What are the guidelines for mechanical ventilation in patients less than 1 year of age?

Mechanical Ventilation Guidelines for Patients Less Than 1 Year of Age

Mechanical ventilation in infants under 1 year of age should follow the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) recommendations, with tidal volumes kept ≤10 mL/kg ideal body weight and potentially lower in lung hypoplasia syndromes to optimize mortality and morbidity outcomes. 1

Ventilator Mode Selection

• Initial ventilator settings:

  • For most acute conditions, use conventional mechanical ventilation
  • Consider high-frequency oscillatory ventilation (HFOV) when conventional ventilation fails 1
  • Do not use high-frequency jet ventilation in obstructive airway disease 1
  • Do not use extracorporeal life support (ECLS) as first-line therapy 1
  • Consider ECLS in reversible disease if conventional ventilation and HFOV fail 1

• Non-invasive support options:

  • Consider CPAP or NIV in mild-to-moderate disease, not severe disease 1
  • High-flow nasal cannula (HFNC) may be considered in mild-to-moderate cardiorespiratory failure 1
  • Do not delay intubation if non-invasive support is failing 1

Ventilator Settings

Pressure and Volume Parameters

• Peak inspiratory pressure:

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

• Driving pressure:

  • Keep ≤10 cmH₂O for healthy lungs 1, 2
  • Optimal values for specific disease conditions are not well established 1

• Tidal volume:

  • Keep ≤10 mL/kg ideal body weight
  • Consider lower volumes in lung hypoplasia syndromes 1

• PEEP:

  • Start with 5-8 cmH₂O
  • Higher PEEP may be necessary based on underlying disease severity (including cardiac patients)
  • Use PEEP titration and consider lung recruitment (also in cardiac patients)
  • Add PEEP in obstructive airway disease when there is air-trapping and to facilitate triggering
  • Use PEEP to stent upper airways in cases of malacia 1

Respiratory Rate and Timing

• Respiratory rate:

  • Set based on underlying disease
  • Use higher rates in restrictive disease 1

• Inspiratory time:

  • Set according to respiratory system mechanics and underlying disease
  • Use time constant and observe flow-time scalar 1

• Patient-ventilator synchrony:

  • Target synchrony between patient and ventilator 1

Monitoring Parameters

• Gas exchange:

  • Measure PCO₂ in arterial or capillary blood samples
  • Consider transcutaneous CO₂ monitoring
  • Measure end-tidal CO₂ in all ventilated infants
  • Measure SpO₂ in all ventilated infants
  • Measure arterial PO₂ in moderate-to-severe disease 1

• Acid-base status:

  • Measure pH, lactate, and central venous saturation in moderate-to-severe disease
  • Use central venous saturation as marker for cardiac output 1

• Ventilator mechanics:

  • Measure peak inspiratory pressure and/or plateau pressure
  • Monitor mean airway pressure and PEEP
  • Consider measuring transpulmonary pressure, dynamic compliance, and intrinsic PEEP
  • Monitor pressure-time and flow-time scalars 1
  • For infants <10 kg, measure pressures near the Y-piece of patient circuit 1

Oxygenation and Ventilation Targets

• Oxygenation targets:

  • SpO₂ ≥95% when breathing room air for healthy lungs
  • For any disease condition or cardiac patients: keep SpO₂ ≤97%
  • For PARDS (Pediatric Acute Respiratory Distress Syndrome):
    • SpO₂ 92-97% when PEEP <10 cmH₂O
    • SpO₂ 88-92% when PEEP ≥10 cmH₂O 1

• Ventilation targets:

  • PCO₂ 35-45 mmHg for healthy lungs
  • Higher PCO₂ acceptable for acute pulmonary and non-pulmonary patients unless specific diseases dictate otherwise
  • Target pH >7.20 (maintain normal pH for patients with pulmonary hypertension) 1

Weaning and Extubation

• Weaning strategy:

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

• Special considerations:

  • Consider non-invasive ventilation in neuromuscular patients
  • Use corticosteroids in patients at increased risk for post-extubation stridor 1

Supportive Measures

• Humidification:

  • Use humidification for all ventilated infants 1

• Endotracheal tube management:

  • Use cuffed endotracheal tube, keep cuff pressure ≤20 cmH₂O
  • Minimize dead space by added components
  • Use double-limb circuits for invasive ventilation 1

• Positioning:

  • Maintain head of bed elevated 30-45° 1, 2

• Suctioning and secretion management:

  • Do not perform endotracheal suctioning routinely, only on indication
  • No routine instillation of isotonic saline prior to suctioning
  • Do not use chest physiotherapy routinely
  • Consider using cough-assist devices in neuromuscular patients 1

• Miscellaneous:

  • Do not use home ventilators during the acute phase in the intensive care unit
  • Avoid hand ventilation unless specific conditions dictate otherwise 1

Disease-Specific Considerations

• Healthy lungs vs. disease states:
  • Ventilation strategies should be adapted based on whether the infant has healthy lungs, restrictive disease, obstructive airway disease, or mixed disease 1
  • Cardiac patients, patients with congenital or chronic disease, and patients with lung hypoplasia syndromes require specific considerations 1

Common Pitfalls and Caveats

1. Delayed recognition of ventilator-induced lung injury: Monitor for signs of barotrauma, volutrauma, and oxygen toxicity.

2. Inadequate sedation: Ensure appropriate sedation to maintain patient-ventilator synchrony.

3. Inappropriate ventilator settings: Avoid excessive tidal volumes and pressures that can cause lung injury.

4. Delayed weaning: Begin weaning as soon as the patient's condition allows to prevent ventilator dependence.

5. Failure to recognize auto-PEEP: Particularly important in obstructive airway disease.

6. Inadequate humidification: Can lead to thickened secretions and airway obstruction.

7. Improper positioning: Failure to maintain head elevation can increase risk of ventilator-associated pneumonia.

8. Inappropriate PEEP: Too low can cause atelectasis, too high can impair cardiac output.