
































J Nepal Paediatr Soc | VOL 42 | ISSUE 03 |SEP-DEC,  2022 1

Original Article

DOI: 103126/JNPS.V4113

Clinical Profile and Outcome of Ventilated Children Admitted to 
Paediatrics Intensive Care Unit in a Tertiary Care Centre

Introduction: Mechanical Ventilation is an essential tool in paediatric 
critical care unit. Judicious use of ventilation when indicated, is essential 
along with very close clinical and hemodynamic monitoring, for successful 
outcome. As prolonged ventilation is associated with numerous adverse 
outcomes, we tried to find out common complications associated with 
invasive mechanical ventilation and its outcome. 

Methods: The study is an observational descriptive study conducted on 
mechanically ventilated children admitted to Paediatric Intensive Care Unit 
during 48 months period (November 2019 to October 2021). Demographic 
features included age, sex, reason for mechanical ventilation, duration of 
mechanical ventilation and any other comorbidities. Outcomes parameters 
included death in hospital, discharge from intensive care unit or shift to ward 
and left against medical advice (LAMA). 

Results: Among 1352 children admitted to PICU, 212 children (15.68%) 
required invasive mechanical ventilation. Common causes for mechanical 
ventilation were sepsis / MODS in 22.64% cases, followed by pulmonary 
(20.28%) and CNS infections 39 (18.39%). 166 (78.30%) children were 
extubated successfully, 24 (11.32%) children expired and 22 (10.37%) 
went on LAMA. Mortality rate of 14.18% was found in children, who were 
ventilated for > 72 hours, which was statistically significant. 

Conclusions: Ventilatory support is essential and lifesaving tool for 
critically ill children. Mortality rate was higher and statistically significant in 
children who were ventilated for > 72 hours. 

Abstract

1Assistant Professor, Department of Paediatrics, Nobel Medical College & Teaching Hospital, Biratnagar, Nepal
2Medical Officer, Greencity Hospital, Kathmandu, Nepal

Sandip Kumar Singh1, Babita Khanal1, Shivani Singh2

*Corresponding Author

Sandip Kumar Singh, 
MD Paediatrics, Fellowship in Pediatric 
Critical Care, Paediatrician and 
Paediatric Intensivist, 
Assistant Professor, 
Department of Paediatrics, 
Nobel Medical College & Teaching 
Hospital, Biratnagar, Nepal.
Email: sandeep272@hotmail.com

Article History 
Received On: 22 Jun, 2022
Accepted On: 23 Apr, 2023

Funding sources: None

Conflict of Interest: None

Keywords: 
Mechanical ventilation, Outcome, PICU

Online Access

DOI:
https://doi.org/10.3126/jnps.v42i3.46063 Introduction

Ventilatory support is an essential and a common form of therapy in 
Paediatric Intensive Care Unit (PICU). With improvement in knowledge, 
understanding of disease and advancement of critical care support, this 
modality has evolved. Nepal is a low income country and number of 
critical care services targeted towards children are limited.1 However with 
availability of critical services, number of children being admitted to PICU 
has increased in last few years. The percentage of children mechanically 
ventilated in different PICU varies from 14 - 60%.2 

Mechanical ventilation can be lifesaving but more than 50% of 
complications in these ventilated child are related to ventilator support, 
if prolonged.3 various complications associated with ventilation includes 
airway complications, air leaks, ventilator induced lung injury, oxygen 
toxicity and ventilator associated pneumonia. In conclusion, judicious use 

Copyrights & Licensing © 2022 by author(s). This is an Open Access article dis-
tributed under Creative Commons Attribution License (CC BY NC )



J Nepal Paediatr Soc | VOL 42 | ISSUE 03 |SEP-DEC,  20222

Original Article Clinical profile and outcome of ventilated children

of ventilation when indicated, is essential along with close 
monitoring, for successful outcome. 

The objective of this study was to determine clinical profile 
of mechanically ventilated children, common complications 
associated with invasive mechanical ventilation and 
outcome of those children. PICU in Nobel Medical College 
is one of the largest referral center in Eastern Nepal. This 
study will guide to formulate hospital policy and help in 
making national guidelines as well. 

