This is an electronic version of the print textbook. Due to electronic rights restrictions, some third party content may be suppressed. Editorial review has deemed. he sought a short 'primer' on mechanical ventilation. None Royal Free Hospital NHS Trust, London. .. (i.e., 'good side down') means that gravity improves the. INTRODUCTION. Mechanical ventilation is an important life support technology that is an integral component of critical care. Mechanical ventilation can be.
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Free Preview ebooks can be used on all reading devices; Immediate eBook download after purchase The Conventional Modes of Mechanical Ventilation. Printed on acid-free paper upon that mechanical ventilation is as yet not an exact science: nately in an effort to bring down dead-space ventilation, it. Buy Clinical Application of Mechanical Ventilation: Read 9 Kindle Store Reviews Send a free sample Due to its large file size, this book may take longer to download; Length: Important Notice: Media content referenced within the product description or the product text may not be available in the ebook version.
The care of patients with multiple life-threatening problems is a monumental challenge. Burgeoning information has deluged the generalist and placed increasing reliance on the specialist. Predictably, this has led to the evolution of a team approach, but this does not assist the novice in critical care, with little practical and relevant information available on learning specific procedures and best practice. This new edition of Understanding Mechanical Ventilation: Physiological concepts are stressed throughout this book in order to address the specifics of mechanical ventilation, while currently accepted strategies for patients with specific disorders are reviewed in detail.
There are no outcome data to recommend on any ventilatory or respiratory assist modes for children with or without lung pathology, cardiac children, or chronically ventilated children requiring escalation of support for acute exacerbations [ 2 , 54 — 59 ]. Ventilator mode should be dictated by clinical experience and theoretical arguments, considering the pathophysiology of the disease [ 60 , 61 ].
HFOV may be considered if conventional ventilation fails strong agreement , using an open lung strategy to maintain optimal lung volume. Careful use of HFOV can be considered in cardiac children who developed severe respiratory failure. Particular caution is advised in children with passive pulmonary blood flow or right ventricular dysfunction strong agreement. Recent retrospective cohort analyses seemed to confirm adult observations of even an increased mortality with HFOV, although major methodological issues have been raised regarding these studies [ 63 — 71 ].
HFOV can judiciously be performed in obstructive airway disease and cardiac children, including those with a Fontan circulation [ 72 — 78 ]. There are insufficient data to recommend on high-frequency jet or high-frequency percussive ventilation strong agreement or airway pressure release ventilation strong agreement. HFJV should not be used in obstructive airway disease because of the risk of dynamic hyperinflation strong agreement. There are no outcome data supporting high—frequency jet HFJV or high—frequency percussive ventilation HFPV for any disease condition outside the operating theatre when managing children with airway disorders [ 79 — 85 ].
We recommend targeted patient ventilator synchrony in any triggered non-invasive positive pressure ventilation strong agreement. The effects of patient-ventilator asynchrony or interventions such as flow cycling on outcome are unclear [ 87 — 89 ].
However, better patient ventilator synchrony has been shown to improve patient comfort [ 89 — 92 ]. We recommend setting the inspiratory time and respiratory rate related to respiratory system mechanics and disease trajectory.
Both are closely correlated and cannot be judged as independent from each other strong agreement. In restrictive lung disease, we recommend a higher respiratory rate to compensate for low tidal volume and maintain minute ventilation strong agreement. There are no outcome data to guide the choice of inspiratory time or I: E ratio. However, the time constant i. At the bedside, we suggest to avoid flow end-inspiratory or expiratory flow interruption, the latter to avoid air-trapping.
We recommend that all children on respiratory support preferably should breathe spontaneously, with the exception of the most severely ill child with obstructive airway strong agreement , restrictive strong agreement or mixed disease strong agreement requiring very high ventilator settings and intermittent neuromuscular blockade strong agreement.
