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Quach S, Reise K, McGregor C, Papaconstantinou E, Nonoyama ML. A Delphi Survey of Canadian Respiratory Therapists' Practice Statements on Pediatric Mechanical Ventilation. Respir Care 2022; 67:1420-1436. [PMID: 35922069 PMCID: PMC9993971 DOI: 10.4187/respcare.09886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pediatric mechanical ventilation practice guidelines are not well established; therefore, the European Society for Paediatric and Neonatal Intensive Care (ESPNIC) developed consensus recommendations on pediatric mechanical ventilation management in 2017. However, the guideline's applicability in different health care settings is unknown. This study aimed to determine the consensus on pediatric mechanical ventilation practices from Canadian respiratory therapists' (RTs) perspectives and consensually validate aspects of the ESPNIC guideline. METHODS A 3-round modified electronic Delphi survey was conducted; contents were guided by ESPNIC. Participants were RTs with at least 5 years of experience working in standalone pediatric ICUs or units with dedicated pediatric intensive care beds across Canada. Round 1 collected open-text feedback, and subsequent rounds gathered feedback using a 6-point Likert scale. Consensus was defined as ≥ 75% agreement; if consensus was unmet, statements were revised for re-ranking in the subsequent round. RESULTS Fifty-two RTs from 14 different pediatric facilities participated in at least one of the 3 rounds. Rounds 1, 2, and 3 had a response rate of 80%, 93%, and 96%, respectively. A total of 59 practice statements achieved consensus by the end of round 3, categorized into 10 sections: (1) noninvasive ventilation and high-flow oxygen therapy, (2) tidal volume and inspiratory pressures, (3) breathing frequency and inspiratory times, (4) PEEP and FIO2 , (5) advanced modes of ventilation, (6) weaning, (7) physiological targets, (8) monitoring, (9) general, and (10) equipment adjuncts. Cumulative text feedback guided the formation of the clinical remarks to supplement these practice statements. CONCLUSIONS This was the first study to survey RTs for their perspectives on the general practice of pediatric mechanical ventilation management in Canada, generally aligning with the ESPNIC guideline. These practice statements considered information from health organizations and institutes, supplemented with clinical remarks. Future studies are necessary to verify and understand these practices' effectiveness.
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Affiliation(s)
- Shirley Quach
- The Hospital for Sick Children, Department of Respiratory Therapy, Toronto, Ontario, Canada; McMaster University, School of Rehabilitation Sciences, Institute for Applied Health Sciences, Hamilton, Ontario, Canada; and Ontario Tech University, Faculty of Health Sciences, Oshawa, Ontario, Canada
| | - Katherine Reise
- The Hospital for Sick Children, Department of Respiratory Therapy, Toronto, Ontario, Canada
| | - Carolyn McGregor
- Ontario Tech University, Faculty of Health Sciences, Oshawa, Ontario, Canada; and University of Technology, Sydney, New South Wales, Australia
| | | | - Mika L Nonoyama
- The Hospital for Sick Children, Department of Respiratory Therapy, Toronto, Ontario, Canada; and Ontario Tech University, Faculty of Health Sciences, Oshawa, Ontario, Canada.
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Mistry S, Das A, Saffaran S, Yehya N, Scott TE, Chikhani M, Laffey JG, Hardman JG, Camporota L, Bates DG. Validation of at-the-bedside formulae for estimating ventilator driving pressure during airway pressure release ventilation using computer simulation. Respir Res 2022; 23:101. [PMID: 35473715 PMCID: PMC9039982 DOI: 10.1186/s12931-022-01985-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Airway pressure release ventilation (APRV) is widely available on mechanical ventilators and has been proposed as an early intervention to prevent lung injury or as a rescue therapy in the management of refractory hypoxemia. Driving pressure ([Formula: see text]) has been identified in numerous studies as a key indicator of ventilator-induced-lung-injury that needs to be carefully controlled. [Formula: see text] delivered by the ventilator in APRV is not directly measurable in dynamic conditions, and there is no "gold standard" method for its estimation. METHODS We used a computational simulator matched to data from 90 patients with acute respiratory distress syndrome (ARDS) to evaluate the accuracy of three "at-the-bedside" methods for estimating ventilator [Formula: see text] during APRV. RESULTS Levels of [Formula: see text] delivered by the ventilator in APRV were generally within safe limits, but in some cases exceeded levels specified by protective ventilation strategies. A formula based on estimating the intrinsic positive end expiratory pressure present at the end of the APRV release provided the most accurate estimates of [Formula: see text]. A second formula based on assuming that expiratory flow, volume and pressure decay mono-exponentially, and a third method that requires temporarily switching to volume-controlled ventilation, also provided accurate estimates of true [Formula: see text]. CONCLUSIONS Levels of [Formula: see text] delivered by the ventilator during APRV can potentially exceed levels specified by standard protective ventilation strategies, highlighting the need for careful monitoring. Our results show that [Formula: see text] delivered by the ventilator during APRV can be accurately estimated at the bedside using simple formulae that are based on readily available measurements.
