Reprinted from the August 1994 issue of RESPIRATORY CARE [Respir Care 1994;39(8):808–816]
AARC Clinical Practice Guideline
Neonatal Time-Triggered, Pressure-Limited, Time-Cycled Mechanical Ventilation
TPTV 1.0 PROCEDURE:
The application of time-triggered, pressure-limited, time-cycled mechanical ventilation (TPTV) to neonates--this Guideline does not address patient-triggered ventilation.
The application of time-triggered, pressure-limited, time-cycled mechanical ventilation in the neonate is typically accomplished by the use of commercially available pressure-limited ventilators specifically designed for this population or of multipurpose, multimodal ventilators with the necessary capabilities. These ventilators permit precise management of ventilator settings.(1-8)
Pressure-limited ventilators commonly incorporate continuous flow to deliver a mixture of oxygen and air. The continuous flow supplies the patient with a fresh gas source for spontaneous breathing.(7,9-14)
Mandatory breaths are time-triggered and time-cycled, based on an adjustable frequency and inspiratory time. As the ventilator time-triggers inspiration, the exhalation valve closes, and the continuous flow is directed to the inspiratory limb of the patient circuit for the length of the inspiratory time.(7,11,12,14)
Once the pressure limit has been reached, remaining flow is diverted to a limiting mechanism. As the ventilator cycles to expiration, the exhalation valve opens to ambient and the continuous flow exits the expiratory limb of the circuit.(7,10,14)
Flow continues to enter the patient's lungs until pressure equilibrates or until the inspiratory time has elapsed, resulting in a decelerating flow pattern. Volume delivery is dependent on lung and chest-wall compliance and airway resistance, including the resistance of the endotracheal tube. As these variables change, deceleration of flow is altered, and the tidal volume (VT) varies.(10,11,15-22) The VT achieved depends on the pressure limit, gas flowrate, inspiratory time (tI), and positive end-expiratory pressure (PEEP). Circuit characteristics that affect VT include compressible volume, presence of condensate, and obstruction of the artificial airway.(3,4,8-10,18,20,23)
TPTV 3.0 SETTINGS:
TPTV is applied by trained personnel in acute care and subacute care hospitals.
TPTV 4.0 INDICATIONS:
The presence of one or more of the following conditions constitutes an indication for TPTV.
- 4.1 Apnea (24-27)
- 4.2 Respiratory or ventilatory failure, despite the use of continuous positive airway pressure (CPAP) and supplemental oxygen (ie, FIO2 > or = 0.60)(24,25,28)
- 4.2.1 Respiratory acidosis with a pH < 7.20-7.25(8,25,29)
- 4.2.2 PaO2 < 50 torr(8,13,25,29,30)
- 4.2.3 Abnormalities on physical examination
- 18.104.22.168 Increased work of breathing demonstrated by grunting, nasal flaring, tachypnea, and sternal and intercostal retractions(5,27,29,31)
- 22.214.171.124 The presence of pale or cyanotic skin and agitation
- 4.3 Alterations in neurologic status that compromise the central drive to breathe:
- 4.3.1 Apnea of prematurity(32)
- 4.3.2 Intracranial hemorrhage(33)
- 4.3.3 Congenital neuromuscular disorders(34)
- 4.4 Impaired respiratory function resulting in a compromised functional residual capacity (FRC) due to decreased lung compliance and/or increased airways resistance,(12,35) including but not limited to
- 4.4.1 Respiratory distress syndrome (RDS)(1,2,28,36-39)
- 4.4.2 Meconium aspiration syndrome (MAS)(40)
- 4.4.3 Pneumonia(41)
- 4.4.4 Bronchopulmonary dysplasia(42-44)
- 4.4.5 Bronchiolitis(41)
- 4.4.6 Congenital diaphragmatic hernia(45)
- 4.4.7 Sepsis(41)
- 4.4.8 Radiographic evidence of decreased lung volume(27)
- 4.5 Impaired cardiovascular function
- 4.5.1 Persistent pulmonary hypertension of the newborn (PPHN)(46,47)
- 4.5.2 Postresuscitation(41)
- 4.5.3 Congenital heart disease(48)
- 4.5.4 Shock(6)
- 4.6 Postoperative state characterized by impaired ventilatory function(45,49)
TPTV 5.0 CONTRAINDICATIONS:
No specific contraindications for neonatal TPTV exist when indications are judged to be present (Section 4.0).
