Received: 15 November 2021 | Revised: 3 December 2021 | Accepted: 6 December 2021

DOI: 10.1111/pan.14368

N A R R AT I V E R E V I E W

Modes of ventilation for pediatric patients under anesthesia:

A Pro/Con conversation

Melissa Brooks Peterson1 | Judit Szolnoki2

1
Pediatric Anesthesiology, University of
Colorado / Children’s Hospital Colorado Abstract
Department of Anesthesiology, Aurora,
The development of sophisticated modes of ventilation for pediatric patients under-
Colorado, USA
2
Pediatric Anesthesiology, University
going anesthesia is ongoing; what remains a challenge for the pediatric anesthesiolo-
of Central Florida, Nemours Children’s gist is thoughtful selection of the mode(s) of ventilation for a particular patient in the
Hospital Department of Anesthesiology,
Orlando, Florida, USA
context of the surgical procedure and the goals of the anesthetic. This article provides
some historical accounting of a variety of modes of ventilation, defines the terminol-
Correspondence
Melissa Brooks Peterson, Pediatric
ogy of modern ventilatory modes, and reviews in detail the benefits and pitfalls of
Anesthesiology, University of Colorado / the specific modes of ventilation and their applicability to the practice of pediatric
Children’s Hospital Colorado Department
of Anesthesiology, 13123 East 16th
anesthesiology. In an attempt to debate the Pros and Cons of different modes of ven-
Avenue Box 090, 80045 Aurora, CO, USA. tilation, and to finally resolve the debate “spontaneous vs. controlled ventilation,” we
Email: melissa.brooks@childrenscolorado.org
share with you a thoughtful conversation of the continuum of modes of ventilation
Section Editor: Britta von Ungern-­ and their applicability to our pediatric anesthesia population.
Sternberg

KEYWORDS
adolescent, child, equipment—­anesthetic machines, infant, neonate, respiration

The hard part isn't making the decision. It's living with of these advances in technology, a safe anesthetic still relies on a
it. well-­selected and executed plan under the watchful eyes of a trained
(Law Abiding Citizen) pediatric anesthesiologist.

1 | I NTRO D U C TI O N 2 | H I S TO R I C A L CO N S I D E R ATI O N S

In the 1968 edition of Smith's Anesthesia for Infants and Children,1
Dr. Smith himself stated the following: “Most of the mechanical ven-
tilating devices may be adapted for use in the operating room, and
several have been designed specifically for this purpose… it seems
preferable to avoid the use of these devices for most pediatric anes-
thesia and to retain the use of manual bag management.” The current
2
edition states: “No anesthesia machines are designed specifically
for pediatric application…The most important change to date in
modern anesthesia machines is the ability to precisely deliver small
tidal volumes accurately by compensating for breathing-­circuit com-
pliance and changes in fresh gas flow”. The past 50 years brought
on many technological advancements in gas delivery, monitoring,
and sophisticated alarms that make the delivery of anesthesia more
precise and safer, especially for pediatric patients. Regardless of all
From a historical perspective, the popularity of spontaneous ventila-
tion with or without assisted ventilation is not surprising. Ether an-
esthesia relied entirely upon the patient's spontaneous breaths and
equipment to achieve positive pressure was slow to develop for the
pediatric population. Ventilation and oxygenation of the pediatric
patient required—­literally—­manpower for the duration of anesthetic
and recovery.3
Mechanical ventilation of pediatric patients undergoing surgery
was cumbersome, as conventional anesthesia ventilators of the past
were not designed for pediatric use. They had several significant
limitations that limited accurate volume delivery. One had to “play”
with the ventilator and then monitor the adequacy of ventilation by
observing the chest excursion of the pediatric patient. While this
was a reasonable approach given the limitations of the machine,

Pediatric Anesthesia. 2022;32:295–301. wileyonlinelibrary.com/journal/pan© 2021 John Wiley & Sons Ltd | 295
 |
296
changes during the case were hard to appropriately compensate for,
4
particularly if the patient was under the surgical drapes. To make
matters worse, the widespread use of uncuffed endotracheal tubes
and the associated leaks further compromised the accuracy of ven-
tilator settings. As a result, ventilation of the pediatric patient was
only an approximation of physiologic ventilation under nonanesthe-
tized spontaneous breathing conditions. As a gap measure, one re-
sorted to hand ventilation and the myth of the “educated hand” was
popularized.5
When pressure ventilation became available, it quickly became
the standard mode of pediatric mechanical ventilation; most pres-
sure modes of ventilation were able to deliver adequate tidal vol-
umes with acceptable pressures while compensating for the leak
around the endotracheal tubes. Appropriate settings chosen by the
anesthesiologist could partially compensate for the compliance of
the circuit, but changes in patient compliance still resulted in hypo
or hyperventilation.
