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Vedrenne-Cloquet M, Tuffet S, Louis B, Khirani S, Collignon C, Renolleau S, Fauroux B, Carteaux G. Accuracy of tidal volume delivery by paediatric intensive care ventilators: A bench-model study. Aust Crit Care 2024; 37:600-605. [PMID: 38267269 DOI: 10.1016/j.aucc.2023.12.007] [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] [Received: 08/12/2023] [Revised: 11/06/2023] [Accepted: 12/02/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Tidal volume (Vt) delivery during mechanical ventilation is influenced by gas compression, humidity, and temperature. OBJECTIVES This bench study aimed at assessing the accuracy of Vt delivery by paediatric intensive care ventilators according to the humidification system. Secondary objectives were to assess the following: (i) the accuracy of Vt delivery in ventilators with an integrated Y-piece pneumotachograph and (ii) the ability of ventilators to deliver and maintain a preset positive end-expiratory pressure. METHODS Six latest-generation intensive care ventilators equipped with a paediatric mode were tested on the ASL5000 test lung in four simulated paediatric bench models (full-term neonate, infant, preschool-age chile, and school-age child), under volume-controlled mode with a heated humidifier (HH) or a heat moisture exchanger, with various loading conditions. Three ventilators equipped with a Y-piece pneumotachograph were tested with or without the pneumotachograph in the neonatal and infant models. "Accurate Vt" delivery was defined as a volume error (percentage of the preset Vt under body temperature and pressure and saturated water vapour conditions) being ≤10 % of the absolute preset value. RESULTS Vt accuracy varied significantly across ventilators but was acceptable in almost all the ventilators and all the models, except the neonatal model. The humidification system had an impact on Vt delivery in the majority of the tested conditions (p < 0.05). The use of an HH was associated with a better Vt accuracy in four ventilators (V500, V800, R860, and ServoU) and allowed to achieve an acceptable level of volume error in the neonatal model as compared to the use of heat moisture exchanger. The use of an integrated pneumotachograph was associated with lower volume error in only one ventilator (p < 0.01). All the tested ventilators were able to maintain adequate positive end-expiratory pressure levels. CONCLUSION The humidification system affects Vt accuracy of paediatric intensive care ventilators, especially in the youngest patients for whom the HH should be preferred.
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Affiliation(s)
- Meryl Vedrenne-Cloquet
- Pediatric Sleep and Noninvasive Ventilation Unit, EA 7330 VIFASOM, AP-HP, Hôpital Necker Enfants-Malades, Paris, France; Université de Paris, Paris, France; Réanimation Médicochirurgicale Pédiatrique, AP-HP, CHU Necker-Enfants Malades, Paris, France.
| | - Samuel Tuffet
- INSERM, Université Paris Est Créteil IMRB, CNRS EMR, 7000, Créteil, France; GRC CARMAS, IMRB, Université Paris Est Créteil, Faculté de Santé de Créteil, Créteil, France; Réanimation Médicale, AP-HP, Centre Hospitalier Universitaire Henri Mondor, Créteil, France
| | - Bruno Louis
- INSERM, Université Paris Est Créteil IMRB, CNRS EMR, 7000, Créteil, France
| | - Sonia Khirani
- Pediatric Sleep and Noninvasive Ventilation Unit, EA 7330 VIFASOM, AP-HP, Hôpital Necker Enfants-Malades, Paris, France; Université de Paris, Paris, France; ASV Santé, Gennevilliers, France
