Pediatric Mechanical Ventilation

A Case Presentation

Ahmed Al Gahtani, BSRC, RRT

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.

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.

CXR on Admission

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.

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

CXR

• Bilateral diffused

opacities.

• Mild cardiomegaly.

• Bilateral pulmonary

edema.

• Mild pleural effusion.

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

Initiation of Mechanical

Ventilation0620

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

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

CXR Post Intubation

• Persistent increased

opacification of both

lungs.

• Worsening mild-to-

moderate pleural

effusion.

• ETT high.

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

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%.

CXR post HFOV

• Good expansion.

• Improved aeration.

• Bilateral diffused

infiltration.

• ETT high.

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/TCOMmmHg

99.8PO2 mmHg

29.8HCO3

4.6BE

109tHb

94% / 100%SaO2/SpO2

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

CXR

• Good expansion with

bilateral infiltration

shows improvement.

• Bilateral mild pleural

effusion.

• Mild cardiomegaly.

• ETT slightly high.

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/TCOMmmHg

85PO2 mmHg

27.1HCO3

1.2BE

95tHb

94% / 95%SaO2/SpO2

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 3 V 3Trigger

21201736Time

ABG (AL)ABG (AL)Type

7.417.64pH

5422PCO2 mmHg

6755PO2 mmHg

3225HCO3

53.2BE

10385tHb

90% / 95%90% / 94%SaO2/SpO2

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

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

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

CXR

• Bilateral infiltration.

• Good expansion.

• Mild pleural effusion.

• ETT in good position.

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

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

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

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

CXR

• Good expansion.

• Mild cardiomegaly.

• Bilateral infiltration.

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:

Plan

• To maintain patient on NIV (PS), 4 hours

on then 2 hours off.

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

CXR

• Bilateral congestion.

• Bilateral diffused

infiltration.

• Pneumonia or ARDS

can not be exluded.

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.

CXR

• Bilateral congestion.

• Bilateral diffused

infiltration.

• ETT high

• Compared with

previous CXR there are

more diffused

opacification Rt ˃ Lt.

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

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

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