Driving Pressure and Normalized Energy Transmission Calculations in Mechanically Ventilated Children Without Lung Disease and Pediatric Acute Respiratory Distress Syndrome*

Díaz, Franco; González‐Dambrauskas, Sebastián; Cristiani, Federico; Casanova, Daniel; Cruces, Pablo

doi:10.1097/pcc.0000000000002780

Cited by 18 publications

(23 citation statements)

References 34 publications

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“…Although Diaz stated in their study that the ΔP value better discriminates ARDS than all formulas including MP, Rauf et al stated in their study that the driving pressure value in pediatric patients was most effective factor for MV-related days and pediatric intensive care unit (PICU) length of stay, but not for mortality (13,25). In our patients, the driving pressures were below 15 cmH 2 O in both Group V and Group P. However, there are multiple risk factors for VILI, and considering driving pressures alone would only be looking at risks from one angle.…”

Section: Discussionmentioning

confidence: 96%

“…A portion of the applied energy is reflected in the tissues as excessive stretching, volume or pressure damage, and heat. Both resistance and elastance of pediatric patients are different from adults (13). In these patients, airway resistance is high, After the MP calculation formula applied by Gattinoni et al for VCV, Becher et al showed the MP calculation formula for PCV.…”

Section: Discussionmentioning

confidence: 99%

“…In this respect, we think that our study will contribute to the literature. One of the limited numbers of studies conducted in pediatric patients was conducted by Diaz et al (13). Intensive care patients with and without ARDS were included.…”

Section: Discussionmentioning

confidence: 99%

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Can Mechanical Power be Used as a Safety Precaution in Pediatric Patients?

Yüksek¹,

Miniksar²,

Yardimci³

et al. 2022

JARSS

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Objective: Mechanical power (MP) is the amount of energy transferred to the respiratory system of patients during each breath period. After overcoming the resistances required for respiration, the remaining energy may end up by damaging the lung parenchyma. The MP limit that should not be exceeded in pediatric patientsis not yet clear. The aim of this observational descriptive study is to compare the perioperative MP measurements in healthy pediatric cases with the values given in the literature. Methods: Perioperative MP was calculated according to the simplified MP formula in pediatric patients without known lung disease and compared with the literature. Results: The mean age of 34 patients was 68.88±31.4 months and the mean weight was 21.82±7.5 kg. The mean MP was 3.93±1.1 J min -1 , and the indexed MP was 0.19±0.08 J min -1 kg -1 . Both MP (p=0.008) and indexed MP (p<0.001) were significantly higher in patients with high tidal volume. In addition, we found a negative correlation between indexed MP and weight (r: -668 and p<0.001). Both MP and indexed MP had sufficient predictive power to predict tidal volume >10 and predictive value was significant [Auc: 0.764, 95%CI: 0.55-0.97, p: 0.026]. The value of MP>3.76 was an indicator for tidal volume >10 with 87 sensitivity and 50 specificity. Predictive value of indexed MP for tidal volume >10 mL kg -1 was 0.25 J kg -1 [AUC 0.856, 95%CI: 0.70-1.0, p=0.003], and indexed MP was a stronger indicator than MP. Conclusion:This study revealed that MP threshold values calculated for adults or patients with ARDS lung are not sensitive for pediatric patients, and a new threshold value should be determined for these patients.

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Section: Discussionmentioning

confidence: 96%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Can Mechanical Power be Used as a Safety Precaution in Pediatric Patients?

Yüksek¹,

Miniksar²,

Yardimci³

et al. 2022

JARSS

View full text Add to dashboard Cite

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“…Presented data is the worst during the first 72h of admission, so time-dependent variables are not analyzed 43 . We did not investigate other parameters associated with PARDS severity or outcomes, i.e., dead space or mechanical power, because it was not part of our objective [53][54][55] . As in many multicenter studies, there might be differences in ventilatory strategy between sites, and comparisons were not possible given the heterogeneity of cases per center.…”

Section: Discussionmentioning

confidence: 99%

Pediatric ARDS phenotypes in critical COVID-19: implications for therapies and outcomes

