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Careplan

Mechanical ventilation invasive pediatric

Mar.17.2020

Mechanical Ventilation Invasive (Pediatric Inpatient)

Clinical Description

  • Care of the hospitalized child experiencing the need for controlled or assisted breathing through an artificial airway.

Key Information

  • Cuff must be deflated (if present) prior to using a speaking valve or capping a tracheostomy tube. Tubes used in children younger than 8 years of age may not have a cuff, as the tube is positioned in the narrowest portion of the cricoid cartilage and acts as the cuff.
  • Laryngeal mask airways may be used for short-term use to facilitate breathing; however, they do not offer aspiration protection and should be changed to an endotracheal tube if there is a need for a prolonged artificial airway.
  • To reduce the risk of pulmonary aspiration, a swallow evaluation should be performed prior to oral intake or feeding.
  • Pediatric-sized and smaller tracheostomies may not have an inner cannula. If an inner cannula is not present, the tracheostomy tube should be changed on a regular schedule to prevent obstruction of the single lumen.
  • Enteral feeding is preferred over parenteral due to physiologic benefits, such as gut integrity and function, stress ulcer prophylaxis and reduction of infection risk.
  • In patients younger than 8 years of age, there is no evidence to support the use of cuffed or uncuffed tubes. Clinician discretion should be used.
  • Evidence regarding pediatric ventilator-induced lung injury, lung protective measures and ventilator-associated pneumonia prevention originates from adult research.

Clinical Goals

By transition of care

A. The patient will achieve the following goals:
  • Effective Communication

  • Optimal Device Function

  • Mechanical Ventilation Liberation

  • Optimal Nutrition Delivery

  • Absence of Device-Related Skin and Tissue Injury

  • Absence of Ventilator-Induced Lung Injury

B. Patient, family or significant other will teach back or demonstrate education topics and points:
  • Education: Overview
  • Education: Self-Management
  • Education: When to Seek Medical Attention

Correlate Health Status

  • Correlate health status to:

    • history, comorbidity, congenital anomaly
    • age, developmental level
    • sex, gender identity
    • baseline assessment data
    • physiologic status
    • response to medication and interventions
    • psychosocial status, social determinants of health
    • barriers to accessing care and services
    • child and family/caregiver:
      • health literacy
      • cultural and spiritual preferences
    • safety risks
    • family interaction
    • plan for transition of care

Communication Impairment

Signs/Symptoms/Presentation

  • agitation
  • anxiety
  • artificial airway present inhibiting vocalization
  • fear
  • frustration expressed
  • irritability
  • maladaptive communication behavior (e.g., facial expressions, hand/head movements)
  • powerlessness
  • social withdrawal
  • soundless crying

Problem Intervention

Ensure Effective Communication

  • Acknowledge and validate intensity and complexity of voicelessness. Maintain eye contact when speaking and awaiting response.
  • Promote calming presence. Involve patient in decision-making and care to promote inclusion, self-efficacy, confidence and sense of control.
  • Establish a nonverbal communication method. Use augmentative techniques to preserve self-identity and self-esteem, such as writing tools, letter board, computer, flash cards or picture boards.
  • If longer-term airway, consider alternative communication methods that facilitate speech, such as speaking valve, tracheostomy or capping. Evaluate need to deflate cuff when using these devices to allow exhalation.
  • Keep call system within reach; adapt to meet needs.
  • Assess and monitor for signs of biopsychosocial concerns that may affect ability to communicate, such as delirium, anxiety and fear.

Associated Documentation

  • Communication Enhancement Strategies

Device-Related Complication Risk

Signs/Symptoms/Presentation

  • air auscultated in stomach
  • airflow out of mouth
  • airway sounds increased
  • breath sounds unequal
  • chest movement asymmetrical
  • difficulty passing suction catheter
  • excessive cough
  • gastric distension
  • gurgling sound from throat
  • inability to ventilate
  • mechanical ventilation with an artificial airway
  • no airflow from device
  • restlessness
  • upper airway sounds increased
  • work of breathing increased

Vital Signs

  • heart rate increased
  • respiratory rate increased
  • SpO2 (peripheral oxygen saturation) decreased
  • EtCO2 (end-tidal carbon dioxide) increased

