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Guide to Neonatal Ventilation Case Study 6

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Clinical Implications and Risks of Mechanical Ventilation
  • Prenatal History: Baby girl Caroline, Twin A, one of dichorionic/diamniotic twins was born to a 26-year-old G 1, P 0 mother. The pregnancy was complicated by preterm labor at 23 weeks gestation, with rupture of membranes at that time. There were no other complications of pregnancy and prenatal ultrasounds had shown that both twins were growing adequately. Mrs. C received betamethasone x 2 and magnesium sulfate.
    At 24 4/7 weeks, she was found to have complete cervical dilation and a ceserean section was performed because Twin B was a transverse lie. Baby A weighed 610 grams and had Apgar scores of 5 and 7 at one and five minutes respectively.

  • Questions
    1. Based on the prenatal history, what are Caroline’s risk factors for respiratory pathology and what outcomes would you expect??
    2. What are the risks of mechanical ventilation for this population?
    3. How has the approach to mechanical ventilation changed in response to these risks?



  • Synchronized Intermittent Mandatory Ventilation (SIMV) and Pressure-Limited Ventilation
    • Baby Caroline was placed on synchronized intermittent mandatory ventilation (SIMV) pressure-limited ventilation with the following settings: peak inspiratory pressure (PIP) 22 cm H2O, positive end expiratory pressure (PEEP) +5 cm H2O, and a rate of 50 breaths/minute. Her FiO2 requirements ranged from .24–.30. Her initial chest x-ray (Figure 1) showed the ETT just above the carina. Heart size was normal and the lung fields were hazy bilaterally consistent with moderate RDS; expanded to eight ribs. No air leaks were noted.

    • Questions
      1. What are the basic principles and benefits of synchronized intermittent mandatory ventilation (SIMV)?
      2. What are the basic principles and benefits of pressure-limited ventilation?
      3. How would choosing pressure-limited ventilation benefit an infant like Caroline who has been diagnosed with moderate RDS?
      4. What are the benefits and limitations of using pressure-limited ventilation?

    • For more information to answer these questions refer to the following learning resources.

      Pressure Supported Ventilation (PSV)  

    • On day of life (DOL) 2 Baby Caroline is noted to have increased work of breathing during her own spontaneous respiratory efforts. Pressure support ventilation (PSV) of 6 cmH2O is added to her settings. She remains on SIMV PIP 22 cmH2O, PEEP +5 cmH2O, and her rate is reduced to 40 breaths/minute. 
    •  Questions
    1.  What are the basic principles of PSV as an adjunct modality?
    2. Why would Caroline’s ventilator rate be reduced after initiating PSV in this scenario?
    •  For more information to answer these questions refer to the following learning resources.
      • Review of Review of Pressure Support Ventilation
        Ventilation Modalities in the NICU—13th National Advanced Practice Neonatal Nurses Conference, April 2016.
        Keszler M, Chatburn RL. Overview of assisted ventilation. In Goldsmith JP, Karotkin E. Goldsmith JP, Karotkin E, Keszler M, and Suresh GK, Assisted Ventilation of the Neonate (6th ed.) Philadelphia; Elsevier 2017, 140–152.


    Volume Targeted Ventilation (VTV/VGV) 

    • On DOL 5 at a PIP of 22 cmH2O, it is noted that Caroline’s tidal volumes were often above 7 mL/kg. The decision was made to switch her from pressure-limited ventilation to volume targeted ventilation. Her updated ventilation settings are Volume Target 3.0 mL (5mL/kg), PEEP 5 cmH2O, PSV 6 cmH2O, Rate 40/minute, FiO2 0.30–0.40.

    •  Questions
      1. What are the basic principles of volume targeted ventilation? 
      2. Based on the above scenario, what would be the rationale for choosing VTV for Caroline at this time?

      What are the benefits and limitations of VTV?

    •  For more information to answer these questions refer to the following learning resources.

  • Available CEU's (processing fees required)

  • About the Contributor

    AnnMarie Barber, MS, MSN, CRNP, is an NNP with over 19 years of experience practicing in the Philadelphia area. She received her BSN and Masters in Human Organization Science degrees from Villanova University and her MSN degree from the University of Pennsylvania. Since 2013 she has been a Clinical Nurse Educator for Mallinckrodt Pharmaceuticals providing expert consultation and education to neonatal clinicians regarding the diagnosis and treatment of PPHN and the utilization of inhaled nitric oxide. She has also been a speaker at several conferences and clinical meetings including the Virginia Society of Respiratory Care Conference, the Robert Wood Johnson University Respiratory Conference, and ANN's 16th National Neonatal Nurses Conference. She served on ANN's Executive Committee from 2014 to 2016.


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