SYMPOSIUM: INTENSIVE CARE

Respiratory support What’s new

in children Over the last few years, the mainstays of respiratory support in
children have remained the same. Characterizing the type of respi-
Anoopindar K Bhalla ratory failure is crucial to choose the appropriate respiratory support.
Christopher JL Newth New objective tools are emerging to help the bedside clinician with
assessment of the child with respiratory failure. Non-invasive
Robinder G Khemani
modalities of respiratory support are also gaining popularity. The
response to the chosen method of support and underlying patho-
Abstract physiology of the disease should guide decision making in a child
Respiratory failure is defined by the inability of the respiratory system to with respiratory failure.
adequately deliver oxygen or remove carbon dioxide from the pulmonary
circulation resulting in hypoxemia, hypercapnia or both. A wide variety of
disease processes can lead to respiratory failure in children. Multiple in-
Overview of respiratory physiology
terventions can support the pediatric patient with respiratory failure, from Gas exchange
simple oxygen delivery devices to high frequency oscillatory ventilation The content of oxygen in the blood leaving the lungs depends on
and Extracorporeal Membrane Oxygenation. This article will review avail- several aspects of lung function; the partial pressure of oxygen in
able devices to improve oxygenation and ventilation, their advantages the alveoli, diffusion of oxygen across the alveolar wall, and the
and disadvantages, and help guide physicians in the management of chil- degree of pulmonary shunt. Pulmonary shunt is the blood flow
dren with respiratory failure. through the lungs that does not encounter areas of ventilation
Keywords anoxia; artificial; hypercapnia; paediatrics; respiration; and therefore does not participate in gas exchange.
respiratory insufficiency The alveolar gas equation describes the partial pressure of
oxygen present in individual alveoli.

PA O2 ¼ FiO2 ðPB  PH20 ÞePA CO2 =RQ

Respiratory support in children
where PAO2 is the partial pressure of oxygen in the alveolus, FiO2
Respiratory illness accounts for approximately 1 in 5 hospital
is the fractional concentration of inspired oxygen, PB is the
admissions and respiratory failure is the leading cause of car-
barometric pressure, PH20 is the partial pressure of water vapor,
diac arrest in children. Specifically, respiratory failure is the
PACO2 is the partial pressure of carbon dioxide in the alveolus
inability of the respiratory system to adequately oxygenate or
(assumed to equal the partial pressure of arterial CO2, the PaCO2)
remove carbon dioxide from the pulmonary circulation,
and RQ is the respiratory quotient (represents the ratio of oxygen
resulting in hypoxemia, hypercapnia or both. Any abnormality
consumption to carbon dioxide production and is usually
of the respiratory system can lead to respiratory failure
approximated at 0.8).
(Table 1). Due to several anatomical and physiological con-
The difference between the PAO2 and the arterial partial
siderations, in any given medical situation infants and young
pressure of oxygen (PaO2) is minimal in healthy lungs (10
children are at greater risk of respiratory failure than older
e15 mmHg). In diseased lungs, this AlveolareArterial (Aea) PO2
children or adults.
gradient represents the severity of pulmonary shunt and
ventilation-perfusion mismatch or rarely, a diffusion abnormal-
ity. Although an elevated PaCO2 from hypoventilation can lead to
Anoopindar K Bhalla MD is an Assistant Professor of Pediatrics in the hypoxemia as demonstrated by the alveolar gas equation, a
Department of Anesthesiology and Critical Care Medicine, Children’s modest increase in FiO2 will easily increase the PaO2. On the
Hospital Los Angeles, Los Angeles, CA, USA and at the Keck School of other hand, improving the hypoxemia related to pulmonary
Medicine, University of Southern California, Los Angeles, CA, USA. Con- shunt or severe ventilation-perfusion mismatch is generally
flicts of interest: no financial or personal conflicts of interest to declare. accomplished only with interventions that lead to resolution of
the shunt.
Christopher J L Newth MD FRCPC FRACP is a Professor of Pediatrics in the
Carbon dioxide removal from the pulmonary circulation is
Department of Anesthesiology and Critical Care Medicine, Children’s
somewhat dependent on the minute ventilation (Minute venti-
Hospital Los Angeles, Los Angeles, CA, USA and at the Keck School of
lation ¼ Tidal Volume  Respiratory Rate). However, this tidal
Medicine, University of Southern California, Los Angeles, CA, USA.
volume includes alveolar volume as well as physiologic dead
Conflicts of interest: no financial or personal conflicts of interest to
space volume, (i.e. volume that is distributed to areas of the
declare.
respiratory system that are ventilated but do not receive perfu-
Robinder G Khemani MD MsCI is an Assistant Professor of Pediatrics in sion and therefore do not participate in gas exchange). The
the Department of Anesthesiology and Critical Care Medicine, Children’s physiologic dead space volume is composed of both airway dead
Hospital Los Angeles, Los Angeles, CA, USA and at the Keck School of space, the mouth and conducting airways, and alveolar dead
Medicine, University of Southern California, Los Angeles, CA, USA. space, (alveoli that are ventilated but not perfused with blood).
Conflicts of interest: no financial or personal conflicts of interest to Normally, physiologic dead space volume is approximately 30%
declare. of each breath, with alveolar dead space being close to zero.

