Next generation ventilation strategies to prevent and manage bronchopulmonary dysplasia

Prevention of bronchopulmonary dysplasia (BPD) has long been an elusive goal in neonatal respiratory support. Although overall incidence of BPD has not decreased, there appears to be a reduction in severity of the disease with less invasive means of support, which include avoidance of intubation when possible, less invasive means of surfactant administration and extubation at the earliest opportunity. When mechanical ventilation is needed, volume-targeted ventilation is the most evidence-based intervention available. High-frequency ventilation is not clearly superior to modern conventional ventilation strategies, but facilitates lung volume recruitment, which is a key component of any lung-protective ventilation strategy. Novel ventilation techniques such as neutrally adjusted ventilatory assist (NAVA) and airway pressure release ventilation have so far not been shown to be effective in reducing BPD. Once chronic lung disease has taken hold, ventilation strategy needs to be adjusted to account for the multi-compartmental lung physiology with longer time constants and increased alveolar dead space. Substantially larger tidal volume, slower ventilator rate and higher end-expiratory pressure are needed in infants with severe established BPD. Adequate respiratory support must take precedence over aggressive weaning at this stage to facilitate growth and neurodevelopment.