| | - Charlotte Collignon
- Réanimation Médicochirurgicale Pédiatrique, AP-HP, CHU Necker-Enfants Malades, Paris, France
| | - Sylvain Renolleau
- Université de Paris, Paris, France; Réanimation Médicochirurgicale Pédiatrique, AP-HP, CHU Necker-Enfants Malades, Paris, France
| | - Brigitte Fauroux
- Pediatric Sleep and Noninvasive Ventilation Unit, EA 7330 VIFASOM, AP-HP, Hôpital Necker Enfants-Malades, Paris, France; Université de Paris, Paris, France
| | - Guillaume Carteaux
- INSERM, Université Paris Est Créteil IMRB, CNRS EMR, 7000, Créteil, France; GRC CARMAS, IMRB, Université Paris Est Créteil, Faculté de Santé de Créteil, Créteil, France; Réanimation Médicale, AP-HP, Centre Hospitalier Universitaire Henri Mondor, Créteil, France
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2
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Wong JJM, Dang H, Gan CS, Phan PH, Kurosawa H, Aoki K, Lee SW, Ong JSM, Fan L, Tai CW, Chuah SL, Lee PC, Chor YK, Ngu L, Anantasit N, Liu C, Xu W, Wati DK, Gede SIB, Jayashree M, Liauw F, Pon KM, Huang L, Chong JY, Zhu X, Hon KLE, Leung KKY, Samransamruajkit R, Cheung YB, Lee JH. Lung-Protective Ventilation for Pediatric Acute Respiratory Distress Syndrome: A Nonrandomized Controlled Trial. Crit Care Med 2024:00003246-990000000-00353. [PMID: 38920618 DOI: 10.1097/ccm.0000000000006357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
OBJECTIVES Despite the recommendation for lung-protective mechanical ventilation (LPMV) in pediatric acute respiratory distress syndrome (PARDS), there is a lack of robust supporting data and variable adherence in clinical practice. This study evaluates the impact of an LPMV protocol vs. standard care and adherence to LPMV elements on mortality. We hypothesized that LPMV strategies deployed as a pragmatic protocol reduces mortality in PARDS. DESIGN Multicenter prospective before-and-after comparison design study. SETTING Twenty-one PICUs. PATIENTS Patients fulfilled the Pediatric Acute Lung Injury Consensus Conference 2015 definition of PARDS and were on invasive mechanical ventilation. INTERVENTIONS The LPMV protocol included a limit on peak inspiratory pressure (PIP), delta/driving pressure (DP), tidal volume, positive end-expiratory pressure (PEEP) to Fio2 combinations of the low PEEP acute respiratory distress syndrome network table, permissive hypercarbia, and conservative oxygen targets. MEASUREMENTS AND MAIN RESULTS There were 285 of 693 (41·1%) and 408 of 693 (58·9%) patients treated with and without the LPMV protocol, respectively. Median age and oxygenation index was 1.5 years (0.4-5.3 yr) and 10.9 years (7.0-18.6 yr), respectively. There was no difference in 60-day mortality between LPMV and non-LPMV protocol groups (65/285 [22.8%] vs. 115/406 [28.3%]; p = 0.104). However, total adherence score did improve in the LPMV compared to non-LPMV group (57.1 [40.0-66.7] vs. 47.6 [31.0-58.3]; p < 0·001). After adjusting for confounders, adherence to LPMV strategies (adjusted hazard ratio, 0.98; 95% CI, 0.97-0.99; p = 0.004) but not the LPMV protocol itself was associated with a reduced risk of 60-day mortality. Adherence to PIP, DP, and PEEP/Fio2 combinations were associated with reduced mortality. CONCLUSIONS Adherence to LPMV elements over the first week of PARDS was associated with reduced mortality. Future work is needed to improve implementation of LPMV in order to improve adherence.