TPTV 6.0 HAZARDS/COMPLICATIONS:
- 6.1 Air leak syndromes due to barotrauma and/or volume overinflation (ie, volutrauma),(2,11,50-54) including
- 6.1.1 Pneumothorax(16,55-59)
- 6.1.2 Pneumomediastinum(55,56,58)
- 6.1.3 Pneumopericardium(55)
- 6.1.4 Pneumoperitoneum(55)
- 6.1.5 Subcutaneous emphysema(55)
- 6.1.6 Pulmonary interstitial emphysema(56,60-62)
- 6.2 Chronic lung disease associated with prolonged positive pressure ventilation and oxygen toxicity(63,64) (eg, bronchopulmonary dysplasia(42,43,65-68))
- 6.3 Airway complications associated with endotracheal intubation
- 6.3.1 Laryngotracheobronchomalacia(69)
- 6.3.2 Damage to upper airway structures(66,69,70)
- 6.3.3 Malpositioning of endotracheal tube (ETT)(69,71)
- 6.3.4 Partial or total obstruction of ETT with mucus(69,71,72)
- 6.3.5 Kinking of ETT(69,71)
- 6.3.6 Unplanned extubation(69,71,73)
- 6.3.7 Air leak around uncuffed ETT
- 6.3.8 Subglottic stenosis(69)
- 6.3.9 Main-stem intubation(69)
- 6.3.10 Pressure necrosis(74)
- 6.3.11 Increased work of breathing (during spontaneous breaths) due to the high resistance of endotracheal tubes of small internal diameter(75)
- 6.4 Nosocomial pulmonary infection (eg, pneumonia(76))
- 6.5 Complications that occur when positive pressure applied to the lungs is transmitted to the cardiovascular system(77,78) or the cerebral vasculature resulting in
- 6.5.1 Decreased venous return(77,78)
- 6.5.2 Decreased cardiac output(77,78)
- 6.5.3 Increased intracranial pressure leading to intraventricular hemorrhage(27,33,79)
- 6.6 Supplemental oxygen in conjunction with TPTV may lead to an increased risk of retinopathy of prematurity (ROP)(80,81)
- 6.7 Complications associated with endotracheal suctioning(82)
- 6.8 Technical complications
- 6.8.1 Ventilator failure(10,83)
- 6.8.2 Ventilator circuit and/or humidifier failure(38,70) (Condensate in the inspiratory limb of the ventilator circuit may result in a reduction in VT(23,84) or inadvertent pulmonary lavage.)
- 6.8.3 Ventilator alarm failure(10,38,69,83)
- 6.8.4 Loss of or inadequate gas supply
- 6.9 Patient-ventilator asynchrony(85,86)
- 6.10 Inappropriate ventilator settings leading to
- 6.10.1 auto-PEEP
- 6.10.2 hypo-or hyperventilation
- 6.10.3 hypo- or hyperoxemia
- 6.10.4 increased work of breathing
TPTV 7.0 LIMITATIONS OF METHOD:
Rapid changes in lung compliance and airways resistance may result in alterations in VT delivery that may significantly alter minute ventilation (VE).(3,4,9,11,19-21)
TPTV 8.0 ASSESSMENT OF NEED:
Determination that valid indications are present by physical, radiographic, and laboratory assessment
TPTV 9.0 ASSESSMENT OF OUTCOME:
Establishment of neonatal assisted ventilation should result in improvement in patient condition and/or reversal of indications (Section 4.0):
- 9.1 Reduction in work of breathing as evidenced by decreases in respiratory rate, severity of retractions, nasal flaring and grunting
- 9.2 Radiographic evidence of improved lung volume(41)
- 9.3 Subjective improvement in lung volume as indicated by increased chest excursion and aeration by chest auscultation(87)
- 9.4 Improved gas exchange
- 9.4.1 Ability to maintain a PaO2 > or = 50 torr with FIO2 < 0.60(8,30)
- 9.4.2 Ability to reverse respiratory acidosis and maintain a pH > 7.258,30
- 9.4.3 Subjective improvement as indicated by a decrease in grunting, nasal flaring, sternal and intercostal retraction, and respiratory rate(31)
TPTV 10.0 RESOURCES:
- 10.1 Equipment-recommended equipment based on individual patient need includes the following. (For a given patient, all mentioned equipment may not be necessary.)
- 10.1.1 Commercially available continuous-flow infant ventilator equipped with TPTV mode or suitably equipped multipurpose, multimodal ventilator, low and high airway pressure alarms, high-pressure release-to-ambient pressure capability, loss of power and gas source alarms, low and high oxygen concentration alarms--alarms may be integral to the ventilator or an add-on.(21,38,83)
- 10.1.2 Servo-regulated humidifier with low compressible volume chamber and preferably a continuous water source(21,38,83)
- 10.1.3 Low-compliance infant ventilator circuit with heated inspiratory and expiratory wires compatible with the servo-regulated humidification system is recommended.(19,23,38,83,88,89) Comparable circuits that permit continual drainage of condensate may also be used.
