O2 via nasal cannula (provides roughly 25%–40% oxygen)*

(Use humidification system)

For non–life-threatening conditions, hypoxemia (asthma, pneumonia, bronchiolitis)

100% oxygen†, typically no more than 4 L/min flow

Well tolerated, easy to use, readily available, no associated toxicity

Skin irritation from cannula, drying of nasal passages, nose bleeds

O2 via simple face mask (provides roughly 35%–50% oxygen)*

For non–life-threatening conditions, hypoxemia (asthma, pneumonia, bronchiolitis)

100% oxygen†at no less than 5 L/min, typically 5–15 L/min

Well tolerated, easy to use, readily available, no associated toxicity, provides more oxygen than nasal cannula

If flow is <5 L/min, “rebreathing” CO2 may occur

O2 via Venturi™ mask (provides 24%–50% oxygen incrementally)

Weaning oxygen from high flow rates

The flow of 100% oxygen through the Venturi mask draws in a controlled, adjustable amount of room air (21% oxygen)

Well tolerated, easy to use, no associated toxicity, fixed and accurate concentration of oxygen

Not readily available

O2 via partial rebreathing face mask (provides roughly 50%–100% oxygen)*

For non–life-threatening conditions, severe hypoxemia (asthma, pneumonia, bronchiolitis)

100% oxygen, 5–15 L/min

Maintain reservoir at least half full on inspiration

High-flow system readily available, provides more oxygen than simple face mask

Nitrogen washout may lead to atelectasis

O2 via nonrebreather facemask (provides ∼80%–100% oxygen)*

Severe hypoxemia, hemodynamically stable pneumothorax (nitrogen washout)

100% oxygen 10–15 L/min

Maintain reservoir at least 2/3 full on inspiration and allow partial collapse on exhalation

Well tolerated, easy to use, readily available

Nitrogen washout may lead to atelectasis

Heliox**, 60%–80% He with 20%–40% O2

Upper airway obstruction (croup, bronchiolitis)

May be beneficial in treatment of lower airway disease (asthma)

Can be administered via nasal cannula and face mask

Do not use with oxygen tent or hood

Lower density gas decreases turbulent flow → increased O2 and medication delivery to distal airways

Beneficial effects of Helium not seen with <60%; therefore, not helpful if patient requires >40% O2

CPAP‡

Acute: Respiratory distress or failure, poor lung compliance, obstructive airway disease , muscle fatigue, CHF, asthma, acute chest syndrome

Chronic: OSA

Typically administer pressures of 5–10 cm H2O

May give supplemental oxygen as needed

Overcomes airway resistance to maintain FRC, ↓ muscle fatigue, ↑ lung recruitment, ↓ atelectasis, ↓ V/Q mismatch

Reduced risk of infection and local trauma to airway compared with ETT

Constant pressure throughout respiratory cycle; no ↑ with inspiration.

Masks may cause skin breakdown with chronic use

BiPAP‡

(same as above for CPAP)

Administer via nose mask

IPAP (8-20 cm H2O), EPAP (5-10) cm H2O, supplemental oxygen as needed

Less use of sedatives

May prevent intubation

Nasal prongs and masks may cause skin breakdown with chronic use

Not well tolerated by some patients

Distended stomach caused by swallowed air

Noninvasive positive pressure ventilation

Respiratory distress

Use a ventilator, set parameters (rate, Vt or PIP, PEEP)

Supplemental O2 as needed

As with BiPAP

May prevent intubation

As with BiPAP

Step 1: Preparation and intubation

Step 2: Pick ventilator mode (choose a familiar mode)

Step 3: Choose control mode (volume vs. pressure)

Step 4: Choose remaining variables

Step 5: Manage patient while intubated

Step 6: Wean and extubate as soon as possible

Controlled mechanical ventilation (CMV)

Y

Y

N

Vent delivers regular, identical breaths; no spontaneous breaths allowed

Rarely used, with the exception of neonatal transport ventilators

Assist-control ventilation (AC)

Y

Y

Y

Typically volume control; full preset TV is delivered at a preset rate; the patient may initiate additional supported cycles (also full preset VT); the patient may change MV as needed but cannot resume the work of breathing

Intermittent mandatory ventilation (IMV)

Y

Y

N

Similar to CMV but allows patient-triggered breaths in between mandatory breaths

Patient may change minute ventilation as needed and as vent rate is weaned, the patient can “take over” the work of breathing

Synchronized intermittent mandatory ventilation (SIMV)

Y

Y

N

Similar to IMV, but internal circuitry manipulates mandatory vent delivered breaths around patient-triggered breaths

Support mode (PS, VS)

N

N

Y

Set pressure or volume is delivered for patient-initiated cycles to support patient-initiated breaths (often combined with other modalities or as a weaning modality, i.e. SIMV + PS)

Pressure regulated volume control (PRVC, VC+)

Y

Y

Y

On some ventilators, these are AC modes, but in others, they are SIMV modes; ask the RT

Delivers preset rate and VT, but flow characteristics are regulated to deliver target volumes at the lowest possible pressure

High-frequency oscillatory ventilation (HFOV)

N/A

N/A

N/A

Escalation of care for patients who require high and have failed conventional ventilators

Consider when PEEP is 10 cm H2O or PIP is >35; better separates control of oxygenation and ventilation

Rate (bpm)

20–30

14–20

14–20

8–14

Ti (sec)

