Академический Документы
Профессиональный Документы
Культура Документы
sumption and carbon dioxide pro- is very small, such as when the breathing frequently observed in
duction. Ventilation is maintained by endotracheal tube is plugged. The patients who have these conditions.
fine adjustments in tidal volume and Hering-Breuer reflex is also time- Another reflex that affects breath-
respiratory rate that minimize the related (ie, a longer inspiration tends ing is the baroreflex. Arterial hyper-
work of breathing. This fine adjust- to stimulate the reflex more). Thus, tension can lead to reflex hypoventi-
ment is accomplished by motoneu- for the same tidal volume, a breath lation or apnea through aortic and
rons in the central nervous system with a longer inspiratory time will carotid sinus baroceptors. Con-
that regulate inspiratory and expira- elicit a stronger Hering-Breuer versely, a decrease in blood pressure
tory muscles. These neurons receive reflex and a longer respiratory may result in hyperventilation.
input primarily from chemoreceptors pause.
and mechanoreceptors. These two At slow ventilator rates, large
components of respiratory control tidal volumes will stimulate aug- Ventilatory Support
provide feedback to adjust ventila- mented inspirations (Head paradox-
tion continuously. Mechanical venti- ical reflex). This reflex reflects CONTINUOUS POSITIVE AIRWAY
lation results in changes in chemo- improved lung compliance, and its PRESSURE (CPAP)
receptor and mechanoreceptor occurrence is increased by adminis- CPAP has been an important tool in
stimulation. tration of theophylline. This may be the treatment of neonates who have
When PaCO2 changes, ventilation one of the mechanisms by which RDS. The mechanisms by which
is adjusted largely because of the theophylline hastens weaning from CPAP produces its beneficial effects
activity of chemoreceptors in the CMV. include: 1) increased alveolar vol-
brain stem. An increase in PaCO2 Mechanoreceptors also are altered umes, 2) alveolar recruitment and
increases respiratory drive. Because by changes in functional residual stability, and 3) redistribution of
the chemoreceptors most likely capacity. An increase in functional lung water (Table 1). The results are
sense the hydrogen ion concentra- residual capacity leads to a longer usually an improvement in
tion, metabolic acidosis and alkalo- expiratory time because the next ventilation-perfusion matching.
sis have strong effects on respiratory inspiratory effort is delayed. High However, high CPAP levels may
drive that are somewhat independent continuous distending pressure (con- lead to side effects (Table 1).
of PaCO2 values. In contrast, most of tinuous positive airway pressure or Multiple clinical trials have eval-
the changes in ventilation and respi- PEEP) can prolong expiratory time uated the use of CPAP in neonates
ratory drive produced by PaO2 and even decrease the respiratory who have respiratory disorders.
changes depend on the peripheral rate due to the intercostal phrenic Meta-analyses generally conclude
chemoreceptors, which include the inhibitory and Hering-Breuer that CPAP is most beneficial early
carotid bodies and, to a lesser reflexes. Also, it is important to in the therapy of neonates who have
extent, the aortic bodies. In neo- remember that during weaning from established RDS. Prophylactic CPAP
nates, acute hypoxia produces a a ventilator, a high PEEP may in preterm infants does not decrease
transient increase in ventilation that decrease the spontaneous respiratory the incidence or severity of RDS
disappears quickly. Moderate or pro- rate. and does not reduce the rate of com-
found respiratory depression can be Other components of the mech- plications or death. Once the diagno-
observed after a couple of minutes anoreceptor system are the jux- sis of RDS is established, the
of hypoxia, and it is believed that tamedullary (J) receptors, which are administration of CPAP decreases
this decline in respiratory drive is an located in the interstitium of the oxygen requirements and the need
important cause of hypoventilation alveolar wall and are stimulated by for mechanical ventilation and may
or apnea in the newborn period. interstitial edema and fibrosis as reduce mortality. However, the inci-
It is also important to consider well as by pulmonary capillary dence of air leaks is increased
the role of mechanoreceptors in the engorgement (eg, congestive heart among infants who receive CPAP.
regulation of breathing, particularly failure). Stimulation of the J recep- The optimal time to start CPAP
during neonatal life and infancy. tors increases respiratory rate and depends on the severity of RDS.