With the advent of the modern anesthesia ventilators and in-
creased use of cuffed endotracheal tubes, mechanical ventilation in
the pediatric patient understandably gained significant popularity;
modern anesthesia machines could calculate and compensate for
circuit compliance and could deliver more precise volumes under
controlled volume or pressure (or both) settings. Modern anesthesia
ventilators in their current configuration have almost reached the
sophistication of intensive care unit ventilators.
3 | D E FI N ITI O N S O F M O D E S O F
V E NTI L ATI O N
We begin our conversation about modes of ventilation with a review
of common set of terminology.
3.1 | Spontaneous ventilation
MBP (Melissa Brooks Peterson): Ok. Let's start with the simplest
mode—­spontaneous. The most traditional definition of spontane-
ous ventilation is that it fully relies on the patient for all phases of
the respiratory cycle. Natural breaths are taken without significant
support.
JS (Judit Szolnoki): Agree, though I am not convinced, it is the
“simplest” mode. I would add that the only support that is acceptable
while talking about spontaneous ventilation is support of the airway
itself, either by a maneuver to adjust the positioning of the airway
(eg, extension of the head to open the mouth and relieve obstruc-
tion of a natural airway) or by instrumentation of the airway with a
variety of available airway devices. It is important to remember that
you can have a secure airway and utilize the spontaneous mode of
ventilation.
MBP: Yes, good point; an airway with an endotracheal tube in
place can still oxygenate and ventilate via a spontaneous mode of
ventilation, and while we do this all the time just before extubation
14609592, 2022, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pan.14368 by Medicinska biblioteken VGR, Wiley Online Library on [15/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
BROOKS PETERSON et al.
it may not be our preferred or recommended mode of ventilation for
the entirety of the anesthetic.
3.2 | Assisted/supportive modes of ventilation
JS: Though it is difficult to draw a line of what is spontaneous venti-
lation and what is not, I think the definition of assisted or supportive
modes of ventilation exist on a continuum with spontaneous ven-
tilation. There are a few ground rules that can help us distinguish
this mode. First, respiratory effort is initiated and the respiratory
rate is therefore set by the patient. The “support” portion of these
modes of ventilation refers to augmentation of tidal volumes once
the breath is initiated by the patient.
MBP: That's an excellent way of framing the terminology of as-
sisted or supportive modes. I would add that “support” in a support-
ive or assisted ventilation mode can come in a variety of forms. One
can utilize the anesthesia machine or the pediatric anesthesiologist's
hand-­delivered breaths with the bag-­mask circuit or “bag” mode on
the anesthesia machine. These augmented breaths are synchronized
with the patient's spontaneous respiratory effort with respect to
initiation of the breath via negative pressure inspiration and the fre-
quency of those inspirations (the respiratory rate). Outside of “hand
assistance” by a pediatric anesthesiologist, continuous positive air-
way pressure can be delivered by the pop-­off valve or dial on the
anesthesia machine. Probably, the most frequently used machine-­
assisted ventilation is our favorite mode of ventilation: pressure sup-
port ventilation (PSV).
JS: Yes, we agree that our favorite mode of ventilation is PSV.
Two additional important pearls to remember about the supportive
or assisted modes: First, these modes should be considered both
semi-­spontaneous and semi-­controlled. Second, in all supportive
or assisted modes of ventilation, positive end-­expiratory pressure
(PEEP) can be provided that also contributes to augmented tidal vol-
umes by maintaining functional residual capacity (FRC). We will get
the value of these “pearls” shortly.
3.3 | Controlled or mechanical modes of ventilation
JS: The simplest way to conceptualize controlled or mechanical modes
of ventilation is that they take over the function of breathing for the
patient at every step in the respiratory cycle. Controlled or mechanical
modes of ventilation initiate the breath using positive pressure, con-
trol the respiratory rate, and then deliver a breath that is measured by
volume, by pressure, or by combined volume-­pressure. Controlled or
mechanical modes of ventilation also dictate the mechanics of expira-
tion using a time-­or flow-­determined exhalation cycle. The simplest
definition of the controlled mode(s) of ventilation is that the anesthesi-
ologist dictates every part of ventilation and oxygenation, and no part
of the patient's respiratory effort is part of the controlled cycle.
