Monitoring of Children With Pediatric Acute Respiratory Distress Syndrome

Émériaud, Guillaume; Newth, Christopher J L

doi:10.1097/pcc.0000000000000436

Cited by 28 publications

(8 citation statements)

References 111 publications

(99 reference statements)

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“…The relatively new concept of driving pressure was not addressed by PALICC 2015 16 as a parameter to be monitored in pediatric ARDS due to the lack of pediatric data. 25 The PALICC recommendations had suggested limiting tidal volume to 5-8 mL/kg (3-6 mL/kg for severe disease), aiming to limit PIP. We feel that monitoring driving pressure may guide clinicians to individualize the tidal volumes and to decide when to use or accept lower tidal volumes than the conventional 6 mL/kg in ARDS.…”

Section: Discussionmentioning

confidence: 99%

Dynamic Airway Driving Pressure and Outcomes in Children With Acute Hypoxemic Respiratory Failure

et al. 2020

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BACKGROUND: Limited adult data suggest that airway driving pressure might better reflect the potential risk for lung injury than tidal volume based on ideal body weight, and the parameter correlates with mortality in ARDS. There is a lack of data about the effect of driving pressure on mortality in pediatric ARDS. This study aimed to evaluate the effect of driving pressure on morbidity and mortality of children with acute hypoxemic respiratory failure. METHODS: This retrospective cohort study was performed in a tertiary level pediatric ICU. Children who received invasive mechanical ventilation for acute hypoxemic respiratory failure (defined as P aO 2 =F IO 2 < 300 within 24 h after intubation), in a 2-y period were included. The cohort was divided into 2 groups based on the highest dynamic driving pressure (DP, calculated as the difference between peak inspiratory pressure and PEEP) in the first 24 h, with a cutoff value of 15 cm H 2 O. RESULTS: Of the 380 children who were mechanically ventilated during the study period, 101 children who met eligibility criteria were enrolled. Common diagnoses were pneumonia (n 5 51), severe sepsis (n 5 24), severe dengue (n 5 10), and aspiration pneumonia (n 5 7). In comparison to the group with high DP (ie, 6 15 cm H 2 O), children in the group with low DP (ie, < 15 cm H 2 O) had significantly lower median (interquartile range) duration of ventilation (5 [4-6] d vs 8 [6-11] d, P < .001], ICU length of stay (6 [5-8] d vs 12 [8-15] d, P < .001], and more ventilator-free days at day 28 (23 [20-24] vs 17 [0-22] d, P < .001). Logistic regression analysis also suggested driving pressure as an independent predictor of morbidity after adjusting for confounding variables. However, there was no statistically significant difference in mortality between the 2 groups (17% in low DP vs 24% in high DP, P 5 .38). Subgroup analysis of 65 subjects who fulfilled ARDS criteria yielded similar results with respect to mortality and morbidity. CONCLUSIONS: Below a threshold of 15 cm H 2 O, DP was associated with significantly decreased morbidity in children with acute hypoxemic respiratory failure.

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Section: Discussionmentioning

confidence: 99%

Dynamic Airway Driving Pressure and Outcomes in Children With Acute Hypoxemic Respiratory Failure

et al. 2020

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“…Additionally, VT as measured in some ventilators is lower than the real volume(24). Investigation of measured lung volumes, compared to those calculated from ABW versus PBW in children, and whether the PBW use has an effect on pediatric ARDS outcomes, is a priority(25). Provocatively, a recent meta-analysis (26) suggested that unlike the ARDSNet trial in adults, VT is not associated with mortality in pediatrics.…”

Section: Discussionmentioning

confidence: 99%

Variability in Usual Care Mechanical Ventilation for Pediatric Acute Respiratory Distress Syndrome: Time for a Decision Support Protocol?*

