Advancing neonatal and pediatric anesthesia excellence, part 1: lung protective ventilation

Why lung protection matters

Neonates, especially those born prematurely, have fewer alveoli, immature surfactant systems, low lung compliance, and highly compliant chest walls.[1] These characteristics increase their vulnerability to atelectasis, volutrauma, and barotrauma during mechanical ventilation.¹ Even minor deviations in tidal volume can lead to significant physiological consequences. As Dr. Jonathan Tan explains, “Effective ventilation management during anesthesia is crucial for neonates and infants due to their small and fragile lung physiology.”[2] Precision in ventilation is therefore essential to minimizing the long-term physical, cognitive, and developmental impacts associated with bronchopulmonary dysplasia (BPD), a chronic lung disease most commonly seen in premature infants requiring prolonged respiratory support. BPD arises from a combination of underdeveloped lung and exposure to mechanical ventilation and oxygen-related injury, resulting in impaired pulmonary growth and function.[3]

A growing body of evidence underscores the importance of lung protective ventilation (LPV) in pediatric surgical care. In a randomized controlled trial involving children under five undergoing one-lung ventilation for pulmonary resection, LPV, characterized by lower tidal volumes and consistent PEEP, significantly reduced postoperative pulmonary complications from 25.5% to 9.1% compared to conventional ventilation.[4] The study also demonstrated improved oxygenation, fewer ultrasound-detected signs of lung injury, and reduced intraoperative desaturation. These findings reinforce the critical role of precision ventilation strategies in minimizing perioperative lung injury and optimizing outcomes in pediatric patients with vulnerable respiratory physiology.

Clinical perspective: tailoring ventilation for tiny lungs

At ESAIC 2025, Dr. Mikaszewska, a pediatric anesthesiologist from Warsaw, shared practical insights on the challenges of ventilating neonates and infants. Her presentation, “Tiny Lungs, Big Care,”[5] emphasized the importance of tailoring ventilation strategies to the unique physiology and pathology of each patient.

“Regardless of experience or equipment, anesthesia for very small children—especially premature neonates—is always a challenge,” she noted. “Most complications arise from ventilatory and airway management.”

She highlighted the impact of anatomical differences, such as a highly compliant chest wall, flattened diaphragm, and horizontal ribs, which contribute to increased airway resistance and susceptibility to lung injury. These factors underscore the importance of precision in tidal volume delivery, PEEP settings, and minimizing apparatus dead space.

Latest guidelines: what’s new?

Clinicians and professional organizations are keenly aware of these challenges. To deliver care based on the latest evidence, clinical frameworks—such as those from the Northwest Neonatal Operational Delivery Network (NWNODN)—offer guidance to optimize ventilation strategies and reduce the risk of lung injury in this vulnerable population. The framework includes a clear recommendation for volume-targeted ventilation.[6]^,[7] This approach is supported by other leading clinical guidelines, including those from the European Consensus Guidelines[8] and the British Association of Perinatal Medicine.[9] 

NWNODN’s key considerations include:

• Use of non-invasive ventilation (NIV) such as CPAP or high-flow nasal cannula (HFNC) as first-line support for stable preterm infants.
• Volume-targeted ventilation (VTV) should be initiated early in invasively ventilated neonates, with a target tidal volume of 4–6 mL/kg.
• Optimal PEEP settings are essential to prevent atelectrauma and maintain end-expiratory lung volume.
• Minimizing end-inspiratory overdistention (volutrauma) and avoiding repeated alveolar collapse and reopening (atelectrauma) are central to lung-protective strategies.

Technology enables precision

As a leader in anesthesia delivery, GE HealthCare supports this clinical direction with the Carestation suite of anesthesia devices, along with the Aisys^TM CS2*. These devices feature PCV-VG, a volume-targeted ventilation mode consistent with the clinical guidelines. Other available modes include PCV, a pressure-controlled ventilation mode, capable of lower tidal volume.