MBP: In addition to settings which determine the mechanics of
the entire respiratory cycle in a controlled mode of ventilation, it is

BROOKS PETERSON et al.
worth noting that settings on the ventilator also dictate oxygenation.
Oxygenation is determined by the anesthesiologist by setting flow
rates of oxygen, air, and nitrous oxide as well as relative flow of these
gases, which determine the fraction of inspired oxygen delivered to
the patient. While this is not unique to a controlled mode of ventila-
tion, it is a critical function of the pediatric anesthesiologist to choose
these settings for each patient in the context of the patient's physiol-
ogy, the surgical procedure, impact on the environment of our inhaled
gases, and the availability of scavenging systems.6
4 | PROS A N D CO N S O F M O D E S O F
V E NTI L ATI O N
4.1 | Pros and Cons of spontaneous ventilation
MBP: A spontaneous mode of ventilation can be employed with a
natural airway, a supraglottic airway, or endotracheal tube (ETT);
each of these modalities carries their own set of risks and benefits.
JS: With respect to the mode of ventilation alone, spontaneous
ventilation will always have its place in pediatric anesthesia. There are
many instances where children need certain levels of sedation to tol-
erate a procedure but do not encounter surgical levels of stimulation.
Many of these procedures or diagnostic studies (eg, auditory brain
response evaluations, magnetic resonance imaging studies) are well
suited to maintain spontaneous ventilation via natural airway.
MBP: Yes, agree that diagnostic studies are the best example of how
spontaneous ventilation is most commonly utilized. Also, cases performed
under a surgical level of regional anesthesia or neuraxial anesthetics (eg,
infant spinals) fit into this category nicely. Furthermore, there are cases
where maintenance of spontaneous respirations is a desired feature, like
in several airway surgeries, diagnostic and therapeutic bronchoscopies.
JS: I may be a proponent of spontaneous ventilation—­with the
caveat of under the right conditions and when this mode is utilized
appropriately. One major benefit of a spontaneous mode of venti-
lation with inhalational anesthetics is that the patient can “breathe
themselves” to an appropriate depth of anesthesia, because the
uptake of the anesthetic agent is dependent on minute ventilation,
and minute ventilation is dependent on the degree of procedural
stimulation (or lack thereof). Furthermore, respiratory rate of the
spontaneously ventilating patient can easily serve as a guide to
narcotic administration, whereby the pediatric anesthesiologist
can titrate single or repeated dose of opioid based on the patient's
respiratory rate, and the change in respiratory rate after repeat
dosing.
MBP: We definitely align in our opinions that one of the stron-
gest arguments for utilizing spontaneous modes of ventilation is for
precise dosing of opioids, without running the risk of overdose or
making a patient apneic. Ongoing research has taught us that each
patient has their own milieu that makes standard opioid dosing
challenging (and potentially dangerous). Pediatric anesthesiologists
can appropriately treat an individual patient's pain and obviate the
issue of individual variability in the opioid response by levering the
|
14609592, 2022, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pan.14368 by Medicinska biblioteken VGR, Wiley Online Library on [15/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
297
spontaneous mode of breathing so that the individual patient “shows
us” what they need.
JS: Don't forget the other body systems as well; from a car-
diovascular standpoint, under the condition of spontaneous ven-
tilation, breaths are achieved by negative pressure inspiration, so
compression of the pulmonary vasculature is minimized, and ve-
nous return is fully maintained. Additionally, ventilation/perfusion
ratios remain more natural in comparison with controlled or posi-
tive pressure ventilation.7 This phenomenon can be crucial for safe
and successful delivery of an anesthetic for certain patients, as we
will discuss later. But let's not get ahead of ourselves, because the
spontaneous mode of ventilation is not fool-­proof. General anes-
thesia with a natural airway and a spontaneously breathing patient
can be quite a challenging scenario for the anesthesiologist taking
care of the pediatric patient. This mode requires expertise of po-
sitioning for airway patency, and even with that skill, the patient
remains at risk for partial or complete airway obstruction, laryngo-
spasm, and aspiration.
