Volume targeting levels and work of breathing in infants with evolving or established bronchopulmonary dysplasia

Hunt, Katie; Dassios, Theodore; Ali, Kamal; Greenough, Anne

doi:10.1136/archdischild-2017-314308

Cited by 19 publications

(8 citation statements)

References 15 publications

(8 reference statements)

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“…The wide range of postnatal ages in our study population may have influenced our results, but advantages of PAV and NAVA over conventional ventilation have been demonstrated in infants with a variety of postnatal ages in previous studies. Targeted tidal volumes of between 5 and 7 mls/kg were used, as studies have shown chronically ventilated infants may require 7 mls/kg [29,30] and in the latter study (30) to reduce the work of breathing. It could be suggested that in babies with BPD 2hour epochs may not be sufficient to demonstrate changes in oxygenation.…”

Section: Discussionmentioning

confidence: 99%

Proportional assist ventilation (PAV) versus neurally adjusted ventilator assist (NAVA): effect on oxygenation in infants with evolving or established bronchopulmonary dysplasia

2020

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Both proportional assist ventilation (PAV) and neurally adjusted ventilatory assist (NAVA) provide pressure support synchronised throughout the respiratory cycle proportional to the patient's respiratory demand. Our aim was to compare the effect of these two modes on oxygenation in infants with evolving or established bronchopulmonary dysplasia. Two-hour periods of PAVand NAVA were delivered in random order to 18 infants born less than 32 weeks of gestation. Quasi oxygenation indices ("OI") and alveolararterial ("A-a") oxygen gradients at the end of each period on PAV, NAVA and baseline ventilation were calculated using capillary blood samples. The mean "OI" was not significantly different on PAV compared to NAVA (7.8 (standard deviation (SD) 3.2) versus 8.1 (SD 3.4), respectively, p = 0.70, but lower on both than on baseline ventilation (mean baseline "OI" 11.0 (SD 5.0)), p = 0.002, 0.004, respectively). The "A-a" oxygen gradient was higher on PAV and baseline ventilation than on NAVA (20.8 (SD 12.3) and 22.9 (SD 11.8) versus 18.5 (SD 10.8) kPa, p = 0.015, < 0.001, respectively). Conclusion: Both NAVA and PAV improved oxygenation compared to conventional ventilation. There was no significant difference in the mean "OI" between the two modes, but the mean "A-a" gradient was better on NAVA. What is Known: • Proportional assist ventilation (PAV) and neurally adjusted ventilatory assist (NAVA) can improve the oxygenation index (OI) in prematurely born infants. • Both PAV and NAVA can provide support proportional to respiratory drive or demand throughout the respiratory cycle. What is New: • In infants with evolving or established BPD, using capillary blood samples, both PAV and NAVA compared to baseline ventilation resulted in improvement in the "OI", but there was no significant difference in the "OI" on PAV compared to NAVA. • The "alveolar-arterial" oxygen gradient was better on NAVA compared to PAV.

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Section: Discussionmentioning

confidence: 99%

Proportional assist ventilation (PAV) versus neurally adjusted ventilator assist (NAVA): effect on oxygenation in infants with evolving or established bronchopulmonary dysplasia

2020

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“…For each breath, the beginning and end of inspiration was determined from the flow signal, in order to delineate the inspiratory work of breathing. The mean PTPdi of the first 20 artefact-free breaths in the last 5 min of each 20 min epoch of ventilation was calculated, as has previously been described [ 16 ].…”

Section: Methodsmentioning

confidence: 99%

Work of breathing at different tidal volume targets in newborn infants with congenital diaphragmatic hernia

et al. 2022

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Congenital diaphragmatic hernia (CDH) results in varying degrees of pulmonary hypoplasia. Volume targeted ventilation (VTV) is a lung protective strategy but the optimal target tidal volume in CDH infants has not previously been studied. The aim of this study was to test the hypothesis that low targeted volumes would be better in CDH infants as determined by measuring the work of breathing (WOB) in CDH infants, at three different targeted tidal volumes. A randomised cross-over study was undertaken. Infants were eligible for inclusion in the study after surgical repair of their diaphragmatic defect. Targeted tidal volumes of 4, 5, and 6 ml/kg were each delivered in random order for 20-min periods with 20-min periods of baseline ventilation between. WOB was assessed and measured by using the pressure–time product of the diaphragm (PTPdi). Nine infants with a median gestational age at birth of 38 + 4 (range 36 + 4–40 + 6) weeks and median birth weight 3202 (range 2855–3800) g were studied. The PTPdi was higher at 4 ml/kg than at both 5, p = 0.008, and 6 ml/kg, p = 0.012.Conclusion: VTV of 4 ml/kg demonstrated an increased PTPdi compared to other VTV levels studied and should be avoided in post-surgical CDH infants. What is Known:• Lung injury secondary to mechanical ventilation increases the mortality and morbidity of infants with CDH.• Volume targeted ventilation (VTV) reduces ‘volutrauma’ and ventilator-induced lung injury in other neonatal intensive care populations. What is New:• A randomised cross-over trial was carried out investigating the response to different VTV levels in infants with CDH.• Despite pulmonary hypoplasia being a common finding in CDH, a VTV of 5ml/kg significantly reduced the work of breathing in infants with CDH compared to a lower VTV level.

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“…The increase in Vt requirement is greatest during the third week of life, which is presumed to be due to enlargement of the upper airways (acquired tracheomegaly) and an increase in alveolar dead space [80]. Interestingly, in infants with evolving or established BPD who remain ventilator-dependent at or beyond seven days of age, a Vt target of 7 mL/kg was found to reduce the work of breathing compared to smaller Vt (4-6 mL/kg) [81]. The application of VG was reported to be feasible even in extremely premature infants [82,83].…”

Section: Volume-targeted Ventilationmentioning

confidence: 99%

The Intertemporal Role of Respiratory Support in Improving Neonatal Outcomes: A Narrative Review

et al. 2021

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Defining improvements in healthcare can be challenging due to the need to assess multiple outcomes and measures. In neonates, although progress in respiratory support has been a key factor in improving survival, the same degree of improvement has not been documented in certain outcomes, such as bronchopulmonary dysplasia. By exploring the evolution of neonatal respiratory care over the last 60 years, this review highlights not only the scientific advances that occurred with the application of invasive mechanical ventilation but also the weakness of the existing knowledge. The contributing role of non-invasive ventilation and less-invasive surfactant administration methods as well as of certain pharmacological therapies is also discussed. Moreover, we analyze the cost–benefit of neonatal care-respiratory support and present future challenges and perspectives.

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Volume targeting levels and work of breathing in infants with evolving or established bronchopulmonary dysplasia

Abstract: Only a tidal volume target of 7 mL/kg reduced the work of breathing below the baseline and may be more appropriate for infants with evolving or established BPD who remained ventilator dependent at or beyond 7 days of age.

Cited by 19 publications

References 15 publications

Proportional assist ventilation (PAV) versus neurally adjusted ventilator assist (NAVA): effect on oxygenation in infants with evolving or established bronchopulmonary dysplasia

Proportional assist ventilation (PAV) versus neurally adjusted ventilator assist (NAVA): effect on oxygenation in infants with evolving or established bronchopulmonary dysplasia

Work of breathing at different tidal volume targets in newborn infants with congenital diaphragmatic hernia

The Intertemporal Role of Respiratory Support in Improving Neonatal Outcomes: A Narrative Review

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