Inverse ratio ventilation versus conventional ratio ventilation during one lung ventilation in neonatal open repair of esophageal atresia/tracheoesophageal fistula: A randomized clinical trial

Background Maintaining oxygenation during neonatal open repair of esophageal atresia/tracheoesophageal fistula is difficult. Inverse ratio ventilation can be used during one lung ventilation to improve the oxygenation and lung mechanics. Objective The aim of this study was to describe the impact of two different ventilatory strategies (inverse ratio ventilation vs. conventional ratio ventilation) during one lung ventilation in neonatal open repair of esophageal atresia/tracheoesophageal fistula on the incidence of oxygen desaturation episodes. Methods We enrolled 40 term neonates undergoing open right thoracotomy for esophageal atresia/tracheoesophageal fistula repair and randomly assigned into two groups based on inspiratory to expiratory ratio of mechanical ventilation parameters (2:1 in inverse ratio ventilation “IRV” and 1:2 in conventional ratio ventilation “CRV”). The incidence of desaturation episodes that required stopping the procedure and reinflation of the lung were recorded as the primary outcome while hemodynamic parameters, incidence of complications, and length of surgical procedure were recorded as the secondary outcomes. Results There was a trend toward a reduction in the incidence of severe desaturations (requiring stopping of surgery) with the use of inverse ratio ventilation (15% in IRV vs. 35% in CRV, RR [95% CI] 0.429 [0.129–1.426]). Incidence of all desaturations (including those requiring only an increase in ventilatory support or inspired oxygen saturation) was also reduced (40% in IRV vs. 75% in CRV, RR [95% CI] 0.533 [0.295–0.965]). This in turn affected the length of surgical procedure being significantly shorter in inverse ratio ventilation group (mean difference −16.3, 95% CI −31.64 to −0.958). The intraoperative fraction of inspired oxygen required to maintain adequate oxygen saturation was significantly lower in the inverse ratio ventilation group than in the conventional ratio ventilation group (mean difference −0.22, 95% CI −0.33 to −0.098), with no significant difference in hemodynamic stability or complications apart from higher blood loss in inverse ratio group. Conclusion There may be a role for inverse ratio ventilation with appropriate positive end‐expiratory pressure to reduce the incidence of hypoxemia during open repair of esophageal atresia/tracheoesophageal fistula in neonates, further studies are required to establish the safety and efficacy of this technique.