pediatric mechanical ventilation, case presentation

1. Pediatric Mechanical Ventilation
A Case Presentation
Ahmed Al Gahtani, BSRC, RRT

2. Case Introduction
• Chief Complaint: Beta Thalassemia Major.
• HPI: Patient is 9 y/o girl suffering from Beta
Thalasemia Major since infancy. She was
admitted for ALLOSCT.
• Family History: Her sister suffers from same
disease, received allogenec stem cell
transplantation 12 years ago.
• Weight: 23 Kg.

3. Physical Examination
• Vitals: Temp 36.7, HR 81, RR 20, SpO2 98%.
• General: Alert and oriented, no acute distress.
• HENT: Normocephalic.
• Respiratory: Normal respiration, clear breath
sounds.
• CVS: Regular rate and rhythm, S1+S2, normal
peripheral perfusion.
• Abdomine: Soft.

4. CXR on Admission

5. Physical Examination
• Impression & Plan: Patient stable, to receive
ALLOSCT, to be discharged 30 days after the
procedure.
• The procedure was done on 26/9/2011 with no
complication.

6. RRT Activation 13/10/2011
• RRT was activated due to increased oxygen
requirement, decreased LOC, and bleeding.
• Vitals:
• VBG:
• CXR ordered, patient received one dose of lasix.
• RRT decided to admit patient to PICU.
GCSSpO2RRHRBPTemp
15/1595%/10L72148137/8637.6
SvO2tHbBEHCO3PO2PCO2pH
66%/10L1240.127.238537.31

7. CXR
• Bilateral diffused
opacities.
• Mild cardiomegaly.
• Bilateral pulmonary
edema.
• Mild pleural effusion.

8. PICU Admission
• Patient admitted on SFM 10 LPM.
• Vitals:
• Patient continued to have respiratory distress
require high oxygen, tachypenic, with patchy
opacities on CXR.
• Patient was intubated with ETT size 6.0 with no
complication.
SpO2RRHRBPTemp
93%/10L54133117/6837.1

9. Initiation of Mechanical
Ventilation
0620
PCVMode
30 / 36Rate (Set/Meas)
100% / 93%FiO2/SpO2
----- / 135Vt (Set/Exh)
5.2MV (Exh)
20 / 37PC (Set/PIP)
23MAP
15PEEP
0.62Ti
V 3Trigger
0657
ABG (AL)Type
7.21pH
73.5PCO2 mmHg
126PO2 mmHg
29.6HCO3
- 0.2BE
130tHb
93% / 98%SaO2/SpO2

10. Patient Assessment
• Vitals:
• CNS: Pt on Fentanyl and Midazolam.
• CVS: Sinus Tachycardia, S1+S2, capillary refill ˂ 3
sec, with flat neck veins. No inotrops.
• Resp: Pt on MV (PCV), symmetrical chest rise,
acyanotic, high PIP, large amount of thick bloody
secretion, good A/E with bilateral coarse crackles.
• Renal: Fluid balance +200, on Lasix 5 mg/hr.
SpO2/FiO2RRHRBPTemp
94%/100%54137127/7138

11. CXR Post Intubation
• Persistent increased
opacification of both
lungs.
• Worsening mild-to-
moderate pleural
effusion.
• ETT high.

13. Initiation of HFOV
0835
HFOVMode
7 HzFreq
100% / 92%FiO2/SpO2
28MAP
60Amp
25Flow
33%Ti %
18 / 39Alarms
0921
ABG (AL)Type
7.47pH
44.3PCO2 mmHg
205.5PO2 mmHg
29.1HCO3
5.0BE
122tHb
99% / 100%SaO2/SpO2
Appearance
Good Chest Wiggle
Symmetrical
Acyanotic

14. Respiratory Care Plan
• Wean MAP to 26 cm H2O if CRX shows adequate
expansion.
• Then wean MAP by 1 cm H2O Q6 hours.
• Obtain CXR.
• ABG Q6 hours + PRN.
• Targeting normal pH and SpO2 ≥ 90%.

