Review

Non invasive monitoring in

mechanically ventilated
pediatric patients
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Expert Rev. Respir. Med. 8(6), 693702 (2014)

Awni M Al-Subu*,
Kyle J Rehder,
Ira M Cheifetz and
David A Turner
Department of Pediatrics, Division of
Pediatric Critical Care Medicine, Duke
Childrens Hospital, Durham, DUMC
Box 3046, Durham, NC 27710, NC,
USA
*Author for correspondence:
Tel.: +1 919 681 3550
Fax: +1 919 681 8357
For personal use only.
Cardiopulmonary monitoring is a key component in the evaluation and management of
critically ill patients. Clinicians typically rely on a combination of invasive and non-invasive
monitoring to assess cardiac output and adequacy of ventilation. Recent technological
advances have led to the introduction: of continuous non-invasive monitors that allow for
data to be obtained at the bedside of critically ill patients. These advances help to identify
hemodynamic changes and allow for interventions before complications occur. In this
manuscript, we highlight several important methods of non-invasive cardiopulmonary
monitoring, including capnography, transcutaneous monitoring, pulse oximetry, and near
infrared spectroscopy.
KEYWORDS: capnography critical care mechanical ventilation near-infrared spectroscopy neonate non-invasive

monitoring oxygenation index PaO2/fraction of inspired oxygen ratio patient safety pediatric pulse oximetry
Awni.alsubu@duke.edu
regional oxygen saturation tissue oxygenation transcutaneous VD/VT

More than 60% of patients admitted to pedi-
atric intensive care units (PICUs) require
mechanical ventilation [1], and cardiopulmo-
nary monitoring is crucial to the successful
management of these patients [2,3]. Tradition-
ally, invasive monitoring has been used to
assess cardiac output and adequacy of ventila-
tion, but invasive monitoring has the potential
for substantial risks and complications [4,5].
Recent advances have led to the introduction
of sophisticated technology that allows for reli-
able noninvasive monitoring of critically ill
patients [6]. This article will review the current
state of noninvasive cardiopulmonary monitor-
ing in the pediatric critical care environment,
including capnography, transcutaneous moni-
toring, pulse oximetry and near infrared spec-
troscopy (NIRS).
Capnography
A capnograph is a monitoring device that
measures the concentration of exhaled CO2
and may provide useful information on cardiac
and respiratory function [7]. Since its introduc-
tion 30 years ago, capnography has become
one of the most common noninvasive moni-
toring techniques in critically ill patients [8],
with recent surveys in the USA and UK
demonstrating that 95100% of surveyed
PICUs utilize capnography [9,10].
Capnography can be either time- or volume-
based. Time-based capnography displays
breath-to-breath exhaled CO2 waveforms and
estimates partial pressure of expired CO2 over
time (FIGURE 1). Volumetric capnography depicts
CO2 concentration against exhaled gas volume
for each breath (FIGURE 2) [11,12]. A single breath
CO2 waveform consists of three phases, and
changes in one or more of these phases can be
used to assess and manage mechanically venti-
lated patients [13]. Phase 1 of the waveform rep-
resents the beginning of expiration when no
CO2 is exhaled due to the anatomic deadspace
in the upper airways. After gas is expelled from
the anatomic deadspace, CO2 from the lower
airways is detected and Phase II of the waveform
begins. Finally, the alveolar plateau (Phase III)
depicts the alveolar CO2 concentration (FIGURE 2).
Capnography has multiple applications in the
management of mechanically ventilated patients
(TABLE 1). The value of capnography begins at the
time of intubation with capnography being con-
sidered the gold standard technique for immedi-
ate confirmation of endotracheal tube (ETT)
placement, both in the prehospital and hospital
settings [1416]. In a prospective study of

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2014 Informa UK Ltd ISSN 1747-6348 693

