,5/12/25, 12:03 AM Approach to mechanical ventilation in very preterm neonates - UpToDate
Official reprint from UpToDate®
www.uptodate.com © 2025 UpToDate, Inc. and/or its affiliates. All Rights Reserved.
Approach to mechanical ventilation in very preterm
neonates
AUTHORS: Nicolas Bamat, MD, MSCE, Eric C Eichenwald, MD
SECTION EDITOR: Richard Martin, MD
DEPUTY EDITOR: Niloufar Tehrani, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2025.
This topic last updated: Aug 23, 2023.
INTRODUCTION
Mechanical ventilation (MV) is a lifesaving intervention, but it also risks injury to the lungs,
brain, and other organ systems. Supporting gas exchange while minimizing harm is the key
therapeutic goal and challenge of MV in neonates.
The approach to MV in very preterm (VPT) neonates (ie, gestational age ≤32 weeks) will be
reviewed here. A discussion of the general principles of MV in neonates, a broad overview of MV
modes, and detailed discussion of MV in other specific neonatal populations at high risk of
respiratory failure, including neonates with persistent pulmonary hypertension of the newborn,
congenital diaphragmatic hernia, and older preterm-born infants with evolving or established
bronchopulmonary dysplasia (BPD) are provided in separate topic reviews:
● (See "Overview of mechanical ventilation in neonates".)
● (See "Persistent pulmonary hypertension of the newborn (PPHN): Management and
outcome", section on 'Respiratory support'.)
● (See "Congenital diaphragmatic hernia (CDH) in the neonate: Management and outcome",
section on 'Mechanical ventilation'.)
● (See "Bronchopulmonary dysplasia (BPD): Management and outcome", section on
'Respiratory support'.)
TERMINOLOGY
https://www.uptodate.com/contents/approach-to-mechanical-ventilation-in-very-preterm-neonates/print?search=non invasive ventilation neonate&topi… 1/30
,5/12/25, 12:03 AM Approach to mechanical ventilation in very preterm neonates - UpToDate
The following terms are used throughout this topic:
● Preterm neonates – Different degrees of prematurity are defined by gestational age (GA) or
birth weight, as detailed in the table ( table 1).
● Very preterm (VPT) neonates – VPT neonates are those born at GA <32 weeks.
● Terms related to MV – Terms used to define different modes and settings for MV in neonates
are summarized in the table ( table 2).
● Ventilator-induced lung injury (VILI) – VILI is lung injury caused by MV. It can result from
exposure to excessive pressure (barotrauma), excessive stretching of the lung tissue
(volutrauma), cyclic collapsing of the alveolar spaces (atelectrauma), and exposure to high
fraction of inspired oxygen (FiO2). (See "Ventilator-induced lung injury".)
RESPIRATORY FAILURE IN VPT NEONATES
Contributing factors — Respiratory failure is the primary cause of morbidity and mortality in
very preterm (VPT) neonates [1]. Respiratory failure results from multiple contributing factors,
including respiratory distress syndrome (RDS) from surfactant deficiency. The pathophysiology
of RDS is discussed in detail separately. (See "Respiratory distress syndrome (RDS) in preterm
neonates: Clinical features and diagnosis", section on 'Pathophysiology'.)
Many factors that contribute to respiratory failure in this population have important
implications for MV management. Examples include:
● Immature respiratory drive – Preterm neonates are prone to central apnea and hypopnea
due to an inconsistent respiratory drive from an immature nervous system. Because of this,
VPT neonates typically require a MV mode with a set mandatory or back-up breath rate. (See
"Pathogenesis, clinical manifestations, and diagnosis of apnea of prematurity".)
● Narrow and collapsible airways – The supraglottic and subglottic airways of VPT neonates
are narrow and lack a mature supporting tissue architecture, making them unstable and
prone to collapse. This is one of several reasons why VPT neonates benefit from continuous
distending airway pressure (noninvasive continuous positive airway pressure [CPAP] and/or
invasive positive end-expiratory pressure [PEEP]) during MV. (See 'Initial conventional MV
settings' below.)
● Reduced alveolar air space – The alveolar air space is reduced due to incomplete
alveolarization, with less surface area available for gas exchange; inadequate surfactant
https://www.uptodate.com/contents/approach-to-mechanical-ventilation-in-very-preterm-neonates/print?search=non invasive ventilation neonate&topi… 2/30
, 5/12/25, 12:03 AM Approach to mechanical ventilation in very preterm neonates - UpToDate
quantity and quality; and edema from a secretory alveolar epithelium, excessive pulmonary
blood flow, underdeveloped pulmonary lymphatics, and inflammation. As a result, gas
exchange in VPT neonates is compromised by low pulmonary compliance,
ventilation/perfusion mismatch, and poor diffusion. Compliance is not static and marked
dynamic changes can occur (eg, after surfactant administration). (See "Respiratory distress
syndrome (RDS) in preterm neonates: Clinical features and diagnosis".)
