mechanical ventilation and care of child on it

1. Care of child requiring long
term ventilation
Moderator : Mrs. Kiran Kaur
Junior Lecturer, C.O.N
PGIMS, Rohtak
Presenter :Aruna Shastri
M.Sc. 2nd year student

2. OBJECTIVES
 Incidence of continuous ventilation
 Goals of mechanical ventilation.
 Classification of different modes of ventilation.
 Adjustment on the ventilator.
 Guidelines recommended during mechanical ventilation
 Monitoring child with continuous ventilation
 Weaning from the ventilation.
 Monitoring child with non-invasive oxygen therapy.
 Complication of continuous ventilation.
 Nursing management of ventilated patient.

3. Introduction:
 Children who are long-term ventilated have been found to have a
significantly health-related poor quality of life.
 Children and young people on long-term ventilation require the most
complex care that is given outside a hospital environment and there
are significant risks involved in looking after a child on long-term
ventilation in the community.
 Competencies and training needed is also a major concern for long
term ventilation.

4. Incidence
 Significant rise in number of children on long term ventilation
- (Wallis et al 2010, Goodwin et al 2011)
 The need for long term ventilation to discharge home is an average of 7-9
months
 The number of tracheostomy ventilated children managed out of hospital is
approximately 250-275 per 10000
 1000-1300 children with complex needs dependent upon non-invasive
ventilation under specialist respiratory follow-up.
 Currently the financial cost of the hospital for recent onset complex long term
ventilation is high
-Pediatric Critical Care Clinical Reference Group (CRG)

5. Normal respiration :
Exchange of oxygen ( O2 ) and carbon dioxide (CO2) between the
lungs and the external environment

6. Difference in pediatric and adult respiratory system

7. 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 ventilation

8. Mechanical ventilation
 Mechanical ventilation can be defined as the technique
through which gas is moved toward and from the lungs
through an external device connected directly to the
patient.
 Mechanical ventilation is the medical term for artificial
ventilation where mechanical means is used to assist or
replace spontaneous breathing

9. Indication for mechanical ventilation in children
 Apnoea with respiratory arrest
 Acute respiratory acidosis with paCO2 > 50 mmHg & pH < 7.25
 Hypoxemia with PaO2 <50 mm Hg with FiO2 > 60%
 Vital capacity <2 times tidal volume
 RR> 35/min
 Acute lung injury (including ARDS, trauma)
 Obstructive diseases like Asthma
 Hypotension including sepsis, shock, CHF
 Neurological diseases such as GB syndrome.

10. Functions
 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 provide safe environment for the patient while
protecting the lungs from damage due to oxygen toxicity,
pressure.

11. Definitions
 Tidal Volume (TV): volume of each breath.
 Rate: Breaths per minute.
 Minute Ventilation (MV): total ventilation per minute. MV = TV x Rate.
 Flow: volume of gas per time.
 Compliance: the distensibility of a system. The higher the
compliance, the easier it is to inflate the lungs.
 Resistance: impediment to airflow.

12. Definitions
 PIP: Maximum pressure measured by the ventilator during inspiration.
 PEEP: Pressure present in the airways at the end of expiration.
 CPAP: Amount of pressure applied to the airway during all phases of the
respiratory cycle.
 PS: Amount of pressure applied to the airway during spontaneous inspiration
by the patient.
 I-time: Amount of time delegated to inspiration.
 SIMV: Patient breathes spontaneously between ventilator breaths. Allows
patient-ventilator synchrony, making for a more comfortable experience.

13. Types of ventilation
1. Positive pressure ventilation.
 Volume cycled
 Pressure cycled
 Time cycled
2. Negative pressure ventilation.

