According to this study:
* Pressure limitation and the use of low tidal volumes are standard in the practice.
* Many aspects of pediatric mechanical ventilation management need to be investigated further.
Current practices in the management of pediatric patients on mechanical ventilation in the ICU are based, in the words of the authors of a recent review, primarily on "anecdotal experience combined with extrapolation from adult data." The authors' review of the recent literature highlights which ventilation strategies are supported and where additional research is necessary to guide practice.
The researchers reviewed studies involving several important components of ventilation management--the timing of intubation, tidal volumes, and the use of positive end expiratory pressure (PEEP). In the review of the timing of intubation, or when to intubate rather than employ noninvasive modalities, study findings suggest that noninvasive ventilation methodologies are beneficial to both adult and pediatric patients in delaying or averting the need for intubation. Determining the exact tidal volume to use in pediatric patients is more subjective, because no pediatric studies have been conducted in that area. In fact, few studies have been done to determine which tidal volumes in adults best protect the lungs from injury, but it's generally accepted that high tidal volumes should not be used--a strategy of low tidal volume and limitation of pressure is favored. Available studies have not reached a consensus on the possible benefits of using PEEP, but the review authors contend that its use is accepted as "generally safe."
Modes of ventilatory support-specifically, high-frequency oscillatory ventilation (HFOV) and airway pressure release ventilation (APRV)-were also reviewed. The researchers found that the use of HFOV has gained some attention recently, but there are few data proving its effectiveness in either adults or children. Therefore, while HFOV is an important alternative mode, it should be used primarily as rescue therapy when conventional ventilation has failed. Studies of the use of APRV in pediatric patients are scant, and its use in practice is still rare. It's thought that one advantage to APRV is the maintenance of alveolar recruitment, but concerns remain as to whether that benefit is maintained in the intermittent-release phases of ventilation.
The authors also examined studies of the use of prone positioning, calfactant, and ventilator weaning methods. Placing pediatric patients in the prone position was not proved to have been effective in acute lung injury, whereas studies investigating the use of calfactant revealed some promise in that regard. In ventilator weaning, studies support the administration of an "air leak" test to assess the risk of extubation failure and postextubation stridor; some studies support the use of corticosteroids to reduce postextubation stridor and, possibly, diminish the need for reintubation.
The authors of the review conclude that, although recent studies have provided some guidance in mechanical ventilation management, many aspects of the practice are still insufficiently investigated in the pediatric population.-AK