- 10.1.4 Endotracheal tube with associated intubation equipment or tracheostomy tube with associated insertion and cleaning accessories and supplies for securing the tube
- 10.1.5 Suction source, suction catheters, and normal saline for instillation to ensure patency of artificial airway(82)
- 10.1.6 Standby resuscitation apparatus with airway manometer and masks of appropriate size(83) and supplies for chest-tube insertion
- 10.1.7 Continuous noninvasive monitoring of oxygenation by either transcutaneous monitor or pulse oximeter with high- and low-alarm capabilities(90,91)
- 10.1.8 Continuous noninvasive monitoring of carbon dioxide by transcutaneous CO2 monitor with high- and low-alarm capabilities is also recommended(38,92) for the unstable baby requiring frequent ventilator changes. Measurements of end-tidal CO2 may also be useful in these infants.(93,94)
- 10.1.9 Continuous cardiorespiratory monitoring (eg, ECG and respiratory rate) with high- and low-alarm capabilities(38)
- 10.1.10 Appropriate and adequate compressed gas supply
- 10.1.11 Graphic display of airway pressure, flow, and tidal volume may be useful.
- 10.2 Personnel: TPTV should be applied under the direction of a physician by trained personnel who hold a recognized credential (eg, CRTT, RRT, RN) and who competently demonstrate
- 10.2.1. proper use, understanding, and mastery of the technical aspects of management of artificial airways, mechanical ventilators, and humidification systems;
- 10.2.2 comprehensive knowledge of ventilator management and understanding of neonatal airway anatomy and pulmonary pathophysiology;
- 10.2.3 patient assessment skills, with an understanding of the interaction between the mechanical ventilator and the patient and ability to recognize and respond to adverse reactions and complications;
- 10.2.4 knowledge and understanding of intubation equipment;
- 10.2.5 ability to interpret monitored and measured blood gas parameters and vital signs;
- 10.2.6 application of Universal Precautions;(92)
- 10.2.7 proper use, understanding, and mastery of emergency resuscitation equipment and procedures;
- 10.2.8 ability to evaluate and document results of outcome assessments (Section 9.0);
- 10.2.9 ability to interpret chest radiographs to determine proper placement of artificial airways and identify complications associated with mechanical ventilation (eg, air leak syndromes).
TPTV 11.0 MONITORING:
- 11.1 Patient-ventilator system checks should be performed every 2-4 hours and should include documentation of ventilator settings and patient assessments as recommended by the AARC CPG Patient-Ventilator System Checks (MV-SC) and AARC CPG Humidification during Mechanical Ventilation (HMV).(95,96)
- 11.2 Oxygen and CO2 monitoring
- 11.2.1 Periodic sampling of blood gas values by arterial, capillary, or venous route.(1,24,30) PaO2 should be kept below 80 torr in preterm infants to minimize the risk of ROP.(6,80,97)
- 11.2.2 The unstable infant should be monitored continuously by transcutaneous O2 monitor or pulse oximeter.(1,90,91)
- 11.2.3 The unstable infant should be monitored continuously by transcutaneous(90) or end-tidal CO2 monitoring.(93,94)
- 11.2.4 Fractional concentration of oxygen delivered by the ventilator should be monitored continuously.(38)
- 11.3 Continuous monitoring of cardiac activity (via electrocardiograph) and respiratory rate(98)
- 11.4 Monitoring of blood pressure by indwelling arterial line or by periodic cuff measurements(24)
- 11.5 Continuous monitoring of proximal airway pressures including peak inspiratory pressure (PIP), PEEP, and mean airway pressure (Paw)(1,39,99)
- 11.5.1 Increases in Paw may result in improved oxygenation; however, Paw > 12 cm H2O has been associated with barotrauma.(8,20,41,99-102)
- 11.5.2 The difference between PIP and PEEP (^P) in conjunction with patient mechanics determines VT. As the ^P changes, VT will vary.(16,51,99,100)
- 11.5.3 PIP should be adjusted initially to achieve adequate VT as reflected by chest excursion and adequate breath sounds(8,29,100) and/or by VT measurement.
- 11.5.4 PEEP increases FRC and may improve oxygenation and ventilation-perfusion relationship (PEEP is typically adjusted at 4-7 cm H2O--levels beyond this range may result in hyperinflation, particularly in patients with obstructive airways disease [eg, MAS or bronchiolitis](5,29,35,103-105)).
- 11.6 Many commercially available neonatal ventilators provide continuous monitoring of ventilator frequency, tI, and I:E. If only two of these variables are directly monitored, the third should be calculated (eg, the proportion of the tI for a given frequency determines the I:E).
