Mechanical Ventilation: Pediatric Volume

Mode (Respiratory Therapy)

ALERT
Match the ventilator settings with the challenges of ventilating the child to provide
optimal oxygenation and ventilation and minimize the harmful effects of positive
pressure in smaller lungs.

OVERVIEW
Conventional modes of mechanical ventilation provide positive pressure ventilation (PPV) to
improve oxygenation and ventilation, prevent cardiovascular failure, manage intracranial
pressure, protect the airways, and improve oxygen delivery to the tissues. PPV can be used
as temporary therapy until the child’s condition no longer warrants support or as long-term
therapy in children with chronic conditions requiring mechanical ventilation. 4

To perform this procedure, the respiratory therapist (RT) must be competent in pediatric
advanced life support and must be able to identify indications for an artificial airway and
other adjuncts used to support ventilation.2

The RT must also know this information:

• Lung volumes and capacities
• Differences in lung volumes for infants and children
• Interface between volume and pressure for the thorax, lungs, and chest wall for adults
and infants
• Physiologic concepts of lung mechanics that interface with the ventilator
• How and when to make ventilator adjustments to improve oxygenation and ventilation

The RT should also understand these facts about PPV:

• Positive pressure ventilators raise the mean airway pressure above intrapleural
pressure, thus reversing the intrathoracic pressure dynamics from spontaneous
breathing.3
• Normal glottis closure at end exhalation is prevented by an endotracheal (ET) tube;
therefore, a minimal amount of positive end-expiratory pressure (PEEP) (approximately
5 cm)3 maintains physiologic functional residual capacity (FRC) in children.
o In children with pulmonary disease, PEEP is adjusted according to underlying
pathophysiology.4
o One goal for the use of PEEP is to reduce the fraction of inspired oxygen (FIO2) to
maintain an adequate arterial pressure of arterial oxygen (PaO2) range.
• Common modes of ventilation include assist control, synchronized intermittent
mechanical ventilation (SIMV), and pressure support.
• The potential complications with mechanical ventilation include decreased cardiac output
and increased intracranial pressure.
• Mechanical ventilators can be used in a volume or pressure mode as well as hybrid
variations that combine aspects of both modes.

Lung protective strategies for a child on PPV include low tidal volume (VT) (6 ml/kg or range
of 5 to 7 ml/kg)4 controlled plateau pressure of 30 mm Hg or less, and early and aggressive
PEEP.1 Recommended strategies to improve oxygenation use FIO2 and PEEP (Table 1).1 An
open-lung model with a stepwise progression of PEEP to recruit atelectatic lung segments in
children with restrictive lung disease, such as acute lung injury, is suggested.

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Mechanical Ventilation: Pediatric Volume
Mode (Respiratory Therapy)
Table 1 Improvement of Oxygenation with Fraction of Inspired Oxygen and
Positive End-Expiratory Pressure
FIO2 0.3 0.4 0.4 0.5 0.5 0.6 0.6 0.7
PEEP 5 5 8 8 10 10 12 12

FIO2 0.7 0.8 0.8 0.9 0.9 1.0 1.0 1.0

PEEP 14 14 16 16 18 20 22 24
FIO2, fraction of inspired oxygen; PEEP, positive end-expiratory pressure
Oxygenation goal: Arterial partial pressure of oxygen (PaO2) 55-80 mm Hg or peripheral oxygen saturation (SpO2)
88%-95%. Use incremental fraction of inspired oxygen/positive end-expiratory pressure (FIO2/PEEP) combinations
to achieve goal. (Adapted from National Institutes of Health [NIH], National Heart, Lung, and Blood Institute
[NHLBI], ARDS Clinical Network. [n.d.]. Mechanical ventilation protocol summary. Retrieved August 20, 2019, from
http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf)

PEEP is based on the child’s disease process. For children undergoing ventilation for general
physiologic support, a minimal PEEP of 5 mm Hg is considered adequate to replicate FRC.3,4
At high levels of PEEP, which increase mean airway pressure, the VT can be reduced for lung
protection in many cases.

