Mechanical

Mechanical Ventilation
Ventilation in
in
Children
Children

Dr Tanuj Aggarwal

1
 Introduction
• Indications
• Basic anatomy and physiology
• Modes of ventilation
• Selection of mode and settings
• Common problems
• Complications
• Weaning and extubation

2
 Indications
• Respiratory Failure
– Apnea / Respiratory Arrest
– inadequate ventilation (acute vs.
chronic)
– inadequate oxygenation
– chronic respiratory insufficiency with
FTT
3
 Indications
• Cardiac Insufficiency
– eliminate work of breathing
– reduce oxygen consumption
• Neurologic dysfunction
– central hypoventilation/ frequent apnea
– patient comatose, GCS < 8
– inability to protect airway

4
 Basic Anatomy
• Upper Airway
– humidifies inhaled gases
– site of most resistance to airflow
• Lower Airway
– conducting airways (anatomic dead space)
– respiratory bronchioles and alveoli (gas
exchange)

5
 Basic Physiology
• Negative pressure circuit
– Gradient between mouth and pleural space is
the driving pressure
– need to overcome resistance
– maintain alveolus open
• overcome elastic recoil forces
– Balance between elastic recoil of chest wall
and the lung

6
 Basic Physiology

7
http://www.biology.eku.edu/RITCHISO/301notes6.htm
 Normal pressure-volume
relationship in the lung

http://physioweb.med.uvm.edu/pulmonary_physiology 8
 Ventilation
• Carbon Dioxide
PaCO2= k * metabolic production
alveolar minute ventilation

Alveolar MV = resp. rate * effective tidal vol.

Effective TV = TV - dead space
Dead Space = anatomic + physiologic

9
 Oxygenation
• Oxygen:
– Minute ventilation is the amount of fresh gas delivered to
the alveolus
– Partial pressure of oxygen in alveolus (P AO2) is the driving
pressure for gas exchange across the alveolar-capillary
barrier
– PAO2 = ({Atmospheric pressure - water vapor}*FiO2) - PaCO2
/ RQ
– Match perfusion to alveoli that are well ventilated
– Hemoglobin is fully saturated 1/3 of the way thru the
capillary

10
 Oxygenation

http://www.biology.eku.edu/RITCHISO/301notes6.htm 11
CO2 vs. Oxygen

12
 Abnormal Gas
Exchange
• Hypoxemia can be • Hypercarbia can be
due to: due to:
– hypoventilation – hypoventilation
– V/Q mismatch – V/Q mismatch
– shunt
– diffusion
impairments
Due to differences between oxygen and CO2 in their
solubility and respective disassociation curves, shunt
and diffusion impairments do not result in 13

hypercarbia
 Definition
• Acute respiratory failure- absent respiratory activity or
inadequate to maintain oxygen uptake & carbon diaoxide
clearance
• Respiratory insufficiency-if gas exchange is maintained at
increased expense of breathing mechanism.
• Resp failure- PaO2 <60mm
• PaCO2 >50mm & rising
• pH<7.25 or less
• Pao2/FiO2 <150
• A-a gradient >350

14
 Goals of MV
• Provide adequate alveolar ventilation (no resp
acidosis/alkalosis)
• Maximise ventilation perfusion relationship for
optimal gas exchange
• Decreased WOB, increased patient comfort
• Min CVS compromise
• Normal ABG
• Increasing oxygenation

15
 Initial evaluation
• Level of consciousness
• Skin color & appearance
• RR, HR, BP, temp
• Tachypnea & tachycardia-early
indicators of hypoxia & decrease by 10
by oxygen means hypoxia

16
 Categories of respiratory
failure
• CNS- resp centre depression, drugs, brain
stem lesions-hhypoventilation or hypercapnic
respiratory failure
• Neuromuscular-LGBS, tetanus, polio
• Increased work of breathing-1-4% total O2
consumption, increased rate, or depth
increases by 35-40%.-pleural effusion,
increased resistence or decreased compliance