- 11.6.1 Lengthening tI increases Paw and should improve oxygenation.(1,2,13,24,41,106,107)
- 11.6.2 I:E in excess of 1:1 may lead to the development of auto-PEEP and hyperinflation.(5,20,24,37,105,106,108)
- 11.6.3 Frequencies of 30-60 per minute with shorter tI (eg, I:E of 1:2) are commonly used in patients with RDS.(8,22,41,50,59,85,109-111)
- 11.7 Depending on the internal diameter of the ventilator circuit, excessive flowrates can result in expiratory resistance that leads to increased work of breathing and automatic increases in PEEP.(17,19,89,98,86,112) Some ventilators are equipped with demand-flow systems that permit the use of lower baseline flowrates but provide the patient with additional flow as needed
- 11.8 Because of the possibility of complete obstruction or kinking of the ETT and the inadequacy of ventilator alarms in these situations, continuous tidal volume monitoring via an appropriately designed (minimum dead space) proximal airway flow sensor is recommended.(98,113,114)
- 11.9 Periodic physical assessment of chest excursion and breath sounds and for signs of increased work of breathing and cyanosis.(3,5,21,87)
- 11.10 Periodic evaluation of chest radiographs to follow the progress of the disease, identify possible complications, and verify ETT placement(21,27,79)
TPTV 12.0 FREQUENCY:
TPTV is intended for continuous use and is discontinued when the patient's clinical condition improves as indicated by results of outcome assessments (Section 9.0).
TPTV 13.0 INFECTION CONTROL:
No special precautions are necessary, but Universal Precautions as described by the Centers for Disease Control should be employed.(95)
Perinatal-Pediatrics Guidelines Committee:
- 13.1 Ventilator circuits and humidifier chambers should not be changed more frequently than every 48 hours. The Clinical Practice Guideline: Ventilator Circuit Changes, the CDC, and, reported experience(114-116) suggest that use periods of > or = 5 days are acceptable when the humidifying device is other than an aerosol generator.
- 13.2 External surfaces of ventilator should be cleaned according to the manufacturer's recommendations when the device has remained in a patient's room for a prolonged period, when soiled, when it has come in contact with potentially transmittable organisms, and after each patient use.
- 13.3 Sterile suctioning procedures should be strictly adhered to.(82)
Lynne K Bower RRT, Chairman, Boston MA
Sherry L Barnhart RRT, Mattoon IL
Peter Betit BS RRT, Boston MA
Barbara Hendon BA RRT RCP, Wylie TX
Joanne Masi-Lynch BS RRT, Salt Lake City UT
Barbara G Wilson MEd RRT, Durham NC
- Herman S, Reynolds EOR. Methods for improving oxygenation in infants mechanically ventilated for severe hyaline membrane disease. Arch Dis Child 1973;48:612-617.
- Manginello FP, Grasssi AE, Schechner S, Krauss AN, Auld PAM. Evaluation of methods of assisted ventilation in hyaline membrane disease. Arch Dis Child 1978;53:878-881.
- Carlo WA, Pacifico L, Chatburn RL, Fanaroff AA. Efficacy of computer-assisted management of respiratory failure in neonates. Pediatrics 1986;78(1):139-143.
- Chatburn RL, Carlo WA, Lough MD. Clinical algorithm for pressure-limited ventilation of neonates with respiratory distress syndrome. Respir Care 1983;28(12):1579-1586.
- Chatburn RL. Similarities and differences in the management of acute lung injury in neonates (IRDS) and in adults (ARDS). Respir Care 1988;33(7):539-553.
- Stern L. Therapy of the respiratory distress syndrome. Pediatr Clin North Am 1972;19(1):221-240.
- Carr DJ, Rich M, Murkowski K, Neu J. A comparative evaluation of three neonatal ventilators. Crit Care Med 1986;14(3):234-236.
- Carlo, WA, Martin RJ. Principles of neonatal assisted ventilation. Pediatr Clin North Am 1986;33(1):221-237.
- Hess D, Lind L. Nomograms for the application of the Bourns model BP200 as a volume-constant ventilator. Respir Care 1980;25(2):248-250.
- Smith JD. Application of mechanical ventilation in acute respiratory failure. Respir Care 1983;28(5):579-585.
- Chatburn RL. Principles and practice of neonatal and pediatric mechanical ventilation. Respir Care 1991;36(6): 569-593.
- deLemos RA, Kirby RR. Early development: intermittent mandatory ventilation in neonatal respiratory support. Int Anesthesiol Clin 1980;18(2):39-51.
- Reynolds EOR. Pressure waveform and ventilator settings for mechanical ventilation in severe hyaline membrane disease. Int Anesthesiol Clin 1974;12(4):259-280.
- Kirby R, Robison E, Schulz J, deLemos RA. Continuous-flow ventilation as an alternative to assisted or controlled ventilation of infants. Anesth Analg 1972;51(6):871-875.
- Marini JJ, Crooke PS III, Truwit JD. Determinants and limits of pressure-preset ventilation: a mathematical model of pressure control. J Appl Physiol 1989;67(3):1081-1092.
- Muramatsu K, Yukitake K, Oda T. Variability of respiratory system compliance in mechanically ventilated infants. Pediatr Pulmonol 1992;12:140-145.