PAEDIATRICS AND CHILD HEALTH --:- 1 Ó 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Bhalla AK, et al., Respiratory support in children, Paediatrics and Child Health (2015), http://dx.doi.org/
10.1016/j.paed.2015.01.003
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Common causes of respiratory failure in children

Site of respiratory failure Examples of disease processes

Upper airway disorders Anaphylaxis

Foreign body
Infection (Croup, Epiglottitis, Bacterial Tracheitis)
Laryngotracheomalacia
Obstructive lower airways disease Asthma
Bronchiolitis
Cystic Fibrosis
Restrictive lung disease Abdominal compartment syndrome
Acute respiratory distress syndrome
Chronic lung disease
Pleural effusion
Pneumonia
Pulmonary edema
Central nervous system disorders Intracranial Injury (Hemorrhage, Hypoxic Ischemic Injury)
Metabolic encephalopathy
Pharmacologic agent (Central Nervous System Depressant)
Disorders of the muscles of respiration and peripheral nervous system Guillain Barre syndrome
Infant botulism
Muscular dystrophy
Myasthenia gravis
Scoliosis
Spinal cord injury

Table 1

However, in children with significant lung disease physiologic ComplianceðoftherespiratorysystemÞ ¼ DVolume=DPressure

dead space can approach 60e70% of each breath. Because the
physiologic dead space volume does not participate in gas ex- Restrictive lung disease, such as pneumonia or a pleural effusion,
change, it does not aid in carbon dioxide removal. Therefore, the is characterized by decreased respiratory system compliance
alveolar minute ventilation determines carbon dioxide removal. with an end-expiratory lung volume that is below normal FRC.

Alveolar Minute Ventilation ¼ ðTidal Volume  Physiologic Dead Space VolumeÞ  Respiratory Rate

It is important to note that in children, particularly infants, These patients develop atelectasis and subsequent hypoxemia
airway dead space is proportionally larger than in adults due to predominantly due to intrapulmonary shunt. While minimal
differences in the anatomy of the oropharynx. Methods to atelectasis and shunt can be overcome with supplemental oxy-
decrease airway dead space, such as washout with high flow gen, patients with significant restrictive disease often require
rates of air (for example with high flow humidified nasal can- additional support with positive pressure to re-expand areas of
nula), can preserve alveolar minute ventilation whilst decreasing lung collapse and consolidation.
the minute ventilation and therefore reduce the effort of In obstructive airways diseases, such as bronchiolitis or asthma,
breathing required for appropriate gas exchange. Carbon dioxide patients develop air trapping with an end-expiratory lung volume
diffuses rapidly; consequently abnormalities in alveolar diffusion above normal FRC. They have mismatching between areas of
do not generally affect ventilation. ventilation and perfusion in the lung and are prone to the devel-
opment of regional atelectasis and over distension. These patients
Respiratory mechanics may require assistance with ventilation secondary to muscle
Inspiration is an active process and exhalation in normal lungs is fatigue or less frequently due to hypoxemia related to shunt.
passive. Given their elastic properties, the lungs and the chest
wall have a tendency to move in opposite directions, the lungs Respiratory support devices
collapse and the chest wall expands outward. The balance point The management of respiratory failure is largely based on
of these two forces occurs when the lung volume is at functional symptomatic support until the underlying disease process abates.
residual capacity (FRC). At FRC, the compliance of the respira- Therapies should be applied in a manner that addresses the
tory system is the greatest. pathophysiology behind the respiratory failure (Table 2).