MBP: In addition to monitoring airway patency and the physi-
ologic chest excursion of the patient as you point out, in a sponta-
neous breathing mode with a natural airway, it is also fundamental
to ensure gas sample analyzation (ETCO2 and FiO2 monitoring)
and to understand the limitations of the sampling apparatus while
using this mode. Monitoring the respiratory parameters can pres-
ent a challenge as both FiO2 and ETCO2 monitoring may be un-
precise compared to the gas monitoring system of a closed circuit.
JS: I would add that reliable gas sampling, and good working
knowledge of its limitations is critical especially when one cannot
directly visualize airway patency and chest excursion (eg, anesthesia
for MRI).
MBP: Another phenomenon that argues against the use of a
spontaneous breathing mode is that when used with an airway de-
vice (ETT or SGA), there is increased work of breathing due to the
increased resistance of the breathing apparatus and circuit when
compared to native or natural airway. We rely on the patient to do
the work of respiration in this mode and may actually increase the
demands of respiration depending on the airway device utilized.8
JS: Increased work of breathing through an airway device, along
with the added dead space of an airway device, can be detrimental
to some patients, particularly premature infants, neonates, and pa-
tients with underlying airway disease or increased work of breathing
at baseline. Reviewing respiratory physiology and mechanics, recall as
well that under anesthesia breaths will be in a nonupright (supine or
prone) position, become more rapid and shallow, and functional resid-
ual capacity (FRC) drops below the closing capacity (CC). All of these
changes in respiratory physiology under general anesthesia result in
atelectasis, worsening of V/Q mismatch and can compromise oxygen-
ation and ventilation. Atelectasis is, in my opinion, the phenomenon
that works against the pediatric anesthesiologist the most when it
comes to replicating the physiology of pediatric respiration.9
MBP: Yes, atelectasis is our number on enemy for sure.
When this results in lower-­
t han-­
expected oxygen saturations,
oxygenation can be augmented for by administering higher
 |
298
FiO2 . Recognizing too that higher FiO2 also can precipitate or
worsen existing atelectasis, so like many instances it is a balance.
However, in patients with baseline respiratory compromise, reli-
ance on spontaneous ventilation and subsequent predictable de-
rangements in normal respiratory mechanics may lead to difficulty
maintaining oxygenation.
JS: Agree that maintaining oxygenation can be tricky in the OR;
the other issue we see as a result is that increased FiO2 requirement
in the OR can also persist as ongoing oxygen requirement in the
PACU or postoperative time period. Avoidance of ongoing hypox-
emia and oxygen requirement in the PACU is a great reason to avoid
a spontaneous mode of ventilation.
MBP: OK, so we have addressed hypoxemia under spontaneous
breathing conditions and we know for our purposes the number one
cause is atelectasis. What about hypercarbia?
JS: Hypercarbia is also our enemy but is usually not as much of
an issue for our patients under anesthesia or patients who have just
arrived to the PACU. With respect to compromised ventilation under
spontaneously breathing conditions, it is not possible to “overcome”
relative hypercarbia, most patients will respond to relative hypercar-
bia by increasing respiratory rate and eventually “breathe off” the
additional CO2 burden as long as the airway is open. For short peri-
ods of spontaneous breathing under general anesthesia, hypercarbia
is usually not a concern but as always, careful monitoring of assuring
an open airway is a must have to keep the patient safe.
MBP: Another consideration is that the neonatal and prema-
ture infant population can have worsening of periventricular leu-
komalacia (PVL) and intraventricular hemorrhage (IVH) from both
hypercarbia and hypocarbia.10,11 Another situation I can think of
where hypercarbia becomes an actual issue that is for patients
who are too ill to effectively increase their minute ventilation and
compensate for hypercarbia due to relative hypoventilation in a
spontaneous breathing mode. For these patients, persistent or ele-
vated hypercarbia may present as derangement in acid-­base status,
somnolence, and worsening respiratory effort. As is all too familiar,
hypercarbia-­acidosis-­somnolence-­hypoventilation can become a
vicious cycle.
JS: True; though I would be shocked to find any patient who is ill
enough to have detrimental effects from hypercarbia being placed
intentionally in a spontaneous mode of ventilation!
MBP: You and me both. Let's move on.
4.2 | Pros and Cons of assisted/supportive
modes of ventilation
JS: Just like spontaneous ventilation, assisted ventilation remains an
important tool in the pediatric anesthesiologist's armamentarium.
One can provide positive pressure by hand ventilation or via pres-
sure support mode of a modern anesthesia ventilator. While we like
to think that “our hands” are better or at least as good as a machine,
in reality, the modern anesthesia machines do a better job providing
synchronized breaths that the patient initiates.
