14: Risk Factors for Pediatric Extubation Failure: The Importance of Respiratory Muscle Strength

Sekayan, Tro; Hotz, Justin; Flink, Rutger C.; Iyer, Narayan P.; Newth, Christopher; Khemani, Robinder G.

doi:10.1097/01.ccm.0000508732.63332.ab

Cited by 1 publication

(3 citation statements)

References 39 publications

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“…P PL or P L estimations may also be helpful to prevent ventilator-induced diaphragmatic dysfunction (VIDD). VIDD has been reported in children 24–26. Mechanisms underlying VIDD comprise ventilatory overassistance leading to low levels of inspiratory effort which may induce muscle atrophy,25 27 28 and patient-ventilator asynchrony (PVA), which in turn may lead to excessive/eccentric activity of the diaphragm 29.…”

Section: Methodsmentioning

confidence: 99%

“…High breathing effort is consistently a risk factor for extubation failure in children, although this assumption is based on subjective clinical examination. Direct measurements, both during SB trials and in the peri-extubation period, are useful to identify patients at risk of extubation failure and who may benefit from non-invasive respiratory support 26. They are also useful to identify patients who have postextubation upper airway obstruction, and follow the consequent therapeutic interventions 62…”

Section: Methodsmentioning

confidence: 99%

“…VIDD has been reported in children. [24][25][26] Mechanisms underlying VIDD comprise ventilatory overassistance leading to low levels of inspiratory effort which may induce muscle atrophy, 25 27 28 and patient-ventilator asynchrony (PVA), which in turn may lead to excessive/eccentric activity of the diaphragm. 29 P PL estimates may afford titration of ventilator settings to maintain patient effort of breathing within a physiologic range, allow a better identification of PVA, [30][31][32] and prevent muscle atrophy.…”

Section: P L and P Pl To Characterise Overdistentionmentioning

confidence: 99%

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Pleural and transpulmonary pressures to tailor protective ventilation in children

Vedrenne-Cloquet¹,

Khirani

Khemani

et al. 2022

Thorax

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This review aims to: (1) describe the rationale of pleural (PPL) and transpulmonary (PL) pressure measurements in children during mechanical ventilation (MV); (2) discuss its usefulness and limitations as a guide for protective MV; (3) propose future directions for paediatric research. We conducted a scoping review on PL in critically ill children using PubMed and Embase search engines. We included peer-reviewed studies using oesophageal (PES) and PL measurements in the paediatric intensive care unit (PICU) published until September 2021, and excluded studies in neonates and patients treated with non-invasive ventilation. PL corresponds to the difference between airway pressure and PPL. Oesophageal manometry allows measurement of PES, a good surrogate of PPL, to estimate PL directly at the bedside. Lung stress is the PL, while strain corresponds to the lung deformation induced by the changing volume during insufflation. Lung stress and strain are the main determinants of MV-related injuries with PL and PPL being key components. PL-targeted therapies allow tailoring of MV: (1) Positive end-expiratory pressure (PEEP) titration based on end-expiratory PL (direct measurement) may be used to avoid lung collapse in the lung surrounding the oesophagus. The clinical benefit of such strategy has not been demonstrated yet. This approach should consider the degree of recruitable lung, and may be limited to patients in which PEEP is set to achieve an end-expiratory PL value close to zero; (2) Protective ventilation based on end-inspiratory PL (derived from the ratio of lung and respiratory system elastances), might be used to limit overdistention and volutrauma by targeting lung stress values < 20–25 cmH2O; (3) PPL may be set to target a physiological respiratory effort in order to avoid both self-induced lung injury and ventilator-induced diaphragm dysfunction; (4) PPL or PL measurements may contribute to a better understanding of cardiopulmonary interactions. The growing cardiorespiratory system makes children theoretically more susceptible to atelectrauma, myotrauma and right ventricle failure. In children with acute respiratory distress, PPL and PL measurements may help to characterise how changes in PEEP affect PPL and potentially haemodynamics. In the PICU, PPL measurement to estimate respiratory effort is useful during weaning and ventilator liberation. Finally, the use of PPL tracings may improve the detection of patient ventilator asynchronies, which are frequent in children. Despite these numerous theoritcal benefits in children, PES measurement is rarely performed in routine paediatric practice. While the lack of robust clincal data partially explains this observation, important limitations of the existing methods to estimate PPL in children, such as their invasiveness and technical limitations, associated with the lack of reference values for lung and chest wall elastances may also play a role. PPL and PL monitoring have numerous potential clinical applications in the PICU to tailor protective MV, but its usefulness is counterbalanced by technical limitations. Paediatric evidence seems currently too weak to consider oesophageal manometry as a routine respiratory monitoring. The development and validation of a noninvasive estimation of PL and multimodal respiratory monitoring may be worth to be evaluated in the future.

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%