Ventilatory assistance

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

Nasal mask	Covers only the nose. First choice of interface for infants. Covers a smaller area than a facial mask and so reduces risk of air leaks. Easier to adjust fit in a child. Each mask has straps to secure the fit around the child’s head. Some masks come with a short segment of integrated tubing. Allows the child to communicate more easily because the mouth is not covered.
Facial mask for non-invasive ventilation	Covers the nose and mouth. ONLY used in children if recommended by the healthcare team. Includes an anti-asphyxia valve in addition to the exhalation valve. In the event of a power failure or device malfunction, the anti-asphyxial valve allows the child to breathe in fresh air from the room rather than re-breathing exhaled air that is trapped in the mask. However, breathing via a facial mask without ventilatory assistance is for short term use only. Each mask has straps to secure the fit around the child’s head. Important to quickly remove the mask if the child is nauseous or vomiting. May be used with a ventilatory bag to replace a ventilatory assistance device or in an emergency situation. Not to be confused with other types of facial masks that are used for manual ventilation or cough assist techniques. Those types of masks do not have an exhalation valve.
Nasal pillows (or nasal “seals” or intranasal cushions)	Soft pads (pillows, seals) rest under the nostrils. May be useful for ventilatory assistance during the day. Allows the child to communicate more easily because the mouth is not covered. Prevents obstruction to vision. Each mask has straps to secure the fit around the child’s head. Useful in children who develop redness or sores on the nasal bridge. Not to be used in children who only breathe through their mouth. May be used with a ventilatory bag to replace a ventilatory assistance device or in an emergency situation.
Mouthpiece (eg, angled mouthpiece, straw)	Plastic mouthpiece shaped like a pipe or straw is placed in the mouth and sealed between the lips or held between the teeth. The mouthpiece has a flexible support arm which can be attached to wheelchair controls or held in place on another surface. Allows the child to control the amount of inspired air and the frequency of use; this optimizes the child’s respiration and ability to cough while allowing for verbal communication. Supports inspiration but must be removed from the mouth in order for the child to exhale. Used in the daytime (while awake) only. Promotes greater autonomy (to talk, eat, move, etc.). More discreet ventilatory assistance in social situations. Does not interfere with vision. No continuous contact with facial skin. Allows for use of inspiratory cough assist techniques (eg, pulmonary hyperinflation).

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®)

Provides two different pressure levels: inspiratory phase pressure (called “IPAP“) and a lower pressure expiratory phase pressure (called “EPAP“). When the child takes a breath, the device senses the effort and pushes more air and increases the pressure up to the IPAP level. At the end of inspiration, the device automatically switches to the expiration phase. The air pressure is decreased until the EPAP level is reached, allowing the child to exhale comfortably.
In addition to supporting the natural breathing of the child, the device has the ability to also initiate breathing (inspiration/expiration) in order to maintain a pre-set minimal number of breaths/minute, thus ensuring adequate ventilatory assistance.
The IPAP, EPAP, and rate of breaths are set by the healthcare team and adjusted to the specific needs of the child.
This device is mainly used for non-invasive ventilation with facial mask, nasal mask or nasal pillows.
Each bi-level ventilatory assistance device is equipped with a removable heated humidifier.
Several models are currently available on the market.

Respirator (eg, Trilogy, Astral)

Provides a specific air pressure (called “controlled pressure“) or a precise amount of air (called “controlled volume“).
Provides two different pressure levels: inspiratory phase pressure (called “IPAP“) and a lower pressure expiratory phase pressure (called “EPAP“). When the child takes a breath, the device senses the effort and pushes more air and increases the pressure up to the IPAP level. At the end of inspiration, the device automatically switches to the expiration phase. The air pressure is decreased until the EPAP level is reached, allowing the child to exhale comfortably.
All the parameters for IPAP, EPAP, frequency, volume and pressure are set by the healthcare team and are adjusted to the specific needs of the child.
Device is mainly used for invasive ventilation or non-invasive ventilation with mouthpiece.
May be used for non-invasive ventilation requiring settings that are not available on the bi-level devices.
May be used with several types of masks (facial, nasal or nasal pillows).
Should be used with a heated external humidifier for invasive or non-invasive ventilation with mask, when the child is stationary. When the child is mobile or during transportation, should be used with an artificial nose in replacement of a heated external humidifier in order to prevent leaks of water in the respirator or in the circuit.
An antibacterial filter should be installed at the ventilatory air outlet during ventilatory assistance.

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.

FAQ – Ventilatory support

When to consult your healthcare team

Mask

Your child remains uncomfortable while wearing the mask.
The skin of the face, nose or the eyes is red or irritated.
Your child’s nose and/or mouth remain dry.
Your child’s nose and sinuses remain congested.
Your child’s eyes remain irritated or red.

Ventilation circuit

Interface or a part of the ventilation circuit is broken (eg, tubing, tracheostomy adapter).
Water condensation persists in the circuit and/or mask.
The air in the circuit remains more warm than usual.
Water continues to accumulate in the tubing of the circuit.

Ventilatory assistance device and humidifier

Any alarm persists.
The device does not operate.
The flow of air from the device remains insufficient.
The screen on the device continues to be irregular.
The water chamber is damaged or broken.
The device continues to push air more forcefully than usual.
The device operates with more noise than usual.

Ventilatory bag

The ventilatory bag does not function, despite your attempts to resolve the problem.

General issues

Your child has difficulty adapting to the ventilatory assistance and to coordinate breathing with the device.
Your child is agitated, crying or uncomfortable with the ventilatory assistance and/or has difficulty falling asleep.
Your child’s abdomen remains distended.
Your child vomits during manual ventilation.
Your child has difficulty speaking or swallowing during non-invasive ventilation.
Your child has other problems during or after ventilatory assistance.

Your child’s healthcare team will take the opportunity during your child’s follow-up appointments to review your child’s care and equipment. Adjustments will be made as required.

Do not hesitate to refer to your child’s healthcare team for any questions or for specific advice related to your child’s condition.

WARNING: The information in this section is meant as a general guide for parents and caregivers with certain problems related to invasive ventilation, non-invasive ventilation and manual ventilation. It is not intended to replace the recommendations of your child’s healthcare team.

Discuss your child’s unique needs with the healthcare team, including WHO and WHEN to contact when problems arise.

Problems related to invasive ventilation and non-invasive ventilation

Ventilatory assistance device alarms

Possible cause(s)

Various

What to do?

