Respiratory Therapy Program, Grossmont Community College, El Cajon, California 92020, USA.
Respir Care. 2011 Sep;56(9):1298-311; discussion 1311-3. doi: 10.4187/respcare.01429.
Although the trend in the neonatal intensive care unit is to use noninvasive ventilation whenever possible, invasive ventilation is still often necessary for supporting pre-term neonates with lung disease. Many different ventilation modes and ventilation strategies are available to assist with the optimization of mechanical ventilation and prevention of ventilator-induced lung injury. Patient-triggered ventilation is favored over machine-triggered forms of invasive ventilation for improving gas exchange and patient-ventilator interaction. However, no studies have shown that patient-triggered ventilation improves mortality or morbidity in premature neonates. A promising new form of patient-triggered ventilation, neurally adjusted ventilatory assist (NAVA), was recently FDA approved for invasive and noninvasive ventilation. Clinical trials are underway to evaluate outcomes in neonates who receive NAVA. New evidence suggests that volume-targeted ventilation modes (ie, volume control or pressure control with adaptive targeting) may provide better lung protection than traditional pressure control modes. Several volume-targeted modes that provide accurate tidal volume delivery in the face of a large endotracheal tube leak were recently introduced to the clinical setting. There is ongoing debate about whether neonates should be managed invasively with high-frequency ventilation or conventional ventilation at birth. The majority of clinical trials performed to date have compared high-frequency ventilation to pressure control modes. Future trials with premature neonates should compare high-frequency ventilation to conventional ventilation with volume-targeted modes. Over the last decade many new promising approaches to lung-protective ventilation have evolved. The key to protecting the neonatal lung during mechanical ventilation is optimizing lung volume and limiting excessive lung expansion, by applying appropriate PEEP and using shorter inspiratory time, smaller tidal volume (4-6 mL/kg), and permissive hypercapnia. This paper reviews new and established neonatal ventilation modes and strategies and evaluates their impact on neonatal outcomes.
虽然新生儿重症监护病房的趋势是尽可能使用无创通气，但对于患有肺部疾病的早产儿，仍常常需要有创通气来支持。有许多不同的通气模式和通气策略可用于协助优化机械通气和预防呼吸机相关肺损伤。与机器触发的有创通气相比，患者触发通气更有利于改善气体交换和患者-呼吸机交互。然而，没有研究表明患者触发通气可以改善早产儿的死亡率或发病率。一种有前途的新形式的患者触发通气，神经调节通气辅助（NAVA），最近已获得美国食品和药物管理局（FDA）批准用于有创和无创通气。正在进行临床试验以评估接受 NAVA 的新生儿的结局。新的证据表明，容量目标通气模式（即容量控制或压力控制与自适应目标）可能比传统的压力控制模式提供更好的肺保护。最近，一些在面对大的气管内导管泄漏时仍能提供准确潮气量输送的容量目标通气模式已被引入临床。目前仍在争论新生儿在出生时应采用高频通气还是常规通气进行有创管理。迄今为止进行的大多数临床试验都将高频通气与压力控制模式进行了比较。未来针对早产儿的试验应将高频通气与容量目标通气模式的常规通气进行比较。在过去的十年中，许多新的有前途的肺保护通气方法已经出现。在机械通气过程中保护新生儿肺的关键是通过应用适当的 PEEP 和使用较短的吸气时间、较小的潮气量（4-6ml/kg）和允许性高碳酸血症来优化肺容积并限制过度肺扩张。本文回顾了新的和已建立的新生儿通气模式和策略，并评估了它们对新生儿结局的影响。
