Ventilator Settings for Pediatric Patients

Initial Ventilator Settings

The appropriate initial ventilator settings for a 10-year-old child weighing 20 kg 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, as recommended by the Intensive Care Medicine guidelines 1, 2
The American Thoracic Society recommends targeting physiologic tidal volume and avoiding exceeding 10 mL/kg ideal body weight (200 mL for a 20 kg child) 2
The initial PEEP setting should be 5-8 cmH2O, adjusting based on underlying disease severity, according to the Intensive Care Medicine guidelines 1, 2
The peak inspiratory pressure should be kept ≤30 cmH2O to prevent ventilator-induced lung injury, as recommended by the Intensive Care Medicine guidelines 1
The inspiratory time/I:E ratio should be set based on respiratory system mechanics and disease trajectory, according to the Intensive Care Medicine guidelines 2

The respiratory rate should be adjusted based on the underlying condition, with higher respiratory rates used for restrictive lung disease and lower respiratory rates used for obstructive airway disease, as recommended by the Intensive Care Medicine guidelines 2
For restrictive lung disease, higher respiratory rates should be used to compensate for lower tidal volumes, according to the Intensive Care Medicine guidelines 2
Target patient-ventilator synchrony to improve comfort and reduce work of breathing, as recommended by the Intensive Care Medicine guidelines 2

The Intensive Care Medicine guidelines recommend measuring peak inspiratory pressure, plateau pressure, mean airway pressure, and PEEP 1
Pressure-time and flow-time scalars should be monitored to assess for air trapping and patient-ventilator synchrony, according to the Intensive Care Medicine guidelines 1
PCO2 should be measured in arterial or capillary blood samples, as recommended by the Intensive Care Medicine guidelines 1
SpO2 should be measured continuously in all ventilated children, according to the Intensive Care Medicine guidelines 1
End-tidal CO2 should be considered for measurement, as recommended by the Intensive Care Medicine guidelines 1

For healthy lungs, the target SpO2 should be ≥95% when breathing room air, according to the Intensive Care Medicine guidelines 1
For disease conditions, the target SpO2 should be ≤97%, as recommended by the Intensive Care Medicine guidelines 1
For PARDS (Pediatric Acute Respiratory Distress Syndrome), the target SpO2 should be 92-97% when PEEP <10 cmH2O and 88-92% when PEEP ≥10 cmH2O, according to the Intensive Care Medicine guidelines 1
PCO2 targets should be 35-45 mmHg for healthy lungs, with higher PCO2 accepted for acute conditions, as recommended by the Intensive Care Medicine guidelines 1
The target pH should be >7.20, according to the Intensive Care Medicine guidelines 1

Inadequate PEEP setting can lead to atelectasis, as warned by the Intensive Care Medicine guidelines 1, 2
Excessively high respiratory rates can lead to incomplete exhalation in obstructive conditions, according to the Intensive Care Medicine guidelines 3
Failing to monitor for patient-ventilator asynchrony can lead to increased work of breathing, as warned by the Intensive Care Medicine guidelines 1, 2

For obstructive airway disease, additional PEEP may be necessary to facilitate triggering, as recommended by the Intensive Care Medicine guidelines 1
For restrictive disease, higher respiratory rates may be necessary to maintain minute ventilation, according to the Intensive Care Medicine guidelines 2
For children with trachea- and/or bronchomalacia, higher PEEP may be necessary to stabilize airways, as recommended by the Intensive Care Medicine guidelines 2
For severe disease requiring high ventilator settings, controlled mechanical ventilation may be considered instead of allowing spontaneous breathing, according to the Intensive Care Medicine guidelines 2

The American Thoracic Society recommends setting inspiratory time and flow based on respiratory system mechanics using the time constant (compliance × resistance), and prioritizing patient-ventilator synchrony over specific flow pattern selection 4, 5
The 2017 Paediatric Mechanical Ventilation Consensus Conference suggests that inspiratory time and respiratory rate must be set in relation to respiratory system mechanics and disease trajectory—these parameters are closely correlated and cannot be judged independently 4, 5
The use of the time constant (τ = compliance × resistance) of the respiratory system as the primary guide for setting inspiratory time is recommended 4, 5

For restrictive lung disease, higher respiratory rates may be used to compensate for low tidal volumes and maintain minute ventilation, and shorter inspiratory times may be appropriate given reduced compliance 4, 5
For obstructive airway disease, ensuring adequate expiratory time to prevent air-trapping, monitoring for intrinsic PEEP development, and using lower respiratory rates with longer expiratory times are recommended 4, 5

The consensus guidelines recommend monitoring flow-time scalars continuously to assess for air trapping and optimize patient-ventilator synchrony 4, 5
Limiting plateau pressure ≤28 cmH2O (or ≤29-32 cmH2O if chest wall elastance is increased) and keeping tidal volume ≤10 mL/kg ideal body weight are recommended 4, 5, 6, 7
Targeting physiologic tidal volumes and maintaining patient-ventilator synchrony are also recommended 5, 6, 7