Look at your child immediately; verify that your child is breathing effectively. If not, rapidly establish breathing using either the manual ventilatory bag or a spare ventilatory assistance device.
If your child is in respiratory distress,
- call 911 immediately;
- if required, begin manual ventilation and CPR as instructed.
If your child is breathing effectively, read the message on the device screen.
Press once on the alarm/silence button on the device to silence the alarm.
Identify the cause of the alarm.
Take appropriate action to address the issue identified by the alarm.
If necessary, consult the manual of the device to solve the issue.
If you are still unable to solve the issue, rapidly contact your child’s healthcare team.

Ventilatory assistance device does not turn on (no lights or alarms)

Possible cause(s)

Device lacks power
Not correctly plugged into electrical wall outlet
Internal battery depleted
Device malfunction
Device plugged into a wall outlet that is controlled by a switch that is turned off

What to do?

Verify that the device is securely plugged into an electrical wall outlet or that the internal battery is adequately charged.
Verify that the electrical wall outlet is not controlled by a switch that is turned off.
Use an alternative device to support your child’s breathing, if necessary.
If the problem persists, rapidly contact your child’s healthcare team.

Disconnected parts in the ventilation circuit

Possible cause(s)

Accident
Incorrect handling of the equipment

What to do?

Make sure that the circuit parts are well connected when installing the ventilatory assistance.
Check that each part of the circuit is in good condition (no cracks or other signs of wear and tear) during installation and disconnection.
Ensure that the circuit is adequately positioned so that there is no pulling or tension on the circuit.

Broken equipment: interface or any components of the ventilation circuit (eg, tubing, tracheostomy adapter)

Possible cause(s)

Accident
Incorrect handling of the equipment
Wear and tear with repeated use

What to do?

Never use damaged or defective materials or equipment when providing ventilatory assistance to your child.
Substitute a replacement piece for the broken one.
Inform your child’s healthcare team that you used spare equipment and arrange to replace the spare items.
Always handle equipment gently and according the recommendations of your healthcare team.

Insufficient air flow from the ventilatory assistance device

Possible cause(s)

Circuit incorrectly assembled
Circuit bent, crushed or obstructed
Accumulation of water in the circuit
Obstructed exhalation valve openings in the mask
Dirty air filter
Blockage of air going into the device
Leaks at the level of the water chamber or humidifier

What to do?

Verify that:
- the circuit is correctly assembled;
- the exhalation valve openings in the mask are clean and not obstructed;
- the tubing of the circuit is not bent, crushed or obstructed;
- there is no accumulation of water in the circuit;
- the air filter is clean; if not clean it or replace it;
- there is no obstruction to the air intake of the device (eg, curtain, blanket, fabric, etc.);
- there is no leak in the water chamber or the humidifier.
If the problem persists, contact your child’s healthcare team.

Warmer air than usual in the ventilation circuit

Possible cause(s)

Dirty air filter
Ventilatory assistance device placed too close to a source of heat (eg, radiator)

What to do?

Verify that the air filter is clean and intact. If not, clean it or replace it. To clean it, follow the recommendations of your healthcare team.
Position the ventilatory assistance device away from direct sunlight or other sources of heat.
Verify that the circulation of air around the device is unobstructed; keep curtains, bed covers and stuffed toys away from the device.
Verify that the humidity level of the humidifier of the ventilatory assistance device is correct; lowering it if necessary.
If the problem persists, contact your child’s healthcare team.

Dropped ventilatory assistance device (device falls to the ground)

Possible cause(s)

Incorrect handling of the device
Accident

What to do?

Use a back up device, if available.
Unplug the dropped device from the electrical outlet.
Pick up the dropped device and put it in correct position on a flat surface, being careful not to let water run into the device.
Remove the water chamber.
If there is spilled water visible, dry the area with a clean cloth.
Reinsert the water chamber into the humidifier.
Verify that no excess water has spilled into the circuit; if present, empty it.
Reconnect the device to an electrical wall outlet.
Install the interface on your child and start up the ventilatory assistance device. If it does not function or does not work as usual, contact your healthcare team.
Prevent accidents by always placing the device in such a way that no one trips on the electrical cord.
Make sure that the ventilatory assistance device is placed on a stable, solid surface so that it does not fall easily.
Make sure that the circuit does not pull or put tension on the device.

Irregular display on the ventilatory assistance device

Possible cause(s)

Device too close to sources of electromagnetic waves
Dropped device
Incorrect handling of the device

What to do?

Position the device away from objects that emit electromagnetic waves (eg, cellphones, base of wireless telephone, some alarm clocks, microwave, etc.).
If the problem persists, contact your child’s healthcare team.

No water in the water chamber of the ventilatory assistance device

Possible cause(s)

Water chamber was not sufficiently filled
Excess air leaks around the mask
Humidity level of the humidifier set too high
Room temperature too cold or room air too dry
Cold air flow directed towards the ventilatory assistance device (eg, air conditioning)
Leak in the water chamber due to cracks or holes.

What to do?

Make sure that the water chamber is adequately filled to the maximum fill line.
Ensure that the mask is well positioned on your child’s face; adjust the mask and straps to eliminate any air leaks.
Verify that the humidity level on the device is appropriately set.
If necessary, increase the room temperature or ambient room humidity.
Make sure that the device is not exposed to cold air drafts.
Ensure that the water chamber is correctly installed in the device.
If the water chamber is damaged, replace it and contact your child’s healthcare team.

Presence of condensation in the ventilation circuit

Possible cause(s)

Cold air flow directed towards the circuit
Room temperature too cold
Humidity level of the humidifier set too high

What to do?

Ensure that the device and circuit are not exposed to cold air drafts.
Make sure that the room temperature is not too cold.
Lower the humidity level of the humidifier.
If the problem persists, contact your child’s healthcare team.

Presence of condensation in the mask and/or your child has droplets of water on the face during non-invasive ventilation

Possible cause(s)

Water chamber of the device
Condensation in the circuit and/or the mask
Cold air flow directed towards the circuit
Room temperature too cold

What to do?

Do not overfill the water chamber; never fill beyond the maximal fill level line.
Lower the humidity level of the humidifier.
Ensure that the device and circuit are not exposed to cold air drafts.
Make sure that the room temperature is not too cold.

Accumulation of water in the tubing of the ventilation circuit

Possible cause(s)

Cold air flow directed towards the circuit
Room temperature too cold
Humidity level of the humidifier set too high

What to do?