14. MODES
Volume cycled
Controlled Mandatory ventilation
Assist-Control Ventilation
Intermittent Mandatory Ventilation (IMV)
Synchronous Intermittent Mandatory Ventilation (SIMV)
Pressure cycled
Pressure Control Ventilation (PCV)
Pressure Support Ventilation (PSV)
PEEP (Positive End Expiratory Pressure)
CPAP (Continuous Positive Airway Pressure)
BiPAP (Bilevel Positive Airway Pressure)


15. Ventilator mode
 Volume control
 Pressure Control
 Pressure Support-CPAP
 Pressure-Regulated Volume Control

16. Volume Control
 The patient is given a specific volume of air during inspiration.
 The ventilator uses a set flow for a set period of time to deliver the
volume.
 The PIP observed is a product of the lung compliance, airway
resistance and flow rate.
 The PIP tends to be higher than during pressure control ventilation to
deliver the same volume of air.

17. Pressure Control
 Patient receives a breath at a fixed airway pressure.
 The ventilator adjusts the flow to maintain the pressure.
 Flow decreases throughout the inspiratory cycle.
 The pressure is constant throughout inspiration.
 Volume delivered depends upon the inspiratory pressure, I-time, pulmonary
compliance and airway resistance.
 The delivered volume can vary from breath-to-breath depending upon the
factors.

18. Tidal volume
Airway pressure
Minute Volume
Inspiratory Flow
VCV
Fixed
Variable
Set
Constant/Square
PCV
Variable
Fixed
Measured
Decelerating
Comparison of ‘volume-controlled’
and ‘pressure-controlled’ breaths

19. CPAP-Pressure Support
 No mandatory breaths.
 Patient sets the rate, I-time, and respiratory effort.
 CPAP performs the same function as PEEP, except that it is constant
throughout the inspiratory and expiratory cycle.
 Pressure Support (PS) helps to overcome airway resistance and
inadequate pulmonary effort and is added on top of the CPAP during
inspiration.

20. Modes of Ventilation:
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:
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.

21. Modes of Ventilation:
SIMV:
 Machine allows the Pt to breath spontaneously while providing preset
FIO2, and a number of ventilator breaths to ensure adequate
ventilation without fatigue. 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.

22. Initial Ventilator Settings
 Rate: 20-24 for infants and preschoolers16-20 for grade school kids
12-16 for adolescents.
 TV: 10-15ml/kg
 PEEP: 3-5cm H2O
 FiO2: 100%
 I-time: 0.7 sec for higher rates, 1sec for lower rates.
 PIP (for pressure control): about 24cm H2O.

23. Adjusting The Ventilator
 pCO2 too high
 pCO2 too low
 pO2 too high
 pO2 too low
 PIP too high

24. The Following Guidelines are Recommended
1. Set the machine to deliver the required tidal volume ( 6 to 8 ml/kg)
2. 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.
3. Record peak inspiratory pressure.
4. Set mode (assist/control or SIMV)and rate according to physician
order.
5. 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)

25. The Following Guidelines :are
Recommended
6. Record minute volume and measure carbon dioxide partial pressure
PaCO2, PH after 20 minutes of mechanical ventilation.
7. Adjust FIO2 and rate according to results of ABG to provide normal
values or those set by the physician.
8. 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.
9. 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.

26. Weaning Priorities
 Wean PIP to <35cm H2O
 Wean FiO2 to <40%
 Wean PEEP to <8cm H2O
 Wean PEEP, PIP, I-time, and rate towards extubating settings.

27. SEDATION & MUSCLE RELAXANTS
Midazolam
 50-150 mcg/kg IV q1-2hr PRN
 1-2 mcg/kg/min IV infusion
 <32 weeks gestation: 0.5
mcg/kg/min IV infusion
Vecuronium
 1-10 years old 0.1 mg/kg IVP;
repeat q1hour PRN; OR
 Continuous Infusion: 0.05-0.07
mg/kg/hour IV
Succinyl choline
 Loading dose
 1-2 mg/kg IV x1 dose
 3-4 mg/kg deep IM x1 dose (no
adequate IV)
 Maintenance dose
 0.3-0.6 mg/kg IV q5-10min PRN
Fentanyl
 0.5-2 mcg/kg/dose IV q1-2hr

28. Extubation Criteria
 Neurologic
 Cardiovascular
 Pulmonary

29. Neurologic
 Patient must be able to protect his airway, e.g, have cough, gag, and
swallow reflexes.
 Level of sedation should be low enough that the patient doesn’t become
apneic once the ETT is removed.
 No apnea on the ventilator.
 Must be strong enough to generate a spontaneous TV
 Being able to follow commands is preferred.