Caution is advised when using sedation and relaxation in the presence of cardiac dysfunction strong agreement. Although there are no data to recommend on maintaining spontaneous breathing, adult data suggest that maintaining spontaneous breathing during MV allows for a more homogeneous lung aeration and reduced risk of muscular atrophy and diaphragmatic dysfunction [ 93 — 97 ].
The only paediatric uncontrolled study on NMBA showed improved oxygenation [ 99 ]. No outcome data are available. Observational studies in severe lung injury identified a direct relationship between peak inspiratory pressure PIP and mortality [ — ]. Measuring transpulmonary pressure Ptp instead of airway pressure Paw better defines lung strain in severe lung injury, especially in the presence of increased chest wall elastance [ , ]. We recommend delta pressure i. There are no data to recommend any acceptable delta pressure in restrictive strong agreement , obstructive airway strong agreement or mixed disease strong agreement.
These observations have not been replicated in children except for one study reporting an independent association between the airway pressure gradient difference between PIP and PEEP and mortality measured under dynamic flow conditions [ ]. There are no data to recommend optimal Vt in restrictive strong agreement , obstructive airway strong agreement , mixed disease strong agreement , in cardiac children strong agreement , children with congenital disorders or chronic ventilation strong agreement.
In children with lung hypoplasia syndromes, optimal Vt may be smaller than physiologic because of the lower lung volumes strong agreement. So far, not a single value of Vt has been associated with mortality in children, irrespective of disease severity i. We recommend PEEP to prevent alveolar collapse.
However, we cannot recommend how much PEEP should be used. In severe disease, high PEEP may be needed strong agreement. PEEP should always be set finding the optimal balance between haemodynamics and oxygenation.
In order to improve oxygenation, PEEP titration should be attempted. There is no defined method to set best PEEP strong agreement. There are no data comparing low versus high PEEP in severe lung injury.
Understanding Mechanical Ventilation
However, assessment of intrinsic PEEP and Pplat may guide setting external PEEP in children with air trapping who are mechanically ventilated and sedated strong agreement. A balance needs to be found between alveolar recruitment and alveolar overdistension strong agreement. There are no data supporting external PEEP to attenuate gas-trapping by splinting the airways open or guiding the allowable amount of external PEEP to facilitate spontaneous breathing [ — ].
Careful titration of PEEP is mandated to avoid cardiovascular compromise strong agreement. If used, it should be lowly titrated to avoid hemodynamic compromise [ , ]. There are insufficient data to recommend any lung recruitment manoeuvre in children with strong agreement or without strong agreement lung injury or in cardiac children strong agreement.
Recruitment manoeuvres RM may resolve atelectasis and improve gas exchange, but there are no data showing improved outcome [ — ]. There are no outcome data to recommend on the best RM i.
There is no indication for routine RMs after endotracheal suctioning [ ]. Recommendations and long text on monitoring can be found in the ESM. We cannot recommend a specific lower or upper limit for SpO 2 for any ventilated non-cardiac child with obstructive airway, restrictive or mixed disease strong agreement. We cannot recommend a specific upper or lower limit for SpO 2 for cardiac children.
In children with cardiorespiratory failure, oxygen therapy should be titrated, balancing pulmonary disease against the underlying cardiac disorder, as well as in some conditions e.
Increasing FiO 2 up to 1. There are no studies identifying the optimal SpO 2 range in the presence or absence of lung injury. In cardiac children, children with or at risk for lung injury or children with pulmonary hypertension, target SpO 2 depends on the type and severity of laesions [ , ]. There are no data reporting the safety and necessity of liberal or restrictive oxygen therapy, but as a rule of thumb the lowest FiO 2 should be targeted [ — ].
We recommend achieving normal CO 2 levels in children with normal lungs strong agreement. For acute non- pulmonary children, higher levels of CO 2 may be accepted unless specific disease conditions dictate otherwise. However, we cannot recommend any specific pH limit.
