In a groundbreaking study poised to redefine neonatal respiratory care during transport, researchers Leslie, Davidson, Forshaw, and colleagues have published compelling evidence comparing the effects of volume-controlled and non-volume-controlled ventilation on carbon dioxide retention in newborns. Published in Pediatric Research on December 2, 2025, this research addresses one of the most critical and delicate interventions in neonatal medicine: maintaining optimal gas exchange during critical transport phases. The nuanced interplay between ventilation strategies and carbon dioxide clearance has long been a contested subject, but this latest study offers unparalleled insights that could shape protocols worldwide.
Neonates, especially those who require urgent transport for specialized care, face heightened vulnerability to respiratory complications. The challenge lies in finely tuning mechanical ventilation to ensure adequate oxygenation and carbon dioxide removal without causing lung injury. Volume-controlled ventilation (VCV) — which guarantees a preset tidal volume for each breath — and non-volume-controlled modes, such as pressure-controlled ventilation (PCV), which maintain preset airway pressures instead of volumes, represent two main strategies clinicians use. Each comes with theoretical pros and cons that have yet to be definitively quantified in the neonatal transport context prior to this investigation.
What makes this inquiry particularly vital is the physiological delicacy of neonatal lungs. Their compliance and resistance parameters are drastically different from adults, meaning that oversimplified assumptions can lead to catastrophic outcomes. The study meticulously tracks partial pressure of carbon dioxide (PaCO₂) following neonatal transport, serving as a prime indicator of how ventilation mode impacts gas exchange efficiency. An accumulation of carbon dioxide during transport can precipitate acidosis, cardiovascular instability, and exacerbate existing respiratory distress syndrome (RDS), underscoring the clinical urgency of establishing ventilator strategies that optimize CO₂ elimination.
The research team employed a prospective cohort design, enrolling neonates requiring mechanical ventilation during interfacility transport to tertiary care centers. This practical, real-world methodology strengthens the study’s applicability over rigid laboratory or animal models. The authors utilized advanced capnography monitoring combined with arterial blood gas analysis to record accurate carbon dioxide levels before, during, and after transport. This dual measurement approach reduces errors inherent in single-method studies and ensures a precise understanding of ventilation efficacy over time.
One of the study’s most striking revelations centers on how VCV manages to stabilize or even reduce PaCO₂ levels during prolonged transport, compared to non-volume modes that showed a tendency towards increased carbon dioxide retention. Researchers attribute this outcome to the constancy of tidal volumes in VCV, which prevents the fluctuation in alveolar ventilation seen in pressure-based modes, where varying lung compliance can lead to inconsistent breath delivery. This has enormous practical implications for transporting neonates with evolving lung pathologies, where sudden changes in compliance are common.
The detailed physiological explanations within the paper underscore the importance of synchronizing delivered tidal volume with changing lung mechanics. Non-volume modes, while beneficial in certain clinical scenarios due to their pressure limitation capabilities, may fall short in assuring consistent CO₂ clearance in transport environments where real-time ventilator adjustments are constrained. The study’s exploration of ventilation waveforms and flow patterns corroborates this by showing irregularity in breaths delivered under non-volume conditions, which hinders effective carbon dioxide washout.
Moreover, the authors discuss how volume-controlled ventilation can potentially reduce the risk of volutrauma by enabling clinicians to preset tidal volumes appropriate for fragile neonatal lungs, minimizing overdistension. Conversely, the non-volume modes’ pressure limitation, while protecting against barotrauma, may inadvertently cause hypoventilation if lung compliance diminishes during transit. The delicate balance between lung protection and gas exchange maintenance is laid bare, presenting a compelling argument for more frequent adoption of volume-controlled modes in transport systems.
It is important, however, to appreciate that no ventilation mode is universally “best.” The study tempers its findings by acknowledging that patient-specific factors — including gestational age, severity of lung disease, and transport duration — influence outcomes. The researchers call for future stratified analyses to establish detailed guidelines tailored for various neonatal subpopulations. Such personalized approaches could revolutionize neonatal critical care transport, moving away from “one-size-fits-all” strategies.
The integration of this ventilation data with neurodevelopmental outcome tracking is another promising frontier suggested by this study. Since inappropriate CO₂ levels can affect cerebral blood flow in neonates, the ability of a ventilation mode to maintain normocapnia could have profound implications beyond respiratory physiology. Leslie et al. emphasize that optimizing mechanical ventilation during transport is not merely a respiratory goal but a cornerstone of overall neonatal survival and neurological integrity.
Technologically, the study advocates for innovations in transport ventilators that enable nuanced volume-controlled ventilation with automated adjustments to tidal volume in response to changing lung compliance. Such smart ventilators could mitigate the challenges of manual setting adjustments in the stressful and resource-limited transport environment. The authors highlight the urgent need to fund and develop these devices, anticipating that technological progress could be the next leap forward in improving neonatal outcomes during transport.
Apart from the physiological insights, the study also highlights logistical and operational considerations. The use of volume-controlled ventilation requires robust ventilator designs and trained personnel capable of monitoring and managing complex ventilation parameters during the unpredictable conditions of neonatal transport. The balance between advanced respiratory technology and practical feasibility underlines a multifaceted challenge that healthcare systems must confront.
In conclusion, this innovative study by Leslie and colleagues significantly advances our understanding of mechanical ventilation modes during neonatal transport, especially regarding their impact on carbon dioxide management. Their work convincingly argues for the preferential use of volume-controlled ventilation in optimizing gas exchange and ultimately improving clinical outcomes for vulnerable neonates. While acknowledging the nuances and limitations, the study sets a new standard for neonatal transport ventilator practices, challenging clinicians and engineers alike to rethink current paradigms.
The implications of this research extend beyond neonatal units into broader pediatric critical care and emergency transport services worldwide. As neonatal transport becomes more sophisticated and survival rates improve even for the most fragile infants, refining ventilation strategies becomes an ethical and medical imperative. This study brings us closer to that ideal, opening doors to enhanced protocols, smarter technologies, and ultimately, healthier starts for our most vulnerable patients.
Pediatric Research’s December 2025 publication of this study is a landmark event that will spark debate, inspire further investigation, and hopefully accelerate the integration of safer, more effective ventilation techniques in neonatal transport systems globally. By shining a light on carbon dioxide dynamics and ventilation mode efficacy, Leslie et al. provide a crucial piece of the neonatal care puzzle that has remained elusive until now.
Subject of Research:
Comparison of volume-controlled and non-volume-controlled ventilation modes on carbon dioxide management following neonatal transport.
Article Title:
Comparison of volume and non-volume ventilation modes on carbon dioxide following neonatal transport.
Article References:
Leslie, A., Davidson, S.L., Forshaw, B. et al. Comparison of volume and non-volume ventilation modes on carbon dioxide following neonatal transport. Pediatr Res (2025). https://doi.org/10.1038/s41390-025-04653-2
Image Credits: AI Generated
DOI: 02 December 2025
