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Research Article

Vol. 9 No. 2 (2006)

Ventilatory management in extremely low birth weight infants

  • Shaun Morris
  • Karen Choong
November 1, 2020


The improvement in survival in premature infants associated with the evolution of mechanical ventilation has been accompanied by an increase in ventilator induced lung injury. High frequency ventilation has been shown to reduce the incidence of ventilator induced lung injury and hence chronic lung disease in the very low birth weight infant. The evolution in understanding how to best use high frequency ventilation in this population has prompted us to ask whether similar strategies to optimize lung volumes on conventional mechanical ventilation can minimize chronic lung disease in the neonate. We retrospectively reviewed the medical charts of 51 extremely low birth weight infants born in Kingston, Ontario in two epochs, 1990 to 1991 and 1999 to 2000, for ventilatory strategy and outcome. From our review, it is clear that surfactant therapy rapidly changes lung mechanics by improving pulmonary compliance and that lung damage may result if there are not changes in the ventilatory management to reflect the altered compliance. Early ventilation strategies during the apparently stable "honeymoon period" in a patient with respiratory distress syndrome (RDS) has significant implications on long term morbidity. In the era prior to the use of surfactant, 30% of infants died and 40% developed chronic lung disease (CLD). Immediately following the use of surfactant, mortality was reduced to 18%, however, the incidence of CLD increased to 78%. In the most recent era, following 10 years of experience with surfactant and mechanical ventilation, morbidity was 17% and CLD 21%. This study demonstrates that a particularly crucial time is in the immediate period following surfactant administration. The use of lower peak inspiratory pressure (PIP) and mean airway pressure (MAP) over the first 24 hours and an increase in the use of synchronous intermittent mandatory ventilation (SIMV) was associated with an improved outcome. The challenge remaining is to determine how to best utilize a conventional mode of ventilation to best optimize lung volume and protect the immature lung.


  1. McGettigan MC, Adolph VR, Ginsberg HG, Goldsmith JP. New Ways to Ventilate Newborns in Acute Respiratory Failure.
  2. Pediatric Clinics of North America 1998; 45 (3): 476-509.
  3. Webb HH, Tierney DF. Experimental pulmonary edema due to intermittent positive pressure ventilation with high inflation pressures. Protection by positive end-expiratory pressure. American Review of Respiratory Disease 1974; 110 (5): 556-65.
  4. Bernstein G, Mannino FL, Heldt GP, et al. Randomized multicenter trial comparing synchronized and conventional intermittent mandatory ventilation in neonates. Journal of Pediatrics 1996; 128 (4): 453-463.
  5. Bernstein G. Syncrynous and patient-triggered ventilation in newborns. Neonatal Respiratory Diseases 3 1993; 6(5): 54-8, 66.
  6. Van Marter LJ, Allred EN, Pagano M, et al. Do Clinical Markers of Barotrauma and Oxygen Toxicity Explain
  7. Interhospital Variation in Rates of Chronic Lung Disease? Pediatrics 2000; 105 (6): 1194-1201.
  8. Avery ME; Tooley WH; Keller JB, et al. Is chronic lung disease in low birth weight infants preventable? A survey of eight
  9. centers. Pediatrics 1987; 79 (1): 26-30.
  10. Jonsson B, Katz-Salamon M, Faxelius G, et al. Neonatal care of very-low-birth weight infants in special-care units and neonatal intensive-care units in Stockholm. Early nasal continuous positive airway pressure versus mechanical ventilatin: gains and losses. Aca Paediatr Suppl 1997; 419: 4-10.
  11. Kuroki Y, Voelker DR. Pulmonary surfactant proteins. Journal of Biological Chemistry 1994; 269 (42): 25943-25946.
  12. The HIFI Study Group. High-frequency oscillatory ventilation compared with conventional mechanical ventilation in the
  13. treatment of respiratory failure in preterm infants. New England Journal of Medicine 1989; 320 (2): 88-93.
  14. Gerstmann DR, Minton SD, Stoddard RA, et al. The Provo multicenter early high-frequency oscillatory ventilation trial:
  15. improved pulmonary and clinical outcome in respiratory distress syndrome. Pediatrics 1994; 98(6 Pt 1) 1044-1057.
  16. Rimensberger PC, Beghetti M, Hanquinet S, Berner M. First intention high-frequency oscillation with early lung volume
  17. optimization improves pulmonary outcome in very low birth weight infants with respiratory distress syndrome. Pediatrics
  18. ; 105(6): 1202-1208.
  19. Courtney SE, Durand DJ, Asseliln JM et al. High Frequency Oscillatory Ventilation versus Conventional Mechanical
  20. Ventilation for Very-Low-Birth-Weight Infants. New England Journal of Medicine 2002; 347 (9): 643-652.
  21. Amato MB, Barbas CS, Medeiros DM, et al. Effect of a protective-ventilation strategy on mortality in the acute
  22. respiratory distress syndrome. New England Journal of Medicine 1998; 338: 347-354.
  23. National Institutes of Health. NHLBI clinical trial stopped early: successful ventilator strategy found for intensive care patients on life support. National Institutes of Health news release. March 15, 1999.
  24. Stewart TE, Meade MO, Cook DJ, et al. Evaluation of a ventilation strategy to prevent barotrauma in patients at high risk
  25. for acute respiratory distress syndrome. Pressure- and Volume-Limited Ventilation Strategy Group. New England Journal of Medicine 1998; 338(6): 355-361.
  26. Vazquez de Anda GF, Gommers D, Verbrugge SJ. Mechanical ventilation with high positive end-expiratory pressure and small driving pressure amplitude is as effective as high-frequency oscillatory ventilation to preserve the function of exogenous surfactant in lung-lavaged rats. Critical Care Medicine 2000; 28 (8): 2921-2925.
  27. Thome U, Kössel H, Lipowsky G, et al. Randomized comparison of high-frequency ventilation with high-rate
  28. intermittent positive pressure ventilation in preterm infants with respiratory failure. Journal of Pediatrics 1999; 135 (1): 39-46.
  29. Johnson AH, Peacock JL, Greenough A, et al. High Frequency Oscillatory Ventilation for the Prevention of Chronic Lung
  30. Disease of Prematurity. New England Journal of Medicine 2002; 347 (9): 633-642.
  31. Stark AR. High Frequency Oscillatory Ventilation to Prevent Bronchopulmonary Dysplasia - Are we there yet? (Editorials). New England Journal of Medicine 2002; 347 (9): 682-683.
  32. Froese AB, McCulloch PR, Sugiura M et al. Optimizing alveolar expansion prolongs the effectiveness of exogenous
  33. surfactant therapy in the adult rabbit. American Review of Respiratory Disease 1993; 148 (3): 569-577.
  34. Blennow M, Jonsson B, Dahlström A, et al. [Lung function in premature infants can be improved. Surfactant therapy and
  35. CPAP reduce the need of respiratory support]. Lakartidningen 1999; 96 (13): 1571-1576.


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