Physiologic Principles

of Mechanical
Ventilation In Neonates

Dr. Ravi Ambey,M.D.

Assistant Professor, Pt.J.L.N.M. Medical
College,
Raipur (C.G.)
 Normal Respiratory
Cycle
 Lungs behaves like a balloons
 The lung is expanded by the force
generated by the diaphragm &
the intercostal muscles
 It recoils secondary to elastic &
surface tension forces
 This facilitates the in flow &
outflow of the respiratory gases
( ventilation )
 How Does This Happens?
• Normal Intrapleural Pressure is sub
atmospheric (negative)
• During a spontaneous inspiration
forces generated by the respiratory
ms causes the intrapleral pr to
become more negative (-6 to –8 cm
H2O)
• During passive expiration the
respiratory ms relax & the
intrapleural pr becomes less
negative
• With forced expiration (HMD),
Normal Respiration
 What Happens in positive
pressure Ventilation
• Positive Pressure Ventilation
causes pressure changes
opposite to that of spontaneous
breathing
• During Inspiation the ventilator
generates positive pressure in
the airway to drive the gases into
the lungs
Positive Pressure Ventilation
Ventilator Breath Cycle
 Why A Newborn Is More
Prone For Respiratory
Failure
• Infants thorax is more cylindrical &
ribs are more horizontal rather than
oblique
• Insertion of diaphragm is more
horizontal than in adults
• Infant has low muscle mass & low
percentage of type I muscle fibers
• Compliant chest wall offers little
opposition against collapse upon
expiration
• Premature newborn suffers from
 Why A Newborn Is More
Prone For Respiratory
Failure
• Airways are small ( less diameter )
• Oxygen consumption per kg body
weight – Higher
• Low FRC reduces the oxygen reserve
& also reduces the time that can be
allowed in an infant
PHYSIOLOGICAL
VARIABLES
 Tidal Volume (VT)
• The amount of gas inspired in a
single spontaneous breath or
delivered through an ET tube
during a single cycle of
ventilation
• Normal 5-8 ml/kg
• Mechanical Ventilation – delivered
VT should be in the range of 5-6
ml/kg
• VT >8.5 ml/kg indicates over
 Minute Ventilation ( VE)

• VE = VT x Respiratory Rate
• In a 3 kg Newborn VT 5-8
ml/kg & RR 40-60/min
• So that VE = 5-8 X 40-60 =
200-480 ml/kg
• 600-1440 ml
• Alveolar Ventilation = (VT –
VD) x RR
 Dead Space
Anatomic Dead Space; the portion of
the incoming VT that fails to arrive to
the level of respiratory bronchioles &
alveoli but instead remains in the
conducting airways occupies the
space known as anatomic dead space
Alveolar Dead Space; Portion of VT may
be delivered to unperfused alveoli,
where gas exchange does not take
place is known as alveolar dead space
Total or Physiologic Dead Space (VDS);
Ratio of Dead Space to Tidal Volume
(VDS/VT); this defines wasted
 Compliance
• Opposite of stiffness
• This is the distensibility of lungs &
chest wall
• This is change in volume per unit
change in pressure
• CL=change V/change P
• Smaller the lung lower the compliance
• Specific Compliance; when lung
compliance is corrected to lung
volume. This value is identical for
The higher
the
compliance
the larger
the delivered
volume per
unit change
in pressure
• In the infant immediately after
delivery , specific compliance is
low but normalizes as fetal lung
fluid is absorbed & a normal FRC is
established
• In premature infant , specific
compliance remains low due in
part to persistent atelectasis &
failure to achieve a normal FRC
• Chest wall compliance is very high
in newborn
• Normal infant; 0.003-0.006 L/cm
 Resistance
• Refers to the inherent capacity of the
air conducting system (airways &
endotracheal tube) and tissue to
oppose airflow
• Airway resistance is defined as
pressure gradient (P1-P2) required to
move gas through the airway at a
constant flow rate(V)
• Raw =(P1-P2) / V
• It is expressed as change in pressure
per unit change in flow
• It depends on the radius & length of
the airways & gas flow rate(viscosity
 It is a good practice to shorten the ET
tube in babies on ventilator to
minimize the extra resistance
imposed by the ET tube
 Viscous Resistance; It is generated
by the tissue elements moving past
one another
 Airway Resistance: That occurs b/n
moving molecules in the gas stream
& b/n these moving molecules & the
wall of respiratory system (eg.
Trachea, bronchi, bronchioles)
 Additional resistance to the flow as
gas passes through the ventilator
 The relatively high viscous resistance
in the newborn is due to increase in
tissue density (I.e. a low ratio of lung
volume to lung weight) & the relative
amount of pulmonary interstitial fluid
 The smaller the lung the greater the
resistance
 It is important to remember that
because of the small diameter of the
airways in the newborn , even a
modest narrowing will result in
marked increase in resistance
 Normal newborn 20-40 cm H2O /L
/sec
 Time Constant ( Tc)
• It is the time taken for the airway
pressure & volume changes to
equilibrate throughout the lungs
• In simple words, it is the measure of
how quickly the lung can deflate (or
inflate)
• Tc = CL X Raw
• One time constant of the respiratory
system is defined as the time it takes
the alveoli to discharge 63% of its
Tidal Volume through the airway to
the mouth or ventilator
• For example; compliance is 0.005
L/cm H2O & resistance is 30
cm H2O / L/sec
• So that Tc = 0.15 sec
• And three Tc = 0.45 sec
• It means 95% of the VT should be
emptied from the lungs within 0.45
seconds of when exhalation begins in
a spontaneously breathing infant
• And in a newborn infant receiving
assisted ventilation the exhalation
valve of the ventilator would have to
 Clinical & radiographic
signs
• Radiographic signs of overexpansion
(e.g. increase in AP diameter of thorax,
flattened diaphragm below the 9th
posterior rib, intercostal pleural
bulging)
• Chest wall movement
• Hypercapnia not responding to an
increase in ventilator rate
• Signs of cardiovascular compromise
such as mottled skin color, BP, CVP,
development of metabolic acidosis
 Ventilator adjustments that
decrease the risk of Gas trapping &
Inadvertent PEEP
• PIP (on a pressure preset ventilator)
• VT ( on a volume preset ventilator)
• Inspiratory time (Ti)
• PEEP( acts by Compliance)
• In HMD, since Compliance is , Tc is
short. So that complete inflation &
deflation occurs faster than normal
lungs.