- Greenough A. The premature infant's respiratory response to mechanical ventilation. Early Hum Dev 1988;17:1-5.
- Hillman DR. Physiological aspects of intermittent positive pressure ventilation. Anaesth Intensive Care 1986;14(3):226-235.
- Lewis RM. Factors affecting lung volume changes during newborn mechanical ventilation: a bench study. Respir Care 1992;37(10):1153-1160.
- Lewis RM. Automatic increases in mean airway pressure during mechanical ventilation. Respir Care 1982;27(6):675-681.
- Keuskamp DHG. Ventilation of premature and newborn infants. Int Anesthesiol Clin 1974;12(4):281-300.
- Boros SJ, Bing DR, Mammel MC, Hagen E, Gordon MJ. Using conventional infant ventilators at unconventional rates. Pediatrics 1984;74:487-492.
- Schena J, Monaghan EJ, Kaufman A, Thompson J, Crone RK. Delivered tidal volume during infant mechanical ventilation (abstract). Respir Care 1983;28(10): 1363.
- Reynolds EOR. Effect of alterations in mechanical ventilator settings on pulmonary gas exchange in hyaline membrane disease. Arch Dis Child 1971;46:152-159.
- Reynolds EOR. Indications for mechanical ventilation in infants with hyaline membrane disease. Pediatrics 1970;46(2):193-202.
- Sedin G. CPAP and mechanical ventilation. Int J Technol Assess Health Care 1991;7(Supp 1):31-40.
- Reynolds EOR, Taghizadeh A. Improved prognosis of infants mechanically ventilated for hyaline membrane disease. Arch Dis Child 1974;49:505-515.
- Meyer HBP, Griffin BE, Sedaghatian MR, Halpe PR, Daily WJR. Ventilatory support of the newborn infant with respiratory distress syndrome and respiratory failure. Int Anesthesiol Clin 1974;12(4):81-110.
- Narang A, Shenoi A. Physiological principles of mechanical ventilation of the newborn. Indian J Pediatr 1992;59:21-27.
- Smith PC, Daily WJR, Fletcher G, Meyer HBP, Taylor G. Mechanical ventilation of newborn infants: I. the effect of rate and pressure on arterial oxygenation of infants with respiratory distress syndrome. Pediatr Res 1969;3:244-254.
- Harrison VC, de V Heese H, Klein M. The significance of grunting in hyaline membrane disease. Pediatrics 1968;41(3):549-559.
- Kattwinkel J, Nearman HS, Fanaroff AA, Katona PG, Klaus MH. Apnea of prematurity: comparative therapeutic effects of cutaneous stimulation and nasal continuous positive airway pressure. J Pediatr 1975;86(4):588-592.
- Allan WC, Volpe JJ. Periventricular-intraventricular hemorrhage. Pediatr Clin North Am 1986;36(1):47-63.
- Roland EH. Neuromuscular disorders in the newborn. Clin Perinat 1989;16(2):519-547.
- Sivan Y, Deakers TW, Newth CJL. Functional residual capacity in ventilated infants and children. Pediatr Res 1990;28(5):451-454.
- Spahr RC, Klein AM, Brown DR, MacDonald HM, Holzman IR. Hyaline membrane disease: a controlled study of inspiratory to expiratory ratio on its management by ventilator. Am J Dis Child 1980;134(4):373-376.
- Greenough A, Pool J, Greenall F, Morley C, Gamsu H. Comparison of different rates of artificial ventilation in preterm neonates with respiratory distress syndrome. Acta Paediatr Scand 1987;76:706-712.
- Hayes B. Ventilation and ventilators-an update. J Med Eng Technol 1988;12(5):197-218.
- Stark AR, Frantz ID. Respiratory distress syndrome. Pediatr Clin North Am 1986;33(3):533-544.
- Wiswell TE, Bent RC. Meconium staining and the meconium aspiration syndrome. Pediatr Clin North Am 1993;40(5):955-981.
- Greenough A, Roberton NRC. Neonatal ventilation. Early Hum Dev 1986;13:127-136.
- Bancalari E, Gerhardt T. Bronchopulmonary dysplasia. Pediatr Clin North Am 1986;33(1):1-23.
- Goldberg RN, Bancalari E. Bronchopulmonary dysplasia: clinical presentation and the role of mechanical ventilation. Respir Care 1986;31(7):591-596.
- Goldberg RN, Bancalari E. Therapeutic approaches to the infant with bronchopulmonary dysplasia. Respir Care 1991;36(6):613-621.
- Wilson JM, Lund DP, Lillehei CW, O'Rourke PP, Vacanti JP. Delayed repair and preoperative ECMO does not improve survival in high-risk congenital diaphragmatic hernia. J Pediatr Surg 1992;27(3):368-375.
