**10. Invasive artificial ventilation of the neonate**

(CPAP), the intermittent insufflation of positive pressure (nasal intermittent positive pressure ventilation, NIPPV), which can be time determined or synchronous triggered by inhalation (synchronous nasal intermittent positive pressure ventilation (SNIPPV)) and ventilation at two levels of positive pressure (bi-level positive pressure ventilation, Bi-Level) or even with high-frequency oscillations (high-frequency oscillation ventilation (HFOV)) have been developed. Different randomized studies have explored the advantages or disadvantages of one method of non-invasive ventilatory support over the other. In comparing the non-invasive ventilation with NIPPV to the nasal CPAP, fewer respiratory failures and the need for intubation in the NIPPV group were found [46]. Meta-analysis of the use of different devices and interfaces for CPAP has elucidated differences in outcome depending on the use of nasal adapters or interfaces, requiring further research [47]. Similarly, there is an open question whether breathing with the help of bi-level CPAP is better than breathing

If higher mean inspiratory pressures are required for the lungs to remain inflated, the potential non-invasive ventilation using HFO via nasal tubes or cannulas may be used since even long-term studies have confirmed advantages of HFO non-invasive ventilation over other

Ventilation of neonates using high-flow rates (high-flow nasal cannula (HFNC)) has some advantages over CPAP due to less damage to the nose and nasal septa and less pneumothorax (PTX) [49]. A multicentre study being conducted in nine centres in Australia and Norway might give answers as to which breathing support is better in very preterm infants, CPAP or

Nose requires special attention because the prolonged nasal respiratory therapy may cause decubitus and malformations of the nose. Regular changes of devices and protection of the nose skin and mucosa with skin-protective strips and/or creams prevent those problems. Gastric distension has to be prevented by an opened nasogastric tube and regular checking of gastric over distension which decrease compromise of diaphragm contractions. Neonatal care in term neutral environment incubators or warm beds and preventive positions like Cocoonababy® Nest or similar home-made products besides frequent changes of neonate's positions improve ventilation during the period of acute respiratory problems. Kangaroo care is a useful method to improve bonding between the neonate and the mother or father but has to be carried out cautiously during non-invasive ventilation [51]. During kangaroo care, observations have to be made whether apnoeic spells are more frequent and whether

Non-invasive respiratory ventilation enables non-aggressive approaches, without sedation, analgesia, tracheal intubation and mechanical ventilation. Complications of non-invasive ventilation are mainly pressure sores of skin around the nose, ulceration and necrosis of the septum, much less likely hyperinflation of the lungs, restlessness, PTX, stomach distension or food intolerance. Non-invasive ventilation failure may be predicted by the use of neonatal

, better oxygenation

with CPAP alone and does it pose an advantage of better exhaling CO<sup>2</sup>

or other physiological indicators [48].

invasive ventilation methods.

54 Selected Topics in Neonatal Care

HFNC [50].

bradycardia occurs.

chest US [52].

Nowadays, the invasive artificial ventilation of the neonate represents a continuation of treatment in cases where non-invasive ventilation with or without the use of surfactant is not possible or successful. In invasive mechanical support ventilation with a respirator, CPAP is usually supplied in combination with intermittent mandatory or synchronized artificial ventilation (i.e. intermittent mandatory ventilation (IMV); synchronized intermittent mandatory ventilation (SIMV)). Ventilation can be sustained at two different positive pressure levels (variable/bi-level positive airway pressure, bi-level (BiPAP)). Other forms of artificial ventilation include ventilation by releasing the pressure (airway pressure release ventilation (APRV)), neuronal-mediated respiratory support (neurally adjusted ventilatory assist (NAVA)), and so on. In the case of the artificial ventilation, one should always set the concentration of a mixture of the inspired oxygen and air, the frequency of the ventilation, the ratio of duration of the inspiration and expiration or time of inspiration, the end-inspiratory pressure or the tidal volume and the end-expiratory pressure. Each respirator is equipped with the heater and humidifier in order that neonates breathe moist and warm mixture of air and oxygen. In cases of severe pulmonary disease with severe RD, high-frequency oscillating ventilators, which use very low inspiratory volumes that do not damage the lung tissue, may be used.

