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4 Muscle relaxants for intubated patients—rocuronium 1– 1.2 mg/kg/dose or vecuronium bromide, starting at 0.1 mg/kg every 1–2 hrs or alternative 0.1–0.2 mg/kg/hr drip PEEP, positive end-expiratory pressure; CPAP, constant positive airway pressure; BiPAP, bilevel positive airway pressure Specific ventilation strategies will vary based on underlying disease In children with acute respiratory failure but normal lung function (e.g., CNS depression), standard airway pressures, and respiratory rates are appropriate Positive end-expiratory pressures (PEEPs) may be useful where alveolar recruitment is important to improve gas exchange (e.g., atelectasis) This can be done manually with a bag and mask, or with CPAP or BiPAP PEEP shifts lungs to a position on the pressure–volume curve that improves alveolar ventilation by increasing the end-expiratory lung volume and functional residual capacity Any ventilation strategy must aim to minimize the risk of volutrauma and barotrauma In patients with decreased lung compliance due to either stiff lungs (e.g., fibrosis) or hyperinflation (e.g., bronchiolitis or asthma), higher pressures must be used to sufficiently ventilate the child The inspiratory:expiratory (I:E) ratio can also be tailored to the disease process An increased I:E ratio is used in obstructive lower airway disease to extend exhalation time to better allow elimination of CO2 Increased I:E ratios (generally greater than 1:3) are frequently required Permissive hypercapnia, accepting elevated PCO2 values as long as pH is maintained (e.g., ≥7.2), may be advantageous, as this may allow for lower peak pressures during ventilation, which will reduce the risk of barotrauma Fluid management is another important component of care for patients with respiratory failure In general, fluids should be titrated to maintain normal intravascular volume as determined by monitoring heart rate, blood pressure, peripheral perfusion, and urine output However, patients with significantly increased work of breathing generate high negative intrathoracic pressure which increases venous return When these patients transition to positive-pressure ventilation, venous return rapidly decreases and may precipitate cardiovascular collapse Therefore, unless clinical circumstances mandate more immediate action, rapid intravascular repletion before initiating positive pressure (through noninvasive ventilation or intubation) is prudent In contrast, for patients with interstitial disease or pulmonary capillary leak, a slightly reduced intravascular volume may improve the cardiopulmonary mechanics necessary for effective ventilation As a result, the FiO2 requirement may be decreased and airway
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