Introduction to Pediatric Ventilation

Bill Chesser, RRT Dept. of Cardiopulmonary Care Shands Hospital

Introduction to Pediatric Ventilation

History Conventional Modes Adjudicative Modes Non-Conventional Modes Wave Forms

Forrest Bird
1955 Bird Mark 7 Released. 1963 Bird Oxygen Blender Released. 1969 Baby Bird Released

Bird Mark 7 (1955)

One of the first Adult Ventilators. Pressure Cycled. Used today for IPPB. Seen in Bullitt.

Baby Bird (1969)

Decreased Infant Breathing Mortality from 70% to 10%. Time Cycled Pressure Limited. Constant Flow.

Parts of a Breath
Cycle Time: The combination of the Inspiratory and Expiratory Phase. Cycle Time = 60 Rate Rate of 10 has a cycle time of 6 seconds.

Parts of a Breath
Inspiratory Phase: The active part of the breath in which the ventilator delivers the tidal volume. Exspiratory Phase: The passive part of the breath in which the tidal volume is released. (Conventional Ventilation).

Respiratory Terms
Compliance: The ability to stretch. (Change in Volume/Change in Pressure) Elastance: The ability to recoil back to a steady state Resistance: The impeding force to flow. Resistance = (Ppeak Pplateau)/Flow. Raw=(Texpiratory/3)/Compliance.

Naming the Mode

What changes Inspiration to Exhalation? How is Tidal Volume Delivered?

Time Cycled
Inspiratory Time (TI) is set. Tidal Volume = Inspiratory Time x Inspiratory Flow. (minus resistance, compliance and gas compressibility) Inspiratory Flow may be set or variable.

Time Cycled - Pressure Limited

Inspiratory Time is set. Tidal Volume is variable. VT = TInspiratory x Inspiratory Flow. Inspiratory Flow may be set or variable. Pressure is Set, with excess flow/pressure being vented to the outside for the duration of the Inspiratory Time.

Volume Cycled
Inspiration ends upon the delivery of a set Tidal Volume. Tidal Volume is constant, Inspiratory Pressure is variable. Inspiratory Flow is set. Inspiratory Time = Tidal Volume/Inspiratory Flow x 60 (square wave only).

Volume Assured, Pressure Regulated Ventilation (VAPRV)

Known as VC+ on PB840 Inspiratory Time is set. Inspiratory Flow is variable. Target Tidal Volume is set, ventilator measures Pt compliance/resistance and calculates a PIP to reach desired VT.

Pressure Cycled
Inspiration ends and exhalation begins upon reaching a set pressure. Bird Mark 7 is the only Pressure Cycled Ventilator.

Control Ventilation
The Rate sets the cycle time. The ventilator fires at the set cycle time regardless of patient respiratory effort. The patient can not breathe between ventilator breaths. Used in Anesthesia Machines in 1950s.

Intermittent Mandatory Ventilation (IMV)

The rate sets the cycle time. The ventilator fires at set cycle time regardless of patient respiratory effort. The patient is allowed to spontaneously breath in between mandatory breaths with variable tidal volumes.

Synchronized Intermittent Mandatory Ventilation (SIMV) Rate sets the cycle Time. Just before the Mandatory Breath, the ventilator Looks for patient inspiratory effort and cycles with the patient effort. The patient is allowed to spontaneously breath in between mandatory breaths with variable tidal volumes.

Assist-Control Ventilation
Rate sets cycle time. If the patient does not initiate a breath before the cycle time, the ventilator fires. If the patient initiates a breath before the cycle time, the ventilator gives a Set tidal volume and Resets the cycle time. Tidal volume may be Volume Controlled or Time Cycled-Pressure Limited.

Airway Pressure Release Ventilation (APRV)

Downs/Stock: Crit Care Med 1987 (May) Pg459-61 Low Pressure Time of 0.6 1.2 seconds. Set High Pressure Set Low Pressure (5cmH2O or Lower). Rate Usually 8 12 breaths/minute.