17
 Terms used in MV
• Respiration-movement of gases across a membrane-
external & internal
• Ventilation-drawing in of gases
• Pressure difference between mouth & alveoli drives air-
end exp-5cm, end insp –10 cm so transpulmonary
pressure
• Compliance-relative ease with which a structure
distends or change in volume to presure-V/P
• Resistance-P/Flow
• PIP highest pressure at end of inspiration

18
• Pressure, time, flow, volume
• Volume delivered=amount of flow, in
time dependent on difference in
pressure
• Time constant-rate at which indvidual
unit fills=compliancexresistance

19
 Gas Exchange
• Hypoventilation and V/Q mismatch are the most
common causes of abnormal gas exchange in
the PICU
• Can correct hypoventilation by increasing
minute ventilation
• Can correct V/Q mismatch by increasing
amount of lung that is ventilated or by improving
perfusion to those areas that are ventilated

20
 Mechanical
Ventilation
• What we can manipulate……
– Minute Ventilation (increase respiratory rate, tidal
volume)
– Pressure Gradient = A-a equation (increase
atmospheric pressure, FiO2, increase ventilation,
change RQ)
– Surface Area = volume of lungs available for
ventilation (increase volume by increasing airway
pressure, i.e., mean airway pressure)
– Solubility = ?perflurocarbons?

21
 Mechanical
Ventilation
Ventilators deliver gas to the lungs
using positive pressure at a
certain rate. The amount of gas
delivered can be limited by time,
pressure or volume. The duration
can be cycled by time, pressure or
flow.

22
 Nomenclature
• Airway Pressures
– Peak Inspiratory Pressure (PIP)
– Positive End Expiratory Pressure (PEEP)
– Pressure above PEEP (PAP or ΔP)
– Mean airway pressure (MAP)
– Continuous Positive Airway Pressure (CPAP)
• Inspiratory Time or I:E ratio
• Tidal Volume: amount of gas delivered with
each breath
23
 Modes
• Control Modes:
– every breath is fully supported by the ventilator
– in classic control modes, patients were unable to
breathe except at the controlled set rate
– in newer control modes, machines may act in
assist-control, with a minimum set rate and all
triggered breaths above that rate also fully
supported.

24
 Modes
• IMV Modes: intermittent mandatory ventilation
modes - breaths “above” set rate not
supported
• SIMV: vent synchronizes IMV “breath” with
patient’s effort
• Pressure Support: vent supplies pressure
support but no set rate; pressure support can
be fixed or variable (volume support, volume
assured support, etc)

25
 Modes
Whenever a breath is supported by the
ventilator, regardless of the mode, the
limit of the support is determined by a
preset pressure OR volume.
– Volume Limited: preset tidal volume
– Pressure Limited: preset PIP or PAP

26
 Mechanical
Ventilation
If volume is set, pressure varies…..if
pressure is set, volume varies…..
….according to the compliance…...

COMPLIANCE =
 Volume /  Pressure
27
 Compliance

Burton SL & Hubmayr RD: Determinants of Patient-Ventilator Interactions:

Bedside Waveform Analysis, in Tobin MJ (ed): Principles & Practice of 28
Intensive Care Monitoring
Assist-control, volume

