventilator alarming VG low then review patient to see if
there has been a change in clinical state or disease process
(lung derecruitment, worsening disease, pneumothorax
etc.). Clinical review by senior clinician prior to further
increases in the amplitude limit.
34
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Commencing VG on HFOV
Without First Stabilising on HFOV
Start VG based on table below:
• Must start TcM monitoring and check accuracy prior to starting VG.
• Adjust VG to achieve appropriate level of chest wiggle for the

patient you are treating.
35
……Commencing VG on HFOV
Review TcM every 10 minutes initially. If TcpCO2 is:
• Below target range for infant : reduce VG by a maximum 10 %.
(Note, because of HFOV efficiency, you may see very rapid change
in the TcpCO2. Start with small changes then increase if no effect.
Stay by the bedside initially to observe and monitor response).
• Above target range for infant : increase VG by a maximum of 10%

(may need to increase amplitude limit). Again – stay by the
bedside initially, as the change in TcpCO2 may be very rapid (1-2
minutes).
• Once infant is sitting in target range then monitor trend with TcMs.
36
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20 inborn infants at 24–32 weeks’ GA with RDS requiring invasive MV
HFOV + VG
HFOV
(VThf:2 ml/kg)
VThf values were Mean DCO2 measurements Amplitude measurements

significantly different were significantly different were not significantly different
(p = 0.019) (p =0.038) (p = 0.218)
Iscan et al. Karger, Neonatology;108:277–282. 2015
……Impact of VG on HFOV
Ventilation characteristics and blood gas analysis results during the trial periods
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……Impact of VG on HFOV
The incidence of hypercarbia & hypocarbia
Median VT during HFOV

Normocapnic 1.74 ml/kg
Hypocapnic 1.97 ml/kg
Hypercapnic 1.54 ml/kg
• HFOV + VG strategy provides better ventilation compared to HFOV

alone and can achieve optimal gas exchange. Because of the lower
VT hf variability and lower incidences of out-of-target PCO2 levels,
HFOV + VG seems to be feasible for preterm infants.
• Further randomized controlled studies with larger sample sizes are

required to determine if HFOV + VG offers short- and long-term
advantages over HFOV alone in preterm infants with RDS.
6 neonates (GA: 22w5d–23w6d, BW: 424–584 g) ventilated with HFOV+VG
VG was applied for 6 hours & removed for the following 6 hours
Ventilator settings
High-frequency tidal volume (VThf) per weight & amplitude
Enomoto et al. Am J Perinatol. 34(01). 2016
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……Effect of VG on HFOV
Percentage of time with desaturation
The proportion of time with SpO2 <80% was decreased by VG overall
Fluctuation of physiological and respiratory parameters
p < 0.05
Standard deviations
of SpO2, MV & DCO2,
but not HR, were
significantly smaller
p < 0.01 p < 0.01 when babies were on
HFOV+VG compared
with without VG
21
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This pilot study suggests VG combined with

HFOV attenuates fluctuation of SpO2 and PaCO2,
which prevents hypoxia and hypocapnia, and
thus might result in a more favorable prognosis.
Retrospective study comprised 20 VLBW infants, who received HFOV without VG
217 results of blood gas analysis Ventilator Parameters &

Results of Blood Gas Analysis
1 2
Normocapnia Hypercapnia
(n=105) (n=112)
44
Yonsei Med J, Jan;59(1):101-106. 2018
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……Effective VT in HFOV
Comparisons of Parameters between Normocapnia and Hypercapnia Group
Correlation analysis between DCO2 and pCO2 and between VT and pCO2
- DCO2 values
showed negative
correlation with
pCO2.
- VT showed
negative
correlation with
pCO2
45
Yonsei Med J, Jan;59(1):101-106. 2018
……Effective VT in HFOV
Receiver Operating Curve (ROC) analysis
The estimated optimal cut-