Ensure that the device and circuit are not exposed to cold air drafts.
Make sure that the room temperature is not too cold.
Lower the humidity level of the humidifier.
Remove excess water from the circuit so that it does not move into the mask or the child’s tracheostomy.
If the problem persists, contact your child’s healthcare team.

Leakage of water from the water chamber of the ventilatory assistance device

Possible cause(s)

Water chamber cracked or damaged
Incorrect installation of the water chamber

What to do?

Verify if the water chamber is damaged or cracked; replace it and contact your child’s healthcare team.
Correctly install the water chamber (refer to the equipment manual if necessary).

Child agitated, crying, uncomfortable and/or having difficulty falling asleep

Possible cause(s)

Incorrect positioning of the mask
Difficulty in adapting to ventilatory assistance
Incorrect humidity setting of the device
Respiratory infection or another health problem

What to do?

This more commonly occurs when ventilatory assistance is first started in children; that is during the initial period of adaptation.
Ensure that the mask fits correctly:
- the straps should be correctly positioned and not too tight;
- verify that there are no pressure points from the mask on your child’s face;
- verify that the mask is correctly placed, as recommended by your child’s healthcare team.
Increase the humidity level gradually as needed in order to avoid condensation in the tubing.
Ensure that there is a sufficient amount of water in the water chamber (eg, during the night).
If the problem persists, contact your child’s healthcare team.

Sensation that the ventilatory assistance device pushes the air more forcefully or is noisier than usual

Possible cause(s)

Leakage of air at the level of the mask or tracheal cannula
Child not optimally positioned to receive ventilatory assistance
Leaks in the circuit (eg, damaged tubing)
Variation in air flow due to the child talking, coughing or breathing in an unusual way

What to do?

Verify that the mask is well placed; straps should not be too tight; follow the recommendations of your healthcare team.
Ensure that the positioning of your child during ventilatory assistance is not causing leaks (eg, hyperextension of the neck if the child has a tracheostomy, mask placement).
Make sure that the circuit is correctly and securely connected.
Ask your child to breathe calmly.
Encourage your child to stay calm and to relax. Consider using distraction techniques, if needed.
If your child is coughing, remove the mask and reinstall it once your child has stopped coughing.
If the problem persists, contact your child’s healthcare team.

Irritation (redness, sores) of facial skin and/or eyes redness, in the child who uses a mask

Possible cause(s)

Mask incorrectly adjusted; too tight
Mask not cleaned regularly
Wrong mask type for the child
Dry skin
Incorrect positioning of the child during mask use
Air leaks around the mask

What to do?

Verify that the mask is well placed; straps should not be too tight; follow the recommendations of the healthcare team.
Avoid rubbing or pushing the mask over the face during placement.
Make sure that the child’s skin is well moisturized.
Verify that there are no pressure points from the mask on the skin caused by the child’s position during use.
Use a different type of mask or alternate between different models to vary the pressure points on the face so that the skin has a chance to heal.
It is normal for the skin to be slightly red at the pressure points of the mask, for up to 3 hours after the mask is removed. If the redness persists after this period, rapidly contact your child’s healthcare team to avoid serious skin breakdown.

Dryness of the nose, in the child who uses a mask

Possible cause(s)

Air leaks around the mask
High air flow from the ventilatory assistance device
Humidity level on the device set too low
Nasal dryness present for other reasons (eg, seasonal variation)

What to do?

This is commonly seen when ventilatory assistance is first started; the mucosa of the nose takes time to adapt to the air flow from the ventilatory assistance device.
Verify that the mask is correctly placed and the degree of leaks is acceptable.
As recommended by your healthcare team, use a water-based lubricant to hydrate the nasal mucosa.
Increase the humidity level gradually as needed in order to avoid condensation in the tubing.
Ensure that there is a sufficient amount of water in the water chamber (eg, during the night).
Increase your child’s hydration during waking hours (eg, drink more water).
Verify that your child’s nasal hygiene is optimized, follow the recommendations of your healthcare team.
Increase the level of humidity in the environment.
If the problem persists, contact your child’s healthcare team.

Nose or sinus congestion, in the child who uses a mask

Possible cause(s)

High air flow from the ventilatory assistance device
Air leaks around the mask
Your child sleeps with an open mouth
Humidity level on the device set too low
Respiratory infection
Seasonal allergies

What to do?

This is mainly an issue during the initial adaptation period to ventilatory assistance.
Verify that the mask is correctly placed; straps should not be too tight, as recommended by your child’s healthcare team.
If your child sleeps with an open mouth, discuss with your healthcare team whether a chin strap should be used with the mask.
Increase the humidity level gradually as needed in order to avoid condensation in the tubing.
Ensure that there is a sufficient amount of water in the water chamber (eg, during the night).
Verify that your child’s nasal hygiene is optimized; follow the recommendations of your healthcare team.
Increase the level of humidity.
If the problem persists, contact your child’s healthcare team.

Red, dry or irritated eyes, in the child who uses a mask

Possible cause(s)

Air leaks around the mask, misdirecting air flow into the eyes
Mask incorrectly adjusted or positioned
Incorrect mask (eg, size, model)

What to do?

Verify that the mask is correctly placed; straps should not be too tight, as recommended by your child’s healthcare team.
Clean the mask daily, following the recommendations of the healthcare team.
If the problem persists, contact your child’s healthcare team.

Mouth dryness, in the child who uses a facial mask

Possible cause(s)

Your child sleeps with an open mouth
Air leaks around the mask
Humidity level too low

What to do?

If your child sleeps with an open mouth, discuss with your healthcare team whether a chin strap should be used with the mask.
Increase the humidity level gradually as needed in order to avoid condensation in the tubing.
Ensure that there is a sufficient amount of water in the water chamber (eg, during the night).
Increase your child’s hydration during waking hours (eg, drink more water).
Increase the level of humidity.
If the problem persists, contact your child’s healthcare team.

Bloated belly or abdominal distension during invasive or non-invasive ventilation

Possible cause(s)

High air flow from ventilatory assistance device, air enters the lungs and the stomach
Difficult coordination between the child’s breathing and the ventilation from the ventilatory assistance device

What to do?

