What are the recommended initial ventilation settings for a 7-month-old patient with a tracheostomy (trach) who has arrested?

Ventilation Settings for a 7-Month-Old Post-Arrest Patient with Tracheostomy

For a 7-month-old who has arrested and has a tracheostomy in place, initiate mechanical ventilation with a respiratory rate of 20-30 breaths per minute (1 breath every 2-3 seconds), tidal volume of 6-8 mL/kg predicted body weight, PEEP of at least 5 cm H₂O, and FiO₂ titrated to SpO₂ 88-95%, using pressure-controlled ventilation mode with plateau pressure <30 cm H₂O. 1, 2

Immediate Post-Arrest Ventilation Strategy

Respiratory Rate

• Deliver 20-30 breaths per minute (1 breath every 2-3 seconds) during active resuscitation with an advanced airway in place. 1
• The 2024 International Consensus recommends ventilatory rates >10 breaths per minute for pediatric cardiac arrest with an advanced airway, specifically suggesting rates close to age-appropriate respiratory rates. 1
• For a 7-month-old infant, the normal respiratory rate is approximately 25-40 breaths per minute when awake, so targeting 20-30 breaths per minute during resuscitation is physiologically appropriate. 1
• Avoid the adult-derived recommendation of 10 breaths per minute, as this causes hypoventilation in infants and children. 1

Tidal Volume and Pressure Targets

• Set tidal volume at 6-8 mL/kg predicted body weight to prevent volutrauma. 2
• Maintain plateau pressure <30 cm H₂O (or <35 cm H₂O if chest wall compliance is reduced). 2
• Use pressure-controlled ventilation mode initially, as this compensates for potential air leaks around the tracheostomy tube and ensures consistent tidal volume delivery. 1

PEEP and Oxygenation

• Apply PEEP of at least 5 cm H₂O to prevent atelectasis. 2
• Titrate FiO₂ to achieve SpO₂ of 88-95% to prevent hyperoxia while ensuring adequate oxygenation. 2
• Avoid hyperoxia, as excessive oxygen can worsen neurological outcomes post-arrest. 2

CPR Quality During Resuscitation

Compression-Ventilation Coordination

• With the tracheostomy (advanced airway) in place, provide continuous chest compressions at 100-120 per minute without pausing for ventilations. 1
• Deliver ventilations asynchronously at 1 breath every 2-3 seconds (20-30 breaths per minute) during continuous compressions. 1
• This differs from the 15:2 compression-ventilation ratio used when no advanced airway is present. 1

Compression Depth and Quality

• Push hard (at least one-third of the anteroposterior diameter of the chest) and fast (100-120 per minute) with complete chest recoil. 1
• Minimize interruptions in compressions, as each interruption requires several compressions to restore coronary perfusion pressure. 1
• Change compressor every 2 minutes or sooner if fatigued. 1

Monitoring and Adjustment

Capnography

• Use waveform capnography to confirm tracheostomy tube placement and monitor ventilation adequacy. 1
• Target PETCO₂ of 30-50 mm Hg (ideally 35-40 mm Hg) once return of spontaneous circulation is achieved. 1
• A visible plateau on PETCO₂ monitoring may indicate inadequate tracheostomy tube size or ventilator settings. 1

Avoid Hyperventilation

• Avoid hyperventilation, as this reduces minute ventilation below baseline and can worsen outcomes. 1
• Hyperventilation increases intrathoracic pressure, decreases venous return, and reduces coronary perfusion pressure during CPR. 1

Tracheostomy-Specific Considerations

Equipment Setup

• Use heated humidification (temperature 26-29°C) connected to the tracheostomy with a swivel adapter. 3
• Ensure the tracheostomy tube is appropriately sized; undersized tubes increase work of breathing and may require higher ventilator settings. 1, 3
• Have a spare tracheostomy tube and Ambu bag immediately available. 1

Pressure Mode Selection

• Use pressure-controlled ventilation or pressure plateau mode to compensate for air leaks around the tracheostomy. 1
• Pressure ventilation ensures consistent lung inflation to the same tidal volume regardless of leak amount, provided the same peak inspiratory pressure is achieved. 1

Common Pitfalls to Avoid

• Do not use adult ventilation rates of 10 breaths per minute, as this causes hypoventilation in infants. 1
• Do not interrupt chest compressions for ventilations when an advanced airway (tracheostomy) is in place. 1
• Do not use BiPAP devices for life-sustaining ventilation via tracheostomy, as they provide variable continuous flow with fixed leak systems that are unreliable in critical situations. 3
• Do not forget to occlude the stoma if attempting oral airway maneuvers, as air will escape through the neck and reduce ventilation effectiveness. 1
• Do not delay securing the airway if the tracheostomy becomes dislodged; be prepared to ventilate via the upper airway with a facemask or supraglottic airway device if needed. 1

Drug Therapy During Resuscitation

• Administer epinephrine 0.01 mg/kg IV/IO (0.1 mL/kg of 0.1 mg/mL concentration) every 3-5 minutes, with maximum single dose of 1 mg. 1
• If no IV/IO access, endotracheal dose is 0.1 mg/kg (0.1 mL/kg of 1 mg/mL concentration), though this route is less preferred. 1