In children at risk for pulmonary hypertension, we recommend to maintain normal pH strong agreement. We recommend using pH as non-pharmacologic tool to modify pulmonary vascular resistance for specific disease conditions strong agreement. There are no studies identifying optimal CO 2 in the presence or absence of lung injury. Normal CO 2 levels i. Increasing ventilator settings in an attempt to normalise mild hypercapnia may be detrimental [ ].
There are no outcome data on the effects of permissive hypercapnia or the lowest tolerable pH [ , ]. Normal pH and PCO 2 should be targeted in severe traumatic brain injury and pulmonary hypertension.
There are insufficient data to recommend on the timing of initiation strong agreement and approach to weaning strong agreement and the routine use of any extubation readiness testing that is superior to clinical judgement strong agreement. Assessing daily weaning readiness may reduce duration of ventilation [ — ].
There are no data supporting superiority of any approach such as protocolised weaning, closed-loop protocols, nurse-led weaning, or the usefulness of predictors for weaning success [ , , — ]. There are no data to recommend how to perform and evaluate extubation readiness testing ERT , although some studies suggest that using a minimum pressure support overestimates extubation success [ — ].
There are insufficient data to recommend the routine use of non-invasive respiratory support after extubation for any patient category. However, early application of NIV combined with cough-assist techniques should be considered in neuromuscular diseases to prevent extubation failure strong agreement.
There is only one small pilot study suggesting that the use of NIV may prevent reintubation in children at high-risk for extubation failure [ 42 ]. Although appealing, post-extubation NIV in combination with cough-assist techniques has not been confirmed to prevent extubation failure in neuromuscular patients yet [ — ]. We recommend airway humidification in ventilated children, but there are insufficient data to recommend any type of humidification strong agreement.
There are no data showing superiority or inferiority of either active or passive humidification [ — ]. However, there is great variability amongst commercially available HMEs regarding humidification efficacy, dead space volumes and imposed work of breathing [ ].
There are insufficient data to recommend on the approach to endotracheal suctioning strong agreement , but the likelihood of derecruitment during suctioning needs to be minimised strong agreement. The routine instillation of isotonic saline prior to endotracheal suctioning is not recommended strong agreement. There is no scientific basis for routine endotracheal suctioning or the approach to suctioning open vs.
There are insufficient data to recommend chest physiotherapy as a standard of care strong agreement. Use of cough-assist techniques should be considered for patients with neuromuscular disease on NIV to prevent failure strong agreement. Chest physiotherapy for airway clearance and sputum evacuation cannot be considered standard of care [ , ]. It is unclear whether cough-assist techniques add any value to patients with neuromuscular disease who require NIV, but their use should be considered to prevent endotracheal intubation [ , , — ].
Endotracheal high-volume low-pressure cuffed tubes can be used in all children. Meticulous attention to cuff pressure monitoring is indicated strong agreement. Cuff pressure monitoring has to be routinely performed using cuff-specific devices [ ]. Dead space apparatus should be reduced as much as possible by using appropriate patient circuits and reduction of swivels strong agreement.
Any component that is added after the Y piece increases dead space and may have clinical relevance [ ]. Single-limb circuits are very sensitive to leaks [ ].
Therefore, single-limb home ventilators are not suitable for invasive ventilation in the PICU [ ]. We recommend avoiding routine use of hand-ventilation.
If needed, pressure measurements and pressure pop-off valves should be used strong agreement. Recommendations for children with acute restrictive, obstructive or mixed disease should also be applied to children with lung hypoplasia syndromes who suffer from acute deterioration strong agreement. In severe or progressive underlying disease, we recommend considering whether or not invasive ventilation is beneficial for the particular child strong agreement.
For chronic neuromuscular children and other children on chronic ventilation with acute deterioration, the same recommendations as for children with normal lungs, acute restrictive, acute obstructive or mixed disease are applicable strong agreement.