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Affiliation(s)
- Judith Ju Ming Wong
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Hongxing Dang
- Children's Hospital of Chongqing Medical University, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
| | - Chin Seng Gan
- Department of Paediatrics, University Malaya Medical Centre, University Malaya, Kuala Lumpur, Malaysia
| | - Phuc Huu Phan
- Vietnam National Children's Hospital, Hanoi, Vietnam
| | | | - Kazunori Aoki
- Hyogo Prefectural Kobe Children's Hospital, Hyogo, Japan
| | - Siew Wah Lee
- Sultanah Aminah Hospital, Johor, Malaysia
- Hospital Tengku Ampuan Rahimah, Selangor, Malaysia
| | | | - Lijia Fan
- Division of Paediatric Critical Care, National University Hospital, Singapore
| | - Chian Wern Tai
- Universiti Kebangsaan Malaysia Specialist Children's Hospital, Kuala Lumpur, Malaysia
| | - Soo Lin Chuah
- Department of Paediatrics, University Malaya Medical Centre, University Malaya, Kuala Lumpur, Malaysia
| | - Pei Chuen Lee
- Universiti Kebangsaan Malaysia Specialist Children's Hospital, Kuala Lumpur, Malaysia
| | | | - Louise Ngu
- Sarawak General Hospital, Sarawak, Malaysia
| | | | - Chunfeng Liu
- Shengjing Hospital of China Medical University, Liaoning, China
| | - Wei Xu
- Shengjing Hospital of China Medical University, Liaoning, China
| | - Dyah Kanya Wati
- Pediatric Emergency and Intensive Care Unit, Prof I.G.N.G Ngoerah Hospital, Bali, Indonesia
- Medical Faculty, Udayana University, Bali, Indonesia
| | - Suparyatha Ida Bagus Gede
- Pediatric Emergency and Intensive Care Unit, Prof I.G.N.G Ngoerah Hospital, Bali, Indonesia
- Medical Faculty, Udayana University, Bali, Indonesia
| | | | - Felix Liauw
- Harapan Kita National Women and Children Health Center, Jakarta, Indonesia
| | | | - Li Huang
- Guangzhou Women and Children's Medical Center, Guangdong, China
| | - Jia Yueh Chong
- Hospital Tunku Azizah Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Xuemei Zhu
- Children's Hospital of Fudan University, Shanghai, China
| | - Kam Lun Ellis Hon
- Paediatric Intensive Care Unit, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Karen Ka Yan Leung
- Paediatric Intensive Care Unit, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Rujipat Samransamruajkit
- Division of Pediatric Critical Care, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yin Bun Cheung
- Duke-NUS Medical School, Singapore
- Tampere Center for Child, Adolescent and Maternal Health Research, Tampere University, Tampere, Finland
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
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O'Hara JE, Graham RJ. Pediatric pulmonology year in review-Pediatric pulmonary critical care. Pediatr Pulmonol 2024. [PMID: 38888167 DOI: 10.1002/ppul.27116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 06/20/2024]
Abstract
Pediatric pulmonary critical care literature has continued to grow in recent years. Our aim in this review is to narrowly focus on publications providing clinically-relevant advances in pediatric pulmonary critical care in 2023.
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Affiliation(s)
- Jill E O'Hara
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Robert J Graham
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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Kneyber MCJ. Positive end-expiratory pressure in the pediatric intensive care unit. Paediatr Respir Rev 2024; 49:5-8. [PMID: 38030513 DOI: 10.1016/j.prrv.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 11/21/2023] [Indexed: 12/01/2023]
Abstract
Application of positive end-expiratory pressure (PEEP) targeted towards improving oxygenation is one of the components of the ventilatory management of pediatric acute respiratory distress syndrome (PARDS). Low end-expiratory airway pressures cause repetitive opening and closure of unstable alveoli, leading to surfactant dysfunction and parenchymal shear injury. Consequently, there is less lung volume available for tidal ventilation when there are atelectatic lung regions. This will increase lung strain in aerated lung areas to which the tidal volume is preferentially distributed. Pediatric critical care practitioners tend to use low levels of PEEP and inherently accept higher FiO2, but these practices may negatively affect patient outcome. The Pediatric Acute Lung Injury Consensus Conference (PALICC) suggests that PEEP should be titrated to oxygenation/oxygen delivery, hemodynamics, and compliance measured under static conditions as compared to other clinical parameters or any of these parameters in isolation in patients with PARDS, while limiting plateau pressure and/or driving pressure limits.
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Affiliation(s)
- Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; Anaesthesiology, Peri-operative & Emergency Medicine, University of Groningen, Groningen, the Netherlands.