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Please cite this article in press as: Bhalla AK, et al., Respiratory support in children, Paediatrics and Child Health (2015), http://dx.doi.org/
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Site specific treatments for respiratory failure in children

Site of respiratory failure Pathophysiology Treatment

Upper airway disorders Turbulent flow Medical therapy to improve obstruction

Upper airway collapse or narrowing Heliox to increase laminar flow
Bypass obstruction with an endotracheal tube
Obstructive lower airways disease Air trapping with decreased compliance Medical therapy to improve obstruction
Respiratory muscle fatigue causing hypoventilation Supplemental oxygen for hypoxemia
Mismatching between ventilation and perfusion In severe cases; mechanical ventilation either
non-invasive or invasive to improve
hypoventilation and decrease work of breathing
Restrictive lung disease Lung atelectasis and consolidation causing Supplemental oxygen for mild hypoxemia
intrapulmonary shunt Hypercapnia or significant hypoxemia requires
Decreased lung compliance Respiratory muscle fatigue positive pressure ventilation
Central nervous system disorders Decreased or absent drive to breathe Endotracheal intubation and mechanical
Loss of airway tone ventilation
Loss of airway protective reflexes
Disorders of the muscles of Respiratory muscle fatigue or paralysis Mechanical ventilation to unload respiratory
respiration and peripheral nervous Loss of airway tone and ability to cough muscles, may be non-invasive or invasive
system depending on weakness severity and chronicity

Table 2

Oxygen delivery devices litres/min. If that child is receiving nasal cannula oxygen at 1
The initial support for hypoxemic respiratory failure is to in- litre/min, the FiO2 of air delivered to the lungs assuming com-
crease the alveolar FiO2 through an oxygen delivery device. For plete nasal breathing can be no more than:

ðFiO2  Oxygen Flow RateÞ þ ð0:21  ðMinute Ventilation  Oxygen Flow RateÞÞ
Max FiO2 delivered ¼
Minute Ventilation