● Compliant chest wall – VPT neonates have biomechanical disadvantages, including a
compliant chest wall and the suboptimal shape and position of the immature ribs and
diaphragm. These disadvantages contribute to a low functional residual capacity and risk
atelectasis, while increasing the work of breathing.
Need for respiratory support — Because the immature respiratory system fails to maintain
adequate gas exchange, most VPT neonates require some form of respiratory support (either
noninvasive support or invasive MV) [2]. The likelihood of requiring invasive MV increases with
decreasing gestational age (GA). Despite the trend towards increasing use of noninvasive
respiratory support in managing VPT neonates since the 1990s and early 2000s, use of invasive
MV remains common in this population, especially in extremely preterm (EPT) infants (GA <28
weeks).
In a study from the Australian and New Zealand Neonatal Network (2007 to 2013) of nearly
12,000 VPT neonates who were initially managed with nasal continuous positive airway
pressure (nCPAP), one-quarter required endotracheal intubation within 72 hours of birth [2].
CPAP failure was more common among neonates born at 25 to 28 weeks GA compared with 29
to 32 weeks GA (43 versus 21 percent, respectively).
In a prospective registry study that included nearly 11,000 neonates <29 weeks GA in the United
States Neonatal Research Network (2013 to 2016), 84 percent required MV at some time in the
postnatal course [3]. MV use increased with decreasing GA, with >99 percent of neonates born
at 23 weeks GA requiring MV compared with 88 percent of infants born at 26 weeks GA and 66
percent of neonates born at 28 weeks GA [4].
CLINICAL APPROACH
The following sections detail the approach to MV in very preterm (VPT) neonates. Management
is tailored to meet the needs of the individual neonate, which will differ between patients and
within the same patient over time. Individualized assessment and frequent reassessment of the
https://www.uptodate.com/contents/approach-to-mechanical-ventilation-in-very-preterm-neonates/print?search=non invasive ventilation neonate&topi… 3/30
Official reprint from UpToDate®
www.uptodate.com © 2025 UpToDate, Inc. and/or its affiliates. All Rights Reserved.
Approach to mechanical ventilation in very preterm
neonates
AUTHORS: Nicolas Bamat, MD, MSCE, Eric C Eichenwald, MD
SECTION EDITOR: Richard Martin, MD
DEPUTY EDITOR: Niloufar Tehrani, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2025.
This topic last updated: Aug 23, 2023.
INTRODUCTION
Mechanical ventilation (MV) is a lifesaving intervention, but it also risks injury to the lungs,
brain, and other organ systems. Supporting gas exchange while minimizing harm is the key
therapeutic goal and challenge of MV in neonates.
The approach to MV in very preterm (VPT) neonates (ie, gestational age ≤32 weeks) will be
reviewed here. A discussion of the general principles of MV in neonates, a broad overview of MV
modes, and detailed discussion of MV in other specific neonatal populations at high risk of
respiratory failure, including neonates with persistent pulmonary hypertension of the newborn,
congenital diaphragmatic hernia, and older preterm-born infants with evolving or established
bronchopulmonary dysplasia (BPD) are provided in separate topic reviews:
● (See "Overview of mechanical ventilation in neonates".)
● (See "Persistent pulmonary hypertension of the newborn (PPHN): Management and
outcome", section on 'Respiratory support'.)
● (See "Congenital diaphragmatic hernia (CDH) in the neonate: Management and outcome",
section on 'Mechanical ventilation'.)
● (See "Bronchopulmonary dysplasia (BPD): Management and outcome", section on
'Respiratory support'.)
TERMINOLOGY
https://www.uptodate.com/contents/approach-to-mechanical-ventilation-in-very-preterm-neonates/print?search=non invasive ventilation neonate&topi… 1/30
,5/12/25, 12:03 AM Approach to mechanical ventilation in very preterm neonates - UpToDate
The following terms are used throughout this topic:
● Preterm neonates – Different degrees of prematurity are defined by gestational age (GA) or
birth weight, as detailed in the table ( table 1).
● Very preterm (VPT) neonates – VPT neonates are those born at GA <32 weeks.
● Terms related to MV – Terms used to define different modes and settings for MV in neonates
are summarized in the table ( table 2).
