Mechanical Ventilation of The Critically Ill Child

Mechanical Ventilation of the
Critically Ill Child:

Where do we stand in 2006?
Ronald C. Sanders Jr., M.D., M.S.
Assistant Professor, Dept. of Pediatrics
Division of Critical Care,
Shands Childrens Hospital
University of Florida
Gainesville, Florida
Outline
Physiological Concepts
Pediatric Considerations
Work of Breathing (WOB)
Indications for Ventilatory Assistance
Initial Settings for Mechanical Ventilation
Mechanical Ventilation and the Pediatric

Heart Patient
Basic Respiratory Physiology
West, JB. Respiratory Physiology. 5th Edition. 1995.
Junqueira LC et al.Basic Histology. Fifth Edition.1986.p.390.
Junqueira LC et al. Basic Histology.Fifth Edition.1986.p.395.
Alveolar Gas Equation
PAO2 = PIO2 -
PACO
PIO = (PB - PH2O) x FIO2 ; R = 0.8

2
A-a gradient = PAO2 - PaO2

( Acceptable gradient < 20 mm Hg on
room air or less than 70 on 100% O2)
West, JB. Respiratory Physiology. 5th Edition. 1995

8
Total
Lung Capacity
Functional
Residual Capacity
Vital Capacity
Liters
6
Inspiratory Reserve Volume
4
Tidal Volume
Expiratory Reserve Volume
Residual Volume
Distribution of Blood Flow

West Zones
Zone 1
PA > Pa > Pv
Zone 2
Pa> PA > Pv
Zone 3
Pa> Pv > PA
PEEP
Definition
Positive end expiratory pressure
Gattinoni L, Caironi P, Pelosi P and Goodman L. What Has CT Taught Us about

ARDS? Am J Respir Crit Care Med 2001
Pressure-Volume Relationships
Vital Capacity (%)
100
Chest wall
Lung TLC
75
50
Chest wall
and lung
25
FRC
0
At low lung volumes

reduced compliance
may be due to stiffening
of chest wall.
-40
-20
0
20
Pressure (cm H20)
40
At high lung
volumes, compliance
of the resp system
is decreased p-v
curve flattens
as it becomes fully
distended
Whenever lung volumes

falls below closing volume,
lung compliance will also
fall due to derecruitment
of functioning units
Children vs. Adults
Airway
In children, the airway is more anterior and the

epiglottis is floppy.
The airways are smaller.

Poiseulles Law states that resistance is inversely
related to the 4th power of the radius (laminar flow).
Children vs. Adults
Chest Wall
In children, the chest wall is more compliant

which limits the capacity for gas exchange.
This anatomical feature may necessitate

increased respiratory rates to maintain adequate
minute ventilation. This leads to increased
metabolic activity.
Children vs. Adults

70
Type I Muscle Fibers (%)

(slow-twitch, highly oxidative)
60
50
40
Diaphragm
Intercostal Muscle
30
20
10
Premature
Term
> 2 Years
Cote CJ, Ryan JF, Todres ID et al. A practice of anesthesia for infants
and children. 2nd ed. Philadelphia: WB Saunders, 1993.
Outline
Physiological Concepts
Pediatric Considerations 9
Work of Breathing (WOB)

Heart Patient
Respiratory System Loads

The combined effect of compliance and resistance
constitute the load experienced by the ventilator and
ventilatory muscles.
The elastic load is the pressure necessary to expand the

lungs and chest wall (i.e. volume/compliance).
The resistance load determines the pressure necessary

to deliver gas at a particular flow rate (i.e. flow x resistance)
P = Flow x Resistance
FLOW
RESISTANCE
VOLUME
COMPLIANCE
Compliance = Volume
Pressure
Volume
Pressure =
+ flow x resistance
Compliance
Total Work of Breathing

Total Work
of Breathing =
WOBT
Physiologic
Work
Elastic work to
expand lungs and
chest wall and flow
resistive work to
overcome airway
resistance
Imposed
Work
Resistive work
imposed by
breathing
apparatus (e.g.
endotracheal tube,
breathing circuit,
and ventilators
demand-flow system)
Patient and Ventilator Work