Ingento EP & Drazen J: Mechanical Ventilators, in Hall JB,

29
Scmidt GA, & Wood LDH(eds.): Principles of Critical Care
 IMV, volume-limited

Ingento EP & Drazen J: Mechanical Ventilators, in Hall JB,

Scmidt GA, & Wood LDH(eds.): Principles of Critical Care30
 SIMV, volume-limited

Ingento EP & Drazen J: Mechanical Ventilators, in Hall

JB, Scmidt GA, & Wood LDH(eds.): Principles of Critical 31
Care
 Control vs. SIMV
Control Modes
• Every breath is supported SIMV Modes
regardless of “trigger” • Vent tries to synchronize
• Can’t wean by decreasing
rate
with pt’s effort
• Patient may • Patient takes “own”
hyperventilate if agitated breaths in between (+/-
• Patient / vent asynchrony
possible and may need
PS)
sedation +/- paralysis • Potential increased work
of breathing
• Can have patient / vent
asynchrony 32
 Pressure vs.
Volume
• Pressure Limited
– Control FiO2 and
• Volume Limited
MAP (oxygenation) – Control minute
– Still can influence ventilation
ventilation somewhat – Still can influence
(respiratory rate, PAP)
– Decelerating flow oxygenation
pattern (lower PIP for somewhat (FiO2,
same TV) PEEP, I-time)
– Square wave flow
pattern
33
 Pressure vs.
Volume
• Pressure Pitfalls • Volume Vitriol
– tidal volume by change – no limit per se on PIP
suddenly as patient’s (usually vent will have
compliance changes
upper pressure limit)
– this can lead to
– square wave(constant)
hypoventilation or
overexpansion of the flow pattern results in
lung higher PIP for same
– if ETT is obstructed tidal volume as
acutely, delivered tidal compared to Pressure
volume will decrease modes

34
 Trigger
• How does the vent know when to give a breath?
- “Trigger”
– patient effort
– elapsed time

• The patient’s effort can be “sensed” as a change

in pressure or a change in flow (in the circuit)

35
 Need a hand??
Pressure Support
• “Triggering” vent requires certain amount of work
by patient
• Can decrease work of breathing by providing flow
during inspiration for patient triggered breaths
• Can be given with spontaneous breaths in IMV
modes or as stand alone mode without set rate
• Flow-cycled

36
 Advanced Modes
• Pressure-regulated volume control
(PRVC)
• Volume support
• Inverse ratio (IRV) or airway-pressure
release ventilation (APRV)
• Bilevel
• High-frequency
37
 Advanced Modes
PRVC
A control mode, which delivers a set tidal
volume with each breath at the lowest
possible peak pressure. Delivers the
breath with a decelerating flow pattern
that is thought to be less injurious to the
lung…… “the guided hand”.

38
 Advanced Modes
Volume Support
– equivalent to smart pressure support
– set a “goal” tidal volume
– the machine watches the delivered
volumes and adjusts the pressure
support to meet desired “goal” within
limits set by you.

39
 Advanced Modes
Airway Pressure Release Ventilation
– Can be thought of as giving a patient two different
levels of CPAP
– Set “high” and “low” pressures with release time
– Length of time at “high” pressure generally
greater than length of time at “low” pressure
– By “releasing” to lower pressure, allow lung
volume to decrease to FRC

40
 Advanced Modes
Inverse Ratio Ventilation
– Pressure Control Mode
– I:E > 1
– Can increase MAP without increasing PIP:
improve oxygenation but limit barotrauma
– Significant risk for air trapping
– Patient will need to be deeply sedated and
perhaps paralyzed as well

41
 Advanced Modes
High Frequency Oscillatory Ventilation
– extremely high rates (Hz = 60/min)
– tidal volumes < anatomic dead space
– set & titrate Mean Airway Pressure
– amplitude equivalent to tidal volume
– mechanism of gas exchange unclear
– traditionally “rescue” therapy
– active expiration

42
 Advanced Modes
High Frequency Oscillatory Ventilation
– patient must be paralyzed
– cannot suction frequently as disconnecting the
patient from the oscillator can result in volume
loss in the lung
– likewise, patient cannot be turned frequently so
decubiti can be an issue
– turn and suction patient 1-2x/day if they can
tolerate it

43
 Advanced Modes
Non Invasive Positive Pressure
Ventilation
– Deliver PS and CPAP via tight fitting mask
(BiPAP: bi-level positive airway pressure)
– Can set “back up” rate
– May still need sedation

44
 Initial Settings
• Pressure Limited • Volume Limited
– FiO2 – FiO2
– Rate – Rate
– I-time or I:E ratio
– I-time or I:E ratio
– PEEP
– PEEP
– PIP or PAP
– Tidal Volume
These choices are with time - cycled
ventilators. Flow cycled vents are available but
not commonly used in pediatrics. 45
 Initial Settings
• Settings
– Rate: start with a rate that is somewhat normal;
i.e., 15 for adolescent/child, 20-30 for
infant/small child
– FiO2: 100% and wean down
– PEEP: 3-5
– Control every breath (A/C) or some (SIMV)
– Mode ?

