Neonatal and Pediatric Respiratory Care; Brian Walsh

Invasive mechanical ventilation of the neonate and pediatric patient

Patient–ventilator interface
Understanding the ventilator circuit is an integral aspect of ventilator management. The circuit is the
interface between the ventilator and the patient system. There are five major factors to consider when
assessing the impact of the circuit on ventilation:

• Compressible volume

• Air leak

• Dead space
• Resistance
• Humidification

Compressible volume
The influence of compressible volume on effective tidal volume during volume control ventilation was
discussed earlier (see Adaptive Ventilation). When the ventilator delivers a breath, pressure inside the
circuit increases and compresses the gas volume within the circuit. This compressed volume never
reaches the patient, and the inspired volume is less than the set volume. During expiration, however,
the compressed volume passes through the exhalation valve and may be (depending on ventilator
design) measured as part of the patient’s exhaled volume. This may result in the patient’s actual
inflation volume being less than that recorded as exhaled volume. If the actual volume delivered to the
lungs of a critically ill infant or young child is not accurately known, the patient may be at risk for
atelectasis, hypoxia, and hypercapnia. All mechanical ventilators that do not measure tidal volume at
the proximal airway calculate the compressible volume during the preuse check. The humidifier also
represents a source for gas compression and is included in calculating compressible volume. It is best
practice to perform the calculation with the circuit and humidifier that will be used for that patient.
Using a constant-level self-feeding humidifier is necessary to minimize variations in compressible
volume in all pediatric ventilation situations. When tidal volumes are measured with a proximal flow
sensor placed at the ETT, ventilator circuit compliance and the confounding circuit variables are no
longer pertinent factors.

Air leak
In the pediatric clinical setting, it is important not to confuse compressible volume loss with air leak. Air
leaks are most notable around a cuffless ETT or tracheostomy tube. Accurately monitoring tidal volume
is difficult in the presence of an air leak. An excessive air leak compromises tidal volume delivery,
reduces lung-distending pressure, and may adversely affect the ventilator triggering mechanism. In
general, air leaks are monitored by the difference between the inhaled and exhaled volumes. Another
way to identify an air leak is by examining the volume-time curve graphics. Figure 17-12 illustrates an air
leak on a volume waveform. In most clinical situations, an air leak greater than 15% of the delivered
tidal volume makes volume ventilation difficult. Usually reintubation is necessary to maintain consistent
volume ventilation and adequate triggering of the ventilator.

FIGURE 17-12Air leak shown on a volume/time scale. Volume never returns to baseline before the
ventilator cycles again.

Dead space and resistance

Dead space (of the ventilator circuit) is the portion of the circuit distal to the main bias flow or circuit
where gas can be rebreathed. This includes the volume of the circuit wye connector, the elbow, any
monitoring device attached to the ETT connector, the ETT, and the conducting airways. The conducting
airways are known as anatomical dead space and are not influenced by the circuit. However, the dead
space added to the circuit is mechanical dead space. With smaller pediatric volumes, mechanical dead
space may result in undesired rebreathing of carbon dioxide. Specially designed pediatric or infant
monitoring devices and circuits help minimize this. Overzealous application of low dead space
monitoring devices may result in increased resistance at the airway if the proper size is not used.
Another component to evaluate as a choke point for gas flow is the adaptor connecting the tubing to the
elbow or the ETT. A rule of thumb is that the ETT should be the point of highest circuit resistance, and
mechanical dead space of 0.5 to 1.0 mL is acceptable. Although the absolute dead space may be 0.5 to
1.0 mL, often fresh gas will penetrate through the mechanical dead space.39 If a circuit component is
smaller in cross-sectional area than the ETT, another circuit or component should be used.

Volutrauma/atelectrauma/barotrauma
Alveolar overdistention is a primary cause of complications encountered during MV and is a result of
high ventilating pressures (barotrauma), large tidal volumes (volutrauma), and repetitive opening and
closing of the terminal lung units at low lung volumes (atelectrauma). Extrapulmonary air leaks, in the
form of pneumothorax, pneumomediastinum, pneumoperitoneum, and subcutaneous emphysema, are
the most notable complications and are the result of overdistention of alveolar and peribronchial
tissues. Treatment consists of detecting the leak, decreasing tidal volume, and decreasing PEEP, relieving
the leak with a chest tube if necessary. Permissive hypercapnia could also be a useful tool in the
treatment of an air leak. Rescue modes such as HFJV, HFOV, and extracorporeal membrane oxygenation
are implemented for excessive air leakage that does not respond during CMV.

Overdistention also causes a decrease in static compliance, an increase in the work of breathing, an
increase in anatomic dead space, an increase in the air leak around the ETT, and possible difficulties in
weaning. As compliance diminishes, the Paco2 may rise or fail to improve. To counter this, ventilation is
increased, which may lead to further distention.

Because volumes are smaller in neonatal and pediatric patients than in adults, avoiding and detecting
overdistention are critical in ventilator management. Alarms that may help detect this are indirect and
can be activated by other problems. These alarms may include high mPaw; exhaled minute ventilation
and tidal volume; high peak pressure; high PEEP; high respiratory frequency; and inverse I/E ratio.
Measures such as using an end-expiratory pause to look for incomplete exhalation and an increase in
PEEP or to detect auto-PEEP, measuring optimal static compliance, inspecting pressure–volume loops to
determine overdistention or exhaled resistance, monitoring changes in mPaw, and obtaining a chest
radiograph all help to detect overdistention.