 Review Al-Subu, Rehder, Cheifetz & Turner

Inhalation Exhalation due to patient movement, improperly

A PEtCO2 B secured ETT and/or inadvertent move-
ment of the ETT [21,22]. Capnography is a
reliable method to immediately recognize
PeCO2

life-threatening ETT displacement (FIGURE 3)

and has been demonstrated as a more sen-
sitive technique than other approaches,
which include monitoring of oxygen
saturation, chest rise and hemodynamic
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Time
variables [2325].
Beyond confirmation of appropriate
Figure 1. Exhaled carbon dioxide time tracing. End-tidal CO2 is measured as the ETT placement, capnography is an impor-
peak PeCO2 prior to inhalation. Section A demonstrates a normal tracing, while section tant tool in the optimization of gas
B demonstrates significant lower airways resistance with prolonged expiratory phase. exchange and mechanical ventilatory sup-
The lack of a plateau indicates incomplete alveolar emptying and physiologic
air trapping. port. Having a capnograph at the bedside
EtCO2: End-tidal CO2; PeCO2: Exhaled CO2. provides continuous monitoring of end-
tidal CO2 (EtCO2) and can provide guid-
ance to adjust ventilator settings and opti-
345 adult patients requiring prehospital emergency intubation, mize gas exchange without the need for frequent blood sampling.
capnography demonstrated sensitivity and specificity approaching Volumetric capnography may be used to optimize gas exchange
100% as a confirmatory technique for endotracheal intubation. though the monitoring of physiological deadspace and ventila-
The authors concluded that capnography sensitivity and specific- tion/perfusion (V/Q) matching, both of which are important in
ity exceeds auscultation (sensitivity 94% and specificity 83%) in the management of patients with lung injury [26]. One strategy in
noncardiopulmonary arrest intubations [16]. In another prospec- which the volumetric capnograph may be used to optimize
For personal use only.

tive neonatal study, researchers compared the accuracy of capnog- mechanical ventilation involves the monitoring of the deadspace
raphy to traditional clinical assessment for detection of ETT to tidal volume ratio (V /V ) [26]. Under normal conditions, the
D T
placement in 55 newborns. Roberts and colleagues concluded that difference between partial pressure of carbon dioxide (PaCO )
2
sensitivity and specificity of capnography greatly exceeded clinical and EtCO is approximately 45 mm Hg due to dead space ven-
2
examination alone [17]. Thus, capnography has become the stan- tilation, and disease processes that alter deadspace ventilation
dard of care in most PICUs to confirm ETT placement [9,10]. and/or V/Q matching will result in a higher discrepancy between
After confirmation of successful placement of the ETT and invasive and noninvasive monitoring [11]. McSwain et al. studied
initiation of mechanical ventilation, maintenance of correct ETT the correlation between EtCO and PaCO in 56 mechanically
2 2
placement is a critical element of management during transport ventilated pediatric patients with variable V /V and concluded
D T
and routine care of critically ill patients. Unrecognized displace- that the correlations were strong at all V /V ranges and the
D T
ment of the ETT may lead to serious complications, including EtCO -PaCO difference increased with increasing V /V .
2 2 D T
hypoxemia, atelectasis, cardiac arrest, neurological injury and Other data demonstrate that V /V correlates with severity of
D T
death [1820]. Patient transport caries a risk of ETT displacement lung injury and can be used as an indicator of lung recruitment
and a predictor of extubation success [2730].
Almeida-Junior and colleagues studied 29 infants with acute
III severe bronchiolitis requiring mechanical ventilation and found
that VD/VT not only detected alterations in gas exchange but
was an indicator of disease severity [27]. Likewise, Arnold et al.
Anatomic
VCO2

