Mechanical Ventilation: Pediatric Volume Mode (Respiratory Therapy)

ALERT

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 from excessive arterial oxygen levels.

OVERVIEW

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. Volume-targeted ventilation (VTV) aims to produce a more stable tidal volume (VT) to reduce lung damage and stabilize the partial pressure of carbon dioxide (PCO₂). To deliver volume-controlled breaths, VT is set as a control variable. Every mechanical breath delivers an identical VT at either a preset inspiratory time or a preset flow rate. Set VT, inspiratory time, and flow all are interrelated.

Neonates ventilated using VTV were more likely to survive free of lung damage and have reduced rates of death or complications, including bronchopulmonary dysplasia, pneumothoraces, hypocarbia, severe cranial pathologies, and duration of ventilation, compared with patients ventilated using pressure-limited ventilation (PLV) modes.^{undefined#ref3">3}

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.

Additional facts about PPV include:

• Mean airway pressure (MAP) is computed using various ventilator variables. The MAP depends on peak inspiratory pressure (PIP), positive end-expiratory pressure (PEEP), and inspiratory time and flow. Waveform graphics can be used to guide adjustments to improve the adequacy of mechanical ventilation.
• Normal glottic closure at end exhalation is prevented by an endotracheal (ET) tube; therefore, a minimal PEEP maintains physiologic functional residual capacity (FRC) in pediatric patients.
• A goal for the use of PEEP is to reduce the fraction of inspired oxygen (FIO₂) to maintain an adequate partial pressure of arterial oxygen (PaO₂) range. In pediatric patients with pulmonary disease, PEEP is adjusted according to the underlying pathophysiology.
• Intensive care ventilators have capabilities to be used in a volume or pressure mode as well as hybrid variations that combine aspects of both modes.
• The potential complications with mechanical ventilation include decreased cardiac output and increased intracranial pressure.⁵
• Prone positioning may improve ventilatory status.⁴

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 [ALI]) (Table 1).

VTV delivers a set volume of gas into the ventilator circuit. Pressure rises passively, inversely related to lung compliance, as gas enters the lungs. A portion of the volume delivered into the circuit is lost in the compression of gas in the circuit, humidification chamber, and the ET tube. There is also loss of VT due to the variable leak around an uncuffed ET tube. Some ventilators compensate for volume loss.

Lung protective strategies include low VT in the range of 5 to 7 ml/kg and a goal of a plateau pressure of 30 mm Hg or less in infants in acute respiratory failure, acute respiratory distress syndrome, and ALI.² In the volume-regulated mode of mechanical ventilation, the patient’s upper airway and lung compliance influence the peak pressure needed to achieve the set VT.

Infants being ventilated are at risk of iatrogenic lung injury, including ventilation-induced lung injury. Synchronizing the ventilation to the patient’s breathing pattern and minimizing lung injury are crucial in reducing complications such as bronchopulmonary dysplasia and long-term respiratory morbidity. Research suggests that when neonates are ventilated using VTV they require a shorter duration of mechanical ventilation, have reduced rates of pneumothorax, and have fewer neurologic sequelae, such as intraventricular hemorrhages and periventricular leukomalacia.¹

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Explain the purpose and possible complications of mechanical ventilation.
• Discuss sensory information, including the sounds of the ventilator, the sensation of lung inflation, and coughing.
• Provide the family with descriptions and explanations of the equipment alarms.
• Discuss with the family the role of sedation during the period of mechanical ventilation and the use of a sedation holiday for weaning.
• Explain that medications, including local anesthetics, sedatives, and pain medications, will be used to minimize pain and anxiety during the procedure.
• Discuss relaxation methods that can be incorporated into the patient’s care, including reading, providing quiet distractions, and facilitating rest.
• Identify a method of communication between the patient and family and the practitioners.
• Provide assurance that the family can be present and involved in their child’s care.
• Discuss the need for suctioning of the ET tube and the expected coughing sensation.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient and family.
3. Verify the correct patient using two identifiers.
4. Assess the patient’s developmental level and ability to interact.
5. Assess the family’s understanding of the reasons for and the risks and benefits of the procedure.
6. Assess the patient’s vital signs.
7. Assess the patient for signs and symptoms of ventilatory failure, including increased arterial PaCO₂, and symptoms of hypercarbia, such as respiratory acidosis, decreased mental status, tachycardia, hypertension, and dilated pupils.
8. Assess the patient for signs and symptoms of hypoxemia, including decreased arterial oxygen saturation, pale or cyanotic color, tachycardia or bradycardia, tachypnea, agitation or decreased mental status, and increased work of breathing (WOB).
9. Assess the patient’s cardiovascular stability.

