Original Article Is there an Advantage of Using Pressure Support Ventilation with Volume Guarantee in the Initial Management of Premature Infants with Respiratory Distress Syndrome? A pilot study Suhas M. Nafday, MD, MRCP (Ire.) Robert S. Green, MD Jing Lin, MD Luc P. Brion, MD Ian Ochshorn, RRT Ian R. Holzman, MD OBJECTIVE: To evaluate the feasibility of using the pressure support ventilation with volume guarantee (PSV-VG) as an initial ventilatory mode in preterm infants with respiratory distress syndrome (RDS) after surfactant treatment to achieve accelerated weaning of peak inspiratory pressure (PIP) and mean airway pressure (MAP). STUDY DESIGN: Initial 24-hour ventilatory parameters were compared in two groups of preterm infants managed by PSV-VG and the synchronized intermittent mandatory ventilation (SIMV) mode in a randomized controlled pilot study after surfactant treatment for RDS. A total of 16 babies were randomized to PSV-VG (1198±108 g [mean±SEM]; 27.9±0.6 weeks) and 18 babies to SIMV (birth weight 1055±77 g; gestational age 27.4±0.5 weeks). Repeated measures analysis of variance was used to compare serial values of PIP and MAP in the two groups. RESULTS: The PIP and MAP decreased over time ( p <0.001) during the first 24 hours after surfactant administration in both groups but the decrease in MAP was faster in the SIMV group compared to PSV-VG group ( p ¼ 0.035). The median numbers of blood gases during the first 24 hours were four and two in the SIMV and PSV-VG groups, respectively ( p <0.001). The overall outcomes were not significantly different between the two groups. CONCLUSION: PSV-VG did not offer any ventilatory advantage over SIMV in the initial management of surfactant-treated premature newborns with RDS except for minimizing the number of blood gases. Journal of Perinatology (2005) 25, 193–197. doi:10.1038/sj.jp.7211233 Published online 27 january 2005 INTRODUCTION Premature newborns with respiratory distress syndrome (RDS) are commonly managed with ventilators employing a pressure-limited mode. In such pressure-limited ventilation modes, tidal volumes (V T ) delivered by the ventilator can be quite variable due to changes in patient’s pulmonary mechanics. In premature infants with RDS, surfactant treatment dramatically increases functional residual capacity (FRC) and pulmonary compliance. 1–3 If ventilator settings are not weaned rapidly, the patient may undergo traumatic lung injury 4,5 or even ischemic brain injury secondary to hyperventilation. 6 Recently, several new modalities have been introduced to address the theoretical deficiencies of a pressure-limited ventilation mode. 7,8 Draeger Babylog 8000 plus ventilators include a number of modifications of time-cycled, pressure-limited ventilation (designed to target a set tidal volume by microprocessor-directed adjustments of peak inspiratory pressure (PIP) or inspiratory time (IT) . They have a ‘‘volume guarantee’’ option (VG), which allows them to deliver a desired V T during inspiration with a minimum possible inspiratory pressure. This is performed with a breath-to-breath determination of the baby’s dynamic compliance, resistance and patient effort, using exhaled V T measurements. Pressure support ventilation (PSV) synchronizes the beginning of inspiration and terminates each breath when inspiratory flow declines to a preset threshold, thereby eliminating inspiratory hold and synchronizing expiration with the onset of the infant’s own expiration. 9 A combination of these two capabilities, pressure support ventilation with VG (PSV-VG), hypothetically should reduce ventilator-inflicted damage to the lungs of premature babies Address correspondence and reprint requests to Suhas M. Nafday, MD, Albert Einstein College of Medicine F Children’s Hospital at Montefiore, Weiler Division, 1825 Eastchester Road, Suite # 725, Bronx, NY 10461, USA. The study was supported in part by a fellowship grant ‘‘Advancing Newborn Medicine’’ to Suhas M. Nafday from Forest Pharmaceuticals Inc. No products from the company were used during this study. Division of Newborn Medicine (S.M.N., R.S.G., J.L., I.O., I.R.H.), Department of Pediatrics, Mount Sinai School of Medicine, New York, NY, USA; and Section of Neonatology (L.P.B.), Children’s Hospital at Montefiore/Albert Einstein College of Medicine of Yeshiva University, Bronx, NY, USA. S.M.N. is currently working at the Children’s Hospital at Montefiore/Albert Einstein College of Medicine of Yeshiva University, Bronx, NY, USA. Journal of Perinatology 2005; 25:193–197 r 2005 Nature Publishing Group All rights reserved. 0743-8346/05 $30 www.nature.com/jp 193