demonstrated that VD/VT could be used to determine improve-

deadspace
II ments in gas exchange and lung compliance in 15 neonates
with severe respiratory failure supported with extracorporeal
membrane oxygenation [28]. Furthermore, Hubble et al. identi-
fied patients at risk for extubation failure by demonstrating that
I
VD/VT < 0.5 was associated with more successful extubation
Exhaled volume when compared with VD/VT > 0.65 [30]. VD/VT has also been
Figure 2. Volumetric carbon dioxide tracing for a single used to identify pulmonary embolism, monitor response to bron-
breath. Phase I demonstrates exhalation of air from the upper chodilator therapy and detect intracardiac shunts in infants with
airways, Phase II is a transitional phase demonstrating exhalation severe cyanotic congenital heart disease [3133].
of air from the lower airways, and Phase III demonstrates As exhalation of CO2 requires perfusion to the alveoli,
emptying of the alveoli. capnography can be a surrogate measure for pulmonary blood
VCO2: Volumetric CO2.
flow and, by extension, cardiac output [34]. The American Heart

694 Expert Rev. Respir. Med. 8(6), (2014)

 Non invasive monitoring in mechanically ventilated pediatric patients Review

Table 1. Characteristics, advantages and limitations of the most common noninvasive monitoring
techniques.
Function Normal Advantages Limitations
values
Capnography Measure the 3545 mmHg Confirm ETT placement and Less accurate in conditions that
concentration of monitor the integrity of the increase deadspace or V/Q
exhaled CO2 at ETT mismatch as well as in severe
the end of ETT Provide information on minute lower airway obstruction
to minute changes in alveolar secondary to gas trapping
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ventilation Limited use in high-frequency

Provide information on CPR mechanical ventilation due to
effectiveness technical issues related to breath
Minimize blood gas sampling size, CO2 dilution and ability to
obtain continuous CO2 sampling
Transcutaneous Obtain CO2 3545 mmHg Provide reliable information on Technical factors may negatively
CO2 measurement at changes in alveolar ventilation. impact TcCO2 values: trapped air
the level of the Minimize blood gas sampling bubbles, improper placement
capillary bed and/orcalibration techniques
Patient factors may negatively
impact TcCO2 value include low
cardiac output or edema
Accuracy decreases at higher
values of PaCO2
Pulse oximetry Detect arterial 92100 % Provide continuous monitoring Reduced accuracy when SaO2 is
oxygen saturation of oxygenation below 75%
For personal use only.

based on the Help detect, manage and Values maybe negatively

fluctuation of the prevent acute hypoxemia impacted by poor blood flow,
absorbed red and Reduce the need for frequent inappropriate sensor positioning,
near infrared light blood sampling excessive patient movement,
with each pigmented dyes, carbon
heartbeat monoxide poisoning and some
hemoglobinopathies
NIRS Measure regional Provide a continuous, safe and Represents a dynamic trend
tissue saturation cost-effective monitoring of change in rSO2 rather than an
in underlying tissue oxygenation and absolute tissue oxygenation value
vascular beds perfusion Values may be affected by skin
using a light with May assist in detecting life- thickness and ambient light
wavelengths threatening conditions during
(l) = 700 routine care as well as during
1000 nm transport
CO2: Carbon dioxide; ETT: Endotracheal tube; NIRS: Near infrared spectroscopy; SaO2: Oxygen saturation; TcCO2: Transcutaneous carbon dioxide; V/Q: Ventilation/
perfusion ratio.

Association resuscitation guidelines recommend the use of cap-
nography during cardiopulmonary resuscitation (CPR) as an
indicator of the effectiveness of chest compressions and return of
spontaneous circulation (FIGURE 4) [35].
Morisaki and colleagues measured EtCO2 in 30 patients who
received CPR for prehospital cardiac arrest and concluded that
EtCO2 monitoring during CPR can be used as an indicator of
chest compression efficiency [36]. Similarly, EtCO2 during CPR
may correlate with adequacy of cerebral perfusion. In a small
study of 16 piglets, Lewis et al. reported that EtCO2 during
closed-chest CPR correlated with cerebral blood flow, which par-
alleled changes in cardiac output [37]. Presence of EtCO2 has also
been reported as a predictor of survival and prognosis in patients
after cardiac arrest and resuscitation. In an adult retrospective
study of 3121 cardiac arrest events, Eckstein et al. found that
EtCO2 >10 and the absence of a fall in EtCO2 more than 25%
at the time of CPR initiation were more commonly observed in
patients who had return of spontaneous circulation [38]. While
several factors may complicate capnography readings in the set-
ting of cardiac arrest, including the etiology of the initial rhythm
and duration of arrest [39], there is a clear role for capnography
monitoring during cardiac arrest.
While potentially life-saving in some circumstances, capnogra-
phy is not without limitations. As noted above, the accuracy of
capnography depends on the combination of lung perfusion
(i.e., cardiac output) and ventilation. Any condition that leads to
increased deadspace or V/Q mismatch will decrease the correla-
tion between EtCO2 and PaCO2 as well as decrease the alveolar