14609592, 2022, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pan.14368 by Medicinska biblioteken VGR, Wiley Online Library on [15/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
BROOKS PETERSON et al.
MBP: Yes, the modern ventilator is pretty good at delivering syn-
chronized breaths. When we attempt to hand ventilate, it is too easy
to inadvertently “take over” the ventilation, or to fail to provide ade-
quate support to overcome resistance to the breathing due to airway
equipment. I would guess we see this most obviously in trainees or
pediatric anesthesiologists in training, but I suspect we are all “bad”
at hand assisting a patient compared to a modern ventilator.
JS: I think I’ll take on the next topic, as it is near and dear to my heart.
When using pressure support mode, many of the positive attributes of
spontaneous ventilation remain. The patient is still setting the pace,
therefore allows for easy titration of anesthetic and analgesic medica-
tions appropriate to surgical stimulation. Furthermore, because of the
positive pressure supplied, it is easy to titrate and maintain best positive
end-­expiratory pressure (PEEP) that reduces the risk of atelectasis.
MBP: Not surprising that you announced the two best features
of a supportive or assisted mode of ventilation; after all, I learned
them from you! I’d only add that assistive modes like pressure sup-
port ventilation also avert many of the issues related to fully con-
trolled modes such as the risk of anaphylactic reactions if paralytics
and reversal agents are used, monitoring the level of muscle relax-
ation and the effects of incomplete reversal of muscle relaxants.
JS: Yes, avoidance of certain medications in pediatric anesthesia
is a major upside of an assisted or supportive mode of ventilation.
Don't forget also that emergence is another key time period we see
a benefit of an assisted or supportive mode.
MBP: Totally true! The magic of supportive modes at emergence
is one of our favorites—­assisted modes can aid in a faster wakeup
by supporting better tidal volumes to exhale the volatile agents in a
minute ventilation-­dependent fashion.
JS: Assisted modes still have their problems, though. There is a
continued risk of losing the airway if it is not secured by an ETT. Risk
of aspiration might even be increased if the pressures used to assist
the ventilation exceed the lower esophageal sphincter pressure re-
sulting in gastric insufflation, depending on the status of the airway
and airway device employed (if one is employed).
MBP: We also have friends in the operating room who may not
love our assisted or supportive modes; during assisted ventilation,
the patient's muscle tone and ability to move are maintained that at
time can result in “belly breathing,” or exaggerated abdominal con-
tractions to achieve respiration which can make the surgical field
less optimal. The lack of muscle relaxation also puts the patient at
risk for movement under general anesthesia, and we know our surgi-
cal colleagues understandably prefer a quieter surgical field!
JS: Yes, a key part of our job is to optimize surgical conditions,
and respiratory parameters of the patient certainly can affect the
surgical field. Another one of my favorite teaching moments in the
OR is a rookie mistake when using an assisted ventilation mode:
When an assisted or supportive mode is set on the ventilator, the
backup mode takes over the respirations for the patient and goes
unnoticed. This leaves the patient unintentionally apneic when the
support is withdrawn. It is important that the concept of support
ventilation is clear to the anesthesiologist (or trainee) to avoid this
pitfall.

BROOKS PETERSON et al.
MBP: The only other conditions I can think of when an assisted
or supportive mode of ventilation would be ill advised is when
ETCO2 needs to be tightly controlled (eg, for a craniotomy) or when
muscle relaxation is required for patient or surgical field purposes.
4.3 | Pros and Cons of controlled or mechanical
modes of ventilation
MBP: Are you ready to kick around the final mode of ventilation?
JS: Sure! You start.
MBP: Precision of monitoring is an important aspect of the prac-
tice of anesthesia, and one method that anesthesiologists maintain
a patient's physiology is by monitoring inhaled and exhaled gases
during general anesthesia. Full mechanical ventilation on a modern
anesthesia machine employs a closed circuit which allows for accu-
rate gas sample analyzation as a measure of oxygenation and venti-
lation and precise delivery of inhaled anesthetic agents. This is one
major advantage of a controlled mode of ventilation—­precision of
monitoring.