off point to predict the
remaining normocapnic
status was a VT of 1.75
mL/kg (sensitivity 73%,
specificity 80%).
In VLBW infants treated with HFOV, VT of 1.75 mL/kg

is recommended for maintaining proper ventilation
46
Yonsei Med J, Jan;59(1):101-106. 2018
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Conclusion
• Heated humidified gas should be used during
resuscitation in the delivery room and during transport.
• Using an RFM results in better ventilation in resuscitation.
• NAVA improves patient-triggered synchronized

ventilation.
• VG is the best mode of mechanical ventilation.
• HFOV + VG strategy provides better ventilation compared

to HFOV alone and can achieve optimal gas exchange
47
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6/27/2019

• “Supporting transition” rather than

• Providing optimal respiratory support is crucial

Monitoring & Lung Protective Ventilation

Lung Protective Strategies?

Non-Invasive Ventilation During Transfer to NICU

Baby requiring non-invasive respiratory support following birth

All Gestational Age

Single prong (ETT) CPAP

• via Neopuff® infant T-Piece Resuscitator

Binasal CPAP (bubble) HFNC

……NIV During Transfer to NICU

< 30 weeks Gestation? ≥ 30 weeks

Binasal CPAP Single prong (ETT) CPAP

≥ 30 % Is ongoing respiratory support required?

Oxygen requirement? YES NO

Current Common Ventilation Management

Monitoring During Neonatal Transition

The Respiratory Functioning Monitoring (RFM) can show in real-time information

Signals recorded by an RFM during stabilization of a preterm infant in the DR

Infants < 32 weeks of GA receiving mask resuscitation with RFM

RFMs in the Visible & Masked Groups

Patient-Triggered Synchronized Ventilation

Neurally Adjusted Ventilatory Assist (NAVA)

The Newborn Lung. Ch 16. 2019

Rev Bras Ter Intensiva. 2017;29(4):408-413

Maximum electrical activity of the Proportional increase in airway

Rev Bras Ter Intensiva. 2017;29(4):408-413

23 infants were studied, with median (range) GA at birth 27 weeks (24–41

Patient ventilator asynchrony was lower during NAVA (18.3%

……SIMVBL VS SIMVADJ VS NAVA

Central apnea, defined as a flat

The frequency & duration of

Pediatr Crit Care Med. 2017

Prospective Randomized Crossover Trial

NAVA allows improving patient-

8 ELBW infants (BW < 1000 g, GA 24-30 weeks)

Trial with additional sample size is needed to be analyzed in the future

Which Ventilation Mode Should I Use?

Volume Targeted Ventilation

Klingenberg C et al. J Perinatol. 2011,1–11

VG ( Volume Guarantee ) Setting

Target VT Based on Various Clinical Situations

Adjusting Settings during VG-ventilation

Escalating Respiratory Support

• requires a high MAP (e.g. >12 cm H2O), or

Early change to HFOV may be more lung protective in these scenarios.

Nasal High Frequency Oscilatory Ventilation

• nHFOV is a non-invasive ventilation mode that applies

• During nHFOV, spontaneous breathing is maintained

• The transmission of actual oscillations to the alveoli

De Luca, D. Arch Dis Child Fetal Neonatal Ed 10(1136). 2016

• Nasal masks are as effective as binasal short prongs in providing CPAP.

Suggested parameters boundaries for NHFOV use in two clinical scenarios

De Luca, D. Arch Dis Child Fetal Neonatal Ed 10(1136). 2016

A total of 8 RCTs involving 463 patients were included.

• nHFOV, as respiratory support in preterm infants, significantly remove CO2

De Luca, D. Arch Dis Child Fetal Neonatal Ed 10(1136). 2016

High-Frequency Oscillatory Ventilation

• During HFOV-VG, the clinician can set a target high-frequency tidal

• Using HFOV-VG reduces fluctuations of VThf & the variability of

• Carbon dioxide diffusion coefficient (DCO2) is considered to be the

Commencing HFOV from CMV