- Wung J-T, James LS, Kilchevsky E, James E. Management of infants with severe respiratory failure and persistence of the fetal circulation, without hyperventilation. Pediatrics 1985;76(4):488-494.
- Roberts JD Jr, Shaul PW. Advances in the treatment of persistent pulmonary hypertension of the newborn. Pediatr Clin North Am 1993;40(5):983-1004.
- Rheuban K. The infant with congenital heart disease: guidelines for care in the first year of life. Clin Perinatol 1984;11(1):199-212.
- Hollinger IB. Postoperative management: ventilation. Int Anesthesiol Clin 1980;18(1):205-216.
- Oxford Region Controlled Trial of Artificial Ventilation (OCTAVE) Study Group. Multicentre randomised controlled trial of high against low frequency positive pressure ventilation. Arch Dis Child 1991;66(7, Spec No):770-775.
- Fisher JB, Mammel MC, Coleman JM, Bing DR, Boros SJ. Identifying lung overdistention during mechanical ventilation by using volume-pressure loops. Pediatr Pulmonol 1988;5:10-14.
- Nilsson R, Grossmann G, Robertson B. Pathogenesis of neonatal lung lesions induced by artificial ventilation: evidence against the role of barotrauma. Respiration 1980;40:218-225.
- Tarnow-Mordi WO, Narang A, Wilkinson AR. Lack of association between barotrauma and air leak in hyaline membrane disease. Arch Dis Child 1985;60:555-559.
- Primhak RA. Factors associated with pulmonary air leak in premature infants receiving mechanical ventilation. J Pediatr 1983;102:764-768.
- Chernick V. Lung rupture in the newborn infant. Respir Care 1986;31(7):628-633.
- Thibeault DW, Lachman RS, Laul VR, Kwong MS. Pulmonary interstitial emphysema, pneumomediastinum, and pneumothorax. Am J Dis Child 1973;126:611-614.
- Moylan FM, Walker AM, Kramer SS, Todres ID, Shannon DC. The relationship of bronchopulmonary dysplasia to the occurrence of alveolar rupture during positive pressure ventilation. Crit Care Med 1978;6(3):140-142.
- Pollack MM, Fields AI, Holbrook PR. Pneumothorax and pneumomediastinum during pediatric mechanical ventilation. Crit Care Med 1979;7(12):536-539.
- Tarnow-Mordi W, Wilkinson A. Mechanical ventilation of the newborn (letter). Br Med J 1986;292:575.
- Caldwell EJ, Powell RD Jr, Mullooly JP. Interstitial emphysema: a study of physiologic factors involved in experimental induction of the lesion. Am Rev Respir Dis 1970;102:516-525.
- Greenough A, Dixon AK, Roberton NRC. Pulmonary interstitial emphysema. Arch Dis Child 1984;59:1046-1051.
- Plenat F, Vert P, Didier F, Andre M. Pulmonary interstitial emphysema. Clin Perinatol 1978;5(2):351-375.
- Cooke RWI. Factors associated with chronic lung disease in preterm infants. Arch Dis Child 1991;66(7, Spec No):776-779.
- Stocks J, Godfrey S. The role of artificial ventilation, oxygen, and CPAP in the pathogenesis of lung damage in neonates: assessment by serial measurements of lung function. Pediatrics 1976;57(3):352-362.
- Taghizadeh A, Reynolds EOR. Pathogenesis of bronchopulmonary dysplasia following hyaline membrane disease. Am J Pathol 1976;82(2):241-264.
- Riedel F. Long term effects of artificial ventilation in neonates. Acta Paediatr Scand 1987;76:24-29.
- Avery ME, Tooley WH, Keller JB, Hurd SS, Bryan MH, Cotton RB, et al. Is chronic lung disease in low birth weight infants preventable? A survey of eight centers. Pediatrics 1987;79(1):26-30.
- Wung J-T, Koons AH, Driscoll JM Jr, James LS. Changing incidence of bronchopulmonary dysplasia. J Pediatr 1979;95(5, Part 2):845-847.
- Truog WE. Complications of mechanical ventilation and airway control in the neonate. Respir Care 1986;31(6): 498-505.
- Loochtan AM, Loochtan RM. Damage to neonatal oral structures: effects of laryngoscopy and intubation. Respir Care 1989;34(10):879-888.
- Benjamin PK, Thompson JE, O'Rourke PP. Complications of mechanical ventilation in a children's hospital multidisciplinary intensive care unit. Respir Care 1990;35(9):873-878.
- Redding GJ, Fan L, Cotton EK, Brooks JG. Partial obstruction of endotracheal tubes in children: incidence, etiology, significance. Crit Care Med 1979;7(5):227-231.
- Kallstrom TJ, Salyer J. The incidence of accidental extubations in a neonatal intensive care unit (abstract). Respir Care 1989;34(11):1006.
