Mechanical Ventilation of Pediatric Patients in the Emergency Department -

Mechanical Ventilation of Pediatric Patients in the Emergency Department
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Publication Date: July 2020 (Volume 17, Number 7)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B CME credits. CME expires 7/01/2023.


Casey Carr, MD
Critical Care Fellow, University of Florida Shands, Gainesville, FL
Courtney W. Mangus, MD, FAAP
Clinical Lecturer, Departments of Emergency Medicine & Pediatrics, The University of Michigan, Ann Arbor, MI
J. Kate Deanehan, MD, RDMS
Assistant Professor, Pediatric Emergency Medicine, Johns Hopkins Children’s Center, Baltimore, MD

Peer Reviewers

Nicole Gerber, MD
Assistant Professor of Clinical Pediatrics, Department of Emergency Medicine, Division of Pediatric Emergency Medicine, New York- Presbyterian/Weill Cornell Medical Center, New York, NY
Garrett S. Pacheco, MD
Assistant Professor, Residency Associate Program Director, EM and Combined EM & Pediatrics, Departments of Emergency Medicine and Pediatrics, University of Arizona, Tucson, AZ


When pediatric patients require mechanical ventilation in the emergency department, the emergency clinician should be prepared to select initial ventilator settings and respond to an intubated patient’s dynamic physiologic needs to ensure ongoing oxygenation, ventilation, and hemodynamic stability. Pressure-targeted ventilation is generally recommended in pediatric patients, with initial ventilator settings varying depending on age and the etiology of respiratory failure. This issue reviews indications for mechanical ventilation and offers recommendations for ventilator settings and dosing of analgesics, sedatives, and neuromuscular blockers, with a focus on patient populations in whom the approach to mechanical ventilation may be different.

Excerpt From This Issue

A 2-month-old boy presents to your community ED with intermittent apnea, cough, and congestion. He was born at 34 weeks’ gestation, and his current weight is 4.5 kg. His parents report the infant's 3-year-old sister was recently diagnosed with respiratory syncytial virus. The baby has increased work of breathing, diffuse coarse breath sounds, and wheezing. Despite suctioning and a trial of noninvasive positive pressure ventilation, he continues to have apneic episodes and is ultimately intubated. The respiratory therapist asks you what ventilator settings you would like to use, but you hesitate. What is the ideal mode of ventilation, and what should the initial settings be? How are you going to keep the baby comfortable while intubated?

An 8-year-old girl presents from home with increasing shortness of breath. She has a history of poorly controlled asthma and has had multiple prior admissions to the PICU for status asthmaticus. She has an upper respiratory tract infection that began 2 days ago, and she has been receiving albuterol every 2 hours via her inhaler for the past 12 hours. She speaks in 1- to 2-word sentences and uses respiratory accessory muscles. On auscultation of her lungs, she has poor air entry and minimal end-expiratory wheezing. Upon arrival to the ED, her vital signs are: heart rate, 160 beats/min; respiratory rate, 50 breaths/min; blood pressure, 110/75 mm Hg; pulse oximetry, 85%. She is given IV corticosteroids, continuous bronchodilators, IV magnesium, and beta agonists. She is started on noninvasive positive pressure ventilation. Within the next hour, she is poorly responsive and her respiratory effort declines. She is intubated and started on mechanical ventilation. While you continue to treat the patient’s status asthmaticus, you recall that young patients with severe asthma can be difficult to manage on a ventilator, and you begin to doubt your initial plan. You wonder whether there is anything that can be done to avoid the difficulties of mechanical ventilation in this patient and what to do if you run into them. What initial ventilator settings should you use for this patient? What are the next steps in assessment if she develops high peak pressures while in a volume-controlled mode of ventilation? What are the next steps in treatment if she develops severe auto–positive end-expiratory pressure and associated hypotension?

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