46
 Dealer’s Choice
• Pressure Limited • Volume Limited
– FiO2 – FiO2
– Rate – Rate
– I-time – Tidal Volume
– PEEP MV
– PEEP
– PIP – I time
MAP

Tidal Volume PIP ( & MAP)

( & MV) Varies Varies 47
 Adjustments
• To affect
oxygenation, adjust: • To affect
ventilation,
– FiO2
adjust:
– PEEP
– I time – Respiratory
– PIP Rate MV
MAP
– Tidal Volume
48
 Adjustments
• PEEP
Can be used to help prevent alveolar
collapse at end inspiration; it can also
be used to recruit collapsed lung
spaces or to stent open floppy airways

49
 Except...
• Is it really that simple ?
– Increasing PEEP can increase dead
space, decrease cardiac output,
increase V/Q mismatch
– Increasing the respiratory rate can lead
to dynamic hyperinflation (aka auto-
PEEP), resulting in worsening
oxygenation and ventilation

50
 Ventilator strategies
• 3 categories
• -normal lungs
• -restrictive lung disease
• -obstructive lung disease
• Normal lungs-Initially full ventilatory support
(FVS)-secure airways, ventilation,
hypercapnia, low pressure, easy to wean

51
 Ventilator strategies
• Restrictive lungs-loss of FRC, hypoxemia
• PEEP, initially FVS with sedation(m.
realxants)
• High PIP
• Obstructive lungs
• Gas trapping, slow rates, permissive
hypercapnia

52
 Volume cycled
• PaO2 normal 80-100mm Hg
• Mild hypoxia 60-80
• Moderate hypoxia 40-60
• Severe hypoxia <40 mm Hg
• Rate-physiological <1 yr-30/min,1-5yr
25-30, 5-10 yr 20, >10 yrs 15/min

53
 Initial settings
• Ti 0.4 to 0.75 sec, maintaining I;:E ratio 1:2
• Flow l/kg/min (tidal volume/inspiratory time)
• P-support- min 10 cm
• PEEP- normal 3-4 cm
• Alarms High P 30 cm
• Low P 10 cm
• Low PEEP –3cm

54
 Initial Settings
Parameter Normal lungs Restrictive Obstructive
lung lung
Tidal volume 12-15 ml/kg 6-10ml/kg 8-12ml/kg

Rate On higher side Normal acc to Less than

age normal
FiO2 To keep PaO2 50-80mm PaO2>60mm
PaO2>80mm
PEEP 3-5 cm 5-8 cm 2-3 cm

PIP Keep <35 cm <35 cm <35 cm

ABG Pao2 80-100 50-80 Allow to rise

PaCO2 35-40 Allow it to >60mm if
rise>60 if necessary
necessary
55
 Troubleshooting
• Is it working ?
–Look at the patient !!
–Listen to the patient !!
– Pulse Ox, ABG, EtCO2
– Chest X ray
– Look at the vent (PIP; expired TV;
alarms)

56
 Improving ventilation
• Minute ventilation=tidal volume x RR
• To decrease PaCO2-increase tidal
volume if RR already physiological
• In hypocapnia decrease RR first
• Desired PaCO2=kPaCO2xkVT or
RR/desired PaCO2(40mm)

57
 Improving oxygenation
• Increase Mean airways pressure (MAP)
• PIP/VT,PEEP,Flow,Ti
• FiO2 (dFiO2=kFiO2/kPO2 x d PO2
• Least toxic FiO2 safe till 60%(initially upto 100%)
• Then PEEP(as FiO2), Ti (as PIP/VT already set
to keep PIP<35 cm).
• Normal MAP 5-10cm, can increase upto 10-15
cm, barotrauma more if >15 cm.

