Bench-to-bedside review: Ventilator strategies to reduce lung injury -- lessons from pediatric and neonatal intensive care.

As in the adult with acute lung injury and acute respiratory distress syndrome, the use of lung-protective ventilation has improved outcomes for neonatal lung diseases. Animal models of neonatal respiratory distress syndrome and congenital diaphragmatic hernia have provided evidence that 'gentle ventilation' with low tidal volumes and 'open-lung' strategies of using positive end-expiratory pressure or high-frequency oscillatory ventilation result in less lung injury than do the traditional modes of mechanical ventilation with high inflating pressures and volumes. Although findings of retrospective studies in infants with respiratory distress syndrome, congenital diaphragmatic hernia, and persistent pulmonary hypertension of the newborn have been similar to those of the animal studies, prospective, randomized, controlled trials have yielded conflicting results. Successful clinical trial design in these infants and in children with acute lung injury/acute respiratory distress syndrome will require an appreciation of the data supporting the modern ventilator management strategies for infants with lung disease.