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Affiliation(s)
- Sonal Mistry
- School of Engineering, University of Warwick, Coventry, CV4 7AL, UK
| | - Anup Das
- School of Engineering, University of Warwick, Coventry, CV4 7AL, UK
| | - Sina Saffaran
- Faculty of Engineering Science, University College London, London, WC1E 6BT, UK
| | - Nadir Yehya
- Department of Anaesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Timothy E Scott
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, ICT Centre, Birmingham, B15 2SQ, UK
| | - Marc Chikhani
- Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, NUI Galway, Galway, Ireland
| | - Jonathan G Hardman
- Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.,Anaesthesia & Critical Care, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Luigi Camporota
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | - Declan G Bates
- School of Engineering, University of Warwick, Coventry, CV4 7AL, UK.
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Cheng J, Ma A, Dong M, Zhou Y, Wang B, Xue Y, Wang P, Yang J, Kang Y. Does airway pressure release ventilation offer new hope for treating acute respiratory distress syndrome? JOURNAL OF INTENSIVE MEDICINE 2022; 2:241-248. [PMID: 36785647 PMCID: PMC8958099 DOI: 10.1016/j.jointm.2022.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/30/2022] [Accepted: 02/16/2022] [Indexed: 01/01/2023]
Abstract
Mechanical ventilation (MV) is an essential life support method for patients with acute respiratory distress syndrome (ARDS), which is one of the most common critical illnesses with high mortality in the intensive care unit (ICU). A lung-protective ventilation strategy based on low tidal volume (LTV) has been recommended since a few years; however, as this did not result in a significant decrease of ARDS-related mortality, a more optimal ventilation mode was required. Airway pressure release ventilation (APRV) is an old method defined as a continuous positive airway pressure (CPAP) with a brief intermittent release phase based on the open lung concept; it also perfectly fits the ARDS treatment principle. Despite this, APRV has not been widely used in the past, rather only as a rescue measure for ARDS patients who are difficult to oxygenate. Over recent years, with an increased understanding of the pathophysiology of ARDS, APRV has been reproposed to improve patient prognosis. Nevertheless, this mode is still not routinely used in ARDS patients given its vague definition and complexity. Consequently, in this paper, we summarize the studies that used APRV in ARDS, including adults, children, and animals, to illustrate the settings of parameters, effectiveness in the population, safety (especially in children), incidence, and mechanism of ventilator-induced lung injury (VILI) and effects on extrapulmonary organs. Finally, we found that APRV is likely associated with improvement in ARDS outcomes, and does not increase injury to the lungs and other organs, thereby indicating that personalized APRV settings may be the new hope for ARDS treatment.
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Affiliation(s)
| | | | | | | | | | | | | | - Jing Yang
- Corresponding authors: Yan Kang and Jing Yang, Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China.
| | - Yan Kang
- Corresponding authors: Yan Kang and Jing Yang, Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China.
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Miller AG, Bartle RM, Feldman A, Mallory P, Reyes E, Scott B, Rotta AT. A narrative review of advanced ventilator modes in the pediatric intensive care unit. Transl Pediatr 2021; 10:2700-2719. [PMID: 34765495 PMCID: PMC8578787 DOI: 10.21037/tp-20-332] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/26/2020] [Indexed: 01/29/2023] Open
Abstract
Respiratory failure is a common reason for pediatric intensive care unit admission. The vast majority of children requiring mechanical ventilation can be supported with conventional mechanical ventilation (CMV) but certain cases with refractory hypoxemia or hypercapnia may require more advanced modes of ventilation. This paper discusses what we have learned about the use of advanced ventilator modes [e.g., high-frequency oscillatory ventilation (HFOV), high-frequency percussive ventilation (HFPV), high-frequency jet ventilation (HFJV) airway pressure release ventilation (APRV), and neurally adjusted ventilatory assist (NAVA)] from clinical, animal, and bench studies. The evidence supporting advanced ventilator modes is weak and consists of largely of single center case series, although a few RCTs have been performed. Animal and bench models illustrate the complexities of different modes and the challenges of applying these clinically. Some modes are proprietary to certain ventilators, are expensive, or may only be available at well-resourced centers. Future efforts should include large, multicenter observational, interventional, or adaptive design trials of different rescue modes (e.g., PROSpect trial), evaluate their use during ECMO, and should incorporate assessments through volumetric capnography, electric impedance tomography, and transpulmonary pressure measurements, along with precise reporting of ventilator parameters and physiologic variables.
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Affiliation(s)
- Andrew G Miller
- Duke University Medical Center, Durham, NC, USA.,Respiratory Care Services, Duke University Medical Center, Durham, NC, USA
| | - Renee M Bartle
- Duke University Medical Center, Durham, NC, USA.,Respiratory Care Services, Duke University Medical Center, Durham, NC, USA
| | - Alexandra Feldman
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Palen Mallory
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Edith Reyes
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Briana Scott
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Alexandre T Rotta
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
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Airway Pressure Release Ventilation as a Rescue Therapy in Pediatric Acute Respiratory Distress Syndrome (pARDS): Goodwill or Devil? Indian J Pediatr 2020; 87:887-888. [PMID: 32939658 DOI: 10.1007/s12098-020-03492-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 09/07/2020] [Indexed: 10/23/2022]
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