informahealthcare.com 695
 Review Al-Subu, Rehder, Cheifetz & Turner

Transcutaneous CO2 monitoring

A B
In a manner similar to capnography,
transcutaneous carbon dioxide (TcCO2)
monitoring provides a continuous CO2
PeCO2

reading that is obtained at the level of

the capillary bed using a probe placed on
the skin. TcCO2 monitoring is achieved
using probes that warm the underlying
skin to induce vasodilatation and increase
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Time CO2 diffusion to capillaries, which is

then measured by the sensor (FIGURE 5) [45].
Figure 3. Normal exhaled carbon dioxide. (A) Time tracing and (B) exhaled CO2 TcCO2 has been reported as an effec-
tracing after endotracheal tube displacement. Tracing B may also be seen with tive technique to estimate PaCO2 in
esophageal intubation. intubated and extubated patients [4653].
PeCO2: Normal exhaled CO2.
It must be stressed that TcCO2 and cap-
nography are inherently different. Trans-
plateau (Phase III) in the capnography waveform [4042]. In cutaneous monitors assess the partial pressure of CO2 in the
addition, in cases of severe lower airway obstruction, an increase superficial capillaries, while capnography measures the partial
in the slope of Phase III of the waveform will indicate a prolonged pressure of CO2 in the exhaled gas. Capnography is affected by
expiratory phase and the capnograph may not accurately the degree of deadspace ventilation, while transcutaneous moni-
reflect CO2 at the alveolar level (i.e., EtCO2) secondary to gas toring is not.
trapping [9,11]. In a study of 25 toddlers and infants intubated due to respira-
Capnography also has limitations in patients on high fre- tory failure, TcCO2 monitors provided a more accurate estima-
quency mechanical ventilation (HFV) due to technical issues tion of PaCO2 than capnography [50]. Moreover, Perrin et al.
For personal use only.

related to breath size, CO2 dilution and ability to obtain continu- studied TcCO2 in 25 patients with severe asthma and/or pneu-
ous CO2 sampling [43,44]. Additionally, capnography may be lim- monia and found that TcCO2 values accurately predicted PaCO2
ited with HFV due to safety concerns related to the inability of obtained via arterial blood gases [51]. TcCO2 has been demon-
the ventilator to sense a circuit disconnect in the present of a strated to accurately reflect changes in ventilation in patients for
CO2 detector at the ETT. whom capnography is not possible, such as patients who are sup-
In summary, capnography can be considered an important ported with HFV, ventilated noninvasively and recently extu-
monitoring tool in the pediatric critical care environment bated [48,53]. In a study of 14 pediatric patients with severe
that can confirm ETT placement and monitor the integrity respiratory failure, TcCO2 monitoring provided an accurate esti-
of the ETT. This technique also provides information on mate of PaCO2 during high-frequency oscillatory ventilation [52].
minute-to-minute changes in alveolar ventilation, helping to While there are numerous potential applications, TcCO2
optimize gas exchange, mechanical ventilatory approaches monitoring is not without limitation. There are a number of
and CPR effectiveness without the need for frequent blood technical and patient-specific factors that impact TcCO2 meas-
gas sampling. urements. Technical factors that may negatively impact TcCO2
monitoring include trapped air bubbles
and improper placement and/or calibra-
tion techniques [45]. Patient factors that
ROSC
affect CO2 delivery to the skin, such as
low cardiac output or edema, may impact
PeCO2

