13. Pediatric Ventilation

Question 1

1. Pediatric ventilation is very _______ specific
2. what does this population often require? why?
3. are peds a quick or slow wean? when?
4. what percentage of this population requires short term ventilation? how long is this typically?
5. what percentage requires long term ventilation? why?

Answer 1

1. disease
2. more sedation and paralysis to avoid pulling of lines and tubes
3. quick once paralysis is turned off and sedation is weaned
4. 80% of healthy children, < 5 days
5. 20% (chronic lung disease, CHD, complex syndromes that require complex weaning plans)

Question 2

1. mode of ventilation is dependent on what? (hint: 3)
2. A/C….. volume ventilation? –> pressure ventilation? –> volume targeted ventilation?
3. SIMV….. volume ventilation? –> pressure ventilation? –> volume targeted ventilation?
4. spontaneous ….. volume ventilation? –> pressure ventilation? –> volume targeted ventilation?

Answer 2

1. the ventilator used, clinical preference, disease pathology
2. A/C ….. VC –> PC –> VG, PRVC, VC+
3. SIMV …..VC + PSV –> PC + PSV –> VG/ PRVC + PSV
4. spontaneous ….. none –> PSV, PC/PSV (drager) –> VS

Question 3

1. what are the 5 additional ventilation modes used in the pediatric population?
2. out of the above modes, which is most commonly used for neonates? (hint: 2)
3. out of the above modes, which one is commonly used for asthma and RSV?

Answer 3

1. HFOV, APRV, NAVA, NIV (CPAP and BiPAP), HFNC
2. HFOV and APRV
3. HFNC

Question 4

1. initial RR for an infant (1-12 m)? toddler (1-3 y)? small child (3-6 y)? child (6-12 y)? adolescent (12-18 y)?
2. initial Vt (ml/kg) for an infant (1-12 m)? toddler (1-2 y)? small child (3-6 y) child (6-12 y)? adolescent (12-18 y)?
3. initial Ti for an infant (1-12 m)? toddler (1-3 y)? small child (3-6 y)? child (6-12 y)? adolescent (12-18 y)?
4. initial PEEP for an infant (1-12 m)? toddler (1-3 y)? small child (3-6 y)? child (6-12 y)? adolescent (12-18 y)?
5. initial FiO2?

Answer 4

1. infant = 25-40, toddler = 20-35, small child = 20-30, child = 18-25, adolescent = 12-20
2. 5-8 ml/kg for all age groups
3. infant = 0.35-0.5s, toddler = 0.5-0.7, small child = 0.65-0.8, child = 0.8-1, adolescent = 0.8-1.2
4. infant = 5-7, toddler = 5-7, small child = 5-7, child = 5-8, adolescent = 5-10
5. start FiO2 to maintain SpO2 > 92%

Question 5

1. Frequency is ______ dependent
2. what 5 things should be considered?
3. set frequency along with _____ to provide adequate ___ and maintain desired ____
4. what 2 lung conditions are at risk of air trapping when frequency is set too high?

Answer 5

1. age
2. patients spontaneous respiratory drive, minute ventilation requirements, how much work you want the pt doing vs the vent, disease process involved, sedation
3. delta P/Vt, Ve, CO2
4. asthma and bronchiolitis

Question 6

1. want to set PIP to target what? (hint: 2)
2. what PIP should be used in patients with healthy lungs? moderate lung disease? severe disease?
3. what tidal volume are we targeting for peds?
4. what do we want to see when setting Vt? what should we be aware of?
5. what other 2 modes allow for setting tidal volume?

Answer 6

1. desired Vt and effective chest rise
2. 15-22 cmH2O, 20-30 cmH2O, 30-40 cmH20
3. 5-8 ml/kg
4. effective chest rise, be aware of pressure generated to achieve Vt
5. VG or PRVC

Question 7

1. Vt for adult ventilation is based on what?
2. Vt for neonatal/peds ventilation is based on what? what else needs to be considered? what does this include?
3. what should ALWAYS be assessed?

Answer 7

1. PBW or IBW
2. actual body weight, lung size including … obesity, failure to thrive and spinal malformations
3. assessing for CHEST RISE

Question 8

1. what is the total PEEP range allowed in peds?
2. what is setting PEEP based on? (hint: 3)
3. with high FiO2 requirements (> 40%), may not have adequately recruited the lung, what should we do with PEEP?
4. what can inadequate recruitment lead to? therefore, needing what?

Answer 8

1. 5-20 cmH2O
2. disease process, expansion on CXR, FiO2 requirements
3. increase PEEP
4. poor compliance therefore, needing higher pressures

Question 9

1. setting Ti is based on what? (hint: 2)
2. what 2 things should be used if available? what else can we look at to assess Ti?
3. suggested Ti for < 1 year? 1-3 years? 3-6 years, 6-12 years, 12-18 years

Answer 9

1. disease pathology and time constants
2. flow termination and Ti max in PSV, waveforms
3. 0.35-0.5, 0.5-0.7, 0.65-0.8, 0.8-1.0, 0.8-1.2

Question 10

1. how can oxygenation be improved? (hint: 3)

2. what can PEEP help to increase?