● Ventilator-induced lung injury (VILI) – VILI is lung injury caused by MV. It can result from
exposure to excessive pressure (barotrauma), excessive stretching of the lung tissue
(volutrauma), cyclic collapsing of the alveolar spaces (atelectrauma), and exposure to high
fraction of inspired oxygen (FiO2). (See "Ventilator-induced lung injury".)
RESPIRATORY FAILURE IN VPT NEONATES
Contributing factors — Respiratory failure is the primary cause of morbidity and mortality in
very preterm (VPT) neonates [1]. Respiratory failure results from multiple contributing factors,
including respiratory distress syndrome (RDS) from surfactant deficiency. The pathophysiology
of RDS is discussed in detail separately. (See "Respiratory distress syndrome (RDS) in preterm
neonates: Clinical features and diagnosis", section on 'Pathophysiology'.)
Many factors that contribute to respiratory failure in this population have important
implications for MV management. Examples include:
● Immature respiratory drive – Preterm neonates are prone to central apnea and hypopnea
due to an inconsistent respiratory drive from an immature nervous system. Because of this,
VPT neonates typically require a MV mode with a set mandatory or back-up breath rate. (See
"Pathogenesis, clinical manifestations, and diagnosis of apnea of prematurity".)
● Narrow and collapsible airways – The supraglottic and subglottic airways of VPT neonates
are narrow and lack a mature supporting tissue architecture, making them unstable and
prone to collapse. This is one of several reasons why VPT neonates benefit from continuous
distending airway pressure (noninvasive continuous positive airway pressure [CPAP] and/or
invasive positive end-expiratory pressure [PEEP]) during MV. (See 'Initial conventional MV
settings' below.)
● Reduced alveolar air space – The alveolar air space is reduced due to incomplete
alveolarization, with less surface area available for gas exchange; inadequate surfactant
https://www.uptodate.com/contents/approach-to-mechanical-ventilation-in-very-preterm-neonates/print?search=non invasive ventilation neonate&topi… 2/30
, 5/12/25, 12:03 AM Approach to mechanical ventilation in very preterm neonates - UpToDate
quantity and quality; and edema from a secretory alveolar epithelium, excessive pulmonary
blood flow, underdeveloped pulmonary lymphatics, and inflammation. As a result, gas
exchange in VPT neonates is compromised by low pulmonary compliance,
ventilation/perfusion mismatch, and poor diffusion. Compliance is not static and marked
dynamic changes can occur (eg, after surfactant administration). (See "Respiratory distress
syndrome (RDS) in preterm neonates: Clinical features and diagnosis".)
● Compliant chest wall – VPT neonates have biomechanical disadvantages, including a
compliant chest wall and the suboptimal shape and position of the immature ribs and
diaphragm. These disadvantages contribute to a low functional residual capacity and risk
atelectasis, while increasing the work of breathing.
Need for respiratory support — Because the immature respiratory system fails to maintain
adequate gas exchange, most VPT neonates require some form of respiratory support (either
noninvasive support or invasive MV) [2]. The likelihood of requiring invasive MV increases with
decreasing gestational age (GA). Despite the trend towards increasing use of noninvasive
respiratory support in managing VPT neonates since the 1990s and early 2000s, use of invasive
MV remains common in this population, especially in extremely preterm (EPT) infants (GA <28
weeks).
In a study from the Australian and New Zealand Neonatal Network (2007 to 2013) of nearly
12,000 VPT neonates who were initially managed with nasal continuous positive airway
pressure (nCPAP), one-quarter required endotracheal intubation within 72 hours of birth [2].
CPAP failure was more common among neonates born at 25 to 28 weeks GA compared with 29
to 32 weeks GA (43 versus 21 percent, respectively).
In a prospective registry study that included nearly 11,000 neonates <29 weeks GA in the United
States Neonatal Research Network (2013 to 2016), 84 percent required MV at some time in the
postnatal course [3]. MV use increased with decreasing GA, with >99 percent of neonates born
at 23 weeks GA requiring MV compared with 88 percent of infants born at 26 weeks GA and 66
percent of neonates born at 28 weeks GA [4].
CLINICAL APPROACH
The following sections detail the approach to MV in very preterm (VPT) neonates. Management
is tailored to meet the needs of the individual neonate, which will differ between patients and
within the same patient over time. Individualized assessment and frequent reassessment of the
https://www.uptodate.com/contents/approach-to-mechanical-ventilation-in-very-preterm-neonates/print?search=non invasive ventilation neonate&topi… 3/30
