Objectives: Reduced morbidity and mortality associated with lung-protective mechanical ventilation is not proven in pediatric acute respiratory distress syndrome. This study aims to determine if a lung-protective mechanical ventilation protocol in pediatric acute respiratory distress syndrome is associated with improved clinical outcomes. Design: This pilot study over April 2016 to September 2019 adopts a before-and-after comparison design of a lung-protective mechanical ventilation protocol. All admissions to the PICU were screened daily for fulfillment of the Pediatric Acute Lung Injury Consensus Conference criteria and included. Setting: Multidisciplinary PICU. Patients: Patients with pediatric acute respiratory distress syndrome. Interventions: Lung-protective mechanical ventilation protocol with elements on peak pressures, tidal volumes, end-expiratory pressure to Fio 2 combinations, permissive hypercapnia, and permissive hypoxemia. Measurements and Main Results: Ventilator and blood gas data were collected for the first 7 days of pediatric acute respiratory distress syndrome and compared between the protocol (n = 63) and nonprotocol groups (n = 69). After implementation of the protocol, median tidal volume (6.4 mL/kg [5.4–7.8 mL/kg] vs 6.0 mL/kg [4.8–7.3 mL/kg]; p = 0.005), Pao 2 (78.1 mm Hg [67.0–94.6 mm Hg] vs 74.5 mm Hg [59.2–91.1 mm Hg]; p = 0.001), and oxygen saturation (97% [95–99%] vs 96% [94–98%]; p = 0.007) were lower, and end-expiratory pressure (8 cm H2O [7–9 cm H2O] vs 8 cm H2O [8–10 cm H2O]; p = 0.002] and Paco 2 (44.9 mm Hg [38.8–53.1 mm Hg] vs 46.4 mm Hg [39.4–56.7 mm Hg]; p = 0.033) were higher, in keeping with lung protective measures. There was no difference in mortality (10/63 [15.9%] vs 18/69 [26.1%]; p = 0.152), ventilator-free days (16.0 [2.0–23.0] vs 19.0 [0.0–23.0]; p = 0.697), and PICU-free days (13.0 [0.0–21.0] vs 16.0 [0.0–22.0]; p = 0.233) between the protocol and nonprotocol groups. After adjusting for severity of illness, organ dysfunction and oxygenation index, the lung-protective mechanical ventilation protocol was associated with decreased mortality (adjusted hazard ratio, 0.37; 95% CI, 0.16–0.88). Conclusions: In pediatric acute respiratory distress syndrome, a lung-protective mechanical ventilation protocol improved adherence to lung-protective mechanical ventilation strategies and potentially mortality.
BackgroundAlveolar dead-space fraction (AVDSF), the volume of alveolar gas that does not participate in gas exchange, has been reported to predict mortality and morbidity in adults with acute respiratory distress syndrome (ARDS). This study aims to characterize AVDSF in patients with pediatric ARDS (PARDS), to determine its association with clinical outcomes and examine the validity of a previously studied cutoff (AVDSF > 0.25).MethodsThis was a prospective cohort study performed in the setting of a lung protective mechanical ventilation protocol. AVDSF was calculated by the equation: AVDSF = [partial pressure of arterial carbon dioxide (PaCO2) – end tidal carbon dioxide (etCO2)]/PaCO2. Receiver operating curve and Youden index were used to identify an AVDSF cutoff associated with mortality, which characterized “high or low AVDSF” groups. Correlation between AVDSF and clinical indices of severity were determined [including daily oxygenation index (OI), admission Pediatric Index of Mortality 2 (PIM 2) and Pediatric Logistic Organ Dysfunction (PELOD) scores]. The primary outcome, mortality in PARDS patients, was compared between the high and low AVDSF groups and analyzed in a multivariable logistic regression adjusting for inotrope use and PIM 2 score. Secondary outcomes included 28-day ventilator-free (VFD) and intensive care unit-free (IFD) days.ResultsSixty-nine PARDS patients with a median (interquartile range) age of 4.5 (0.8, 10.6) years were included in this analysis. Daily AVDSF correlated with daily OI (R2 = 0.10; p < 0.001). Mean AVDSF over the first 7 days of PARDS correlated with PIM 2 (R2 = 0.10; p = 0.010) and PELOD (R2 = 0.12; p = 0.004) scores. The greatest area under the curve identified an AVDSF cutoff of 0.22, which was close to the previously suggested 0.25. The high AVDSF group had higher mortality [7/19 (36.8%) vs. 5/50 (10.0%); p = 0.009] and lower VFD [2 (0, 18) vs. 21 (15, 24); p = 0.007] and IFD [0 (0, 16) vs. 16 (5, 21); p = 0.013]. In the multivariable model, being in the high AVDSF group [adjusted odds ratio 4.67 (95% CI: 1.12, 19.39)] was significantly associated with mortality.ConclusionsHigh AVDSF was independently associated with increased mortality and decreased VFD and IFD. AVDSF may be complementary to oxygenation indices in risk stratifying PARDS and warrant further study.