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5
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Mohamed S, Batra K, Pang N, Runge E, Kioka MJ. A prospective study on the precision of height data from electronic medical records in tidal volume calculation for lung-protective ventilation. Medicine (Baltimore) 2023; 102:e36196. [PMID: 38013288 PMCID: PMC10681549 DOI: 10.1097/md.0000000000036196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/27/2023] [Indexed: 11/29/2023] Open
Abstract
Lung-protective ventilation is now the norm for all patients, regardless of the presence of acute respiratory distress syndrome (ARDS), owing to the mortality associated with higher tidal volumes (TV). Clinicians calculate TV using recorded height from medical records and predicted body weight (PBW); however, the accuracy remains uncertain. Our study aimed to validate accurate TV settings for lung-protective ventilation by examining the correlation between the charted height and bedside measurements. In a single-center study, we compared PBW-based TV calculated from recorded height to PBW-based TV from measured height and identified factors causing height overestimation during charting. Our team measured patient height within 24 hours of admission using metal tape. TV calculated from recorded height (6-8 mL/kg PBW) was significantly larger (391.55 ± 65.98 to 522.07 ± 87.97) than measured height-based TV (162.62 ± 12.62 to 470.28 ± 89.64) (P < .01). In the height overestimated group, 57.7% were prescribed TV by healthcare provider, which was more than TV of 8 mL/kg of PBW, as determined by measured height. Negative predictors for height overestimation were male sex (OR: 0.45 [95% CI: 0.25-0.82]; P = .008) and presence of driver's license information (OR: 0.45 [95% CI: 0.25-0.80]; P = .007), whereas Asian ethnicity was a positive predictor (OR: 4.34 [95% CI: 1.09-17.27]; P = .04). The height overestimation group had a higher in-patient mortality rate (38.5%) than the matched/underestimation group (20%) (P < .01). In stadiometer-limited hospitals, the PBW-based TV is overestimated using the recorded height instead of the measured height. In the group where heights were overestimated, over half of the patients received TV prescriptions from healthcare providers that surpassed the TV of calculated 8 mL/kg PBW based on their measured height. The risk factors for height overestimation include female sex, Asian ethnicity, and missing driver's license data. Alternative height measurement methods should be explored to ensure precise ventilation settings and patient safety.
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Affiliation(s)
- Salman Mohamed
- Kirk Kekorian School of Medicine at University of Nevada, Las Vegas, NV
| | - Kavita Batra
- Office of Research, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas, NV
- Department of Medical Education and Office of Academic Affairs, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas, NV
| | - Nicole Pang
- Kirk Kekorian School of Medicine at University of Nevada, Las Vegas, NV
| | - Elliot Runge
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas, NV
| | - Mutsumi John Kioka
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas, NV
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Kneyber MCJ, Cheifetz IM. Mechanical ventilation during pediatric extracorporeal life support. Curr Opin Pediatr 2023; 35:596-602. [PMID: 37497765 DOI: 10.1097/mop.0000000000001277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
PURPOSE OF REVIEW To discuss the role of ventilator induced lung injury (VILI) and patient self-inflicted lung injury in ventilated children supported on extracorporeal membrane oxygenation (ECMO). RECENT FINDINGS While extracorporeal life support is used routinely used every day around the globe to support neonatal, pediatric, and adult patients with refractory cardiac and/or respiratory failure, the optimal approach to mechanical ventilation, especially for those with acute respiratory distress syndrome (ARDS), remains unknown and controversial. Given the lack of definitive data in this population, one must rely on available evidence in those with ARDS not supported with ECMO and extrapolate adult observations. Ventilatory management should include, as a minimum standard, limiting inspiratory and driving pressures, providing a sufficient level of positive end-expiratory pressure, and setting a low rate to reduce mechanical power. Allowing for spontaneous breathing and use of pulmonary specific ancillary treatment modalities must be individualized, while balancing the risk and benefits. Future studies delineating the best strategies for optimizing MV during pediatric extracorporeal life support are much needed. SUMMARY Future investigations will hopefully provide the needed evidence and better understanding of the overall goal of reducing mechanical ventilation intensity to decrease risk for VILI and promote lung recovery for those supported with ECMO.