Preparation

1. Ensure that all equipment and supplies are present at the bedside and that the equipment is functioning properly.
2. Ensure that a manual ventilation bag, a mask, and suction are immediately available and connected at the patient’s bedside.
3. Ensure that the ventilator has been appropriately calibrated per the organization’s practice and the manufacturer’s recommendations.
4. Ensure that the ventilator circuit and humidification device are appropriately assembled on the ventilator and that they are ready for attachment to the patient.
5. Ensure that all necessary connections are made to connect the ventilator to medical air, oxygen, and electricity (emergency red outlets).
6. Ensure that all the ventilator alarms are functioning appropriately.
7. Ensure that the ventilator circuit humidification system is turned on and heating properly with water in the heater chamber and that the temperature alarms are appropriately set per the organization’s practice and the manufacturer’s recommendations.
8. Ensure that the ET tube is secured to the patient with the appropriate securing device.
9. Position the patient supine with elevation of the head of the bed 15 to 30 degrees and the head in a position of comfort to avoid putting pressure on the ET tube and ventilator circuit interface.⁵
10. Ensure that the ventilator graphics are recording data.

PROCEDURE

1. Perform hand hygiene. Don appropriate PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Explain the procedure to the family and ensure that they agree to treatment.
4. Ensure that the cardiopulmonary monitor is in place to measure end-tidal carbon dioxide (ETCO₂) and peripheral oxygen saturation (SpO₂).
5. Ensure that the ventilator is turned on and is close to the patient.
6. Confirm ET tube placement, including:
   1. Bilateral breath sounds
   2. Bilateral chest rise
   3. ETCO₂ monitoring
7. Select the mode of ventilation.

   Rationale: The choice of mode must be individualized to the patient (Table 2).

8. Set the initial VT; observe chest excursion and auscultate lung sounds to ensure that the patient has adequate aeration.

   Rationale: The VT is individualized to the patient and disease state.

9. Set the cycle mechanism (volume, time, or flow). A patient with hypoxemia may benefit from a longer controlled inspiratory time, and the time-cycled mode may be preferred over the flow- or volume-cycled mode.

   Rationale: The cycle mechanism is individualized to the patient and determines when inspiration terminates.

10. Set the ventilator rate.
    1. An initial rate setting should be based on the patient’s age and size (Table 2).
    2. In the event of apnea or if sedative or neuromuscular blocking medication is used, an appropriate minimum rate is set. The rate may be adjusted based on PaCO₂, with the assumption that the VT is held constant.
    3. Initially, VT can be estimated. For complete control, a calculated rate is used:
    
    

    New rate =		PaCO2 (patient) × (set)
    		Desired PaCO2

    
    
    4. For spontaneous breathing, a lower rate is chosen and then adjusted based on the PaCO₂.
    5. When permissive hypercapnia is desired for lung protection, pH (rather than PaCO₂) drives changes in the rate.⁵

       Rationale: The rate is set to achieve appropriate minute ventilation, where minute ventilation = VT × respiratory rate. The rate setting depends on how much mandatory ventilation is desired.

11. Set the inspiratory:expiratory (I:E) ratio; typically, it is 1:2.²
    1. For a patient with restrictive lung disease, a longer inspiratory time may be beneficial.
    2. For a patient with obstructive disease, a longer expiratory time may be necessary.

       Rationale: Inspiratory time influences oxygenation, and expiratory time influences carbon dioxide elimination.

12. Select the PEEP. Set PEEP for an optimal balance between hemodynamics and oxygenation. To improve oxygenation, attempt to titrate PEEP based on the patient’s lung function and disease process.

    Increasing the level of PEEP can cause an increase in intrathoracic pressure, which leads to a decrease in venous return (hemodynamic compromise).

    Do not interrupt the ventilator circuit (e.g., during suctioning) for a patient on higher levels of PEEP; doing so may cause a significant loss of FRC.

13. Adjust the trigger sensitivity to the most sensitive level to reduce the effort the patient must make to access flow from the circuit.
    1. For a patient who has just started mechanical ventilation, the sensitivity is adjusted to provide complete comfort and rest.
    2. The ventilator is triggered when either a pressure sensor or a flow sensor recognizes the patient’s effort.
14. Tailor the flow rate and pattern to meet or exceed the patient’s needs (asleep versus awake). The circuit may provide continuous flow or demand flow.
15. Set the appropriate alarms and limits.

    Rationale: High- and low-pressure alarms, inspiratory time, and VT limits are always set, and the values are based on the cycling mechanism chosen. Low-pressure alarms are used to detect disconnection or leaks in the system. High-pressure alarms are used for notification of increased pressure in the system.

    In the volume-controlled mode, the patient’s lung compliance may cause variable PIP. Set the high-pressure alarm, per the organization’s practice, above the patient’s PIP to protect the lungs from sudden changes in resistance or compliance.

16. Set the pressure-support ventilation (PSV).
    1. Consider comfort and a target VT with the initiation of PSV. PSV is used with or without synchronized intermittent mandatory ventilation.
    2. Set a pressure level that provides enough support to achieve a targeted VT. Some patients may need higher initial PSV levels, depending on their disease, to overcome the WOB of the ET tube.
17. Discard supplies, remove PPE, and perform hand hygiene.
18. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Monitor cardiopulmonary status, including vital signs and indicators of oxygenation and ventilation.
2. Monitor physiologic stability, including cardiac function and hemodynamic changes (heart sounds, heart rate, blood pressure, and perfusion).