Insp
Exp
WOB P
WOB P + V
VT
WOB V
PAW
Pes
TIME
Evaluating WOB in Ventilated

Subjects
Are there differences in WOB based on

mode of ventilation?
Hypothesis: The WOBT will be
unchanged between the SV300,VIP and
the EV4 despite mode of triggering.
Methods
For WOB data, airway pressure and flow
rate were measured at the proximal end of
the ET tube using a differential flow
transducer.
Intrapleural pressure was measured using an
esophageal catheter.
The transducers and esophageal catheter
were connected to a Bicore CP-100
pulmonary monitor.
Methods
Ventilator
HME
Esophageal
Pressure
(PES )
PNEUMOTACHOGRAPH
(Measurement of VolumeandFlowrate)
0
0
0
Bicore CP-100
Volume
Flowrate
PES
WOB-Campbell Diagram
100
Elastic work
Physiologic
Work CL
Work imposed by
the breathing app.
-40
-30
50
VT
I
-20 -10
35
Intrapleural pressure (cm H20)
10
FRC
% Vital Capacity
CCW
Flow resistive work
Imposed work
Stored energy of the

chest wall

SV 300 vs VIP Bird
(Both on Pressure Triggering)
Pressure Support 5 cm H2O
1.4
1.2
**122%
*87%
1
WOBT
J/L
0.8
SV 300
Bird
0.6
0.4
0.2
0
PEEP 0
PEEP 3
cm H2O
* p=0.028
**p=0.028
Sanders RC, Thurman TL, Holt,SJ, Taft K and Heulitt MJ. Work of Breathing
Associated with Pressure Support Ventilation in Two Different Ventilators.
Pediatric Pulmonology. 32:62-70, 2001

SV 300 (Flow Trigger) vs VIP Bird (Pressure Trigger)
Pressure Support 5 cm H2O
1.4
1.2
**144%
*125%
1
WOBT
J/L
0.8
SV 300
Bird
0.6
0.4
* p=0.043
**p=0.028
0.2
0
PEEP 0
PEEP 3
To Pig
HME
To Ventilator
pneumotach
SV300
Carrier demodulators
Transducer
ZERO SPAN
CD 15
All signals collected from

the Drager Babylog 8000
were routed via the pneumotach.
Transducer
ZERO SPAN
CD 15
2 10
3 11
4 12
5 13
6 14
Digital
Analog
Analog Channels
7 15
8 16
POWER
BUSY
0
BIOPAC Systems, Inc.
MP100
UIM100A
Millennia XKU 300MHZ
SV 300
a b
c
Maximum flow
15.0000
Flow
Start of deflection of flow
pressure
Volume
Insp. Flow
5.00000
Insp. Pressure
Exp. Pressure
Pressure
Most negative deflection of pressure
Exp. Flow
17.500
18.000
0.00000
Vent signal
18.500
19.000
seconds
a- b Start of deflection of flow to most negative deflection of pressure

a - c Start of deflection of flow to maximum flow
Flow, and Pressure are signals received from pneumotach, Flow is integrated for Volume
Insp. Flow, Exp. Flow, Insp. Pressure and Exp. Pressure are signals received from the SV 300 Ventilator
Vent Signal is a signal received from the ventilator to indicate patient trigger
cm H20
10.0000
Patient and Ventilator Work

a
Insp
Exp
WOB P
WOB P + V
VT
WOB V
PAW
Pes
TIME
SV 300, Flow Trigger, Pressure Support 5, PEEP 0

84 ms
a b
235 ms
15.0000
Flow
10.0000
Insp. Flow
5.00000
cm H20
pressure
Volume
Insp. Pressure
Exp. Pressure
Pressure
-.38 cmH20
0.00000
Exp. Flow
Vent signal
17.500
18.000
18.500
seconds