Laboratory Values

  • PaCO2 (arterial carbon dioxide) increased
  • PaO2 (partial pressure of arterial oxygen) decreased

Diagnostic Results

  • CXR (chest x-ray) confirmation of abnormal tube position
  • EtCO2 (end-tidal carbon dioxide) waveform abnormal
  • obstruction visualized with bronchoscopy
  • ultrasonography abnormal tube position

Problem Intervention

Optimize Device Care and Function

  • Maintain semirecumbent position to minimize aspiration risk.
  • Provide oral care regularly with antimicrobial solution and subglottic suction to reduce the risk of infection; perform prior to cuff deflation.
  • Assess tube size, depth, location and securement frequently to minimize the risk of tube displacement; regularly confirm placement with radiography or ultrasonography.
  • Facilitate regular mechanical ventilator and humidification equipment checks to ensure proper function; monitor and manage ventilator and alarm settings.
  • Provide humidification and evaluate need for suctioning to minimize risk of airway obstruction; regularly replace closed in-line suction equipment.
  • Perform ongoing tracheostomy and stoma care to prevent infection; minimize excessive moisture around device; replace or clean inner cannula or tracheostomy regularly to prevent obstruction from secretions.
  • Monitor and manage cuff pressure routinely, if present; deflate cuff when not clinically indicated.
  • Provide emergency equipment that includes appropriate-sized manual resuscitation bag, mask, suction equipment and cleaning supplies; replace device or assist breathing if displacement occurs.

Associated Documentation

  • Airway Safety Measures
  • Aspiration Precautions

Inability to Wean

Signs/Symptoms/Presentation

  • confusion
  • continued need for mechanical ventilation
  • disconnected from reality
  • fear
  • inability to decrease ventilator settings
  • increase in oxygenation or ventilation requirements
  • level of consciousness decreased
  • lung compliance decreased
  • muscle weakness
  • positive fluid balance
  • respiratory effort absent
  • unable to follow commands

Vital Signs

  • heart rate increased
  • respiratory rate increased
  • blood pressure increased or decreased
  • SpO2 (peripheral oxygen saturation) decreased
  • EtCO2 (end-tidal carbon dioxide) increased

Laboratory Values

  • ABG (arterial blood gas) abnormal

Problem Intervention

Promote Extubation and Mechanical Ventilation Liberation

  • Assess for pain and agitation regularly, utilizing a validated tool; minimize medication effects that may contribute to agitation, delirium or delay extubation.
  • Encourage early rehabilitation using therapeutic intervention and functional mobility training to minimize deconditioning, weakness, functional dependence and delirium.
  • Assess readiness to wake up, breathe, wean and extubate; consider protocol approach to reduce ventilator and intensive care days.
  • Perform SBT (spontaneous breathing trial).
  • Facilitate clustered care and uninterrupted sleep/rest pattern that supports home sleep routine; promote calm environment.
  • Acknowledge fear and anxiety related to the patient’s and support system’s experience of prolonged mechanical ventilation; encourage complementary therapies, such as music and playtime.

Associated Documentation

  • Environmental Support
  • Medication Review/Management
  • Sleep/Rest Enhancement

Nutrition Impaired

Signs/Symptoms/Presentation

  • inability to intake nutrition via oral route

Problem Intervention

Optimize Nutrition Delivery

  • Perform a nutritional assessment; include a nutrition-focused physical exam.
  • Determine calorie, protein, vitamin, mineral and fluid requirements; use indirect calorimetry if nutrition support is required.
  • Initiate early enteral nutrition support; consider another form of stress ulcer prophylaxis, if enteral feeding is contraindicated.
  • Optimize protein intake, unless contraindicated.
  • Consider postpyloric versus gastric tube feeding for patient at increased risk of aspiration.
  • Advocate for, and adjust, infusion rate, formulation or volume based on feeding tolerance and clinical status (e.g., hemodynamic stability); minimize unnecessary interruptions.
  • Anticipate the need for a promotility agent, if reduced gastric emptying or delayed bowel motility is suspected.
  • Monitor nutrition delivery to ensure safe practices (e.g., confirmation of tube placement, tube patency, medication delivery, head of bed elevation, oral care).

