What is the role of mechanical ventilation in the treatment and management of persistent pulmonary hypertension of the newborn (PPHN)?

Updated: Sep 03, 2019
  • Author: Kate A Tauber, MD; Chief Editor: Howard S Weber, MD, FSCAI  more...
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Answer

Answer

Endotracheal intubation and mechanical ventilation are almost always necessary for the newborn with PPHN. The goal of mechanical ventilation should be to maintain normal functional residual capacity (FRC) by recruiting areas of atelectasis, as well as to avoid overexpansion.

Adjust ventilator settings to maintain normal lung expansion (ie, of approximately 9 ribs) on chest radiography. Monitoring of tidal volume and of pulmonary mechanics is frequently helpful in preventing overexpansion, which can elevate PVR, aggravate right-to-left shunting, and increase the risk for pneumothorax.

In newborns with severe airspace disease who require high peak inspiratory pressures (ie, >30 cm water) or mean airway pressures (>15 cm water), consider HFV to reduce barotraumas and associated air leak syndrome. When HFV is used, the goal should still be to optimize lung expansion and FRC and to avoid overdistention.

A frequent concern is determining the target arterial PaO2 level. Although hyperoxic ventilation continues to be a mainstay in the treatment of PPHN, surprisingly little is known about what oxygen concentrations maximize benefits and minimize risks. PaO2 levels of 50 mm Hg or more typically provide for adequate tissue oxygen delivery. Aiming for higher PaO2 concentrations may lead to increased ventilator support and barotrauma. Further, the use of extreme hyperoxia in PPHN management may be toxic to the developing lung, owing to the formation of reactive oxygen radicals.

Newborns with PPHN nearly always require sedation to minimize agitation, which can increase pulmonary vascular resistance (PVR). Often morphine in combination with a benzodiazepine is used.


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