Airway Pressure Release Ventilation (APRV)

Rate of 8 b/m is a cycle time of 7.5 seconds. If the Low Pressure Time is 0.6 seconds, the High Pressure Time is 6.9 seconds.

PEEPH, PEEPL and PS Pressure Relationships

PEEPH and PEEPL are specific settings

PEEPH Setting

P
PEEPL Setting

Airway Pressure Release Ventilation (APRV)

Used for severe ARDS. Eliminates CO2 due to High Elastic Recoil of Non-Compliant Lung. Improves oxygenation and ventilation by improving V/Q mismatch. Allows spontaneous breathing at any point in the ventilatory Cycle.

APRV
Ways of Choosing the High Pressure
28-35 cmH2O and work down. Mean airway pressure of conventional ventilation. Plateau pressure of conventional ventilation. PHigh and TExhalation which delivers tidal volume of 6-10 ml/Kg.

APRV Weaning
Wean FIO2 first. Wean PHigh to keep VT 6-10 ml/Kg.
As compliance improves, volume will increase with same pressure. When PHigh is at 10-15 cmH2O, return to Conventional Ventilation or CPAP.

Pressure Support
Developed to overcome increased Work of Breathing (WOB) caused by the ETT. VT should be 75% of desired mechanical VT. Having PS too high makes weaning difficult. Tracheotomy tubes have little resistance.

Pressure Support
Tidal volume is based upon patient effort and lung compliance. Inspiratory phase is terminated as percent of total flow delivered (PB840). Flow is determined by patient inspiratory effort.

High Frequency Ventilation (HFV)

Rate of above 150 breaths per minute. Good for Eliminating CO2. High Frequency Oscillatory Ventilation. High Frequency Jet Ventilation.
Requires conventional ventilator for PEEP.

High Frequency Oscillatory Ventilation (HFOV)

Amplitude Mean Airway Pressure Rate (Hz) Inspiratory Time (33%) FIO2

HFOV-Amplitude
Adjust to get good chest wiggle. Raising amplitude decreases CO2.

HFOV-Mean Airway Pressure

Set 2-5 cmH2O higher than conventional MAP. CXR to check for over distension. Increase MAP to raise PaO2.

HFOV-Rate
1 Hz = 60 cycles per second. Neonates: 10-15 Hz. Infants: 8-12 Hz. Pediatrics/Adults: 5-10 Hz.

HFOV-Rate
Both inspiration and exhalation are active. Decrease Hz to decrease PaCO2.

HFOV-Things to Know
Takes hours to see initial results. Suction as little as possible (Q12 hours). Not as effective in adult population.

How Much is Too Much?

Old School Look at the patient!
Chest movement. Breath sounds. Chest X-rays. Arterial Blood Gases.

New School
Old School + Wave Forms

Basic Pressure Waveform

No active breathing Treats lung as single unit

PIP
resistance flow

Pplat
end-inspiratory alveolar pressure

compliance tidal volume

PEEP

Waveforms
30 A B C PIP

Baseline

P aw cmH O
2

Mean Airway Pressure 1 2 3 4 5 6

Sec

-10

Typical Flow Curve

60 A B C D
INSP

. V
LPM

SEC

E 60

EXH

Detecting Auto-PEEP
120

. V
LPM

SEC

120

The transition from expiratory to inspiratory occurs without the expiratory flow returning to zero

Mandatory Breath
VT
LITERS

0.6

Expiration
0.4

Inspiration
0.2

P aw
cmH2 O -60 40 20 0 20 40 60

Flow-Volume Loop
A: Critical Opening Pressure. B: Over Distension Pressure. C: Critical Closing Pressure.
Volume C

A Pressure

The Whole Picture

What mode is best for the patient? Are we over ventilating? Should we allow permissive hypercapnia? What is the patient fluid status? Does the patient have infections?