Mechanical Ventilation Strategies for Neonatal and Pediatric Patients

Invasive Ventilation Strategies

The American Thoracic Society recommends using synchronized patient-triggered modes with volume-targeting (SIMV + PSV or AC) as the preferred invasive ventilation strategy for neonatal and pediatric patients, with disease-specific adjustments based on whether the pathology is restrictive, obstructive, or mixed, escalating to high-frequency oscillatory ventilation for severe refractory hypoxemia 1
For restrictive lung disease, the European Society of Pediatric and Neonatal Intensive Care recommends initial tidal volume settings of ≤10 mL/kg ideal body weight, potentially lower (6-8 mL/kg) in severe disease or lung hypoplasia, with higher PEEP levels based on severity, and peak pressure ≤28 cmH2O 1, 2
The Society of Critical Care Medicine suggests targeting SpO2 levels of 92-97% when PEEP <10 cmH2O and 88-92% when PEEP ≥10 cmH2O, with a pH target >7.20 (accepting permissive hypercapnia) 2, 3, 4

The American Academy of Pediatrics recommends starting with High Flow Nasal Cannula (HFNC) for initial respiratory support across all disease patterns, providing heated humidified oxygen with mild PEEP effect, and escalating to CPAP if HFNC fails 1
The European Respiratory Society suggests considering non-invasive ventilation (NIV) particularly for neuromuscular patients to avoid intubation, with a preference for NIV in neuromuscular disease to prioritize non-invasive ventilation and avoid intubation 2, 6, 1

The Society of Critical Care Medicine recommends measuring PCO2 in arterial or capillary blood samples, considering transcutaneous monitoring, and measuring end-tidal CO2 in all ventilated children, with continuous SpO2 monitoring in all patients 2, 1
The American Thoracic Society suggests using cuffed endotracheal tubes with cuff pressure ≤20 cmH2O, maintaining head of bed elevated 30-45°, and using humidification for all ventilated patients 2, 1

The European Society of Pediatric and Neonatal Intensive Care recommends performing daily extubation readiness testing as soon as patient condition allows, starting weaning immediately when clinically appropriate, and using NIV in neuromuscular patients post-extubation 2, 1

The Society of Critical Care Medicine warns against volutrauma, even with volume-targeted modes, and recommends monitoring plateau pressures and maintaining ≤28 cmH2O in restrictive disease, as well as recognizing and compensating for intrinsic PEEP in obstructive disease to avoid patient-ventilator dyssynchrony and hemodynamic compromise 1, 2