Neonatal and Pediatric Mechanical Ventilation

Neonatal and Pediatric Mechanical Ventilation

• Mechanical ventilation is the method of mechanically assisting or replacing spontaneous breathing using a ventilator or breathing apparatus.

Objectives

• Define mechanical ventilation
• Recognize indications for mechanical ventilation in neonatal and pediatric patients
• Identify different types of pressure ventilation in neonatal and pediatric patients
• Identify indications and complications of mechanical ventilation in neonatal and pediatric patients
• Identify and manage ventilator parameters

Mechanical Ventilation of the Newborn

• Assisted ventilation involves understanding pulmonary mechanics, gas exchange, respiration control, lung injury, and the disease process to enhance mechanical ventilation.

Indications for Mechanical Ventilation of the Newborn

• Hypoxemic:
  • PaO2 <50 mmHg on an FiO2 of >60%
  • PaCO2 <30 mmHg with Respiratory Alkalosis (pH > 7.5)
  • Clinical signs: cyanosis, tachycardia, bradycardia, nasal flaring, grunting, and retractions
• Hypercapneic:
  • PaCO2 > 50 mmHg, Acidotic pH <7.25
• Mixed respiratory failure:
  • Manifested by both hypoxemia and hypercapnia
  • Acidemia is present

Hazards of Mechanical Ventilation

• Oxygen toxicity
• Absorption atelectasis
• Pneumothorax
• Tracheal stenosis
• Hypotension

Approaches to Mechanical Ventilation of the Newborn

• CPAP (Continuous Positive Airway Pressure):
  • Goal: support spontaneously breathing infants to optimize lung mechanics
  • Methods: NeoPuff, Cardens, bubble cpap, or mechanical ventilator
  • Use: newborn infants ≥26 weeks with early distress, infants in NICU with new distress or apnea
• CMV (Continuous Mandatory Ventilation): (Modes: CPAP, IMV, P-SIMV, Assist/Control (PAC))

Intermittent Mandatory Ventilation (IMV/PSIMV)

• Goal: support and improve Ve in spontaneously breathing infants requiring intubation, eliminate breath volume variation, and allow patient control via synchronization of some breaths
• Methods: Using a mechanical ventilator; may be done noninvasively or invasively

Assist/control (PAC/TCPL)

• Setup: ET tube
• Variables:
  • Rate: 40-60 bpm (minimum acceptable rate; actual rate depends on patient effort)
  • Tidal Volume: 4-6 mL/kg
  • Peak inspiratory pressure: 16-18 cmH2O
  • PEEP: 5-7 cmH2O
  • Time-set Ti (inspiratory time): 0.3-0.5 sec
• VT is set by peak inspiratory pressure and either IT or I:E ratio, lung compliance, and tubing resistance.

Ventilator Parameters

• PIP (Peak Inspiratory Pressure):

  • Increasing PIP increases PaO2 and decreases PaCO2
  • Use of high PIP may increase risk of volutrauma
  • Level depends on respiratory system compliance
  • Alter MAP

• PEEP (Positive End-Expiratory Pressure):

  • Helps prevent alveolar collapse, maintains lung volume at expiration, improves V/Q matching
  • Increased PEEP usually increases oxygenation
  • High levels may decrease pulmonary perfusion
  • Minimum PEEP 4-5 cmH2O is recommended in an ETT
  • Alter MAP

• Frequency(Rate):

  • Alters alveolar minute ventilation
  • Increasing rate decreases PaCO2
  • Decreasing rate increases PaCO2

• Inspiratory Time (Ti):

  • A long inspiratory time increases the risk of pneumothorax
  • Shortening is advantageous during weaning
  • Changing Ti may alter MAP

• I:E Ratio (Inspiration-to-Expiration Ratio):

  • Increasing I:E ratio increases MAP and improves oxygenation
  • Inverse I:E ratio is effective in increasing PaO2

• FiO2 (Fraction of Inspired Oxygen):

  • Adjusts patient oxygenation
  • Balance MAP and FiO2 to manage oxygenation
  • During support, increase FiO2 to 0.6-0.7
  • During weaning, decrease FiO2 to <0.5 before altering MAP

• Flow (L/min):

  • 5-12 L/min is sufficient for most newborns, depending on the ETT used

• Ventilator Settings (IMV, SIMV, A/C, PSV): Details outlined in Table of Ventilator Setup

Normal Blood Gases

• pH: 7.35-7.45
• PaCO2: 35-45 mmHg
• PaO2 80-100mmHg (full-term) / 45-65 mmHg (pre-term)
• HCO3: ±24
• SaO2: 95-100%

This quiz covers the fundamentals of mechanical ventilation specifically tailored for neonatal and pediatric patients. It addresses key objectives such as defining mechanical ventilation, recognizing indications, and managing ventilator parameters. Perfect for healthcare professionals looking to enhance their understanding of ventilatory support in young patients.