Lower back-up rates improve ventilator triggering during assist-control ventilation: a randomized crossover trial

Jaysainghe

Arch Dis Child Fetal Neonatal Ed

2023

BackgroundNational Institute for Health and Clinical Effectiveness (NICE), UK, guideline published in 2019 recommends the use of volume-targeted ventilation (VTV). It recommends synchronised intermittent mandatory ventilation (SIMV) over the modes that support-all-breaths, for example, assist control ventilation (ACV). We conducted a systematic review and meta-analysis of the studies comparing SIMV mode with triggered modes supporting all breaths.MethodsPatients: Neonates receiving mechanical ventilation.Intervention: SIMV ventilation.Comparison: Modes that support-all-breaths: ACV, pressure support ventilation and neurally adjusted ventilation.Outcomes: Death before discharge and bronchopulmonary dysplasia (BPD) at 36 weeks’ corrected gestation, weaning duration, incidence of air leaks, extubation failure, postnatal steroid use, patent ductus arteriosus requiring treatment, severe (grade 3/4) intraventricular haemorrhage, periventricular leukomalacia and neurodevelopmental outcome at 2 years.Randomised or quasi-randomised clinical trials comparing SIMV with triggered ventilation modes supporting all breaths in neonates, reporting on at least one outcome of interest were eligible for inclusion in the review.ResultsSeven publications describing eight studies fulfilled the eligibility criteria. No significant difference in mortality (OR 0.74, 95% CI 0.32 to 1.74) or BPD at 36 weeks (OR 0.63, 95% CI 0.33 to 1.24), but the weaning duration was significantly shorter in support-all-breaths group with a mean difference of −22.67 hours (95% CI –44.33 to –1.01). No difference in any other outcomes.ConclusionCompared with SIMV, synchronised modes supporting all breaths are associated with a shorter weaning duration with no statistically significant difference in mortality, BPD at 36 weeks or other outcomes. Larger studies with explicit ventilator and weaning protocols are needed to compare these modes in the current neonatal population.PROSPERO registration numberThe review was prospectively registered with PROSPERO: CRD42020207601.

Section: Discussionmentioning

confidence: 97%

Supporting all breaths versus supporting some breaths during synchronised mechanical ventilation in neonates: a systematic review and meta-analysis

Jaysainghe

Arch Dis Child Fetal Neonatal Ed

2023

Pediatric Quality &Amp; Safety

“…A backup rate that is too high prevents adequate triggering by the neonate. 16 In our NICU, we employ VTV in the assist control mode. We outlined initial ventilator settings as a targeted TV of 4–6 ml/kg, peak end-expiratory pressure of 5–6 mm Hg, and a backup respiratory rate of 30–40 breaths/min.…”

Section: Methodsmentioning

confidence: 99%

Implementing Volume-targeted Ventilation to Decrease Hypocarbia in Extremely Low Birth Weight Infants during the First Week of Life: A Quality Improvement Project

Akpan

Patel

Driver

et al. 2021

Introduction: Hypocarbia in neonates increases the risk of poor neurodevelopmental outcomes. Volume-targeted ventilation (VTV) is associated with decreased hypocarbia and other respiratory morbidities. We noticed a high incidence of hypocarbia in extremely low birth weight (ELBW; <1,000 g) neonates in our Neonatal Intensive Care Unit. Thus, we undertook a quality improvement project to decrease the incidence of hypocarbia (the occurrence of PCO 2 < 35 mm Hg) in ELBW neonates during the first week of life by 50% over 1 year. Methods: Our major interventions were employing VTV as the primary mode of mechanical ventilation in neonates less than 28 weeks of gestation or ELBW at birth and increasing staff knowledge regarding hypocarbia. The baseline period spanned May–August 2016. We implemented the interventions in October 2016 and tracked the use of VTV and the incidence of hypocarbia during the first week of life for 12 months. Results: We analyzed data on 28 and 77 patients in the baseline and postintervention periods, respectively. The use of VTV increased from 39% to 65%. However, the incidence of hypocarbia was not reduced (57% preintervention vs. 64% postintervention). In the postintervention cohort, the incidence of hypocarbia was comparable between VTV and other modes (60% vs. 70%; 95% confidence interval: −32%, 12%; P = 0.367), but we noted decreased blood gas sampling and earlier extubation in the VTV group ( P = 0.002 and P = 0.046, respectively). Conclusions: Successfully increasing VTV in our Neonatal Intensive Care Unit did not decrease hypocarbia during the first week of life. However, we observed the safety of VTV and obtained other desirable results.

“…A meta-analysis (14) comprising 14 studies concluded that triggered ventilation leads to a shorter duration of ventilation overall as well as a reduction in air leaks compared to mandatory conventional ventilation. Another recent randomized, crossover trial of 26 stable preterm neonates with a mean gestational age of 27 weeks, found that a reduced back up rate (30bpm compared to 50) resulted in greater triggering of breaths and no discernible difference in cardiovascular stability (15). Supporting a neonate's own respiratory efforts should therefore be encouraged by the use of triggered ventilation with an optimum back up rate while allowing them to take control of their own breathing in time.…”

Section: Patient Trigger Ventilation (Ptv) or 'Assist Control' (A/c)mentioning

confidence: 99%

Understanding Neonatal Ventilation: Strategies for Decision Making in the NICU

Petty¹

2013

Neonatal Network

Neonatal ventilation is an integral component of care delivered in the neonatal unit. The aim of any ventilation strategy is to support the neonate's respiratory system during compromise while limiting any long-term damage to the lungs. Understanding the principles behind neonatal ventilation is essential so that health professionals caring for sick neonates and families have the necessary knowledge to understand best practice. Given the range of existing ventilation modes and parameters available, these require explanation and clarification in the context of current evidence. Many factors can influence clinical decision making on both an individual level and within the wider perspective of neonatal care.