30. Cardiovascular
 Patient must be able to increase cardiac output to meet demands of
work of breathing.
 Patient should have evidence of adequate cardiac output without
being on significant inotropic support.
 Patient must be hemodynamically stable.

31. Pulmonary
 Patient should have a patent airway.
 Pulmonary compliance and resistance should be near normal.
 Patient should have normal blood gas and work-of-breathing on the
following settings:
FiO2 <40%
PEEP 3-5cm H2O
Rate: 6bpm for infants, 2bpm for toddlers, CPAP/PS for 1hr for
older children and adolescents
PS 5-8cm H2O
Spontaneous TV of 5-7ml/kg

32. ABG
 ABG analysis is the gold standard for monitoring the adequacy of gas
exchange
• SpO2 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 SpO2 between 92-95 % and in
children with cyanotic CHD SpO2 between 70 -75% are acceptable if
tissue oxygenation is good.

34. Respiratory Disturbances
 Acute respiratory acidosis occurs when CO2 is retained acutely.
 Chronic respiratory acidosis occurs when the retained CO2 gets
buffered by renal retention of HCO3.
 The pH is higher than in acute respiratory acidosis, but it is still <7.4.

35. 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.

36. Tube securing/ fixation of ET tube

38. ET SUCTIONING
Indications for ET suctioning
 Presence of visible secretions in the tube
 Drop in oxygen saturation
 High pressure ventilator alarm
 Increase in respiratory rate and decrease in tidal volume.
 Suctioning is a PRN procedure

39. Post extubation management
 Close monitoring
 Every patient should be oxygenated post-extubation.
 Oxygenation and airway clearance
 This may include suctioning, bronchodilator therapy, diuresis, or
Noninvasive positive pressure ventilation (NPPV)
 Devices that provide adequate oxygenation and comfort for the patient
are preferred – low flow devices

40. Complications
Pulmonary
Barotrauma
Ventilator-induced lung injury
Nosocomial pneumonia
Tracheal stenosis
Tracheomalacia
Pneumothorax
Cardiac
Myocardial ischemia
Reduced cardiac output
Gastrointestinal
Ileus
Hemorrhage
Pneumoperiteneum
Renal
Fluid retention
Nutritional
Malnutrition
Overfeeding

41. Troubleshooting mechanical ventilation
DOPE
 D – DISPLACEMENT OF TUBE.
 O – OBSTRUCTION OF TUBE.
 P – PNEUMOTHORAX
 E – EQUIPMENT FAILURE

42. Care of child on ventilator is a
Team approach include
Physician
Nursing staff
Physiotherapist
Respiratory physiotherapist(available in some
selected tertiary centre )

43.  Bundle is a structured way of improving the
processes of care and patient outcomes.
 A small straightforward set of evidence –based
practices-generally 3-5 that performed collectively
and reliably, have been proven to improve patients
outcomes,

44.  Bundle can be used to ensure the delivery of
minimum standard care.
 Used as a audit tool to assess the delivery of
interventions.
 Most utilized bundle is sepsis care bundle
worldwide.

