Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC)

 

## Voting on the recommendations
The drafted recommendations were presented and discussed at a two-day meeting in Rome, Italy by all experts and members of the SC. The aim was not necessarily to reach a single and convergent opinion regarding all proposals, but to bring out the points of agreement, disagreement or equipoise with possible redrafting of individual recommendations. This final set of recommendations was subject to electronic voting in December 2015 using the RAND/UCLA appropriateness method scale . Each expert and member of the SC rated all recommendations using a scoring system ranging from 1 (complete disagreement) to 9 (complete agreement) with each expert and member of the SC having an equal vote. After elimination of one lowest and one highest value, the median and confidence interval of the scores were calculated. A recommendation reached "strong agreement" if the median was between 7 -9 and all experts rated the recommendation 3 7.
Recommendations were labelled "equipoise" if the median was between 7 -9 but not all experts rated the recommendation 3 7 or if the median was between 4 -6, and "disagreement" if the median was between 1 -3. All recommendations that did not reach strong agreement in the first round were sent back to all experts and members for the SC for input on how it should be rephrased so that it could reach strong agreement. The SC redrafted these recommendations based on this input and subjected them to a second round of electronic voting (February 2016). The same approach was followed. Recommendations that did not reach strong agreement in the second round were classified as "weak agreement". The percentage of agreement was calculated for these recommendations (i.e. the percentage of experts that rated the recommendation 3 7) to quantify the level of disagreement. As it was expected a priori that there would be very little, if any, randomized controlled trials or systematic reviews, it was decided by the SC not to use the GRADE system but to keep the consensus guideline descriptive . 

## Disease definitions based on respiratory physiology
Healthy lungs - Respiratory physiology: loss of respiratory drive, normal compliance, normal chest wall compliance, normal resistance
- Examples: patients who undergo elective ventilation for any reasons (e.g. surgery, procedural), emergency ventilation for depression of respiratory drive or acute neuromuscular disorder or semi -elective ventilation for underlying depression of respiratory drive or neuromuscular disorders Obstructive respiratory disease - Respiratory physiology: normal lung compliance, increased peripheral airway resistance leading to airflow limitation. Increased risk of dynamic hyperinflation potentially leading to intrinsic PEEP. Respiratory system compliance may be reduced at high lung volumes (overdistension)
- Examples: status asthmaticus, bronchopulmonary dysplasia, bronchiolitis obliterans, cystic fibrosis Restrictive respiratory disease - Respiratory physiology: reduced lung compliance and/or reduced chest wall compliance, normal airway resistance. inhomogeneous distribution of aeration, favouring the non-dependent lung. This leads to a reduced functional residual capacity (FRC) and increased physiological deadspace (Vd/Vt). The required pressure to open collapsed diseased lungs (and alveoli) and the pressure to maintain lung (or alveolar) volume is increased in acute restrictive lung disease. The closing pressure may be or is lower than the opening pressure. Recruitment and derecruitment are both time-and pressure dependent - Examples: acute respiratory distress syndrome, pneumonia, pulmonary contusion, abdominal hypertension.

