Pediatric Acute Respiratory Distress Syndrome: Approaches in Mechanical Ventilation

Abstract

Regarding mechanics, the lung can be described as a prestressed network of viscoelastic tissue elements deformed by surface tension and the action of respiratory

Editor’s Choice Articles for February

“…First, go back to the December 2022 issue and the review on “clinical challenges of pediatric ventilation liberation” (21). Next, read the beautifully illustrated PCCM Concise Clinical Physiology Review on approaches to mechanical ventilation for patients with PARDS (22).…”

Editor’s Choice Articles for July

“…Then, review PCCM ’s two other clinical research articles (24, 25) and editorials (26, 27) on this topic over the last two years. Next, look at the 2023 Concise Clinical Physiology Review about PARDS, including mechanical power (28). Last, place all this material in the context of the 2023 Pediatric Acute Lung Injury Consensus Conference guidance for lung mechanics monitoring (29).…”

Plateau Pressure and Driving Pressure in Volume- and Pressure-Controlled Ventilation: Comparison of Frictional and Viscoelastic Resistive Components in Pediatric Acute Respiratory Distress Syndrome

“…The concept of protective mechanical ventilation (MV) emphasizes the close monitoring of tidal volume (V t ), plateau pressure (P PLAT ), driving pressure (ΔP), and intrinsic positive end-expiratory pressure (iPEEP), among other parameters (1, 2). Monitoring of these airway pressures allows us to establish the safety of ventilatory settings because we can derive assessments of the resistive, elastic, and threshold components of working pressure (3–5). Unfortunately, pediatric data are scarce, so most recommendations for MV in critically ill children are extrapolated from studies and clinical trials in the adult population (1, 2, 6–8).…”

“…The role of the resistive component is relevant in pediatric MV because airway diameter is inversely related to airway resistance (9–11). The resistive component has two subcomponents (3): frictional resistance corresponds to changes in the resistive airway pressure due to inspiratory flow variations; viscoelastic resistance is the lung stress relaxation and gas redistribution, which dissipates energy through the lung parenchyma. The former subcomponent does not increase the risk of ventilator-induced lung injury (VILI), but the latter potentially leads to lung parenchyma damage (3).…”

“…The resistive component has two subcomponents (3): frictional resistance corresponds to changes in the resistive airway pressure due to inspiratory flow variations; viscoelastic resistance is the lung stress relaxation and gas redistribution, which dissipates energy through the lung parenchyma. The former subcomponent does not increase the risk of ventilator-induced lung injury (VILI), but the latter potentially leads to lung parenchyma damage (3). Discriminating between the resistive subcomponents was developed in the 1990s by identifying the first pressure drop upon reaching zero flow during the inspiratory hold on volume-controlled ventilation (VCV, squared-shaped-flow) (12–14).…”