19.000
delta p = .53 cmH20
Evita 4 Flow Trigger, Pressure Support 5, PEEP 0

a
139 ms
341 ms
10.0000
5.00000
Volume
Pressure
0.00000
-2.48 cmH20
1.5000
cm H20
pressure
Flow
2.0000
seconds
-5.00000
2.5000

3.0000
delta p = 3.94 cmH20
Bird (Pressure Trigger)

a
Maximum flow
~ 440 ms
Maximum pressure
10.0000
Flow
5.00000
Volume
0.00000
Most negative deflection of pressure

.0000
1.5000
2.0000
seconds
2.5000
a- b Start of deflection of pressure to most negative deflection of pressure

a - c Start of deflection of pressure to maximum flow
a - d Start of deflection of pressure to second increase in pressure
a - e Start of deflection of pressure to max pressure
-5.00000
cm H20
pressure
Start of deflection of pressure
Outline
Physiological Concepts 9
Work of Breathing (WOB) 9

Heart Patient
Indications for Mechanical

Ventilation
Ventilatory Failure
Hypoxia
Hemodynamic Instability
ICP Management
Airway protection
Slutsky AS. Consensus Conference on Mechanical Ventilation.

Intensive Care Medicine 1994
Ventilatory Failure
A
clinical diagnosis!
Apnea
PaCO2 > 60 (in patient with previous
normal lungs)
Vital capacity < 15 ml/kg
Dead space/tidal volume ratio> 0.6
Martin LD, Bratton SL. Principles and Practice of

Respiratory Support and Mechanical Ventilation. In:
Rogers MC,ed. Textbook of Pediatric Intensive Care, 1996.
Hypoxia
Cyanosis despite FiO2 > 0.6
PaO2 < 70 torr with FiO2 > 0.6
AaDO2 > 300 torr with FiO2 = 1.0

Qs/QT > 15-20%
Qs/QT = Cco2 Cao2
[Normal = 0.03 0.07]
Cco2 Cvo2
Martin LD, Bratton SL. Principles and Practice of

Respiratory Support and Mechanical Ventilation. In:
Rogers MC,ed. Textbook of Pediatric Intensive Care, 1996.
Imbalance between metabolic supply and demand.
Typically, objective measures of oxygen and

ventilation (e.g. PaCO2) are normal.
Agitation, pain, blood draws and performing

procedures places the patient in peril.
2 y.o male with 3 day

history of shortness of
breath, lethargy and
emesis.
Patient intubated due to

respiratory distress.
Determined to have poor

pulses & echocardiogram
reveals an ejection fraction
of ~ 20%.
Dilated Cardiomyopathy Case

300
7.6
7.5
250
7.4
200
7.3
150
7.2
100
7.1
Extubated
50
6.9
PaCO2
PaO2
pH
3-13-06
3-16-06
3-18-06
3-21-06

30
Base Deficit
Lactate
25
20
BNP Level
>54,000
Fluid Balance
+ 450 ml
15
10
Lasix, Bumex
Metalozone
IVF
Outline
Physiological Concepts 9
Work of Breathing (WOB) 9

Heart Patient
Recommended Criteria For

Acute Lung Injury (ALI)
Acute onset of respiratory disease with

bilateral infiltrates on a frontal chest
x-ray.
Pulmonary Artery Wedge Pressure

(PAWP) < 18 mm Hg or no clinical
evidence of left atrial hypertension
[yet may coexist]
Bernard GR et al. The American-European Consensus Conference on ARDS

Am J Respir Crit Care Med 1994.
Recommended Criteria For

ALI & ARDS
Comparison of P/F Ratios
350
300
*Oxygenation
ALI PaO2/FiO2 < 300
ARDS PaO2/FiO2 < 200
250
200
150
100
* regardless of PEEP
50
4 7 10 13 16 19 22 25 28 31 34 37 40 43
Time (Days)
Bernard GR et al. The American-European Consensus Conference on ARDS

