Abstract
Invasive mechanical ventilation (MV) is one of the most practiced interventions in the intensive care unit (ICU) and is unmistakably lifesaving for children with acute respiratory failure (ARF). However, if delivered inappropriately (i.e. ignoring the respiratory system mechanics and not targeted to the need of the individual patient at a specific time point in the disease trajectory), the side effects will outweigh the benefits. Decades of experimental and clinical investigations have resulted in a better understanding of three important detrimental effects of MV. These are ventilation-induced lung injury (VILI), patient self-inflicted lung injury (P-SILI), and ventilation-induced diaphragmatic injury (VIDD). VILI, P-SILI, and VIDD have in common that they occur when there is either too much or too little ventilatory assistance.
Conclusion: The purpose of this review is to give the paediatrician an overview of the challenges to prevent these detrimental effects and titrate MV to the individual patient needs.
Key Points
- MV in Pediatrics: MV is critical for managing pediatric ARF but carries risks if not tailored to patient-specific needs.
- Types of MV: Includes continuous mandatory ventilation (CMV), intermittent mandatory ventilation (IMV), and continuous spontaneous ventilation (CSV), with volume- or pressure-controlled settings.
- VILI Mechanisms: Comprises barotrauma, volutrauma, atelectrauma, and biotrauma, often caused by excessive pressures or tidal volumes.
- P-SILI Insights: Spontaneous, vigorous breathing in injured lungs can exacerbate stress and strain, leading to further damage, particularly in dependent lung regions.
- VIDD Risks: Prolonged MV can cause diaphragm atrophy due to disuse or injury from excessive workload, affecting extubation success.
- Lung-Protective Strategies: Includes limiting tidal volumes to 5–8 mL/kg and maintaining plateau pressures below 28 cmH₂O to minimize stress and strain.
- PEEP and Recruitment: Positive end-expiratory pressure (PEEP) prevents alveolar collapse, and recruitment maneuvers can improve ventilation distribution but require careful application to avoid overdistension.
- Monitoring Techniques: Parameters such as driving pressure, compliance, and esophageal pressure help optimize MV settings and reduce lung injury risk.
- Pediatric-Specific Challenges: Children’s lungs are more susceptible to injury, necessitating careful adherence to lung-protective ventilation principles, even in non-ARDS settings.
- Future Directions: Emphasis on integrating advanced diagnostics and personalized approaches to balance MV benefits and risks in pediatric populations.
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