Stretch receptors in airway smooth may explain the rapid, shallow Early CPAP (ie, when the arterial-
muscles respond to changes in tidal
volume. For example, immediately
following an inflation, a brief period TABLE 1. CPAP or High PEEP in Infants Who Have RDS
of decreased or absent respiratory PROS CONS
effort can be detected. This is called
the Hering-Breuer inflation reflex, Increased alveolar volume and FRC Increased risk for air leaks
and usually it is observed in neo- Alveolar recruitment Overdistention
nates during CMV when a large Alveolar stability CO2 retention
enough tidal volume is delivered. Redistribution of lung water Cardiovascular impairment
The presence of the Hering-Breuer Improved V/Q matching Decreased compliance
inflation reflex is a clinical indica- Potential to increase PVR
tion that a relatively good tidal vol- FRC: functional residual capacity; V: ventilation; Q: perfusion; PVR: pulmonary vascu-
ume is delivered. This reflex will be lar resistance.
absent if the ventilator tidal volume
to-alveolar oxygen ratio is approxi- sounds. In contrast, weight, resis- suggests that PEEP levels in the
mately higher than 0.20) decreases tance, time constant, and PEEP lower end of this range may be pref-
the subsequent need for CMV and should not be considered in the erable in infants who have RDS.
the duration of respiratory assis- selection of the level of PIP. PEEP has a variable effect on lung
tance. These meta-analyses suggest compliance. An initial improvement
that CPAP should be initiated in PEEP in compliance occurs in response to
newborns who have RDS, for exam- Adequate PEEP prevents alveolar low levels of end expiratory pres-
ple, when the PaO2 is approximately collapse, maintains lung volume at sure, but it may worsen at higher
less than 50 torr and the FiO2 is 0.40 end expiration, and improves levels of PEEP (.5 to 6 cm H2O).
or more. Studies performed to deter- ventilation-perfusion matching.
mine whether CPAP facilitates suc- Increases in PEEP will raise MAP
cessful extubation have not shown and functional residual capacity, RATE
consistent results. thereby improving oxygenation. Changes in frequency alter alveolar
Nonetheless, use of a very elevated minute ventilation and, thus, PaCO2.
CMV PEEP does not benefit oxygenation In large randomized trials, relatively
Strategies for optimizing CMV have consistently (Table 1). For example, high ventilatory rates (60 breaths/
been developed based on principles older infants who have chronic lung min) resulted in a decreased inci-
of pulmonary mechanics and gas disease may tolerate higher levels of dence of pneumothorax in preterm
exchange. It has been shown that PEEP with improvement in oxygen- infants who had RDS. An individu-
these ventilatory strategies result in ation, but a very high PEEP may alized approach should be taken,
more frequent improvement of blood decrease venous return, cardiac out- with the goal of providing adequate
gases than ventilatory changes that put, and oxygen transport and minute ventilation using minimal
follow alternate decisions. Nonethe- increase pulmonary vascular resis- mechanical force. Generally, a high
less, the complexities of the multiple tance. It is important to emphasize rate, low tidal volume strategy is
patient presentations and available that although increases in both PIP preferred (Table 2). However, if a
ventilatory changes result in contin- and PEEP will increase MAP and very short expiratory time is
ued controversy in this area. Much oxygenation, they usually have employed, expiration may be incom-
research remains to be done to clar- opposite effects on carbon dioxide plete. The gas trapped in the lungs
ify the relationship between the opti- elimination. By altering the delta can increase functional residual
mal ventilatory pattern and the pressure (PIP minus PEEP), an ele- capacity and place the infant on the
underlying lung pathology. vation of PEEP may decrease tidal flat part of the pressure-volume
volume and carbon dioxide elimina- curve, thus decreasing lung compli-
tion and, therefore, increase PaCO2. ance. Furthermore, tidal volume
PIP
However, if functional residual decreases as inspiratory time is
Changes in PIP affect both PaO2 (by capacity is low, an increase in PEEP reduced beyond a critical level,
altering the MAP) and PaCO2 (by its may improve ventilation-perfusion depending on the time constant of
effects on tidal volume and, thus, matching and relieve both hypox- the respiratory system. Thus, minute
alveolar ventilation). Therefore, an emia and hypercapnia. ventilation is not a linear function of
increase in PIP will improve oxy- Various approaches have been frequency above a certain ventilator
genation and decrease PaCO2. A high proposed to optimize the effects of rate during pressure-limited ventila-
PIP should be used cautiously PEEP. These include efforts to tion. Alveolar ventilation actually
because it may increase the risk of reduce the physiologic shunt frac- may fall with higher ventilatory
volutrauma, with resultant air leaks tion, improve lung compliance, rates as tidal volumes approach the
and bronchopulmonary dysplasia. increase maximal oxygen delivery, volume of the anatomic dead space
Tidal volume can be measured, but and improve cardiac output. PEEP when inspiratory or expiratory times
in most clinical settings, breath in the range of 4 to 6 cm H2O become insufficient.
