A 32-week neonate is intubated at birth for respiratory distress syndrome. Despite surfactant administration, the ventilator requirement increases over the next 48 hours. X-ray shows pulmonary interstitial emphysema (PIE). The ventilator strategy most likely to limit further barotrauma is:

• A High tidal volume ventilation to reduce respiratory rate
• B High-frequency oscillatory ventilation (HFOV) ✓
• C Conventional ventilation with PEEP 8 cmH2O
• D Volume guarantee ventilation targeting TV 8 mL/kg

Explanation

High-frequency oscillatory ventilation (HFOV) delivers very small tidal volumes (1–2 mL/kg) at high frequency, minimising volutrauma and barotrauma, making it the preferred rescue strategy for pulmonary interstitial emphysema. PIE results from overdistension and air leak into perivascular tissue; conventional ventilation with high PEEP or high tidal volumes would worsen it. Volume guarantee targeting 8 mL/kg is too high and would perpetuate injury.

Reference: Ghai Essential Pediatrics, 10th ed.

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Written and medically reviewed by the StethoPrep medical team.