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Match the ventilator settings with the challenges of ventilating the child to provide optimal oxygenation and ventilation and minimize the harmful effects of positive pressure in smaller lungs.
Conventional modes of mechanical ventilation provide positive pressure ventilation (PPV) to improve oxygenation and ventilation, prevent cardiovascular failure, manage intracranial pressure, protect the airways, and improve oxygen delivery to the tissues. PPV can be used as temporary therapy until the child’s condition no longer warrants support or as long-term therapy in children with chronic conditions requiring mechanical ventilation.4
To perform this procedure, the respiratory therapist (RT) must be competent in pediatric advanced life support and must be able to identify indications for an artificial airway and other adjuncts used to support ventilation.2
The RT must also know this information:
The RT should also understand these facts about PPV:
Lung protective strategies for a child on PPV include low tidal volume (VT) (6 ml/kg or range of 5 to 7 ml/kg)4 controlled plateau pressure of 30 mm Hg or less, and early and aggressive PEEP.1 Recommended strategies to improve oxygenation use FIO2 and PEEP (Table 1).1 An open-lung model with a stepwise progression of PEEP to recruit atelectatic lung segments in children with restrictive lung disease, such as acute lung injury, is suggested.
PEEP is based on the child’s disease process. For children undergoing ventilation for general physiologic support, a minimal PEEP of 5 mm Hg is considered adequate to replicate FRC.3,4 At high levels of PEEP, which increase mean airway pressure, the VT can be reduced for lung protection in many cases.
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Rationale: The choice of mode must be individualized to the child.
Rationale: The V
T is individualized to the child and disease state.
Rationale: The cycle mechanism is individualized to the child and the capabilities of the ventilator and determines when inspiration terminates.
Rationale: The rate is set to achieve appropriate minute ventilation, where minute ventilation = V
T × respiratory rate. The rate setting depends on how much mandatory ventilation is desired.
Rationale: Inspiratory time influences oxygenation, and expiratory time influences ventilation.
Rationale: The PEEP is based on the child’s lung function and disease process.
Do not interrupt the ventilator circuit (e.g., during suctioning) for children on higher levels of PEEP; doing so may cause a significant loss of FRC.
Rationale: High- and low-pressure alarms, inspiratory time, and V
T limits are always set, and the values are based on the cycling mechanism chosen. Low-pressure alarms are used to detect disconnection in the system. High-pressure alarms are used for notification of increased pressure in the system.
In the volume-controlled mode, the child’s lung compliance may cause variable PIP. Set the high-pressure alarm per the organization’s practice above the child’s PIP to protect the lungs from sudden changes in resistance or compliance.
Rationale: Increased intrathoracic positive pressure may reduce venous return and cardiac output. Likewise, positive pressure may cause pneumothorax, which may also decrease cardiac output.
Rationale: Asynchrony causes increased work of breathing and distress. Asynchrony in a small child is commonly associated with flow regulation; access to flow and speed of delivery influence the child’s ability to breathe comfortably.
Rationale: Changes in oxygen flow may occur from the oxygen source; auto-PEEP may also occur. Body temperature can be significantly altered by the temperature of inspired gas.
Rationale: Early intervention when inadequate ventilator support and hemodynamic instability occur may prevent further clinical deterioration.
Rationale: Changes in lung compliance may change the PIP or V
Rationale: An alarm indicating an increase in PIP or change in V
T may be associated with a need for suctioning or an airway obstruction. A low-pressure alarm may indicate that the ventilator tubing has been disconnected.
Rationale: Attaching the circuit to the bed or device eliminates undue pressure on the child’s skin from the ET tube and tubing.
Rationale: Suctioning the ET tube maintains airway patency and removes secretions.
Rationale: Ventilator-associated pneumonia (VAP) is a significant cause of morbidity in children undergoing ventilation.
Rationale: Sedation and neuromuscular blockade may be necessary to achieve ventilator synchrony, but paralytics mask the child’s underlying neurologic state. Early identification of the child’s discomfort allows immediate attention to problems.
Rationale: Elevating the head of the bed reduces the incidence of aspiration.
* In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.
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