Neo/Peds test 3

What are the three basic goals of pediatric mechanical ventilation?

Safety, comfort, and liberation from mechanical ventilation.

What are the three safety goals of mechanical ventilation?

Ensure adequate gas exchange, provide lung protection, and minimize atelectrauma and volutrauma.

What is the comfort goal of mechanical ventilation?

Maximize patient-ventilator synchrony and meet the patient's work-of-breathing demand.

What is the liberation goal of mechanical ventilation?

Minimize ventilation duration and reduce risks associated with prolonged ventilation.

What is conventional mechanical ventilation (CMV) in pediatrics?

Ventilation using modes that provide 150 or fewer breaths/min.

What is high-frequency ventilation (HFV)?

Mechanical ventilation providing more than 150 breaths/min.

What is the main difference between low-frequency and high-frequency ventilation?

Low-frequency uses normal rates/volumes; high-frequency uses very rapid rates with much smaller volumes.

When is HFOV generally used in pediatric patients?

As a rescue therapy when conventional mechanical ventilation is failing.

When is HFJV commonly used?

During and after cardiac surgery.

What should be done before initiating mechanical ventilation?

Assess patient, identify general goal, determine specific objective, and formulate clinical aim.

What is the most popular initial ventilation mode for pediatric patients in these slides?

SIMV-PRVC.

What should determine the initial ventilator mode in a pediatric patient?

The patient's clinical condition and the specific goal/objective of ventilation.

What is the equation for minute ventilation?

V̇E = RR × VT.

If PaCO₂ is too high, what ventilator variable is generally manipulated first?

Minute ventilation, usually by increasing respiratory rate and/or tidal volume.

What is the major cause of ventilator-induced lung injury?

Lung overdistention caused by volutrauma, followed by atelectrauma.

Why is avoiding excessive tidal volume particularly important during pediatric ventilation?

It prevents overdistention and volutrauma, reducing ventilator-induced lung injury.

What is the formula for calculating desired FiO₂?

Desired FiO₂ = desired PaO₂ × (current FiO₂ ÷ current PaO₂).

What happens to PaO₂ when mean airway pressure (mPaw) is increased?

PaO₂ generally increases as mean airway pressure increases.

What is considered the safest way to increase mean airway pressure?

Increasing PEEP.

Besides PEEP, what ventilator factors can affect mean airway pressure?

Flow and inspiratory time.

What is the purpose of PEEP during pediatric mechanical ventilation?

To increase mean airway pressure, improve oxygenation, and maintain alveolar recruitment.

What should be monitored during low-frequency mechanical ventilation?

Airway pressure, flow, respiratory frequency, tidal volume, and minute volume.

What is the purpose of esophageal pressure monitoring?

Provides information about pressures affecting the respiratory system and assesses mechanics.

What is weaning from mechanical ventilation?

Gradual process of discontinuing ventilation as the patient resumes spontaneous breathing.

What PEEP level is considered acceptable for weaning?

PEEP < 8 cm H₂O.

What peak pressure is considered acceptable for weaning?

Peak pressure < 25 cm H₂O.

What FiO₂ is considered acceptable for weaning?

FiO₂ < 0.50.

What spontaneous breathing capability is needed for weaning?

Ability to breathe spontaneously while maintaining a clinically acceptable PaCO₂.

What are three basic weaning techniques used in neonates and pediatric patients?

CPAP, SIMV, and PSV.

What is an extubation readiness test (ERT)?

An assessment determining whether a patient is ready for extubation.

What is a spontaneous breathing trial (SBT)?

A trial reducing ventilator support to test if the patient can breathe independently.

What should you assess if a mechanically ventilated pediatric patient suddenly deteriorates?

Vital signs, ventilator alarms, chest-wall movement, and overall clinical status.

What are important strategies for minimizing complications of mechanical ventilation?

Proper positioning, HOB elevation, early mobilization, lung protection, and minimizing duration.

What is permissive hypercapnia?

Controlled PaCO₂ increase to avoid high pressures/volumes when prioritizing lung protection.