the accuracy of TcCO2 monitoring [50]. In

CPR
addition, TcCO2 accuracy decreases at
higher values of PaCO2 as demonstrated
by Martin et al. in 14 patients [53]. Like-
wise, Berkenbosch et al. found that
Time TcCO2 monitoring becomes less accurate
with PaCO2 > 50 mmHg [52]. Despite
Figure 4. Exhaled carbon dioxide time tracing during cardiopulmonary
resuscitation.
potential limitations, TcCO2 monitoring

Signifies a fresh provider giving chest compressions, after degradation in chest allows clinicians to manage a range of criti-
compression quality by the first provider. ROSC correlates with a sudden rise in PeCO2 cally ill patients with noninvasive monitor-
caused by increased cardiac output and pulmonary blood flow. ing by providing an accurate measurement
CPR: Cardiopulmonary resuscitation; PeCO2: Exhaled CO2; ROSC: Return of spontaneous of PaCO2 when capnography is not possi-
circulation.
ble or when patients have elevated VD/VT.

696 Expert Rev. Respir. Med. 8(6), (2014)

 Non invasive monitoring in mechanically ventilated pediatric patients
Pulse oximetry
Any discussion of noninvasive monitoring would be incomplete
without a discussion of pulse oximetry. Pulse oximetry is based
on BeerLamberts law, which accounts for the difference in
absorption of the red and near infrared light between oxygen-
ated hemoglobin (Hgb) and deoxygenated Hgb, enabling one
to detect arterial oxygen saturation based on the fluctuation of
the absorbed light with each heartbeat [54,55]. Since its develop-
ment during World War II, the pulse oximeter has become a
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reference standard for care in the management of critically ill
patients [5557], often being referred to as the fifth vital
sign [58,59]. The broad implementation of pulse oximetry in the
critical care unit has led to less invasive monitoring and less
frequent blood gas sampling [6063].
Along with the clear benefits of routine monitoring of oxy-
gen saturation, pulse oximetry has a potential role in the moni-
toring of the severity of lung injury and the course of illness.
Traditionally, degree of acute lung injury (ALI) has been
described using the PaO2 to FiO2 ratio (P/F), a measurement
that requires invasive blood gas sampling. Recent studies in
children and adults support the use of a pulse oximeter derived
hemoglobin oxygen saturation/fraction of inspired oxygen ratio
(S/F) as a potential noninvasive surrogate to estimate P/F and
identify patients with severe impairment in gas exchange [63].
For personal use only.
Studies demonstrate that an S/F of 263296 and 201236 in
children and 315 and 215 in adults correlate with a P/F of
300 and 200, respectively [6365]. Similarly, S/F has been used in
adults and children to identify patients at risk of failing nonin-
vasive ventilation (NIV) and to direct timely intubation to avoid
the morbidity and mortality that may be associated with delayed
intubation [66,67]. Mayordomo-Colunga et al. studied 369 chil-
dren requiring NIV for respiratory failure and concluded that
S/F 190 obtained 1 h after NIV initiation, combined with
other respiratory distress assessment tools, should prompt the
consideration of intubation [67].
In addition, S/F has been included along with P/F in many
organ failure and trauma assessment scores, such as the Sequen-
tial Organ Failure Assessment and the Pediatric Index of
Mortality 2 [6870]. Multiple factors can affect the accuracy of
S/F, some related to factors that limit the accuracy of pulse
oximetry and others related to oxygen saturation, as oxygen
saturation 97% may decrease the S/F accuracy as the linear
correlation between PaO2 and oxygen saturation is lost [65].
Further investigation is needed to validate the use of S/F in
ALI and acute respiratory distress syndrome (ARDS) patients.
In addition, many clinicians also assess the severity of lung dis-
ease and hypoxia using the Oxygenation Index (OI), which is a
calculation of mean airway pressure (MAP) multiplied by FiO2
divided by PaO2 [OI = (MAP  FiO2)/PaO2]. OI may help
guide prognostication and may assist in ventilation strategy, but
this value also depends on invasive blood gas measurements.
Recently, pulse oximetry has been integrated as a noninvasive
method to estimate OI using the Oxygen Saturation Index
