What is it?
- Breathing, or respiration, involves the inspiration (breathing in) of oxygen (O2) and the expiration (breathing out) of carbon dioxide (CO2).
- With every inspiration, oxygen enters the lungs and then is absorbed into the blood so that it is delivered to all the cells of the body. At the same time, carbon dioxide, a waste product of cell function, is carried in the blood and delivered to the lungs where it can be removed from the body through expiration. Breathing balances and regulates the amount of oxygen and carbon dioxide in the body.
- Some children are unable to breathe adequately because of various health conditions (for example, weakness of the respiratory muscles, spinal cord injury or neurological problems).
- Ventilatory assistance (or ventilation or assisted ventilation or artificial ventilation) with a specific device helps children breathe more effectively; a mechanical device pushes air with oxygen (O2) into the lungs, like inspiration, and facilitates the removal of carbon dioxide (CO2), like expiration. Ventilatory assistance supports the child’s activities and development.
- A ventilatory assistance device may be used during sleep and/or when the child is awake, depending upon the needs of the child, in order to improve/support respiration and overall health quality.
- Ventilatory assistance is divided into two categories depending on the type of interface between the child and the ventilatory assistance device:
- invasive ventilation: the device is connected to a tracheal cannula.
- non-invasive ventilation: the device is connected to a mask (nasal, facial or nasal pillows) with a integrated exhalation valve or to a mouthpiece.
- Manual ventilation with a ventilatory bag (or manual ventilatory bag or manual ventilatory device or bag valve mask or self-inflating bag with a non-rebreathing valve or Ambu bag) may be necessary if your child is unable to breathe effectively independently. Here are some situations when manual ventilation may be required:
- to replace a mechanical ventilatory assistance device while it is disconnected for transportation or to facilitate mobility (eg, transferring your child from chair to bed, re-positioning, daily care such as bathing, etc.);
- to change the ventilatory circuit or ventilatory assistance device;
- to mobilize and improve clearance of secretions and/or aspiration of secretions;
- to ventilate in an emergency situation such as respiratory distress, obstruction or accidental decannulation of the tracheal cannula, breakage of ventilatory assistance device, unresolved ventilatory assistance device alarms, etc.;
- to do cough assist techniques, ideally with a modified ventilatory bag;
- to ventilate during cardiopulmonary resuscitation (CPR).
How does it work?
- Invasive ventilation provides stable, regular ventilation at a pressure/volume and frequency that is prescribed for your child.
- The equipment that is necessary to receive this type of respiratory assistance includes ventilatory assistance device and a ventilation circuit including: tracheostomy adapter, dead space (extension piece of tubing to improve comfort and mobility), adapter (eg, 15-22 mm), exhalation valve (differs according to the different models of ventilatory assistance device) and tubing.
- The invasive ventilatory circuit must be connected to a heated humidifier before being connected to a ventilatory assistance device. The heated humidifier warms and humidifies inspired air from the device and is used when the child is stationary.
- At the top of the water chamber, there are two openings. One opening of the water chamber is used to connect the ventilatory circuit to the tracheal cannula. Short tubing is connected to the second opening of the water chamber and to the antibacterial filter of the ventilatory assistance device.
- The heated humidifier must be removed when the child is mobile or during transportation in order to prevent leaks of water in the ventilatory assistance device or in the circuit.
- An artificial nose replaces the heated humidifier in an invasive ventilatory circuit when the child is mobile or during transportation.
- The artificial nose is inserted between the dead space and the adapter of the invasive ventilation circuit.
- There are several different interfaces available to permit non-invasive ventilation.
- Non-invasive ventilation with mask provides stable, regular ventilation at a pressure and frequency that is prescribed for your child.
- The equipment that is necessary to receive this type of respiratory assistance is a ventilatory assistance device and a ventilation circuit which includes a mask (nasal, facial or nasal pillows) with integrated tubing.
- All masks have an exhalation valve (or escape valve) for expiration of exhaled carbon dioxide gas.
- The non-invasive ventilation circuit with mask must be connected to a heated humidifier before being connected to a ventilatory assistance device. The heated humidifier warms and humidifies inspired air from the device and is used when the child is stationary. The heated humidifier must be removed when the child is mobile or during transportation in order to prevent leaks of water in the ventilatory assistance device or in the circuit.
- Non-invasive ventilation with mouthpiece is an “as needed” type of ventilation where the child initiates use of the interface to breath in (inspiration) when desired. An expiration device is not required as the child breathes out independently.
- This type of ventilatory assistance is used for children who can identify their own breathing needs and who are capable of putting on the mouthpiece and initiating a breath.
- The equipment that is necessary to receive non-invasive ventilation with mouthpiece includes ventilatory assistance device and a ventilation circuit which includes a mouthpiece, adapters and tubing.
- Non-invasive ventilation with mouthpiece is used only during the day, when the child is awake; at night, or during sleep, these children would use non-invasive ventilation with a mask.
- Your healthcare team will recommend the appropriate interface for your child (including headstraps, if required) which will best meet your child’s non-invasive ventilatory needs and adapts to the child’s daily activities. The interfaces are available in a variety of models and formats.
Interfaces for non-invasive ventilation
|Facial mask for non-invasive ventilation|
|Nasal pillows (or nasal “seals” or intranasal cushions)|
|Mouthpiece (eg, angled mouthpiece, straw)|
- The type of ventilatory assistance device connected to the interface varies depending upon the needs and characteristics of the child (eg, ventilatory needs, weight of the child).
Ventilatory assistance device
|Bi-level (eg, BiPAP®, VPAP®)|
|Respirator (eg, Trilogy, Astral)|
- Each ventilatory assistance device is equipped with visual and audible alarms to indicate if there is a technical problem (eg, too many air leaks in the circuit, device failure, loss of power supply) or related to a change in the condition of the child (eg, accumulation of secretions, respiratory deterioration, excessive or inadequate pressure or volume of air). Refer to your healthcare team or the device instruction manual for further details.
- A T-piece can be added to the invasive and non-invasive ventilation circuit of certain devices to allow inhalation of an aerosol medication contained in a small volume nebulizer. Refer to your healthcare team for the specifics of administration technique.
- Air leaks can occur during invasive or non-invasive ventilation. They may occur for various reasons, including when: tubing is poorly connected, the mask is poorly fitted to the face or the child is inadequately positioned during sleep. If air leaks are not well controlled, then the effectiveness of the invasive or non-invasive ventilation is not optimal. Air leaks can also cause eye irritation in children who use non-invasive ventilation.
- Manual ventilation is provided using a ventilatory bag.
- This device consists of a bag and a ventilatory valve to provide an inspiratory volume of air to an individual who is unable to breathe in sufficiently. This device also allows for the elimination of carbon dioxide. The ventilatory bag can replace a ventilatory assistance device in the event of an emergency or power failure.
- Different ventilatory bag models are available, depending upon the amount of air delivered by compression. The amount of air delivered corresponds to the depth of compression.
- Do not confuse the ventilatory bag for manual ventilation with the modified ventilatory bag which is a specific device used for cough assistance techniques. The modified ventilatory bag does not allow the child to exhale which is DANGEROUS.
- The air outlet of the ventilatory bag is connected to a tracheal cannula or a facial mask specific to this use.
- If necessary, the air outlet of the bag can be connected to a dead space and a adapter before being connected to the tracheal cannula.
- A ventilatory bag may also be used with a tracheostomy adapter.
- The facial mask used for manual ventilation does not have an exhalation valve or straps to fit around the child’s head.
- Your healthcare team will determine whether your child requires a manual ventilatory bag and/or a second ventilatory assistance device as a back-up in the case of an emergency.