Jean-Michel Arnal, Eduardo Bancalari, Katherine C. Clement, Sherry E. Courtney , Claude Danan, Steven M. Donn et al. Pages PDF. DRM-free; Included format: EPUB, PDF; ebooks can be used on all reading devices; Immediate eBook download after download Thereafter, the rational use of mechanical ventilation in various pediatric and neonatal pathologies is. Peter C. Rimensberger. Editor. Pediatric and Neonatal. Mechanical Ventilation. From Basics to Clinical Practice.
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Request PDF on ResearchGate | Pediatric and neonatal mechanical ventilation: From basics to clinical practice | Written by outstanding authorities from all over. Objectives of Mechanical Ventilation in the pediatric patient include: • Improved pulmonary normal Hb and hematocrit(in neonates), maintain normothermia, deepen sedation/consider . See Pediatric Ventilation tool pdf. REFERENCES-. 1. words: pediatric, respiratory, pulmonary, mechanical ventilation, acute lung injury 31st RESPIRATORY CARE Journal Conference, Current Trends in Neonatal.
Current recommendations for the conventionally ventilated neonate SIMV, AC, VG, and VC and for those who are on CPAP continuous positive airway pressure aim to clean the artificial airways before nebulization, remove the ventilator flow sensor from the wye connector, use vibrating mesh nebulizer Aeroneb, Pari e-flow or MDI with holding chamber, place the device in the inspiratory limb in the circuit 20 cm from the wye connector, and optimize breathing support increase inspiratory time as much as possible, decrease respiratory rate as much as possible, bypass the humidifier, and maintaining air flow heating during nebulization [ 53 ].
Prevention of Infection Infection, and its prevention, is an important concern in neonatal ventilated patients, particularly those of very low birth weight. There are no universally accepted criteria to diagnose VAP in the neonatal period [ 58 ]. Microbiological study of tracheal aspirates is not reliable for the diagnosis of VAP since airway colonization cannot be dismissed by this technique.
The standard for microbiological sampling of the airway is bronchoscopic bronchoalveolar lavage and protected specimen brush, whose invasive character precludes its universal use in neonates intubated with small diameter tubes for whom blind-protected bronchoalveolar lavage should be applied [ 61 — 65 ].
Several risk factors have been associated with the occurrence of VAP. Of these, duration of mechanical ventilation and ELBW infants seem to be the most significant in multivariate analysis [ 60 , 61 ], although others like length of hospital stay, reintubation, enteral feeding, mechanical ventilation, transfusion, low birth weight, prematurity, bronchopulmonary dysplasia, and parenteral nutrition have been identified in a recent meta-analysis of observational studies [ 62 ].
On the contrary, decreasing the frequency of ventilator circuit changes from every seven to 14 days does not seem to influence the VAP rate [ 62 ]. The most common agents involved in VAP are Gram-negative bacteria particularly Pseudomonas aeruginosa, Enterobacter species, and Klebsiella species although Gram-positive bacteria, namely, coagulase negative staphylococci and Staphylococcus aureus, also play a role [ 61 , 62 , 64 , 65 ].
Polymicrobial cultures are frequently found when tracheal aspirate sampling is used. There is no consensus for the initial treatment of VAP. Initial empirical treatment should include broad spectrum antibiotics with coverage for Gram-positive and Gram-negative bacteria, based on likely causative agents and local antimicrobial resistance patterns [ 65 ].
VAP is associated with increased length of hospital stay and mortality [ 61 ]. In the Neo-Kiss registry, Leistner and coworkers found that VAP incidence may influence mortality rate in infants with birth weight between g and g [ 56 ], in accordance with results from other groups of researchers [ 64 ]. Such bundles, which apply several evidence-based practices at the same time, have proved to result in greater practice improvements than the sum of the benefits of each practice on its own [ 66 ].
They should include practices relative to head position in the ventilated neonate, the use of closed multiuse suction catheters, frequency at which suctioning systems should be changed, routine changing of breathing circuits, assessment of readiness for extubation and cautious evaluation of the need for reintubation, use of medications that interfere with gastric acidity, use of antibiotic bowel decontamination and oral hygiene, and use of separate oral and tracheal suctioning equipment [ 66 ].
As with other healthcare-related infections, improvement of caregiver education and hand hygiene remains a very important measure to control VAP incidence. Sedation and Analgesia It is now known that preterm infants are more sensitive to pain than older children and that intubation and invasive mechanical ventilation have physiologic changes determining stress and pain, which can be reduced with sedatives and analgesics [ 67 ].
Nowadays, the prevention and treatment of pain and distress represents an essential component of clinical practice [ 67 , 68 ].
After the correct pain assessment, the treatment of pain and stress should be done. Nonpharmacological interventions such as nonnutritive sucking and sucrose must be tried. Their use in extremely preterm, unstable, ventilated neonates needs to be addressed [ 71 ]. Routine administration of sedation or analgesia in preterm neonates is not recommended due to the safety concerns regarding the pharmacotherapy.