EDUCATION
• Provide individualized, developmentally appropriate education to the family based on the
desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Explain the reasons for and the purpose and risks of PPV therapy.
• Discuss sensory information, including the sounds of the ventilator, the sensation of lung
inflation, and coughing.
• Provide the family with descriptions and explanations of the equipment alarms.
• Explain that medications, including local anesthetics, sedatives, and pain medications
will be used to minimize the child’s pain and anxiety during the procedure.
• Discuss relaxation methods that can be incorporated into the child’s care, including
reading to him or her, providing quiet distractions, and facilitating rest.
• Identify a method of communication between the child and family and the authorized
practitioners.
• Provide assurance that the family can be present and involved in the child’s care.
• Discuss the need for suctioning of the ET tube at regular intervals and the expected
coughing sensation.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment
1. Perform hand hygiene before patient contact.
2. Introduce yourself to the child and family.
3. Verify the correct child using two identifiers.
4. If able, assess the child’s developmental level and ability to interact.
5. Assess the family’s understanding of the reasons for and the risks and benefits of
conventional modes of mechanical ventilation.
6. Assess the child’s vital signs.
7. Assess the child for signs and symptoms of ventilatory failure, including increased arterial
partial pressure of carbon dioxide (PaCO2) and symptoms of hypercarbia, such as respiratory
acidosis, decreased mental status, tachycardia, hypertension, and dilated pupils.

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Mechanical Ventilation: Pediatric Volume
Mode (Respiratory Therapy)
8. Assess the child for signs and symptoms of hypoxemia, including decreased arterial
oxygen saturation, pale or cyanotic color, tachycardia or bradycardia, tachypnea, agitation
or decreased mental status, and increased work of breathing.
9. Assess the child’s cardiovascular stability.

Preparation
1. Ensure that all necessary equipment and supplies have been collected and that the
equipment is working properly.
2. Ensure that a manual ventilation bag, a mask, and suction are immediately available and
connected at the child’s bedside.

PROCEDURE
1. Perform hand hygiene and don gloves, gown, mask, and eye protection as indicated.
2. Verify the correct child using two identifiers.
3. Explain the procedure to the family and ensure that they agree to treatment.
4. Ensure that end-tidal carbon dioxide (ETCO2) and peripheral oxygen saturation (SpO2)
monitoring are in place, if indicated.
5. Select the mode of ventilation.

Rationale: The choice of mode must be individualized to the child.

6. Set the initial VT; observe chest excursion and auscultate lung sounds to ensure that the
child has adequate aeration.

Rationale: The VT is individualized to the child and disease state.

7. Set the cycle mechanism (volume, time, or flow). Children with hypoxemia may benefit
from a longer controlled inspiratory time, and the time-cycled mode may be preferred over
the flow- or volume-cycled mode.3

Rationale: The cycle mechanism is individualized to the child and the

capabilities of the ventilator and determines when inspiration terminates.

8. Set the ventilator rate.

a. An initial rate setting should be based on age and the size of the neonate, infant, or child.
b. The rate may be adjusted on the basis of PaCO2 with the assumption that the VT is held
constant.
c. Initially, VT can be estimated. For complete control, the calculated rate is used.

New rate = PaCO2 (child)  (set)

Desired PaCO2

d. For spontaneous breathing, a lower rate is chosen and then adjusted based on the PaCO2.
e. When permissive hypercapnia is desired for lung protection, pH (rather than PaCO2) drives
changes in the rate.3

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Mechanical Ventilation: Pediatric Volume
Mode (Respiratory Therapy)
Rationale: The rate is set to achieve appropriate minute ventilation, where
minute ventilation = VT × respiratory rate. The rate setting depends on how
much mandatory ventilation is desired.

9. Set the inspiratory:expiratory (I:E) ratio; typically, it is 1:2.1

a. In children with restrictive lung disease, a longer inspiratory time may be beneficial.
b. In children with obstructive disease, a longer expiratory time may be necessary. 3

Rationale: Inspiratory time influences oxygenation, and expiratory time

influences ventilation.

10. Select the PEEP.

Rationale: The PEEP is based on the child’s lung function and disease process.

Do not interrupt the ventilator circuit (e.g., during suctioning) for

children on higher levels of PEEP; doing so may cause a significant
loss of FRC.

