Consensus Statements

Mechanical Ventilation: Beyond the ICU
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Long-term Ventilatory Management
of Pediatric Patients

The respiratory system of adolescents is similar to that of adults, but in normal infants and small children, the respiratory system is immature, may be unstable, and is subject to dysfunction as well as to constant change and development. The infant lung is predisposed to lung diseases such as atelectasis, airway obstruction, increased pulmonary vascular resistance, and pulmonary edema due to developmental immaturity of pulmonary mechanics.

Infants and small children may require long-term ventilatory support due to three categories of respiratory system dysfunction:

Increased respiratory load

• bronchopulmonary dysplasia
• hypoxia and hypercapnia
• pediatric COPD
• restrictive parenchymal lung disease
• chest wall abnormalities

Ventilatory muscle weakness

• motor neuron disease
• primary myopathies—eg, Duchenne muscular dystrophy
• spinal cord injury

Failure of neurologic control of ventilation

• congenital central hypoventilation syndrome (Ondine's Curse)
• acquired central hypoventilation syndrome—eg, brainstem tumor, hemorrhage
• myelomeningocele
• developmental disorders of neurologic control of breathing—eg, apnea of prematurity

Table 7 lists criteria for respiratory failure due to cardiopulmonary disorders in infants and small children.

Table 7—Criteria for Chronic Respiratory Failure due to Cardiopulmonary Disorders in Infants and Children

Clinical criteria Decreased inspiratory breath sounds Increased retractions, use of accessory muscles Cyanosis breathing room air Decreased level of normal activity/function Poor weight gain (mass) (IMPORTANT)

Physiological criteria PaCO2 > 45 mm Hg PaO2 < 65 mm Hg Oxygen saturation < 95% breathing room air

Table 8 lists criteria for chronic respiratory insufficiency due to CNS, neuromuscular, and skeletal conditions in infants and small children.

Table 8— Criteria for Chronic Respiratory Insufficiency Due to Central Nervous System, Neuromuscular, and Skeletal Conditions in Infants and Children

Clinical criteria Weak cough Retained airway secretions Increased use of accessory muscles Incompetent swallowing Weak or absent gag reflex Decreased level of normal activity/function (IMPORTANT)

Physiological criteria Vital capacity < 15 mL/kg Inspiratory force < 20 cm H20 PaCO2 > 40 mm Hg PaO2 < 70 mm Hg Oxygen saturation < 97% breathing room air

The same as for adults, Table 3 and Table 4 list criteria for discharge to non-ICU facilities. Discharge issues unique to children include:

• assuring respiratory system stability
• assuring ventilator requirement stability—eg, specific pathophysiology may indicate use of CPAP
• assuring stability of other medical conditions

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