Answer 10

1. FiO2, MAP and LRM

2. MAP

Question 11

1. a study on LRM’s in pediatric patients explained the positives to using an LRM, what are they? (hint: 2)
2. what pressure is used? for how long?
3. how often can a LRM be performed? when else can it be performed?
4. what does an LRM require?

Answer 11

1. LRM’s are safe and well tolerated in hemodynamically stable children with ARDS and may improve lung function in severe hypoxemia
2. CPAP 20-40 cmH2O x 30-40 seconds
3. Q12H following and disconnections from the vent
4. an order

Question 12

1. what controls ventilation?

2. what 6 things should be considered?

Answer 12

1. Ve = RR x Vt

2. Vt, PIP, RR, Ti, spontaneous drive, mode

Question 13

1. what is the mode of choice in pediatric patients?
2. this mode allows for a preset what?
3. in PCV, what is set? what fluctuates with patients condition?
4. what else is set in PCV? what is variable and what is this based on?

Answer 13

1. volume control
2. Vt and flow
3. pressure, volume
4. Ti, flow is variable based on patients inspiratory demand

Question 14

1. Servo i/u in VTV adjusts what? based on what? can this vent function with a ETT leak? why or why not?
2. drager VN (500) in VTV adjusts what? based on what? can this vent function with a ETT leak? why or why not?
3. how does volume targeted ventilation work?

Answer 14

1. adjusts PIP, based on inspiratory Vt, NOT function with a large ETT leak because inspiratory Vt will be higher than expiratory therefore vent will give a Vt in the middle of these two values not the Vt set.
2. adjusts PIP, based on calculated Vt, can function up to a 50% leak because vent adjusts pressure based on the calculation of Vt.
3. set Vt, pressure will increase or decrease in order to achieve set Vt based off the previous breath

Question 15

1. how should the trigger sensitivity be set?
2. how can a ventilator be triggered? (hint: 3)
3. what trigger is typically used for the avea? what is the back up trigger?
4. what trigger is typically used for the servo i/u?
5. what trigger is typically used for the VN 500?

Answer 15

1. minimal value to allow for easy spontaneous breathing without allowing for auto-cycling
2. time, flow or pressure
3. usually flow, back up of pressure triggering
4. set flow or pressure triggering
5. ONLY flow triggering

Question 16

1. pressure triggering is set in what units?
2. flow triggering is set using what? what is considered least sensitive? what is considered most sensitive?
3. what number is a good starting range for sensitivity?
4. what are red values at high risk for?
5. flow triggering should be used in the presence of what? why?

Answer 16

1. cmH2O
2. using a reference number, 0 = least sensitive, 10 = most sensitive
3. 5 and adjust from here
4. auto cycling
5. auto PEEP to ensure patient can appropriately trigger the ventilator instead of pressure triggering

Question 17

1. what 15 things can help us monitor our ventilated patients?

Answer 17

• vital signs, physical exam including B/S, assessment of WOB, ventilator settings, patients ventilator data, patient ventilator interaction, waveforms, alarms, humidification and circuit, assessing the need for suctioning, Labs + CXR, artificial airway, adjunctive monitoring (EtCO2/TcpCO2), documentation, systematic approach

Question 18

2 year old weighing 11kg female intubated for airway protection due to status seizures. She has required sedation to help stop her seizures therefore, her respiratory drive has been blunted. what 3 things do we know our patient may need/have?

Answer 18

• normal lungs (unless aspiration occurs from one of her seizures)
• minimal support (minimal pressures/PEEP)
• requires a lot of sedation (appropriate RR)

Question 19

6 year old patient with Duchenne Muscular Dystrophy and Pneumonia, weighs 40 kg. what 3 things do we know our patient may need/have?

Answer 19

• higher PEEP/FiO2 requirements
• chronic aspiration from muscle weakness
• chronic pneumonias

Question 20

4 year old girl with sepsis and ARDS weighing 25 kg. What type of ventilation strategy should we use? what 5 things does this include?

Answer 20

lung protective strategy:

• low Vt 3-6 ml/kg
• Pplat < 28 cmH2O
• permissive hypoxemia
• PEEP > 10 cmH2O
• permissive hypercapnia

Question 21

1. what do we want to try to always maintain when ventilating pediatric patients?
2. how much sedation should be given (general)?

Answer 21

1. spontaneous breathing

2. enough to stop child from pulling tubes/lines but NOT enough to blunt the respiratory drive

Question 22

1. want to assess what when weaning?
2. what question should you ask yourself?
3. the patient should have a stable ________ ______
4. patient should have minimal ________, ____, _____
5. does the patient have a good _______ _____ and _____ _______
6. what other question should you ask yourself?
7. what do you want to make sure is present BEFORE extubating a pediatric patient?