Occasionally present during the initial adaptation period to ventilatory assistance.
Encourage your child to coordinate breathing with the ventilatory support from the device as taught by your healthcare team.
If the problem persists, rapidly contact your child’s healthcare team.
If your child’s abdomen becomes hard or tender to touch or if your child is agitated, in discomfort, reporting abdominal pain or crying for no obvious reason, then rapidly contact your child’s healthcare team.

Difficulty to speak or swallow during non-invasive ventilation

Possible cause(s)

Difficulty in coordination between the child’s breathing and the ventilation from the ventilatory assistance device

What to do?

This is mainly observed during the initial adaptation period to ventilatory assistance.
In order to speak or swallow, the child must coordinate their breathing efforts with the air flow of the ventilatory assistance device. It is easier for the child to speak and swallow during the expiration phase.
If the problem persists, contact your child’s healthcare team.

Problems related to manual ventilation

Absence of movement of the chest during manual ventilation

Possible cause(s)

Air leaks around the facial mask
Air leakage around the tracheal cannula (eg, cuff deflation or incorrect positioning of the child)
Disconnection between the ventilatory bag and the tracheostomy connector or the mask specific for manual ventilation
Defective ventilatory bag

What to do?

Reposition the mask.
Ensure that the child’s head is correctly positioned.
Verify that the cuff of the tracheal cannula is correctly inflated, if present.
Ensure that the ventilatory bag and tubing are securely connected.
Verify that the ventilatory bag is correctly functioning: compress the bag with one hand and then release it; at the same time check with your other hand if air is coming out of the bag at the air outlet. The bag should reinflate quickly and automatically.

Unable to compress the ventilatory bag during manual ventilation

Possible cause(s)

Obstruction of the child’s airways or the interface
Defective ventilatory bag

What to do?

Ensure that the tracheal cannula is not obstructed with secretions; suction the secretions if needed.
Make sure that there are no blockages in the mask.
Ensure that there is no obstruction of the mouth or nose (secretions or foreign body); suction the secretions if needed.
Verify that the ventilatory bag is correctly functioning: compress the bag with one hand and then release it; at the same time check with your other hand if air is coming out of the bag at the air outlet. The bag should reinflate quickly and automatically.
If the problem persists, contact your child’s healthcare team.

Vomiting during manual ventilation

Possible cause(s)

Air pushed into the stomach rather than into the lungs

What to do?

Rapidly remove the face mask from your child.
Suction the secretions.
Clean your child’s face as needed.
Monitor your child’s breathing after the vomiting; there is a risk that some of the vomit may have entered the lungs (aspiration). This would cause your child to have more difficulty breathing. Rapidly contact your child’s healthcare team.

No resistance during compression of the ventilatory bag during manual ventilation

Possible cause(s)

Disconnect between the ventilatory bag and the tracheostomy connector or the mask specific for manual ventilation
Defective ventilatory bag

What to do?

Ensure that the ventilatory bag and tubing are securely connected.
Verify that the ventilatory bag is correctly functioning: compress the bag with one hand and then release it; at the same time check with your other hand if air is coming out of the bag at the air outlet. The bag should reinflate quickly and automatically.
If the problem persists, contact your child’s healthcare team.

Distention of the abdomen during manual ventilation

Possible cause(s)

Bag compressions too forceful
Bag compressions too rapid
Model of ventilatory bag inappropriate for the quantity of air required by the child

What to do?

Review the technique for correct manual ventilation.
Compress the ventilatory bag with less force.
Ensure that the correct model of ventilatory bag is used. If needed, verify with your healthcare team.

Do not hesitate to refer to your child’s healthcare team for any questions or for specific advice related to your child’s condition.

Everyday tips

Clothing

If your child has a tracheostomy, refer to the appropriate section to complete the information.

Bathing and swimming

If your child has a tracheostomy, refer to the appropriate section to complete the information.

Bath:

Discuss with your healthcare team the option to have longer tubing in the ventilation circuit to facilitate bathing.
Keep the ventilatory assistance device as far away as possible from the bath to protect it from water splashing.

Facial care:

Check your child’s skin daily, especially at the points of contact of the mask to the face, if applicable. In particular, check the bridge of the nose where skin breakdown may occur.
Gently clean the skin, avoid rubbing and pat gently to dry.
Avoid hot water and scented soaps which may dry or irritate the skin.
Hydrate facial skin by applying a moisturizer as needed; this may help keep the skin soft and supple.
Make sure the skin is dry before putting the ventilation mask on your child.

Mouth care:

It is important to clean your child’s mouth at least twice a day.
If your child has no teeth, use a small face cloth or a gauze dampened with water and rolled around your index finger, to gently rub your child’s gums front to back.
Once teeth start to appear, it is important to brush your child’s teeth after each meal and at bedtime. If your child does not eat by mouth, brush the teeth twice daily. Since young children have a tendency to swallow toothpaste instead of spitting it out, use only the size of a small grain of rice in children under 2 years old and the size of a small pea in children up to 6 years old. Use this time to also gently massage their gums with the toothbrush.
As your child matures, teach and supervise brushing of the teeth.
Apply, if required, a hydrating product for the lips if they are chapped and dry.

Nose care:

In all children, secretions, along with bacteria and viruses collect in the nose. Keeping your child’s nose clean helps prevent lung infections.
If your child is incapable of blowing his/her own nose effectively, saline drops will be helpful to keep the nose clean.
Refer to your child’s healthcare team for the technique and the frequency of nasal care recommended for your child, including the procedure for the preparation of homemade saline solution and safe storage.

Swimming:

Discuss with your healthcare team whether it is possible for your child to swim or not.
If swimming is permitted, then discuss the addition of longer tubing in the ventilation circuit with the healthcare team.
Keep the ventilatory assistance device as far away as possible from the water to protect it from splashing.

Sleeping

Position the circuit tubing towards the head of the bed to prevent it from curling, bending getting stuck underneath the child.
Avoid pulling the tubing or putting tension on the mask to prevent air leaks around the mask.
Avoid pulling on the tubing or putting tension on the connection to the tracheal cannula to reduce the risk of tracheal injury, accidental decannulation and/or air leakage.
Ensure that the pillow does not block the exhalation valve mask.
If a heated humidifier is used, install the ventilatory assistance device as close as possible to the bedside, preferably at a level lower than or equal to the head of the child so that excess condensation, if any, will flow into the water chamber and not into the child’s mask.
If your child has a tracheostomy, refer to the appropriate section to complete the information.