each child, the optimal oxygen delivery device depends on the The maximum FiO2 that can be delivered to this child by
FiO2 it can deliver, the severity of hypoxemia, and the likelihood simple nasal cannula ¼ ((1  1) þ (0.21  2.6))/3.6 ¼ 0.43. That
the patient will tolerate the device. is, 43% inspired O2.
The majority of air entering the lungs in this child is entrained
Blow by or wafting oxygen room air, not oxygen. Moreover, the maximal FiO2 delivered to
Blow by oxygen describes blowing or wafting oxygen near the the patient will decrease if minute ventilation increases, given
face of a patient. Generally this is used briefly in patients who are the same oxygen flow rate. Simple nasal cannulas are generally
unable or unwilling to tolerate other methods of oxygen delivery. not used at higher than 3 litres/min in children due to irritation
This is not a reliable method of oxygen delivery and should be and drying of the nares that can occur at higher flow rates. They
used only while preparing a more suitable device. are well tolerated by patients and have the distinct advantage of
allowing patients to feed while receiving oxygen therapy. This is
Oxygen hood or headbox oxygen a very important piece of simple physiology that should be un-
The oxygen hood is a clear plastic tent surrounding the head of derstood by all those looking after children.
the patient into which oxygen is infused at a flow rate of 10e15
litres/min. An oxygen hood can achieve up to 0.9 FiO2. Most Simple face mask
hoods are not suitable for patients greater than a year of age, as The simple face mask forms a reservoir for oxygen to collect.
these patients are likely to move causing disruption of the seal Room air enters the mask reservoir and mixes with the oxygen
and allowing oxygen to escape. during inspiration. The flow of oxygen should be at least 5 litres/
min to limit the rebreathing of exhaled carbon dioxide. Depending
Nasal cannula on the mask fit, oxygen flow rate, and minute ventilation a simple
A simple nasal cannula delivers oxygen into the nares through face mask can deliver an FiO2 from 0.35 to 0.5.
prongs. The oxygen mixes with room air in the nasopharynx
prior to entering the lungs. Similar to any oxygen delivery device, Partial rebreather face mask/Non-rebreather face mask
the FiO2 of oxygen delivered to the lungs depends on the minute A partial rebreather mask is a simple face mask attached to a bag
ventilation of the patient and the amount of oxygen lost to the reservoir (Figure 1). This maximizes the FiO2 of air drawn into
environment. the lungs and limits entrained room air. At flow rates of 10e15
For example, a child breathing with a tidal volume of 120 ml litres/min, a partial rebreather face mask can achieve an FiO2 of
at a rate of 30 breaths per minute has a minute ventilation of 3.6 0.5e0.6.

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Please cite this article in press as: Bhalla AK, et al., Respiratory support in children, Paediatrics and Child Health (2015), http://dx.doi.org/
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to a simple mask. The highest FiO2 that can be delivered through

a Venturi mask is 0.6. Oxygen is forced through a small jet orifice
on the device generating a high velocity stream leading to sub
atmospheric pressure that entrains a constant portion of room air
into the mask. The device functions based on Bernoulli’s prin-
ciple, the increase in velocity of a gas as it travels through a
narrowed tube creates a fall in the pressure it exerts. Venturi
masks are advantageous when a specific FiO2 is required.

High flow heated humidified or vaporized nasal cannula

High flow heated nasal cannula (HFNC) can be used at high flow
rates (from 3 to 20 litres/min in children) without drying respi-
ratory mucus membranes due to the heating and humidification
or vaporization of the delivered gas. New evidence suggests that
HFNC can significantly decrease effort of breathing in children
with respiratory failure. The precise mechanism of this effect,
while not clear, is likely related to both the generation of positive
Figure 1 Partial rebreather face mask. pressure and in small children the washout of airway dead space
(see above). Because of the high flow rates, HFNC can also
A non-rebreather face mask contains additional one way deliver higher FiO2 than simple nasal cannula. HFNC should be
valves on the mask and the bag reservoir which limit mixing of used primarily in patients who may benefit from higher FiO2 than
the oxygen supply with room air or exhaled carbon dioxide can be delivered with simple nasal cannula or have mild to
(Figure 2). Normally, one port on the mask does not have a moderate increased effort of breathing, but do not have a clear
valve, allowing room air to enter and preventing suffocation if indication for mechanical ventilation.
the mask is disconnected from the oxygen source. Of all simple
oxygen delivery devices (no positive pressure), non-rebreather Ventilation and advanced oxygenation support
face masks provide the highest concentration of oxygen (FiO2
Indications
up to 0.95 at 15 litres/min) to a spontaneously breathing patient.
Children with respiratory failure require ventilation and
advanced oxygenation support for many reasons. Fundamen-
Venturi (air entrainment) mask
tally, ventilation and advanced oxygenation support devices
Venturi masks deliver oxygen at a high flow rate, significantly
provide different degrees of positive intrathoracic pressure. For
exceeding the minute ventilation of the patient, thereby
patients with decreased alveolar minute ventilation causing hy-
providing a constant FiO2. Venturi air entrainment devices attach
percapnic respiratory failure related to decreased tidal volume,
increased dead space, or decreased respiratory rate, mechanical
ventilation can guarantee a minimal respiratory rate and provide
positive pressure during inspiration to increase tidal volume and
decrease effort of breathing. Patients with significant hypoxemia
from intrapulmonary shunt require advanced oxygenation sup-
port with continuous positive airway pressure (CPAP) or me-
chanical ventilation to recruit atelectatic and consolidated lung,
improve lung compliance, and offer a delivery method for high
concentrations of FiO2. For patients with decreased tidal volume
due to muscle fatigue or weakness, positive end expiratory
pressure (PEEP) helps maintain lung expansion to optimize
compliance and inspiratory pressure assists the patient with lung
inflation to decrease the work of breathing. In obstructive air-
ways disease where muscle fatigue can lead to hypoventilation,
applied PEEP can match the intrinsic PEEP associated with air
trapping decreasing the effort required to inhale.