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Affiliation(s)
- Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen
- Critical care, Anesthesiology, Peri-operative & Emergency medicine (CAPE), University of Groningen, Groningen, The Netherlands
| | - Ira M Cheifetz
- Department of Pediatrics, Rainbow Babies and Children's Hospital and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Percy AG, Mai MV, Bhalla AK, Yehya N. Mechanical Power Is Associated With Mortality in Pediatric Acute Respiratory Distress Syndrome. Pediatr Crit Care Med 2023; 24:e307-e316. [PMID: 36883840 PMCID: PMC10329976 DOI: 10.1097/pcc.0000000000003214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
OBJECTIVES Mechanical power (MP) transferred from the ventilator to the lungs has been proposed as a summary variable that may impact mortality in children with acute respiratory distress syndrome (ARDS). To date, no study has shown an association between higher MP and mortality in children with ARDS. DESIGN Secondary analysis of a prospective observational study. SETTING Single-center, tertiary, academic PICU. PATIENTS Five hundred forty-six intubated children with ARDS enrolled between January 2013 and December 2019 receiving pressure-controlled ventilation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Higher MP was associated with increased mortality (adjusted hazard ratio [HR] 1.34 per 1 sd increase, 95% CI 1.08-1.65; p = 0.007). When assessing the contribution of individual components of MP, only positive end-expiratory pressure (PEEP) was associated with mortality (HR 1.32; p = 0.007), whereas tidal volume, respiratory rate, and driving pressure (ΔP = [peak inspiratory pressure (PIP)-PEEP]) were not. Finally, we tested whether there remained an association when specific terms were removed from the MP equation by calculating MP from static strain (remove ΔP), MP from dynamic strain (remove PEEP), and mechanical energy (remove respiratory rate). MP from static strain (HR 1.44; p < 0.001), MP from dynamic strain (HR 1.25; p = 0.042), and mechanical energy (HR 1.29; p = 0.009) were all associated with mortality. MP was associated with ventilator-free days only when using MP normalized to predicted body weight, but not when using measured weight. CONCLUSIONS Higher MP was associated with mortality in pediatric ARDS, and PEEP appears to be the component most consistently driving this association. As higher PEEP is used in sicker patients, the association between MP and mortality may reflect a marker of illness severity rather than MP itself being causal for mortality. However, our results support future trials testing different levels of PEEP in children with ARDS as a potential means to improve outcome.
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Affiliation(s)
- Andrew G Percy
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Mark V Mai
- Division of Critical Care Medicine, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Anoopindar K Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Invasive Ventilatory Support in Patients With Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2023; 24:S61-S75. [PMID: 36661436 DOI: 10.1097/pcc.0000000000003159] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To provide evidence for the Second Pediatric Acute Lung Injury Consensus Conference updated recommendations and consensus statements for clinical practice and future research on invasive mechanical ventilation support of patients with pediatric acute respiratory distress syndrome (PARDS). DATA SOURCES MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). STUDY SELECTION We included clinical studies of critically ill patients undergoing invasive mechanical ventilation for PARDS, January 2013 to April 2022. In addition, meta-analyses and systematic reviews focused on the adult acute respiratory distress syndrome population were included to explore new relevant concepts (e.g., mechanical power, driving pressure, etc.) still underrepresented in the contemporary pediatric literature. DATA EXTRACTION Title/abstract review, full text review, and data extraction using a standardized data collection form. DATA SYNTHESIS The Grading of Recommendations Assessment, Development and Evaluation approach was used to identify and summarize relevant evidence and develop recommendations, good practice statements and research statements. We identified 26 pediatric studies for inclusion and 36 meta-analyses or systematic reviews in adults. We generated 12 recommendations, two research statements, and five good practice statements related to modes of ventilation, tidal volume, ventilation pressures, lung-protective ventilation bundles, driving pressure, mechanical power, recruitment maneuvers, prone positioning, and high-frequency ventilation. Only one recommendation, related to use of positive end-expiratory pressure, is classified as strong, with moderate certainty of evidence. CONCLUSIONS Limited pediatric data exist to make definitive recommendations for the management of invasive mechanical ventilation for patients with PARDS. Ongoing research is needed to better understand how to guide best practices and improve outcomes for patients with PARDS requiring invasive mechanical ventilation.