## Mixed disease
- Respiratory physiology: reduced lung compliance and/or chest wall compliance.
Respiratory system compliance can be reduced at low lung volumes or at high lung volumes (overdistension). Increased peripheral airway resistance resulting in airflow limitation. Increased risk for dynamic hyperinflation.
- Examples: status asthmaticus with both CO 2 retention and hypoxia due to acute lung injury, viral bronchiolitis / pneumonia, bronchopulmonary dysplasia with acute infection Congenital and chronic restrictive disease - Respiratory physiology: reduced compliance, reduced chest wall compliance, normal or increased resistance due to a congenital or chronic condition - Examples: congenital diseases are linked to foetal and/or congenital conditions, such as congenital cystic adenomatous malformation, congenital lobar emphysema, chylothorax, congenital sequestration, congenital flail chest and other chest wall malformations, vascular lung malformations. Chronic restrictive include neuro-muscular diseases in severe phases, cerebral palsy, Jeune Syndrome, Jarcho-Levin Syndrome (spondylocostal dysostosis and spondylothoracic dysplasia), chest wall or spine abnormalities/deformities unrelated to the above described conditions Lung hypoplasia syndromes including CDH - Respiratory physiology: normal chest wall compliance, normal or reduced compliance and normal or increased resistance supposed to be related to lung hypoplasia - Examples: congenital diaphragmatic hernia (various types), fibrotic post-ARDS lung hypoplasia, fibrotic post-radio or chemotherapy lung hypoplasia, Potter-like syndromes, (lung hypoplasia associated to extreme prematurity, lung hypoplasia associated with multi-cystic kidney disease, lung hypoplasia associated to skeletal diseases (including Merckel-Grueber syndrome)), congenital unilateral lung hypoplasia/aplasia, congenital primitive fibrosis, certain massive pulmonary malformation treated by the section n5 (e.g.: congenital pulmonary adenomatous malformation, giant sequestration, chylothorax) may also qualify if they cause a relative absence of functional lung tissue. 10. At present, there is insufficient paediatric data to provide recommendations on the optimal interface for CPAP (strong agreement) . At present, there is insufficient paediatric data to provide recommendations on the optimal interface for non-invasive ventilation. However, we recommend that any interface with the least leakage needs to be used (strong agreement) . We recommend that, dependent on local experiences and materials, total-face mask, although this needs to be judged in relation to ventilator settings (87% agreement) . We suggest that pulse oximetry is usually sufficient to assess oxygenation in ventilated patients with mild disease and patients on non-invasive ventilation (strong agreement) . We recommend using indwelling arterial lines in more severely ill patients on invasive ventilation, allowing PaO 2 measurements for an accurate assessment of oxygenation and measurements of pH and lactate (strong agreement) . We suggest that there is no strict indication for using indwelling arterial lines for the purpose of pCO 2 measurements (93% agreement) . We suggest that capillary pCO 2 is sufficient to assess gas exchange in ventilated patients with mild disease and patients on non-invasive ventilation (strong agreement) . We recommend that venous pCO 2 measurements are of limited use in providing reliable information about ventilatory gas exchange. They might be used for following evolution of disease (strong agreement) [bib_ref] Bubble continuous positive airway pressure for children with severe pneumonia and hypoxaemia..., Chisti [/bib_ref] 3. We recommend reducing dead space apparatus as much as possible by using appropriate patient circuits and reduction of swivels (strong agreement)

## Modes of respiratory support

## E. weaning and extubation readiness
1. At present, there is insufficient paediatric data to provide recommendations on the timing of initiation of weaning. In the absence of evidence, we recommend to start weaning as early as possible (strong agreement)
2. At present, there is insufficient paediatric data to provide recommendations on any specific weaning approach in ventilated children, irrespective of approach to ventilation (invasive, non-invasive) (strong agreement)
3. At present, there is insufficient paediatric data to recommend the routine use of noninvasive respiratory support after extubation. However, early application of non-invasive ventilation combined with cough-assist techniques should be considered in patients with neuromuscular diseases (strong agreement) . At present, there is insufficient paediatric data to provide recommendations on the routine use of any extubation readiness testing approach that is superior to clinical judgement in invasively ventilated children (strong agreement) 5. We recommend using corticosteroids in patients at increased risk for post-extubation stridor. However, the optimal dosage and timing is unclear (strong agreement) . At present, there is insufficient paediatric data to recommend the routine use of noninvasive respiratory support after extubation. However, early application of non-invasive ventilation combined with cough-assist techniques should be considered in patients with neuromuscular diseases (strong agreement)

## F. normal lungs
1. At present, we cannot recommend on the optimal mode of ventilation (i.e. volume controlled versus pressure controlled) for patients with normal lungs (strong agreement)
2. At present, we cannot recommend a specific plateau pressure limit. In the absence of evidence, we recommend that delta pressure (i.e. the difference between end inspiratory and end expiratory pressure) levels should be expected to be less than 10 cmH 2 O for normal lungs (strong agreement)
3. We recommend using tidal volumes in the physiologic range (i.e. 5 -8 mL/kg ideal bodyweight according to national growth charts) (strong agreement) . In the absence of evidence, we recommend using a certain level of PEEP in invasively mechanically ventilated children with healthy lungs to prevent alveolar collapse.
However, we cannot provide any recommendation of how much PEEP should be used in these patients. Physiological data in children without lung injury suggests a range of 3 9. In the most severe cases, controlled mechanical ventilation (pressure or volume) should be preferred mandating the need for sedation and/or muscle relaxants. There is no agreement either mode to be preferential over other modes (strong agreement) [bib_ref] Investigators of the Pediatric Acute Lung, I, Sepsis, N (2016) Invasive Mechanical..., Rowan [/bib_ref] 10. By observing the flow -time and/or flow -volume curve and/or measurement of total PEEP, it may be possible to set the appropriate expiratory time to allow the emptying of the lungs (strong agreement) . At present, there is insufficient data to provide any recommendations on the use of heliox in patients with obstructive disease (strong agreement)
12. At present, there is insufficient data to provide any recommendations on the use of NAVA in patients with obstructive disease (strong agreement) . We recommend that high-frequency jet ventilation should not be used because of the risk of dynamic hyperinflation (strong agreement)

