Congenital malformations of the heart are the most common of all birth defects, congenital heart defects can affect normally different parts or functions of the heart, although 40 to 60% of babies with Down syndrome are born with some type of cardiac abnormalities, most receive surgical correction within the first few years of life; however, an abnormality large percentage was develop Mitral Valve Prolapse (MVP) by adulthood. (1).Which the most common congenital heart disease is ventricular septal defects, ventricular septal defect is very close to the tricuspid valve which may be damaged which may lead to aortic regurgitation, aortic stenosis, aortic insufficiency, pulmonary stenosis, and hyperemia.(2).Sixty-nine percent of all Aerial Ventricular Septal defects have Down syndrome, Echocardiography or cardiac catheterization established the cardiac diagnoses ,phrenic nerve dysfunction, airway problem, pulmonary vascular hypertension, and pleural effusion (3). Pleural effusion is consider as a most serious pulmonary complications, cardiorespiratory stability was continuously monitored in all patients, and supplemental oxygen was administered as necessary.(4). If the patient requiring ventilatory assistance it is important to auscultate both lung and epigastrium, intubation route, sedation given, arterial blood gases, pulse oximetry, end-tidal CO 2, lung sounds, vital signs, level of consciousness, secretions (presence, amount, color), peak inspiratory pressures, exhaled tidal volumes, and if the patient was in need for suctioning, it is important to monitor the respiratory