What advanced therapies may be used in pediatric respiratory failure?

HFV, inhaled nitric oxide, corticosteroids, prone positioning, permissive hypercapnia, and ECMO.

What does it mean that modern ventilators are increasingly becoming "partial support"?

They assist the patient's spontaneous breathing rather than completely controlling ventilation.

A ventilated child has a rising PaCO₂. What primary ventilator variable should you evaluate?

Minute ventilation (V̇E = RR × VT). Increasing it eliminates more CO₂.

A child has worsening oxygenation despite adequate FiO₂. How can mean airway pressure be improved?

Increase PEEP, which is the safest method to raise mean airway pressure.

A pediatric patient receives excessive tidal volumes causing lung overdistention. What injury is this?

Volutrauma.

A ventilated child has collapsed/repeatedly derecruiting alveoli. What type of injury is associated?

Atelectrauma.

Do FiO₂ 0.40, PEEP 6, peak pressure 22, and good spontaneous PaCO₂ meet weaning criteria?

Yes. All values fall within acceptable ranges.

Is a child with PEEP of 10 cm H₂O and FiO₂ of 0.60 ready for weaning?

No. Both PEEP and FiO₂ exceed acceptable thresholds.

Why is patient-ventilator synchrony important in pediatric mechanical ventilation?

It improves comfort and matches ventilator assistance to the patient's respiratory demand.

What is the overall principle when selecting pediatric ventilator settings?

Match patient size, disease, and gas-exchange goals while minimizing ventilator-induced injury.

What is noninvasive ventilation (NIV)?

Respiratory assistance that does not require an indwelling artificial airway.

What are the two main objectives of NIV?

Decrease work of breathing (WOB) and improve respiratory gas exchange.

What should be assessed before starting NIV in a child?

The child's age, pattern of respiratory dysfunction, clinical setting, and ventilatory demand.

What should be assessed immediately after initiating NIV?

Determine whether WOB has decreased and whether gas exchange has improved sufficiently.

What are the primary clinical objectives of CPAP?

Increase end-expiratory lung volume/FRC and improve oxygenation.

How does NIV differ from CPAP in its effect on ventilation?

NIV provides inspiratory pressure support to improve tidal volume and alveolar ventilation.

What is FRC, and why is it important during pediatric NIV/CPAP?

Functional residual capacity air after normal expiration; increasing it improves alveolar recruitment.

Why can both NIV and CPAP be useful in children with restrictive lung disorders?

Restrictive disorders reduce FRC and cause hypoxemia; both restore end-expiratory volume.

When is NIV particularly useful in chronic respiratory disease?

In children with chronic hypoventilation disorders.

What is HFNC's primary advantage compared with mask-based NIV?

Provides respiratory support while avoiding relative discomfort of a mask interface.

What effect does HFNC have on FRC and airway patency?

HFNC can increase FRC and help maintain airway patency.

In infants with bronchiolitis, how much airway pressure does HFNC generate per 1 L/min increase in flow?

Approximately 0.45 cm H₂O per 1 L/min.

What is one clinical benefit associated with HFNC in infants with bronchiolitis?

Reduced intubation rates.

What pediatric conditions are commonly treated with NIV?

Acute respiratory distress, chronic respiratory failure, obstructive sleep apnea, and morbid obesity.

How may NIV be used in chronic respiratory failure?

As both rescue therapy and long-term therapy.

What is an alternative use of NIV in children with obstructive sleep apnea or morbid obesity?

NIV may be used as an alternative to nasal CPAP.

What does EPAP stand for?

Expiratory positive airway pressure.

What does IPAP stand for?

Inspiratory positive airway pressure.

What does IPAP primarily provide during bilevel NIV?

Inspiratory pressure support, increasing tidal volume and reducing WOB.

What does EPAP primarily help accomplish?

Maintains airway/alveolar patency, improves oxygenation, and prevents obstructive apnea.

What are the common NIV modes listed in the presentation?

CPAP, spontaneous, timed, and spontaneous/timed (S/T).

Which bilevel mode is typical for pediatric patients?