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Emeriaud G, López-Fernández YM, Iyer NP, Bembea MM, Agulnik A, Barbaro RP, Baudin F, Bhalla A, Brunow de Carvalho W, Carroll CL, Cheifetz IM, Chisti MJ, Cruces P, Curley MAQ, Dahmer MK, Dalton HJ, Erickson SJ, Essouri S, Fernández A, Flori HR, Grunwell JR, Jouvet P, Killien EY, Kneyber MCJ, Kudchadkar SR, Korang SK, Lee JH, Macrae DJ, Maddux A, Modesto I Alapont V, Morrow BM, Nadkarni VM, Napolitano N, Newth CJL, Pons-Odena M, Quasney MW, Rajapreyar P, Rambaud J, Randolph AG, Rimensberger P, Rowan CM, Sanchez-Pinto LN, Sapru A, Sauthier M, Shein SL, Smith LS, Steffen K, Takeuchi M, Thomas NJ, Tse SM, Valentine S, Ward S, Watson RS, Yehya N, Zimmerman JJ, Khemani RG. Executive Summary of the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2). Pediatr Crit Care Med 2023; 24:143-168. [PMID: 36661420 PMCID: PMC9848214 DOI: 10.1097/pcc.0000000000003147] [Citation(s) in RCA: 62] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES We sought to update our 2015 work in the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) guidelines for the diagnosis and management of pediatric acute respiratory distress syndrome (PARDS), considering new evidence and topic areas that were not previously addressed. DESIGN International consensus conference series involving 52 multidisciplinary international content experts in PARDS and four methodology experts from 15 countries, using consensus conference methodology, and implementation science. SETTING Not applicable. PATIENTS Patients with or at risk for PARDS. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Eleven subgroups conducted systematic or scoping reviews addressing 11 topic areas: 1) definition, incidence, and epidemiology; 2) pathobiology, severity, and risk stratification; 3) ventilatory support; 4) pulmonary-specific ancillary treatment; 5) nonpulmonary treatment; 6) monitoring; 7) noninvasive respiratory support; 8) extracorporeal support; 9) morbidity and long-term outcomes; 10) clinical informatics and data science; and 11) resource-limited settings. The search included MEDLINE, EMBASE, and CINAHL Complete (EBSCOhost) and was updated in March 2022. Grading of Recommendations, Assessment, Development, and Evaluation methodology was used to summarize evidence and develop the recommendations, which were discussed and voted on by all PALICC-2 experts. There were 146 recommendations and statements, including: 34 recommendations for clinical practice; 112 consensus-based statements with 18 on PARDS definition, 55 on good practice, seven on policy, and 32 on research. All recommendations and statements had agreement greater than 80%. CONCLUSIONS PALICC-2 recommendations and consensus-based statements should facilitate the implementation and adherence to the best clinical practice in patients with PARDS. These results will also inform the development of future programs of research that are crucially needed to provide stronger evidence to guide the pediatric critical care teams managing these patients.
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Affiliation(s)
- Guillaume Emeriaud
- Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montréal, QC, Canada
| | - Yolanda M López-Fernández
- Pediatric Intensive Care Unit, Department of Pediatrics, Cruces University Hospital, Biocruces-Bizkaia Health Research Institute, Bizkaia, Spain
| | - Narayan Prabhu Iyer
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Melania M Bembea
- Departments of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN
| | - Ryan P Barbaro
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Florent Baudin
- Pediatric Intensive Care Unit, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Réanimation Pédiatrique, Lyon, France
| | - Anoopindar Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles. Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | | | - Ira M Cheifetz
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Mohammod J Chisti
- Dhaka Hospital, International Centre for Diarrhoeal Disease Research, Bangladesh
| | - Pablo Cruces
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
- Departamento de Pediatría, Unidad de Paciente Crítico Pediátrico, Facultad de Ciencias de la Vida, Hospital El Carmen de Maipú, Santiago, Chile
| | - Martha A Q Curley
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA
- Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mary K Dahmer
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Heidi J Dalton
- Department of Pediatrics and Heart and Vascular Institute, INOVA Fairfax Medical Center, Falls Church, VA
| | - Simon J Erickson
- Department of Paediatric Critical Care, Perth Children's Hospital Western Australia, Perth, WA, Australia
| | - Sandrine Essouri
- Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montréal, QC, Canada
| | - Analía Fernández
- Pediatric Intensive Care Unit, Emergency Department, Hospital General de Agudos "C. Durand" Ciudad Autónoma de Buenos Aires, Buenos Aires, Argentina
| | - Heidi R Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Jocelyn R Grunwell
- Division of Critical Care, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Philippe Jouvet
- Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montréal, QC, Canada
| | - Elizabeth Y Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Sapna R Kudchadkar