58
 Troubleshooting
• When in doubt, DISCONNECT THE
PATIENT FROM THE VENT, and begin
bag ventilation.
• Ensure you are bagging with 100% O2.
• This eliminates the vent circuit as the
source of the problem.
• Bagging by hand can also help you gauge
patient’s compliance

59
 Troubleshooting
• Airway first: is the tube still in? (may need
DL/EtCO2 to confirm) Is it patent? Is it in the
right position?
• Breathing next: is the chest rising? Breath
sounds present and equal? Changes in exam?
Atelectasis, bronchospasm, pneumothorax,
pneumonia? (Consider needle thoracentesis)
• Circulation: shock? Sepsis?

60
 Troubleshooting
• Well, it isn’t working…..
– Right settings ? Right Mode ?
– Does the vent need to do more work ?
• Patient unable to do so
• Underlying process worsening (or new problem?)
– Air leaks?
– Does the patient need to be more sedated ?
– Does the patient need to be extubated ?
– Vent is only human…..(is it working ?)
61
 Troubleshooting
• Patient - Ventilator Interaction
– Vent must recognize patient’s respiratory
efforts (trigger)
– Vent must be able to meet patient’s
demands (response)
– Vent must not interfere with patient’s efforts
(synchrony)

62
 Troubleshooting
• Improving Ventilation and/or Oxygenation
– can increase respiratory rate (or decrease rate if
air trapping is an issue)
– can increase tidal volume/PAP to increase tidal
volume
– can increase PEEP to help recruit collapsed areas
– can increase pressure support and/or decrease
sedation to improve patient’s spontaneous effort

63
 Lowered
Expectations
• Permissive Hypercapnia
– accept higher PaCO2s in exchange for limiting peak
airway pressures
– can titrate pH as desired with sodium bicarbonate or
other buffer
• Permissive Hypoxemia
– accept PaO2 of 55-65; SaO2 88-90% in exchange for
limiting FiO2 (<.60) and PEEP
– can maintain oxygen content by keeping hematocrit >
30%

64
 Adjunctive
Therapies
• Proning
– re-expand collapsed dorsal areas of the lung
– chest wall has more favorable compliance curve in
prone position
– heart moves away from the lungs
– net result is usually improved oxygenation
– care of patient (suctioning, lines, decubiti) trickier but
not impossible
– not everyone maintains their response or even
responds in the first place

65
 Adjunctive
Therapies
• Inhaled Nitric Oxide
– vasodilator with very short half life that can be
delivered via ETT
– vasodilate blood vessels that supply ventilated
alveoli and thus improve V/Q
– no systemic effects due to rapid inactivation by
binding to hemoglobin
– improves oxygenation but does not improve
outcome

66
 Complications
• Ventilator Induced Lung Injury
– Oxygen toxicity
– Barotrauma / Volutrauma
• Peak Pressure
• Plateau Pressure
• Shear Injury (tidal volume)
• PEEP

67
 Complications
• Cardiovascular Complications
– Impaired venous return to RH
– Bowing of the Interventricular Septum
– Decreased left sided afterload (good)
– Altered right sided afterload
• Sum Effect…..decreased cardiac output
(usually, not always and often we don’t even
notice)

68
 Complications
• Other Complications
– Ventilator Associated Pneumonia
– Sinusitis
– Sedation
– Risks from associated devices
(CVLs, A-lines)
– Unplanned Extubation
69
 Extubation
• Weaning
– Is the cause of respiratory failure gone
or getting better ?
– Is the patient well oxygenated and
ventilated ?
– Can the heart tolerate the increased
work of breathing ?

70
 Extubation
• Weaning (cont.)
– decrease the PEEP (4-5)
– decrease the rate
– decrease the PIP (as needed)
• What you want to do is decrease what
the vent does and see if the patient can
make up the difference….

71
 Weaning
• Gradually change repsiratory rate,
watch for changes in HR,RR, or BP, if
change of >20% stop weaning.
• Infants decrease RR to 10, then put on
T-tube, in older children decrease to 6-
8 breaths.

72
 Extubation
• Extubation
– Control of airway reflexes
– Patent upper airway (air leak around tube?)
– Minimal oxygen requirement
– Minimal rate
– Minimize pressure support (0-10)
– “Awake ” patient

73
THANK YOU

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