Minute Volume and Ventilation Guidelines in Infants
Following placement of a secure airway, avoid excess ventilation of infants during resuscitation from cardiac arrest, and use ventilatory rates close to age-appropriate respiratory rates while avoiding both hypoventilation and hyperventilation. 1
Normal Tidal Volumes and Ventilation Parameters in Infants
- For term newborns, median tidal volumes of approximately 4.5-5.7 ml/kg have been observed during resuscitation with T-piece resuscitators 2
- For extremely low birth weight infants (<800g), appropriate tidal volumes increase with age: 5.15 ml/kg on day 1, rising to 6.07 ml/kg by days 18-21 3
- In infants with congenital diaphragmatic hernia (CDH), an initial target for delivered tidal volumes of approximately 3.5 to 5 ml/kg is recommended to minimize volutrauma 1, 4
- Synchronized ventilation modes allow for larger and more consistent tidal volumes compared to non-synchronized modes (7.4 ml/kg vs 6.2 ml/kg) 5
Ventilation During Cardiac Arrest
- There are insufficient data to identify the optimal tidal volume or respiratory rate for infants during CPR 1
- For cardiac arrest with an advanced airway in place, ventilatory rates >10 breaths per minute may be reasonable 1
- The 2024 guidelines recommend using ventilatory rates close to age-appropriate respiratory rates while avoiding hypoventilation and hyperventilation 1
- Previous recommendations of 10 breaths per minute were derived from adult data and may cause hypoventilation in infants 1
Minute Ventilation Considerations
- A reduction in minute ventilation to less than baseline for age is reasonable during CPR to maintain adequate ventilation-to-perfusion ratio while avoiding harmful effects of excessive ventilation 1
- Excessive ventilation during resuscitation from cardiac arrest can decrease cerebral perfusion pressure, return of spontaneous circulation, and survival 1
- Increasing respiratory rate during conditions of reduced cardiac output can improve alveolar ventilation but may reduce coronary perfusion pressure 1
Special Considerations for Different Conditions
- In infants with restrictive lung disease, a higher respiratory rate is recommended to compensate for low tidal volume and maintain minute ventilation 1
- For infants with pulmonary hypertension, careful ventilation management is critical as excessive ventilation can worsen outcomes 1
- In infants with CDH, ventilation strategies should account for both lung hypoplasia and potential left ventricular dysfunction 6, 4
Monitoring and Verification
- No single assessment method accurately and consistently confirms tracheal tube position in infants 1
- Detection of exhaled CO2 using a colorimetric detector or capnometer has high sensitivity and specificity for confirming endotracheal tube placement when a perfusing cardiac rhythm is present 1
- In cardiac arrest situations, the sensitivity of exhaled CO2 detection decreases to approximately 85% 1
Common Pitfalls to Avoid
- Avoid excessive ventilation during resuscitation as it can decrease cerebral perfusion pressure and survival 1
- Be cautious with ventilation strategies in infants with CDH, as inappropriate ventilation can worsen pulmonary edema, especially when left ventricular dysfunction is present 6, 4
- Recognize that tidal volume requirements change with age in premature infants, necessitating regular reassessment 3
- Be aware that despite stable peak inflating pressures, there can be substantial variation in delivered tidal volumes during newborn resuscitation 2