This document provides information about mechanical ventilation for pediatric patients. It discusses indications for mechanical ventilation, different ventilation modes, adjusting the ventilator, monitoring the patient, potential complications, weaning from ventilation, and nursing management of ventilated patients. Key points include classifications of ventilation modes, guidelines for adjusting settings based on blood gas results, monitoring oxygenation, ventilation and other vital signs, common complications like infections and injuries, and a process for gradually weaning patients off the ventilator.

1. Damanhur university.
Faculty of nursing.
Pediatric department.
20142015
Prepared by:…..
‫احمد‬ ‫الفتاح‬ ‫عبد‬ ‫مريم‬

2. Introduction
indications
goals of mechanical ventilation.
Classification of different modes of ventilation.
Adjustment on the ventilator.
Guide lines recommended.
Monitoring the ventilated patient for.
Complication of m.v .
Weaning from the ventilation.
Nursing managementof ventilated patient.
References.

3. Normal respiration :
• Exchange of oxygen ( O2 ) and carbon
dioxide (CO2) between the organism and the external
environment
:Respiratory Failure
•Inability of the pulmonary system to meet the metabolic
demands of the body through adequate gas exchange.
•Two types of respiratory failure:
Hypoxemic
Hypercarbic
•Each can be acute and chronic.
•Both can be present in the same patient.
•Management of this condition required assisted
mechanical
What dose Mechanical ventilation mean?
•“Assisted Ventilation involves the Delivery of Flow and Pressure to
the Patient’s Airway in Order to Effect Change in Lung Volume”
•A mechanical ventilator is a machine that generates controlled
flow of gas into a patient’s airway.
Mechanical ventilation is an invasive life support procedure with
many effects on the cardiopulmonary system.

4. —Is a machine that generates a controlled flow of gas into a
patient’s airways. Oxygen and air are received from cylinders
or wall outlets, the gas is pressure reduced and blended
according to the prescribed inspired oxygen tension (FiO2),
accumulated in a receptacle within the machine, and delivered
to the patient using one of many available modes of
ventilations.

5. Apnea(prolonged or repetitive unresponsive apnea associated with bradycardia
or cyanosis)
obstructive pulmonarydiseaseChronic)COPD(
Hypoxemic respiratory failure is characterized by failure of lungs to
maintain oxygenation.
Acute lung injury (includingARDS, trauma)
Acute severe asthma, requiring intubation
-(Paco2>50with partial pressure ofrespiratory acidosisAcute
55mmHg with Ph<7.25)
Hypotension includingsepsis, shock, congestive heart failure
Increased work of breathing as evidenced by significant
tachypnea,retractions, and other physicalsigns of respiratory
distress
Respiratory muscle dysfunction
Respiratory muscle fatigue
To decrease systemic or myocardial oxygen consumption.
eg. septic and cardiogenic shock.
Need for positive end expiratory pressure.
Chest wall abnormalities.
—Use of hyperventilation to reduce intracranial pressure.

6. Neuromusculardiseases(Neurologicaldiseases such as
muscular dystrophy and amyotrophic lateral sclerosis(
Left ventricle failure.
Achieve and maintain adequate pulmonary gas exchange
Minimize the risk of lung injury
Reduce patient work of breathing
Optimize patient comfort
To normalize blood gases and provide comfortable breathing
To maintain sufficient oxygenation and ventilation to ensure
rocess has resolved .tissue viability until the disease p
, and pH levels are maintained in ranges that provide2, Paco2Pao
a safe environment for the patient while protecting the lungs from
damage due to oxygen toxicity, pressure

7. Controlled:
The machine controls the patient ventilation according to set tidal
volume and respiratory rate . spontaneous respiratory effort of Pt. is
locked out , ( patient who receives sedation and paralyzing drugs he
will on controlled Mode.
:Assist / Control
In this mode all spontaneous breaths that exceed the trigger
sensitivity result in delivery of a mechanical breath synchronous to
the patients inspiratory effort.
If a patient fails to breath or cannot trigger the ventilator, a
control breath will be provided at the desired interval.
The Pt. triggers the machine with negative inspiratory effort. If the Pt.
fails to breath the machine will deliver a controlled breath at a
minimum rate and volume already set.
Synchronized Intermittent MandatoryVentilation:
(SIMV)