Associated Documentation

  • Nutrition Support Management

Skin and Tissue Injury

Signs/Symptoms/Presentation

  • bleeding
  • laceration
  • localized swelling
  • redness
  • skin blanching
  • skin integrity disrupted
  • stoma granulation
  • stridor
  • tracheal granuloma
  • voice hoarse

Problem Intervention

Maintain Skin and Tissue Health

  • Monitor depth of suction catheter advancement to minimize the risk of internal tracheobronchial tissue injury.
  • Reposition and resecure endotracheal tube regularly; ensure proper tube location.
  • Monitor tightness of securement device, as well as skin and mucosal areas, regularly; consider skin barrier protection.
  • Minimize pressure points and prevent traction on device, using careful positioning, flexible extenders and props.
  • Assess and monitor for the presence of bleeding that may indicate injury to tracheobronchial tissue. Notify provider for persistent bleeding.
  • Anticipate the need for further treatment or procedure, if bleeding persists.
  • Anticipate adjunct therapy, such as cool mist, racemic epinephrine, corticosteroid or heliox, for symptoms related to airway swelling or stridor after removal of tube.

Associated Documentation

  • Device Skin Pressure Protection

Ventilator-Induced Lung Injury

Signs/Symptoms/Presentation

  • lung compliance decreasing
  • oxygenation requirements increasing (e.g., FiO2 or positive end expiratory pressure needs)
  • ventilatory requirements increasing (e.g., minute volume, respiratory rate)

Vital Signs

  • heart rate increased
  • respiratory rate increased
  • blood pressure increased or decreased
  • SpO2 (peripheral oxygen saturation) decreased
  • EtCO2 (end-tidal carbon dioxide) increased

Laboratory Values

  • oxygen index decreased
  • PaCO2 (arterial carbon dioxide) increased
  • PaO2 (partial pressure of arterial oxygen) decreased

Diagnostic Results

  • bronchoscopy abnormal
  • CXR (chest x-ray) abnormal

Problem Intervention

Facilitate Lung-Protection Measures

  • Provide oxygen therapy judiciously to maintain oxygenation goals; adjust to avoid hyperoxia.
  • Monitor and limit ventilator tidal volumes to minimize volutrauma; initiate low tidal-volume strategy (e.g., less than 8 mL/kg for ideal body weight).
  • Monitor and limit ventilator pressure to reduce risk of barotrauma; maintain less than 30cm H2O (e.g., plateau, inspiratory pressure delta).
  • Apply PEEP (positive end expiratory pressure) to minimize atelectasis; adjust for changes in lung compliance and oxygenation.
  • Monitor fluid balance closely to minimize the risk of fluid overload.
  • Monitor ventilator waveforms and promote patient-ventilator synchrony; adjust ventilator settings and sedation.

Associated Documentation

  • Lung Protection Measures

Problem Intervention

Prevent Ventilator-Associated Pneumonia

  • Assess readiness to extubate; perform sedation interruption and spontaneous breathing trial.
  • Maintain semirecumbent position to minimize aspiration risk.
  • Provide ongoing oral care to reduce pathogens in oral cavity; anticipate antiseptic oral decontamination.
  • Minimize ventilator circuit breaks; consider use of closed suction device.
  • Minimize microaspiration risk; consider the use of ultrathin polyurethane tapered endotracheal tubes with subglottic secretion drainage, as well as cuff pressure monitoring.
  • Assess need for stress ulcer and venous thromboembolism prophylaxis due to increased risk during mechanical ventilation.

Associated Documentation

  • Head of Bed (HOB) Positioning
  • Oral Care
  • VAP Prevention Bundle

Education

CPG-Specific Education Topics

Overview

  • description

  • indications

Self-Management

  • CPR education

  • VAP prevention

  • VTE prevention

When to Seek Medical Attention

  • unresolved/worsening symptoms

General Education Topics

General Education

  • admission, transition of care

  • orientation to care setting, routine

  • advance care planning

  • diagnostic tests/procedures

  • diet modification

  • opioid medication management

  • oral health

  • medication management

  • pain assessment process

  • safe medication disposal

  • tobacco use, smoke exposure

  • treatment plan

Safety Education

  • call light use

  • equipment/home supplies

  • fall prevention

  • harm prevention

  • infection prevention

  • MDRO (multidrug-resistant organism) care

  • personal health information

  • resources for support

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Disclaimer

Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.