11. Adjust the trigger sensitivity to reduce the effort the child must make to access flow
from the circuit.

a. For a child who has just started mechanical ventilation, adjust the sensitivity to provide
complete comfort and rest.
b. The ventilator is triggered when either a pressure sensor or a flow sensor recognizes the
child’s effort.

12. Tailor the flow rate and pattern to meet the child’s needs. The circuit may provide
continuous flow or demand flow.
13. Set the appropriate alarms and limits.

Rationale: High- and low-pressure alarms, inspiratory time, and VT limits are
always set, and the values are based on the cycling mechanism chosen. Low-
pressure alarms are used to detect disconnection in the system. High-
pressure alarms are used for notification of increased pressure in the system.

In the volume-controlled mode, the child’s lung compliance may

cause variable PIP. Set the high-pressure alarm per the
organization’s practice above the child’s PIP to protect the lungs from
sudden changes in resistance or compliance.

14. Set the pressure-support ventilation (PSV), if required. With the initiation of PSV,
consider comfort and a target VT. PSV is used with or without SIMV.

a. Set a pressure level that provides enough support to achieve a targeted VT.
b. Some children may need higher initial PSV levels, depending on their disease and their
strength.3

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Mechanical Ventilation: Pediatric Volume
Mode (Respiratory Therapy)
15. Discard supplies, remove personal protective equipment (PPE), and perform hand
hygiene.
16. Document the procedure in the child’s record.

MONITORING AND CARE

1. Monitor cardiopulmonary status including vital signs and indicators of oxygenation and
ventilation.
2. Monitor physiologic stability, including cardiac function and hemodynamic changes (heart
sounds, heart rate, blood pressure, and perfusion).

Rationale: Increased intrathoracic positive pressure may reduce venous

return and cardiac output. Likewise, positive pressure may cause
pneumothorax, which may also decrease cardiac output.

3. Observe the child for child-ventilator synchrony.

Rationale: Asynchrony causes increased work of breathing and distress.

Asynchrony in a small child is commonly associated with flow regulation;
access to flow and speed of delivery influence the child’s ability to breathe
comfortably.

4. Perform a ventilator check including FIO2, PIP, VT, PEEP, mean airway pressure, and other
relevant settings, such as the temperature of the inspired gas.

Rationale: Changes in oxygen flow may occur from the oxygen source; auto-
PEEP may also occur. Body temperature can be significantly altered by the
temperature of inspired gas.

5. Confirm the activation of all alarms during each shift.

6. Provide additional ventilatory support, including manual breaths and adjustments in
mechanical ventilation as indicated by the signs of hypoxemia, hypercarbia, and
hemodynamic instability.

Rationale: Early intervention when inadequate ventilator support and

hemodynamic instability occur may prevent further clinical deterioration.

7. Monitor and adjust the ventilator’s settings according to treatment strategies.

Rationale: Changes in lung compliance may change the PIP or VT.

8. Monitor the ventilator’s alarms and watch for changes from prescribed settings, including
an increased PIP or a change in VT.

Rationale: An alarm indicating an increase in PIP or change in VT may be

associated with a need for suctioning or an airway obstruction. A low-pressure
alarm may indicate that the ventilator tubing has been disconnected.3

9. Ensure that the ET tube is secure and stabilized.

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Mechanical Ventilation: Pediatric Volume
Mode (Respiratory Therapy)
a. Consider attaching the circuit to the bed or device to ensure security while allowing the
child to move.

Rationale: Attaching the circuit to the bed or device eliminates undue

pressure on the child’s skin from the ET tube and tubing.

b. Replace loosened tape quickly.

10. Suction the ET tube as indicated and observe the characteristics of secretions.

Rationale: Suctioning the ET tube maintains airway patency and removes

secretions.

11. Minimize sources of infection by limiting interruptions of the circuit and by emptying
condensation from the tubing.

Rationale: Ventilator-associated pneumonia (VAP) is a significant cause of

morbidity in children undergoing ventilation.

12. Encourage daily drug holidays or neurostimulation monitors if the child is undergoing
paralytic therapy.

Rationale: Sedation and neuromuscular blockade may be necessary to

achieve ventilator synchrony, but paralytics mask the child’s underlying
neurologic state. Early identification of the child’s discomfort allows immediate
attention to problems.

