New tools in ventilatory support: high frequency ventilation, nitric oxide, tracheal gas insufflation, non-invasive ventilation.

Protection of the lungs against ventilator-induced lung injury is becoming one of the main concerns in pediatric and neonatal intensive care. High frequency ventilation using a constant distending pressure with small variations during respiratory cycles allows adequate recruitment. High frequency oscillation is the most promising HFV mode especially in premature neonates but clinical studies are contradictory. Nitric oxide, an inhaled gas with specific pulmonary vasodilating effects, has become a powerful tool in the treatment of pulmonary arterial hypertension alone or in combination with HFO, but studies have failed to show improvement in survival in neonates as well as in children with ARDS. Tracheal gas insufflation, in addition to conventional ventilation, by washing dead space during exhalation, improves gas exchange while lowering tidal volume. It is however still experimental. Maintenance of spontaneous ventilation during conventional ventilation improves gas exchange, hemodynamic functions, mobilization, active coughing, and avoids prolonged muscle weakness. Non invasive modes of ventilation like BiPAP have certain indications in pediatrics but need to become more familiar to the pediatric intensivist.