Care of the ventilated child

Dr S.Shanthi MD.DCH
Professor of Pediatrics
Stanley Medical College
Chennai
Mechanical ventilation (MV) is a life saving intervention in a critically ill child. MV in
general delivers positive pressure breaths in contrast to the negative pressure ventilation in
spontaneously breathing individuals. Hence MV is associated with a number of
complications like ventilator associated lung injury, air leak syndromes and ventilator
associated pneumonia. In order to prevent or reduce these complications MV should be
initiated only if absolutely essential. Wherever possible non invasive ventilation should be
tried. Once a decision to ventilate a child is taken it is mandatory to closely monitor them.
Wean the child from the ventilator at the earliest. Do a spontaneous breathing trial daily.
Before connecting the child to the ventilator make sure the circuits are sterile if reusable
circuits are used (most are autoclavable).Disposable circuits are preferred. See if the
circuits are connected properly. Fill the humidifier with clean water up to the mark.
Connect the test lung and see if the ventilator is functioning properly. The initial ventilator
settings depend upon the underlying disease.
Set the alarms properly. For example if you set the high pressure alarm at 30 cm of water
for a child with ARDS whose PIP requirement may be high, say 40 cm of water there will
be a continuous high pressure alarm. The fraction of inspired oxygen should be brought to
a non toxic level (0.6-0.5) at the earliest based on pao2 or Spo2. Any water in the circuits
should be periodically removed as it can increase airway resistance and auto trigger.
Change filters as recommended by the manufacturer.

Monitoring:
The child on the ventilator should be monitored both clinically and technologically.
Clinical monitoring is the most important aspect in the care of the ventilated child. The
best monitor is a physician or a nurse who sits by the side of the patient . Changes in the
vital signs should immediately alert the physician and he should analyse the cause for the
change. Cardio pulmonary cerebral assessment has to be done atleast hourly for every child
on the ventilator and documented in a data chart which must be kept at the bed side. It has
to be repeated after every intervention. A ventilator chart, I/O chart,temperature chart,drug
charts ,nurses chart are other charts which should be kept at the bed side.
Cardio pulmonary cerebral assessment comprises of the airway,breathing, circulation and
disability.Based on this the physiological status is assessed . Look for adequate chest rise,
any asymmetry, air entry,any increase in work of breathing, colour ,respiratory rate(RR),
heart rate(HR), distal pulses, capillary refill time, blood pressure(BP), liverspan, Glasgow
coma scale(GCS),pupillary size, reaction, dolls eye movement in a comatose child.
Tachycardia in a ventilated child may be the earliest sign of hypoxia. The other causes are
pain,anxiety,fever,shock,drugs and tube block. Bradycardia is more ominous and is a late
sign of hypoxia . It may be secondary to vagal stimulation during suctioning, use of drugs
like digoxin , propranalol and sometimes due to heart block.
Hypotension may be secondary to hypovolemia, myocardial dysfunction,bleeding , cardiac
tamponade especially in the post op patient. It should be corrected with fluids,inotropes
blood as needed. It may be secondary to high mean airway pressure(MAP) as a result of
high peak end expiratory pressue(PEEP). These patients may need small boluses of fluid.
Tachypnea in a ventilated child may be due to fever,pain,anxiety, metabolic
acidosis,shock,tube block,pneumothorax. Tube block is the most common cause of
respiratory distress in a child on ventilator. It is identified by tachycardia, ventilator patient
asynchrony, sweating, altered level of consciousness, fall in saturation and increased
resistance while bagging. If the early signs are not detected it can progress to bradycardia
and cardiac arrest.
Asymmetric chest rise, decreased air entry and mediastinal shift can suggest pneumothorax
or collapse.
Technological monitoring:
The child should be connected to a cardiorespiratory monitor. The ECG, heart
rate(HR),respiratory rate(RR), oxygen saturation and non invasive blood pressure(NIBP)
should be monitored continuously. End tidal cabondioxide (EtCO2) monitor if available is
very useful to identify tube displacement and the ventilatory status of the patient. The trend
of the EtCO2 helps us to know if the child is developing hypercarbia.The EtCO2 is about 5
less than PaCO2.
Central venous pressure(CVP) monitoring and intra arterial blood pressure monitoring may
be needed in patients with refractory septic shock, cardiogenic shock and post operative
cardiac patients. However these require transducers and cardiac monitors with invasive
monitoring facility. Very close monitoring of the patency of the lines, strict asepsis and
close watch of the perfusion of the limb distal to the line especially the arterial line is
critical to prevent complications. Arterial lines are very useful once secured as ABG
sampling can be easily done in the critically ill child. Blood samples can be taken from
the central venous lines also.
Arterial blood gas: This is a valuable investigation to know about the oxygenation ,
ventilation and acid base status of the patient. Ideally it should be done 20 minutes after
connecting a child to the ventilator, after any change in the ventilator settings, before
weaning and extubation or if the child is deteriorating. In many centers ABG is done
atleast twice a day. However as the cost of this investigation is very high and due to non
availability of the test in many centers it may not be possible to do it often. The
combination of SpO2 and EtCO2 will reduce the need for frequent ABGs. They are also
non invasive and show a trend which will be very useful rather than a single ABG which
will only show the values at the time of sampling.
Care of the endotracheal tube(ET):
As soon as the ET is secured document the position of the tube at the lips.Orotracheal
tube is preferred .If cuffed tube is used deflate the cuff every four hours for atleast 5min.