sounds, chest excursions, and respi- improves oxygenation in neonates Frequency changes alone (with a
ratory reflexes are good indicators who have RDS without compromis- constant I:E ratio) usually do not
of appropriate tidal volume. ing lung mechanics, carbon dioxide alter MAP or substantially affect
A common mistake made by cli- elimination, or hemodynamic stabil- PaO2. In contrast, any changes in TI
nicians is to relate PIP to weight ity. Careful assessment of tidal vol- that accompany frequency adjust-
(eg, the misconception that larger umes and carbon dioxide elimination ments may affect the airway pres-
infants need a higher PIP). Rather,
PIP requirements are strongly deter-
mined by the compliance of the TABLE 2. High Rate, Low Tidal Volume (Low PIP)
respiratory system, and larger infants
PROS CONS
tend to have more compliant lungs,
therefore requiring a lower PIP. In Decreased air leaks Gas trapping/inadvertent PEEP
addition to compliance, the factors Decreased volutrauma Generalized atelectasis
that should be considered in select- Decreased cardiovascular side effects Maldistribution of gas
ing the PIP level are blood gas Decreased risk of pulmonary edema Increased resistance
derangements, chest rise, and breath
sure waveform and, thus, alter MAP longer than the time constant of the affect arterial blood gases minimally
and oxygenation. respiratory system allows relatively as long as a sufficient flow is used.
complete inspiration. A long TI In general, flows of 8 to 12 L/min
I:E RATIO increases the risk of pneumothorax. are sufficient in most neonates. High
The major effect of an increase in Shortening TI is advantageous dur- flows are needed when inspiratory
the I:E ratio is to increase MAP and ing weaning (Table 4). In a random- time is shortened to maintain an
improve oxygenation (Table 3). ized trial, limitation of TI to 0.5 sec- adequate tidal volume.
However, when corrected for MAP, onds rather than 1.0 second resulted
changes in the I:E ratio are not as in a significantly shorter duration of
weaning. In contrast, patients who Pathophysiology-based
effective in increasing oxygenation Ventilatory Strategies
as are changes in PIP or PEEP. have chronic lung disease may have
A reversed I:E ratio (inspiratory a prolonged time constant. In these RDS is characterized by low com-
time longer than expiratory time) as patients, a longer TI (around 0.8 sec) pliance and low functional residual
high as 4:1 has been shown to be may result in improved tidal volume capacity. An optimal CMV strategy
effective in increasing PaO2, but side and better carbon dioxide may include conservative indications
effects may occur (Table 3). elimination. for CMV, the lowest PIP and tidal
Although one study suggested a volume required, moderate PEEP
decreased incidence of bronchopul- FiO2 (3 to 5 cm H2O), permissive hyper-
monary dysplasia with the use of Changes in FiO2 alter alveolar oxy- capnia, judicious use of sedation/
reversed I:E ratios, a large, well- gen pressure and, thus, oxygenation. paralysis, and aggressive weaning
controlled, randomized trial has Because FiO2 and MAP both deter- (Table 5).
