MONITORING & CARE OF VENTILATED PATIENT Mechanical ventilation in children is lifesaving; But it involves careful monitoring and meticulous

care of ventilated patient to ensure patient safety and successful outcome. Trained medical and nursing staff should be available all the time. Monitoring of Ventilated Child: This includes the following: 1. Clinical Assessment 2. Multiparameter Monitoring 3. Ventilator Monitoring 4. Radiological Assessment 5. Laboratory Assessment CLINICAL EVALUATION: Assess for adequacy and symmetry of chest rise as well as air entry Assess frequency and strength of Mechanical and spontaneous breaths and see whether ventilator breaths are synchronous with the patient efforts. Assess whether there is any tachypnoea or increased work of breathing Monitor the vitals hourly including Heart rate, BP noninvasive or invasive BP in sick patients, Respiratory rate, Temperature, Central and distal pulses, CFT, GCS, Pupillary size and reaction, Hourly intake and output, Abdominal distension, bowel sounds and gastric aspirates.

MULTIPARAMETER MONITORING: Oxygen Saturation: Continuous Oxygen Saturation monitoring is mandatory and helps in titrating FiO2. Aim should be to keep FiO2 as low as possible and at the same time avoiding hypoxia. Target Saturation depends on disease condition eg. Saturation target in patient with raised ICP may be 98-100% while the target in a patient with ARDS may be only 90%. Oxygen Saturation reflects the amount of Oxyhemoglobin in the blood which is the predominant form oxygen transport whereas Partial Pressure of Oxygen measured by ABG is a measure of dissolved Oxygen in Plasma. Hence weaning FiO2 can be done by monitoring the Saturation alone without need frequent blood gases. However Saturation may not be reliable in poor perfusion, excess movements and use of nail polish etc. End Tidal CO2: This an optional monitoring which helps to indirectly monitor blood CO2 levels by measuring CO2 in each expired breath. Capnography gives End Tidal CO2 level, graphic display as well as respiratory rate. ET CO2 monitoring greatly reduces the need for ABGs and helps to detect partial Tube blocks, disconnection and displacement much before clinical signs become obvious. Central Venous Pressure Monitoring: The measured CVP values in the monitor will increase when high PEEP is used in ventilating a patient. CVP should be measured at end of expiration and allowance should be given for high PEEP to account for high CVP. A low CVP in ventilated patients usually indicates hypovolemia whereas high CVP does not rule out hypovolemia. Trends of CVP, other clinical parameters and response to fluid challenge will help in assessing hydration status of the patient. VENTILATOR MONITORING

This includes: 1. Measured Parameters Expired Tidal Volume, Minute Ventilation, Peak Airway Pressure, Mean Airway Pressure, % of Leak, compliance and resistance are measured and displayed in most ventilators. Assess whether the set Trigger/ sensitivity is comfortable for patient and all breathing efforts are assisted without over-triggering. 2. Alarms Ventilator alarm limits should be set as soon as the ventilator settings are made. If settings are too narrow, it will result in too frequent alarms whereas if the alarms are too wide, serious events may not be picked by alarm.
a) High Pressure Alarm usually set about 10 cm above PIP. When high Pressure alarm is

activated, inspiratory flow to patient ends and excess gases are vented out. High Pressure alarm indicates ETT related issues like secretions, patient biting the tube or worsening of lung/airway pathology. Note If High Pressure Alarm is inappropriately set below set PIP, child will get lower PIP than set and result in hypoventilation.
b) Low Pressure Alarm usually set 5 cm below PIP. This indicates leaks in the circuit or

disconnection. Most common sites of leaks are around humidifier, water traps or any point where there are joints in the circuit. Sometimes leak may be around the ET Tube due to small size of ETT.
c) Low Minute Ventilation/ Low Tidal Volume usually set depending on respiratory rate and

Tidal Volume of 6-8 ml/kg. This indicates ETT related issues like secretions or worsening