Answer 22

1. readiness to extubate successfully
2. is the underlying disease pathology resolved?
3. cardiovascular system
4. sedation, FiO2 and PEEP
5. spontaneous drive and lung compliance
6. will the patient be a quick or slow wean?
7. positive cuff leak test

Question 23

1. ______ ______ of mechanical ventilation compared to neonates and adults
2. ____ of pediatric patients are extubated within ___ _____
3. _____ phase is ____
4. _____ lung issues, ______ ventilation with ______ with ______ wake up, _____ and ______. what specific patients does this statement pertain to?
5. remaining patients require _______ _______ and _______ weaning processes. what specific patients does this statement pertain to?

Answer 23

1. shorter length
2. 50% within 48 hours
3. wean phase is short
4. no lung issues, full ventilation with sedation with quick wake up, wean and extubate. Pertains to post op and status epilepticus patients
5. prolonged support and complex weaning processes. Pertains to chronic lung disease, ARDS, and congenital heart defect patients

Question 24

1. with neonatal patients, what do we want to push for when extubating these patients? what does this reduce the risk of?
2. what should be adequate before extubation?
3. what vent settings should be low before extubation?
4. what should be done if the patient is being ventilated for a longer period of time?

Answer 24

1. extubating as soon as they are ready to NIV/CPAP to reduce risk of developing BPD
2. good spontaneous drive and lung compliance
3. PEEP and FiO2
4. wean slowly and daily SBT’s (5-8 cmH20)

Question 25

1. when should the SIMV weaning technique be used? 2. what should be weaned over time in this method? why? 3. what can be trialed prior to extubation with this technique? 4. when should the pressure support weaning technique be used? (hint: 2) 5. what should be assessed when using this method?

Answer 25

1. in patients with longer days of ventilation 2. RR to allow for the patient to do more breathing on their own with pressure support 3. PSV prior to extubation 4. shorter days of ventilation, more normal compliance and resistance 5. patients ability to breathe on their own with minimal support

Question 26

what 6 things can help us monitor our patient when weaning?

Answer 26

- watching for increasing RR - falling tidal volumes - apnea common in neonates (make sure apnea ventilation set appropriately) - cyanosis, retractions, agitation - may need to increase pressures/rate and rest patient as they are not ready - will the patient do well on CPAP or BiPAP when extubated?

Question 27

1. what should you always check before applying NIV to a pediatric patient? 2. what 5 devices/methods are available for delivering NCPAP? 3. what are the 2 devices/methods for delivering NIPPV?

Answer 27

1. weight requirements! 2. vision, V60, ventilator, VPAP machine, HFNC (optiflow/vapotherm) 3. ventilator NIPPV, BiPAP (vision, V60, Stellar 150)

Question 28

1. what two interfaces are available for applying NIPPV/BiPAP? 2. ___________ with patient effort 3. what does IPAP assist with? 4. advantages of EPAP? (hint: 3)

Answer 28

1. nasal or full face mask 2. synchronized 3. improving tidal volume and clearing CO2 4. improves FRC, recruits alveoli and improves oxygenation, reduce WOB associated with autoPEEP

Question 29

use for NIV in pediatric patients? (hint: 8)

Answer 29

- ARDS - post-extubation - neuromuscular disorders - pulmonary edema - asthma - chronic lung disease - nocturnal hypoventilation - post operative

Question 30

contraindications to using NIV? (hint: 5)

Answer 30

- impaired LOC - unable to protect airway and handle secretions - poor cooperation - hemodynamic instability - recent gastric, esophageal or laryngeal surgeries

Question 31

1. what two problems is the RESMED Stellar 150 used for? 2. describe the CPAP mode of this device. 3. how does the spontaneous (S mode) function? 4. how does the spontaneous/timed (S/T mode) function?

Answer 31

1. nocturnal hypoventilation and neuromuscular disorders 2. delivers a fixed pressure 3. device senses the patient breath and triggers IPAP in response to an increase in flow, and cycles into EPAP at the end of inspiration. The breath rate and the respiratory pattern will be determined by the patient 4. device augments any breath initiated by the patient, but will also supply additional breaths should the patient breath rate fall below the clinician's set ’backup’ breath rate.

Question 32

1. how does the timed (T mode) function in the RESMED Stellar 150? 2. how does the pressure assist control (PAC mode) function? 3. how does the iVAPS mode (intelligent volume assured pressure support) function?

Answer 32

1. the fixed breath rate and the fixed inspiration time set by the clinician are supplied regardless of patient effort. 2. inspiration time is present in the PAC mode. There is no spontaneous/flow cycling. The inspiration can be triggered by the patient when respiratory rate is above a preset value, or time triggered breaths will be delivered at the backup breath rate 3. designed to maintain a preset target alveolar ventilation by monitoring delivered ventilation, adjusting the pressure support and providing an intelligent backup breath automatically. Patients > 30 kg (pressure changes to augment tidal volume)