(OSI). OSI is the product of MAP multiplied by FiO2 divided
by oxygen saturation (SaO2) (OSI = [MAP  FiO2]/SaO2).
informahealthcare.com
Review
Sensor
Water
CO2
Figure 5. Transcutaneous carbon dioxide monitoring. A
bead of water is placed on the skin and heated to promote CO2
diffusion from capillaries. A sensor measures the pCO2 in the
water, estimating partial pressure of carbon dioxide.
CO2: Carbon dioxide.
A recent pediatric study showed that OSI values of 6.0, 9.9,
13.7 and 24.7 correspond to OI values of 6, 13, 20 and 40,
respectively [56]. However, extensive research is needed to better
validate the OSI and determine its clinical utility.
As with other noninvasive monitors, pulse oximetry has
limitations. Pulse oximetry performance is better when SaO2
is above 75 %, likely due to the difficulty of obtaining reli-
able human calibration data at lower SaO2 levels [71,70]. Pulse
oximetry accuracy also decreases with poor blood flow, inap-
propriate sensor positioning, excessive patient movement,
pigmented dyes, carbon monoxide poisoning and some
hemoglobinopathies [54].
Pulse oximetry is considered standard monitoring technology
and a parameter that clinicians rely on in managing critically ill
patients. Pulse oximetry provides continuous monitoring of
patients oxygenation, helps to detect, manage and prevent acute
hypoxemia, and reduces the need for frequent blood sampling.
NIRS
NIRS is a relatively new technique that uses infrared light to
continuously monitor regional tissue oxygenation via cutaneous
sensors that may be placed on various parts of the body. Using
a light with wavelengths (l) = 7001000 nm, these sensors
measure absorption in underlying vascular beds of two wave-
lengths of light, representing oxygenated and deoxygenated
Hgb in that vascular bed (FIGURE 6). As 7580% of the light
absorption is from blood contained within venous beds, NIRS
signals primarily reflect venous saturation [72]. Several studies
demonstrate that NIRS trends correlate well with mixed venous
saturations (SvO2) measured via invasive central venous cathe-
ters in the superior vena cava, and these trends can be used to
assess changes in regional tissue saturation [7375]. Just as SvO2
may be used as a marker for global oxygen delivery, NIRS can
be used to assess a patients cardiac output.
NIRS probes are routinely placed on the forehead to measure
cerebral regional saturations (rSO2) and the flank to measure
697
 Review Al-Subu, Rehder, Cheifetz & Turner
Light source
Shallow sensors
Deep senso
sensors
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Figure 6. Near-infrared spectroscopy. This schematic demon-
strates how a cerebral oximeter placed on the scalp emits a
range of wavelengths of infrared light, which penetrate to differ-
ent tissue depths. Shallow and deep sensors measure absorption
of different wavelengths, providing a regional venous saturation.
somatic (renal) rSO2. These two sites represent two opposite
poles of circulation, which can help the provider to assess condi-
tions with low cardiac output, such as cardiogenic, hemorrhagic
and septic shock [7678]. Under normal conditions, somatic rSO2
measured by NIRS is usually higher than cerebral rSO2 due to
lower oxygen extraction in the somatic circulation [76]. NIRS
For personal use only.
trends can be followed as oxygen delivery and tissue perfusion
decrease, which leads to increased vascular resistance in the
somatic circulation, shifting the blood toward more vital organs.
Hanson et al. studied the use of cerebral and somatic NIRS in
17 moderately dehydrated patients during intravenous rehydra-
tion and found that cerebral rSO2 remained unchanged during
rehydration, while the somato-cerebral rSO2 difference increased
from 5 to 13%, correlating with volume resuscitation. The
authors concluded that two-site NIRS may help in detection of
regional hypoperfusion in dehydrated children [76,79]. NIRS has
also been used as an adjunct during and after cardiac surgery to
detect and manage conditions associated with low cardiac out-
put [80,81]. Similarly, NIRS has been used as a continuous monitor
to assess the adequacy of resuscitation and optimize therapies in
adult patients with severe trauma and in those with severe septic
shock [78,82,83]. In an animal study of 60 piglets with induced brain
