A form of synchronous ventilation in which baby triggers/initiates the breath while ventilator does the work of breathing. In other words, rate of ventilation is determined by baby while pressures are determined by operator via ventilator

• Set humidifier temperature at 39°C (negative 2) to achieve airway temperature of 37°C

Set up Babylog^® (Drager)

• Flow 6–10 L/min 
• Select SIPPV mode
• Select highest trigger sensitivity (1: bar is all unshaded)
• Select T_insp (inspiratory time) between 0.3–0.4 sec
• Adjust T_exp (expiratory time) to achieve back-up rate of 35–40/min
• Peak inspiratory pressure (PIP) 16–18 cm H₂O
• Peak end expiratory pressure (PEEP) 5 cm H₂O
• FiO₂ to achieve target SpO₂ for gestation (see Oxygen saturation targets guideline)

Set up SLE 5000/6000

• Select patient triggered ventilation (PTV) mode
• Select highest trigger sensitivity (0.2 L/min for ≤28 weeks’ gestation, 0.4–0.6 L/min for >28 weeks’ gestation). Look at baby to confirm triggering adequately by observing baby generated breaths are triggering ventilator support
• Select T_insp for back-up breaths between 0.3–0.4 sec
• Set back-up rate of 35–40/min
• PIP 16–18 cm H₂O
• PEEP 5 cm H₂O
• FiO₂ to achieve target SpO₂ for gestation (see Oxygen saturation targets guideline)
• Software allows compensation for a leak of 10–60%
• Observe tidal volume (Vt) settings to confirm between 4–6 mL/kg

Baby

• If gestation <34 weeks, consider loading baby with IV caffeine citrate (20 mg/kg) 
• Discontinue sedation 

• Once baby connected to ventilator:
  
  • check SpO₂ (see Oxygen saturation targets guideline) and adjust FiO₂ accordingly
  • check baby’s chest moving adequately, and measured Vt. Chest expansion should be just visible, and Vt should be between 4–6 mL/kg. If not, adjust PIP/PEEP to maintain adequate oxygenation and ventilation
  • check ventilator triggering in synchrony with baby. Assess by listening to ventilator while watching baby’s respiratory effort

• Check blood gas within 30 min of initiation of SIPPV
• Aim for: 
  
  • PaO₂: 6–10 kPa or target appropriate SpO₂ level
  • PaCO₂: 4.5–8.5 kPa day 1–3, 4.5–10 kPa day 4 onwards
  • pH >7.25

To improve oxygenation

• Increase FiO₂
• Rule out pneumothorax
• Increase PIP and/or PEEP
• Increase T_insp (not more than 0.4 sec)

To decrease PaCO₂

• Rule out pneumothorax
• Increase PIP
• Check if baby triggering adequately. If not, try shortening T_insp, or increasing back-up rate 

Low PaCO₂

• Decrease PIP
• Decrease back-up rate if >35/min (if baby not breathing above this rate)
• In a vigorous hypocapnic baby, transfer to synchronised intermittent mandatory ventilation (SIMV) at a rate of at least 20/min

• Monitor SpO₂ continuously 
• Check arterial blood gases at least 4–6 hrly depending on stage of disease  
• In babies successfully ventilated in SIPPV mode, sedation is unnecessary 
• Remember, most common cause of baby fighting ventilator is ASYNCHRONY. Always carry out checks and adjustments (see Management of asynchrony)
• If baby still ‛fights’ ventilator, consider morphine bolus (50–100 microgram/kg)
• If baby continues to ‛fight’ ventilator, use continuous sedation and change to other conventional ventilation (SIMV) mode (see Ventilation: conventional guideline)

While baby on SIPPV, hourly observations

• Back-up rate set
• Baby’s own respiratory rate
• Vt (in mL)
• Minute ventilation [MV (in 1/min)]

If alarm goes off, check

• Synchrony between baby and ventilator
• Excessive water droplets in ventilator tubing
• Flow graph for evidence of blocked tube or excessive T_insp
• Disconnection

Checklist

• Is endotracheal tube (ETT) patent (look at flow graph and Vt)
• Is T_insp too long? (is baby exhaling against ventilator?), if so shorten T_insp to 0.3 sec
• Is back-up rate too high? If so, consider dropping to 30–35 breaths/min 
• Is there water condensation in ventilator tubing?
• If all above fails, consider morphine bolus (100 microgram/kg) over 3–5 min
• If baby still continues to ‛fight’ ventilator, use continuous sedation and revert to SIMV

• False triggering occurs when ventilator delivers a mechanical breath artefactually when baby not actually initiating a spontaneous respiration
• Usually results from presence of water droplets in ventilatory circuit, or an excessive ETT leak
• If baby’s trigger rate appears to be in excess of 80/min, ensure this is actual rate by observing baby’s own respiratory movements. If not:
  
  • check ventilatory circuit for excessive water condensation and empty if necessary
  • decrease trigger sensitivity by increasing trigger threshold e.g. from 0.4 to 0.6 L/min
  • look for amount of ETT leak on Babylog display. If in excess of 50%, consider changing to slightly wider ETT

• Once baby stable (triggering above set rate, saturating in FiO₂ <0.3), wean by:
  
  • decreasing PIP by 1–2 cm H₂O each time (in SIPPV/PTV mode, weaning rate in a baby who is already triggering above it is useless)
  • check baby breathing regularly and effortlessly (no chest recessions), and blood gases and oximetry are acceptable
  • once PIP between 14–16 cm H₂O (depending on size of baby), consider extubation
  • assess need for nasal CPAP/high-flow by checking for chest recessions, spontaneous minute ventilation, and regularity of breathing
• During weaning PaCO₂ can rise above 7 kPa and Vt may fall below 4 mL/kg
  
  • provided baby triggering well, is not visibly tired and pH >7.25, no action required
  • if poor triggering, visibly tired or abnormal pH, increase PIP, and later back-up rate