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Can you help me in mechanical ventilation in paediatrics
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"mechanical ventilation" AND "pediatric" AND "children"
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Mechanical Ventilation in Paediatrics
1. Why Children Are Different
Children are NOT small adults. Several physiologic and anatomic differences drive a distinct approach:
Physiologic differences:
- Higher metabolic rate → increased O2 consumption → rapid desaturation even after brief apnea
- Small functional residual capacity (FRC) → reduced O2 reservoir
- Tachypnea is the primary compensatory response to most respiratory insults
- Larger extracellular fluid compartment → faster onset and shorter duration of RSI drugs, often requiring higher mg/kg doses
- Below SpO2 90%, desaturation is particularly steep and rapid
Anatomic differences (most prominent in infants, transition toward adult by age 8):
| Anatomy | Implication | Management |
|---|---|---|
| Large head/occiput | Neck flexion occludes airway | Shoulder roll in infants |
| Large tongue | Upper airway obstruction when sedated | Jaw thrust, oral airway |
| Anterior, cephalad larynx | Difficult visualisation | Straight blade preferred |
| Omega-shaped epiglottis | Floppy, difficult to lift | Straight blade to directly lift |
| Narrow subglottis (cricoid) | Smallest airway diameter | ETT size critical |
| Short trachea | Risk of right main-stem intubation | Confirm depth carefully |
Surgical cricothyrotomy is contraindicated <10 years (membrane too small). Use needle cricothyrotomy as the rescue subglottic airway in this age group.
- Tintinalli's Emergency Medicine, p. 754
2. Bag-Mask Ventilation (BMV)
BMV is the cornerstone of paediatric resuscitation - arguably the most important skill to master.
Key points:
- Most children can be bag-ventilated with good technique even with partial obstruction
- Common errors: excessive rate, pressure, and volume
- A "paediatric" self-inflating bag holds ~500 mL - but a 20 kg child needs only ~160 mL (8 mL/kg). Squeeze only enough for visible chest rise
- Gastric insufflation is a significant complication, worsened by younger age - place an OG/NG tube early
E-C clamp technique is the standard hand position. Use two-person BMV when seal is difficult.
Initial ventilation parameters (Tintinalli's):
| Weight (kg) | Tidal Volume (mL/kg) | Rate (breaths/min) |
|---|---|---|
| 3-9 kg | 6-8 | 20-25 |
| 10-18 kg | 6-8 | 15-25 |
| 19-36 kg | 6-8 | 12-20 |
3. Non-Invasive Ventilation (NIV)
| Method | Indications | Common Settings |
|---|---|---|
| Standard nasal cannula | Mild hypoxemia, apneic oxygenation | 0.5-4 L/min (up to 5-15 L/min for apneic oxygenation) |
| High-flow nasal cannula (HFNC) | Bronchiolitis, mild-moderate WOB increase, status asthmaticus | 1-2 L/kg/min |
| CPAP | Upper airway obstruction, status asthmaticus, moderate-severe WOB | 5-8 cmH2O |
| BiPAP | Neuromuscular disease, respiratory distress not improved with CPAP | IPAP 8-15 cmH2O / EPAP 4-8 cmH2O |
Note: Keep FiO2 as low as possible with NIV to avoid masking hypoventilation. Use with caution in high aspiration risk.
4. Endotracheal Intubation
ETT Size (Barash Clinical Anesthesia / Tintinalli's)
| Age | Uncuffed ID (mm) | Cuffed ID (mm) | Depth at gums |
|---|---|---|---|
| Preterm <1500g | 2.5 | - | 6-7 cm |
| Preterm >1500g | 3.0 | - | 7-9 cm |
| Term | 3.5 | 3.0 | 9-10 cm |
| 0-6 months | 4.0 | 3.5 | - |
| 1-2 years | - | Age/4 + 3 | - |
| >2 years | Age/4 + 4 | Age/4 + 3.5 | Height(cm)/10 + 5 |
Formula quick reference (>2 years):
- Uncuffed = (Age/4) + 4
- Cuffed = (Age/4) + 3.5
- Depth = (Age/2) + 12 cm (oral) or weight(kg)/2 + 10
Blade selection: Straight (Miller) blade preferred in infants and young children. Curved (Macintosh) from ~age 5-6 onwards.