Methods
The study is an observational descriptive study conducted 
on mechanically ventilated children admitted to PICU of 
Nobel Medical College and Teaching Hospital during 48 
months period from November 2019 to October 2021. 
This study was started after acquiring approval from the 
Institutional Review Committee of Nobel Medical College 
(IRC). Nobel Medical College is a tertiary referral center 
located in Biratnagar, Nepal. Department of Paediatrics 
consists of 63 bedded paediatric ward and 15 bedded 
level III PICU. Various indications for ventilating a sick child 
includes respiratory failure, airway protection, refractory 
shock, and neurological disorders. Usual rate of intubation 
in our center ranges from 13 - 24% over few years. All 
ventilated children more than one month till 15 years 
of age were included in this study. Children who were 
ventilated for less than 24 hours and children who were 
transferred from other center on bag and tube ventilation 
were excluded from this study. All children were ventilated 
using A/C PC, PRVC or SIMV mode, depending upon the 
clinical scenario. Once the underlying disease process 
improved, if the child has adequate gas exchange and 
good respiratory efforts, they were weaned and extubated 
after spontaneous breath trial (SBT). Majority of them were 
extubated to either CPAP or HFNC. Demographic features 
were analyzed including age, sex, reason for mechanical 
ventilation, duration of mechanical ventilation and any 
other comorbidities. Outcomes parameters included 
death in hospital, discharge from PICU or shift to ward 
and Left Against Medical Advice (LAMA). Categorical 
data (included age, gender, underlying medical condition, 
outcome and complications) were expressed as absolute 
counts and percentages. Continuous data (for age and 
duration of ventilation) were expressed as mean and 
standard deviation. To study the association of outcome 
of ventilated children to with duration of ventilation, chi 
square test was used. Data were considered significant at 
p value of < 0.05. Statistical analysis was done using SPSS 
version 11.0 for windows.

Results
Total number of PICU admissions during the study period 
was 1352. A total of 212 (15.68%) of PICU admissions 

requiring invasive mechanical ventilation satisfied the 
inclusion criteria and were included in this study. Children 
between one to five years contributed to 32.07 % of total 
ventilated cases, followed by children < 1 year (26.41%) 
and children > 10 years (21.69%). Among them males 
were 53.77% and females were 46.22% as shown in fig 
1.

Table 1: Showing age distribution of ventilated children 
admitted to PICU

Age in Years No of cases Percentage

< 1 years 56 26.41%

1 - 5 years 68 32.07%

5 – 10 years 42 19.8 %

>10 years 46 21.69%

Total 212 100%

Figure 1: Showing age and sex distribution of mechanical 
ventilated children in PICU

Table 2: Showing various etiologies for which children 
were mechanically ventilated in PICU

Clinical Diagnosis Number of cases 
(Percentage)

Sepsis / Septic shock / MODS 48 (22.64%)

Pulmonary 43 (20.28%)

CNS Infection / Encephalopathy 39 (18.39%)

Cardiac 12 (5.66%)

Severe dengue 6 (2.83%)

Post-surgery 22 (10.37%)

Poisoning 10 (4.71%)

Polytrauma 10 (4.71%)

Snake bite 6 (2.83%)

MISC/ Severe Covid 6 (2.83%)

Others 10 (4.71%)

Total 212 



J Nepal Paediatr Soc | VOL 42 | ISSUE 03 |SEP-DEC,  2022 3

Original ArticleClinical profile and outcome of ventilated children

Most common causes for requirement of mechanical 
ventilation were sepsis / Multi - Organ Dysfunction 
Syndrome (MODS) in 22.64% cases, followed by 
pulmonary infections (20.28%) and CNS infections 
/ encephalopathy (18.39%). Others causes includes 
Guillain-Barre syndrome, submersion injury, scrub typhus 
and diabetic ketoacidosis. 

Table 3: Showing duration of mechanical ventilation 
required for children

Duration of Ventilation No. of cases Percentage

< 72 hours 64 30.18%

72 hours to 7 days 126 59.43%

> 7 days 22 10.37%

It was observed that, among the children who were 
ventilated, 126 children (59.43%) were ventilated for 
72 hours to seven days duration. The mean duration of 
mechanical ventilation was 5.38 days ± 3.66 days. Children 
were ventilated mainly on A/C PC, PRVC or SIMV mode, 
depending upon the clinical condition. Once the children 
improved, gradually mechanical ventilation was weaned 
off using either CPAP / PS, SIMV or T Piece. CPAP / PS 
was major method of weaning in 126 (75.90%) children, 
followed by SIMV in 21 (12.65%) children and T Piece in 
nine (6.62%) children. Some children on SIMV mode were 
weaned directly from SIMV by reducing rate and pressure 
support. However, 10 (6.02%) of children were extubated 
accidently, among which, six (60%) were self - extubated 
when sedation was stopped for SBT (Spontaneous 
Breathing Trial). Among 10 children accidently extubated, 
only three (30%) required re-intubation. We do not 
practice routine change of endotracheal tube in our PICU. 
All children ventilated for > 72 hours, we practice giving 
dexamethasone 0.15 mg / kg / dose every 6 hourly for 
6 doses with the first dose administered 6 - 12 hours prior 
to extubation. However, 13 (7.83%) children required re-
intubation for various reasons, the commonest cause being 
extubation failure due to poor respiratory efforts in six 
cases (46.15%), followed by airway edema in four cases 
(13.33%) and displacement in three cases (23.07%). 

