Intensive Care Medicine

, Volume 44, Issue 3, pp 366–370 | Cite as

The top ten unknowns in paediatric mechanical ventilation

  • Peter C. RimensbergerEmail author
  • Ira M. Cheifetz
  • Martin C. J. Kneyber
What's New in Intensive Care


There is inconsistent mechanical ventilation (MV) practice in children [1] given the fact that even today it is largely based on expert opinion and data extrapolation from adults despite the paediatric catchphrase “a child is not just a small adult”. Unique maturational differences related to lung growth and maturation (to the age of about 8 years), respiratory system development (e.g. small airways, compliant chest wall), immune response and surfactant homeostasis prevent data generated in adults being directly applicable to children. Moreover, a possible age-related susceptibility to ventilator-induced lung injury has been suggested [2]. Furthermore, there is a much larger spectrum of pathologies associated with hypoxemic and/or hypercapnic respiratory failure in infants and children than in adults.

Given this context, we identified 10 major unknowns regarding paediatric MV in the following categories: (1) lung “protective” ventilation strategies, (2) concepts to assist...


  1. 1.
    Santschi M, Jouvet P, Leclerc F, Gauvin F, Newth CJ, Carroll CL, Flori H, Tasker RC, Rimensberger PC, Randolph AG, PALIVE Investigators, Pediatric Acute Lung Injury and Sepsis Investigators Network (PALISI), European Society of Pediatric and Neonatal Intensive Care (ESPNIC) (2010) Acute lung injury in children: therapeutic practice and feasibility of international clinical trials. Pediatr Crit Care Med 11:681–689CrossRefPubMedGoogle Scholar
  2. 2.
    Kneyber MC, Zhang H, Slutsky AS (2014) Ventilator-induced lung injury. Similarity and differences between children and adults. Am J Respir Crit Care Med 190:258–265PubMedPubMedCentralGoogle Scholar
  3. 3.
    de Jager P, Burgerhof JG, van Heerde M, Albers MJ, Markhorst DG, Kneyber MC (2014) Tidal volume and mortality in mechanically ventilated children: a systematic review and meta-analysis of observational studies. Crit Care Med 42:2461–2472CrossRefPubMedGoogle Scholar
  4. 4.
    Erickson S, Schibler A, Numa A, Nuthall G, Yung M, Pascoe E, Wilkins B, Paediatric Study Group, Australian and New Zealand Intensive Care Society (2007) Acute lung injury in pediatric intensive care in Australia and New Zealand: a prospective, multicenter, observational study. Pediatr Crit Care Med 8:317–323PubMedGoogle Scholar
  5. 5.
    Khemani RG, Conti D, Alonzo TA, Bart RD 3rd, Newth CJ (2009) Effect of tidal volume in children with acute hypoxemic respiratory failure. Intensive Care Med 35:1428–1437CrossRefPubMedGoogle Scholar
  6. 6.
    Khemani RG, Rubin S, Belani S, Leung D, Erickson S, Smith LS, Zimmerman JJ, Newth CJ (2015) Pulse oximetry vs. PaO2 metrics in mechanically ventilated children: Berlin definition of ARDS and mortality risk. Intensive Care Med 41:94–102CrossRefPubMedGoogle Scholar
  7. 7.
    Boriosi JP, Sapru A, Hanson JH, Asselin J, Gildengorin G, Newman V, Sabato K, Flori HR (2011) Efficacy and safety of lung recruitment in pediatric patients with acute lung injury. Pediatr Crit Care Med 12:431–436CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Ingaramo OA, Ngo T, Khemani RG, Newth CJ (2014) Impact of positive end-expiratory pressure on cardiac index measured by ultrasound cardiac output monitor. Pediatr Crit Care Med 15:15–20CrossRefPubMedGoogle Scholar
  9. 9.
    Gupta P, Green JW, Tang X, Gall CM, Gossett JM, Rice TB, Kacmarek RM, Wetzel RC (2014) Comparison of high-frequency oscillatory ventilation and conventional mechanical ventilation in pediatric respiratory failure. JAMA Pediatr 168:243–249CrossRefPubMedGoogle Scholar
  10. 10.