## H. restrictive diseases
1. There is insufficient paediatric outcome data to recommend on the routine use of high flow nasal cannula in patients with restrictive disease (strong agreement)
2. There is insufficient paediatric outcome data to recommend on the routine use of CPAP . At present, there is no paediatric data to guide recommendations on the optimal tidal [bib_ref] Semi-recumbent position versus supine position for the prevention of ventilator-associated pneumonia in..., Wang [/bib_ref] volume for patients with acute restrictive lung disease. However, we recommend avoiding tidal volumes larger than 10 mL/kg ideal bodyweight in any circumstances (strong agreement) . In the absence of transpulmonary pressure measurements, we recommend an inspiratory plateau pressure limit of 28 cm water pressure (87% agreement) . In the absence of transpulmonary pressure measurements, we recommend an inspiratory plateau pressure limit of 29 -32 cm water pressure as a rule of thumb for patients with increased chest wall elastance (i.e., reduced chest wall compliance) (93% agreement) . We recommend that high respiratory rate should be used to compensate for low tidal volume and maintain minute ventilation (strong agreement) . We recommend that in order to improve oxygenation, PEEP titration should be attempted. There is not a defined method to set the best PEEP. PEEP should always be set finding optimal balance between haemodynamics and oxygenation. In severe paediatric ARDS high levels of PEEP may be needed (strong agreement) . At present, there is insufficient paediatric outcome data to recommend any lung recruitment manoeuvre in patients with restrictive disease (strong agreement) . We recommend that HFOV may be considered in failing conventional ventilation, using an open lung strategy to obtain optimal lung volume (strong agreement) . We recommend adhering to the paediatric acute lung injury consensus collaborative [bib_ref] Correlation of simultaneously obtained capillary, venous, and arterial blood gases of patients..., Yildizdas [/bib_ref] 6. At present, there is no paediatric data to guide recommendations on the optimal tidal volume. However, we recommend avoiding tidal volumes larger than 10 mL/kg ideal bodyweight in any circumstances (strong agreement) . In the absence of transpulmonary pressure measurements, we recommend an inspiratory plateau pressure limit of 28 cm water pressure, allowing for slightly higher plateau pressures (29-32 cm water pressure) for patients with increased chest wall elastance (i.e., reduced chest wall compliance) (strong agreement) . In the absence of evidence, based on adult data we recommend that for patients with reduced lung volumes, the driving pressure (Vt / Crs) target may dictate the optimal tidal volume (strong agreement) . In the absence of paediatric data, we recommend that early HFOV and/or extracorporeal life support might be considered when conventional ventilation fails (93% agreement) . We recommend that high levels of PEEP may be used to stabilize airways in ventilated patients with trachea-and/or bronchomalacia. Careful titration of PEEP using is mandated to avoid cardiovascular compromise (strong agreement) . We recommend using double limb circuits for invasive ventilation (strong agreement)
12. We recommend preferentially using single limb circuit during NIV (93% agreement) . We recommend that in cardiac patients with additional restrictive or obstructive lung disease the principles for that specific pathology will apply, but titration of ventilator settings should be done even more carefully (strong agreement) . We recommend that increasing FiO 2 up to 1,0 in life-threatening acute pulmonary hypertension crisis may be required (strong agreement) . In patients at risk for pulmonary hypertension, we recommend to maintain normal pH (strong agreement) . We recommend using pH as one non-pharmacologic tool to modify the pulmonary vascular resistance for specific disease conditions (strong agreement) [bib_ref] Capillary blood gases in a pediatric intensive care unit, Escalante-Kanashiro [/bib_ref] L. Lung hypoplasia 1. We recommend that recommendations proposed for patients with acute restrictive, obstructive or mixed disease are also applicable to patients with lung hypoplasia syndromes who suffer from acute deterioration (strong agreement) 2. At present, there is insufficient paediatric data to guide a recommendation on optimal tidal volume for these patients. Tidal volumes may be smaller than conventional because of lower residual lung volume in these patients (strong agreement) [bib_ref] Validity of venous blood gas analysis for diagnosis of acid-base imbalance in..., Bilan [/bib_ref] and 100%) . The aim was to assess whether a conservative protocol for oxygen supplementation could improve outcomes in patients admitted in ICU. Despite the study was stopped early due to difficulties in enrolment, mortality was significantly lower in the conservative oxygen therapy group (11.6% vs 44% respectively). Since no paediatric patients were included, this study will not affect our recommendations but underscore the need for paediatric investigations.