0.2–0.5

0.5–0.8

0.5–0.8

0.75–1

VT (cc/kg)*

N/A†

N/A†

6-8

6–8‡

PEEP (cm H2O)

2–5

2–5

2–5

2–5

PIP (cm H2O)

20–25

20–25

N/A†

N/A†

PS (cm H2O)

5–10 (in addition to PEEP)

FiO2

Start at 1.0 and wean as aggressively as possible to avoid O2 toxicity (goal <0.6)

Improving oxygenation

Increase Paw by ↑ PEEP, PIP, or Ti (PEEP has greater effect); increase FiO2

PEEP maintains FRC and ↓ V/Q mismatch; has >effect than PIP:

= K(PIP-PEEP) × [Ti/(Ti + Te)] + PEEP

Overdistension with PEEP will lead to worsening oxygenation

Consider HFOV if PEEP >10

Improving ventilation

Increase MV by ↑ RR or ↑ VT (in VC modalities) or PIP (in PC modalities)

CO2 directly related to minute ventilation. Rule of thumb: Current PaCO2 × Current respiratory rate = Desired PaCO2 × Desired respiratory rate

Allow for permissive hypercapnia (pCO2 ∼60 if pH >7.2) to reduce the potential for barotrauma

With obstructive airway diseases, reducing the respiratory rate may improve ventilation by allowing for a longer Te

Definition of trial: 2 h on respiratory support of CPAP ≤5 cm H2O or T-piece (CPAP = 0)

Clinical Criteria

• Diaphoresis
• Nasal flaring
• Increasing respiratory effort
• Tachypnea
• Tachycardia (increase in HR >20–40 bpm)
• Cardiac arrhythmias
• Hypotension
• Apnea

Laboratory Criteria

• Increase of PETCO2 >10 mm Hg
• Decrease of arterial pH to <7.32
• Absolute decline in arterial pH >0.07
• PaO2 <60 mm Hg with FIO2 >0.40 (PaO2/FiO2 ratio <!–150)
• SpO2 declines >5%

Respiratory Rate

< 2 mos < 50

2-12 mos < 40

1-5 yrs < 30

> 5 yrs < 20

< 2 mos 50-60

2-12 mos 40-50

> 1-5 yrs 30-40

> 5 yrs 20-30

< 2 mos > 60

2-12 mos > 50

> 1-5 yrs > 40

> 5 yrs > 30

Auscultation

Good air movement, scattered expiratory wheezing, loose rales/crackles.

Decreased air movement, inspiratory and expiratory wheezes or rales/crackles

Diminished or absent breath sounds, severe wheezing or rales/crackles, or markedly prolonged expiration.

Use of Accessory Muscles

Mild to no use of accessory muscles. Mild to no retractions or nasal flaring on inspiration.

Moderate intercostal retractions, mild to moderate use of accessory muscles, nasal flaring.

Severe intercostal and substernal retractions, nasal flaring.

Mental Status

Normal to mildly irritable

Irritable, agitated, restless.

Lethargic

Room Air SpO2

> 95%

90 – 95 %

< 90%

Color

Normal

Pale to normal

Cyanotic, dusty

Total Score (Sum of the component scores)

Albuterol

SABA (airway smooth muscle relaxation)

Inhaled (nebulized or MDI)

Nebulization: 0.15–0.5 mg/kg/h or 10–20 mg/h of continuous therapy; can give sequential nebulization × 3 (≤5 mg each)

Max, 20 mg/h

MDI: 4–8 puffs per dose Q20 min × 3; then Q1h

Levalbuterol

SABA (levorotary enantiomer, airway smooth muscle relaxation)

Inhaled (nebulized or MDI)

MDI: 4–8 puffs Q20 min × 3 then Q1h

Methylprednisolone

Steroid* (antiinflammatory)

IV

2 mg/kg IV once; then 1 mg/kg IV Q6h

Max, 60 mg/dose

Prednisone

Steroid* (antiinflammatory)

PO

2 mg/kg PO once; then 1–2 mg/kg/day divided Q12h

Max, 60 mg/dose

Second-Line Treatment

Ipratropium bromide

Anticholinergic (airway smooth muscle relaxation)

Inhaled (nebulized or MDI)

<12 yr: Nebulization 250 mcg Q20 min × 3 then Q2–4h prn; MDI 4–8 puffs per dose

>12 yr: Nebulization 500 mcg Q30 min × 3 then Q2–4h prn; MDI 4–8 puffs per dose

Can “spike” the albuterol nebulization solution with ipratropium bromide dose and give as one treatment

Magnesium sulfate

Electrolyte (smooth muscle relaxation)

IV

40 mg/kg IV over 20 min; max 2g

Although hypotension is exceedingly rare, watch for hypotension and be ready to give a 10–20 cc/kg NS bolus if it develops

Terbutaline†

β-agonist (smooth muscle relaxation)

Sub-Q, IV

IV: 10 mcg/kg IV once; then IV infusion starting at 0.5 mcg/kg/min, titrate as HR tolerates to goal 3–6 mcg/kg/min

Max, 10 mcg/kg/min

Aminophylline‡

Bronchodilator

IV

6 mg/kg load over 20–30 min; then continuous infusion

Ketamine

Dissociative anesthetic, bronchodilator

IV

0.5–2.0 mg/kg IV; may be used as a continuous infusion

May have bizarre dreams, hallucinations; watch for oversedation and need for immediate intubation

Often reserved as a last medication trial or sedative before intubation

Heliox

Gas

Inhaled

Available as 70/30 or 80/20 concentrations