Am J Respir Crit Care Med 1994.
Acute Lung Injury [ALI] Case

#1
BC was a 5 y.o. with history of renal transplant for

ESRD 2 to HUS who presented to an outside hospital
for evaluation of fever.
She developed
respiratory failure due
to CMV pneumonitis
that progressed to
endotracheal intubation
and conventional
mechanical ventilation
8 days later.
ALI Case #1
Her pulmonary status deteriorated further

and she required high frequency oscillatory
ventilation (HFOV).
She developed renal failure and pancreatitis.
Her ventilation support was maximized and

pulmonary hemorrhage developed.
ALI Case #1
After 5 days in the PICU, Tertiary Care Center (TCC) was

consulted for Extracorporeal Membrane Oxygenation
(ECMO). Patient did not meet criteria.
She was transferred to TCC after a 17 day stay in PICU.

Her peak inspiratory pressures were between 40 and 50 cm
H2O.
The patient required multiple fluid boluses and she

developed refractory hypoxemia and hypercarbia despite
maximum support. Care withdrawn after 46 days.
ALI Case #2
JM was a 16 y.o. WM who was involved in

a MVA at an intersection in Northwest AR
vs. an 18-wheel semi-truck.
He sustained multiple injuries including a

clavicle fx, rib fx, pneumothorax, ruptured
spleen, T2 spine fx and multiple lung
contusions.
ALI Case #2
He required splenectomy and was placed on

mechanical ventilation.
During his hospitalization, he developed multiple

pneumothoraces and pneumomediastinum
requiring several chest tubes. A tracheobronchial
tear was suspected, but never confirmed.
He accidently extubated himself on the 2nd day

and had a questionable aspiration event.
ALI Case #2
Transferred to TCC 5 days after accident for ventilation

management of Acute Respiratory Distress Syndrome
(ARDS).
In referring hospital: FIO2 100%, Positive End-Expiratory

Pressure (PEEP) 15 cm H2O and Tidal Volume (TV) of
700ml (12.5 ml/kg). Weight = 56 kg
At TCC: FIO2 100%, PEEP 17 cm H2O and TV decreased

to 350 ml (6.5 ml/kg)
ALI Case #2
Over the next 45 days, the patient eventually required 18

days of HFOV, developed neuropathy of critical illness,
frequent management of pulmonary secretions and
eventually tracheostomy.
He was successfully weaned to a tracheostomy collar and

transferred to the rehabilitation unit.
His recovery went well, the tracheostomy was reversed

and he was discharged home 4 months after the accident.
A-a Gradient Comparison
600
Alveolar-arterial oxygen gradient

(A-a gradient)
500
400
JM Mean A-a Grad

BC Mean A-a Grad
300
200
100
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43
Time (Days)
Comparison of P/F
Comparison
of Ratios
P/F Ratios
350
300
BM PF Ratios
JM PF Ratios
PaO
2 /FiO
22 Ratios
PaO
Ratios
2 / FiO
250
200
150
100
50
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43
Time (Days)
Initial Mechanical Ventilation

Settings
Objectives
Support oxygenation and ventilation
while avoiding ventilator-induced injury.
Goals
Peak Inspiratory Pressure (PIP) < 35 cm H2O
Tidal Volume (TV): 6-8 ml/kg
FIO2 < 0.55

Settings
FIO2 at 1.0 (in noncardiac patients)
Positive End-Expiratory Pressure (PEEP)
Pulse ox > 95% and PaO2 > 80 mm Hg
Start at 5 cm H2O and titrate in 2 cm H2O steps

every 5 minutes.
Inspiratory Time (I Time)
Newborn
One year to 12 years
Adolescent-Adult
0.6 second
0.7 second
1.0 second

Settings
Rate: normal for age
< 1 year
30 - 35
1-6 years
25 - 30
> 6 years
20 25
(Rates need to be lower in pts with obstructive lung
disease)
Tidal Volume: 6-8 ml/kg in patients with lung

injury
TV of 10 ml/kg is reasonable in patients without

lung injury.
Always assess for symmetrical chest sounds and
movement.
I:E ratio: 1:2
Cardiopulmonary Bypass and Respiratory

