Twenty-Four–Hour Esophageal pH Measurement in Mechanically Ventilated Children: A Prospective Cohort Study*

Abstract

Objectives: To assess the prevalence of gastroesophageal reflux in mechanically ventilated children using 24-hour esophageal pH-metry and its role as a risk factor for ventilator-associated pneumonia. Design: Prospective cohort study. Setting: PICU of a tertiary care hospital from North India. Patients: Mechanically ventilated children 1–15 years old in PICU from July 2015 to June 2017, excluding those receiving acid suppressants, known cases of gastroesophageal reflux disease, having upper gastrointestinal bleed. Intervention: Demographic details, baseline investigations, diagnosis, treatment details, and Pediatric Risk of Mortality III score were recorded at enrollment. Gastroesophageal reflux was evaluated using 24-hour esophageal pH-metry. Children were followed up for 7 days or 48 hours after extubation for development of ventilator-associated pneumonia using Centers for Disease Control and Prevention criteria. Pathologic acidic gastroesophageal reflux was defined as fall in esophageal pH less than 4 for more than 4% of total time, whereas pathologic alkaline gastroesophageal reflux as rise in esophageal pH greater than 7 for more than 17% of total time. Measurements and Main Results: Sixty-one children (median [interquartile range], age 73 mo [30–132 mo]; 44 boys [72%]) were enrolled. Median Pediatric Risk of Mortality III score was 10.0 (3–16). Median duration of ventilation was 6 days (3–9 d). Pathologic gastroesophageal reflux (acidic or alkaline) was present in 47 children (77%). Twelve children (19.7%) met criteria for pathologic acidic gastroesophageal reflux, whereas 44 children (72.1%) had pathologic alkaline gastroesophageal reflux; nine children (14.7%) had both pathologic acidic and alkaline gastroesophageal reflux. Of the enrolled children, 17 (27.9 %) developed ventilator-associated pneumonia. No patient had both pathologic acidic gastroesophageal reflux and ventilator-associated pneumonia. Of 17 children who developed ventilator-associated pneumonia, 12 (70.5%) had pathologic alkaline gastroesophageal reflux as compared to 32 children (72.7%) among the 44 children who did not develop ventilator-associated pneumonia (p = 0.87). Conclusions: The current study shows high incidence of gastroesophageal reflux on 24-hour esophageal pH-metry in mechanically ventilated children with medical diagnoses. The significance of this finding and its impact on ventilator-associated pneumonia and other ventilator-associated events need to be examined in larger studies.

Mortality Rate and Causing Factors in Ventilator Associated Pneumonia in Children

“…Not only that, the only VAP suspicion should be managed by the use of essential antibiotics 14 . This demonstrates the importance of meeting the clinical criteria in preventing inappropriate antibiotic therapy in the diagnosis of VAP 15 .…”

Challenges and advances in nutrition for the critically ill child

“…A single-center prospective cohort study evaluated the prevalence of gastroesophageal reflux (GER) in mechanically ventilated children using 24-h esophageal pH monitoring and the incidence of ventilator-associated pneumonia (VAP). They found that children with acidic GER had a decreased frequency of VAP though this was not statistically significant [64]. Studies to date suggest potential harm in prescribing these medications, while not showing a clear benefit in outcomes.…”