Physiology
The forces generated to move air in and out of the lungs during
ventilation support are a combination of the muscular effort of
the patient and support from the positive pressure device. Flow
occurs during inspiration when the total force exceeds the elastic
and the resistive elements of the lungs and the chest wall.

Figure 2 Non-rebreather face mask. Note the one way valves limiting the Paw þ Pmus ¼ Volume=Compliance þ Flow  Resistance
mixing of room air or exhaled carbon dioxide with the oxygen supply.

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Please cite this article in press as: Bhalla AK, et al., Respiratory support in children, Paediatrics and Child Health (2015), http://dx.doi.org/
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Where Paw is the pressure generated by the ventilation support Non-invasive mechanical ventilation
device, Pmus is the pressure generated by the patient, flow x Non-invasive mechanical ventilation refers to any type of me-
resistance are the resistive forces, and volume/compliance are chanical ventilation delivered through a non-invasive interface
the elastic forces that the system must overcome. (nasal mask, face mask, nasal prongs). Although a face mask
provides the most effective ventilation by ensuring no escape of
Ventilation bags air through the mouth, a nasal mask is often most comfortable
Bag mask manual ventilation is the most immediate mechanism for patients. A ventilator delivers either CPAP or bi-level positive
for positive pressure ventilation support. Two main devices are airway pressure (BiPAP), an inspiratory positive airway pressure
used for bag mask ventilation, a self-inflating bag and a flow- (IPAP) for each breath and a baseline expiratory positive airway
inflating bag (Figure 3). Self-inflating bags re-inflate by a recoil pressure (EPAP). Adding IPAP to the EPAP assists the patient in
mechanism, allowing them to function without an external gas the work of inflating the lungs and can increase the tidal volume
source. When the self-inflating bag is used with oxygen, attach- of each breath.
ing an oxygen reservoir ensures that oxygen is the primary gas Although the indications for non-invasive ventilation in pe-
entering the bag during expansion. Self-inflating bags usually diatric patients are not clearly defined, practitioners commonly
have a one way valve preventing re-breathing of exhaled air; use it for post extubation support, pulmonary edema, asthma and
oxygen only reliably flows to the patient when the bag is long term nocturnal support for patients with chronic lung dis-
squeezed. ease, obstructive sleep apnea, or neuromuscular disease. Non-
Flow-inflating bags on the other hand do require an external invasive ventilation should not be used for patients who have
gas source to inflate. An advantage of the flow-inflating bag is the suffered a cardiac or respiratory arrest, have severely impaired
ability to provide oxygen or CPAP to spontaneously breathing consciousness, are unable to cooperate or protect their airway, or
patients because a constant flow of oxygen is present even are likely to require a prolonged period of continuous support.
without inflation or deflation of the bag. Flow-inflating bags are Ideal candidates for non-invasive support are either likely to
more difficult to operate effectively as they require skill in improve quickly due to the initiation of a definitive medical
achieving a suitable mask seal and delivering appropriate airway therapy or only need intermittent long term support while
pressure to the patient. Bag mask ventilation with either type of sleeping. Other limitations of non-invasive ventilation include
bag is a temporary method of support while preparations are skin breakdown at the site of the interface or gastric distension
made for endotracheal intubation and mechanical ventilation. with the inability to feed. Asynchrony between the patient’s

Figure 3 There are two types of ventilation bags for bag mask manual ventilation the self-inflating bag (a) and the flow-inflating bag (b).

