Initial mechanical ventilation settings (peds)

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This page is for pediatric patients. For adult patients, see: initial mechanical ventilation settings.

Background

  • In the neonate, volume-targeted ventilation mode has been shown to have improved outcomes over pressure-limited ventilation[1]
    • Must use cuffed tube for volume-targeted ventilation

Normal Pediatric Respiratory Rates by Age[2]

Age Normal Respiratory Rate
0-12 months 35-55
12 months - 2 years 25-45
2 years - 6 years 20-30
6 years -12 years 20-25

Non-Pulmonary Problem (e.g. trauma)

As a general rule, a traditional strategy is appropriate for most patients (similar to adults)[3]

  • FiO2: 100% (1.0) and ween down
  • Rate: See normal respiratory rates by age above
  • Mode: Volume assist control (AC)
    • A/C = default (most)
  • PEEP: 5 cmH20
  • Tidal volume: 8 cc/kg
    • (adjust to plateau pressure <35 cmH20)

Lung Protective Strategy

Background

  • Focuses on low-tidal volume ventilation to reduce ventilator-associated lung injury (e.g. barotrauma and volutrauma worsening/causing ARDS)[4]
  • Indicated for all intubated patients who do not have obstructive lung disease (COPD, asthma)[5]

Lung Protective Mechanical Ventilation for Pediatric Patients

Lung Protective Ventilator Settings[6] should be the default for all intubated patients, unless contraindicated. It has demonstrated mortality benefit for ARDS-like pulmonary conditions; limits barotrauma and decreases complications of high FiO2[7][8]

  1. Mode
    • Volume-assist control
  2. Tidal Volume
    • Start 6-8cc/kg predicted body weight[9]
      • Predicted/"ideal" body weight is used because a person's lung parenchyma does not increase in size as the person gains more weight.
    • Target a peak pressure of < 30-35 cmH2O (see figure 1) and/or a plateau pressure < 28 cmH2O (i.e. titrate down)[10]
  3. Inspiratory Flow Rate (comfort)
    • More comfortable if higher rather than lower
    • Start at 60-80 LPM
  4. Respiratory Rate (titrate for ventilation)
    • Average patient on ventilator requires 120mL/kg/min for eucapnia
    • Start at normal rate for age (see chart)
    • Maintain pH = 7.30-7.45
  5. FiO2/PEEP (titrate for oxygenation)
    • Move in tandem to achieve:
    • SpO2 BETWEEN 88-95%
    • PaO2 BETWEEN 55-80

Lung Protective FiO2 and PEEP Scale[11][12][13]

FiO2 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9 0.9 0.9 1.0 1.0 1.0
PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 20 22 24

Obstruction Strategy

Background

  • For patients with active bronchoconstriction (e.g. COPD, asthma)
  • The best ventilatory strategy for these patients is to avoid intubation if possible; mechanical ventilation will often make the pulmonary situation worse, rather than better.[14]
  • Goal = adequate time for expiration
  • Frequently requires deep sedation and analgesia (first-line); may required paralysis (second-line)[15]

Settings

  1. Mode
    • Volume-assist control
  2. Tidal Volume
    • Vt = 6-8 cc/kg of Ideal Body Weight
      • Ideal Body Weight used because lung parenchyma does not increase in size as the person gains more weight
  3. Inspiratory Flow Rate
    • 60-80 L/minute
      • Some advocate for higher rates (e.g. 80-100 LPM) to allow more expiration time, however this will increase the peak pressures and has not shown to produce any clinically meaningful change in the expiration time[16][17]
  4. FiO2/PEEP
    • Titrate FiO2 to desired SpO2
    • Set PEEP 0-5
  5. Respiratory Rate
    • Set low - 10 BPM
    • Adjust for I:E 1:4 or 1:5
    • Permissive hypercapnia to avoid breath stacking
      • Ok as long as pH > 7.00-7.10
      • Maintain plateau pressure <30[18]
        • If >30 go down on rate

Hypovolemic

  • Consider reducing PEEP to maintain adequate preload and prevent/minimize hypotension

Miscellaneous

Normally already set

  • Inspiratory flow rate = 60L/min[19] (100 L/min with asthma)
  • Sensitivity = 1-2 cmH2O

See Also

Pediatric Critical Care

Mechanical Ventilation Pages

External Links

References

  1. ↑ Wheeler K, Klingenberg C, McCallion N, Morley CJ, Davis PG. Volume-targeted versus pressure-limited ventilation in the neonate. Cochrane Database Syst Rev 2010;11:CD003666.
  2. ↑ Flemming et al. Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: a systematic review of observational studies. Lancet. 2011 Mar 19;377(9770):1011-8.
  3. ↑ Kneyber et.al. Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC). Intensive Care Med. 2017 Dec;43(12):1764-178.
  4. ↑ Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617
  5. ↑ Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617
  6. ↑ The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301-1308.
  7. ↑ ARDSnet
  8. ↑ O'Brien J. Absorption Atelectasis: Incidence and Clinical Implications. AANA Journal. June 2013. Vol. 81, No. 3.
  9. ↑ Brower RG, et al. "Ventilation With Lower Tidal Volumes As Compared With Traditional Tidal Volumes For Acute Lung Injury And The Acute Respiratory Distress Syndrome". The New England Journal of Medicine. 2000. 342(18):1301-1308.
  10. ↑ Kneyber et.al. Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC). Intensive Care Med. 2017 Dec;43(12):1764-178.
  11. ↑ The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301-1308.
  12. ↑ Kallet RH, et al. "Respiratory controversies in the critical care setting. Do the NIH ARDS Clinical Trials Network PEEP/FIO2 tables provide the best evidence-based guide to balancing PEEP and FIO2 settings in adults?" Respiratory Care. 2007. 52(4):461-75.
  13. ↑ ARDSnet protocol card
  14. ↑ Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617
  15. ↑ Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617
  16. ↑ Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617
  17. ↑ Leatherman JW, McArthur C, Shapiro RS. Effect of prolongation of expiratory time on dynamic hyperinflation in mechanically ventilated patients with severe asthma. Crit Care Med. 2004;32:1542-1545.
  18. ↑ 20. Oddo M, Feihl F, Schaller MD, Perret C. Management of mechanical ventilation in acute severe asthma: practical aspects. Intensive Care Med. 2006; 32(4):501-510.
  19. ↑ Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617
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