45. VAP BUNDLE
SEPSIS CARE BUNDLE
CENTRAL LINE CARE BUNDLE

46. HOB ELEVATION
PEPTIC ULCER
PROPHYLAXIS
DAILY SEDATION &
VACATION& READY
TO EXTUBATE
DVT PROPHYLAXIS
DAILY ORAL CARE
VAP
BUNDL
E

47. MONITOR LACTATE LEVEL
OBTAIN BLOOD CULTURES PRIOR
TO ADMINISTRATION OF
ANTIBIOTICS
ADMINISTER 30ML/KG
CRYSTALLOID FOR
HYPOTENSION OR LACTATE
>4MMOL/L
ADMINISTER BROAD
SPECTRUM ANTIBIOTICS
SEPSIS CARE
BUNDLE
3-HOUR
RESUSCITATIO
N BUNDLE

48. APPLY VASOPRESSORS
FOR HYPOTENSION
MEASURE CVP
REMEASURE LACTATE LEVEL
SEPSIS CARE
BUNDLE
6-HOUR
RESUSCITATION
BUNDLE

49. CENTRAL LINE CARE BUNDLE
HAND HYGIENE
OPTIMAL
CATHETER CARE
SITE SELECTION
MAXIMAL BARRIER
PRECAUTION
UPON INSERTION
DAILY REVIEW
OF LINE
CHLORHEXIDINE
SKIN ANTISEPSIS

50. Nursing Management of Ventilated Patient
1) Promote respiratory function.
2) Monitor for complications
3) Prevent infections.
4) Provide adequate nutrition.
5) Monitor GI bleeding.

51. 1. Promote respiratory function
 Auscultate lungs frequently to assess for abnormal sounds.
 Suction as needed.
 Turn and reposition every 2 hours.
 Secure ETT properly.
 Monitor ABG value and pulse oximetry.

52. Mobilize
the
secretions
Prevent
pneumonia
Reduce
hospital
stay

53. 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)

54. 2. 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.

55. Monitor for complications
3. assess for signs and symptoms of barotrauma(rupture of the lungs)
increasing dyspnea.
 Agitation.
 Decrease or absent breath sounds.
 Tracheal deviation away from affected side.
 Decreasing pao2 level .
4. Assess for cardiovascular depression: hypotension tachycardia and
bradycardia dysrhythmias.

56. 3. Prevent infection
1. Maintain sterile technique when suctioning.
2. Monitor color, amount and consistency of sputum.
4. 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. 3. Monitor I&O .
5. MONITOR FOR GI BLEEDING
1. Monitor bowel sounds.
2. Monitor gastric PH and hematest gastric secretions every shift.

57.  ORAL CARE:
a) Tooth brushing twice a day
b) Chlorhexidine rinse twice a day
Munro CL, et al.(2006) found CHX significantly reduced VAP
(24.4% vs. 52.4%, p=0.0093) compared with tooth
brushing alone

58.  EYE CARE:
a) Ventilated patient is often sedated & Increase the risk
of(muscle relaxed)
1. Exposure keratitis
2. Corneal ulceration
3. Infection
TT. Passive closure of eyelid, use lubricants, (artificial tear.
Prevention: eye packing, lubricating ointments and artificial
tears, antibiotics eye drops)

59.  SKIN CARE:
• Apply lotion to skin
• Prevent from decubitus ulcer formation
• Change position frequently
• Skin care to be given, massaging to be done to increase
circulation
 Moisturizers
 Skin disinfectants(cause skin necrosis, blistering, burns)
 Povidone-iodine proved better than 70% isopropyl alcohol
in pediatric patient.

60. NURSING DIAGNOSIS:-
1. Ineffective airway clearance R/T ET obstruction
* Suctioning sos
* Watch for Resp. Distress, agitation or alteration in LOC .
* Auscultate chest
* Monitor Pao2 & saturation
* Ensure that inspired air is adequately humidified

61. NURSING DIAGNOSIS:-
2. Breathing pattern – ineffective R/T ventilator malfunction,
inappropriate ventilator support.
- Monitor patients color, responsiveness (LOC), Clinical
appearance.
- Asses patency & position of ET
- Ensure the chest expands equally & bilaterally
- Verify ventilator variables hourly.
- Check connections of all tubing's hourly
- Alarms should be active all times
- Monitor PIP ( PIP  Pneumothorax)

62. NURSING DIAGNOSIS:-
 3. Altered cardiac output R/T hypoxia
* Monitor for adequate perfusion
* Assess tube position & patency
* Support CV function with fluids or with inotropic.
* Monitor fluid balance daily (+ve or –ve balance)
 4. Alteration in nutrition less than body requirements R/T
chronic Immobility.
I.V,TPN, Plan calories & protein.