ischemia, Kurth and colleagues reported that brain lactate produc-
tion increased when cerebral rSO decreased below 45% [84,85].
There are a number of additional potential applications of
NIRS that have yet to be fully investigated. As NIRS is a mon-
itor of saturation, a sudden decrease should direct attention to
the patients airway, breathing and circulation. Cerebral NIRS
may also be used to identify brain hypoxia in patients with
severe brain injury. In a prospective study of 22 adult patients
with severe traumatic brain injury, Leal-Noval et al. reported
that cerebral rSO2 was able to accurately detect severe intracere-
bral hypoxemia when compared with values that were measured
by brain tissue oxygen tension catheters [8587].
Research is ongoing to evaluate the utility of abdominal NIRS
at times of concern for intestinal ischemia (e.g., necrotizing
enterocolitis in neonates) [88] and limb rSO2 to detect
698
compartment syndrome. In a study of nine adult trauma patients
with clinically confirmed compartment syndrome, NIRS values
collected at the affected extremities were significantly diminished
at time of diagnosis and normalized after fasciotomy [89]. Simi-
larly, Toledo and colleagues reported the use of extremity NIRS
to confirm the diagnosis of lower limb compartment syndrome
in a 15 year old on extracorporeal membrane oxygenation [90,91].
While there are a number of important applications in the
critical care environment, NIRS does have limitations of which
clinicians should be aware; most notably, NIRS represents a
dynamic change in rSO2 rather than an absolute tissue oxygen-
ation value. NIRS values may be affected by skin thickness and
ambient light, both of which may result in loss of light inten-
sity due to scattering and absorption [92,93].
Despite these limitations, NIRS provides a continuous, safe
and cost-effective monitoring of tissue oxygenation and perfu-
sion. This technology can help to guide therapy and may assist
in detecting life-threatening conditions during routine care as
well as during transport. Further studies are needed as the use
of NIRS is extended in the pediatric population.
Expert commentary & five-year view
Although the interest in noninvasive technology to monitor
intubated patients has vastly increased over the past two deca-
des, none of the currently available technologies alone have
been proven to be superior to others in monitoring clinical sta-
tus and improving outcomes. Clinical assessment is always nec-
essary, and invasive monitoring may be needed in many
circumstances. It is important to integrate multiple pieces of
available data, obtained both invasively and noninvasively, to
manage critically ill patients.
Capnography has become standard in most PICUs and has
numerous applications in the management of critically ill
patients. However, the utility of capnography to predict pulmo-
nary blood flow and cardiac output is still limited. Currently,
investigators at Montreal Heart Institute in Canada are investi-
gating the correlation between capnography and indexed car-
diac output in adults, as measured by thermodilution, during a
reversible fluid challenge [94].
NIRS is another important noninvasive technique in the man-
agement of critically ill patients. NIRS does not require pulsatility
and is effective during low cardiac output states (relative to pulse
oximetry) and may provide a tool for oxygenation monitoring in
patients with severe septic shock, poor peripheral perfusion,
hypothermia or patients with decreased pulsatility while being
supported with extracorporeal membrane oxygenation or left ven-
tricular assist devices. However, these applications of NIRS are in
need of additional validation and investigation [95,96].
There are also limited data that apply to the application of
NIRS in the monitoring of patients with severe traumatic brain
injury and in neonates at risk of developing necrotizing entero-
colitis. Neonatologists at University Hospital of Montpellier,
France, are currently evaluating the use of cerebro-splanchnic
oxygenation ratio for early diagnosis of necrotizing enterocolitis
in neonates with rectal bleeding and/or abdominal
Expert Rev. Respir. Med. 8(6), (2014)
 Non invasive monitoring in mechanically ventilated pediatric patients Review