15. CXR post HFOV
• Good expansion.
• Improved aeration.
• Bilateral diffused
infiltration.
• ETT high.

16. HFOV Alteration
1209
HFOVMode
7 HzFreq
40% / 92%FiO2/SpO2
26MAP
60Amp
25Flow
33%Ti %
18 / 39Alarms
1247
ABG (AL)Type
7.42pH
46.5 / 42PCO2/TCOM
mmHg
99.8PO2 mmHg
29.8HCO3
4.6BE
109tHb
94% / 100%SaO2/SpO2

17. Day 4 in PICU
• Vitals:
• CNS: Pt on Fentanyl, Midazolam, and Atracurium.
• CVS: Sinus Tachycardia, S1+S2, capillary refill ˂ 3
sec, with flat neck veins. On levophed & dopamine.
• Resp: Pt on HFOV, good chest wiggle, acyanotic,
with moderate amount of thick brown secretion,
targeting pH 7.30 & SpO2 ≥ 90% .
• Renal: Fluid balance - 500, on Lasix 5 mg/hr.
SpO2/FiO2RRHRBPTemp
95%/40%HFOV115100/6536.5

18. CXR
• Good expansion with
bilateral infiltration
shows improvement.
• Bilateral mild pleural
effusion.
• Mild cardiomegaly.
• ETT slightly high.

19. Mechanical Ventilation
1300
HFOVMode
9 HzFreq
40% / 92%FiO2/SpO2
20MAP
55Amp
25Flow
33%Ti %
15 / 25Alarms
1429
ABG (AL)Type
7.35pH
49.5 / 47PCO2/TCOM
mmHg
85PO2 mmHg
27.1HCO3
1.2BE
95tHb
94% / 95%SaO2/SpO2

21. Mechanical Ventilation
19301630Time
PCVPCVMode
16 / 1630 / 30Rate (Set/Meas)
50% / 96%50% / 100%FiO2/SpO2
----- / 188---- / 250Vt (Set/Exh)
3.19.9MV (Exh)
18 / 3024 / 34PC (Set/PIP)
1618MAP
1110PEEP
0.970.79Ti
V 3V 3Trigger
21201736Time
ABG (AL)ABG (AL)Type
7.417.64pH
5422PCO2 mmHg
6755PO2 mmHg
3225HCO3
53.2BE
10385tHb
90% / 95%90% / 94%SaO2/SpO2

22. Day 5 in PICU
• Vitals:
• CNS: Pt on Fentanyl & Midazolam.
• CVS: Sinus Rhythm, S1+S2, capillary refill ˂ 3 sec,
with flat neck veins. On dopamine.
• Resp: Pt on CMV (PCV), symmetrical, acyanotic,
with large amount of thick brown secretion, good
A/E clear breath sounds, targeting pH 7.30 & SpO2
≥ 90% .
• Renal: Fluid balance - 521, on Lasix 2 mg/hr then
off.
SpO2/FiO2RRHRBPTemp
99%/45%1610099 / 6836.4

23. Mechanical Ventilation
08450815Time
SPRVCPCVMode
14 / 1416/ 16Rate (Set/Meas)
40% / 99%45% / 98%FiO2/SpO2
180 / 177---- / 206Vt (Set/Exh)
2.73.6MV (Exh)
---- / 2717 / 28PC (Set/PIP)
12 / ---------PS (Set/Meas)
1315MAP
911PEEP
0.960.97Ti
V 3V 3Trigger
1030
ABG (AL)Type
7.41pH
55PCO2 mmHg
80PO2 mmHg
34HCO3
8.9BE
95tHb
92% / 97%SaO2/SpO2

24. Day 13 in PICU
• Vitals:
• CNS: Pt on Fentanyl, GCS 13/15.
• CVS: Sinus Rhythm, S1+S2, capillary refill ˂ 3 sec,
with flat neck veins. No inotrops.
• Resp: Pt on CMV (PSV), symmetrical, acyanotic,
with moderate amount of thick white secretion, good
A/E clear breath sounds, targeting pH 7.28 & SpO2
≥ 90% .
• Renal: Fluid balance – 1.4 L.
SpO2/FiO2RRHRBPTemp
97%/35%2897101 / 5937.2

25. CXR
• Bilateral infiltration.
• Good expansion.
• Mild pleural effusion.
• ETT in good position.

26. Mechanical Ventilation
1135Time
PSVMode
27Rate (Meas)
35%/97%FiO2/SpO2
145Vt (supported)
4.0MV (supported)
10PS (Set/Meas)
7MAP
5PEEP
V 3Trigger
1416
VBGType
7.38pH
53PCO2 mmHg
40PO2 mmHg
32HCO3
5.6BE
102tHb
75% / 99%SaO2/SpO2

