Volume-Targeted Ventilation in Extremely Low Birth Weight Neonates

Abstract

Background: Ventilation modes with set tidal volume have been proven beneficial and widely used as a lung protective strategy in adult patients for decades. More recently, volume-targeted ventilation (VTV) was demonstrated to be protective against BPD in premature infants. As a consequence, mechanical ventilator manufacturers have developed VTV modes for neonatal patients. We detail our experience of incorporating VTV in our NICU.

Methods: Utilization of VTV in our NICU began with literature review and bench evaluation of pressure-regulated volume control (PRVC) mode of 4 mechanical ventilators available at our institution. Education was provided to all clinical role groups. Use of VTV mode was added to our existing Small Baby Initiative, where infants whose BW was < 1,500 g and/or GA < 32 weeks were preferentially ventilated in this manner. Retrospective chart review of all inborn infants was conducted 7 months before and after the initiative began. This research has been reviewed by local IRB.

Results: Through the 7 months after initiation, 22 intubated infants were ventilated with VTV as the preferred mode. Average GA was 24 4/7 weeks (22 3/7 to 29 weeks) with a birth weight average of 841 g (495 to 1,538 g). Feedback from RT staff included lack of objective assessment of work of breathing as pressure control levels were down titrated. Therefore, a routine assessment of P_0.1 was implemented and monitored. The mean P_0.1 was 0.78 (0.4-2.8). Of the 22 patients, 17 (77%) had no oxygen requirement upon discharge and no infants were diagnosed with severe BPD (requiring invasive ventilatory support after 36 weeks PMA or discharge). In comparison to the 7 months prior to practice change, 21 intubated premature infants received mechanical ventilation in our NICU. Average GA of these patients was 27 1/7 weeks (23 1/7 to 29 6/7) with a birth weight average of 939 g (603 to 1,985 g). Number of patients with no oxygen requirement were similar (n = 16, 76%), but there were 2 patients with severe BPD who required tracheostomy and high-level mechanical ventilatory support and were transferred to a long-term care facility.

Conclusions: Technology of volume-targeted ventilation has recently improved for support of premature neonates. Significant change in practice can be accomplished easily through a multidisciplinary approach. Understanding the latest technology and implementing new approaches can have a large impact on the life of a newborn infant and their family, and our healthcare system.