8. Machine allows the Pt to breath spontaneously while providing
preset FIO2 , and a number of ventilator breaths to ensure adequate
ventilation without fatigue.
A set number of mandatory breaths per minute are synchronized
with the patient initiated breaths. SIMV can be volume or pressure
controlled.
Spontaneous:
—The machine is not giving pressure breath.
—The Pt. breath spontaneously.
—The Pt. needs only specific FIO2 to maintain its normal blood
gases.
Every breath is generated by the patient, the patient determines the
rate , inspiratory and expiratory times, the breaths are triggered and
cycled by the patient but limited by the ventilator.
Mode of ventilation Control vs. SIMV
SIMV ModesControl Mode
•Vent tries to synchronize with
pt’s effort
•Every breath is supported
regardless of “trigger”
•Patient takes “own” breaths in
between (+/-PS)
•Can’t wean by decreasing rate
•Potential increased work of
breathing
•Patient may hyperventilate if
agitated

9. •Can have patient / vent
asynchrony
•Patient / vent asynchrony
possible and may need sedation
+/-paralysis
—
—The ventilator is adjusted so that the pt. is comfortable with the
machine.
—Minimal alteration of the normal cardiovascular
—and pulmonary dynamics is desired.
If the volume of ventilator is adjusted appropriately , the pt. arterial
blood level will be satisfactory and there will be no or little
cardiovascular compromise.
Adjustments
Adequate chest expansion
Adequate air entry.
Absence of retractions
Pink color
Normal BP.
Pulse oximetry: oxygen saturation 90-95% in term babies and
children
Blood gases
pa02 50-80 mmHg

10. paCo2 40-50 mmHg
pH 7.35-7.45
The changes in the ventilator settings must be made in short steps
PIP and PEEP should be altered only by 1.0 cm H2O at a time , rate
2breaths/min
FiO2 in steps of 0.05(5%) and Ti in installments of 0.05 seconds
ABG should be done after 20-30 minutes of each change.

11. set the machine to deliver the required tidal volume ( 6 to 8
ml/kg)
adjust the machine to deliver the lowest concentration of the
oxygen to maintain normal PaO2 (80 to 100mmhg).The setting
may be set high and gradually reduced based on ABGs result.
Record peak inspiratory pressure.
Set mode (assist/control or SIMV)and rate according to physician
order.
If Pt. is on assist/control mode , adjust sensitivity so that the Pt.
can trigger the ventilator with the minimum effort( usually
2mmHg negative inspiratory force)
Record minute volume and measure carbon dioxide partial
pressure PaCO2, PH after 20 minutes of mechanical ventilation.
Adjust FIO2 and rate according to results of ABG to provide
normal values or those set by the physician.
In case of sudden onset of confusion , agitation or unexplained "
bucking the ventilator " the Pt. should be assessed for hypoxemia
and manually ventilated on 100% oxygen with resuscitation bag (
AMBU bag) Bag – Valve – mask.
Patient who are on controlled ventilation and have spontaneous
respiration may " fight or buck " the ventilator, because they
cannot synchronize their own respiration with the machine cycle.

12. • Babies requiring mechanical ventilation require close
monitoring to optimize the respiratory support and limit the
potential complications of ventilator induced lung injury,
oxygen toxicity , air leaks and nosocomial infections.
• Physical examination
• Respiratory rate
• Evidence of respiratory distress
• Auscultation for equal air entry.
• Ventilator patient synchrony should be observed.
• Rapid shallow breathing and the presence of subcostal or
intercostal retractions in ventilated babies may suggest air
hunger or increased work of breathing
• CVS parameters include skin color ,HR , perfusion ,BP & urine
output.
• Monitoring oxygenation
• ABG analysis is the gold standard for monitoring the adequacy
of gas exchange
• SaO2 targets of 85-93% is the most appropriate.
• In term and near term infants and older children who are
mechanically ventilated it is acceptable to target SaO2 between
92-95 % and in children with cyanotic CHD SaO2 between 70-
75% are acceptable if tissue oxygenation is good.
• Ventilation