28. Day 13 in PICU
• Patient was extubated @ 1445 to NC 3 LPM with no
complication.
• Vitals: HR 104, BP 93/60 (66), RR 30,
SpO2 100%
• B/S: clear bilateral, with good A/E.
• Potential Risks: Stridor, atelectasis, or difficulty
clearing secretions.
• Plan: Racrmic Epi, CPT (IS), NTS as needed

29. Day 13 in PICU
• Oxygen requirement
increased.
• Respiratory rate in the
30s and 40s.
• Patient on SFM 8 to
10 LPM.
1600
VBGType
7.43pH
50PCO2 mmHg
38PO2 mmHg
32.5HCO3
7.2BE
104tHb
69% / 99%SaO2/SpO2

31. Day 14 in PICU
• Vitals:
• CNS: Pt on Midazolam & Precedex.
• CVS: Sinus Rhythm, S1+S2, capillary refill ˂ 3 sec,
with flat neck veins. No inotrops.
• Resp: Pt on 8 LPM SFM, symmetrical, acyanotic,
with decreased A/E and clear breath sounds,
targeting pH 7.28 & SpO2 ≥ 90% .
• Renal: Fluid balance – 183 cc.
SpO2/FiO2RRHRBPTemp
92%/10 LPM3593121 / 6037.8

32. CXR
• Good expansion.
• Mild cardiomegaly.
• Bilateral infiltration.

33. Initiation of NIV
1000Time
NIV (PS)Mode
30Rate (Meas)
35%/98%FiO2/SpO2
160Vt (supported)
4.8MV (supported)
10PS (Set/Meas)
5PEEP
1345
VBGType
7.40pH
47PCO2 mmHg
40PO2 mmHg
29.1HCO3
3.7BE
95tHb
76% / 100%SaO2/SpO2
• Patient continue on SFM 8LPM, SpO2 89%, RR in
the 40s, with increased WOB.
• Team decided to start the patient on NIV as follow:

34. Plan
• To maintain patient on NIV (PS), 4 hours
on then 2 hours off.

35. Day 19 in PICU
• Vitals:
• CNS: no sedation, GCS 15/15, agitated & anxious.
• CVS: Sinus Tachycardia, S1+S2, capillary refill ˂ 3
sec, with flat neck veins. No inotrops.
• Resp: Pt is alternating on and off NIV (PS 12/ PEEP
7 with FiO2 60%), with increased oxygen
requirement and tachypenia with increased WOB,
targeting pH 7.28 & SpO2 ≥ 90%.
• Impression: pulmonary hemorrhage with
respiratory distress.
SpO2/FiO2RRHRBPTemp
93% / 60%45120130 / 8538

36. CXR
• Bilateral congestion.
• Bilateral diffused
infiltration.
• Pneumonia or ARDS
can not be exluded.

38. Day 19 in PICU
• Patient was reintubated @ 2200 due to moderate-
to-severe distress.
• B/S: equal bilateral with coarse crackles.
• No complication.
• CXR ordered.

39. CXR
• Bilateral congestion.
• Bilateral diffused
infiltration.
• ETT high
• Compared with
previous CXR there are
more diffused
opacification Rt ˃ Lt.

40. Mechanical Ventilation
23002200Time
PCPRVCMode
30 / 3030 / 30Rate (Set/Meas)
100% / 87%100% / 91%FiO2/SpO2
---- / 193180 / 176Vt (Set/Exh)
6.86.2MV (Exh)
26 / 35---- / 37PC (Set/PIP)
2021MAP
88PEEP
0.790.79Ti
V 3V 3Trigger
2325
ABG (AL)Type
7.25pH
60PCO2 mmHg
55PO2 mmHg
21.5HCO3
- 5.9BE
95tHb
82% / 87%SaO2/SpO2
Sedation
Fentanyl
Midazolam

42. Day 19 in PICU
04582345Time
HFOVHFOVMode
6 Hz8 HzFreq
70% / 94%100% / 84%FiO2/SpO2
3527MAP
7555Amp
3025Flow
33%33%Ti %
33 / 4220 / 32Alarms
0550
ABG (AL)Type
7.40pH
35PCO2 mmHg
79PO2 mmHg
24HCO3
- 3.8BE
92tHb
95% / 97%SaO2/SpO2

44. THANK YOU