- Benjamin PK, Thompson JE, Arnold JH. ETT pressure necrosis in a pediatric cardiac intensive care unit (CICU) (abstract). Respir Care 1992;37(11):1331.
- Farstad T, Bratild D. Effects of endotracheal tube size and ventilator settings on the mechanics of a test system during intermittent flow ventilation. Pediatr Pulmonol 1991;11:15-21.
- Sottile FD, Marrie TJ, Prough DS, Hobgood CD, Gower DJ, Webb LX, Costerton JW, Gristina AG. Nosocomial pulmonary infection: possible etiologic significance of bacterial adhesion to endotracheal tubes. Crit Care Med 1986;14(4):265-270.
- MacDonnell KF. Physiologic consequences of mechanical ventilation. Compr Ther 1977;3(12):49-58.
- Douglas ME, Downs JB. Cardiopulmonary effects of intermittent mandatory ventilation. Int Anesthesiol Clin 1980;18(2):97-121.
- Peabody JL. Mechanical ventilation of the newborn: good news . . . bad news. Crit Care Med 1981;9(10):710-713.
- Avery GB, Glass P. Retinopathy of prematurity: what causes it? Clin Perinatol 1988;15(4):917-928.
- Reisner SH, Amir J, Shohat M, Krikler R, Nissenkorn I, Ben-Sira I. Retinopathy of prematurity: incidence and treatment. Arch Dis Child 1985;60:698-701.
- American Association for Respiratory Care. Clinical practice guideline: endotracheal suctioning of mechanically ventilated adults and children with artificial airways. Respir Care 1993;38(5):500-504.
- Lawrence JC. Breathing system gas pressure monitoring and venting, ventilator monitors and alarms. Anaesth Intensive Care 1988;16(1):38-40.
- Schachter EN, Lehnert BE, Specht W. Pressure-time relationships of pressure-limited neonatal ventilators. Crit Care Med 1983;11(3):177-181.
- Greenough A, Greenall F, Gamsu H. Synchronous respiration: which ventilator rate is best? Acta Paediatr Scand 1987;76:713-718.
- Field D, Milner AD, Hopkin IE. Manipulation of ventilator settings to prevent active expiration against positive pressure inflation. Arch Dis Child 1985;60:1036-1040.
- Goldstein B, Catlin EA, Vetere JM, Arguin LJ. The role of in-line manometers in minimizing peak and mean airway pressure during the hand-regulated ventilation of newborn infants. Respir Care 1989;34(1):23-27.
- Sullivan L, Strong K, Trahey J, Hess D. Relative humidity delivered by a neonatal heated wire circuit (abstract). Respir Care 1993;38(11):1249.
- Scott LR, Benson MS, Pierson DJ. Effect of inspiratory flowrate and circuit compressible volume on auto-PEEP during mechanical ventilation. Respir Care 1986;31(11): 1075-1079.
- Severinghaus JW. Transcutaneous blood gas analysis. Respir Care 1982;27(2):152-159.
- Hay Jr WW, Brockway JM, Eyzaguirre M. Neonatal pulse oximetry: accuracy and reliability. Pediatrics 1989;83(5):717-722.
- Centers for Disease Control. Update: Universal Precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health care settings. MMWR 1988;37:377-382,387-388.
- Watkins AMC, Weindling AM. Monitoring of end tidal CO2 in neonatal intensive care. Arch Dis Child 1987;62:837-859.
- Beatty B, Roberts J. End-tidal CO2 measurements in intubated neonates weighing less than 2000 grams (abstract). Respir Care 1992;37(11):1341.
- American Association for Respiratory Care. Clinical practice guideline: humidification during mechanical ventilation. Respir Care 1992;37(8):887-890.
- American Association for Respiratory Care. Clinical practice guideline: patient-ventilator system checks. Respir Care 1992;37(8):882-886.
- American Association for Respiratory Care. Clinical practice guideline: oxygen therapy in the acute care hospital. Respir Care 1991;36(12):1410-1413.
- McCann EM, Goldman SL, Brady JP. Pulmonary function in the sick newborn infant. Pediatr Res 1987;21(4): 313-325.
- Stewart AR, Finer NN, Peters KL. Effects of alterations of inspiratory and expiratory pressures and inspiratory/expiratory ratios on mean airway pressure, blood gases, and intracranial pressure. Pediarics 1981;67(4):474-481.
- Ciszek TA, Modanlou HD, Owings D, Nelson P. Mean airway pressure-significance during mechanical ventilation in neonates. J Pediatr 1981;99(1):121-126.
- Pesenti A, Marcolin R, Prato P, Borelli M, Riboni A, Gattinoni L. Mean airway pressure vs positive end-expiratory pressure during mechanical ventilation. Crit Care Med 1985;13(1):34-37.
- Boros SJ, Matalon SV, Ewald R, Leonard AS, Hunt CE. The effect of independent variations in inspiratory-expiratory ratio and end expiratory pressure during mechanical ventilation in hyaline membrane disease: the significance of mean airway pressure. J Pediatr 1977;91(5): 794-798.