13. • PaCo2 determined from an ABG is a reliable measure of
ventilation
• A free flowing capillary sample is an acceptable alternative
• Capnography and trans -cutaneous CO2 detectors provide non
invasive alternatives to monitor ventilation.
• Chest radiograph:
• The findings to look for:
• Position of the ET, central lines and umbilical catheters.
• Optimal positioning for ETT is approximately 1-1.5 cm above the
carina.
• Displacement of the tube into the oesophagus is indicated by a
low ETT position.
• Poor aeration of the lungs and gaseous distension of the GI
tract
• Look for the atelectasis, flattening of the diaphragm and lung
expansion reaching the tenth rib suggests over expansion and
increased risk of pulmonary air leaks and lung injury.
. The most commonly seen clinical circumstance that produces
immediate concern involves sudden deterioration of an infant on a
ventilator. In such circumstances, the child may appear well one
moment but rapidly become cyanotic, with pallor, bradycardia,
hypotension, and hypercapnea.
Airway Injury

14. Subglottic stenosis
Pulmonary interstitial emphysema (PIE)
Pneumothorax
Pneumomediastinum
Pneumopericardium
Pneumoperitoneum
Air embolism syndrome
Decreased cardiac output
Endotracheal Tube Complications
Dislodgment
Obstruction
Accidental extubation
Airway erosion
Apnea
Infection
Feeding intolerance
Developmental delay
Hyperinflation
Intraventricular hemorrhage
(IVH)
Aspiration,
GI bleeding,
Inappropriate ventilation
respiratory acidosis or alkalosis,
Thick secretions
Anxiety and fear,
Dysrhythmias
Tracheal inflammation
Tracheobronchomalacia
Nasal septal injury
Necrotizing tracheobronchitis

15. Inability to tolerate ventilator mode
Increased Intracranial Pressure (ICP)
Hepatic congestion
Decreased Renal Perfusion
Nosocomial Pneumonia
Weaning is a process of gradual transition from mechanical to
spontaneous breathing by decreasing the support provided by the
ventilator.
• Following parameters to be considered:
• Resolution of underlying condition causing respiratory failure.
• Adequate gas exchange with minimal settings: PaO2>60mmHg
with FiO2<30-40% and PEEP <5cm H2O
• Adequate spontaneous breathing.
• Hemodynamic stability (normal cardiac function with minimal
or no inotropic support).
• Absence of major organ dysfunction.
• Normal electrolytes, adequate nutrition and normal body
temperature also facilitate successful weaning.

16. • Stepwise weaning protocols
• Oxygenation Ventilation
Determinants
PIP Tidal volume
PEEP PIP-PEEP(delta P)
Ti RATE: I:E ratio
Minute ventilation(VT*RR)
• Decrease FiO2 to 30-40% - decrease VT
• Decrease PIP,PEEP - decrease delta P(PIP)
• Decrease Ti - decrease rate
• IF CO2 retention,increase -if hypoxemia is an issue
rate,PIP,PEEP. Increase PEEP
Nursing Management:
1. Promote respiratory function.
2. Monitor for complications
3. Prevent infections.
4. Provide adequate nutrition.
5. Monitor GI bleeding.
PROMOTE RESPIRATORY FUNCTION:
1. Auscultate lungs frequently to assess for abnormal sounds.

17. 2. Suction as needed.
3. Turn and reposition every 2 hours.
4. Secure ETT properly.
5. Monitor ABG value and pulse oximetry.
Suction of an Artificial Airway:
1. To maintain a patent airway
2. To improve gas exchange.
3. To obtain tracheal aspirate specimen.
4. To prevent effect of retained secretions.
( Its important to OXYGENATE before and after suctioning
MONITOR FOR COMPLICATIONS:
1. Assess for possible early complications
Rapid electrolyte changes.
Severe alkalosis.
Hypotension secondary to change in
Cardiac output.
2. Monitor for signs of respiratory distress:
Restlessness
Apprehension
Irritability and increase HR.
—PREVENT INFECTION
1. Maintain sterile technique when suctioning.

18. 2. Monitor color, amount and consistency of sputum.
—PROVIDE ADEQUATE NUTRITION
1. Begin tube feeding as soon as it is evident the patient will
remain on the ventilator for a long time.
2. Weigh daily.
3. Monitor I&O .
—MONITOR FOR GI BLEEDING
1. Monitor bowel sounds.
Monitor gastric PH and hematest gastric secretions every shift
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http://en.wikipedia.org/wiki/Mechanical_ventilation