High-frequency oscillation ventilation is a method of artificial ventilation, which in cases of severe RD can be the least harmful way of ensuring good oxygenation and due to the active exhalation wash out carbon dioxide as well. High-frequency oscillation ventilation will only be successful if the pulmonary alveoli are optimally opened prior to the start of oscillations. In HFO, the optimization of lung volume is achieved by small increments of continuous positive distending airway pressure and the pressure in lung alveoli. Gradually, the increase of continuous positive distending airway pressure leads to opening of the small, collapsed non-ventilated lung and by that to the increment of the FRC of the lungs that ensure good ventilation and oxygenation. Consequently, the optimally opened lung tissue is then oscillated with very small tidal gas volume (order of the neonate's dead space of the lungs), which regulates the exhalation of carbon dioxide from the lungs. Oscillations with small volumes are less harmful for the delicate lung parenchyma and do not damage it, thereby preventing the secondary injury such as barotrauma and volutrauma. When lung function improves, the neonate's ventilation can be switched to conventional artificial ventilation again [53].

The most important factor in invasive artificial ventilation of the neonate is to prevent the lung over-distension, because it injures the delicate lung tissue and causes air leakage outside the airway with the development of pulmonary interstitial emphysema (PIE), PTX or pneumomediastinum (PM) and other even more severe forms the air leakage into the chest. When lungs become more compliant, the pressure-guided artificial ventilation may lead to lung over-distension, therefore many of the neonatal respirators are programmed to the restriction of tidal volume (volume-targeted ventilation; volume-guaranteed ventilation (VGV)). Care should be taken not to cause hypocapnia during ventilation since it decreases the brain blood flow and causes periventricular leukomalacia (PVL) and IVH which jeopardize the neurological development. The volume-targeted artificial ventilation was shown to shorten the duration of artificial ventilation and hypocapnia, lessen the incidence of BPD, IVH grade III/IV, PTX and PVL in comparison to the pressure-controlled ventilation in preterm neonates. The mortality rate was unaffected by the mode of artificial ventilation [54].

**Author details**

Štefan Grosek1,2\* and Petja Fister<sup>3</sup>

Ljubljana, Ljubljana, Slovenia

Saunders; 2011. pp. 19-46

nancy Childbirth. 2016;**16**(1):281

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Obstetrics & Gynecology. 2014;**124**(1):47-56

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2014;**35**(10):417-428; quiz 29

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**101**(3):F266-F271

**References**

\*Address all correspondence to: stefan.grosek@kclj.si

Medical Centre Ljubljana, Ljubljana, Slovenia

1 Department of Pediatric Surgery and Intensive Therapy, Surgical Service, University

Respiratory Care of the Neonate

57

http://dx.doi.org/10.5772/intechopen.69674

3 Department of Neonatology, University Children's Hospital, University Medical Centre

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[8] Backes CH, Rivera BK, Haque U, Bridge JA, Smith CV, Hutchon DJ, et al. Placental transfusion strategies in very preterm neonates: A systematic review and meta-analysis.

[9] Mercer JS, Erickson-Owens DA, Vohr BR, Tucker RJ, Parker AB, Oh W, et al. Effects of placental transfusion on neonatal and 18 month outcomes in preterm infants: A random-

2 Department of Pediatrics, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia

During intubation and invasive ventilation, neonates are prone to cardio- and cerebrovascular instability. The intensive invasive therapy subjects neonates to more infections and the invasive ventilation to volu-, barotrauma and shear stress. Common complications due to intubations and invasive ventilation are hoarseness, aphonia, tracheal stenosis, and feeding and perioral sensation disorders.