Nutrition and hydration

It is not recommended for your child to eat or drink while wearing a mask, in order to reduce the risk of choking. Refer to your child’s healthcare team for specific recommendations.
Ensure adequate hydration; this hydrates the airway passages (nose, throat) and optimizes your child’s comfort.
If your child has a tracheostomy, refer to the appropriate section for further information.

Activities

Your child may participate in daily activities according to ability, endurance and underlying conditions. Discuss with your child’s healthcare team.
Position your child in the most comfortable position possible to facilitate breathing.
If your child has a tracheostomy, refer to the appropriate section to identify activities which should be avoided.

Travel and transportation

Always have on hand a travel bag for all trips outside the home. This bag should contain, at least:
- ventilatory assistance device with:
  - the power cable for electrical wall outlet
  - a fully charged built-in battery (if present)
  - cable with a 12 volt car adapter, if necessary
  - an external spare battery with the appropriate cables, if present and if necessary
- two circuits for the ventilatory assistance device (one extra in reserve)
- two interfaces (including a spare)
- ventilatory bag for manual ventilation with the appropriate face mask
- demineralized water for the humidifier, if needed
- a second ventilatory assistance device as a back-up, if necessary.
Always have an up-to-date list of the contents of the travel bag to reduce the risk of missing items. Confirm with your healthcare team how often you should verify supply and status of equipment and materials, including expiry date for demineralized water.
Keep a resource list close at hand with the names and telephone numbers of hospital, doctors, other members of your child’s healthcare team and equipment providers. Make sure you know how to contact these resources outside of regular hours and during vacations.
During the winter months, always heat up the car interior before placing your child in the vehicle.
Before leaving on a trip:
- contact your healthcare team to plan travel with ventilatory assistance devices;
- ensure with your insurance provider that travel outside of your home region is covered;
- verify that the electrical voltage required for the ventilatory assistance device is available at your destination;
- make sure you have a document from the healthcare team describing your child’s condition and your child’s needs regarding ventilatory assistance (ventilator parameters) and a complete list of medications;
- have on hand a recent height and weight for your child and the specific sizes of all equipment;
- bring enough supplies to last for the duration of the trip and add a bit extra as a reserve;
- make sure to ask if equipment providers and other resources are available at your destination in the event of equipment failure or other healthcare needs;
- take the climate of your destination into consideration because the relative humidity of the ambient air could modify the level of humidity necessary to adequately hydrate your child’s airway passages.
During your travels:
- ensure that the battery of the ventilatory assistance device is fully charged;
- remove the heated humidifier if the ventilatory assistance device is used while the child is mobile; if your child has a tracheostomy, replace the heated humidifier by an artificial nose during transportation;
- always empty the water chamber of the heated humidifier before packing it in the storage bag.
For travel by airplane:
- contact the airline company to inquire about their policy concerning the transport of medical equipment;
- keep all medical equipment and supplies, medications and documents with you in the cabin.
If your child has a tracheostomy, refer to the appropriate section to complete the information.

Others

Cardio Pulmonary Resuscitation (CPR): Make sure that you and all persons responsible for your child’s care are trained. Consult your child’s healthcare team regarding referral to pertinent resources and the frequency of training renewal required.

Emergencies:

Always have a telephone nearby in case of an emergency. Make sure your cell phone is charged at all times. When you go out, bring what you need to charge the phone, when necessary (cable with charger and portable Power Bank charger).
During the time that your child is receiving ventilatory assistance, your child should always be monitored by a trained and competent individual capable of intervening, as needed. Some children require increased supervision due to their specific needs; discuss with your child’s healthcare team.
Outside of the time that your child receives ventilatory assistance, your child should have access, at all times, to a trained and competent individual who is able to assess your child’s respiratory status and intervene as required (eg, aspirate secretions, start ventilatory assistance earlier than planned).
If your child has a tracheostomy, refer to the appropriate section to complete the information.

Humidity:

Air entering the nose and passing through the throat (pharynx) is filtered, warmed and moistened by the airways before reaching the lungs. As your child receives ventilatory assistance, air is pushed into the lungs by the device at high flow rates; the body’s “natural” humidification system may be insufficient. Thus, air must be warmed and moistened to prevent dryness and irritation of lining of the airways. Excessive dryness causes irritation which may result in nosebleeds, nasal congestion, and increased production of secretions. Secretions may be thick, sticky and difficult to clear; this increases the risk of respiratory infections.
Lack of humidity can also cause discomfort and make the ventilatory assistance more difficult.
Avoid extremes of temperature (hot or cold) which may cause condensation in the ventilation circuit tubing.
The recommended relative humidity in the home, measured with a hygrometer, should be between 40 to 50%.
If your home air is too humid (55% and more), install a dehumidifier and clean it every week in order to prevent the presence of mold in the air that your child breathes.
If your home air is too dry (less than 40%), the following daily habits can help increase the moisture in your home:
- do not activate the exhaust fan when you cook or boil water;
- avoid using an air conditioner in the summer;
- keep the bathroom door open when you shower;
- minimize the use of electric heaters, wood burning stoves and fireplaces during the winter;
- eliminate carpeting and rugs in the home.
For a child receiving invasive or non-invasive ventilation, the level of air humidity should be increased at night and as often as possible during the day; this is accomplished by connecting the ventilatory assistance device to a heated humidifier. During the day, an artificial nose may replace a heated humidifier only in an invasive ventilation circuit.
Water chamber of the heated humidifier in the ventilatory assistance device:
- It is essential to use distilled or demineralized water in the water chamber of the humidifier. Tap water or bottled water contains minerals which can form limestone scale in the bottom of the water chamber. This scale is difficult to remove and particles from the limestone may irritate your child’s airways and lungs.
- Change the water in the water chamber every day. If there is water left in the water chamber at the end of the day, discard it. Rinse the water chamber with tap water and refill it with distilled or demineralized water. The daily rinsing of the water chamber prevents growth of bacteria and mold.
- If the ventilatory assistance device is used several times a day, then the water in the water chamber is good for period of 24 consecutive hours. Make a habit of rinsing the water chamber and changing the water at the same time of day.
- Do not add scented products or decongestants to the water. These products may irritate your child’s airways and damage the water chamber.
Discuss with your child’s healthcare team ways to improve the humidity; this will improve your child’s comfort and keep secretions loose for easier clearance.
If your child has a tracheostomy, it is even more important to ensure adequate humidity because inhaled air bypasses the nose and throat where natural humidification usually takes place; refer to the appropriate section for more details.