revealed only reductions in the dura- mine oxygenation, they can be bal- Chronic lung disease is usually
tion of a high inspired oxygen con- anced as follows. During increasing heterogeneous, with varying time
centration and PEEP exposure with support, FiO2 is increased initially constants among lung areas. Resis-
reversed I:E ratios and no differ- until it reaches about 0.6 to 0.7, tance may be markedly increased,
ences in morbidity or mortality. when additional increases in MAP and frequent exacerbations may
Changes in the I:E ratio usually do are warranted. During weaning, FiO2 occur. A higher PEEP (4 to 6 cm
not alter tidal volume unless TI and is decreased initially (to about 0.4 to H2O) often is used, and longer TIs
TE become relatively too short. 0.7) before MAP is reduced because and TEs with low flow rates are pre-
Thus, carbon dioxide elimination maintaining an appropriate MAP ferred. Hypercarbia and a compen-
usually is not altered by changes in may allow substantial reduction in sated respiratory acidosis often are
I:E ratio. FiO2. MAP should be reduced before tolerated to avoid increasing lung
a very low FiO2 is reached because a injury with aggressive CMV.
TI AND TE higher incidence of air leaks has Persistent pulmonary hyperten-
been observed if distending pres- sion of the neonate may be primary
The effects of changes in TI and TE or associated with meconium aspira-
on gas exchange are strongly influ- sures are not weaned earlier.
tion syndrome, prolonged intrauter-
enced by the relationships of these ine hypoxia, congenital diaphrag-
times to the inspiratory and expira- FLOW
matic hernia, or other causes.
tory time constant, respectively. Changes in flow have not been well Ventilatory management of these
A TI that is three to five times studied in infants, but they probably infants often is controversial and
varies markedly among centers. In
general, FiO2 is adjusted to maintain
TABLE 3. High I:E Ratio/Long Inspiratory Time PaO2 between 80 and 100 torr to
minimize hypoxia-mediated pulmo-
PROS CONS nary vasoconstriction. Ventilatory
rates and pressures are adjusted to
Increased oxygenation Gas trapping/inadvertent PEEP
maintain an arterial pH between
May improve gas distribution in Increased risk of volutrauma
7.45 and 7.55. Care should be taken
lungs that have atelectasis and air leaks
to prevent extremely low PaCO2
Impaired venous return
(,20 torr), which can cause cerebral
Increased pulmonary vascular
vasoconstriction. The addition of
resistance
inhaled nitric oxide to CMV reduces
the need for extracorporeal mem-
brane oxygenation.
TABLE 4. Short Inspiratory Time
PROS CONS Strategies to Prevent Lung
Faster weaning Insufficient tidal volume Injury
Decreased risk for pneumothorax May need high flow rates Recently emphasis is being placed
Allows use of higher ventilator rate on the evidence that lung injury is
partially dependent on the particular
from 5 to 8 mL/kg compared with ers a ventilator breath of predeter- ized clinical trials are needed to
4 to 6 mL/kg among infants who mined settings (PIP, inspiratory determine if proportional assist ven-
have RDS. In our pilot study, tidal duration, and flow). Although tilation leads to major benefits com-
volumes of 4 to 5 mL/kg per minute improved oxygenation has been pared with CMV.
generally were used in infants in the observed, patient-triggered ventila-
permissive hypercapnia group tion frequently needs to be discon-
(unpublished observations). How- tinued in some very immature TRACHEAL GAS INSUFFLATION
ever, insufficient data are available infants because of weak respiratory The added dead space of the endo-
to recommend a specific size of efforts. A backup rate may be used tracheal tube and the ventilator
tidal volume in these infants. It to reduce this problem. adapter that connects to the endotra-
should be noted that infants who cheal tube contributes to the ana-
have severe pulmonary disease SYNCHRONIZED INTERMITTENT tomic dead space and reduces alveo-
should be ventilated with small tidal MANDATORY VENTILATION lar minute ventilation, leading to
volumes because lung heterogeneity reduced carbon dioxide elimination.