JS: That is an interesting way to start the conversation, keeping
in mind that gas analyzation is accurate in a controlled mode but
only if the anesthesia machine is fully checked with the circuit in the
condition it will be in for the case. This is especially important in
pediatric anesthesia and for our smallest patients, because as long
as the machine is checked and calibrated with the circuit stretched
to the desired length the delivered tidal volumes will be accurate, as
these machines account for circuit compliance and operate indepen-
dent of fresh gas flow.12
MBP: Agreed on the importance of a full machine check to en-
sure we are delivering what we think we are delivering in a con-
trolled mode. Another benefit of using a mechanical or controlled
mode of ventilation is the availability of flow-­volume loops on our
modern anesthesia machines, which can guide the anesthesiologist
in diagnostic and therapeutic decisions intraoperatively.
JS: As we alluded to earlier—­another advantage of the controlled
mode of ventilation mode is the ability to initiate and titrate PEEP.
Just like in an assisted mode, the ability to accurately titrate PEEP
will help fight against the development of atelectasis. While this is
not an advantage that is unique to the controlled mode of ventila-
tion (because PEEP can also be titrated in our favorite assisted or
supportive modes of ventilation), provision of PEEP provides a huge
argument against the use of spontaneous modes of ventilation.
MBP: Agreed and to strengthen your point, I would say that if you
and I have one thing to hold as the “ultimate champion” of “closing
argument” of a nonspontaneous mode of ventilation, it is the use of
PEEP.
JS: In addition to application (or absence!) of PEEP, we have
discussed work of breathing a fair amount in this conversation,
so it is worth noting that a controlled or mechanical ventilation
mode helps to reduce the work of breathing by offloading some
of that work to the machine. This can help to overcome patient
|
14609592, 2022, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pan.14368 by Medicinska biblioteken VGR, Wiley Online Library on [15/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
299
fatigue of respiratory effort both for oxygenation and ventilation
purposes.
MBP: Reducing a patient's work of breathing is especially use-
ful for longer surgical procedures, for patients who are already at
risk for respiratory failure due to pulmonary disease or coexisting
medical conditions, or for whom the surgical procedure itself will
induce increased work of breathing regardless of the duration of the
procedure.
JS: Our surgeons also may benefit from a controlled mode of
ventilation. “Control” or “manipulation” of the surgical field is a sim-
ple but important advantage to a controlled mode of ventilation,
because the anesthesiologist can adjust the ventilator settings with
respect to tidal volume and respiratory rate, thereby adjusting the
surgical field for optimal surgical conditions (eg, providing smaller
more frequent breaths can minimize movement of the surgical field
in a neonate patient undergoing a thoracoscopic TEF repair).
MBP: That's an excellent point, and possibly an under-­valued aspect
of the practice of anesthesiology. If we can help to optimize the surgical
conditions by choosing smart ventilator settings when appropriate, we
can potentially improve surgical conditions (and hopefully outcomes!) in
the operating room. But also to not “overdo” it when a patient may not
need a controlled mode of ventilation but the surgeon “wants” it.
JS: As with many things we do in the operating room, it is a bal-
ancing act.
JS: We have addressed some of the medication caveats of as-
sisted or controlled modes of ventilation, and I think understanding
utilization of anesthesia medications in a controlled mode is import-
ant. A controlled mode of ventilation indirectly allows for the use
of muscle relaxants; therefore, a more balanced anesthetic can be
provided; anesthetics can be used for unconsciousness, pain modu-
lators can be titrated for analgesia, and muscle relaxants to provide
paralysis and therefore an optimal surgical field.
MBP: So, the take-­home message is that another “advantage”
(albeit indirect) of choosing a controlled mode of ventilation usually
means utilizing muscle relaxants which should result in less usage
and exposure to inhaled anesthetics. There are some associated pa-
tient/physiologic, economic, and environmental benefits to reducing
use of inhaled anesthetic agents.6
JS: Agreed on the beauty of a balanced anesthetic. In an effort to
continue to keep this conversation patient-­centric, we know that he-
modynamic stability is easier achieved with lower doses of anesthet-
ics and a balanced anesthetic approach. Another indirect benefit of
choosing controlled mode of mechanical ventilation for the patient
is that the airway device(s) required to use this mode offer airway
protection and reduce risk of aspiration.
MBP: But we aren't saying a controlled mode of ventilation is the
answer, are we?
JS: No, not at all. Despite the potential advantages of controlled
modes of ventilation, there are distinct disadvantages. Positive pressure
breath delivery is a requirement of controlled modes of ventilation, and
positive pressure in the chest can impede venous return. Positive pres-
sure breath delivery may not affect the hemodynamics of a healthy child
 |
300
with normal heart and lungs, but for children who are susceptible to he-
modynamic compromise with even a slight decrease in venous return,
positive pressure modes of controlled ventilation can cause catastrophe.
