What are mechanical power cut-offs in pediatric mechanical ventilation?

Mechanical Power Cut-offs in Pediatric Mechanical Ventilation

In pediatric mechanical ventilation, peak inspiratory pressure (PIP) should be kept ≤28 cmH2O in patients with normal chest wall elastance and ≤29-32 cmH2O in patients with increased chest wall elastance, while plateau pressure should be maintained ≤30 cmH2O in obstructive airway disease to minimize ventilator-induced lung injury. 1

Key Mechanical Power Parameters in Pediatric Ventilation

Pressure Limits

• Peak Inspiratory Pressure (PIP):

  • ≤28 cmH2O for normal chest wall elastance
  • ≤29-32 cmH2O for increased chest wall elastance
  • ≤30 cmH2O in obstructive airway disease 1

• Driving Pressure:

  • Should be maintained ≤10 cmH2O when possible (plateau pressure - PEEP) 2
  • Critical for minimizing lung injury

• PEEP Settings:

  • 5-8 cmH2O baseline
  • Higher PEEP may be necessary based on underlying disease severity
  • Physiological data in children without lung injury suggests 3-5 cmH2O 1
  • PEEP titration should balance hemodynamics and oxygenation

Volume Parameters

• Tidal Volume:
  • Keep ≤10 mL/kg ideal body weight
  • May need to be lower in lung hypoplasia syndromes 1
  • No single optimal tidal volume has been consistently associated with mortality in children 1

Disease-Specific Considerations

Healthy Lungs

• PIP ≤28 cmH2O
• PEEP 3-5 cmH2O
• Tidal volume ≤10 mL/kg ideal body weight
• Target PCO2 35-45 mmHg
• Target SpO2 ≥95% when breathing room air 1

Restrictive Disease

• Higher PEEP may be necessary
• Consider lung recruitment maneuvers
• Maintain driving pressure ≤10 cmH2O
• Higher respiratory rates may be needed to maintain minute ventilation 1

Obstructive Airway Disease

• PIP ≤30 cmH2O
• Add PEEP when air-trapping is present to facilitate triggering
• Assessment of intrinsic PEEP and plateau pressure should guide external PEEP settings
• Longer expiratory times to prevent air trapping 1

PARDS (Pediatric Acute Respiratory Distress Syndrome)

• SpO2 targets: 92-97% when PEEP <10 cmH2O and 88-92% when PEEP ≥10 cmH2O
• Higher PCO2 may be accepted (permissive hypercapnia)
• Target pH >7.20 (normal pH for patients with pulmonary hypertension) 1

Monitoring Recommendations

Essential Monitoring Parameters

• Peak inspiratory pressure and/or plateau pressure
• Mean airway pressure
• Positive end-expiratory pressure
• Consider measuring transpulmonary pressure, dynamic compliance, and intrinsic PEEP 1

Gas Exchange Monitoring

• PCO2 in arterial or capillary blood samples
• End-tidal CO2 in all ventilated children
• SpO2 in all ventilated children
• Arterial PO2 in moderate-to-severe disease 1

Common Pitfalls and Caveats

1. Delayed Recognition of Ventilator-Induced Lung Injury:

   • Monitor for signs of barotrauma, volutrauma, and atelectrauma
   • Regular assessment of pressure-time and flow-time scalars 1

2. Inappropriate Ventilator Settings:

   • Avoid excessive tidal volumes
   • Pediatric ventilation has been poorly studied with practices often adapted from adult protocols 3
   • Compliance with delivering specific tidal volume ranges has been poor in clinical practice 4

3. Inadequate PEEP Titration:

   • General acceptance of higher FiO2 and less aggressive PEEP titration compared to adults 3
   • PEEP should be titrated based on individual patient response

4. Ventilator Asynchrony:

   • Target patient-ventilator synchrony
   • Set inspiratory time by respiratory system mechanics and underlying disease 1
   • Use time constant and observe flow-time scalar

5. Delayed Weaning:

   • Start weaning as soon as possible
   • Perform daily extubation readiness testing 1

By adhering to these mechanical power cut-offs and monitoring parameters, clinicians can optimize ventilation strategies for pediatric patients while minimizing the risk of ventilator-induced lung injury.