Synchronized mechanical ventilation for respiratory support in newborn infants
Abstract
Background
During synchronized mechanical ventilation, positive airway pressure and spontaneous inspiration coincide. Thus, if synchronous ventilation is provoked, adequate gas exchange should be achieved at lower peak airway pressures, potentially reducing barotrauma and hence airleak and chronic lung disease. Synchronous ventilation can be achieved by manipulation of rate and inspiratory time during conventional ventilation and employment of patient assisted ventilation.
Objectives
To compare
(i) the efficacy of synchronized mechanical ventilation, delivered as high frequency positive pressure ventilation or triggered ventilation (patient triggered ventilation (PTV) or synchronous intermittent mandatory ventilation (SIMV)) with conventional ventilation
(ii) different types of triggered ventilation
Search methods
Searches from 1985‐2004 of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2004), Oxford Database of Perinatal Trials, MEDLINE, previous reviews, abstracts and symposia proceedings; hand searches of journals in the English language and contact with expert informants.
Selection criteria
Randomized or quasi randomized clinical trials comparing synchronized ventilation delivered as high frequency positive pressure ventilation (HFPPV) or triggered ventilation (PTV/SIMV) to conventional mechanical ventilation (CMV) in neonates. Randomized trials comparing different triggered ventilation modes (PTV and SIMV) in neonates.
Data collection and analysis
Data regarding clinical outcomes including mortality, airleaks (pneumothorax or pulmonary interstitial emphysema (PIE)), severe intracerebral haemorrhage (grades 3 and 4), chronic lung disease (oxygen dependency beyond 28 days) and duration of weaning/ventilation.
Three comparisons were made: (i) HFPPV vs CMV; (ii) PTV/SIMV vs CMV; (iii) PTV vs SIMV. Data analysis was conducted using relative risk for categorical outcomes, weighted mean difference for outcomes measured on a continuous scale.
Main results
Eleven studies were eligible for inclusion. The meta‐analysis demonstrate that HFPPV compared to CMV was associated with a reduction in the risk of airleak (typical relative risk for pneumothorax was 0.69, 95% CI 0.51, 0.93). PTV/SIMV compared to CMV was associated with a shorter duration of ventilation (weighted mean difference ‐34.8 hours, 95% CI ‐62.1, ‐7.4). PTV compared to SIMV was associated with a trend to a shorter duration of weaning (weighted mean difference ‐42.4 hours, 95% CI ‐94.4, 9.6). Neither HFPPV nor triggered ventilation was associated with a significant reduction in the incidence of chronic lung disease. There was a non‐significant trend towards a lower mortality rate using HFPPV versus CMV, but a non‐significant trend towards a higher mortality rate using triggered ventilation versus CMV. No disadvantage of HFPPV or triggered ventilation was noted regarding other outcomes.
Authors' conclusions
Compared to conventional ventilation, benefit is demonstrated for both HFPPV and triggered ventilation with regard to a reduction in airleak and a shorter duration of ventilation, respectively. In none of the trials was complex respiratory monitoring undertaken and thus it is not possible to conclude that the mechanism of producing those benefits is by provocation of synchronized ventilation. Further trials are needed to determine whether synchronized ventilation is associated with other benefits, but optimization of trigger and ventilator design with respect to respiratory diagnosis is encouraged before embarking on further trials.
PICOs
Plain language summary
High frequency positive pressure ventilation and triggered ventilation may reduce airleaks and duration of ventilation respectively in newborns needing mechanical assistance to breathe properly.
When newborn babies need mechanical assistance to support their breathing, the majority also breathe on their own to some degree. If the baby's attempts to breathe are synchronized with the mechanical breaths from the ventilator, less pressure may be needed. This could reduce the chance of airleak or variations in blood flow to the brain. The review of trials found, when compared to conventional mechanical ventilation (CMV), high frequency positive pressure ventilation (HFPPV) reduced the risk of airleak and triggered ventilation was associated with a shorter duration of ventilation.