Although, mechanical ventilation is a lifesaving 
procedure, it can cause multiple complications. Some 
of the complications can be life threatening as well. The 
commonest complication in the ventilated children was 
ventilator associated pneumonia in 16 (7.54%) children, 
followed by air leaks in 15 (7.07%) children. The various 
complications encountered in ventilated children in PICU 
were as follows:

Table 4: Showing various complications associated with 
mechanical ventilation in PICU

Complications No of cases Percentage

Ventilator associated 
pneumonia

16 7.54%

Air leaks 15 7.07%

Pressure sores 15 7.54%

Post extubation stridor 14 6.60%

Collapse / Atelectasis 12 5.66%

Pulmonary haemorrhage 8 3.77%

Equipment failure 6 2.83%

Only four children (1.88%) required tracheostomy, which 
was required as children required prolonged mechanical 
ventilation. Among them three had Acute Encephalitis 
Syndrome with refractory status epilepticus and one child 
had drowning leading to hypoxic ischemic brain injury. 
Out of 212 children, 166 (78.30%) were successfully 
extubated and discharged, 24 (11.32%) children expired 
and 22 (10.37%) children went on LAMA. Out of 22 
children, who went on LAMA, 12 (54.54%) went on LAMA 
due to poor neurological outcome of child whereas 10 
(45.45%) children went on LAMA due to financial issues. 

Table 5: Showing relation of mechanical ventilation >72 
hours with outcome

Duration of 
ventilation

Survived Expired

P value 
– 0.045

< 72 hours 
(Total 64 cases)

61 (95.31%) 3 (4.68%)

> 72 hours
 (Total 148 cases)

127 (85.81%) 21 (14.18%)

Out of 212 cases, 64 cases (30.18%) were mechanically 
ventilated for < 72 hours and 148 cases (69.81%) were 
ventilated for > 72 hours. Out of 24 children expired, three 
(12.5%) children were ventilated for < 72 hours whereas 
21 (87.5%) children were ventilated > 72 hours. The 
mortality rate of 14.18% was found in children, who were 
ventilated for > 72 hours, which was statistically significant 
(p value 0.045).

Discussion
PICU is a place where critically ill children requiring various 
organ supports are admitted. Though PICU set up in Nepal 
is still an emerging specialty, need and requirement for 
PICU is still rising. Therefore this study will give an idea 
and highlight about disease in children requiring invasive 
mechanical ventilation, complications associated with it 
and outcome. The percentage of children in PICU requiring 
mechanical ventilation in our study was 15.68%, similar 
to study done in Pakistan by Bhori NS et al4 whereas 



J Nepal Paediatr Soc | VOL 42 | ISSUE 03 |SEP-DEC,  20224

Original Article Clinical profile and outcome of ventilated children

study done by Vijayakumary et al5 and Mukhtar B et al6 
showed higher rates of mechanical ventilation 52% and 
50.7% respectively. Children between one to five years of 
age constituted 32.07% of our ventilated case, followed 
by infants in 26.41% of cases, similar to other studies.4-6 
Commonest indications for mechanical ventilation in our 
study was septic shock / MODS (22.64%), followed by 
respiratory failure (20.28%) unlike other studies, where 
neurological indications predominated in the study by 
Kendirli et al7 and respiratory cause was predominated in 
study by Indrajit et al.8 The mean duration of mechanical 
ventilation was 5.38 days ± 3.66 days, which is similar to 
study done by Wolfler A et al.9 

Out of 13 (7.83%) children requiring re-intubation for 
various reasons, the commonest cause was extubation 
failure in six cases (2.8%), followed by obstruction in four 
cases (1.88%) and displacement in three cases (1.41%). 
Nosocomial pneumonia was significantly associated 
with reintubation, which was also reported by the study 
by Elward et al.10 The commonest complication in the 
ventilated children was ventilator associated pneumonia in 
16 (7.54%) cases and air leaks in 15 (7.07%) children. 
Similar findings were observed in study by Benjamin et al,11 
where incidence of air leak was reported 6.9%. 1.88% 
children required tracheostomy, which was required as 
children required prolonged mechanical ventilation, similar 
to Da Silva et al.12 Mortality in the ventilated children in 
the study was 11.32% which was comparable to study 
done by Da Silva et al12 and Indrajit et al8 (19.8 % and 
24% respectively). However it is much lower compared to 
the observations made by Kendirli et al7 where mortality 
was 58.3%, which could be attributed to large number of 
manual ventilated cases in the study, where lung pressure 
would not be regulated leading to excessive lung injury. 