Air quality:

Avoid all exposure to traditional or electronic cigarette smoke or vapour, especially at home.
Clean and regularly change filters on the air conditioners.
Make sure that the air around your child and the ventilatory assistance device is free of dust and smoke.
In your child’s proximity, avoid:
- accumulation of dust, presence of rugs, upholstered furniture and home accessories that are difficult to clean (eg, heavy drapery),
- dust from renovations,
- wood burning heating systems (stove or fireplace),
- excessive pollution (eg, smog, heavy traffic, strong winds).
In your child’s room:
- avoid the presence of toys and stuffed animals in your child’s bed,
- use pillows cases, sheets, and blankets made of washable synthetic material (hypo-allergenic),
- avoid sheets that are very soft and fluffy with fibres (eg, flannel sheets) are not recommended: they attract dust,
- wash bedding in hot water every week in order to destroy dust mites,
- dry bedding in a dryer if your child is allergic to pollen.
If your child has a tracheostomy, refer to the appropriate section for further information.

Prevention of infections:

Always wash your hands before providing care to your child and have your child wash his hands before and after all meals and frequently during the day.
If you have a cold, the flu or another respiratory infection, use non sterile gloves and wear a mask when providing care to your child.
Be sure to clean and maintain equipment and materials as recommended.
If your child has a tracheostomy, refer to the appropriate section for further information.

Power supply for the ventilatory assistance device:

Ventilatory assistance devices can be powered in different ways:
- by electricity directly from a wall outlet; if direct access to an electrical outlet is impossible, then a multisocket extension cord with circuit breaker can be used,
- by a built-in rechargeable battery, if present,
- by an external battery with the appropriate cables, if present,
- by a cable with a 12 Volt adapter for connection in a car.
The power cables of the bi-level devices have two parts: a power cord which connects the power adaptor to the electric wall outlet and a power adaptor cord which connects the power adaptor to the bi-level device.

If a battery is used, make sure that there is an adequate charge for the predicted duration of ventilatory assistance.
It is not recommended to use a portable power bank to operate the ventilatory assistance device.
The electrical wall outlet should be clearly visible and easily accessible. At home, identify the fuse or circuit breaker that is connected to this electrical outlet.
Do not connect the device to an electric outlet that is controlled by a wall switch.
Ensure that one or more external batteries (if present) are fully charged at all times.

Installation of the ventilatory assistance device:

The device must always be installed in a clean, well-ventilated, dust-free room.
The device should be placed on a firm, level surface that is at the same height as your child’s head or slightly lower.
Arrange the device so that the power cable is not in the way of foot traffic.
The device should be placed away from any heating or cooling equipment (eg, radiator), direct sunlight, cold drafts and any device which emit electromagnetic waves (eg, cell phone, tablet, cordless telephone base, microwave, etc.).
Air must be able to flow freely around the device so that it works properly.
Make sure that there are no soiled, wet or moldy items near the air inlet of the device (eg, plants, curtains or stuffed toys, etc.).
Avoid exposing the device to extreme temperatures (hot or cold) and ensure that it is protected in case of rain or snow.
If a heated humidifier is used, install the ventilatory assistance device as close as possible to a bedside table, preferably at a level lower than or equal to your child’s bed to ensure that any excess condensation stays in the water chamber and not in the face mask.
If the heated humidifier is not integrated in the ventilatory assistance device, it should be installed in one of the following ways to stabilize the humidifier: on a roller stand or on a table stand.

If the device is used while your child is in a wheelchair, remove the heated humidifier and store it in a suitable transport bag, securely attached to the wheelchair.

Equipment replacement frequency:

Refer to your healthcare team or the manufacturer’s recommendations for the replacement frequency of the parts of the ventilation circuit, the interfaces and all other required equipment (eg, filters, water chamber, chin rest, etc.).
Any equipment must be changed (eg, tubing, mask, water chamber), if you notice that it is worn or damaged (eg, cracks, colour change).

Maintenance and cleaning of medical supplies and equipment:

Always refer to the manufacturer’s recommendations and those provided by your healthcare team. There may be certain recommendations for the cleaning and maintenance of equipment based upon the unique features of your child (eg, health condition, comfort, safety, living environment, etc.).
A general guide for the cleaning and maintenance of equipment is as follows:
- Always wash your hands before starting.
- Prepare the sink: wash it, disinfect it with bleach and then rinse thoroughly with running tap water or use a large bowl reserved only for the cleaning of your child’s medical equipment.
- Disassemble all the equipment (according to your child’s healthcare team’s recommendations) so that all the parts can be cleaned thoroughly.
- Rinse all the parts under warm tap water so as to remove any debris (eg, secretions, saliva, blood).
- Soak all parts in a sink or in a dish washing bin filled with warm water and non-perfumed, non-antibacterial dish soap, (eg, Sunlight) for 10-15 minutes.
- Never use bleach, alcohol or non-diluted hydrogen peroxide to clean equipment; these products may damage the equipment.
- If needed, brush the interior and exterior of the parts that remain soiled with a soft baby bottle brush.
- Rinse all parts with warm/hot water. Hot water may damage certain equipment.
- Shake off as much excess water as possible from items that have been rinsed.
- Allow all parts to dry on a clean towel placing them in such a fashion that will allow water to drain away from them.
- Reassemble all components once thoroughly dry.
- Store the equipment that is not in use in a bag used only for this purpose (eg, cotton pillowcase) that will protect the equipment from dust and dirt, according to your child’s healthcare team recommendations.

