Mechanical ventilation or positive-pressure ventilation is ordered by a healthcare prescriber. Ventilatory parameters are set by the healthcare prescriber in collaboration with the respiratory therapist to maintain pH, partial arterial carbon dioxide (PaCO2), partial arterial oxygen (PaO2), and arterial saturations (SaO2).
It is the responsibility of the healthcare prescriber, respiratory therapist (RT), registered nurse (RN), and licensed practical nurse (LPN) to collaborate and manage the moment-to-moment ventilatory needs of the child.
The RN or LPN must have demonstrated knowledge and competence in basic ventilator mechanisms of action (Chart 115-1) and in the assessment, monitoring, and ongoing care of the child on a ventilator.
The purpose of mechanical ventilation is to promote gas exchange in the lung by producing positive intrathoracic pressure and airway pressure. This positive pressure may be delivered to the airway through a mask, cannula, or endotracheal or tracheotomy tube. The amount of gas exchange that takes place is dependent on the resistance and compliance of the lung.
The goals of positive-pressure ventilation are to maintain adequate alveolar ventilation, correct hypoxemia, and decrease the work of breathing while providing adequate respirations.
Mechanical ventilators can be categorized in three ways: those that deliver a preset amount of tidal volume, those that deliver a preset amount of inspiratory pressure, and those that deliver rates at high frequency (60 to 3,000 oscillations per minute) with low tidal volumes.
Positive-pressure ventilation is indicated for the child with respiratory failure. Hypoxemia, metabolic acidosis, respiratory acidosis, inadequate tissue oxygenation, and respiratory muscle fatigue are all signs and symptoms of respiratory failure. This may be due to acute or chronic lung injury, neurologic disorders, trauma, chemical or medical respiratory depressants (i.e., sedation, anesthesia, or pain medications), multiorgan system failure, or other disease entities.
Children receiving ventilatory support may be placed on intermittent administration or continuous drips of a sedative, pain medication, or a paralytic agent to decrease the work of breathing and allow the ventilator to work more effectively. Whenever a paralytic agent is used, sedation and pain medications are used to reduce the fear and anxiety that may be present due to the patient’s inability to move or breathe on their own.
Nonsterile gloves
Size appropriate manual resuscitation bag and face mask with a positive end-expiratory pressure (PEEP) valve
Suction equipment and size appropriate catheters
Two sources of oxygen delivery (one with oxygen flowmeter for resuscitation bag and one to attach to mechanical ventilator)
Air source (for ventilator connection) Constant electrical source
Sterile water
Mechanical ventilator with heated, filtered humidifier, and in-line thermometer
Oxygen analyzer
Stethoscope
Cardiopulmonary monitor and equipment (see Chapter 24)
Pulse oximetry equipment (see Chapter 94)
Intravascular therapy equipment (as needed) (see Chapter 53)
Prescribed sedation, pain, and/or paralytic medications.
Inform the child and the family of the need for mechanical ventilation or positive-pressure ventilation. Discuss the following:
The purpose of mechanical ventilation or positivepressure ventilation and the reason for it’s use (e.g., respiratory failure, complications of pneumonia, acid-base imbalance)
Signs and symptoms that may indicate complications of mechanical ventilation
The need for artificial airway change or removal
The need for supplemental sedation, pain control, and possible neuromuscular blockade (paralyzation)
The possibility of physical restraints, used as a last resort, to keep the child from pulling out the artificial airway while ventilated
The sensations the child may experience (i.e., noise of the ventilator, alarm sounds, breathing relief)
Prepare the family to provide interaction with the child, including touch, talking with, and providing other comfort measures, even while the child may be sedated. Discuss how the family can promote relaxation in the child and let the ventilator “breathe” for the child. Establish a way of nonverbal communication with the child (e.g., picture board, writing pad), so that the child can maintain communication, if applicable, even while intubated. Have call bell within ease of reach, if appropriate.
Determine the child’s baseline weight. This will aid in determining how much tidal volume or pressure is required for mechanical ventilation.
CHART 115-1 Terms of Mechanical Ventilation
PROCEDUREManaging the Child During System Setup
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