Rapid Sequence Intubation (RSI) in Children
The approach follows adult RSI principles but with weight-based dosing. Key points:
- Pre-oxygenate aggressively - apnea time is shorter than adults
- Have BMV ready at all times
- Use a length-based tape (e.g., Broselow) to estimate weight and drug doses
5. Ventilator Settings After Intubation
Initial Settings
| Parameter | Recommendation |
|---|---|
| Tidal Volume | 6-8 mL/kg predicted body weight |
| Rate | Age-appropriate (see BMV table above) |
| PEEP | 5-8 cmH2O (starting point) |
| FiO2 | Titrate to SpO2 92-97% |
| Peak Inspiratory Pressure | Aim <28-30 cmH2O |
Mode of Ventilation
- Pressure-Control Ventilation (PCV) has historically been preferred in paediatrics to avoid barotrauma and overcome circuit compliance issues in small patients
- Modern anesthesia/ICU ventilators can deliver accurate Volume-Control down to 15-20 mL, making volume-targeted ventilation feasible even in infants
- For neonates and premature infants, dedicated neonatal ICU ventilators are used
6. Paediatric ARDS (PARDS) - The PALICC Definition & Management
PALICC Definition (2015)
- Lung injury within 7 days of known clinical insult
- Excludes neonatal perinatal lung disease
- Hypoxemia not explained by cardiac failure/fluid overload
- New infiltrates on chest X-ray
Severity stratification by Oxygenation Index (OI) or Oxygen Saturation Index (OSI):
| Severity | OI | OSI |
|---|---|---|
| Mild | 4 ≤ OI < 8 | 5 ≤ OSI < 7.5 |
| Moderate | 8 ≤ OI < 16 | 7.5 ≤ OSI < 12.3 |
| Severe | OI ≥ 16 | OSI ≥ 12.3 |
OI formula: OI = (FiO2 × MAP × 100) / PaO2
OSI formula: OSI = (FiO2 × MAP × 100) / SpO2
PARDS Management Strategy (PALICC Guidelines)
- Tidal volume restriction - target 5-8 mL/kg (physiologic range for age/weight)
- Higher PEEP - 10-15 cmH2O for severe PARDS; may need >15 in selected patients; monitor haemodynamics
- Permissive hypoxaemia - tolerate relative hypoxemia as long as systemic O2 delivery is maintained
- Permissive hypercapnia - tolerate mild hypercarbia to reduce stretch injury from high pressures
- Lung-protective ventilation - prioritize avoiding volutrauma and barotrauma
Using PEEP settings lower than those recommended by the ARDS Network Protocol is associated with increased mortality in PARDS (Khemani et al.)
- Miller's Anesthesia, 10e, p. 11341
PARDS Adjuncts (insufficient evidence for routine use)
- Inhaled nitric oxide - use if documented pulmonary hypertension or right heart dysfunction (evidence of possible harm otherwise)
- Prone positioning
- HFOV - rescue therapy only (adult trials OSCAR/OSCILLATE were negative/harmful)
- ECMO - rescue; institution-dependent
- Corticosteroids, surfactant, neuromuscular blockade - insufficient data
7. Weaning and Extubation
- Daily Spontaneous Breathing Trials (SBTs) are the most effective weaning strategy
- In RESTORE trial analysis: 43% of children with lower respiratory tract disease passed their first extubation readiness test; of those who passed, 66% were extubated within 10 hours
- Protocol-driven SBTs can be safely performed by respiratory therapy staff
- Computerised ventilation protocols are increasingly used in PICUs to reduce variability
- Balance: avoid too little support (patient struggles, fatigue) vs. too much support (diaphragmatic atrophy)
8. Capnography in Paediatrics
- Sidestream capnography is preferred in infants/neonates (avoids added dead space)
- Mainstream capnography is avoided in small patients as the sensor is heavy and increases dead space at the ETT
- Accurate even in neonates with small tidal volumes when specialised adapters are used
Recent Evidence
A 2024 systematic review in JAMA Network Open (PMID 39110460) found that daily sedation interruption vs. continuous sedation in mechanically ventilated children remains an area of active investigation - outcomes are comparable to adults but paediatric-specific data are still limited.
The 2025 European Consensus Guidelines on RDS management (PMID 41802129) provide updated neonatal ventilation guidance.
Quick Reference Summary
| Topic | Key Point |
|---|---|
| Desaturation | Rapid in children - pre-oxygenate aggressively |
| BMV | Most important skill; 6-8 mL/kg, chest rise only |
| ETT uncuffed >2y | Age/4 + 4 |
| ETT cuffed >2y | Age/4 + 3.5 |
| Criocothyrotomy | Contraindicated <10y; use needle cricothyrotomy |
| TV setting | 6-8 mL/kg (healthy), 5-8 mL/kg (PARDS) |
| PARDS PEEP | 10-15 cmH2O for severe |
| Weaning | Daily SBTs |
Would you like me to go deeper on any specific aspect - such as PARDS management, RSI drug dosing, neonatal ventilation, ventilator modes (PCV vs VCV), or weaning protocols?
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