Here are further recommendations for specific equipment in addition to the general guidelines described above:

Mask:
- daily:
  - Clean the inner surface including the inside cushion of the mask using a damp cloth soaked in mild soap and water. All traces of face oil must be removed from the mask so that it continues to fit properly.
  - If the exhalation valve is dirty, clean it with a soft bristle brush according to the guide above.
  - Inspect the mask and straps for signs of wear and tear.
- each week: Disassemble the mask and the straps according to your child’s healthcare team recommendations; soak them to clean using the guidelines above.
Mouthpiece:
- daily: Clean the surface with a damp cloth soaked in mild soap and water.
- each week: Clean according the guide above.
Tracheostomy adapter:
- each week and more often if needed (eg, soiled with accumulation of saliva or secretions): Clean using the general guide above.
Ventilatory assistance device:
- Outside surface: Clean the outside surface using a damp cloth once weekly; allow to dry.
- Unplug the device before cleaning and check that it is dry before reconnecting it to an electrical supply.
- Handle the device carefully to avoid damage. Always remove the water chamber prior to cleaning to prevent water leaking into the device.
- Do not immerse the device or the power cables in water; keep the device dry.
- Filter: Clean and maintain according to the manufacturer’s recommendations.
Humidifier:
- Clean the outside surface weekly with a damp cloth and let dry.
- The heating element of the humidifier may be hot; let it cool for at least 10 minutes before cleaning.
Water chamber:
- daily:
  - Change the water in the water chamber every day. If water remains in the water chamber at the end of the day, discard it. Rinse the water chamber with tap water and refill it using distilled or demineralized water.
  - Do not use tap water or bottled water to refill the water chamber.
- each week:
  - Clean using the general guide above.
  - Some models can be cleaned in the dishwasher; refer to the manufacturer’s recommendations.
  - If deposits remain in the water chamber, use a dilute solution of water and vinegar to de-scale. Refer to your healthcare team for specific instructions and proportions of vinegar:water to use.
Artificial nose:
- daily and more often if needed (eg, soiled with secretions or water accumulation): Discard and replace.
Invasive ventilation circuit and non-invasive ventilation circuit with mask:
- each week and more often if needed (eg, presence of blood, secretions): Clean the tubing, dead space, adapter and exhalation valve, if present, according to the general guidelines above.
- each week: Replace the antibacterial filter, if present.
Circuit for mouthpiece:
- each month: Discard and replace with a new circuit.
Ventilatory bag and corresponding face mask (specific for use with the ventilatory bag):
- as needed: Clean the outside surface with a damp cloth soaked in mild soap and water.
- Do not immerse the ventilatory bag in water.

Communication:

In order to speak, a child with non-invasive ventilation must learn to coordinate self breathing with the air flow from the ventilatory assistance device. It is usually easier for children to speak during the expiratory phase of ventilation. Discuss with your child’s healthcare team if needed.
If you child has a tracheostomy, refer to the appropriate section for further information.

Daycare and school:

Your child’s healthcare team will evaluate your child’s needs and will support you in the planning of integration to daycare or to school.
Advise school staff of the treatment and care that your child requires.

Methods of care

Methods of care : Invasive ventilation

Indications

Invasive ventilation helps the child with a tracheostomy to breathe better by mechanically pushing air and oxygen (O2) into the lungs (inspiration) and facilitating the release of carbon dioxide (CO2) in exhaled air (expiration). Ventilatory assistance supports the child’s life and improves the child’s ability to do activities and to develop.
Below is a suggested method that can serve as a guide; discuss the specific type of medical supplies and equipment used for your child with the healthcare team.

Considerations:

A tracheal cannula with or without a cuff may be used for invasive ventilation.
If your child requires medications during the time that invasive ventilation is being used, refer to your healthcare team to learn the techniques for correct administration.
Invasive ventilation may be interrupted if your child requires aspiration of secretions; refer to your child’s healthcare team to learn how to do this correctly.
Evaluate the need for a second person to help keep your child in a safe position during the procedure (eg, your child is young or moving around a lot).
Good handwashing is essential before and after providing care.
Ensure the comfort of your child during care by using different positioning and distraction techniques.

Frequency

Your child may require invasive ventilation episodically, only at night or at all times, depending upon your child’s condition.
Some children require increased ventilatory assistance during respiratory infections.
Verify the recommended frequency of invasive ventilation with your child’s healthcare team.

Required materials

Ventilation circuit: tracheostomy adapter, dead space, adapter (eg, 15-22 mm), exhalation valve, tubing
Ventilatory assistance device with electrical power cables and built-in batteries
Heated humidifier, water chamber and short tubing OR artificial nose for the ventilation circuit
Antibacterial filter
Demineralized or distilled water

If needed:

10 ml syringe, if your child has a cuffed tracheal cannula
Materials to suction secretions
Oxygen and associated equipment, as indicated by your child’s healthcare team, according to your child’s condition

The method of care below is illustrated using a Trilogy respirator.

Refer to your child’s healthcare team if the material or the sequence of steps you have been taught is different than those described here.

Step 1: Anticipation

See the full description here

Summary:

Collaborate and form a team with your child. When you invest the time to form a strong team, children feel more comfortable and less anxious – this will help you complete the care with less stress – for you and your child.

Use these tips, from the start, to set the stage for a positive care procedure:

Create the right moment: integrate the care in a routine.
Alert your child to the needed care and communicate together.
Form a team with your child: Encourage autonomy by offering realistic choices such as the method of distraction. Stay tuned to your child. Manage pain and anxiety, using distraction and positioning for comfort.

Step 2: Preparation

See the full description here

Summary:

Prepare the environment: Identify a routine place for care. Close windows, doors and fans. Wash and dry the work surface and gather the needed materials for the care and to distract your child.
Prepare your child: Get help if needed. Position your child for comfort to receive the care and start to use the selected distraction method.
Prepare yourself: Find the right time when you are ready to provide the care safely. Review the list of care steps. Wash your hands.

Now that you are ready to start the care procedure, take the opportunity to encourage and praise your child.

Step 3: Procedure

See the full description here

Summary 3 key concepts:

Safety: Carefully follow the care practice steps as you have been taught.
Flexibility: Be ready to adjust according to your child’s reactions during the procedure. As needed, reposition or select an alternative distraction strategy. Follow your child’s pace and rhythm.
Collaboration: Reassure your child, verbally and non-verbally. Acknowledge your child’s emotions and reactions. Help your child differentiate between the different sensations during a procedure.

Step 4: Prepare the device

Connect the device to an electrical wall outlet or an external battery. The built-in battery may also be used.
Make sure that the antibacterial filter is connected to the air outlet of the respirator.

Why ?

This step ensures the proper set-up for the ventilatory assistance device, in preparation for the next steps.

Step 5: Assemble the ventilation circuit

Connect all parts of the ventilation circuit: tracheostomy adapter, dead space, heated humidifier or artificial nose, adapter, exhalation valve and tubing.
Make sure that the circuit parts are well connected to each other.
Verify that the tubing of the circuit is not bent, pinched or obstructed.

Why ?

A correct assembly of the circuit parts avoids air leaks during ventilatory assistance.

Air leaks can reduce the effectiveness of ventilatory assistance.

Correct positioning of tubing helps to prevent the accumulation of water inside the tubing.

