Intubation and Ventilation Guidelines
Paedaitrics - Intubation and Ventilation Guidelines
Rapid sequence induction for mechanical ventilation
Ventilator settings and blood gases
What to check for if ventilating poorly
INDICATIONS:
- Respiratory arrest / severe apnoea.
- Impending hypoventilation:
- Rising PaCO2 > 7.5kPa
- Clinically getting tired
- Inappropriately low respiratory rate, poor respiratory efforts, gasping respiration.
- Failure of arterial oxygenation:
- Cyanosis (Saturations <90%) requiring ≥60% oxygen on nasal CPAP
- PaO2 < 8.5kPa with inspired oxygen of ≥60%
- Other indicators of impaired oxygenation.
- Upper airway obstruction with respiratory failure (e.g. CROUP with Grade 4 stridor)
| Normal arterial blood gas values: (mmHg ≈ kPA X 7.5) | |
| pH = 7.35 - 7.45 | PaO2 = 10 - 13 kPa |
| PaCO2 = 4.5 - 6 kPa | HCO3 = 22 - 26 |
RAPID SEQUENCE INDUCTION FOR MECHANICAL VENTILATION
- Pre-oxygenate with Neopuff / Bag-mask ventilation
- Atropine 0.02mg/kg IV
- Ketamine 2mg/kg IV OR Morphine 0.1 mg/kg IV
- Scoline 2mg/kg IV (first make sure that Bag Mask ventilation is effective, as child will stop breathing!)
- Nasal intubation stat
- Confirm ventilation of both lungs clinically
- Ventilate and arrange transfer to ICU
ENDOTRACHEAL TUBE (ETT): LENGTH AND FIXATION
Nasotracheal intubation is the rout of choice. Endotracheal intubation through the mouth is used for acute resuscitation (e.g. labour ward) if nasotracheal intubation is not possible. It should be fixed in a stable position against the lip and hard palate, using zinc oxide plaster over Granuflex strips if available.Confirm ET tube position on CXR. ET tube tip should be at level of the medial ends of the clavicles.
| ETT SIZE AND LENGTH | ||
| ET tube size | Child: | (Age/4) + 4 |
| Neonate: | <1.25kg Size 2.5 ETT 1.25-3kg Size 3.0 ETT >3kg Size 3.5 ETT | |
| ET tube length (oral intubation) | Child: | (Age/2) + 12 |
| Neonate: | Weight (kg) + 6 | |
| ET tube length (nasal intubation) | Child: | (Age/2) +15 |
| Neonate: | Weight (kg) + 7 | |
STARTING VENTILATION
| Type of ventilation: | SIMV: Synchronized intermittent mandatory ventilation |
| Oxygen: | Start high and wean down. Aim for Sats > 90%. Oxygen flow rate ≥8 liters/min. |
| Rate of breathing (RR): | Start at 30-40bpm ( 6 0 bpm in neonates) |
| Inspiratory time (Ti): | 0.4-0.5 sec ( 0.4 in neonates) |
| I:E Ratio | 1:2 - 1:1.5 (will change by setting Rate and Ti) |
| Peak Inspiratory Pressures (PIP): | Paediatrics 20-25cmH2O and Neonates 18-20cmH2O Check if adequate chest wall movement. Increase if poor expansion and cyanotic. |
| Positive End Exp Pressure (PEEP): | 4-5cmH2O. Can increase if cyanosis due to atelectasis, collapse, other causes. |
| Tidal Volume (Vt): | Aim for 5-10ml/kg if no tube leaks (don’t forget leaks and dead space) |
There are different types of ventilation. In children and neonates SIMV is preferred, which gives synchronized pressure limited ventilation and support. Note that both children and their mothers are distressed during ventilation. In children, suitable sedation and pain control (e.g. morphine or midazolam infusions) must be considered. In older children and mothers need clear explanation and support.
VENTILATOR SETTINGS AND BLOOD GASES
| What will change in settings have on ventilation? | ||
| Setting | Effect on PaCO2 | Effect on PaO2 |
| ↑ FiO2 | No Change | ↑ |
| ↑ Rate (IMV) | ↓ | Minimal ↑ |
| ↑ PIP | ↓ | ↑ |
| ↑ PEEP | ↑ | ↑ |
| Cynoses: Increase the FiO2, PEEP, PIP and IT. Increase rate may help. High CO2: Increase the Rate, PIP. Decrease PEEP. Check for effective ventilation. | ||
WHAT TO CHECK FOR IF VENTILATING POORLY (DOPES!!)
D: Displaced ETT. Check position. Check chest movement.
O: Obstructed ETT. Suction tube. Listen for air entry in chest.
P: Pneumothorax. Check for equal chest movement, percussion and air entry.
E: Equipment failure. Check equipment and ventilator settings.
S: Sedation. Ensure not fighting the ventilator. Sedate adequately.
If in doubt, ventilate manually with Ambu-Bag. If above is cleared, also consider pulmonary hypertension, severe atelectasis or collapse, severe lung disease, systemic hypotension and others.
WHEN TO STOP VENTILATION
A. When the child is healing: Ventilation usually no longer required when:
- Inspired oxygen <40%
- PaCO2 < 6kPa
- PIP ≤ 15cm
- PEEP ≤ 4cm
B. When Child is Brain Death.
- Absent brain stem function.
- Fixed dilated pupils or mid-size pupils.
- Absent oculo-vestibular response to cold water into both ears alternately.
- Absent corneal / pharyngeal responses.
- Apnoea in presence of elevated PaCO2 (off ventilator 10-15min after pre-oxygenation)
- Absent occulocephalic reflex (doll’s eye reflex)
- Absent cerebral function.
In Absence of the following:
- Treatable metabolic derangement.
- Hypothermia.
- Cardiovascular shock.
- Drug intoxication.
- Neuromuscular blockade.
- Decorticate / decerebrate posturing