Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC)

Abstract

PurposeMuch of the common practice in paediatric mechanical ventilation is based on personal experiences and what paediatric critical care practitioners have adopted from adult and neonatal experience. This presents a barrier to planning and interpretation of clinical trials on the use of specific and targeted interventions. We aim to establish a European consensus guideline on mechanical ventilation of critically children.MethodsThe European Society for Paediatric and Neonatal Intensive Care initiated a consensus conference of international European experts in paediatric mechanical ventilation to provide recommendations using the Research and Development/University of California, Los Angeles, appropriateness method. An electronic literature search in PubMed and EMBASE was performed using a combination of medical subject heading terms and text words related to mechanical ventilation and disease-specific terms.ResultsThe Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) consisted of a panel of 15 experts who developed and voted on 152 recommendations related to the following topics: (1) general recommendations, (2) monitoring, (3) targets of oxygenation and ventilation, (4) supportive measures, (5) weaning and extubation readiness, (6) normal lungs, (7) obstructive diseases, (8) restrictive diseases, (9) mixed diseases, (10) chronically ventilated patients, (11) cardiac patients and (12) lung hypoplasia syndromes. There were 142 (93.4%) recommendations with “strong agreement”. The final iteration of the recommendations had none with equipoise or disagreement.ConclusionsThese recommendations should help to harmonise the approach to paediatric mechanical ventilation and can be proposed as a standard-of-care applicable in daily clinical practice and clinical research.Electronic supplementary materialThe online version of this article (doi:10.1007/s00134-017-4920-z) contains supplementary material, which is available to authorized users.

Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children

“…However, noninvasive ventilation should be reserved for children with sepsis who are responding to initial resuscitation, do not have evidence for ongoing or worsening end-organ dysfunction, and in whom close monitoring and frequent reevaluation can be ensured [253,255,259]. This recommendation for children with sepsis-induced PARDS aligns with the 2015 PALICC [260] and 2017 Pediatric Mechanical Ventilation Consensus Conference (PEMVECC) [261] guidelines.…”

“…In 2017, a multicenter observational study by the Collaborative Pediatric Critical Care Research Network reported that pediatric critical care clinicians almost uniformly limit PEEP to 10 cm H2O irrespective of oxygenation and Fio2 [264]. This is in contrast to the PEMVECC [261] and PALICC [24] recommendations for use of PEEP in excess of 15 cm H2O for severe PARDS patients. Our panel reviewed several observational studies of PARDS patients, all published since 2007, each including 12-30% sepsis-induced PARDS [264][265][266][267][268][269][270][271][272][273][274][275][276].…”

“…However, many clinicians and researchers remain concerned that the optimal strategy for lung recruitment has not been determined and injudicious implementation of recruitment maneuvers can result in hemodynamic compromise [277], hypercarbia [278], and/or ventilator-induced lung injury [279]. PEM-VECC did not recommend use of recruitment maneuvers in children, citing an overall lack of evidence in this area [261]. In contrast, the 2015 PALICC provided a weak recommendation in favor of recruitment maneuvers with prioritization of a slow stepwise incremental and decremental PEEP method [24].…”

“…HFOV may be difficult to apply effectively in centers with little experience and is not universally available. Despite these practical limitations, both PALICC [24] and PEMVECC [261] endorsed cautionary use of HFOV as an alternative type therapy in patients with severe PARDS. In our panel, clinicians who use versus those who do not use HFOV in patients with severe PARDS and refractory hypoxia were nearly evenly distributed.…”

Focus on paediatrics: 2017

“…In ICM in 2017, the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) developed and voted on 152 recommendations about paediatric mechanical ventilation [12]. However, data from randomised clinical trials were available for only three topic areas and most recommendations were either deferred *Correspondence: WeissS@email.chop.eduor based on low-to-moderate evidence.…”