lung/ airway pathology especially in Pressure Control Mode where Pressure will not go up but Tidal volume will go down. 3. Graphics display Most modern ventilators display real time Pressure, Volume and Flow changes in graphics format in the screen. Display may be scalars like Pressuretime, Flow-Time or Volume- Time or Loops like Pressure-Volume and Flow-Volume. Familiarity with ventilator graphics will id in early detection of problems before clinical deterioration occurs. RADIOLOGICAL EVALUATION: Chest X ray should be done immediately after Endotracheal intubation and Central Line insertion and atleast once daily and whenever there is deterioration in all ventilated patients in the acute stage. Frequency can be decreased in very stable ventilated patients. Things to be checked in the Chest X ray includes: 1. Position of ET Tube Tip It should be atleast 1 cm above carina at the level of T2 or T3 vertebra or level of Second rib. It must be remembered that ET Tube tip moves down when neck is flexed and moves up when neck is extended i.e. ET tip moves in the direction of chin. 2. Position of Nasogastric Tube should be inside stomach 3. Position of Central line Tip should be at the junction of SVC-RA or IVC-RA and not inside the heart 4. Lung volume should be able to count 8 posterior ribs when well inflated. 5. Presence of new lung infiltrates, atelectasis, pulmonary edema 6. Presence of Air leaks Pneumothorax, Pneumomediastinum, Interstitial Emphysema 7. Heart size, presence of chest wall edema

Child should be well sedated, ECG leads should be moved away from lung fields and head should be in midline during Chest xray. LABORATORY EVALUATION:

Arterial Blood Gas (ABG) should be done within 30 minutes of initiating ventilation and ideally after major setting changes and 4-6 hourly thereafter. ABG targets depend on underlying disease and emphasis should be on preventing Ventilator-induced Lung Injury rather than achieving normal Blood gas parameters.

Blood counts and biochemical parameters should be done as when clinically indicated. Microbiological testing for suspected Ventilator-associated Pneumonia or Tracheo-bronchitis like ET secretions culture when infection is suspected. Colonisation of ET Tube with oral flora is common and does not warrant Antibiotic therapy unless there are features of VAP like fever, hypothermia, elevated white cell count or new onset infiltrates in Chest X-ray.

GENERAL CARE OF VENTILATED CHILD

The head end of the patient should be elevated by 30-45o as it prevents microaspiration and VAP.

Frequent Position Change: The patient should be turned on to left and right lateral positions every 2 hours by placing a pillow or rolls.

The ventilator circuit should be kept free from condensates by keeping the water traps in a dependent position so that condensate do not drain into patients ETT. There is no need to change the circuit unless visibly soiled.

Care of ET Tube Correct Tube position should be ensured all the time by keeping the tapes dry and secure, ensuring same marking at lip level and verifying ETT position on CxR. (Prevent Displacement) If cuffed ET tube is used, Tracheal cuff should be inflated just enough to ensure that there is a palpable leak to prevent mucosal injury, sub glottis edema and later stenosis. If available, cuff pressure should be measured once every shift to ensure that the cuff pressure does not exceed 20-25 mm Hg. (Prevent Sub glottic edema/ stenosis) Suctioning the ETT (Prevent Tube Block) 1) Suction when there are secretions and not based on time. Decrease in Tidal Volume, increase Airway Pressure, Rise in ET CO2 usually indicate accumulation of secretions. 2) Child should be pre-oxygenated before suctioning for about a minute. 3) A clean technique (clean, non-sterile gloves with hand-rub disinfection) is adequate and does not increase incidence of VAP. 4) Child should be closely monitored during and after suctioning to prevent hypoxia and hypotension. 5) Doubling of ET tube internal diameter gives indication of which FG size to use. Use the lowest pressure that effectively removes secretions. 6) Catheter inserted without vacuum and inserted only deep enough to go just beyond the ETT tip and not close to carina. Suction should be applied only on withdrawal. Application of suction should be for < 10 sec and patient should be ventilated before resuctioning. 7) Routine use of saline is not recommended. It should be used only when the secretions are very thick and tenacious.

8) Routine use of in-line closed suctioning and recruitment maneuvers after suctioning is not necessary; But may be useful in situations with low compliance like ARDS.

Oral Care Frequent suctioning of oral and pharyngeal secretions especially before and after ETT suctioning is very useful to prevent micro-aspirations and VAP. Thrice daily oral hygiene with 2% Chlorhexidine is important to decrease the incidence of VAP.

Eye & Skin Care: Eye care with artificial tears and eye pads is essential if the patient is unconscious or paralysed Pressure areas and bony prominences should be well protected to prevent bed sores. In older children who are immobile, DVT prophylaxis with LMW Heparin and/ or Intermittent Pneumatic compressions are essential to prevent DVT. ANALGESIA, SEDATION & COMFORT: Presence various tubes and catheters, monitor alarms, illness, unfamiliar environment, separation for parent etc all cause pain and anxiety in ventilated children necessitating use of analgesics and sedatives. Before sedating, it must be ensured that fighting the ventilator is not due to hypoxia or cerebral ischemia. Common analgesics and sedatives used are: DRUGS ANALGESICS Morphine DOSE 20-60 microgram/kg/hr PREPARATION 1 mg/kg in 50 ml NS, gives

Fentanyl Paracetamol SEDATIVES Midazolam Syp Pedichloryl

1-5 microgram/kg/hr 20 mg/kg/dose PO Q6H 1-3 microgram/kg/min 25-50 mg/kg PO Q4-6H

1 ml/hr = 20 microgrm/kg/hr 50 microgram/kg in 50 ml NS, 1 ml/hr = 1 microgram/kg/hr 3 mg/kg in 50 ml NS, gives 1 ml/hr = 1 microgram/kg/min

Doses of analgesics and sedatives should be titrated regularly according to Pain and Sedation Scores.