13. Consider keeping the head of the bed elevated.

Rationale: Elevating the head of the bed reduces the incidence of aspiration.

14. Observe the child for signs and symptoms of pain. If pain is suspected, report it to the
authorized practitioner.

EXPECTED OUTCOMES
• Adequate oxygenation and ventilation
• Maintenance of adequate pH and PaCO2
• Decreased work of breathing
• Ventilation without lung injury
• Hemodynamic stability
• Maintenance of skin integrity
• Airway in correct position
• No infection
• Mobilization and removal of secretions
• Adequate airway humidification
• Adequate pain control during the procedure

UNEXPECTED OUTCOMES
• Inadequate ventilation and oxygenation (hypoxemia, hypercarbia, acidosis, alkalosis)

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Mechanical Ventilation: Pediatric Volume
Mode (Respiratory Therapy)
• Lung overinflation, air-leak syndrome (pneumothorax, pneumomediastinum,
pneumoperitoneum, subcutaneous emphysema)
• Acute lung injury (volutrauma or progression of lung disease)
• Hemodynamic instability
• Skin breakdown or pressure injury
• Unplanned extubation or malpositioned ET tube
• VAP
• Tenacious sputum
• ET tube obstruction
• Infection
• Inadequately managed pain or anxiety

DOCUMENTATION
• Cardiopulmonary assessment before and after procedure, including vital signs, lung
sounds, work of breathing, arterial blood gas analysis, pulse oximetry, and ETCO2
monitoring
• ET tube size: cuffed or uncuffed
• ET tube marking at the teeth or gums for correct placement
• Date and time of initiation of ventilator assistance
• Record of ventilator settings, including FIO2, mode, VT, PIP, rate, and PEEP
• Record of ventilator checks as indicated, including FIO2, mode, VT, PIP, rate, and PEEP
• Timing of suctioning and characteristics of ET tube secretions
• Pain assessment and specific interventions provided
• Child’s response to the procedure
• Child and family education
• Unexpected outcomes and related interventions

REFERENCES
1. Acute Respiratory Distress Syndrome (ARDS) Network and others. (2000). Ventilation
with lower tidal volumes as compared with traditional tidal volumes for acute lung injury
and the acute respiratory distress syndrome. The New England Journal of Medicine, 342(18),
1301-1308. doi:10.1056/NEJM200005043421801 (classic reference)* (Level II)
2. de Caen, A.R. and others. (2015). Part 12: Pediatric advanced life support: 2015
American Heart Association guidelines update for cardiopulmonary resuscitation and
emergency cardiovascular care. Circulation, 132(18 Suppl. 2), S526-S542.
doi:10.1161/CIR.0000000000000266 Retrieved August 19, 2019, from
https://www.ahajournals.org/doi/abs/10.1161/cir.0000000000000266 (Level VII)
3. Grossbach, I., Chlan, L., Tracy, M.F. (2011). Overview of mechanical ventilatory support
and management of patient- and ventilator-related responses. Critical Care Nurse, 31(3),
30-44. doi:10.4037/ccn2011595 (classic reference)*
4. Klein, J.M. (n.d.). Protocol for initial respiratory settings for mechanical ventilation of
infants. Retrieved August 19, 2019, from https://uichildrens.org/health-library/protocol-
initial-respiratory-settings-mechanical-ventilation-infants

*In these skills, a “classic” reference is a widely cited, standard work of established
excellence that significantly affects current practice and may also represent the foundational
research for practice.

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Mechanical Ventilation: Pediatric Volume
Mode (Respiratory Therapy)
Elsevier Skills Levels of Evidence
• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports

Supplies
• Air source
• ET tube and airway box at bedside
• Appropriate-size mask (to provide PPV as needed via bag-mask ventilation in the event
of unplanned extubation or planned extubation with subsequent respiratory distress)
• Cardiopulmonary monitor
• Invasive or noninvasive mechanical ventilator
• ETCO2 monitor
• Manual ventilation device (i.e., flow-inflating or self-inflating bag)
• Oxygen source
• PPE (gloves, mask, gown, and eye protection, as indicated)
• Pulse oximeter
• Suction source and catheter(s)

Clinical Review: Alan Roth, MS, RRT-NPS, RPFT, FAARC, FCCP

Published: November 2019

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