What is the appropriate volume control mode setting on a mechanical ventilator for a 10-year-old child weighing 20 kg?

Appropriate Volume Control Mode Settings for a 10-Year-Old Child Weighing 20 kg

For a 10-year-old child weighing 20 kg, the appropriate volume control mode settings should include a tidal volume of ≤10 mL/kg ideal body weight (approximately 200 mL), PEEP of 5-8 cmH2O, peak inspiratory pressure ≤30 cmH2O, and respiratory rate adjusted based on the underlying condition. 1

Initial Ventilator Settings

• Mode: Volume control mode with a tidal volume of ≤10 mL/kg ideal body weight (approximately 200 mL) 1
• Tidal Volume: Target physiologic tidal volume and avoid exceeding 10 mL/kg ideal body weight (200 mL for a 20 kg child) 1
• PEEP: Start with 5-8 cmH2O, adjusting based on underlying disease severity 1
• Peak Inspiratory Pressure: Keep ≤30 cmH2O to prevent ventilator-induced lung injury 1
• Inspiratory Time/I:E Ratio: Set based on respiratory system mechanics and disease trajectory 1

Respiratory Rate Considerations

• Adjust respiratory rate based on the underlying condition 1:
  • For restrictive lung disease: Use higher respiratory rates to compensate for lower tidal volumes 1
  • For obstructive airway disease: Use lower respiratory rates to allow for complete exhalation 2
• Target patient-ventilator synchrony to improve comfort and reduce work of breathing 1

Monitoring Parameters

• Measure peak inspiratory pressure, plateau pressure, mean airway pressure, and PEEP 1
• Monitor pressure-time and flow-time scalars to assess for air trapping and patient-ventilator synchrony 1
• Measure PCO2 in arterial or capillary blood samples 1
• Measure SpO2 continuously in all ventilated children 1
• Consider measuring end-tidal CO2 1

Oxygenation and Ventilation Targets

• For healthy lungs: Target SpO2 ≥95% when breathing room air 1
• For disease conditions: Keep SpO2 ≤97% 1
• For PARDS (Pediatric Acute Respiratory Distress Syndrome): Target SpO2 92-97% when PEEP <10 cmH2O and 88-92% when PEEP ≥10 cmH2O 1
• PCO2 targets: 35-45 mmHg for healthy lungs; higher PCO2 may be accepted for acute conditions 1
• Target pH >7.20 1

Flow Pattern Considerations

• Consider using a decelerating flow waveform rather than a square flow waveform, as it may provide better oxygenation at lower peak inspiratory pressures 3
• Observe flow-time scalar to set appropriate inspiratory time 1

Common Pitfalls to Avoid

• Using actual body weight instead of ideal body weight for tidal volume calculations, which can lead to excessive tidal volumes, especially in overweight children 4
• Setting inadequate PEEP, which can lead to atelectasis 1
• Using excessively high respiratory rates that don't allow complete exhalation in obstructive conditions 2
• Failing to monitor for patient-ventilator asynchrony 1
• Setting inappropriate trigger sensitivity that can increase work of breathing 5

Special Considerations

• For obstructive airway disease: Consider adding additional PEEP when there is air-trapping to facilitate triggering 1, 2
• For restrictive disease: Higher respiratory rates may be necessary to maintain minute ventilation 1
• For children with trachea- and/or bronchomalacia: Consider using higher PEEP to stabilize airways 1
• For severe disease requiring high ventilator settings: Consider controlled mechanical ventilation rather than allowing spontaneous breathing 1