- Simbruner G. Inadvertent positive end-expiratory pressure in mechanically ventilated newborn infants: detection and effect on lung mechanics and gas exchange. J Pediatr 1986;108:589-595.
- Pierson DJ. Alveolar rupture during mechanical ventilation: role of PEEP, peak airway pressure, and distending volume. Respir Care 1988;33(6):472-484.
- Ramsden CA, Reynolds EOR. Ventilator settings for newborn infants. Arch Dis Child 1987;62:529-538.
- Boros SJ, Campbell K. A comparison of the effects of high frequency-low tidal volume and low frequency-high tidal volume mechanical ventilation. J Pediatr 1980;97(1):108-112.
- Hird M, Greenough A. Inflation time in mechanical ventilation of preterm neonates. Eur J Pediatr 1991;150(6):440-443.
- Heicher DA, Kasting DS, Harrod JR. Prospective clinical comparison of two methods for mechanical ventilation of neonates: rapid rate and short inspiratory time versus slow rate and long inspiratory time. J Pediatr 1981;98(6):957-961.
- Greenough A, Greenall F. Performance of respirators at fast rates commonly used in neonatal intensive care units. Pediatr Pulmonol 1987;3:357-361.
- Pohlandt F, Saule H, Schroder H, Leonhardt A, Hornchen H, Wolff C, and Study Group. Decreased incidence of extra-alveolar air leakage or death prior to air leakage in high versus low rate positive pressure ventilation: results of a randomised seven-centre trial in preterm infants. Eur J Pediatrics 1992;151:904-909.
- Field, D, Milner AD, Hopkin IE. High and conventional rates of positive pressure ventilation. Arch Dis Child 1984;59:1151-1154.
- Brown WR, Deming D. Ventilator circuit flow does affect lung mechanics of ventilated infants (abstract). Respir Care 1990;35(11):1101.
- Kanter RK, Blatt SD, Zimmerman JJ. Initial mechanical ventilator settings for pediatric patients: clinical judgment in selection of tidal volume. Am J Emerg Med 1987;5:113-117.
- MacDonald KD, Wang PB. Comparison of four systems for measuring neonatal tidal volumes (abstract). Respir Care 1989;34(11):1006.
- Kacmarek RM, English P, Vallende N, Hopkins CC. Extended use of heated neonatal/pediatric ventilator circuits (abstract). Respir Care 1991;36(11):1287.
- Eller R, Kennedy K, Weber P, Nadzam T, Vargo J, Nield M (abstract). The impact of 96-hour ventilator circuit changes on rates of ventilator-associated pneumonia and costs. Respir Care 1993;38(11):1262.
- American Association for Respiratory Care. Clinical practice guideline: ventilator circuit changes. Respir Care 1994;39(8):797-802.
Boros SJ. Principles of ventilator care. In: Thibeault DW, Gregory GA, eds. Neonatal pulmonary care, 2nd edition. Norwalk CT: Appleton-Century-Crofts, 1986:367-385.
Betit P, Thompson JE, Benjamin PK. Mechanical ventilation. In: Koff PB, Eitzman D, Neu J, eds. Neonatal and pediatric respiratory care, 2nd edition. St Louis: Mosby-Year Book, 1993:324-344.
Goldsmith JP, Karotkin EH. Introduction to assisted ventilation. In: Goldsmith JP, Karotkin EH, eds. Assisted ventilation of the neonate, 2nd edition. Philadelphia: WB Saunders Co, 1988:1-21.
Korones SB. Complications. In: Goldsmith JP, Karotkin EH, eds. Assisted ventilation of the neonate, 2nd edition. Philadelphia: WB Saunders Co, 1988:245-271.
Brady JP, Gregory GA. Assisted ventilation. In: Klaus MH, Fanaroff AA, eds. Care of the high-risk neonate, 2nd edition. Philadelphia: WB Saunders Co, 1988:205-223.
Wung J-T, James LS. Optimizing conventional respiratory support. In: Arensman RM, Cornish JD, eds. Extracorporeal life support. Boston: Blackwell Scientific Publications, 1992:51-67.
Carlo WA, Chatburn RL. Assisted ventilation of the newborn. In: Carlos WA, Chatburn RL, eds. Neonatal respiratory care, 2nd edition. Chicago: Year Book Medical Publishers, 1988:320-346.
Crone RK. Assisted ventilation in children. In: Gregory GA, ed. Respiratory failure in the child. New York: Churchill Livingstone, 1981.
Interested persons may copy these Guidelines for noncommercial
purposes of scientific or educational advancement. Please credit AARC and Respiratory
Reprinted from the August 1994 issue of RESPIRATORY CARE [Respir Care 1994;39(8):808–816]