63. NURSING DIAGNOSIS:-
5. a) Restlessness R/T hypoxia
* Watch for pink lips & mucous membranes
* Watch for bilateral chest expansion.
* Watch for signs of hypoxia - PR, RR, alteration in systemic
perfusion deterioration in LOC, Sao2, Pao2
- Nasal flaring,  Pul. Congestion, breath sounds.
- Check ventilator settings every hour.
b) Restlessness due to constant stimulation
- Provide comfortable bed & position
- Allow for undisturbed sleep times
- Reduce overhead lighting.
- Minimize Environmental Noise.

64. NURSING DIAGNOSIS:-
 6. Potential for impaired gas exchange R/T Atelectasis.
* Auscultate breath sounds hrly
* Check adequate PEEP is provided
* Monitor for resp. distress
* Give 100% O2 before suctioning
* Change position every 2nd hrly.
* Monitor regularly with chest x-ray & arterial blood gas.
* Chest Physio hrly – cuffing, vibration

65. NURSING DIAGNOSIS:-
7. Potential for hypoxia R/T pul edema or damage to alveolar
surface caused by barotraumas.
* Fluid restriction
* Monitor Sao2, capillary refill, Pao2.
* Auscultate lung every hour.
8. Potential for fluid vol excess R/T  levels of ADH secretion
during ventilation at high peak or end exp. Pressure
* Monitor I/O Chart
* See + ve or –ve balance
* Calculate Fluid requirement daily & administer.
* Auscultate breath sounds for evidence of pul edema.
* Aminister diuretics as ordered.
* Monitor electrolyte balance

66. NURSING DIAGNOSIS:-
9. Potential for infection R/T
a. bypass of normal body defense mechanism (upper airway)
b. Break in aseptic technique during intubation & suctioning
c. Repeated traumatic suctioning
d. Compromise in nutritional status
e. Underlying pulmonary disease
* Assess for fever, leukocytosis (WBC) Respiration distress Quantity or
change in
consistency of secretions, pulmonary congestion by auscultation, & on chest
x-ray.
* Follow meticulous hand washing.
* Aseptic technique during suctioning, intubation & change in ventilator
circuit.
* Monitor for WBC, platelet count for infection.

67. NURSING DIAGNOSIS:-
10. Potential for difficulty in weaning R/T failure of resolution of pul
disease or due to nutritional compromise.
* Monitor clinical appearance throughout.
* Change only one parameter at a time.
* Assisted ventilation should be ready during resp. distress

68. Conclusion
 Monitoring to optimize the respiratory support and limit the potential
complications of ventilator induced lung injury, oxygen toxicity , air leaks
and nosocomial infections.
 In acute intensive care units, more than one-fourth of patients with
invasive ventilation required prolonged ventilation. Babies requiring
mechanical ventilation require close observation

69. REFERENCES
 Smeltzer SC, Bare BG. Textbook of Medical Surgical Nursing 9th ed. USA :Lippincott William &
Wilkins, 2000: 503-13
 Paul L.Marino.The ICU Book 3rd ed.India: . Wolters Kluwer (India) Pvt Ltd/Lippincott Williams
and Wilkins, 2009
 http://en.wikipedia.org/wiki/Mechanical_ventilation
 Display&type=bookPage&d http://www.expertconsu
 kPage&search=none s0160%3Bfrom%3Dprev%3Btype%3Dboo
 http://www.respiratoryupdate.com/members/Indications_for_Neonatal_Mechanical_Ventil