Nevertheless, preterm newborns who remain ventilated can be under morphine. Rarely fentanyl or remifentanil should be used [ 71 ]. We focus in the sedative and analgesic medication usually used in NICUs: midazolam, morphine, and other opioids, namely, fentanyl and remifentanil Table 2 [ 67 , 72 — 77 ]. Table 2: Sedative and analgesic medication usually used. In the delivery room, nasal midazolam was more efficient than ketamine to adequately sedate neonates requiring intubation.
The hemodynamics and respiratory effects of both drugs were comparable [ 78 ]. Preterm infants receiving MIST minimal invasive surfactant therapy were more comfortable when sedation was given, but needed ventilation more often [ 79 ].
A randomized controlled trial is necessary to test whether the benefit of sedation outweighs the risks of complications. A neonatal pain and sedation protocol should be implemented in each NICU. It can increase the opiate exposure, but seems not to affect neurodevelopmental outcomes of extremely preterm infants [ 80 ]. However, as with any medication, the possibility of short- and long-term adverse reactions must be considered. Nonpharmacological therapy should be used as much as possible [ 81 , 82 ].
Neuromuscular blocking agents are not recommended in the NICU. A transient curarization can be used during brief diagnostic or therapeutic procedures in order to avoid hemodynamic consequences of deep sedation [ 83 ]. Sedation should be reduced and stopped if possible before extubation [ 85 ].
Methylxanthines are helpful in the preterm neonate, and these populations should be started on nasal CPAP or high flow nasal cannula after extubation [ 86 ]. Systemic steroids and diuretics may be useful to extubate preterms still ventilated after the first week of life [ 86 ]. Prone positioning can be helpful in stabilizing the chest wall and improving diaphragmatic excursion.
A chest radiograph is not routinely necessary, unless there is clinical evidence of respiratory distress [ 86 ]. Tracheostomy Neonatal tracheostomy is a common need of newborns requiring prolonged ventilation.
Studies have shown that early tracheostomy reduces the incidence of subglottic and tracheal stenosis in children who are intubated for long periods and results in improved comfort, decreased need for sedation, systemic corticosteroid, improved nutrition and growth, ability to attempt oral feeds, and, once established, vocalization with a speaking valve.
Improved survival of extremely low and very low birth weight and medically complex infants can result in prolonged mechanical ventilation and sometimes tracheostomy [ 87 ].
The indications for neonatal tracheostomy have changed over time. With the need for long-term ventilation, it has become more common [ 88 ]. Overman et al. Overall tracheostomy rate was 6. Common indications for neonatal and infant tracheostomy include congenital or acquired airway obstruction and chronic medical conditions cardiac disease, neuromuscular disease, and bronchopulmonary dysplasia. Decisions about tracheostomy in neonates involve careful consideration of a number of factors.
Mortality, potential short- and long-term outcomes, prospects for home ventilation therapy, and alternatives to tracheostomy should be considered [ 89 ]. The specific technique of neonatal tracheostomy varies little from a well-performed tracheostomy and should be performed in the operating room [ 90 ]. Tracheostomy has the potential for significant morbidity.
Meticulous technique, surgeon experience, and specialized care may play a role in reducing the complication rate. However, complications are usually minor in neonates and do not require additional surgical interventions [ 91 ]. Ventilation in Palliative Care Despite advances in neonatal medicine and intensive care, there are some infants whose treatments are harmful, are not or are no longer beneficial, and may be discontinued after discussion with the family [ 92 ].
The aim of palliative care is to keep the baby comfortable and to support the parents in caring for their baby according to their wishes and beliefs [ 93 , 94 ]. The process of withdrawal includes the explanation to the parents what will happen; which member of staff will be responsible for the actual removal of the endotracheal tube and turning the ventilator off; the aspiration of the nasogastric tube considering not feeding the infant just prior to extubation ; the alarms of the ventilator and monitors should be turned off prior the disconnection; the endotracheal tube should be suctioned before removal; the parents should be given the choice of being present and holding their infant.
Withdrawal of less invasive forms or respiratory support such as nasal continuous positive airway pressure and nasal cannula oxygen may be appropriate if a baby is dying and continued provision of respiratory support only serves to delay death [ 92 — 95 ]. Neuromuscular blocking agents should never be introduced when the ventilator is being withdrawn.
If the newborn has been on paralytics, these should ideally have been weaned off hours to days earlier [ 93 ]. Analgesics and sedatives should be titrated to relieve pain. It is common for children to experience increased pain, agitation, and dyspnea after extubation, requiring increased doses of medication [ 92 ]. In some cases, it is not necessary to turn off the ventilator or extubate the neonate, the parameters of ventilation can be decreased until reaching minimum values, with a decrease of oxygen.
