Paediatric Ventilation Strategies

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Paediatric Ventilation Strategies

• Sheffield Childrens NHS Foundation Trust
• PCCU

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Principles

• Ventilation is not a cure, it is life support
• Aim to provide an environment for recovery (time,
  anti-virals etc) while doing minimal harm

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Principles

• Use your adult critical care knowledge
• Apply this with reference to the child's
  age/weight

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Principles

• Its not rocket science
• ......its just intensive care!

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Intubation

• Consider possible benefits of NIV
• Dont delay once decision is made
• Prepare equipment and drugs
• Rapid sequence intravenous induction is indicated
  in most cases
• Inhalational induction is challenging in
  respiratory failure

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Drugs
neonates 3mg/kg, infants 2mg/kg, older children
1mg/kg
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ETT

• Generally un-cuffed in pre-pubertal children
• Diameter (mm) age in years/4 4
• Oral length (cm) age/2 12
• Nasal length (cm) age/2 15
• Cut the tube 2-3cm longer to allow for adjustment
  and fixation
• Get a CXR to confirm position (T2/clavicles)
• Getting the length right is IMPORTANT

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Leak

• We dont worry about it too much
• Substantial leak will interfere with ventilation
• Packs are not an adequate solution
• If increasing the PIP doesnt allow you to cope
  with the leak then up-size the ETT or use a cuff

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Tips

• Dont forget you are an airway expert
• They are smaller and that presents some technical
  difficulties
• but an airway is an airway
• and an anaesthetic is an anaesthetic
• Anticipate a difficult airway
• but remember most children have a grade 1 or 2
  view
• Use ETCO2
• Nasal ETT are better tolerated and easier to
  secure but are not essential
• if it was difficult, leave it oral
• LENGTH

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Ventilation

• The principles are the same

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Circuits

• Compliance
• Needs to be low
• Causes loss of tidal volume and confuses the
  ventilator
• Dead space
• Must be minimised
• The smaller the child the greater the concern
• Catheter mounts, HME, ETCO2
• Humidification
• More important in paediatrics

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Modes

• Time cycled, pressure controlled with monitoring
  of tidal volume
• Pressure support for spontaneous breaths
• e.g. BIPAP ASB
• Time cycled, volume controlled with pressure
  limitation
• Pressure support for spontaneous breaths
• e.g. SIMV ASB

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Initial settings

• Ti
• 0.4 1.2
• Rate
• 10 40
• PIP
• 14 30
• Vt
• 6 8ml/kg
• PEEP
• 5 15

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Bottom line

• Adequate CHEST MOVEMENT
• Acceptable saturations and ETCO2

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Blood gases

• Arterial
• or
• Capillary
• Permissive hypercapnoea
• and hypoxia?

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Poor oxygenation

• Increase FiO2
• Assess patient
• Consider a CXR
• Consider suction/physio
• Increase PEEP
• Increase PIP (avoid high Vt)
• Consider alternative ventilation stategies
• Consider proning
• Reconsider your end points

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Ventilation (CO2)

• Too low
• If oxygenation adequate (FiO2lt0.4) then reduce
  PIP
• If oxygenation poor and Vt lt10ml/kg then reduce
  rate
• Too high (is it really too high?)
• Is the ETT obstructed?
• Has the leak changed?
• Has the ETT migrated distally?
• Is the patient fighting the ventilator?
• Is there new collapse/consolidation or an air
  leak?
• If oxygenation and lung recruitment adequate
  increase the rate
• If oxygenation is a problem and Vtlt8ml/kg
  increase the PIP

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Weaning

• Wean FiO2 0.3
• Wean pressures 12-18/5
• Wean sedation
• Convert to CPAP ASB
• Awake, cough, gag ? extubate
• NIV can be helpful

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Get the basics right - VAP

• Head up positioning
• Dont over sedate or use relaxants unnecessarily
• Safe suctioning
• Enteral feeding
• Only use ranitidine if indicated

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Pandemic flu ventilation

• Experience from North America indicates a severe
  haemorrhagic necrotising pneumonitis
• Standard ARDS strategies utilised but many
  patients noted to have reasonable compliance but
  very poor oxygenation
• Fluid restriction and diuresis required
• Some patients required CVVH, HFOV, ECMO

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Questions