The mortality rate of 14.18% was found in children, who 
were ventilated for > 72 hours, which was statistically 
significant (p value 0.045). This can be explained by the 
fact that children requiring prolonged ventilation, will have 
higher chances of ventilator induced lung injury and will 
have higher risk for ventilator induced infection and other 
complications. One major limitation in our study was lack 
of categorizing cases based on severity, which could have 
further highlighted mortality and morbidity parameters. 
Children ventilated for less than 24 hours and children 
who were transferred from other centers on bag and tube 
ventilation were excluded from this study, which might have 
resulted in lower mortality rate. Only duration of invasive 
mechanical ventilation was correlated with outcome, there 
could be various other factors affecting mortality like 
disease severity, co-morbidities. This is single center study, 
similar multicenter study from various PICU is required for 
further standardization of level of care in PICU. 

Conclusions
Ventilatory support is essential and lifesaving tool for 
critically ill children, admitted to PICU. Around 15.68% of 
children admitted to intensive care unit requires ventilator 
support with common indication being sepsis, septic 
shock and MODS. Organized and effective courses and 
trainings dedicated to healthcare personnel working in 
PICU will reduce chances of complications associated with 
mechanical ventilation. Similar studies from other PICU will 
help in developing protocols for mechanical ventilation in 
critically ill children. 

Acknowledgement 
I would like thank Department of Paediatrics, Nobel Medical 
College, Biratnagar for support during my research.

References
1. Acharya SP. Critical care medicine in Nepal: where are 

we? Int Health. 2013;5(2):92-5.    
DOI:10.1093/inthealth/iht010

2. Farias JA, Frutos F, Esteban A, Flores JC, Retta A, Baltodano 
A, et al. What is the daily practice of mechanical ventilation 
in pediatric intensive care units? A multicenter study. Intensive 
Care Med.2004;30(5):918–925.    
DOI: 10.1007/s00134-004-2225-5.

3. Manczur TI, Greenough A, Pryor D, Rafferty GF. Comparison 
of predictors of extubation from mechanical ventilation in 
children. Pediatr Crit Care Med 2000; 1:28-32.   
DOI: 10.1097/00130478-200007000-00005

4. Bhori NS, Ghate SV, Chhajed PS. A study of Mechanical 
Ventilation in Children. Int J Contemp Pediatr. 2017 
Nov; 4(6):2088-2092.    
DOI:10.18203/2349-3291.ijcp20174737

5. Vijayakumary T, de Silva JR, Sarathchandra J, Kumarendran 
B. Prospective study of ventilated patients in the paediatric 
medical intensive care unit of Lady Ridgeway Hospital. Sri 
Lanka J. Child Health. 2012 Aug 31; 41(3):114-117.   
DOI:10.4038/sljch.v41i3.4598

6. Mukhtar B, Siddiqui NR, Haque A. Clinical characteristics 
and immediate-outcome of children mechanically ventilated 
in a Pediatric Intensive Care Units. Pak J Med Sci. 2014; 
30(5):927-930.     
DOI: 10.12669/pjms.305.5159

7. Kendirli T, Kavaz A, Yalaki Z, OzturkHismi B, Derelli E, Ince 
E. Mechanical ventilation in children. Turk J Pediatr. 2006; 
48 (4): 323–7.      
PMID: 17290566

8. Majumdar I, Sachdev A, Gupta D, Chugh K. To evaluate 
the impact of initial chest radiograph on final outcome of 
ventilated patients. Ind J Crit Care Med 2005; 9(2):77-80. 
DOI: 10.4103/0972-5229.17092

http://doi.org/10.4038/sljch.v41i3.4598
http://dx.doi.org/10.4103/0972-5229.17092


J Nepal Paediatr Soc | VOL 42 | ISSUE 03 |SEP-DEC,  2022 5

Original ArticleClinical profile and outcome of ventilated children

9. Wolfler A, Calderoni E, Ottonello G, Conti G, Baroncini S, 
Santuz P, et al. Daily practice of mechanical ventilation in 
Italian pediatric intensive care units: a prospective survey. 
Pediatr Crit Care Med. 2011; 12(2):141-146.  
DOI: 10.1097/ PCC.0b013e3181dbaeb3

10. Elward AM, Warren DK, Fraser VJ. Ventilator-associated 
pneumonia in pediatric intensive care unit patients: risk 
factors and outcomes. Pediatrics. 2002; 109:758–64.  
DOI: 10.1542/peds.109.5.758. PMID: 11986433.

11. Benjamin PK, Thompson JE, O’Rourke PP. Complications of 
mechanical ventilation in a children’s hospital multidisciplinary 
intensive care unit. Respir Care 1990; 35 (9):873-8.  
PMID: 10145335

12. Silva DC, Shibata AR, Farias JA, Troster EJ. How is mechanical 
ventilation employed in a pediatric intensive care unit in 
Brazil? Clinics (Sao Paulo). 2009; 64(12):1161-6.   
DOI: 10.1590/S1807-59322009001 200005.   
PMID: 20037703; PMCID: PMC2797584.


