Pediatric Ventilation
First few minute survival guide
Scenario

Emergency Department is
flooded with people who have flu
like symptoms.

14 people in two days have
been intubated in the ED who
had presented with the flu like
symptoms

ICU is full to capacity. (20 admissions in 2 days). It is suspected that many of these
people are infected with H1N1 influenza

There are two sick calls for staff this shift that we can not seem to replace

You have just been informed that all elective surgery has been cancelled until
further notice
Scenario

At 1300 hrs a toddler is carried in to the
UH Emergency Room by her mother.

The child is about 2 years old and
weighs about 35 lb or 16 kg.

The child is unresponsive and has
decreased muscle tone.
Scenario

The vital signs are;





RR ~60/min
HR 170/min
BP 110/70
Temp 38.1
SpO2 71%

Child has +++ use of
accessory muscles
 ++ in-drawing and
tracheal tug
 Unresponsive
 Skin mottled
What needs to be done?

O2/IV/monitor

Where do you find the paed nonrebreather mask?
a)
b)
c)
d)
Neo box
Back of Tower in the rescs room
Arrest cart
We don’t have any, you need to bag
Actions

The RTs place the child on 100 % via paeds
non-rebreather mask

found in the arrest cart

The RNs immediately gain IV access and
utilize the Brozelow tape to determine weight
estimate and medication and fluid
administration doses.

The Emerg consultant wants to intubate. He is
calculating the doses for sedation.
Actions

a)
b)
c)
d)
Patient is being bagged by the RT. Chest is
not moving well, but it is noticed that the
blow off valve for the bag is continually
popping off. You next actions should be;
Panic - run around in circles
Check to make sure head position and bag
valve mask technique is appropriate
Call for a STAT CXR
Insert a nasal airway
Position and technique look good

a)
b)
c)
d)
Chest still not moving well with the pop
off valve blowing off. What now?
Call a lawyer
Disable pop off valve
Get a larger bag
Nothing - You will have to live with it
Things are not going well

a)
b)
c)
d)
The pop off valve is bypassed and the chest
begins to move well, but SpO2 remains
~84% What should we do?
Confirm patient is receiving 100% oxygen
and move to intubate ASAP
Scoop and run kiddie to Children’s Hospital
Pray - Not much more can be done
None of the above
Equipment Prep

You look to the Broselow tape to find what
size ETT and blade to use. The tape
recommends a 5.0 uncuffed ETT, but you
think you should use a cuffed tube. Why?
a)
b)
c)
d)
It is likely the child will require high pressures with
ventilation and will therefore need a cuff to
ventilate effectively
Child may vomit since they were not NPO prior to
coming in.
If the tube size comes with a cuff that is what
should be inserted
Always put in a uncuffed tube on a child under 8
Intubating a child

The RRT at UH can intubate a child if;
a)
b)
c)
d)
They are >8 years old
Any age, since this is an emergency
Any age if the RT has met and maintained
the training requirements
Any age but only with a physician's order
Intubating a child

The patient is tubed easily by the ER
consultant. ETT is taped, (what level)

a)
b)
c)
d)
but SPO2 remains 88%. Next actions;
Confirm placement with absence of sounds over
the epigastrum,CO2 Detector and bilateral chest
expansion
Suction patient to confirm ETT is patent, and
rule our mucus plug.
Assess for bilateral breath sounds and chest
expansion to rule out pneuomothorax
All of the above
Let’s Ship

The ED & RT are working at capacity

Paed/Neo Transport team is called to come to
transport patient to VH Children’s Hospital. They can
not respond to assist for another 6 hours (as they are
on another run)

Call to Children’s Hospital reveals they are not
prepared to take the patient as PCCU is at capacity
and they are currently arranging to alternative space to
place that patient.

They will need 3 - 4 hours
What now?

a)
b)
c)
d)
We are stuck with this very sick toddler
for at least a few hours. – We need to
ventilate this child. What vent do you
choose?
LTV 1000
ADU
Vision
PB 840
PB 840

Ok for use down to 25 mL
 Adult Circuit is good from 10 kg and greater

Paed circuit is needed for a smaller child (<10
kg or ~ 1year old or less)
 Use _______ (circuits in the ED and RT Dept)
Initial Parameters

a)
What to set them up on?
A/C 30/min Vt 100mL, PEEP 3 cmH2O, FiO2
1.0
b) A/C 25/min, Press Control 15 (distending of
10 cmH2O) aim for VT of 5-8 mL/kg, PEEP 5,
FiO2 1.0
c) Pressure Support 15cmH2O, aim for VT of 58 mL/kg, PEEP 5 cmH2O, FiO2 1.0
d) A/C 25/min, Press Control 15 (distending of
10 cmH2O) aim for VT of 5-8 mL/kg, PEEP 5,
FiO2 0.4 (concern about rentenopathy)
Paediatric Ventilation - Initial
Parameters

Use PB 840 with adult circuit (>1 year old or
10 kg)
 FiO2 1.0
 PEEP 5 cmH2O
 Pressure control 10 cmH2O (above PEEP)



Target Vt 5-8 mL/Kg
Rate 25/min
Ti 0.6 seconds for a 1 year old and gradually
increase until reaching typical adult I times at
about 13-14 years of age
 Consult with RTs in PCCU (15565)
Initial Parameters

Pressure Control of 10 cmH2O is likely not enough. Look
for adequate chest expansion and exhaled Vt of ~5-8
mL/kg

If baby wakes up, they could possibly breathe faster than
the vent could respond. There maybe no choice but to
sedate or paralyze. H1N1 infection apparently requires
lots of sedation.

Watch BP. It may drop due to;
 Increased intrathoracic pressure
 Sedation
 decrease work of Breathing
Initial Parameters
Consult with RTs in PCCU
 PEEP strategy is very similar to what we
use in adults, but the levels may be a
little lower due to;

More compliant thorax
 Thinner and more friable


Consult with RTs in PCCU (15565)
Spontaneous breathing modes

Careful with keeping the child on straight
PSV for extended periods (during the
acute phase)

Response time for the vent may be too
slow with the very rapid RR of the child.
If the child is asynchronous with the vent,
consider sedation or paralysis.
Care for the ventilated child

What needs to be done next?
a)
b)
c)
d)
I/O line, fluid bolus
Gases and CXR
OG tube placement
All of the above
Maintenance
Abgs (heal prick for babies, Cap gases
(ear) for toddlers)
 CXR- Make sure head is neutral with the
CXR is taken.

If the head is flexed the tube will be further
out. If the head is extended the ETT may be
deeper.
 The younger the child the more pronounced
the effect

Infant Ventilation - Initial parameters

Use _______with an infant circuit (<1 year or
10 kg)
 FiO2 1.0
 PEEP 5 cmH2O
 Pressure control 10 cmH2O (above PEEP)


Target Vt 5-8 mL/Kg
Rate 30-35/min (more if very low pH pre ETT)
– max rate ~50-55/min
 Ti 0.35 seconds for a 1 year old and lower
 Consult with RTs in PCCU (15565)