• In MAS, since Resistance is , Tc is

long. So more time must be provided
for expiration (Te), otherwise air
trapping may occur.

• If Inspiratory time is too short there

will be decrease in VT delivery & MAP
 Flow Rate
• The range of flow rate generated by a
spontaneously breathing newborn is
0.6 – 9.9 L/min
• Generally this parameter is not altered
during the ventilation
• Flow condition becomes turbulent
when ventilator flow exceeds 10 L/min
in an infant with 2.5 mm ET tube or
when rate exceeds 10 L/min in an
infant with 3.0 mm ET tube
• With turbulent flow Resistance
increases exponentially
• High flow leads to Resistance, air
 Airway or Tube Length
• The shorter the tube the lower the
resistance
 Airway or Tube Diameter
 When flow is laminar Resistance
can be described by Poiseuille’s
Law
 R = L / r4
 Resistance is the function of the
tube length divided by the radius
of the tube to fourth power
 Therefore reduction in the radius
by half results in 16 fold increase
in the driving pressure required to
maintain a given flow
 This effect is exaggerated in
 Resistance during inspiration is
less than resistance during
expiration because the airway
dilates upon inspiration
 Any process that results in an
increase in lung volume should in
theory reduce resistance to air
flow
 Any process that causes a
reduction in lung volume
( atelectasis) results in increase
in airway resistance
 Gas Density
• The relationship b/n airway
resistance & the density of the gas
in turbulent flow is directly
proportional & linear
• Decreasing the density by 2/3rd ,
such as occurs when a Heliox
mixture (helium 80% & O2 20%) is
administered, reduces airway
resistance to 1/3rd compared to
that when room air is breathed
• Heliox can be useful for reducing
upper airway resistance in
 Work of Breathing
• It is the force generated to overcome
the frictional resistance & static
elastic forces that opposes lung
expansion and gas flow into & out of
the lungs during respiration
• Workload depends on the elastic
properties of the lung & chest wall,
airway resistance, tidal volume, RR
• Energy expenditure correlates with O2
consumption
• Mechanical ventilation reduces O2
• CDP (PEEP/CPAP) may reduce the
work of breathing by increasing the
FRC & bringing breathing to a higher
level on the pressure volume curve
where the Compliance is higher
• Reduction in respiratory work with the
application of CDP have been shown
in newborn recovering from RDS & in
babies after surgery for CHD
• If the lungs are already over inflated ,
increasing CDP will not result in
decrease in work of breathing
Extended compliance curve with
flattened areas ( A & C )
 Elastic Recoil
• During Expiration driving force is the elastic
recoil.
• Elastic recoil is the tendency of stretched
objects to return to normal shape
• Elastic recoil depends on the surface
tension & elastic elements of tissue &
ribcage
• Pressure required to counteract the
tendency of bronchioles & terminal
airspaces to collapse ( elastic recoil ) is
described by Laplace’s relationship;
• P = 2 ST/ r
• In premature babies r is smaller so more
pressure is required to keep the lungs open.
Thank
you