Chapter 36: Pediatric Intensive Care – Respiratory Support, Intubation, Ventilation, Weaning

Post‑resuscitation stabilization · Indications for MV · Intubation technique · Ventilator modes & settings · Consequences · Newer strategies (HFOV, APRV) · Weaning protocol
🫁 Core principles: Post‑ROSC stabilization (optimize BP, oxygenation, temperature). Indications for MV: apnea, failure to protect airway, impending respiratory failure. Intubation: RSI, tube size (age/4 +4), ETCO2 confirmation. Ventilator settings: tidal volume 4-8 mL/kg, PEEP, FiO2. Weaning: decreasing support, spontaneous breathing trials.

📘 Pediatric Intensive Care: post‑resuscitation, ventilation, weaning

🔄 Post‑resuscitation stabilization
Maintain SpO2 94-99%, normocapnia, normotension. Targeted temperature management (normothermia). Avoid hyperoxia/hypoxia. Organ perfusion assessment.
🫁 Indications for mechanical ventilation (MV)
Apnea, inadequate ventilation (↑PaCO2), hypoxemia refractory to O2, inability to protect airway (GCS ≤8), impending respiratory failure, neuromuscular weakness.
🦷 Technique of intubation
RSI: etomidate/ketamine + rocuronium (1 mg/kg). Tube size (ID): (age/4)+4 (cuffed) or (age/4)+3.5 (uncuffed). Confirm with capnography, breath sounds, CXR.
⚙️ Ventilator settings (volume/pressure control)
Tidal volume 4-8 mL/kg (ideal body weight). Rate: age‑dependent (infants 20-40, older 12-20). PEEP 5-8 cmH2O, FiO2 to target SpO2 92-96%.
⚠️ Consequences of ventilation
Barotrauma/volutrauma (pneumothorax), hemodynamic compromise (↓ preload), VILI, atelectasis, VAP (ventilator‑associated pneumonia).
🆕 Newer ventilation strategies
High‑frequency oscillatory ventilation (HFOV) for severe ARDS; APRV (airway pressure release ventilation); pressure‑regulated volume control (PRVC).
📉 Weaning ventilation
Daily spontaneous breathing trials (SBT) on minimal support. Reduce rate, FiO2, PEEP. Assess readiness: adequate gas exchange, hemodynamic stability, intact respiratory drive.
📊 Key formulas: ETT depth (cm) = 3 x tube ID (internal diameter). Rapid shallow breathing index (RSBI) <100 predicts weaning success.

🔍 Approach to the child requiring intensive care & ventilation

1
Recognize respiratory failure – Hypoxemia (SpO2 <90% on FiO2 >0.4), hypercapnia (PaCO2 >50 mmHg with acidosis), increased work of breathing, or apnea.
2
Post‑resuscitation stabilization – After ROSC: target normothermia (36-37.5°C), maintain BP, avoid hyperoxia (SpO2 94-98%). Consider EEG for seizures.
3
Safe intubation (RSI) – Preoxygenate, prepare drugs, equipment (suction, ETT, bag). Use cuffed ETT in children (except neonates?). Confirm position.
4
Initial ventilator settings – Volume control (6 mL/kg), PEEP 5, rate age‑appropriate. Adjust to achieve PaCO2 35-45, SpO2 >92%.
5
Weaning readiness – Daily screen: FiO2 ≤0.4, PEEP ≤8, hemodynamic stability, spontaneous breathing trial (T‑piece or low PS).

📋 Stepwise management – mechanical ventilation & weaning

1
Post‑intubation stabilization – CXR to confirm ETT position (T4‑T6). Capnography waveform. Secure tube, sedation/analgesia (fentanyl, midazolam).
2
Ventilator management (lung protective) – Tidal volume 4-8 mL/kg (ideal body weight), plateau pressure <28-30 cmH2O. Use PEEP to optimize oxygenation.
3
Consequences – prevention strategies – VAP prevention: head of bed elevation, oral care, subglottic suctioning. Avoid volutrauma, hemodynamic monitoring.
4
Advanced modes (HFOV, APRV) – HFOV for refractory hypoxemia (high mean airway pressure, low tidal volumes). APRV for ARDS (spontaneous breathing allowed).
5
Weaning protocol – Daily SBT (30-120 min) on CPAP or low pressure support. Extubate if: stable gas exchange, good cough, minimal secretions, no stridor after cuff leak.
⚡ Key reminder: Cuffed ETT preferred in children >1 year (better leak detection, lower reintubation). Use size (age/4)+4. Post‑extubation stridor → nebulized adrenaline and dexamethasone.

🧠 Reflex prompts – PICU, ventilation, weaning

📏 Uncuffed ETT size formula (child >2 years)?
(Age/4)+3.5 (cuffed: +4).
🫁 Initial tidal volume setting (volume control)?
6 mL/kg ideal body weight (range 4-8 mL/kg).
⚠️ Most common complication of mechanical ventilation?
Ventilator‑associated pneumonia (VAP).
🧪 Weaning predictor – RSBI (rapid shallow breathing index)?
RSBI = f/Vt (breaths/min/L). Value <100 suggests weaning success.
🔥 Mode of choice for severe ARDS with hypoxemia?
High‑frequency oscillatory ventilation (HFOV) or APRV.
🩺 Post‑extubation stridor – treatment?
Nebulized racemic adrenaline + dexamethasone (0.25-0.5 mg/kg).