Welcome to this month’s What’s Your Diagnosis Challenge!
But before we begin, check to see if you got last month’s case on Seizures in Neonates: Diagnosis and Management in the Emergency Department right.
Case Presentation: Mechanical Ventilation of Pediatric Patients in the Emergency Department
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?
While considering what ventilator settings to use for the 2-month-old boy with intermittent apnea, cough, and congestion, you recalled that pressure-controlled ventilation is preferred for infants. Given his age and apnea, you selected SIMV with pressure control. You advised the respiratory therapist to set the ventilator with a PIP of 20 cm H2O, PEEP of 5 cm H2O, a respiratory rate of 30 breaths/min, and a pressure support of 10 cm H2O. You recommended targeting tidal volumes of 7 mL/kg and requested that oxygen be titrated to achieve saturation of 92% to 97%. Though the baby had been paralyzed for intubation, you recognized the need for ongoing sedation and analgesia and ordered infusions of fentanyl (1 mcg/ kg/hr) and midazolam (0.05 mg/kg/hr). The critical care transport team from the pediatric hospital arrived, and the baby was transferred to their PICU for ongoing care. The infant made a full recovery 6 days later.
Last Updated on July 21, 2020