    Bateman ST, Borasino S, Asaro LA, Cheifetz IM, Diane S, Wypij D, Curley MA, RESTORE Study Investigators (2016) Early high-frequency oscillatory ventilation in pediatric acute respiratory failure. a propensity score analysis. Am J Respir Crit Care Med 193:495–503CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Curley MA, Hibberd PL, Fineman LD, Wypij D, Shih MC, Thompson JE, Grant MJ, Barr FE, Cvijanovich NZ, Sorce L, Luckett PM, Matthay MA, Arnold JH (2005) Effect of prone positioning on clinical outcomes in children with acute lung injury: a randomized controlled trial. JAMA 294:229–237CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Wilsterman ME, de Jager P, Blokpoel R, Frerichs I, Dijkstra SK, Albers MJ, Burgerhof JG, Markhorst DG, Kneyber MC (2016) Short-term effects of neuromuscular blockade on global and regional lung mechanics, oxygenation and ventilation in pediatric acute hypoxemic respiratory failure. Ann Intensive Care 6:103CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Vignaux L, Grazioli S, Piquilloud L, Bochaton N, Karam O, Jaecklin T, Levy-Jamet Y, Tourneux P, Jolliet P, Rimensberger PC (2013) Optimizing patient-ventilator synchrony during invasive ventilator assist in children and infants remains a difficult task. Pediatr Crit Care Med 14:e316–e325CrossRefPubMedGoogle Scholar
  14. 14.
    Yoshida T, Uchiyama A, Matsuura N, Mashimo T, Fujino Y (2012) Spontaneous breathing during lung-protective ventilation in an experimental acute lung injury model: high transpulmonary pressure associated with strong spontaneous breathing effort may worsen lung injury. Crit Care Med 40:1578–1585CrossRefPubMedGoogle Scholar
  15. 15.
    Clement KC, Thurman TL, Holt SJ, Heulitt MJ (2011) Neurally triggered breaths reduce trigger delay and improve ventilator response times in ventilated infants with bronchiolitis. Intensive Care Med 37:1826–1832CrossRefPubMedGoogle Scholar
  16. 16.
    Essouri S, Durand P, Chevret L, Haas V, Perot C, Clement A, Devictor D, Fauroux B (2008) Physiological effects of noninvasive positive ventilation during acute moderate hypercapnic respiratory insufficiency in children. Intensive Care Med 34:2248–2255CrossRefPubMedGoogle Scholar
  17. 17.
    Shah PS, Ohlsson A, Shah JP (2008) Continuous negative extrathoracic pressure or continuous positive airway pressure for acute hypoxemic respiratory failure in children. Cochrane Database Syst Rev (3):CD003699Google Scholar
  18. 18.
    Mikalsen IB, Davis P, Oymar K (2016) High flow nasal cannula in children: a literature review. Scand J Trauma Resusc Emerg Med 24:93CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Newth CJ, Venkataraman S, Willson DF, Meert KL, Harrison R, Dean JM, Pollack M, Zimmerman J, Anand KJ, Carcillo JA, Nicholson CE, Eunice Shriver Kennedy National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network (2009) Weaning and extubation readiness in pediatric patients. Pediatr Crit Care Med 10:1–11CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Jouvet P, Farges C, Hatzakis G, Monir A, Lesage F, Dupic L, Brochard L, Hubert P (2007) Weaning children from mechanical ventilation with a computer-driven system (closed-loop protocol): a pilot study. Pediatr Crit Care Med 8:425–432CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2017

Authors and Affiliations

  • Peter C. Rimensberger
    • 1
    Email author
  • Ira M. Cheifetz
    • 2
  • Martin C. J. Kneyber
    • 3
    • 4
  1. 1.Service of Neonatology and Pediatric Intensive Care, Department of PaediatricsUniversity Hospital of GenevaGenevaSwitzerland
  2. 2.Pediatric Critical Care MedicineDuke Children’s HospitalDurhamUSA
  3. 3.Division of Pediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children’s HospitalUniversity Medical Center GroningenGroningenThe Netherlands
  4. 4.Critical Care Anaesthesiology, Peri-operative and Emergency Medicine (CAPE)University of GroningenGroningenThe Netherlands

Personalised recommendations