MBP: That's an excellent point. In the wrong patient, positive
pressure ventilation or a controlled mode of ventilation can be
enough to kill. It sounds dramatic but can be true. Consider for ex-
ample, a patient with single ventricle physiology who lives on the
edge of adequate venous return under negative-­inspiratory pressure
conditions, who is ill and requires an emergent surgery so is already
decompensated from a cardiac function standpoint.
JS: Another disadvantage worth noting of a controlled mode of ven-
tilation is the fact that a secured airway can also be considered a “dou-
ble edged sword.” Meaning, when one considers the associated risks of
airway instrumentation and securement, including but limited to mul-
tiple airway attempts and resultant swelling/airway compromise, sub-
glottic stenosis as a complication of ETT placement, and laryngospasm
or bronchospasm on emergence from anesthesia and ETT removal.
MBP: That is an ominous outlook but important to be fully aware
of our own limitations or potential for iatrogenesis! In a similar vein,
while a using muscle relaxant is beneficial in certain scenarios, it re-
mains the most common anesthetic medication cause of anaphylac-
tic reactions under anesthesia.
JS: Yes, the realization that this risk is only applicable if a
muscle relaxant is administered (and conversely the risk is zero
if the medication is not administered). Also, when using muscle
relaxant in pediatric patients, there is very poor reliability and
applicability of twitch monitoring and monitoring of the degree
of muscle relaxation.13 Lastly, administration of a muscle relax-
ant also then requires the administration of reversal agent(s) and
further risks of incomplete reversal, persistent weakness post-
operatively and potential associated complications from that in-
complete reversal.
5 | CO N C LU S I O N
MBP: I hope we have provided a coherent conversation about the
pros and cons of different modes of ventilation; as we have learned
over time, and hope to convey, there really is no “one best” mode.
JS: There is definitely no “one right answer”—­but a continuum of
modes and their application to specific patients and operating room sce-
narios. I think the most important message is that, regardless of the mode
of ventilation selected, it is critical to have an in-­depth working knowl-
edge of the advantages and limitations of the machine you are using. The
concepts behind the modern anesthesia ventilator, and their subsequent
application to a patient hooked up to that machine, require the pediatric
anesthesiologist to understand that the accuracy of volume and pressure
delivery, and the ventilation and oxygenation parameters that the ma-
chine displays will depend on proper calibration of the machine.
MBP: And as a reminder, the ability to actually use the modern
anesthesia ventilator correctly requires not only completing a ma-
chine precheck but also adjusting the circuit length to what it will
be during the procedure, so the compliance test and calculation will
14609592, 2022, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pan.14368 by Medicinska biblioteken VGR, Wiley Online Library on [15/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
BROOKS PETERSON et al.
remain true all through the procedure. If the circuit is altered during
the procedure, the calculations will no longer hold true and the deliv-
ered tidal volumes might become too small or too large.12
JS: To use the different modes of ventilation available effectively,
the operator must understand those modes and their complexities.
This assumes ongoing training and equipment education, and also re-
quires upkeep and maintenance of modern equipment which can be
costly and burdensome on pediatric anesthesia practices.
MBP and JS: In consideration of the “Pros” and “Cons” of each
mode of ventilation, we conclude that there is no winner in the Pro/
Con debate of spontaneous vs. controlled ventilation. Instead, we
hope we have presented a thoughtful dialogue and show that the
availability and application modes of ventilation actually exist on a
continuum. Furthermore, we hope we have convinced you that it
is the responsibility and expertise of the pediatric anesthesiologist
to employ the right mode at the right time for the right patient. A
variety of modes of ventilation can be applied to the patient's con-
dition, goals of the planned anesthetic, and desired outcomes of the
surgical procedure. These mode(s) can—­and should!—­be applied in
a stepwise spontaneous, supportive, assisted, or controlled man-
ner. Sometimes, every mode of ventilation can be used in a single
anesthetic. It is the hallmark of pediatric anesthesiology to have an
in-­depth, working, and nimble knowledge of modes of ventilation
of our patients and of our modern anesthesia machines, advantages
and disadvantages of the device(s) used to apply those modes, the
medications that ensure safe utilization of each mode, and the appli-
cation of a variety of ventilatory and oxygenation methods regard-
less of the airway device or mode of ventilation selected. The most
important take-­home “Pro” we definitely agree on is this: It is critical
for the pediatric anesthesiologist to have fluency in transitioning
from one mode to another, display flexibility to adapt to changes pa-
tient or procedural concerns, and possess the communication skills
to share and teach that unique expertise.