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respiratory effort and the support delivered by the non-invasive of fully supported ventilator breaths and generally providing
ventilation device can be a common problem as triggering some support, either pressure or volume support, to additional
mechanisms are either absent or insensitive. New technologies spontaneous breaths. In contrast, in assist control ventilation
such as Neurally Adjusted Ventilatory Assist (NAVA) are every spontaneous breath of the patient is fully supported by the
improving this problem. NAVA uses an esophageal catheter to ventilator with the preset variables. In either mode, if the patient
obtain the neural respiratory signal as it is transmitted through is not triggering the ventilator, the ventilator will deliver breaths
the phrenic nerve to the diaphragm in order to trigger the at the preset rate.
ventilator, decreasing asynchrony.
Pressure regulated volume control
Conventional mechanical ventilation Pressure regulated volume control (PRVC) is a hybrid mode that
Patients who are unresponsive to the interventions previously controls pressure and targets a set volume. The pressure is
discussed or those who present with severe hypoxemia or hy- adjusted from breath to breath to meet a set volume target. In
percapnia, cardiac or respiratory arrest, or loss of airway pro- addition, there is a pressure limit above which no further volume
tective reflexes (cough, gag) require endotracheal intubation and will be delivered. As each breath is pressure controlled, there is a
conventional mechanical ventilation. decelerating flow pattern during inspiration. The advantage of
Ventilator modes are classified by the one independent PRVC is maintaining minute ventilation while limiting peak
inspiratory variable they control; pressure, volume, or flow. In pressures.
all control modes, the clinician sets a PEEP, an inspiratory time,
an FiO2, and a mandatory breath rate. Exhalation remains a Airway pressure release ventilation
passive process in conventional mechanical ventilation, gov- Airway pressure release ventilation provides a continuous level
erned by the elastic and resistive forces of the respiratory system. of positive airway pressure that is terminated for brief periods of
time. The elevated pressure aids oxygenation while the releases
Pressure control modes in pressure allow ventilation. The patient breathes spontaneously
In pressure control modes the clinician sets the pressure, the during both phases with or without additional pressure support.
independent variable. Flow increases rapidly at the beginning of There is some evidence that oxygenation and ventilation can be
inspiration to generate the set pressure, then decreases over maintained at lower pressures using this mode in comparison to
inspiration as alveolar volume increases. The volume delivered pressure or volume control modes.
varies as a function of the compliance and resistance of the
respiratory system and patient effort. The constant pressure im- Patient ventilator asynchrony
proves the distribution of ventilation from well opened alveoli to Patient ventilator asynchrony can be caused by difficulty trig-
more collapsed areas. This is theoretically helpful when children gering the ventilator to deliver a breath, inadequacy of the flow
have non-homogenous lung disease (such as in pneumonia or delivered, or delayed or premature breath termination. This can
Acute Respiratory Distress Syndrome). The initial high flow is lead to patient discomfort, increased sedation requirement, and
thought to be beneficial to open stiff alveoli and is more wasted patient effort. NAVA is also being used with conventional
comfortable for patients as it matches their initial high flow de- ventilation allowing the ventilator to respond quickly to patient
mand. The peak inspiratory pressure (PIP) for the same tidal attempts to breathe.
volume is usually less during pressure control ventilation than Patients with obstructive airways disease often develop
volume control ventilation. The largest limitation of pressure intrinsic PEEP (PEEPi). In order to trigger a breath, the patient
control ventilation is the variability in delivered tidal volume as must lower their pleural pressure enough to overcome both the
the compliance or resistance of the respiratory system changes. PEEPi and the ventilator sensitivity triggering pressure or flow
threshold. If the patient is unable to reach this threshold, the
Flow control modes ventilator is not triggered, the breath is not delivered, and there is
Volume control modes are actually constant flow control modes. wasted patient effort. If the PEEP set on the ventilator is
Flow is the set independent variable and pressure is the depen- increased to match the PEEPi of the patient (judged clinically in
dent variable. Flow is delivered constantly throughout the set spontaneously breathing patients or with the assistance of tools
inspiration time to achieve a specific volume target. The airway such as esophageal manometry) only the sensitivity threshold
pressure varies depending on the compliance and the resistance must be met to trigger the ventilator, decreasing the effort of
of the system. The advantage of this mode is consistent minute breathing for the patient.
ventilation; however, the pressure delivered can vary signifi-
cantly with changes in the compliance or resistance of the res- High frequency oscillation ventilation
piratory system. Children with severe restrictive lung disease and hypoxemia or
carbon dioxide retention refractory to management with conven-
Synchronized intermittent mandatory ventilation and assist tional ventilation may have better oxygenation at lower peak
control (D) airway pressures with high frequency oscillatory ventilation
Synchronized intermittent mandatory ventilation (SIMV) delivers (HFOV). HFOV delivers very small tidal volumes of 1e3 ml/kg at a
a preset number of breaths, controlled by the selected mode, in rate of 180e1200 breaths/min. Inspiration and expiration are
coordination with the spontaneous effort breaths of the patient. pushed and pulled actively from the lungs by the force of a piston.
The ventilator attempts to synchronize all breaths to the spon- The mean airway pressure (MAP) is generally set initially 5e10 cm
taneous breaths of the patient, delivering both the preset number H2O higher than on the conventional ventilator due to attenuation