This mode of ventilation achieves
and unexpanded alveoli will lead to In smaller infants or with increasing
synchrony between the patient and
overdistention and injury of the severity of pulmonary disease, dead
the ventilator breaths. Synchrony
most compliant alveoli if a normal space becomes the largest proportion
easily occurs in most neonates
tidal volume is used. Nonetheless, of the tidal volume. With tracheal
because strong respiratory reflexes
maintenance of an adequate func- gas insufflation, gas delivered to the
during early life elicit relaxation of
tional residual capacity is also distal part of the endotracheal tube
respiratory muscles at the end of
necessary. during exhalation washes out this
lung inflation. Furthermore, inspira-
dead space and the accompanying
tory efforts usually start when lung
carbon dioxide. Tracheal gas insuf-
volume is decreased at the end of
Strategies Based on flation results in a decrease in
exhalation. Synchrony may be
Alternative Modes of PaCO2, PIP, or both. If proven safe
achieved by nearly matching the
Ventilation and effective, tracheal gas insuffla-
ventilator frequency to the spontane-
Technological advances, including tion should be useful in reducing
ous respiratory rate or by simply
improvement in flow delivery sys- tidal volume and the accompanying
ventilating at relatively high rates
tems, breath termination criteria, volutrauma, particularly in very pre-
(60 to 120 breaths/min). Triggering
guaranteed tidal volume delivery, term infants and infants who have
systems can be used to achieve syn-
stability of PEEP, air leak compen- very decreased lung compliance.
chronization when synchrony does
sation, prevention of pressure over- not occur with these maneuvers.
shoot, on-line pulmonary function Synchronized intermittent mandatory HIGH-FREQUENCY VENTILATION
monitoring, and triggering systems, ventilation is as effective as CMV,
have resulted in better ventilators. Because of its potential to reduce
but no major benefits were observed
Patient-initiated mechanical ventila- volutrauma, there has been a surge
in a large randomized controlled
tion, patient-triggered ventilation, of interest in high-frequency ventila-
trial.
and synchronized intermittent man- tion in the past few years. High-
datory ventilation are being used frequency ventilation may improve
PROPORTIONAL ASSIST blood gases because, in addition to
increasingly in neonates. High- VENTILATION
frequency ventilation is another the gas transport by convection,
mode that may reduce lung injury Both patient-triggered ventilation other mechanisms of gas exchange
and improve pulmonary outcome. and synchronized intermittent man- may become active at high frequen-
datory ventilation are designed to cies. There has been extensive clini-
synchronize only the onset of the cal use of various high-frequency
PATIENT-TRIGGERED inspiratory support. In contrast, pro- ventilators in neonates. Controlled
VENTILATION portional assist ventilation matches trials with high-frequency positive
The most frequently used ventilators the onset and duration of both pressure using rates of 60 breaths/
in neonates are time-triggered at a inspiratory and expiratory support. min (versus 30 to 40 breaths/min for
preset frequency, but because of the Furthermore, ventilatory support is CMV) reported a decreased inci-
available bias flow, the patient also in proportion to the volume and dence of air leaks. Small random-
can take spontaneous breaths. In flow of the spontaneous breath. ized trials suggest that bronchopul-
contrast, patient-triggered ventilation Thus, the ventilator can decrease the monary dysplasia may be prevented
(also called assist/control) uses elastic or resistive work of breathing with high-frequency jet ventilation,
spontaneous respiratory efforts to selectively. The magnitude of the but results are inconclusive. The
trigger the ventilator. With pressure- support can be adjusted according to largest randomized trial of high-
triggered ventilation airflow, chest the patients needs. When compared frequency ventilation revealed that
wall movement, airway pressure, or with conventional and patient- early use of high-frequency oscilla-
esophageal pressure is used as an triggered ventilation, proportional tory ventilation did not improve out-
indicator of the onset of the inspira- assist ventilation reduces ventilatory come. Although various randomized
tory effort. Once the ventilator pressures while maintaining or controlled trials show heterogeneous
detects an inspiratory effort, it deliv- improving gas exchange. Random- results, meta-analyses largely con-
firm the original findings. However, SUGGESTED READING Henderson-Smart DJ, Bhuta T, Cools F, et al.