Noninvasive ventilation can be used to relief signs of respiratory distress [ 93 ]. Veno-arterial VA ECMO, in addition to increasing blood oxygen content, may provide hemodynamic support by increasing systemic blood flow.
This technique, in the presence of pulmonary pathology, should allow the recovery of pulmonary structure and function in order to ensure the survival of the newborn [ 96 , 97 ]. Improvement of native cardiac function may translate into a reduction in arterial oxygen saturation, but with increased tissue oxygen delivery.
After initiating VV-ECMO, weaning from ventilatory and hemodynamic support should be done slowly and with caution, since oxygen delivery is dependent on native myocardial function and, on the other hand, the native lung still provides gas exchanges. The use of a high PEEP may compromise pulmonary blood flow and cardiac output. In acute technical failure e. Complications: Air Leaks and Pulmonary Hemorrhage Air leak syndrome refers to the extravasation of air from the tracheobronchial tree into the lung parenchyma and pleural spaces where it is not normally present, and includes pneumothorax, pulmonary interstitial emphysema, pneumomediastinum, pneumopericardium, pneumoperitoneum, subcutaneous emphysema, and systemic air embolism.
Risk factors include prematurity, very low birth weight, low Apgar score, high peak inspiratory pressure, high tidal volume, high inspiratory time, respiratory distress syndrome, meconium aspiration syndrome, amniotic fluid aspiration, pneumonia, and pulmonary hypoplasia [ — ].
The most frequent air leak in mechanical ventilated newborns is pneumothorax. Different ventilatory strategies affect the risk of pneumothorax with evidence that high-frequency ventilation [ ], volume-targeted ventilation [ ], and increased PEEP [ ] are associated with a decreased risk, and continuous positive inspiratory pressure is associated with an increased risk of pneumothorax [ , ].
The clinical presentation ranges from asymptomatic to severe progressive respiratory distress [ ] and, in case of tension pneumothorax, hemodynamic compromise [ ]. Physical examination may reveal tracheal deviation, asymmetrical chest rise, diminished breath sounds over the affected side, and muffled or shifted heart sounds [ ]. Diagnosis is usually made by radiography [ ]. However, in neonates, the classic appearance may be more difficult to recognize.
Therefore, these signs should be looked for in ventilated newborns in order to perform an early diagnosis of pneumothorax. A tension pneumothorax requires immediate diagnosis and intervention even before imaging is obtained, and chest transillumination plays a role in these cases [ , ]. Treatment options include conservative management, nitrogen washout with oxygen, needle aspiration, intercostals tube drainage, and placement of a pigtail catheter.
A study including only adult patients reports a rate of spontaneous reabsorption of pneumothorax of 1. An expectant management may be effective even in neonates undergoing mechanical ventilation [ , ], but intervention is most often needed [ ]. Placing the infant under high concentrations of oxygen may hasten the reabsorption of gas in the pleural space by creating a diffusion gradient.
However, in neonates, this technique is limited by the oxygen toxicity and increased risk of retinopathy of prematurity [ ]. Needle thoracentesis with aspiration is the preferred treatment in emergencies such as a tension pneumothorax, but may not completely correct the situation [ , ].
The most traditional method of treatment of a pneumothorax is a chest tube placed by thoracostomy [ , , ]. However, a recent systematic review found insufficient evidence to determine the efficacy and safety of needle aspiration versus intercostal tube drainage in the management of pneumothorax in newborns [ ].
More recently, pigtail catheters have been used for treatment of pneumothorax in newborns, with evidence to be safe, effective, and reduce discomfort during insertion and complications [ ] including in preterm neonates [ ]. Further prospective randomized controlled trials are necessary to determine which method is superior in the management of neonatal pneumothorax in mechanical ventilated patients. Other risk factors include pulmonary interstitial emphysema PIE , pneumothorax, pulmonary infection, metabolic acidosis, shock, hypothermia, hypoglycemia, disseminated intravascular coagulation DIC , ECMO therapy, hereditary coagulation disorders, and airway trauma especially following endotracheal intubation [ , ].
Pulmonary hemorrhage clinically presents with a rapidly worsening pulmonary function the speed of the setting depends obviously on the magnitude of the hemorrhage , with hypoxia, hypercarbia, and the need for increased ventilatory parameters.
Blood can be seen in oropharyngeal or tracheal aspirates. A systemic deterioration is established with metabolic acidosis and shock. Investigations should include a chest X-ray, an echocardiogram to exclude a PDA , work-up for sepsis, and eventual screening for hereditary diseases of coagulation if no other risk factors are detected [ ].