Step 6: Prepare the heated humidifier, if being used

If your child uses an artificial nose, then go to the next step.

Remove the water chamber from the humidifier.
Empty any residual water from previous use, if any.
Place the water chamber on a solid flat surface (eg, table top).
Fill water chamber with distilled or demineralized water to the maximal fill line.
Put the water chamber back into the humidifier.
Using the short tubing, connect one end of the tubing to the antibacterial filter of the respirator and the other end to one of the openings on top of the water chamber of the heated humidifier.

Using the ventilation circuit tubing that goes towards the child, connect the circuit tubing to the other opening on the top of the water chamber of the heated humidifier.
Turn the humidifier on by pressing the power button.

Make sure that the humidity level on the humidifier is correctly set, according to the recommendations of the healthcare team.
Go to step 8.

Why ?

The addition of humidity to the air flow from the device helps to prevent irritation and overdrying of the lining of the airways.

Step 7: Prepare the artificial nose, if being used

If your child is not using an artificial nose, then go to the next step.

Connect the artificial nose between the dead space and the adapter of the ventilation circuit.
Connect the tubing of the circuit to the antibacterial filter of the respirator.

Why ?

The addition of humidity to the air flow from the device helps to prevent irritation and overdrying of the lining of the airways.

Step 8: Position and prepare your child

Place your child in a comfortable position (sitting or lying down) that easily allows you to access the tracheal cannula.
Remove the speaking valve or the artificial nose if one is in place over the tracheal cannula.
Suction the secretions if needed.

Why ?

The best position is one which optimizes your child’s comfort and the effectiveness of ventilatory assistance.

Step 9: Inflate the cuffed tracheal cannula, if present

If your child has a tracheal cannula without a cuff, then go to the next step.

Fill the syringe with the amount of air specified by your healthcare team.
Insert the tip of the syringe into the valve of the pilot balloon of the tracheal cannula, screwing it to connect securely.
Slowly push the air into the cuff, 0.5 ml at a time.
Once the cuff is inflated, detach the syringe by unscrewing it.

Why ?

If your child uses a cuffed tracheal cannula, then this step helps to reduce air leaks and improves the effectiveness of ventilatory assistance.

Step 10: Turn on the device

Press and release the start button of the ventilatory assistance device.
The backlight of the display should light up; red and yellow lights flash on briefly and a beeping sound is heard when the device is turned on.

Why ?

The device must be turned on in order to provide ventilatory assistance to your child.

Always start the device BEFORE connecting the device to your child. This ensures that your child is not exposed to a possible rapid burst of air flow when the device is first started.

Step 11: Connect the circuit to the tracheal cannula

Hold the tracheostomy connector with one hand to stabilize it.
With the other hand, connect the tracheostomy adapter portion of the ventilation circuit to the tracheostomy connector.
Turn on the oxygen supply, if prescribed, according to the methods taught by your child’s healthcare team.
If present, ensure that the exhalation valve is not blocked.

Why ?

This step connects the ventilation circuit and the ventilatory assistance device to your child.

Correct connection of the tracheostomy adapter of the circuit to the tracheostomy connector of your child helps to avoid air leaks during ventilatory assistance.

The exhalation valve allows release of exhaled air.

Step 12: Continue and supervise ventilatory assistance

Check that the device is working properly: your child should be receiving air flow and the pressure graph (green bar) on the device screen should be moving back and forth.
Make sure that there are no significant air leaks in the circuit: check the level of leaks displayed on the device screen and compare this to the acceptable levels as indicated by your child’s healthcare team. If there is an excessive air leak, correct the problem.
Make sure that there is no tension or pulling on the ventilation circuit and on the tracheal cannula connector.
Ensure that the humidifier is on and functioning correctly (eg, temperature displayed, lights on).
Verify that there is no accumulation of water in the tubing.
Correct any device alarm situations, if any.
Contact your healthcare team for any persistent alarms.

Why ?

This step ensures safe ventilatory assistance.

Air leaks may reduce the effectiveness of ventilatory assistance.

Step 13: Discontinue ventilation and disconnect the circuit from the tracheal cannula

When the period of ventilatory assistance for the child is over:

Hold the tracheostomy connector with one hand to stabilize it.
With the other hand, disconnect the tracheostomy adapter portion of the ventilation circuit from the tracheostomy connector.

Why ?

This step allows the ventilatory assistance to be discontinued safely.

Step 14: Turn off the device

Turn off the oxygen supply, if used.
Press and release the device stop button.
Confirm your intention to turn off the device by pressing the button at the bottom right of the screen.
Turn off the humidifier by pressing on the stop button of the humidifier.

Why ?

This step allows the device to be turned off securely.

Step 15: Deflate the cuffed tracheal cannula, if present

If your child has a tracheal cannula without a cuff, then go to the next step.

Before deflating the cuff, suction the secretions.
Holding the syringe, push the plunger all the way in to remove any air.
Insert the tip of the syringe into the valve of the pilot balloon of the tracheal cannula, screwing it to connect securely.
Pull the plunger out slowly until you feel resistance.
Verify that you have removed the volume of air that was injected into the cuff in step 9.
Once the cuff is deflated, detach the syringe by unscrewing it.

Why ?

Deflating the cuff allows the passage of air into the lungs via the nose and mouth, in addition to the tracheal cannula.

Aspirating the secretions before deflating the cuff prevents any accumulated secretions from going into the lungs.

Step 16: Replace the speaking valve or the artificial nose, if needed

Suction the secretions, if needed.
Replace the speaking valve or the artificial nose on the tracheal cannula, if needed.

Always ensure that the cuff of the tracheal cannula is deflated before putting the speaking valve in place.

Why ?

This step allows you to reinstall the accessories necessary for your child’s breathing, if required.

Step 17: Clean and store the equipment

Clean and store the equipment according to the recommendations.

Why ?

This step is required to prevent infections and to maintain the equipment in working order.

Step 18: Recovery

See the full description here

Summary:

The treatment is finished. Wash your hands again.

Be prepared to recognize the challenges faced and to provide positive feedback. Help your child recognize his/her strengths. Acknowledge the collaborative teamwork.

Listen to what your child says about the parts of the procedure that were difficult or painful.
Comfort your child and recognize your child’s collaboration with positive feedback.
Highlight your child’s specific strengths that helped make the procedure positive.
Discuss with your child what might be done the same or differently the next time the care is needed.
Keep your promises if you have promised a reward, follow through.
Reward yourself too.

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