Preservation of spontaneous breathing should be aimed for in these children strong agreement. In the absence of data, we suggest that the recommendations for children with acute restrictive, obstructive or mixed disease are also applicable in this patient category. Positive pressure ventilation may reduce work of breathing and afterload in LV failure, but it may increase afterload in RV failure strong agreement. In cardiac children with or without lung disease, the principles for any specific pathology will apply, but titration of ventilator settings should be carried out even more carefully strong agreement.
We cannot recommend on a specific level of PEEP in cardiac children with or without lung disease, irrespective of whether or not there is increased pulmonary blood flow, but sufficient PEEP should be used to maintain end-expiratory lung volume strong agreement. Many of the assumptions on cardiopulmonary interactions in children are mainly based on adult data [ — ]. For cardiac children, assisted rather than controlled ventilation may be preferable [ 57 , 59 ]. This means that, for cardiac children, the same principles for MV apply as for non-cardiac children [ , ].
Our consensus conference has clearly but also painfully emphasised that there is very little, if any, scientific evidence supporting our current approach to paediatric mechanical ventilation Fig. Given this absence of evidence, our recommendations reflect a consensus on a specific topic that we agreed upon.
A Practical Handbook
To date, most of what we do is either based on personal experiences or how it works in adults. This lack of scientific background should challenge everybody involved in paediatric mechanical ventilation to embark on local or global initiatives to fill this huge gap of knowledge. This European paediatric mechanical ventilation consensus conference is a first step towards a better and substantiated use of this life-saving technique in critically ill children Figs. Overview of published literature related to all aspects of paediatric mechanical ventilation for the disease conditions discussed in the consensus conference.
It is also applicable for cardiac patients, patients with congenital of chronic disease and patients with lung hypoplasia syndromes. The colour gradient denotes increasing applicability of a specific consideration with increasing disease severity. Absence of the colour gradient indicates that there is no relationship with disease severity. The question mark associated with specific interventions highlights the uncertainties because of the lack of paediatric data.
We also like to thank Mrs. Sjoukje van der Werf from the library of the University Medical Center Groningen for performing the literature search.
The authors declare the following conflicts of interest: His institution received research technical support from Vyaire and Applied Biosignals. Take-home message: The PEMVECC guidelines should help to harmonise the approach to paediatric mechanical ventilation and thereby propose a standard-of-care applicable in daily clinical practice and clinical research. Electronic supplementary material.
National Center for Biotechnology Information , U. Intensive Care Medicine.
Understanding Mechanical Ventilation - A Practical Handbook | Ashfaq Hasan | Springer
Intensive Care Med. Published online Sep Martin C. Dick G. Peter C. Author information Article notes Copyright and License information Disclaimer. Kneyber, Phone: Corresponding author. Received May 24; Accepted Aug This article has been cited by other articles in PMC. Abstract Purpose Much of the common practice in paediatric mechanical ventilation is based on personal experiences and what paediatric critical care practitioners have adopted from adult and neonatal experience.
Conclusions These recommendations should help to harmonise the approach to paediatric mechanical ventilation and can be proposed as a standard-of-care applicable in daily clinical practice and clinical research. Electronic supplementary material The online version of this article doi: Mechanical ventilation, Physiology, Paediatrics, Lung disease.
Introduction Huge variability in size, lung maturity and the range of acute and chronic diagnoses have contributed to a lack of clinical evidence supporting the daily practice of paediatric mechanical ventilation MV Fig. Open in a separate window. Methods The steering committee M. Ventilator modes We cannot make recommendations on any mode of mechanical ventilation for children with normal lungs strong agreement , obstructive airway strong agreement , restrictive strong agreement , mixed disease strong agreement , chronically ventilated children strong agreement , cardiac children strong agreement or children with lung hypoplasia strong agreement.
Setting the ventilator Triggering We recommend targeted patient ventilator synchrony in any triggered non-invasive positive pressure ventilation strong agreement. Setting the I: Maintaining spontaneous breathing We recommend that all children on respiratory support preferably should breathe spontaneously, with the exception of the most severely ill child with obstructive airway strong agreement , restrictive strong agreement or mixed disease strong agreement requiring very high ventilator settings and intermittent neuromuscular blockade strong agreement.
