Pediatric ICU management
David E. Wesson, Bindi Naik-Mathuria in Pediatric Trauma, 2017
Lung-protective ventilation describes a strategy to achieve adequate (not necessarily normal) gas exchange by using low VT to prevent overdistention of the lung, PEEP to reduce atelectasis, and minimal required FiO2 to avoid oxidative stress. These practices have largely been extrapolated from studies of adult ICU patients with ARDS [42], although there is also significant interest in the neonatal population where lung-protective strategies have been shown to reduce risk for bronchopulmonary dysplasia and retinopathy of prematurity [43]. In general, VT should be 6 mL/kg of body weight, PEEP should range between 5 and 12 cm H2O, and FiO2 should be maintained at the lowest possible level to keep oxygen saturation between 88% and 94%. Plateau pressure should not exceed 30 cm H2O; however, higher pressures may be tolerated in patients with chest wall trauma that reduces compliance. Permissive hypercapnia, as appropriate, allows us to maintain low VT ventilation.
Diagnosis and Treatment of COVID-19
Wenguang Xia, Xiaolin Huang in Rehabilitation from COVID-19, 2021
Invasive mechanical ventilation: Use lung protective ventilation strategy, that is, small tidal volume (6–8 mL/kg ideal body weight) and low level of airway plateau pressure (≤ 30 cm H2O) for mechanical ventilation to reduce ventilator-related lung injury. When the airway plateau pressure is ≤ 35 cm H2O, high positive end-expiratory pressure (PEEP) can be appropriately used. Keep the airway warm and humid, avoid prolonged sedation, awaken patients early, and perform pulmonary rehabilitation treatment. For those patients who encounter problems with man-machine synchronization, sedation and muscle relaxants should be used in time. According to the airway secretions, closed sputum suction should be considered, and bronchoscopy should be performed if necessary.
Critical Care of the Trauma Patient
Kenneth D Boffard in Manual of Definitive Surgical Trauma Care: Incorporating Definitive Anaesthetic Trauma Care, 2019
Ventilatory support should be instituted earlier rather than later; select a mode of ventilation tailored to the patient's need using appropriate tidal volumes and amounts of positive end-expiratory pressure (PEEP): Pressure support ventilation (PSV) – poorly tolerated following severe injury.Lung protective ventilation (LPV) with low volume and low peak pressures is frequently not possible early in resuscitation due to severe hypoxia and low compliance, use adequate volumes despite the frequent requirement for higher pressures.High positive end-expiratory pressure PEEP (>10 up to 20–25 cm H2O may be required) to recruit alveoli.ECMO (extracorporeal membrane oxygenation) may be considered where appropriate (see also Section 17.3).Non-invasive ventilatory support in selected cases only.A safe strategy is to maintain a driving pressure (plateau pressure – PEEP) of <15 cm water while accounting for lung injury.4
Lung and diaphragm protective ventilation: a synthesis of recent data
Published in Expert Review of Respiratory Medicine, 2022
Vlasios Karageorgos, Athanasia Proklou, Katerina Vaporidi
The pressure that develops within the respiratory system at the end of inspiration, the plateau pressure, was the first indicator of lung stress used in clinical practice [4]. The ratio of tidal volume (VT) to respiratory system compliance (CRS), termed driving pressure (ΔP, calculated as the difference between passive Pplat and PEEP), better reflects the lung stress since the respiratory system compliance is strongly related to the functional lung size [13]. Retrospective analysis of large patient datasets [13,14] and prospective studies have identified a threshold of ΔP above 15 cmH2O to be associated with adverse patient outcomes [13,15]. Importantly, a recent analysis showed an association with improved mortality when pre-specified changes in ventilator settings resulted in a decrease of ΔP, but not, when they only resulted in an increase in PaO2/FiO2, again emphasizing the potential benefit of targeting driving pressure in clinical practice [16].
Targeting transpulmonary pressure to prevent ventilator-induced lung injury
Published in Expert Review of Respiratory Medicine, 2019
Luciano Gattinoni, Lorenzo Giosa, Matteo Bonifazi, Iacopo Pasticci, Mattia Busana, Matteo Macri, Federica Romitti, Francesco Vassalli, Michael Quintel
In order to better characterize lung mechanics, PL must be estimated under static conditions when the flow in the system is equal to zero. This is mandatory to avoid taking into account the pressure needed to overcome the airway resistances. The airway pressure that is measured under static conditions, during an inspiratory hold, is the plateau pressure, which results from the sum of the pressures associated to both tidal volume and the volume of PEEP, if present. The importance of Plateau pressure lies in the fact that it is often considered a reflection of alveolar pressure (Palv), which is the real pressure distending the respiratory system [31]. It must be kept in mind, however, that the assumption that Plateau Pressure = Palv is only true when there is a total communication between the airways and the alveoli, which may not be true in the ARDS patients who often develop airway occlusion or alveolar flooding [32].
Lifestyle and rehabilitation during the COVID-19 pandemic: guidance for health professionals and support for exercise and rehabilitation programs
Published in Expert Review of Anti-infective Therapy, 2021
Cássia Da Luz Goulart, Rebeca Nunes Silva, Murilo Rezende Oliveira, Solange Guizilini, Isadora Salvador Rocco, Vanessa Marques Ferreira Mendez, José Carlos Bonjorno, Flavia Rossi Caruso, Ross Arena, Audrey Borghi-Silva
Due to the potential severity of pulmonary lesions associated with SARS-CoV-2, infected patients may evolve to severe SARS in a few hours post hospital admission [86]. This observation underlines the clinical recommendation of early invasive mechanical ventilation. Protective ventilatory strategies are highly recommended in these patients by early adoption of the following: 1) lower tidal volume (between 4 to 6 ml/kg of predicted body weight for severe ARDS and 4 to 8 ml/kg for mild to moderate SARS); 2) controlled positive end expiratory pressure (PEEP) by PEEP table of ART Study (preference of high PEEP levels) [92] or by an individual lung compliance best threshold; 3) driving pressure lower than 15 cmH2O (plateau pressure minus PEEP); 4) plateau pressure below 27 cmH2O; and 5) inspiratory fraction of oxygen combined with PEEP management to achieve a SpO2 between 92 to 95% [93]. Moreover, following intubation, attention regarding the degree of SARS is required. It is recommended to pay closer attention to some parameters, such as the ratio of SpO2 and O2 inspired fraction offered (PaO2/FiO2) for mechanical ventilation management. Studies report that, even with early adoption of protective lung ventilation and closer adjustment of PEEP, patients often preset with a PaO2/FiO2 below 150 mmHg [94]. Therefore, it is important to detect these alterations within 4 hours after intubation for early adoption of the prone position strategy.
Related Knowledge Centers
- Pulmonary Alveolus
- Modes of Mechanical Ventilation
- Mechanical Ventilation
- Ventilator