Domínguez-Rojas

Luna-Delgado²,

Caqui-Vilca

et al. 2022

Preprint

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Purposeto describe lung mechanics in Pediatric Acute Respiratory Disease Syndrome (PARDS) associated with COVID-19. We hypothesize two phenotypes according to respiratory system mechanics and clinical diagnosis.Methodsa concurrent multicenter observational study was performed, analyzing clinical variables and pulmonary mechanics of PARDS associated with COVID-19 in 4 Pediatric intensive care units (PICUs) of Perú. Subgroup analysis included PARDS associated with multisystem inflammatory syndrome in children (MIS-C), MIS-PARDS, and PARDS with COVID-19 primary respiratory infection, C-PARDS. In addition, receiver operator curve analysis (ROC) for mortality was performed.Results30 patients were included. Age was 7.5(4-11) years, 60% male, and mortality 23%. 47% corresponded to MIS-PARDS and 53% to C-PARDS phenotypes. C-PARDS had positive RT-PCR in 67% and MIS-PARDS none (p<0.001). C-PARDS group had more profound hypoxemia (P/Fratio<100, 86%vs38%,p<0.01) and higher driving-pressure (DP) [14(10-22)vs10(10-12)cmH2O], and lower compliance of the respiratory system (CRS)[0.5(0.3-0.6)vs 0.7(0.6-0.8)ml/kg/cmH2O] compared to MIS-PARDS (all p<0.05). ROC-analysis for mortality showed that DP had the best performance [AUC 0.91(95%CI0.81-1.00), with the best cut-point of 15 cmH2O (100% sensitivity and 87% of specificity). Mortality in C-PARDS was 38% and 7% in MIS-PARDS(p=0.09). MV free-days were 12(0-23) in C-PARDS and 23(21-25) in MIS-PARDS(p=0.02)Conclusioncritical pediatric COVID-19 is heterogeneous in children. COVID-19 PARDS had two phenotypes with distinctive pulmonary mechanics features. Characteristics of C-PARDS are like a classic primary PARDS, while a decoupling between compliance and hypoxemia was more frequent in MIS-PARDS. In addition, C-PARDS had fewer MV free-days. DP ≥ 15 cmH2O had the best performance of the quasi-static calculations to discriminate for mortality. Standardized pulmonary mechanics measurements in PARDS might reveal essential information to tailor the ventilatory strategy in pediatric critical COVID-19.‘Take-home message’PARDS associated with COVID-19 have two different phenotypes based on clinical diagnosis and pulmonary mechanics.C-PARDS group was characterized as a classic moderate to severe primary ARDS. A decoupling between compliance and hypoxemia was more frequent in MIS-PARDS. Regarding outcomes, C-PARDS had less VFD and a trend toward higher mortality.Data from the quasi-static calculations were associated with mortality; DP≥ 15 cmH2O was the best discriminator.Standardized pulmonary mechanics measurements in PARDS might reveal essential information to tailor the ventilatory strategy, characterizing different phenotypes and parameters associated with outcomes.TweetLung mechanics help to differentiate two different phenotypes in PARDS associated with COVID-19. C-PARDS associated with respiratory infection, and MIS-PARDS, associated with MIS-C. Also, lung mechanics variables were associated with mortality, being DP ≥ 15 cmH2O the best discriminator.

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“…The formal recognition of pediatric critical care medicine led to improvement not only in those being trained but also in those doing the training. It elevated the bar for the entire specialty by elevating the bar of expectations of training pathways, which extends to maintenance of certification, self-assessment, and the ongoing improvement of care (5,6).…”

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confidence: 99%

Should We Embrace Mechanical Power to Understand the Risk of Ventilator-Induced Lung Injury in Children?*

Khemani

2022

Pediatric Critical Care Medicine

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In this month's issue of Pediatric Critical Care Medicine, Proulx et al (1) present a sophisticated time-sequence analysis of the evolution of organ failure, gas exchange, ventilator settings, and lung mechanics in children with severe pediatric acute respiratory distress syndrome (PARDS). Their approach leverages over 12,000 hours of data during conventional mechanical ventilation in about 80 children with severe PARDS. They have confirmed the association amongst multiple organ failure, oxygenation deficits, and dead space with mortality in PARDS. Furthermore, they have found that an estimate for mechanical power, a composite variable reflecting the total energy given to the lungs during mechanical ventilation, which is associated with mortality in adults with acute respiratory distress syndrome (ARDS) (2), is also associated with mortality in severe PARDS.The authors should be commended for their work, as their approach has leveraged valuable data from the electronic health record to give us a deeper understanding of how these variables evolve over time among PARDS survivors and nonsurvivors. They have also highlighted that an often-ignored variable in ventilator management, the respiratory rate, may have prognostic relevance in severe PARDS. Respiratory rate is a particularly problematic variable for analysis in pediatrics, as it is age-dependent. The authors addressed this age dependence by normalizing respiratory rate using a z score method and identified that nonsurvivors had respiratory rates 2 z scores higher than survivors.Mechanical power is an attractive concept to characterize the degree of lung-protective ventilation because it is a composite metric representative of the energy delivered to the lung. It includes elastic static components, elastic dynamic components, and resistive components (3). Positive end-expiratory pressure (PEEP), inspiratory pressure (both peak inspiratory pressure and plateau pressure), tidal volume, flow, and respiratory rate contribute to mechanical power, to different extents (4). These individual variables are of course coupled with one another based on the elastance and resistance properties of the respiratory system, which has always made it difficult to understand the individual associations of these variables with outcomes in patients with PARDS, as, in most analyses, many of these variables are colinear with one another. This certainly increases the attractiveness of using mechanical power as an alternative approach to characterize the degree of lung-protective ventilation that is being used.

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Driving Pressure and Normalized Energy Transmission Calculations in Mechanically Ventilated Children Without Lung Disease and Pediatric Acute Respiratory Distress Syndrome*

Cited by 18 publications

References 34 publications

Can Mechanical Power be Used as a Safety Precaution in Pediatric Patients?

Can Mechanical Power be Used as a Safety Precaution in Pediatric Patients?

Pediatric ARDS phenotypes in critical COVID-19: implications for therapies and outcomes

Should We Embrace Mechanical Power to Understand the Risk of Ventilator-Induced Lung Injury in Children?*

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