Spontaneous/timed (S/T).

Why is minimizing mask leaks important during NIV?

A significant leak can prevent reaching target inspiratory pressure.

What happens to the inspiratory pressure target when there is a significant mask leak?

The target pressure may never be reached.

What IPAP range is typically sufficient in day-to-day pediatric practice?

Approximately 8-12 cm H₂O.

What IPAP level may be poorly tolerated by children younger than 12 years without sedation?

Pressures above 20 cm H₂O.

What EPAP range is effective for improving oxygenation and preventing obstructive apnea?

Approximately 6-8 cm H₂O.

What EPAP level is poorly tolerated by many children?

Above 10 cm H₂O.

A child on NIV has persistent hypoxemia. Which pressure primarily affects oxygenation?

EPAP, by increasing end-expiratory lung volume and alveolar recruitment.

A child on bilevel NIV has inadequate ventilation and high PaCO₂. Which pressure should be evaluated?

IPAP, because increasing inspiratory support increases tidal volume and ventilation.

A child on NIV has a large mask leak and is not reaching set IPAP. What should be addressed first?

Correct the mask/interface leak.

What is NAVA?

Neurally Adjusted Ventilatory Assist; pressure is proportional to patient effort.

What signal does NAVA use to control ventilation?

Electrical activity of the diaphragm, measured using a specialized NG tube.

What three aspects of ventilation are controlled using the diaphragmatic electrical signal in NAVA?

Triggering, cycling, and pressure control.

What is an advantage of volume-control NIV for some pediatric patients?

Performs better with neuromuscular weakness or central hypoventilation struggling to trigger bilevel.

Why may volume-cycled NIV require a larger tidal volume than normal?

The delivered tidal volume must compensate for dead space in conducting airways.

Approximately how large should the delivered tidal volume be in volume-cycled NIV?

Approximately twice the child's physiologic tidal volume.

What are limitations of volume-control NIV devices?

Size, limited portability, and limited high inspiratory flow capacity.

How does negative-pressure ventilation work?

Subatmospheric pressure around chest wall causes inspiration; expiration occurs upon return to atmospheric.

What are two examples of negative-pressure ventilators?

Cuirass and tank/iron lung.

In what pediatric condition can negative-pressure ventilation be effective?

Hypoventilation.

What are common NIV interfaces for pediatric patients?

Nasal masks, nasal-oral masks, nasal plugs, nasal pillows, and helmets.

What is the major goal when selecting an NIV interface?

Optimize effectiveness and comfort while minimizing leaks and complications.

Why is proper interface fit particularly important in pediatric NIV?

Poor fit causes leaks, inadequate pressure, discomfort, and skin injury.

What should be monitored during pediatric NIV?

SaO₂, ABGs, work of breathing, hemodynamics, and mental status.

Why is monitoring work of breathing important after starting NIV?

Persistent or worsening WOB indicates inadequate support or NIV failure.

What clinical finding would suggest NIV is not adequately supporting a child?

Persistent/increasing WOB or inadequate improvement in gas exchange.

What facial complications can occur with chronic pediatric NIV?

Midface and jaw growth changes, facial flattening, and mandibular retraction.

What skin complications can occur with NIV interfaces?

Skin irritation and skin necrosis.

What nasal complications can occur with NIV?

Nasal dryness, discomfort, and epistaxis.

What eye complication can occur from NIV?

Eye irritation from air leaks around the interface.

Why can chronic NIV affect facial development in children?

Prolonged interface pressure alters midface/jaw growth and causes mandibular retraction.

What is the only absolute contraindication to a trial of NIV in acute respiratory distress?

Cardiovascular instability.

What are relative contraindications to pediatric NIV?

Nasopharyngeal obstruction, massive hemoptysis, poor secretion clearance, and extreme agitation.

Why can profuse oral secretions make NIV inappropriate?

Inability to clear secretions increases risk of airway obstruction and aspiration.

Why can extreme agitation or anxiety interfere with NIV?

The child may be unable to tolerate or cooperate with the interface.