- Departments of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Departments of Pediatrics, Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Steven Kwasi Korang
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles. Keck School of Medicine, University of Southern California, Los Angeles, CA
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jan Hau Lee
- KK Women's and Children's Hospital, Singapore and Duke-NUS Medical School, Singapore
| | | | - Aline Maddux
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | | | - Brenda M Morrow
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Vinay M Nadkarni
- Department of Anesthesiology, Critical Care and Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Natalie Napolitano
- Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles. Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Martí Pons-Odena
- Immunological and Respiratory Disorders, Paediatric Critical Care Unit Research Group, Institut de Recerca Sant Joan de Déu, Pediatric Intensive Care and Intermediate Care Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Michael W Quasney
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | | | - Jerome Rambaud
- Departement of Pediatric and Neonatal Intensive Care, Armand-Trousseau Hospital, Sorbonne University, Paris, France
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, and Departments of Anaesthesia and Pediatrics, Harvard Medical School, Boston, MA
| | - Peter Rimensberger
- Division of Neonatology and Paediatric Intensive Care, University of Geneva, Geneva, Switzerland
| | - Courtney M Rowan
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN
| | - L Nelson Sanchez-Pinto
- Departments of Pediatrics (Critical Care) and Preventive Medicine (Health & Biomedical Informatics), Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Anil Sapru
- Division of Pediatric Critical Care, Department of Pediatrics, University of California Los Angeles, Los Angeles, CA
| | - Michael Sauthier
- Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montréal, QC, Canada
| | - Steve L Shein
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Lincoln S Smith
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, WA
| | - Katerine Steffen
- Department of Pediatrics, Division of Pediatric Critical Care, Stanford University, Palo Alto, CA
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Neal J Thomas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Public Health Sciences, Penn State University College of Medicine, Hershey, PA
| | - Sze Man Tse
- Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montréal, QC, Canada
| | - Stacey Valentine
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
| | - Shan Ward
- Department of Pediatrics, University of California San Francisco, Benioff Children's Hospitals, San Francisco and Oakland, CA
| | - R Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute Seattle, WA
| | - Nadir Yehya
- Department of Anesthesiology, Critical Care and Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jerry J Zimmerman
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, WA
- Harborview Medical Center, University of Washington School of Medicine, Seattle, WA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles. Keck School of Medicine, University of Southern California, Los Angeles, CA
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10
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Bhalla A, Baudin F, Takeuchi M, Cruces P. Monitoring in Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2023; 24:S112-S123. [PMID: 36661440 PMCID: PMC9980912 DOI: 10.1097/pcc.0000000000003163] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Monitoring is essential to assess changes in the lung condition, to identify heart-lung interactions, and to personalize and improve respiratory support and adjuvant therapies in pediatric acute respiratory distress syndrome (PARDS). The objective of this article is to report the rationale of the revised recommendations/statements on monitoring from the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2). DATA SOURCES MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). STUDY SELECTION We included studies focused on respiratory or cardiovascular monitoring of children less than 18 years old with a diagnosis of PARDS. We excluded studies focused on neonates. DATA EXTRACTION Title/abstract review, full-text review, and data extraction using a standardized data collection form. DATA SYNTHESIS The Grading of Recommendations Assessment, Development and Evaluation approach was used to identify and summarize evidence and develop recommendations. We identified 342 studies for full-text review. Seventeen good practice statements were generated related to respiratory and cardiovascular monitoring. Four research statements were generated related to respiratory mechanics and imaging monitoring, hemodynamics monitoring, and extubation readiness monitoring. CONCLUSIONS PALICC-2 monitoring good practice and research statements were developed to improve the care of patients with PARDS and were based on new knowledge generated in recent years in patients with PARDS, specifically in topics of general monitoring, respiratory system mechanics, gas exchange, weaning considerations, lung imaging, and hemodynamic monitoring.
