Optimal Strategies of Mechanical Ventilation: Can We Avoid or Reduce Lung Injury?

Background: Despite the increasing use of non-invasive support modalities, many preterm infants still need invasive mechanical ventilation. Mechanical ventilation can lead to so-called ventilator-induced lung injury, which is considered an important risk factor in the development of bronchopulmonary dysplasia. Understanding the concepts of lung protective ventilation strategies is imperative to reduce the risk of BPD.

Summary: Overdistension, atelectasis, and oxygen toxicity are the most important risk factors for VILI. A lung protective ventilation strategy should therefore optimize lung volume (resolve atelectasis), limit tidal volumes, and reduce oxygen exposure. Executing such a lung protective ventilation strategy requires basic knowledge on neonatal lung physiology. Studies have shown that volume-targeted ventilation (VTV) stabilizes tidal volume delivery, reduces VILI, and reduces BPD in preterm infants with respiratory distress syndrome. High-frequency ventilation (HFV) also reduces BPD although the effect is modest and inconsistent. It is unclear if these benefits also apply to infants with more heterogeneous lung disease.

Key Messages: Understanding basic physiology and the concept of ventilator-induced lung injury is essential in neonatal mechanical ventilation. Current evidence suggests that the principles of lung protective ventilation are best captured by VTV and HFV.