The ET position should be checked during each shift for inadvertent movement of the
tube.Kinking, bending, patient biting the ET can all lead to decreased tidal volume. The ET
is suctioned to remove secretions as needed. X-ray is taken to confirm the position of the
tube. The lower end of the ET should be at the level of the lower border of T3 vertebra. It
is important to keep the head in the mid position while taking a X-ray to check the tube
position as flexion and extension of the neck will alter the tube position.
If a child on a ventilator deteriorates consider DOPE. Disconnect the child from
ventilator and manually ventilate. If the child improves the problem is in the equipment.
D-displacement of endotracheal tube(ET) into right.main bronchus or esophagus.
O-Obstruction secondary to secretions. Some time the ET may be kinked or the child may
bite the tube.
P-Pneumothorax-If tension pneumothorax is suspected immediately do a needle
thoracocentesis to let out the air without waiting for x-ray confirmation
E-equipment failure. Check the connections, oxygen and gas source, leak in the circuit or
improper settings.
Always keep an AMBU bag and appropriate size mask ready at the bedside of every
patient who is ventilated.
Radiological evaluation is needed after intubation, central venous catheter and gastric
tube placement to confirm tube placement. X-ray chest is needed to diagnose pneumonia,
pneumothorax , as part of sepsis workup and post extubation .Look for volume of
lungs.Hyperinflated lungs (more than 9 intercostal spaces) may indicate air trapping and
excessive tidal volume.
Nosocomial infections:
Children on ventilator can develop hospital acquired infections like ventilator associated
pneumonia(VAP), urinary tract infection, venepuncture site infection. The common
sources of infection are health care providers and equipments like nebulisers, humidifiers,
manual ventilation bag, tracheal tubes
Prevention:To prevent these infections strict hand hygiene should be followed.The most
effective method is strict hand washing before and after touching the patients. Aseptic
precautions should be followed for intubation and catheterization of the bladder. For
central venous catheter(CVC) placement asepsis as for a surgical procedure should be
followed.Placing the child in a propped up position (unless the child is hypotensive) will
prevent nosocomial pneumonia. Proper sterilization of ventilator circuits and humidifiers
can prevent ventilator associated pneumonia. Microbiological surveillance should be
carried out periodically in PICU to know about the common pathogens and their sensitivity
Microbiological evaluation: Tracheal aspirate may indicate colonization or infection. It
should be clinically correlated..Blood culture from CVC and peripheral vein have to be
taken simultaneously and cultured to find out catheter related blood stream infection.Urine
microscopy and culture are done to identify UTI. Any septic foci have to be aspirated and
sent for culture.
Physiotherapy: is an important component of management of the ventilated child. It helps
in removal of secretions, mucus plug, and prevent collapse and re-expand collapsed
segments. The various techniques employed are postural drainage,chest percussion,chest
vibration and nebulization.
Positioning of the child: The child is placed in the semi recumbent position. The position
should be changed every 4- 6 hours to prevent bed sore.
Care of the skin: The skin over the pressure points should be inspected daily for any
pressure sores. Use of water bed or alpha bed will prevent bed sores. If not available
placing water packets beneath the head and pressure points may prevent sores .
Venepuncture site should also be inspected for any extravasation or thrombophlebitis. The
skin shoud be kept dry. Diapers should be changed as soon as they are soiled.
Care of the eyes: If the child is comatose the eyes should be covered and lubricants
applied to prevent exposure keratitis. An opthalmologists opinion should be sought early.
Care of the bladder: Urinary catheter is quite often introduced in critically ill children especially
if they are in shock. Strict aseptic measures should be taken while catheterising the bladder.
Remove the catheter as early as possible to prevent urinary tract infection(UTI). Use condom
drainage if feasible in male children.
Nutrition: Most children on ventilator especially those with sepsis have a high catabolic
rate. They will lose weight very rapidly if adequate nutrition is not provided. Malnutrition
can affect the ventilated chid in many ways.
Effects of undernutrition: There will be depletion of glycogen & protein,fatigue of
respiratory muscles,impaired pulmonary function,decreased cell mediated immunity,poor
wound healing and decreased surfactant production.
Early enteral feeds are recommended. The requirements are higher;100-120kcal/kg,2-
3gm/kg proteins if PICU stay>5-7 days. Maintain Hb > 10 gms. Supplement vitamins,
trace metals. Parenteral nutrition is not used routinely and may be indicated only if there
is a recent abdominal surgery
Sedation and analgesia: are needed in most ventilated patients to facilitate ventilation.
Intermittent doses may suffice though sometimes an infusion may be needed.Morphine 10-
30 mcg/kg/hr, Midazolam 0.1-0.2 mcg/kg/min, fentanyl 1-2 mcg/kg/hr and ,ketamine are
commonly employed. Use of paracetamol and trichlorofos will reduce the need for more
potent sedatives.
Muscle relaxants are no more routinely used in PICU as prolonged use causes critical
care neuropathy. They are indicated during procedures and in head trauma and ARDS
patients in the initial hours of ventilation..Ensure adequate analgesia and amnesia
whenever muscle relaxants are used.
Care of the ventilated child needs team work. Frequent monitoring is essential. A team
comprising of dedicated doctors, nurses and paramedical people are essential to improve
the outcome of the critically ill child. It is also important to counsel the parents and the
older child to allay their anxiety.