there are trends toward decreases in Avery ME, Tooley WH, Keller JB, et al. Is Elective high frequency oscillatory ventila-
chronic lung disease in low birth weight tion vs conventional ventilation in preterm
bronchopulmonary dysplasia/chronic infants with acute pulmonary dysfunction.
infants preventable? A survey of eight
lung disease, but increases in severe centers. Pediatrics. 1987;79:26 30 Cochrane Collaboration, http://silk.nih-
intraventricular hemorrhage and Bancalari E, Sinclair JC. Mechanical ventila- .gov/SILK/COCHRANE/COCHRANE.htm.
periventricular leukomalacia as well tion. In: Sinclair JC, Bracken ME, eds. 1998
as small increases in air leaks with Effective Care of the Newborn Infant. New Kraybill EN, Runyan DK, Bose CL, Khan
York, NY: Oxford University Press; 1992: JH. Risk factors for chronic lung disease
high-frequency oscillatory ventila- 200 218 in infants with birth weights of 751 to
tion or high-frequency flow inter- Bernstein G, Mannino FL, Heldt GP, et al. 1000 grams. J Pediatr. 1989;115:115120
rupters. High-frequency ventilation Randomized multicenter trial comparing Mammel MC, Bing DR. Mechanical ventila-
is a safe alternative for infants who synchronized and conventional intermittent tion of the newborn: an overview. Clin
mandatory ventilation in neonates. J Pedi- Chest Med. 1996;17:603 613
fail CMV. atr. 1996;128:453 463 Mariani G, Cifuentes J, Carlo WA. Random-
Boynton BR, Hammond MD. Pulmonary gas ized controlled trial of permissive hyper-
exchange: basic principles and the effects capnia in preterm infants. A pilot study.
of mechanical ventilation. In: Boynton BR, Pediatrics. In press
Summary Carlo WA, eds. New Therapies for Neona- Oxford Region Controlled Trial of Artificial
tal Respiratory Failure: A Physiological Ventilation (OCTAVE) Study Group. Mul-
Many advances in neonatal care Approach. New York, NY: Cambridge ticenter randomized controlled trial of high
have led to increased survival of University Press; 1994:115130 against low frequency positive pressure
smaller and more critically ill Carlo WA, Greenough A, Chatburn RL. ventilation. Arch Dis Child. 1991;66:
infants. CMV is being used on Advances in conventional mechanical ven- 770 775
tilation. In: Boynton BR, Carlo WA, eds.
smaller and sicker infants for longer Pohlandt F, Saule H, Schroder H, et al.
New Therapies for Neonatal Respiratory
durations. Sound application of the Decreased incidence of extra-alveolar air
Failure: A Physiological Approach. New
leakage or death prior to air leakage in
basic concepts of gas exchange, pul- York, NY: Cambridge University Press;
high versus low rate positive pressure ven-
monary mechanics, and control of 1994:131151
tilation: results of a randomized seven-
Carlo WA, Martin RJ. Principles of neonatal
breathing is necessary to optimize assisted ventilation. Pediatr Clin North center trial in preterm infants. Eur J Pedi-
CMV. Employing pathophysiology- Am. 1986;33:221237 atr. 1992;151:904 909
based ventilatory strategies, strate- Garland JS, Buck RK, Allred EN, Leviton A. Sinha SK, Donn SM. Advances in neonatal
Hypocarbia before surfactant therapy conventional ventilation. Arch Dis Child.
gies to prevent lung injury, and
appears to increase bronchopulmonary 1996;75:F135
alternative modes of ventilation dysplasia risk in infants with respiratory Slutsky AS. Mechanical ventilation. ACCP
should result in further improvement distress syndrome. Arch Pediatr Adolesc Consensus Conference. Chest. 1993;104:
in neonatal outcome. Med. 1995;149:617 622 18331859