Paeds · acute-care-resuscitation-and-toxicology
Mechanical ventilation principles in children
Also known as Paediatric mechanical ventilation · Invasive ventilation in children · Paediatric lung-protective ventilation · PICU ventilation principles · Ventilator modes in children
Fellowship guide to mechanical ventilation principles in children: why a child is intubated, how the ventilator delivers a breath, how the modes differ in what they control and what they let the patient do, and the lung-protective strategy that sets low tidal volume, limited plateau pressure, optimised PEEP and permissive hypercapnia that now governs the paralysed diseased lung. Covers the settings a candidate must be able to justify, the weaning and liberation approach including spontaneous breathing trials and post-extubation non-invasive support, sedation and the difficulty of translating adult liberation protocols to children, ventilator-associated pneumonia prevention, and the way every choice is judged against the type of respiratory failure in front of you.
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Target exams
Red flags
- A ventilated child who deteriorates is approached as machine then patient: check the circuit is connected and unbent, the endotracheal tube is patent and secure, the settings are correct and the alarm envelope is understood before chasing the disease
- Rising peak inspiratory pressure with falling tidal volume in a volume-control breath means the lungs have become stiffer or the tube is blocked or kinked; dropping pressure with rising volume in pressure control means compliance is improving or there is a large leak
- Untreated pain, agitation and dyssynchrony drive breath-stacking and patient-ventilator asynchrony that worsens lung injury, so analgesia-first sedation is part of lung protection, not an afterthought
- Failure of a ventilated child to liberate is most often inadequate respiratory drive, residual neuromuscular weakness, electrolyte and metabolic disturbance, oversedation or unaddressed secretion load rather than primary lung disease
- Do not extubate without a plan for the airway: predicted extubation failure in young infants and those with chronic lung or airway disease is reduced by planned post-extubation high-flow nasal cannula, CPAP or bilevel support
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Clinical exam formats
Board mappings
- Principles of mechanical ventilation in children
- Paediatric lung-protective ventilation and ventilator liberation
- Mechanical ventilation: indications, modes and lung-protective strategy
- Long case: the ventilated child in intensive care
- Short case: ventilator settings, alarms and liberation
- Critical care: principles of mechanical ventilation
- Mechanical ventilation principles in children
- Critical care: the ventilated child
- Critical Care: mechanical ventilation principles
- Patient Care: mechanical ventilation and ventilator liberation in children
- Medical Expert: paediatric mechanical ventilation
Overview & Definition
Mechanical ventilation in children is the delivery of positive-pressure breaths through an invasive artificial airway, almost always an endotracheal tube, in order to take over or assist the work of breathing when the child's own gas exchange or respiratory effort has failed. The decision to intubate is therefore a decision that oxygenation, ventilation, or the effort of breathing has become unsafe, and ventilation is bought at a price, because the very act of pushing gas into diseased lung can injure it. The organising principle of modern paediatric practice is lung-protective ventilation, which deliberately limits how much each breath stretches the lung so that the ventilator supports recovery rather than adding harm. [3] [1]
The topic rewards a candidate who holds three things in mind at once. The first is the indication, because ventilation is started for apnoea or exhausted effort, for refractory hypoxaemia, for failure to clear carbon dioxide, or to protect the airway and reduce work of breathing in shock. The second is the mode, which is simply rule ventilator follows to deliver each breath: what it controls, what the patient is allowed to trigger, and how hard it works. The third is the protective target, the low tidal volume and limited pressure that translate the insight that overdistending an injured lung makes it worse into numbers set on the machine. [3] [2]
References11ShowHide
- [1]Pediatric Acute Lung Injury Consensus Conference Group Pediatric acute respiratory distress syndrome: consensus recommendations from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med, 2015.PMID 25647235
- [2]Emeriaud G; López-Fernández YM; Iyer NP; Blackwood B; Curley MAQ; Dobyns EL; et al Executive Summary of the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2). Pediatr Crit Care Med, 2023.PMID 36661420
- [3]Kneyber MCJ; de Luca D; Calderini E; Jarreau PH; Javouhey E; Lopez-Fernandez Y; et al Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC). Intensive Care Med, 2017.PMID 28936698
- [4]Abu-Sultaneh S; Iyer NP; Fernández A; Bauman S; Carroll CL; Cheifetz IM; et al Executive Summary: International Clinical Practice Guidelines for Pediatric Ventilator Liberation, A Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network Document. Am J Respir Crit Care Med, 2023.PMID 36583619
- [5]Wong JJM; Dang H; Gan CS; Phua HP; Goh RSY; Mok YH; et al Lung-Protective Ventilation for Pediatric Acute Respiratory Distress Syndrome: A Nonrandomized Controlled Trial. Crit Care Med, 2024.PMID 38920618
- [6]Khemani RG; Smith L; Lopez-Fernandez YM; Shi H; Rapoport S; Newth CJL; et al Paediatric acute respiratory distress syndrome incidence and epidemiology (PARDIE): an international, observational study. Lancet Respir Med, 2019.PMID 30361119
- [7]Curley MA; Wypij D; Watson RS; Grant MJ; Asaro LA; Dodson BL; et al Protocolized sedation vs usual care in pediatric patients mechanically ventilated for acute respiratory failure: a randomized clinical trial. JAMA, 2015.PMID 25602358
- [8]Blackwood B; Tume LN; Morris KP; Swinton F; Turnbull KL; Linke-Heer D; et al Effect of a Sedation and Ventilator Liberation Protocol vs Usual Care on Duration of Invasive Mechanical Ventilation in Pediatric Intensive Care Units: A Randomized Clinical Trial. JAMA, 2021.PMID 34342620
- [9]Chang I; Schibler A Ventilator Associated Pneumonia in Children. Paediatr Respir Rev, 2016.PMID 26527358
- [10]Egbuta C; Easley RB Update on ventilation management in the Pediatric Intensive Care Unit. Paediatr Anaesth, 2022.PMID 34882910
- [11]Iyer NP; Rotta AT; Essouri S; Schiller O; Mhanna MJ; St Julien JP; et al Association of Extubation Failure Rates With High-Flow Nasal Cannula, Continuous Positive Airway Pressure, and Bilevel Positive Airway Pressure vs Conventional Oxygen Therapy in Infants and Young Children: A Systematic Review and Network Meta-Analysis. JAMA Pediatr, 2023.PMID 37273226