Setting tidal volume There are no data to recommend optimal Vt in restrictive strong agreement , obstructive airway strong agreement , mixed disease strong agreement , in cardiac children strong agreement , children with congenital disorders or chronic ventilation strong agreement. Lung recruitment There are insufficient data to recommend any lung recruitment manoeuvre in children with strong agreement or without strong agreement lung injury or in cardiac children strong agreement.
Monitoring Recommendations and long text on monitoring can be found in the ESM. Targets for oxygenation and ventilation Oxygenation We cannot recommend a specific lower or upper limit for SpO 2 for any ventilated non-cardiac child with obstructive airway, restrictive or mixed disease strong agreement. Ventilation We recommend achieving normal CO 2 levels in children with normal lungs strong agreement.
Weaning and extubation readiness testing There are insufficient data to recommend on the timing of initiation strong agreement and approach to weaning strong agreement and the routine use of any extubation readiness testing that is superior to clinical judgement strong agreement.
Supportive measures Humidification, suctioning, positioning and chest physiotherapy We recommend airway humidification in ventilated children, but there are insufficient data to recommend any type of humidification strong agreement.
Endotracheal tube and patient circuit Endotracheal high-volume low-pressure cuffed tubes can be used in all children. Miscellaneous We recommend avoiding routine use of hand-ventilation. Specific patient populations Lung hypoplasia Recommendations for children with acute restrictive, obstructive or mixed disease should also be applied to children with lung hypoplasia syndromes who suffer from acute deterioration strong agreement.
Cardiac children Positive pressure ventilation may reduce work of breathing and afterload in LV failure, but it may increase afterload in RV failure strong agreement.
Reflecting on the consensus conference Our consensus conference has clearly but also painfully emphasised that there is very little, if any, scientific evidence supporting our current approach to paediatric mechanical ventilation Fig. E ratio Set inspiratory time by respiratory system mechanics and underlying disease use time constant and observe flow-time scalar. Electronic supplementary material Below is the link to the electronic supplementary material.
Compliance with ethical standards Conflicts of interest The authors declare the following conflicts of interest: Footnotes Take-home message: References 1. Pediatric Acute Lung I. Sepsis Investigators N. European Society of P. Neonatal Intensive C Acute lung injury in children: Pediatr Crit Care Med. Invasive ventilation modes in children: Crit Care. The emphasis throughout the book is on presenting material in a reader-friendly, practical style incorporating numerous figures and tables.
Buy eBook. Effects and Complications of Positive Pressure Ventilation. Classification of Mechanical Ventilators. Operating Modes of Mechanical Ventilation. Special Airways for Ventilation. Airway Management in Mechanical Ventilation. Noninvasive Positive Pressure Ventilation. Initiation of Mechanical Ventilation. Monitoring in Mechanical Ventilation.
Hemodynamic Monitoring. Ventilator Waveform. Management of Mechanical Ventilation. Procedures Related to Mechanical Ventilation. Critical Care Issues.
Pharmacotherapy for Mechanical Ventilation. Weaning from Mechanical Ventilation. Neonatal and Pediatric Mechanical Ventilation. Mechanical Ventilation in Non-Traditional Settings. Case Studies. Appendix 1.
Reference Laboratory Values. Appendix 2. Respiratory Care Equations and Normal Values.
Appendix 3. Hemodynamic Equations and Normal Values. Appendix 4. Conversion Factors. Appendix 5. Dubois Body Surface Chart. Appendix 6. Anatomic Values in Children and Adults. Appendix 7. Selection of Airways for Children and Adults.
Appendix 8. Oxygen Transport Normal Ranges. Appendix 9. Glasgow Coma Score. Appendix Triage Scores for Mass Casualty Incidence. David W. Product details File Size: Cengage Learning; edition January 31, Publication Date: January 31, Sold by:
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