REFLECTIVE QUESTIONS
(1) Consider the variety of modes of ventilation you utilize
in a single routine anesthetic. How do these modes rep-
resent a ‘continuum’ of respiratory care/ventilator set-
ting, vs. how are they distinct modes and settings?
(2) Identify times during an anesthetic where a different
mode of ventilation may be another viable option (eg,
omitting paralysis and instead choosing an assistive
mode like Pressure Support Pro).
(3) When planning or delivering a general anesthetic what
ventilation techniques allow you to best optimize opioid
administration?
(4) What are the risks and benefits of choosing a ventila-
tion mode that delivers PEEP?

BROOKS PETERSON et al.
AC K N OW L E D G E M E N T S
None.
C O N FL I C T O F I N T E R E S T
The authors have no conflicts of interest to declare.
DATA AVA I L A B I L I T Y S TAT E M E N T
Data sharing is not applicable to this article as no new data were cre-
ated or analyzed in this study.
ORCID
Melissa Brooks Peterson https://orcid.org/0000-0001-9226-1096
REFERENCES
1. Smith RM. Anesthesia for infants and children. Mosby; 1968.
2. R H. Airway Management. In: Davis PJ CF, ed. Smith’s Anesthesia for
Infants and Children, 9th ed. Elsevier; 2017:349-­369.
3. Costarino AT Jr, Downes JJ. Pediatric anesthesia historical perspec-
tive. Anesthesiol Clin North Am. 2005;23(4):573-­595, vii.
4. Stayer S, Olutoye O. Anesthesia ventilators: better options for chil-
dren. Anesthesiol Clin North Am. 2005;23(4):677-­691, ix.
5. Spears RS Jr, Yeh A, Fisher DM, Zwass MS. The "educated hand".
Can anesthesiologists assess changes in neonatal pulmonary com-
pliance manually? Anesthesiology. 1991;75(4):693-­696.
6. Varughese S, Ahmed R. Environmental and occupational consider-
ations of anesthesia: a narrative review and update. Anesth Analg.
2021;133(4):826-­835.
7. Radke OC, Schneider T, Heller AR, Koch T. Spontaneous breath-
ing during general anesthesia prevents the ventral redistribution
|
14609592, 2022, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pan.14368 by Medicinska biblioteken VGR, Wiley Online Library on [15/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
301
of ventilation as detected by electrical impedance tomography: a
randomized trial. Anesthesiology. 2012;116(6):1227-­1234.
8. Keidan I, Fine GF, Kagawa T, Schneck FX, Motoyama EK. Work
of breathing during spontaneous ventilation in anesthetized
children: a comparative study among the face mask, laryngeal
mask airway and endotracheal tube. Anesth Analg. 2000;91(6):​
1381-­1388.
9. Jeong H, Tanatporn P, Ahn HJ, et al. Pressure support versus spon-
taneous ventilation during anesthetic emergence-­effect on post-
operative atelectasis: a randomized controlled trial. Anesthesiology.
2021;135(6):1004-­1014.
10. McCann ME, Schouten AN. Beyond survival; influences of blood
pressure, cerebral perfusion and anesthesia on neurodevelopment.
Paediatr Anaesth. 2014;24(1):68-­73.
11. Fabres J, Carlo WA, Phillips V, Howard G, Ambalavanan N. Both
extremes of arterial carbon dioxide pressure and the magnitude of
fluctuations in arterial carbon dioxide pressure are associated with
severe intraventricular hemorrhage in preterm infants. Pediatrics.
2007;119(2):299-­3 05.
12. Feldman JM. Optimal ventilation of the anesthetized pediatric pa-
tient. Anesth Analg. 2015;120(1):165-­175.
13. Faulk DJ, Austin TM, Thomas JJ, Strupp K, Macrae AW, Yaster M.
A survey of the society for pediatric anesthesia on the use, moni-
toring, and antagonism of neuromuscular blockade. Anesth Analg.
2021;132(6):1518-­1526.
How to cite this article: Brooks Peterson M, Szolnoki J. Modes
of ventilation for pediatric patients under anesthesia: A Pro/
Con conversation. Pediatr Anesth. 2022;32:295–­301.
doi:10.1111/pan.14368