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the ECMO circuit, patients who are bleeding or at significant risk

for bleeding should not be placed on ECMO. Respiratory ECMO
should only be used in children with reversible conditions.
Another method of extracorporeal support is through extra-
corporeal CO2 removal (ECCO2). The goal of this approach is to
use extracorporeal CO2 removal through venousevenous bypass
while using lung protective ventilation settings, high airway
pressures with low tidal volumes, through either a conventional
ventilator or HFOV to oxygenate the lung. This method is
currently used infrequently in pediatric respiratory failure.

Weaning from mechanical ventilation

As the indication for mechanical ventilation resolves, the patient
can be weaned from mechanical ventilation support. The main
objective in weaning from mechanical ventilation is to transition
the work of breathing from the ventilator to the patient. Nor-
mally, the patient is weaned to a mode of spontaneous breathing
or intermittently placed on a mode of spontaneous breathing
Figure 4 High frequency oscillatory ventilation uses smaller tidal volumes
during periods of sprinting. Pressure support or volume support
and lower peak airway pressures than conventional ventilation. During
mechanical ventilation, both conventional ventilation settings and HFOV (no set rate) is commonly attempted first where every breath is
settings should avoid the upper inflection point (overdistension) and the initiated by the patient with a set amount of pressure or volume
lower inflection point (atelectasis) danger zones of mechanical ventila- supplied for the breath. The patient may then be placed on a
tion. In these danger zones, there is a small change in volume for a given CPAP mode where they must utilize their respiratory muscles to
change in pressure. generate the flow of air into their lungs. A T-piece trial, oxygen
supplied to the endotracheal tube with zero positive pressure,
of the pressure in the airway and the general need for improved may be indicated for some patients prior to extubation.
alveolar recruitment. The MAP is then adjusted to achieve
appropriate lung expansion and oxygenation. The amplitude, or Respiratory support for other disorders
driving pressure DP, and frequency, or the rate of oscillations are
adjusted to achieve appropriate ventilation. As opposed to con- The management of patients with respiratory failure caused by
ventional ventilation, a lower frequency increases the tidal vol- an abnormality besides a primary restrictive lung or obstructive
ume and minute ventilation. HFOV can be very effective at CO2 lower airways disease utilizes many of the treatments outlined
removal; however, because it is an active mode of exhalation it previously. There are also additional disease specific therapies
should not be used in patients with significant airway obstruction. worth highlighting.
Due to smaller tidal volumes and lower peak airway pressures,
Respiratory support for upper airway disorders
HFOV may be helpful in limiting ventilator associated lung injury
The subglottic region is the narrowest area in the pediatric
and in the management of pneumothorax (Figure 4).
airway, predisposing children to obstruction with any type of
Extracorporeal membrane oxygenation airway swelling such as that caused by viral illness or endotra-
Extracorporeal membrane oxygenation (ECMO) is considered cheal intubation.
only in patients with respiratory failure when the strategies
Heliox
outlined above have failed. During ECMO, venous blood is
Heliox is a combination of oxygen and helium (useful clinically
extracted from the body, circulated outside the body to an
in mixes from 60/40% to 80/20% helium/oxygen) delivered
oxygenator which performs the main function of the lungs;
through a hood, nasal cannula, or face mask for upper airway
removing the carbon dioxide and fully saturating the blood with
obstruction. The Reynolds number determines the tendency for
oxygen. The oxygenated blood is then infused back into the body
gas flow through a tube to be either laminar (lower number) or
in a central vein or artery. Although ECMO is considered
turbulent (higher number).

