Mechanical ventilation in critically ill pediatric patients

Pediatric mechanical ventilation has evolved from the isolated normalization of blood gases toward individualized support that limits lung and diaphragm injury, avoids hyperoxia, preserves cardiopulmonary interactions, and facilitates timely liberation. This narrative review summarizes contemporary recommendations for noninvasive and invasive respiratory support, initial ventilator selection and settings, lung-protective ventilation in pediatric acute respiratory distress syndrome (PARDS), monitoring of respiratory mechanics and patient-ventilator interaction, and the rational use of prone positioning, high-frequency oscillatory ventilation, pulmonary vasodilators, and extracorporeal support. Current oxygenation targets, including evidence from the Oxy-PICU trial, and international guidance on ventilator liberation, spontaneous breathing trials, and extubation are reviewed. Disease-specific strategies for obstructive, restrictive, neurologic, and cardiac conditions are discussed together with emerging tools such as lung and diaphragm ultrasound, electrical impedance tomography, and automated decision-support systems. A brief special consideration addresses intubation during hemorrhagic shock, when positive-pressure ventilation may precipitate cardiovascular collapse and hemorrhage control must be integrated with airway management. Because pediatric evidence remains limited in many areas, ventilator parameters should be regarded as starting points and individualized according to pathophysiology, trends in respiratory mechanics, gas exchange, hemodynamics, and clinical response.