Ventilation in neonatology—How can lung damage be avoided?

Abstract

Diseases of the lungs, such as respiratory distress syndrome (RDS), severe meconium aspiration syndrome and respiratory failure due to severe pulmonary or systemic infection, are associated with substantial morbidity and mortality both in term and preterm neonates. The still developing immature lungs are extremely prone to damaging insults, e.g., ventilator-induced lung injury (VILI) due to (too) high pressure (barotrauma), overdistention (volutrauma) and the alternation between alveolar collapse and overdistention (atelectrauma). Inflammatory cells and mediators cause additional harm to the alveolae (biotrauma). The administration of oxygen also contributes to lung damage by reactive oxygen species. This article discusses measures, such as prenatal lung maturation with corticosteroids, minimally invasive handling strategies and support of spontaneous breathing, e.g., by less invasive surfactant administration (LISA), to avoid, minimize or delay endotracheal intubation. Noninvasive strategies of respiratory support, such as continuous positive airway pressure (CPAP) or high-flow nasal cannula (HFNC) play a key role in this context. If mechanical ventilation must nevertheless be initiated, the focus should be on lung protective strategies. The avoidance of (too) large tidal volumes, even accepting a mild degree of respiratory acidosis (permissive hypercapnia) and the use of modern ventilation techniques, e.g., volume guarantee ventilation (VGV), high-frequency oscillatory ventilation (HFOV), are helpful in this context. Directly after successful endotracheal intubation consideration should be given to the earliest time for initiation of weaning. The use of caffeine and noninvasive respiratory support (e.g., nasal intermittent positive pressure ventilation, NIPPV) play a key role in successful weaning.