Mechanics
Induction of
anesthesia
20-30
minutes
4
hours
7
hours
Off
Bypass
Ranieri, VM et al. Time-course of impairment of respiratory mechanics
after cardiac surgery and cardiopulmonary bypass. Crit Care Med 1999;
27:1454-1460 .
HLHS Case
5 day old girl with HLHS characterized by

poor cardiac function and cyanosis.
Patient taken to the

OR for Norwood
Stage I correction
with modified Sano
technique.
HLHS & The Sano Procedure

Small Aorta
Hypoplastic
Left Heart
Sano Shunt
HLHS Case
Pre-operative
CXR
Post-operative
CXR
HLHS Case
POD #1
CXR
POD #3
CXR
Cardiopulmonary Bypass
Congenital Heart Disease
Mechanical Ventilation in the

Post-Operative Congenital Heart
What is an appropriate amount of PEEP?
Congenital Heart Disease

Pulmonary Vascular Resistance
Vascular Resistance
(cm H2O/L/min)
120
110
100
PVR is lowest at FRC!

90
80
70
60
60
100
150
175
Lung Volume (ml)
Summary
Compared to adults, infants and children have

developmental features that result in lower
respiratory reserves.
After deciding on mechanical ventilation, think of

elastic and resistive loads faced by the patient after
re-establishing homeostasis.
Always provide PEEP to maintain FRC in order to

keep alveoli recruited, PVR decreased and
volutrauma/barotrauma minimized.
Go Gators!!

Mechanical Ventilation of The Critically Ill Child

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Mechanical Ventilation of the

Critically Ill Child:

Indications for Ventilatory Assistance

Initial Settings for Mechanical Ventilation

Mechanical Ventilation and the Pediatric

Basic Respiratory Physiology

West, JB. Respiratory Physiology. 5th Edition. 1995.

Junqueira LC et al.Basic Histology. Fifth Edition.1986.p.390.

Junqueira LC et al. Basic Histology.Fifth Edition.1986.p.395.

Basic Respiratory Physiology

Alveolar Gas Equation

PIO = (PB - PH2O) x FIO2 ; R = 0.8

A-a gradient = PAO2 - PaO2

West, JB. Respiratory Physiology. 5th Edition. 1995

Basic Respiratory Physiology

Expiratory Reserve Volume

Distribution of Blood Flow

Positive end expiratory pressure

Gattinoni L, Caironi P, Pelosi P and Goodman L. What Has CT Taught Us about

Vital Capacity (%)

At low lung volumes

Whenever lung volumes

Children vs. Adults

In children, the airway is more anterior and the

The airways are smaller.

Children vs. Adults

In children, the chest wall is more compliant

This anatomical feature may necessitate

Children vs. Adults

Type I Muscle Fibers (%)

Indications for Ventilatory Assistance

Initial Settings for Mechanical Ventilation

Mechanical Ventilation and the Pediatric

Respiratory System Loads

The elastic load is the pressure necessary to expand the

The resistance load determines the pressure necessary

Total Work of Breathing

Patient and Ventilator Work

Evaluating WOB in Ventilated

Are there differences in WOB based on

Intrapleural pressure (cm H20)

Flow resistive work

Stored energy of the

Total Work of Breathing

Total Work of Breathing

All signals collected from

Most negative deflection of pressure

a- b Start of deflection of flow to most negative deflection of pressure

Patient and Ventilator Work

SV 300, Flow Trigger, Pressure Support 5, PEEP 0

a- b Start of deflection of flow to most negative deflection of pressure

delta p = .53 cmH20

Evita 4 Flow Trigger, Pressure Support 5, PEEP 0

a- b Start of deflection of flow to most negative deflection of pressure

delta p = 3.94 cmH20

Bird (Pressure Trigger)

Most negative deflection of pressure

a- b Start of deflection of pressure to most negative deflection of pressure

Start of deflection of pressure

Indications for Ventilatory Assistance

Mechanical Ventilation and the Pediatric

Indications for Mechanical

Slutsky AS. Consensus Conference on Mechanical Ventilation.