Daily Drug Holiday should be practiced appropriately and weaning planned to reduce VAP and Withdrawal syndrome

Pain score in ventilated children (Behaviour Assessment Pain Score): Score Parameter Face Face muscles relaxed Facial muscle tension, frown, grimace Frequent to constant frown, clenched jaw 0 1 2

Restlessness

Quiet, relaxed appearance Normal movement Normal muscle tone Tolerating ventilator or movement (alarms not activated)

Occasional restless movement, shifting position Increased tone flexion of fingers and toes Coughing but tolerating (alarms stop spontaneously)

Frequent restless movement may include extremities or head Rigid tone Fighting ventilator, asynchrony blocking ventilation (alarms frequently activated) Difficult to comfort by talk or touch

Muscle Tone Compliance with ventilator

Consolability

Content, relaxed

Reassured by touch, distractible

Score > 4 is significant

Sedation score (Ramsay): 1 Patient is anxious and agitated or restless, or both 2 3 4 5 Patient is co-operative, oriented, and tranquil Patient responds to commands only Patient exhibits brisk response to light glabellar tap or loud auditory stimulus Patient exhibits a sluggish response to light glabellar tap or loud auditory stimulus

6 Patient exhibits no response

Muscle Relaxants should be used as sparingly as possible due to the risk of developing critical illness polyneuropathy/ myopathy. Some indications for paralysis are Raised ICP, Severe Pulmonary Hypertension, Severe ARDS with high PEEP & Inverse Ratio Ventilation. In such patients, analgesia and sedation should be adequate using muscle relaxants.

PICU Ambience:

Noise and Lighting level should be reduced and invasive procedures

avoided at night to facilitate sleep; If the child is fully awake eg GBS, frequent visit by parents, Touch & play therapy, music and videos should be encouraged.

FEEDING & NUTRITION: Once patient is stable on ventilator, Nasogastric feeds should be started at small amounts and gradually increased to full feeds to meet the caloric and protein requirement of the child; Prokinetics may be added when needed. Few patients in whom enteral feeds cannot be started like ileus, abdominal surgery should receive Parenteral nutrition. However very high carbohydrate should be avoided as it may increase CO2 production. Vitamins and micronutrient - minerals should be taken care of in long term ventilated patients.

DETERIORATION IN VENTILATED CHILDREN:

SUDDEN DETERIORATION D Displacement O - Obstruction P - Pneumothorax E Equipment failure GRADUAL DETERIORATION Partial tube obstruction Sepsis/ pneumonia Myocardial dysfunction Biochemical abnormalities

VAP BUNDLE to prevent VAP: Bundle concept was developed by Institute for Healthcare Improvement to improve patient care outcomes. A Bundle is defined as a set of evidence-based practices which when performed collectively results in improved patient outcomes. VAP Bundle is a set of practices which when performed together results in reduction in the incidence of VAP. The components of VAP Bundle for Children are:

Hand hygiene-Before and after touching the patient. Head end elevation to 30-45o. Daily sedation vacation when sedatives doses are decreased or ceased. Daily assessment of readiness to extubation Peptic Ulcer Disease Prophylaxis

Oral care protocol with 2% Chlorhexidine mouth wash atleast thrice daily and frequent pharyngeal secretion clearance.

References:
1. Venkatraman ST: Mechanical Ventilation and respiratory care. In: Pediatric Critical Care.

Fuhrman and Zimmerman (Eds). 3rd ed. Philadelphia, PA, 2006, Mosby Elsevier, 683-719.
2. Martin LD, Bratton SL, Walker LK. Principles and Practice of Respiratory Support &

Mechanical Ventiltion. In: Rogers Textbook of Pediatric Intensive Care. 3rd ed. William & Wilkins, 1996.
3. Suchitra Ranjit: Setting up the ventilator and Care of ventilated patient; In: Manual of

Pediatric Emergencies and Critical Care. 2nd Ed. Paras Medical Publisher, 2010.