   Rationale: Increased intrathoracic positive pressure may reduce venous return and cardiac output. Likewise, positive pressure may cause pneumothorax, which may also decrease cardiac output.

3. Observe the patient for patient-ventilator synchrony.

   Rationale: Asynchrony causes increased WOB and distress. Asynchrony in a small patient is commonly associated with flow regulation; access to flow and speed of delivery influence the patient’s ability to breathe comfortably.

4. Perform a ventilator and patient assessment, including FIO₂, PIP, VT, PEEP, MAP, and other relevant settings, such as the temperature of the inspired gas.
5. Confirm the appropriate limits of all alarms during each shift.
6. Provide additional ventilatory support, including manual breaths and adjustments in mechanical ventilation as indicated by the signs of hypoxemia, hypercarbia, and hemodynamic instability.
7. Monitor and adjust the ventilator’s settings according to treatment protocols.

   Rationale: Changes in lung compliance may change the PIP or VT.

8. Monitor the ventilator’s alarms and watch for changes from prescribed settings, including an increased PIP or a change in VT.

   Rationale: An alarm indicating an increase in PIP or change in VT may be associated with a need for suctioning or an airway obstruction. A low-pressure alarm may indicate that there is a leak or break in the ventilator circuit and a disconnect has occurred.

9. Ensure that the ET tube is secure and stabilized. Change the tape or tube holder per the organization’s practice. Assess the skin for signs of pressure injury from the device.
   1. Use a device to ensure security while allowing the patient to move.

      Rationale: A device eliminates undue pressure on the patient’s skin from the ET tube and tubing.

   2. Suction the ET tube and provide oral care as part of a ventilator bundle to reduce the incidence of ventilator-associated events (VAEs).
10. Minimize sources of infection by limiting interruptions of the circuit and emptying condensation from the tubing into a trap and not back into the humidification system.
11. Encourage daily sedation holidays or neurostimulation monitors if the patient is undergoing neuromuscular blockade.

    Rationale: Sedation and neuromuscular blockade may be necessary to achieve ventilator synchrony. Neuromuscular blockade masks the patient’s physiologic responses to pain and anxiety.

12. Observe the patient for signs and symptoms of pain. If pain is suspected, report it to the authorized practitioner.

EXPECTED OUTCOMES

• Adequate oxygenation and ventilation
• Maintenance of adequate pH and PaCO₂
• Decreased WOB
• Ventilation without lung injury
• Hemodynamic stability
• Maintenance of skin integrity
• Airway in correct position
• No infection
• Mobilization and removal of secretions
• Adequate airway humidification
• Adequate pain control during the procedure

UNEXPECTED OUTCOMES

• Inadequate ventilation and oxygenation (hypoxemia, hypercarbia, acidosis, alkalosis)
• Lung overinflation, air-leak syndrome (pneumothorax, pneumomediastinum, pneumoperitoneum, subcutaneous emphysema)
• ALI (volutrauma or progression of lung disease)
• Hemodynamic instability
• Skin breakdown or pressure injury
• Unplanned extubation or malpositioned ET tube
• Ventilator-associated pneumonia (VAP)
• Tenacious sputum
• ET tube obstruction
• Infection
• Inadequately managed pain or anxiety

DOCUMENTATION

• Cardiopulmonary assessment before and after procedure, including vital signs, lung sounds, WOB, arterial blood gas analysis, pulse oximetry, and ETCO₂ monitoring
• ET tube size: cuffed or uncuffed
• ET tube marking at the teeth or gums for correct placement
• Date and time of initiation of ventilator assistance
• Record of ventilator settings, including FIO₂, mode, VT, PIP, rate, and PEEP
• Record of ventilator checks as indicated, including FIO₂, mode, VT, PIP, rate, and PEEP
• Length of time of SBT
• Timing of suctioning and characteristics of ET tube secretions
• Significant events that have occurred during the shift
• Temperature of inspired gas
• Assessment of pain, treatment if necessary, and reassessment
• Patient’s response to the procedure
• Patient and family education
• Unexpected outcomes and related interventions

REFERENCES

1. Gibbons, J.T.D., Wilson, A.C., Simpson, S.J. (2020). Predicting lung health trajectories for survivors of preterm birth. Frontiers in Pediatrics, 8, 318. doi:10.3389/fped.2020.00318 (Level VII)
2. Kacmarek, R.M. (2021). Chapter 49: Initiating and adjusting invasive ventilatory support. In R.M. Kacmarek, J.K. Stoller, A.J. Heuer (Eds.), Egan’s fundamentals of respiratory care (12th ed., pp. 1072-1104). St. Louis: Elsevier.
3. 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)
4. Mireles-Cabodevila, E. (2021). Chapter 11: Ventilation. In R.M. Kacmarek, J.K. Stoller, A.J. Heuer (Eds.), Egan’s fundamentals of respiratory care (12th ed., pp. 225-245). St. Louis: Elsevier.
5. Walsh, B.K. (2022). Chapter 32: Invasive mechanical ventilation of the child. In B.K. Walsh (Ed.), Neonatal and pediatric respiratory care (6th ed., pp. 518-534). St. Louis: Elsevier.

*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.

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports