CARE OF A CHILD

IN VENTILATOR
S U B M I T T E D B Y,
ISHIKA ROY
M.SC. NURSING STUDENT
MECHANICAL VENTILATION:-

• Mechanical ventilation is aiding ventilation

mechanically when spontaneous efforts of respiration
are lacking.
• It is an external device connected to trachea via
endotracheal or tracheostomy tube, which provides
movement of air in and out of the lungs.
AIM:

The overall goals of mechanical ventilation are to

optimize gas exchange, patient work of breathing, and
patient comfort while minimizing ventilator-induced
lung injury.
OBJECTIVES OF MECHANICAL VENTILATION IN THE
PEDIATRIC PATIENT:-
• Improved pulmonary gas exchange
• Relief of respiratory distress (by relieving upper and
lower airway obstruction, reducing oxygen
consumption, and relieving respiratory fatigue)
• Management of pulmonary mechanisms (by
normalizing and maintaining the distribution of lung
volume and providing pulmonary drainage)
• Provide airway protection
• Provide general cardiopulmonary support
TERMINOLOGY:-

• The term mechanical ventilation refers to various artificial

means used to support ventilation and oxygenation. They
encompass all forms of positive pressure ventilation as well
as ventilators capable of taking over the entire function of
breathing. In order to decide the need for mechanical
ventilation, as well as monitor a patient it is worthwhile to
familiarize with some common terms.
CONT…..
• Tidal Volume: This is the volume of air inspired or expired in
each breath.

• Functional residual capacity: It is a measure of the volume of

the lungs at end expiration.

• Inspiratory time (Ti) and Expiratory time (Te): Time allowed

for inflow and outflow of the air-gas mixture.

• I:E ratio: Ratio between inspiratory time and expiratory time.

 CONT…..
• Peak inspiratory pressure (PIP):
Highest pressure reached during the inspiratory phase.

• Positive end-expiratory pressure (PEEP):

it is the pressure in the lungs above atmospheric pressure
that exists at the end of expiration.
• Mean airway pressure (MAP):
It is the average pressure in the respiratory passage during
ventilation.
CONT…
• FiO2 : Fraction of oxygen in the inspired air gas mixture.

• PaO2 : This denotes the partial pressure of O2 in arterial

blood.

• PaCO2 : This denotes the partial pressure of CO2 in

arterial blood.

• SpO2 : This denotes the oxygen saturation of

hemoglobin in arterial blood.
CONT…
• Compliance:
It is the stiffness or distensibility of the lung and chest wall,
i.e., the change in lung volume produced by a change in
pressure.

• Resistance:
Resistance describes the opposition to gas flow entering the
respiratory system during inspiration, which is caused by
frictional forces.
TYPICAL VENTILATORY PARAMETERS:-
Ventilatory parameter Value (unit)
Tidal volume 10-15 ml/kg body weight
Respiratory rate 20-40 breaths per minute
FiO2 0.2-1.0
PaO2 Day 1: 54-95 mm Hg
  Thereafter: 83-108 mm Hg
PaCO2 Newborn: 27-40 mm Hg
  Thereafter: 35-48 mm Hg
SpO2 Newborn: 90-95%
  Thereafter: 95-99%
Mean airway pressure (MAP) 5-20 cm water
Peak inspiratory pressure (PIP) 20-25 cm
Resistance 6-31 cm water/1/sec
Compliance 2.5-25 ml/cm water
INDICATIONS OF MECHANICAL VENTILATION

• Hypoxemia (type 1 respiratory failure): Defined as a PaO2 <60

mm Hg with normal or increased PaCO2 (SaO2 <90%).
• Acute hypoventilation (type 2 respiratory failure): defined as
acute respiratory acidosis (PaCO2 >50-55 mm Hg) with pH <7 .
25 when ventilatory pump (diaphragm/ chest wall muscles)
mechanism, the neural control fails. Frequently respiratory
failure is a combination of both hypoxemic and hypercapnic
failure.
• Apnea: Apnea can be central (absence of respiratory efforts),
obstructive (absence of airflow in spite of respiratory efforts) or
mixed.
CONT….
• To reduce work of breathing (WOB): reduces O2 consumption and
relieve discomfort while primary disease process improves, e.g.
pneumonia.
• Anesthesia (secure airway): Cardiac, abdominal, neurosurgery
and other procedures which might require anaesthesia and
control of airway. In patients with depressed sensorium, head
injury, poor airway reflexes and in those recovering from
anesthesia and during transport of a sick patient.
• To decrease systemic or myocardial 02 consumption: Septic and
cardiogenic shock.
• To reduce intracranial pressure (ICP): controlled hyperventilation
• To stabilize the chest wall: As in flail chest.
MODES OF VENTILATION:-
• Controlled Mechanical Ventilation (CMV):
In this mode, the ventilator controls all the ventilation
while patient has minimal or no respiratory effort. This is the
mode used at the initiation of mechanical ventilation. It is
divided into 3 subtypes:-
– Pressure controlled ventilation
– Volume controlled ventilation
– Pressure regulated volume controlled ventilation
CONT…
• Assist Control Ventilation (ACV):
All breaths are triggered when the patient’s inspiratory effort
exceeds the preset sensitivity threshold of negative pressure. However, if the
patients fails to initiate the breathing within a prescribed time the ventilator
triggers the breathing and provides a controlled breath as in CMV, thus
ensuring a guaranteed minute ventilation.

• Intermittent Mandatory Ventilation (IMV):

It is essentially a combination of spontaneous breathing and CMV.
A modified circuit provides a continuous gas flow that allows the patient to
breathe spontaneously with minimal work of breathing, At a predetermined
frequency, the ventilator provides a positive pressure breath to the patient.
CONT….

• Synchronized Intermittent Mandatory Ventilation (SIMV):

In conventional intermittent mandatory ventilation, the
controlled breaths may conflict with the patient’s own
respiratory effort. SIMV overcomes this problem by allowing the
patient to trigger the mandatory breath in the assist mode
thereby synchronizing it with the patient’s respiratory effort.
However, if the patient does not trigger a breath within an
allotted time; the ventilator delivers a conventional breath.
POSITIVE END EXPIRATORY PRESSURE
(PEEP)
PEEP is the most established means of providing airway pressure
therapy. It can be added to every type of mechanical ventilation
including spontaneous respiration where it is known as
continuous positive airway pressure (CPAP). The primary goals of
the use of PEEP are to increase the functional residual capacity,
distend patient alveoli and recruit previously collapsed alveoli.
This results in considerable improvement in gaseous exchange
and improves SpO2 significantly.
CONTINUOUS POSITIVE AIRWAY
PRESSURE (CPAP)
CPAP is best described as PEEP during spontaneous respiration.
Infants with severe respiratory disease develop grunting which is
a compensatory mechanism to elevate physiologic PEEP. In
spontaneously breathing patients, CPAP can be administered
through a valve or water column in the expiratory circuit. Most
ventilators are, however, equipped with a CPAP mode. It can be
administered through tight fitting mask, nasopharyngeal
catheter, nasal prongs or through endotracheal tube.
BILEVEL POSITIVE AIRWAY PRESSURE:- (BIPAP)

BIPAP is an airway pressure strategy that applies

independent positive airway pressures to both
inspiration and expiration.
SOME NEWER SOPHISTICATED MODES OF VENTILATION:

• Airway pressure release ventilation (APRV)

• Proportional assist ventilation (PAV)
• Adaptive support ventilation (ASV)
• Neutrally adjusted ventilator assist (NAVA).
SELECTION OF VENTILATION MODE:-
• Disease state and extent of lung involvement
• Lung condition
• Presence and adequacy of spontaneous drive
• Age of the child.

For example, lungs of a child with severe respiratory failure are

usually ventilated in a fully controlled mode. In less severe
conditions where children have their own respiratory support,
he/she can be ventilated either using assist control, SIMV, SIMV
with PSV or PSV alone.
ALGORITHM FOR CARING NEWBORN ON VENTILATOR
ASSESSMENT OF NEWBORN:-
• Provides early evidence of potentially dangerous conditions -
gas trapping and hyperinflation
• Helps to determine optimal PEEP
• Gives immediate feedback on the effects of changes in
ventilator parameters
• Real-time monitoring should decrease the need for and
frequency of many ancillary tests, such as chest radiography
and blood gas analysis, thus decreasing the cost of health care.
• Allows better control of some variables
WHEN TO MONITOR?

• Before you touch the Ventilator and the Baby

• Once the newborn is ventilated and then on…

BEFORE YOU TOUCH THE VENTILATOR.....

(a) Look at the blood gas result.

(b) Look at the baby.
– Is the chest moving?
– Is the baby very tachypnoeic or is the baby apnoeic?
(c) Look at the ventilator.
– What tidal volume (VT) is the baby getting?
– Is there a significant leak?
– Is it set up properly with an appropriate inspiratory time and with
appropriate pressures?
(d) Look at the nursing flow chart.
– How stable has the baby been over the past few hours or days?
CONTINUOUS MONITORING TECHNIQUES:

• Pulse Oximetry
• Transcutaneous Gases
• Pulmonary Mechanics
OTHERS:-
a) Intensive monitoring
• Vitals (look for PDA especially in preterm), FiO2, Weight, Abd
girth, blood sugar, PCV
• Strict Intake – output
b) Anticipate problems and closely observe
• Activity, behavior, signs of sepsis, apnea
c) Hemodynamic Stability, Color, Saturation, CRT, CVP, urine
output
SUPPORTIVE CARE OF VENTILATED NEWBORN
Positioning
• Place healthy lung on the dependent position as this result in
increased perfusion of the good lung segments and possible
improvement of the involved lung.
• Change position: Supine, right or left lateral every 2 – 4 hourly and
prone if feasible
• Encourages postural drainage when indicated
• Passive physiotherapy – Plastic cup with padded rim or soft circular
mask are used to apply kinetic energy to chest wall by
rhythmically striking the thorax over the lung segment.
• Augment with nebulization with or without aerosolized medicines.
CONT:-
Prevention of nosocomial infection
• Routine :Weekly swabs from various sites of NICU
• Strict aseptic procedures
• Carbolysation / disinfection of all equipments / items entering
NICU
CONT…..
Provision of in-utero like milieu:-
• Nesting, Gentle handling
• Reduce ambient noise levels
• Control NICU environment - Optimum Lighting, < 45 DB
• Thermal Comfort : Thermoneutral environment
CONT….
Minimizing Oxygen demand
• Treat fever, pain and agitation x SOS as they increase oxygen consumption
• Neutro Thermal Environment
• Pharmacologic paralysis
• Attend to crying, excessive movements of limbs, discomfort through linen,
cotton, gauze, chill hands, noise, vibrations from bowls, articles of care, etc
increase BMR and hence oxygen demand.
• Schedule care activities at one go – club together
• Approach softly and gently
CONT…..
Humidification and Pulmonary Hygiene
ET Intubation bypasses the natural gas humidification at the upper airway
level. Inadequate humidification of the inspired air may result in increased
volume and viscosity of secretions and this increases risk of airway
obstruction.

Suctioning
• Strictly a sterile procedure
• Duration is short – entire procedure not more than 10 – 20 sec
• Catheter should not occlude more than 2 / 3rd diameter of ET Tube

ABG Monitoring
CONT….
Fluid and Nutritional support
Positive Pressure Ventilation is associated with increased
levels of circulating ADH, so the kidneys will retain free water.
Hence the child with compromised ventilation should receive
about 66 to 75 % of calculated maintenance fluid requirements
unless presented with significant dehydration or hypovolemia.
Generous fluid administration may contribute to the
development of pulmonary edema and worsening of respiratory
failure.
GAS EXCHANGE RELATED PROBLEM:-
Hypoxemia-
• Increase FiO2 and MAP. Need to find a balance as per clinical
situation
• Increase tidal volume if volume limited mode, PEEP, or
inspiratory time.
• If saturation worse, look for air leak, if increasing PEEP
decreases saturations, suspect low cardiac output due to
tamponade effect of PEEP(treat by fluids and inotropes) or
pneumothorax.
• Other measures- normalize cardiac output (by fluids and
inotropes), maintain normal Hb and haematocrit (in neonates),
maintain normothermia, deep sedation/consider
CONT…..
Hypercarbia-
• If volume limited: increase tidal volume or rate.
• If asthma- increase expiratory time to >1:3.
• If pressure limited: increase PIP, decrease Positive End Expiratory
Pressure (PEEP), increase rate.
• Decrease dead space( increase Cardiac Output, decrease PEEP,
vasodilator, shorten ET tube).
• Decrease CO2 production : cool, increase sedation, decrease
carbohydrate load.
• Change endotracheal tube if blocked(may be remedied by suction),
kinked, mal-placed or out, check proper placement.
• Fix leaks in the circuit, endotracheal tube cuff, humidifier.
VENTILATOR EMERGENCIES:-
If patient fighting ventilator and desaturating immediately check
for DOPE:-
• D-Displacement-check tube placement. When in doubt take ET
Tube out and start manual ventilation with 100% O2 and with
bag and mask.
• O-Obstruction-is the chest rising. Are breath sounds present
and equal? Changes in examination?. Atelactasis, treat
bronchospasm/tube block/malposition/pneumothorax(consider
needle thoracocentesis). Examine circulation:?Shock, ?Sepsis.
• P-Pneumothorax-check ABG, saturation and Check for
pneumothorax and worsening lung condition.
• E-Equipment failure-examine ventilator, ventilator
circuit/humidifier/gas source.
HANDLING EMERGENCIES:-
If a child shows a sudden drop in the oxygen saturation immediately
assess the child, look at the child’s chest expansion. Auscultate for air
entry.
• If there is no chest expansion with the ventilator breaths and air entry
is heard in the epigastrium, then the tube is likely to be displaced and
the child will need reintubation. For this remove the tube, ventilate
the child with bag and mask using 100% oxygen. Once the child
stabilizes, reintubate.
• There is chest movement and air entry only on one side, the cause
could be placement of the tube in one of the main bronchi, collapse of
one lung or a pneumothorax. The pneumothorax can be diagnosed on
many occasions by careful examinations; at times a radiological
confirmation is required.
CONT…
• If the tube appears to be too much in, then reposition and
resecure the tube. Recheck the chest movement and air entry.
• If there are features of collapse present (no chest movement
on the affected side, no air entry over the affected side, dull
sound on percussion of the affected side, and shift of trachea
to that side), aggressive physiotherapy followed by
endotracheal suctioning is warranted.
• If a pneumothorax is suspected on the basis of physical signs
and the child is not improving with ventilation, then insert a
needle (usually a 22G venflon) into the second intercostal
space, midclavicular line connected to a syringe filled with
saline. On aspirating, air bubbles will appear if pneumothorax
is present. Prepare for insertion of an intercostal catheter.
CONT…
• Ventilator problems can often be picked up easily. There may
be leak in the circuit, in this scenario the machine will not be
able to deliver the set PIP, In that case, detach the patient from
the ventilator and manually bag using ambu bag attached to
endotracheal tube. If the child is easy to ventilate and settles
once removed from ventilator-the ventilator is identified as the
primary source of ventilator emergency. The ventilator should
be checked as per the manufacturer's guidelines. If the
problem cannot be identified change the ventilator.
CONT…
• If the patient is easy to manually ventilate but an audible air
leak is present, check the cuff and the tube size. If the leak
persists or is unsealable, check tube position/length and air
entry. The tube may have to be reinserted to correct length.
• If the patient is difficult to ventilate, attempt to pass a suction
catheter. If the catheter cannot be passed further than 5 cm
then verify that the child is not biting the ETT. Insert an
oropharyngeal airway to prevent this. If the catheter can be
passed further, do a thorough suction and watch for
improvement. If problem persists change the tube.
DRUGS USED DURING MECHANICAL VENTILATION
Duration of
Drug Intravenous dose Infusion dose
action
    Sedatives:-      
Midazolam 0.05-0.1 mg/kg 2h Loading: 0.05 mg/kg/IV
Maintenance: 0.025
     
mg/kg/h
Fentany1 2-10 mg/kg 30-60 min Loading: 2-10 mg/kg/IV
      Maintenance: 1-5 mg/kg/h
Morphine 0.1 mg/kg 4h Loading: 0.05 mg/kg/IV
Maintenance: 0.02
     
mg/kg/h
Lorazepam 0.05-0.1 mg/kg 4-6 h  
Diazepam 0.1-0.2 mg/kg 4-6 h  
Phenobarbitone 2-3 mg/kg 8-12 h  
    Muscle
     
Relaxants:-
Pancuronium 0.1 mg/kg 50-60 min  
Vecuronium 0.1 mg/kg 25-35 min 0.1 mg/kg/h
Atracurium 0.5 mg/kg 20-30 min 0.3-0.6 mg/kg/h
Succinylcholine 1-2 mg/kg 5-15 min  
COMPLICATIONS:-
• Ventilator:- patient asynchrony refers to lack of synchrony between the
patients breath and ventilator delivered breath.

• Patient related factors: - Anxiety, pain secretions, bronchospasm, pulmonary

edema, dynamic hyperinflation, abnormal respiratory derive, drugs and
nutrition.

• Ventilator related:- Ventilator disconnection, system leak, circuit malfunction,

inadequate FiO2, inadequate ventilator support and low trigger sensitivity.

• Complications of airway intubation:- Accidental extubation, postextubation

subglottic edema/stenosis, vocal cord damage, glottic injury.

• Infection:- Ventilator associated pneumonia (VAP).

CONT….
• Complications of PPV: Ventilator induced lung injury (VILI),
barotrauma, volume trauma (pneumothorax,
pneumomediastinum, interstitial emphysema), oxygen toxicity,
cardiovascular compromise.

• Adverse effects of sedation and paralysis: Hypotension,

reduced cardiac output, retention of secretions (atelectasis),
muscle wasting.

• Other complications: renal dysfunction, gut distention, stress

ulcers, hypomotility of gut, liver dysfunction (raised liver
enzymes), rise in intracranial pressure.
CRITERIA OF WEANING
• Improvement in status of disease for which the child is being
treated.
• Hemodynamic stability including level of
consciousness/absence of major organs failure.
• Improving compliance noted on pressure/ volume loop, chest X-
ray.
• Reduction in requirement of FiO2 (<0.4), PaO2 >60 mm of Hg
with FiO2 <0.4, PEEP <5 cm, PIP <20 cm of H20, ventilator rate
<10/min
• Low PaCO2 allowing to decrease PIP, PEEP, Ti rate
• Ability to maintain patent airway.
• During weaning, the ventilator's contribution to total
WEANING GUIDELINES

• Decrease FiO2 to keep SpO2 >90%

• Decrease PEEP to 4-5 cm by decrement of 1-2 cm of H20
• Decrease SIMV rate to 10-15 breaths/min
• Decrease PIP to 15 cm of H20 by reducing 2 cm of H2O each
time/tidal volume to no less than 5 mL/kg
• Ventilator rate and PIP can be Changed alternately.
PAUSE WEANING:-

• If FiO2 requirement is >0.6

• Child in stress with fast spontaneous respiration.
• Child lethargic or developing hypercapnia.
EXTUBATIO N CRITERIA-

• Some will need pressure support 5-10 above PEEP with CPAP,
while others may need CPAP 5cm water before extubation
• . Infants intubated >3days usually, after extubation, require
nasal CPAP, and then nasal prongs.
• There is control of airway reflexes, minimal secretions; patent
upper airway(air leak around tube), good breath sounds, minimal
O2 requirement <30% with SpO2 >94; Also, minimal pressure
support(5-10 above PEEP), Awake patient, Adequate muscle
tone(squeeze examiners fingers/vigorous cough), Minimal/no
inotropic support, normal electrolytes and no fluid overload.
EXTUBATION PROCEDURE-

• Keep NBM 4hrs before planned extubation.

• Suction endotracheal tube and deflate cuff if using a cuffed
tube. Suction the oral cavity and nostrils.
• Suction the NGT before removing to empty the stomach
• Keep oxygen by facemask ready. Nasal cannula can be taped
to the face even before extubation to avoid immediate
hypoxia/stress upon extubation.
WHO NOT TO VENTILATE:-
Absolute indications:
• Anencephaly
• Hydrancephaly
• Trisomy 13, 18
• Triploidy
• Renal Agenesis
• Short Limb Dwarfism (eg Thanotropic Dysplasia)
• Palliative cases – e.g oncology cases where relapses occur or
treatment either not available locally or unaffordable abroad.
RELATIVE INDICATIONS-TO BE DISCUSSED WITH
CONSULTANT
• Extreme preterm <28weeks with weight<800g,
• Multiple congenital anomaly cases,
• Congenital heart disease with poor chance of long term
survival
• Cardiomyopathy with ejection fraction < 25% and pulmonary
edema unresponsive to therapy
• Severe chronic lung disease including pulmonary fibrosis,
cystic fibrosis, obstructive or restrictive diseases requiring
continuous home oxygen or mechanical ventilation.
CONT…
• Central nervous system, solid organ, or hematopoietic
malignancy with poor prognosis for recovery.
• Liver disease with ascites, history of variceal bleeding, fixed
coagulopathy or encephalopathy, acute hepatic failure
• Acute and chronic and irreversible neurologic impairment,
which makes patient dependent for all personal cares (e.g.:
severe stroke, congenital syndrome, persistent vegetative
state, severe dementia etc.).
CONT….
When there is conflict of interest, e.g family demands ventilation
where medical condition falls in the absolute no ventilation or relative
indication category the following options are to be taken:
a) consultant is to call consultant on call in another division and
present the merits of the case. If the 2 consultants concur that
ventilation is not indicated, Consultant in charge of the case to inform
the family of the decision.
b) In the event that after a) family still insist on ventilation, then
consultant in charge of the case to discuss with medical
superintendent of the hospital where patient is admitted.
NURSING CARE:-
• Impaired gas exchange or oxygenation r/t respiratory distress or unconscious
state.
• Risk for airway obstruction r/t artificial airway, dehumidification or presence of
secretion.
• Pain and discomfort related to presence of artificial airway.
• Risk for fluid electrolyte imbalance r/t non-osmotic ADH release due to positive
pressure ventilation.
• Risk for infection r/t invasive care procedures.
• Risk for skin integrity r/t unconsciousness or immobility or invasive procedures.

Other nursing care include:-

• Maintenance of adequate PH or PaCO2.
• Maintaining hemodynamic stability.