## Relevant papers published since voting

## Non-invasive support
For high -flow nasal cannula (HFNC), some papers of interest were published since voting on the recommendations. Milesi and colleagues performed a randomised controlled trial in five paediatric intensive care units (PICU) to compare 7 cmH 2 O nCPAP with 2 L/kg/min highflow oxygen therapy in infants < 6 months with moderate to severe acute viral bronchiolitis . nCPAP was associated with a lower failure rate and non-inferiority of high-flow oxygen therapy could not be confirmed. This study suggests that nCPAP may be more efficient for initial respiratory support in this patient category. The effect on our recommendations would be that we would recommend against initial use of high-flow oxygen therapy in moderate-tosevere acute bronchiolitis and suggest that nCPAP is probably better than HFNC during the [bib_ref] Comparison of blood gas values in arterial and venous blood, Kirubakaran [/bib_ref] initial phase of moderate to severe bronchiolitis. A single-center cohort study reported that the use of HFNC delayed non-invasive ventilation with inherent prolonged length of respiratory support and PICU stay in paediatric status asthmaticus, but this study has no effect on our recommendations . From a systematic review and meta-analysis of adult data it was concluded that the use of high-flow oxygen therapy compared with usual care had no effect on mortality or intubation rates . However, four recent RCTs in adults showed a clear benefit of HFNC over NIV in terms of patient outcome . Since no paediatric patients were included in these studies, they will not affect our recommendations but underscore the need for paediatric investigations. A trial in adults reduced intubation rates and lower mortality in those who were managed with a helmet as opposed to a face mask, underscoring the need for paediatric explorations [bib_ref] Bubble continuous positive airway pressure for children with severe pneumonia and hypoxaemia..., Chisti [/bib_ref].

## Hfov
Sud and co-workers updated their previous systematic review on high -frequency oscillatory ventilation (HFOV) in acute respiratory distress syndrome (ARDS), adding two published adult trials . The findings of this systematic review were that HFOV did not reduce hospital and 30-day mortality due to ARDS, although the quality of evidence was very low. The effect of this systematic review on our recommendations are none, since there was no new paediatric data incorporated. Individual patient data meta-analysis of the OSCILLATE trial suggested that early HFOV may reduce mortality in those with severe ARDS, calling for proper patient stratification when using rescue therapies . In fact, in the Gupta paper, early HFOV was associated with improved patient outcome [bib_ref] Comparison of High-Frequency Oscillatory Ventilation and Conventional Mechanical Ventilation in Pediatric Respiratory..., Gupta [/bib_ref].
Rowan and co-workers studied the current respiratory practice patterns in N = 222 paediatric haematopoietic stem cell recipients and noted that a more aggressive approach including endotracheal intubation and "early" HFOV was feasible and may offer an opportunity to improve outcomes [bib_ref] Investigators of the Pediatric Acute Lung, I, Sepsis, N (2016) Invasive Mechanical..., Rowan [/bib_ref].
Supportive measures [bib_ref] Low inferior vena caval catheters for hemodynamic and pulmonary function monitoring in..., Fernandez [/bib_ref] A recent systematic review in adults on head elevation concluded that a semi-recumbent position ( 30o) might reduce clinically suspected ventilator-associated pneumonia compared to a 0 to 10 supine position, although the available adult was seriously limited with a high risk of bias [bib_ref] Semi-recumbent position versus supine position for the prevention of ventilator-associated pneumonia in..., Wang [/bib_ref]. Since no paediatric patients were included, this study will not affect our recommendations but underscore the need for paediatric investigations.

