Acute lung injury in children: Therapeutic practice and feasibility of international clinical trials*

Santschi, Miriam; Jouvet, Philippe; Leclerc, F.; Gauvin, France; Newth, Christopher J L; Carroll, Christopher L.; Flori, Heidi R.; Tasker, Robert C.; Rimensberger, Peter C.; Randolph, Adrienne G.

doi:10.1097/pcc.0b013e3181d904c0

Cited by 183 publications

(145 citation statements)

References 46 publications

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“…However, clinicians most frequently make decisions to change ventilator rate, tidal volume, or peak inspiratory pressure during the acute phase of illness based on arterial pH or P aCO 2 . The most widely used noninvasive sensor to estimate adequacy of ventilation is end-tidal carbon dioxide pressure (P ETCO 2 ).…”

Section: Introductionmentioning

confidence: 99%

“…Pulse oximetry (S pO 2 ) is routinely used for clinical decision making, 8 and clinicians change PEEP or F IO 2 in response to either P aO 2 or S pO 2 both in the acute phase of illness and during weaning. However, clinicians most frequently make decisions to change ventilator rate, tidal volume, or peak inspiratory pressure during the acute phase of illness based on arterial pH or P aCO 2 .…”

Section: Introductionmentioning

confidence: 99%

“…1,2 Explicit ventilator protocols can standardize mechanical ventilation, provided that practitioners follow recommendations. 1,[3][4][5][6] Specifically, potentially injurious ventilator settings are frequently not reduced, even with normal or over-ventilated pH or P aCO 2 .…”

Section: Introductionmentioning

confidence: 99%

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Algorithms to Estimate P_aCO₂and pH Using Noninvasive Parameters for Children with Hypoxemic Respiratory Failure

et al. 2013

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BACKGROUND: Ventilator management for children with hypoxemic respiratory failure may benefit from ventilator protocols, which rely on blood gases. Accurate noninvasive estimates for pH or P aCO 2 could allow frequent ventilator changes to optimize lung-protective ventilation strategies. If these models are highly accurate, they can facilitate the development of closed-loop ventilator systems. We sought to develop and test algorithms for estimating pH and P aCO 2 from measures of ventilator support, pulse oximetry, and end-tidal carbon dioxide pressure (P ETCO 2 ). We also sought to determine whether surrogates for changes in dead space can improve prediction. METHODS: Algorithms were developed and tested using 2 data sets from previously published investigations. A baseline model estimated pH and P aCO 2 from P ETCO 2 using the previously observed relationship between P ETCO 2 and P aCO 2 or pH (using the Henderson-Hasselbalch equation). We developed a multivariate gaussian process (MGP) model incorporating other available noninvasive measurements. RESULTS: The training data set had 2,386 observations from 274 children, and the testing data set had 658 observations from 83 children. The baseline model predicted P aCO 2 within ؎ 7 mm Hg of the observed P aCO 2 80% of the time. The MGP model improved this to ؎ 6 mm Hg. When the MGP model predicted P aCO 2 between 35 and 60 mm Hg, the 80% prediction interval narrowed to ؎ 5 mm Hg. The baseline model predicted pH within ؎ 0.07 of the observed pH 80% of the time. The MGP model improved this to ؎ 0.05. CONCLUSIONS: We have demonstrated a conceptual first step for predictive models that estimate pH and P aCO 2 to facilitate clinical decision making for children with lung injury. These models may have some applicability when incorporated in ventilator protocols to encourage practitioners to maintain permissive hypercapnia when using high ventilator support. Refinement with additional data may improve model accuracy.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Algorithms to Estimate P_aCO₂and pH Using Noninvasive Parameters for Children with Hypoxemic Respiratory Failure

et al. 2013

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“…The oscillatory pressure amplitude is highly attenuated over the ETT and the airways, and results in the delivery of a very small V T , usually lower than anatomical dead space. 23 Because of this small V T , there is a decreased risk of entering the so-called non-safe zones within the pressure-volume loop of the diseased lung. 22 The use of HFOV in pediatric critical care varies between 3% and 30% of all ventilated children.…”

Section: Introductionmentioning

confidence: 99%

“…22 The use of HFOV in pediatric critical care varies between 3% and 30% of all ventilated children. [23][24][25][26][27] This relatively low use may be explained by several factors. First, lack of equipment or disbelief of the attending physician because of the absence of sound evidence of effect.…”

Section: Introductionmentioning

confidence: 99%

Reflections on Pediatric High-Frequency Oscillatory Ventilation From a Physiologic Perspective

2012

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Mechanical ventilation using low tidal volumes has become universally accepted to prevent ventilator-induced lung injury. High-frequency oscillatory ventilation (HFOV) allows pulmonary gas exchange using very small tidal volume (1-2 mL/kg) with concomitant decreased risk of atelectrauma. However, its use in pediatric critical care varies between only 3% and 30% of all ventilated children. This might be explained by the fact that the beneficial effect of HFOV on patient outcome has not been ascertained. Alternatively, in contrast with present recommendations, one can ask if HFOV has been employed in its most optimal fashion related especially to the indications for and timing of HFOV, as well as to using the best oscillator settings. The first was addressed in one small randomized study showing that early use of HFOV, instead of rescue use, was associated with improved survival. From a physiologic perspective, the oscillator settings could be refined. Lung volume is the main determinant of oxygenation in diffuse alveolar disease, suggesting using an open-lung strategy by recruitment maneuvers, although this is in practice not custom. Using such an approach, the patient can be oscillated on the deflation limb of the pressurevolume (P-V) curve, allowing less pressure required to maintain a certain amount of lung volume. Gas exchange is determined by the frequency and the oscillatory power setting, controlling the magnitude of the membrane displacement. Experimental work as well as preliminary human data have shown that it is possible to achieve the smallest tidal volume with concomitant adequate gas exchange when oscillating at high frequency and high fixed power setting. Future studies are needed to validate these novel approaches and to evaluate their effect on patient outcome.

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It Is Too Early to Declare Early or Late Rescue High-Frequency Oscillatory Ventilation Dead

Rimensberger

Bachman

2014

JAMA Pediatr

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Acute lung injury in children: Therapeutic practice and feasibility of international clinical trials*

Cited by 183 publications

References 46 publications

Algorithms to Estimate P_aCO₂and pH Using Noninvasive Parameters for Children with Hypoxemic Respiratory Failure

Algorithms to Estimate P_aCO₂and pH Using Noninvasive Parameters for Children with Hypoxemic Respiratory Failure

Reflections on Pediatric High-Frequency Oscillatory Ventilation From a Physiologic Perspective

It Is Too Early to Declare Early or Late Rescue High-Frequency Oscillatory Ventilation Dead

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Acute lung injury in children: Therapeutic practice and feasibility of international clinical trials*

Cited by 183 publications

References 46 publications

Algorithms to Estimate PaCO2and pH Using Noninvasive Parameters for Children with Hypoxemic Respiratory Failure

Algorithms to Estimate PaCO2and pH Using Noninvasive Parameters for Children with Hypoxemic Respiratory Failure

Reflections on Pediatric High-Frequency Oscillatory Ventilation From a Physiologic Perspective

It Is Too Early to Declare Early or Late Rescue High-Frequency Oscillatory Ventilation Dead

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Product

Resources

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Algorithms to Estimate P_aCO₂and pH Using Noninvasive Parameters for Children with Hypoxemic Respiratory Failure

Algorithms to Estimate P_aCO₂and pH Using Noninvasive Parameters for Children with Hypoxemic Respiratory Failure