Mechanical Ventilation: Pediatric Pressure Mode (Respiratory Therapy)
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Mechanical ventilation has inherent risks, including infection, barotrauma, volutrauma, bronchopulmonary dysplasia, and lung injury.
Increased levels of supplemental oxygen during mechanical ventilation can result in retinopathy of prematurity and lung injury due to excessive arterial oxygen levels.
The basic goals of mechanical ventilation are to improve oxygen delivery to meet metabolic demand and eliminate carbon dioxide, while also reducing the work of breathing (WOB). The basic aim of assisted ventilation is to meet the goals while minimizing the associated deleterious effects.undefined#ref1">1
Oxygenation and respiratory mechanics in infants on mechanical ventilation are significantly improved in the prone position versus those in the supine position.2 Prone positioning improves hemodynamics, gas exchange, and respiratory mechanics.2 In preterm newborns who are receiving nasal noninvasive ventilation for mild to moderate respiratory distress, arterial and cerebral oxygenations were better in the prone position.5
Positive pressure ventilation (PPV) improves oxygenation and ventilation, prevents cardiovascular failure, manages intracranial pressure, and protects the airway. PPV can be either pressure mode or volume mode.
Most conventional ventilators include graphics and scalar waveform displays that enable the practitioner to optimize treatment. Changes in mechanical ventilation are made in response to the patient’s status.
The respiratory therapist (RT) must use critical thinking skills around these key factors related to mechanical ventilation:
Additional facts about PPV include:
Although an appropriate PEEP level may result in clinical benefits, both inappropriately low and high levels may cause harm. An appropriate PEEP level may be achieved by an individualized approach, based on the patient’s disease process. PEEP should be set at the lowest level to achieve an acceptable level of PaO2 within a lung protective strategy. An open lung model with a stepwise progression of PEEP to recruit atelectatic lung segments should be used in pediatric patients with restrictive lung disease (i.e., acute lung injury) (Table 1).
Normal glottic closure at end exhalation is prevented when an artificial airway is present; therefore, minimal PEEP (approximately 5 cm H2O of pressure) maintains physiologic FRC, which is the volume of air left in the lungs at end expiration.1
Modes of ventilation:
Understanding how and when to make ventilator adjustments to improve oxygenation and ventilation is important (Figure 1). Patients with severe acute respiratory distress syndrome (ARDS) may require even lower VT (4 to 5 ml/kg). In addition, PIP or plateau pressure or both should be maintained at less than 28 cm H2O and driving pressure at less than or equal to 15 cm H2O.1
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Rationale: Pressure-controlled ventilation is selected when a ventilation strategy focused on maintaining an exact PIP-to-PEEP ratio is the goal.
Rationale: Parameters are based on previous ventilator settings and the RT’s assessment after reviewing ventilator waveform displays and graphics.
Rationale: The cycle mechanism determines the termination of inspiration with a preset inspiratory time, VT, or flow.
Rationale: The goal is to set the ventilator to deliver the target VT with the least pressure, which may be preset or variable (with a high-pressure limit). The patient’s size and condition guide the I:E ratio.
Rationale: Alarm settings are based on the cycling mechanism chosen. Low-pressure alarms are used to detect disconnections in the system. High-pressure alarms are used for notification of increased pressure in the system.
In some cases, a spontaneous breathing trial may not be feasible because a reduction in sedation may result in the patient pulling on the ET tube and IV lines, and unplanned extubation may occur.4
Rationale: Increased intrathoracic positive pressure may reduce venous return and cardiac output. Likewise, positive pressure may cause a pneumothorax, which may also decrease cardiac output.
Rationale: Asynchrony causes increased WOB and distress. Asynchrony in a small child is commonly associated with flow regulation; access to flow and pressure influence the patient’s ability to breathe comfortably.7
Rationale: Body temperature can be significantly altered by the temperature of inspired gas.
Make sure that the parameters being set meet the patient’s physiologic demands by allowing sufficient flow, FIO2, and PEEP without compromising hemodynamics and reducing the WOB.
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 VT.
Rationale: An alarm indicating an increased PIP or change in VT 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: Suctioning the artificial airway maintains airway patency and removes secretions.
Rationale: Sedation and neuromuscular blockade may be necessary to achieve ventilator synchrony, but paralytics mask the patient’s underlying neurologic state. Daily sedation interruption improves outcomes and significantly reduces the duration of mechanical ventilation and intensive care.4
Hsu, A. and others. (2021). 2021 Interim guidance to health care providers for basic and advanced cardiac life support in adults, children, and neonates with suspected or confirmed COVID-19. Circulation Cardiovascular Quality and Outcomes, 14(10), e008396. doi:10.1161/CIRCOUTCOMES.121.008396
Klingenberg, C. and others. (2017). Volume-targeted versus pressure-limited ventilation in neonates. Cochrane Database of Systematic Reviews, 10, Art. No.: CD003666. doi:10.1002/14651858.CD003666.pub4 (classic reference)* (Level I)
van der Staay, M., Chatburn, R.L. (2018). Advanced modes of mechanical ventilation and optimal targeting schemes. Intensive Care Medicine Experimental, 6(1), 1-17. doi:10.1186/s40635-018-0195-0 (Level VII)
*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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