## Weaning and extubation
Faustino and co-workers performed a secondary analysis of data from the Randomized 28

## Monitoring

## Monitoring of ventilation

## Indwelling arterial lines are not mandated for pco 2 measurements (93% agreement).
Capillary PCO 2 is sufficient to assess gas exchange in mild disease and during NIV (strong agreement). Venous PCO 2 measurements provide limited information but could be used as a trend to assess the disease trajectory (strong agreement). We

## Suggest considering transcutaneous co 2 measurements in very young children and neonates; their value in older patients is unclear (strong agreement)
Capillary PCO 2 adequately reflects arterial PCO 2 in the absence of (severe) hypotension or poor peripheral perfusion, thereby not mandating indwelling arterial lines [bib_ref] Correlation of simultaneously obtained capillary, venous, and arterial blood gases of patients..., Yildizdas [/bib_ref] [bib_ref] Comparison of simultaneously obtained arterial and capillary blood gases in pediatric intensive..., Harrison [/bib_ref] [bib_ref] Capillary blood gases in a pediatric intensive care unit, Escalante-Kanashiro [/bib_ref].
Alternatively, central but not peripheral venous PCO 2 can be monitored albeit that it poorly correlates with PaCO 2 [bib_ref] Correlation of simultaneously obtained capillary, venous, and arterial blood gases of patients..., Yildizdas [/bib_ref] [bib_ref] Validity of venous blood gas analysis for diagnosis of acid-base imbalance in..., Bilan [/bib_ref] [bib_ref] Comparison of blood gas values in arterial and venous blood, Kirubakaran [/bib_ref] [bib_ref] Low inferior vena caval catheters for hemodynamic and pulmonary function monitoring in..., Fernandez [/bib_ref]. Transcutaneous CO 2 (TcCO 2 ) monitoring may be applicable in infants and older children [bib_ref] Transcutaneous carbon dioxide monitoring for the prevention of neonatal morbidity and mortality, Bruschettini [/bib_ref] [bib_ref] Transcutaneous carbon dioxide monitoring in infants and children, Tobias [/bib_ref] [bib_ref] Transcutaneous carbon dioxide monitoring during high-frequency oscillatory ventilation in infants and children, Berkenbosch [/bib_ref] [bib_ref] Transcutaneous monitoring of carbon dioxide tension after cardiothoracic surgery in infants and..., Tobias [/bib_ref] [bib_ref] Noninvasive monitoring of carbon dioxide during respiratory failure in toddlers and infants:..., Tobias [/bib_ref] [bib_ref] Continuous transcutaneous oxygen and carbon dioxide monitoring in the pediatric ICU, Monaco [/bib_ref].
Capnography, preferably end-tidal CO 2 (ET-CO 2 ), should be used during conventional

## Mv. added dead space when measuring et-co 2 should be minimal, especially in small children (strong agreement).
There is insufficient data to recommend routine volumetric capnography. However, we suggest using volumetric capnography to assess changes in physiologic dead space in ventilated children with restrictive lung

## Disease (strong agreement)
Monitoring end-tidal CO 2 (ET-CO 2 ) allowing for rapid assessment of respiration, haemodynamics and artificial airway patency is considered standard-of-care despite the lack of outcome data [bib_ref] Monitoring of standard hemodynamic parameters: heart rate, systemic blood pressure, atrial pressure,..., Sivarajan [/bib_ref] [bib_ref] Accuracy of physiologic deadspace measurement in intubated pediatric patients using a metabolic..., Lum [/bib_ref] [bib_ref] End-tidal carbon dioxide monitoring in the prehospital setting, Bhende [/bib_ref] [bib_ref] Alterations of end-tidal carbon dioxide during the intrahospital transport of children, Tobias [/bib_ref]. ET-CO 2 can also be used to calculate end-tidal alveolar dead space fraction (AVDSF) [bib_ref] Higher Dead Space Is Associated With Increased Mortality in Critically Ill Children, Bhalla [/bib_ref] [bib_ref] Monitoring Dead Space in Mechanically Ventilated Children: Volumetric Capnography Versus Time-Based Capnography, Bhalla [/bib_ref] [bib_ref] The association between the end tidal alveolar dead space fraction and mortality..., Ghuman [/bib_ref]. There is no data showing improved outcomes with capnography-guided therapy, although high dead space is associated with disease severity [bib_ref] Higher Dead Space Is Associated With Increased Mortality in Critically Ill Children, Bhalla [/bib_ref] [bib_ref] Relationship between physiologic deadspace/tidal volume ratio and gas exchange in infants with..., Almeida-Junior [/bib_ref]. [bib_ref] Noninvasive monitoring of carbon dioxide during respiratory failure in toddlers and infants:..., Tobias [/bib_ref] 

## Monitoring of oxygenation
We recommend transcutaneous saturation (tcSpO 2 ) monitoring (i.e. pulse oximetry) in every ventilated child (strong agreement). Pulse oximetry is usually sufficient to assess oxygenation in mild disease and during NIV (strong agreement). We recommend using indwelling arterial lines in more severely ill children on invasive ventilation to measure PaO 2 accurate assessment of oxygenation (strong agreement).

