Initial management of a child requiring long term ventilator support with respiratory distress on the general medical wards

• Summary
• Aims
• Objectives
• Background
• Diagnosis
• Management

Summary of Guideline

Describes the initial management of the child with long term ventilator (LTV) support who has increased respiratory distress.

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Aims

To ensure that patients requiring ventilator support have appropriate management if they have increased respiratory distress on a paediatric ward outside of a critical care unit.

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Objectives

• To provide support for nurses and doctors not used to dealing with patients requiring LTV
• To ensure good clinical management of patients requiring LTV on the pediatric wards.
• To reduce delay in escalation of care if required.

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Background

Patients requiring long term ventilation may do so for many reasons; it is a very heterogeneous group of patients. For this reason one guideline cannot cover all possible events.

Most LTV patients will have normal respiratory parameters when they are managed well. They will not be on a general paediatric ward otherwise.

However, all LTV patients do have a care plan and the aim of this guideline is to provide a pathway for people not experienced in the management of LTV children to follow.

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Diagnosis

Signs of respiratory distress in a patient with LTV would be those you would expect in a normal child:

• Increased respiratory rate
• Accessory muscle use
• Low saturations
• Increase in oxygen requirement
• Increase in secretions

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Treatment / Management

Primary management is to ensure airway is patent with suction and consider change of tracheostomy. Equipment should be checked to ensure functioning appropriately. If patient still has signs of respiratory distress:

1. Patient needs a medical assessment (respiratory registrar/general paediatrics registrar/specialties registrar)
   • Add in or increase oxygen as required
   • Change to “step up” or “unwell” settings as per the patients care plan
   • Ask for an urgent physiotherapy assessment
   • Capillary blood gas (CBG) after 15 minutes
   • Discuss result with respiratory consultant
   • Other bloods/CXR as per assessment
2. If respiratory rate/oxygen requirement not improving OR CBG worse than baseline OR pH<7.25; OR CO2 >7
   • Discuss with PICU consultant
   • Move to PICU/HDU for closer observation

Low threshold for escalation of care.

*Respiratory cause indicated by:

• Increased respiratory rate
• Accessory muscle use
• Low saturations
• Increase in oxygen requirement
• Increase in secretions