Mechanical Ventilation Strategies for Pediatric Patients

Introduction to Mechanical Ventilation

The Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) provides comprehensive recommendations for mechanical ventilation strategies in critically ill children, with approaches tailored to specific disease patterns and severity to optimize outcomes and minimize complications 1

High Flow Nasal Cannula (HFNC) delivers heated and humidified oxygen at flow rates exceeding patient's inspiratory flow, providing mild PEEP effect, and is appropriate for mild respiratory distress across various disease patterns 1, 2
Continuous Positive Airway Pressure (CPAP) maintains constant positive pressure throughout respiratory cycle, preventing alveolar collapse, and is useful in obstructive airway disease and as post-extubation support for patients at risk of stridor 1, 3
Non-Invasive Ventilation (NIV) is particularly beneficial for neuromuscular patients to prevent intubation and as a bridge during weaning from mechanical ventilation 1, 2

High-Frequency Oscillatory Ventilation (HFOV) delivers very small tidal volumes at rapid rates (3-15 Hz) and is considered for severe cases with refractory hypoxemia despite conventional ventilation 1, 2
Extracorporeal Life Support (ECLS) is reserved for the most severe cases with refractory hypoxemia despite optimized conventional ventilation strategies 1

For healthy lungs, tidal volume should be ≤10 mL/kg ideal body weight, PEEP 5-8 cmH2O, peak pressure ≤28 cmH2O, target SpO2 ≥95% when breathing room air, and target PCO2 35-45 mmHg 1
For restrictive disease, tidal volume should be ≤10 mL/kg ideal body weight, potentially lower in lung hypoplasia syndromes, and PEEP should be higher levels based on disease severity, with titration and consideration of lung recruitment 1, 2
For obstructive airway disease, tidal volume should be ≤10 mL/kg ideal body weight, PEEP should be added when air-trapping is present to facilitate triggering, and peak pressure should be ≤30 cmH2O 1

Cardiac patients require careful PEEP titration with hemodynamic monitoring 1, 2
Neuromuscular disease patients should consider non-invasive ventilation and cough-assist devices 1
Upper airway malacia patients should use PEEP to stent airways 1

Gas exchange should be measured by PCO2 in arterial or capillary blood samples, and consider transcutaneous CO2 monitoring 1
Oxygenation should be continuously measured by SpO2, and measure arterial PO2 in moderate-to-severe disease 1
Ventilator parameters should be monitored, including peak inspiratory pressure, plateau pressure, mean airway pressure, and PEEP 1

Weaning should start as soon as the patient's condition allows, with daily extubation readiness testing, and consider non-invasive ventilation, particularly in neuromuscular patients 1
Post-extubation support should consider non-invasive ventilation, and stridor prevention should use preventive measures in patients at increased risk for post-extubation stridor 1

Home ventilators should not be used during the acute phase in the intensive care unit 1
Hand ventilation should be avoided unless specific conditions dictate otherwise 1