## We recommend monitoring central venous saturation (svo 2 ) and/or arterial lactate in invasively mechanically ventilated children with severe lung injury to assess oxygen debt (strong agreement) and as an indirect assessment of cardiac output (strong agreement)
Pulse oximetry allowing for non-invasive, continuous, fast and easy assessment of oxygenation and peripheral perfusion (unless tcSpO 2  80% or haemoglobin anomalies are present) is to be considered standard-of-care monitoring despite the lack of outcome data [bib_ref] Monitoring of standard hemodynamic parameters: heart rate, systemic blood pressure, atrial pressure,..., Sivarajan [/bib_ref] [bib_ref] A single-blind study of pulse oximetry in children, Cote [/bib_ref] [bib_ref] Pulse oximetry in pediatric intensive care: comparison with measured saturations and transcutaneous..., Fanconi [/bib_ref]. PO 2 can only be measured reliably in arterial blood, hence metrics of oxygenation (PaO 2 /FiO 2 or oxygenation index) mandate indwelling arterial lines [bib_ref] Correlation of simultaneously obtained capillary, venous, and arterial blood gases of patients..., Yildizdas [/bib_ref] [bib_ref] Comparison of simultaneously obtained arterial and capillary blood gases in pediatric intensive..., Harrison [/bib_ref] [bib_ref] Pulse oximetry vs. PaO2 metrics in mechanically ventilated children: Berlin definition of..., Khemani [/bib_ref].
Alternative metrics include SpO 2 /FiO 2 ratio and oxygen saturation index when SpO 2  97% [bib_ref] Pulse oximetry vs. PaO2 metrics in mechanically ventilated children: Berlin definition of..., Khemani [/bib_ref] [bib_ref] Comparison of the pulse oximetric saturation/fraction of inspired oxygen ratio and the..., Khemani [/bib_ref] [bib_ref] Correlation of oxygen saturation as measured by pulse oximetry/fraction of inspired oxygen..., Lobete [/bib_ref] [bib_ref] Pediatric Acute Lung, I, Sepsis Network, I (2012) Comparison of SpO2 to..., Khemani [/bib_ref] [bib_ref] Defining acute lung disease in children with the oxygenation saturation index, Thomas [/bib_ref]. Mixed central venous saturation (SvO 2 ) and arterial lactate may better reflect tissue oxygen need, but there is no data identifying their usefulness in ARF [bib_ref] Monitoring oxygen delivery in the critically ill, Huang [/bib_ref] [bib_ref] Pathophysiology of oxygen delivery in respiratory failure, Levy [/bib_ref].

## Monitoring of tidal volume

## We recommend proximal vt measurements (i.e. near the y-piece of the patient circuit) in small children (strong agreement).
Delivered Vt may be underestimated in small children (< 10 kg) when no proximal flow sensors are used [bib_ref] Tidal volumes for ventilated infants should be determined with a pneumotachometer placed..., Cannon [/bib_ref]. Compensating for circuit volume does not overcome this, suggesting using a proximal flow sensor [bib_ref] Tidal volumes for ventilated infants should be determined with a pneumotachometer placed..., Cannon [/bib_ref] [bib_ref] Accuracy of displayed values of tidal volume in the pediatric intensive care..., Castle [/bib_ref] [bib_ref] Reliability of displayed tidal volume in infants and children during dual-controlled ventilation, Heulitt [/bib_ref]. However, there is no outcome data to recommend on the necessity of highly precise Vt measurements. [bib_ref] Continuous transcutaneous oxygen and carbon dioxide monitoring in the pediatric ICU, Monaco [/bib_ref] Monitoring of lung mechanics

## We recommend measuring peepi and pplat during zero-flow conditions to obtain quasi-static crs during mechanical ventilation in children with
[table] Table: relevant studies published since voting [/table]