Treatment should include general supportive measures: transfusions of blood, plasma or platelets, as indicated; correction of metabolic acidosis; inotropic drugs to improve systemic blood pressure; PDA treatment except severe thrombocytopenia ; antibiotic treatment including vancomycin; and coverage for Gram-negative bacteria [ , ]. The ventilatory strategy employed is essentially based on empirical observations, without recommendations based on evidence.
Although without evidence, observational studies suggest that the support with high-frequency oscillatory ventilation HFOV allows to control more cases of pulmonary hemorrhage when comparing to conventional support [ , ]. Other specific therapeutic measures include treatment with recombinant factor VIIa dose, frequency, and consistency of response not yet established in neonatal patients , nebulized epinephrine, and repeated instillations of epinephrine 0. Monitoring of the Ventilated Neonate Along with respiratory care for the ventilated neonate, ventilation monitoring is of great importance for a good oxygenation avoiding hypercapnia and hypocapnia, both associated with deleterious effects not only on preterm but also on term brain.
Pulse oximetry, pH and blood gases measurements, transcutaneous carbon dioxide measurement, and capnography are standard of care in most actual NICUs [ ]. Capnography is a standard tool in mechanically ventilated adult and pediatric patients, but it has physiological and technical limitations in neonates.
The high respiratory rate and low tidal volume in neonates require main-stream sensors with fast response times and minimal dead-space or low suction flow when using side-stream measurements. These technical requirements are difficult to fulfil in neonates and the measured end-tidal CO2 Pet CO2 , which should reflect the alveolar CO2 is often misleading, and capnography is mostly used to evaluate the trend of Pet CO2 [ ].
Online pulmonary function and mechanics testing are currently valuable tools to aid clinical decision making in the management of ventilated infants. They are a tool for assessment of patient status, therapeutic evaluation, and management guidance of infants on ventilator. The knowledge of pulmonary graphics also improves understanding of pulmonary physiology and pathophysiology and their responses to mechanical ventilatory support [ , ].
The new ventilators now provide such information and the clinicians should be familiar with. Neonatal echocardiography is a valuable and increasingly used tool in the NICU and can contribute substantially to hemodynamic management of the ventilated neonate. It has a major role in excluding a congenital heart defect, in the evaluation of pulmonary hypertension, in the evaluation of cases of hypotension or shock, and the response to therapy, as well as in the management of a patent ductus arteriosus [ ].
NIRS measures the regional cerebral saturation in oxygen and may provide an early alert of low levels of cerebral blood flow and brain oxygenation, potentially helping in preventing intraventricular hemorrhage or periventricular leukomalacia in the neonate [ ]. Lung ultrasound is an emerging tool of diagnosis and can be of added value helping in monitoring due to the specific pathology inherent in lung immaturity as well as in the particular sensitivity of neonates to repeated radiation exposure.
Conclusion In conclusion, we can say that invasive ventilation is often necessary for the treatment of newborn infants with respiratory insufficiency, and the neonatal patient has unique physiological characteristics.
Each clinical situation imposes a global attention to the overall clinical status of the patient and associated comorbidities. The importance of this review is to highlight important aspects to be taken in during care of the ventilated newborn in order to optimize patient ventilation and monitoring, simultaneously without causing lesions possibly resulting from inadequate ventilation.
Conflicts of Interest The authors declare that they have no conflicts of interest. References F. Flor-de-Lima, G. Rocha, and H. Azevedo, F. Rocha, C. Rodrigues, and H. View at Google Scholar H. Rocha, G. Vasconcellos et al. Klingenberg, K. Wheeler, N.
McCallion, C. Morley, and P. Almeida, S. Pissarra da Silva, F. Flor de Lima Caldas de Oliveira, and M. Langhammer, S. Becker-Peth, and B. Sathyamoorthy, J. Lerman, V. Okhomina, and A. Oca, M. Becker, R. Dechert, and S. View at Google Scholar T. Manczur, A. Greenough, G. Nicholson, and G. Spaeth, J.
Steinmann, S. Guttmann, and S. Fayoux, L. Devisme, O. Merrot, and B. Thomas, S. Rao, and C. F—F, Rao, C. Minutillo, B. Hullett, and M. De Michele, N. Vajaria, H. Wang, D. Sweeney, K. Powers, and J. It provides a review of respiratory care of critically ill children. The audience includes providers of pediatric and neonatal critical care in fellowship or practice.
Free Preview. Meets the need for a comprehensive reference covering the full scope of mechanical ventilation in children and neonates Clearly documents the use of mechanical ventilation in various pathologies Allows both students and experienced physicians to extract essential information easily Considers technical and equipment issues in the context of the financial constraints experienced in developing countries see more benefits. download eBook.
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About this book Written by outstanding authorities from all over the world, this comprehensive new textbook on pediatric and neonatal ventilation puts the focus on the effective delivery of respiratory support to children, infants and newborns. Show all. Pages The Neonatal Neuromechanical Unit: Generalities of Operation Mortola, Jacopo P.