GE HealthCare’s anesthesia ventilators have evolved to meet the demands of neonatal care. Features such as compliance compensation, fresh gas flow compensation, and accurate tidal volume delivery allow clinicians to ventilate small neonates with remarkable precision, reinforcing intraoperative lung protective ventilation strategies. These ventilators also integrate advanced monitoring tools like continuous capnography, which provide real-time feedback on gas exchange and lung mechanics. This enables clinicians to adjust ventilation parameters dynamically, helping improve outcomes and reduce complications.

Dr. Mikaszewska emphasized the importance and safety in caring for neonates with ventilators capable of helping clinicians adapt to bronchospasm, airway resistance, and compromised lung mechanics—especially during procedures like thoracoscopy or laparoscopy, where surgical pressures counteract ventilation.⁵

Practical considerations

To implement intraoperative lung protective ventilation effectively, anesthesia teams should:²

• Minimize apparatus dead space to reduce the risk of CO₂ rebreathing.
• Select an appropriately sized endotracheal tube to ensure optimal airway resistance and ventilation efficiency.
• Ensure adequate humidification to maintain mucociliary function and prevent airway injury.

Purposeful planning along with implementing ventilation tools that enable real-time assessment of gas exchange and lung mechanics, help clinicians make timely, informed adjustments to ventilation parameters.

“You must have a plan for this small creature because the safety of the child is in our hands.” – Dr. Mikaszewska

Looking ahead

As neonatal and infant anesthesia continues to evolve, lung protective ventilation will remain a cornerstone of safe and effective care. The integration of modern ventilator technology, adherence to updated guidelines, and a commitment to precision will help reduce the burden of chronic lung disease and improve long-term outcomes for the smallest patients.

“Anesthesia teams caring for neonates and infants can now deliver more precise and personalized ventilation when using modern anesthesia ventilators equipped with compliance compensation, accurate tidal volume controls, and sophisticated respiratory monitoring systems.” — Dr. Jonathan M. Tan

References

1. Yadav S, Lee B. Neonatal Respiratory Distress Syndrome. [Updated 2023 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560779/

2. Tan, Jonathan (2025). Optimizing Pediatric Anesthesia Care for Neonates and Infants. GE HealthCare, Clinical View. https://clinicalview.gehealthcare.com/article/optimizing-pediatric-anesthesia-care-neonates-and-infants 

3. Homan TD, Nayak RP. Short- and long-term complications of bronchopulmonary dysplasia. Respir Care. 2021;66(10):1618–1629. doi: 10.4187/respcare.08401. 

4. Lee JH, Bae JI, Jang YE, Kim EH, Kim HS, Kim JT. Lung protective ventilation during pulmonary resection in children: a prospective, single-centre, randomised controlled trial. Br J Anaesth. 2019;122(5):692-701. doi:10.1016/j.bja.2019.02.013

5. Mikaszewska M. Tiny lungs big care (2025). https://clinicalview.gehealthcare.com/webinar/tiny-lungs-big-care

6. Sur, A. et al. (2024) Volume targeted ventilation- a Framework of Practice, https://www.neonatalnetwork.co.uk/nwnodn/wp-content/uploads/2025/01/GL-…. Available at: https://www.neonatalnetwork.co.uk/nwnodn/wp-content/uploads/2025/01/GL-ODN-24-VTV-framework.pdf. 

7. Klingenberg C, Wheeler KI, McCallion N, Morley CJ, Davis PG. Volume-targeted versus pressure-limited ventilation in neonates. Cochrane Database of Systematic Reviews. 2017 Oct 17;2017(10). 

8. Sweet DG, Carnielli VP, Greisen G, Hallman M, Klebermass-Schrehof K, Ozek E, et al. European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update. Neonatology. 2023;120(1):3–23.

9. https://www.bapm.org/resources/BPD-Toolkit

Disclaimer: Nothing in this material should be used to diagnose or treat any disease or condition. Readers must consult a healthcare professional.

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