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Use appropriate ventilator settings to overcome the challenges of ventilating children and provide optimal oxygenation and ventilation and minimize the potential harmful effects of positive pressure in smaller lungs.
Conventional modes of mechanical ventilation provide positive pressure ventilation (PPV) in an attempt 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 on a short-term basis as a temporary mode of support until the child’s condition no longer warrants it or as long-term therapy in children with chronic conditions requiring mechanical ventilation. PPV can be either pressure mode or volume mode.
Positive pressure ventilators raise the mean airway pressure above intrapleural pressure, thus reversing the intrathoracic pressure dynamics from spontaneous breathing. Normal glottis closure at end-exhalation is prevented when an artificial airway is present; therefore, a minimal amount of positive end-expiratory pressure (PEEP) (approximately 5 cm) maintains physiologic functional residual capacity (FRC), which is the amount of air left in the lungs at end-expiration in children.1 In children with pulmonary disease, PEEP is adjusted according to underlying pathophysiology. One goal for the use of PEEP is to reduce the fraction of inspired oxygen (FIO2).
Common modes of ventilation:
It is important to understand how and when to make ventilator adjustments to improve oxygenation and ventilation (Figure 1). An important aspect of caring for a child on PPV is the use of lung protective strategies, which include VT for age and body weight (5 to 8 ml/kg), controlled plateau pressure of 28 mm Hg or less, and moderate levels of PEEP.2
PEEP is based on the child’s disease process. For children undergoing ventilation for general physiologic support, a minimum PEEP of 5 mm Hg is considered adequate to replicate FRC.1 For children with pulmonary disease, the PEEP is adjusted according to the underlying pathophysiology. 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: Pressure-controlled ventilation is selected for children who require a ventilation strategy focused on maintaining an exact PIP-to-PEEP ratio.
Rationale: Parameters are based on previous ventilator settings or the respiratory therapist’s (RT’s) best estimate.
Rationale: The cycle mechanism determines the termination of inspiration with a preset inspiratory time, V
T, or flow.
Rationale: The goal is to set the ventilator to deliver the target V
T with the least amount of pressure, which may be preset or variable (with a high-pressure limit). The child’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.
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 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: Alarms help ensure that the child is safe.
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 increased 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 skin from the artificial airway and tubing.
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 child’s underlying neurologic state. Daily sedation interruption improves outcomes in children and significantly reduces the duration of mechanical ventilation and intensive care.
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