ReynoldsNumber ¼ ð2  airwayradius  densityofgas  velocityÞ=gasviscosity

routinely as the last resort for the support of neonates with res- By replacing nitrogen in the gas the patient breathes with
piratory failure or for the post-operative support of congenital helium, a much lower density gas with similar viscosity, the
heart disease, ECMO in pediatric respiratory failure is contro- Reynolds number is decreased and flow becomes less turbulent
versial. For this reason, criteria for ECMO vary significantly from through areas of narrowing. Laminar flow has lower resistance
institution to institution. Due to the anticoagulation required for and reduces the work of breathing for the patient. The minute

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Please cite this article in press as: Bhalla AK, et al., Respiratory support in children, Paediatrics and Child Health (2015), http://dx.doi.org/
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ventilation of the patient should be mostly supplied from the FURTHER READING
heliox flow; practitioners should ensure a good face mask seal or Abboud P, Raake J, Wheeler DS. Supplemental oxygen and bag-valve-
deliver a high flow via the nasal cannula because any entrained mask ventilation. In: Wheeler DS, Wong HR, Shanley TP, eds. Resus-
room air will increase the Reynolds number again. In addition, citation and stabilization of the critically ill child. London: Springer-
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Respiratory support for disorders of the muscles of
respiration or peripheral nervous system
Patients with muscle weakness may have respiratory failure due Practice points
to hypoventilation related to muscular fatigue, poor airway tone
C Oxygen delivery devices vary significantly in the FiO2 they can
with upper airway obstruction, or an inability to cough effec-
deliver and for non-invasive devices that do not provide positive
tively and clear secretions leading to atelectasis. These patients
pressure, the non-rebreather face mask delivers the highest
may benefit initially from intermittent non-invasive mechanical
concentration of oxygen to a spontaneously breathing patient.
ventilation (BiPAP) during sleep when their hypoventilation is
C Patients with hypoxemic respiratory failure refractory to supple-
generally more pronounced. If the muscle weakness is progres-
mental oxygen or with hypercapnic respiratory failure require aid
sive or if the patient has paralysis, invasive mechanical ventila-
with positive airway pressure.
tion is generally required.
C Continuous non-invasive ventilation should be limited to patients
who require short term support while a definitive medical therapy
Summary
is implemented.
Although respiratory failure is common in children, there are a C Patients with severe hypoxemia or hypercapnia, cardiac or res-
multitude of options available for the respiratory support of these piratory arrest, or a loss of airway protective reflexes require
patients. Understanding the advantages, disadvantages, and endotracheal intubation and mechanical ventilation.
limitations of each respiratory support option is important in C HFOV can be useful in patients with severe hypoxemic or hyper-
implementing the appropriate management plan for each carbic respiratory failure refractory to management with conven-
child. A tional mechanical ventilation.

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Please cite this article in press as: Bhalla AK, et al., Respiratory support in children, Paediatrics and Child Health (2015), http://dx.doi.org/
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