Introduction There is lack of consensus on what constitutes best practice when assessing extubation readiness in children. This systematic review aims to synthesize data from existing literature on pre-extubation assessments and evaluate their diagnostic accuracies in predicting extubation failure (EF) in children. Methods A systematic search in PubMed, EMBASE, Web of Science, CINAHL, and Cochrane was performed from inception of each database to 15 July 2021. Randomized controlled trials or observational studies that studied the association between pre-extubation assessments and extubation outcome in the pediatric intensive care unit population were included. Meta-analysis was performed for studies that report diagnostic tests results of a combination of parameters. Results In total, 41 of 11,663 publications screened were included (total patients, n = 8111). Definition of EF across studies was heterogeneous. Fifty-five unique pre-extubation assessments were identified. Parameters most studied were: respiratory rate (RR) (13/41, n = 1945), partial pressure of arterial carbon dioxide (10/41, n = 1379), tidal volume (13/41, n = 1945), rapid shallow breathing index (RBSI) (9/41, n = 1400), and spontaneous breathing trials (SBT) (13/41, n = 5652). Meta-analysis shows that RSBI, compliance rate oxygenation pressure (CROP) index, and SBT had sensitivities ranging from 0.14 to 0.57. CROP index had the highest sensitivity [0.57, 95% confidence interval (CI) 0.4–0.73] and area under curve (AUC, 0.98). SBT had the highest specificity (0.93, 95% CI 0.92–0.94). Conclusions Pre-extubation assessments studied thus far remain poor predictors of EF. CROP index, having the highest AUC, should be further explored as a predictor of EF. Standardizing the EF definition will allow better comparison of pre-extubation assessments. Supplementary Information The online version contains supplementary material available at 10.1007/s41030-022-00204-w.
BackgroundThe longitudinal course of patients with pediatric acute respiratory distress syndrome (PARDS) is not well described. In this study, we describe the oxygenation index (OI) and oxygen saturation index (OSI) in mild, moderate, and severe PARDS over 28 days and provide pilot data for the time to resolution of PARDS (Tres), as a short-term respiratory-specific outcome, hypothesizing that it is associated with the severity of PARDS and clinical outcomes.MethodsThis prospective observational study recruited consecutive patients with PARDS. OI and OSI were trended daily over 28 days. Tres (defined as OI < 4 or OSI < 5.3 on 2 consecutive days) were described based on PARDS severity and analyzed with Poisson and logistic regression to determine its association with conventional outcomes [mechanical ventilation (MV) duration, intensive care unit (ICU) and hospital length of stay, 28-day ventilator-free days (VFD), and 28-day ICU-free days (IFD)].ResultsThere were 121 children included in this study, 33/121(27.3%), 44/121(36.4%), and 44/121(36.4%) in the mild, moderate, and severe groups of PARDS, respectively. OI and OSI clearly differentiated mild, moderate, and severe groups in the first 7days of PARDS; however, this differentiation was no longer present after 7days. Median Tres was 4 (interquartile range: 3, 6), 5 (4, 7), and 7.5 (7, 11.5) days; p < 0.001 for the mild, moderate, and severe groups of PARDS, respectively. Tres was associated with increased MV duration, ICU and hospital length of stay, and decreased VFD and IFD.ConclusionThe oxygenation defect in PARDS took progressively longer to resolve across the mild, moderate, and severe groups. Tres is a potential short-term respiratory-specific outcome, which may be useful in addition to conventional clinical outcomes but needs further validation in external cohorts.
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