distension [94]. The coming years may involve further expansion
of the application of NIRS, potentially aiding the clinician in
optimizing sedation, detecting subclinical seizures and identify-
ing acute internal organ injury.
Preliminary investigations have demonstrated the potential
benefits of noninvasive monitoring of lung injury using S/F
and OSI ratios for early recognition of patients at risk of ALI/
ARDS. However, the uses of these values remain limited in the
management of respiratory failure patients until further investi-
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carboxyhemoglobin concentrations in critically ill patients
[97,102,103]. These applications have been mostly studied under
stable conditions, but their utilization in critically ill patients
remains a source of ongoing investigation. While not widely
available in many circumstances, this technology provides a prom-
ising noninvasive monitoring technique that may help reduce
frequent blood sampling, detect low volume status and assess
fluid responsiveness in critically ill and mechanically ventilated
pediatric patients [104].

gation is completed. In summary, extensive research is still needed to continue to

Recently, upgrades and improvements had been made in pulse
oximetry technology, which include the addition of digital filters
and additional light wavelengths to reduce artifacts related to
motion and poor peripheral perfusion [97101]. These upgrades not
only optimize the accuracy of pulse oximeters, but enable these
devices to provide continuous measurement of the respiratory var-
iation in plethysmographic wave amplitude and a new parameter,
the pleth variable index [102]. Pleth variable index is a continuous,
automatic and noninvasive technology that calculates the
ventilation-induced respiratory changes in perfusion index over a
given period and has been used to predict fluid responsiveness in
mechanically ventilated patients [103,104]. Pulse oximeter waveform
analysis in this manner can provide a dynamic and noninvasive
method to predict and guide volume responsiveness during fluid
For personal use only.
validate and investigate the use of these noninvasive monitors
in critically ill children. Increased utilization of these techniques
should lead to decreasing dependence on traditional invasive
lines and monitors, minimizing potential risks and complica-
tions. We anticipate that advancement of technology will con-
tinue and the use of newer technologies will become standard
practice in the critical care setting.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with
any organization or entity with a financial interest in or financial conflict
with the subject matter or materials discussed in the manuscript. This
includes employment, consultancies, honoraria, stock ownership or options,
expert testimony, grants or patents received or pending, or royalties.

resuscitation, and measure total Hgb, methhemoglobin and No writing assistance was utilized in the production of this manuscript.

Key issues
A combination of invasive and noninvasive monitoring is necessary to assess and manage cardiac output and adequacy of ventilation in
critically ill patients.
Capnography can be used to confirm endotracheal tube placement, monitor the integrity of the ventilator circuit, monitor alveolar
ventilation and optimize gas exchange, while reducing the need for frequent blood sampling. Areas for further study include the use of
capnography during high frequency mechanical ventilation and the relationship between volumetric capnography and cardiac output.
Transcutaneous carbon dioxide monitoring can provide a reliable measurement of partial pressure of carbon dioxide and assist in the
management of critically ill patients.
Pulse oximetry provides continuous monitoring of oxygenation and helps to detect, manage and prevent acute hypoxemia. Further
studies are needed to assess the potential benefits of using S/F and OSI ratios for early recognition of patients at risk of acute lung
injury/acute respiratory distress syndrome.
Near infrared spectroscopy provides continuous and safe monitoring of both tissue oxygenation and perfusion. It may assist in detecting
life-threatening conditions during routine patient care, but additional studies are needed to validate the use of near infrared
spectroscopy in patients with necrotizing enterocolitis, sepsis and traumatic brain injury.

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