Newth

Sward

Khemani

et al. 2017

Pediatric Critical Care Medicine

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Objective Although pediatric intensivists philosophically embrace lung protective ventilation for Acute Lung Injury (ALI) and Acute Respiratory Distress Syndrome (ARDS), we hypothesized that ventilator management varies. We assessed ventilator management by evaluating changes to ventilator settings in response to blood gases, pulse oximetry or end tidal CO2. We also assessed the potential impact that a pediatric mechanical ventilation (MV) protocol adapted from NHLBI ARDSNet protocols could have on reducing variability by comparing actual changes in ventilator settings to those recommended by the protocol. Design Prospective observational study. Setting Eight tertiary care US PICUs, October 2011 – April 2012. Patients 120 patients (age range 17 days to 18 years) with ALI/ARDS. Measurements and Main Results 2100 arterial and capillary blood gases, 3964 SpO2 and 2757 PETCO2 values were associated with 3983 ventilator settings. Ventilation mode at study onset was Pressure Control (PC) 60%, Volume Control (VC) 19%, Pressure-regulated Volume Control (PRVC) 18%, High Frequency Oscillatory Ventilation (HFOV) 3%. Clinicians changed FiO2 by ±5 or ±10% increments every 8 hours. PEEP was limited at ~10 cmH20 as oxygenation worsened, lower than would have been recommended by the protocol. In the first 72 hours of MV, maximum tidal volume/kg using predicted versus actual body weight was 10.3 ml/kg; 8.5–12.9 (median; IQR) versus 9.2 ml/kg; 7.6–12.0 (p<0.001). Intensivists made changes similar to protocol recommendations 29% of the time, opposite the protocol’s recommendation 12% of the time and no changes 56% of the time. Conclusions Ventilator management varies substantially in children with ARDS. Opportunities exist to minimize variability and potentially injurious ventilator settings by utilizing a pediatric mechanical ventilation protocol offering adequately explicit instructions for given clinical situations. An accepted protocol could also reduce confounding by MV management in a clinical trial.

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“…At present, there are no recommendations related to weaning children from the ventilator that can be supported by rigorous evidence, and our review does not provide any definitive answers (84). There is a need to generate more evidence related to pediatric ventilator liberation so that any recommendations can have stronger certainty (85, 86). Many patients do not need a weaning strategy, as they are likely to pass a SBT on the first attempt and can successfully be extubated if other ERT criteria are met.…”

Section: Clinical Implications and Directions For Further Researchmentioning

confidence: 99%

Clinical Challenges in Pediatric Ventilation Liberation: A Meta-Narrative Review

Dijk

Blokpoel

Abu‐Sultaneh

et al. 2022

Pediatric Critical Care Medicine

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OBJECTIVES: To map the evidence for ventilation liberation practices in pediatric respiratory failure using the Realist And MEta-narrative Evidence Syntheses: Evolving Standards publication standards. DATA SOURCES: CINAHL, MEDLINE, COCHRANE, and EMBASE. Trial registers included the following: ClinicalTrials.gov, European Union clinical trials register, International Standardized Randomized Controlled Trial Number register. STUDY SELECTION: Abstracts were screened followed by review of full text. Articles published in English language incorporating a heterogeneous population of both infants and older children were assessed. DATA EXTRACTION: None. DATA SYNTHESIS: Weaning can be considered as the process by which positive pressure is decreased and the patient becomes increasingly responsible for generating the energy necessary for effective gas exchange. With the growing use of noninvasive respiratory support, extubation can lie in the middle of the weaning process if some additional positive pressure is used after extubation, while for some extubation may constitute the end of weaning. Testing for extubation readiness is a key component of the weaning process as it allows the critical care practitioner to assess the capability and endurance of the patient’s respiratory system to resume unassisted ventilation. Spontaneous breathing trials (SBTs) are often seen as extubation readiness testing (ERT), but the SBT is used to determine if the patient can maintain adequate spontaneous ventilation with minimal ventilatory support, whereas ERT implies the patient is ready for extubation. CONCLUSIONS: Current literature suggests using a structured approach that includes a daily assessment of patient’s readiness to extubate may reduce total ventilation time. Increasing evidence indicates that such daily assessments needs to include SBTs without added pressure support. Measures of elevated load as well as measures of impaired respiratory muscle capacity are independently associated with extubation failure in children, indicating that these should also be assessed as part of ERT.

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Monitoring of Children With Pediatric Acute Respiratory Distress Syndrome

Cited by 28 publications

References 111 publications

Dynamic Airway Driving Pressure and Outcomes in Children With Acute Hypoxemic Respiratory Failure

Dynamic Airway Driving Pressure and Outcomes in Children With Acute Hypoxemic Respiratory Failure

Variability in Usual Care Mechanical Ventilation for Pediatric Acute Respiratory Distress Syndrome: Time for a Decision Support Protocol?*

Clinical Challenges in Pediatric Ventilation Liberation: A Meta-Narrative Review

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