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Affiliation(s)
- Anoopindar Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Florent Baudin
- Hospices civils de Lyon, Hôpital Femme Mère Enfant, Service de réanimation pédiatrique, Bron F-69500, France
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women’s and Children’s Hospital, Osaka, Japan
| | - Pablo Cruces
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile; and Pediatric Intensive Care Unit, Hospital el Carmen de Maipú, Santiago, Chile
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11
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Vedrenne-Cloquet M, Khirani S, Khemani R, Lesage F, Oualha M, Renolleau S, Chiumello D, Demoule A, Fauroux B. Pleural and transpulmonary pressures to tailor protective ventilation in children. Thorax 2023; 78:97-105. [PMID: 35803726 DOI: 10.1136/thorax-2021-218538] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 06/12/2022] [Indexed: 02/07/2023]
Abstract
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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Affiliation(s)
- Meryl Vedrenne-Cloquet
- Pediatric intensive care unit, Necker-Enfants Malades Hospitals, Paris, France .,Université de Paris Cité, VIFASOM, Paris, France.,Pediatric Non Invasive Ventilation Unit, Necker-Enfants Malades Hospitals, Paris, France
| | - Sonia Khirani
- Pediatric Non Invasive Ventilation Unit, Necker-Enfants Malades Hospitals, Paris, France.,ASV Santé, Genevilliers, France
| | - Robinder Khemani
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, California, USA
| | - Fabrice Lesage
- Pediatric intensive care unit, Necker-Enfants Malades Hospitals, Paris, France
| | - Mehdi Oualha
- Pediatric intensive care unit, Necker-Enfants Malades Hospitals, Paris, France
| | - Sylvain Renolleau
- Pediatric intensive care unit, Necker-Enfants Malades Hospitals, Paris, France
| | - Davide Chiumello
- Dipartimento di Anestesia, Rianimazione e Terapia del Dolore, Fondazione, IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Alexandre Demoule
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France.,UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, Sorbonne Université, INSERM, Paris, France
| | - Brigitte Fauroux
- Université de Paris Cité, VIFASOM, Paris, France.,Pediatric Non Invasive Ventilation Unit, Necker-Enfants Malades Hospitals, Paris, France
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12
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Miller AG, Scott BL. 2021 Year in Review: Pediatric Mechanical Ventilation. Respir Care 2022; 67:1476-1488. [PMID: 36100276 PMCID: PMC9993959 DOI: 10.4187/respcare.10311] [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
Mechanical ventilation is commonly used in the pediatric intensive care unit. This paper reviews studies of pediatric mechanical ventilation published in 2021. Topics include physiology, ventilator modes, alarms, disease states, airway suctioning, ventilator liberation, prolonged ventilation, and others.
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Affiliation(s)
- Andrew G Miller
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina; and Respiratory Care Services, Duke University Medical Center, Durham, North Carolina.
| | - Briana L Scott
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
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13
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Ma L, Yin M, Yang XL, Xu W. Risk factors for air leakage during invasive mechanical ventilation in pediatric intensive care units. Eur J Med Res 2022; 27:218. [DOI: 10.1186/s40001-022-00858-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 10/16/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Purpose
This study aimed to investigate air leakage during invasive mechanical ventilation (IMV) in a pediatric intensive care unit (PICU) and explore potential risk factors.
Methods
We conducted a retrospective cohort study of children who underwent IMV in a single-center PICU in a tertiary referral hospital. Air leakage risk factors and factors associated with an improved outcome were assessed.
Results
A total of 548 children who underwent IMV were enrolled in this study. Air leakage occurred in 7.5% (41/548) of the cases in the PICU. Air leakage increased the duration of IMV and hospitalization time. Multivariate logistic regression analysis showed a higher risk of air leakage during IMV for PICU patients with acute respiratory dyspnea syndrome (ARDS) (OR = 4.38), a higher pediatric critical illness score (PCIS) (OR = 1.08), or a higher peak inspiratory pressure (PIP) (OR = 1.08), whereas the risk was lower for patients with central respiratory failure (OR = 0.14). The logistic model had excellent predictive power for air leakage, with an area under the curve of 0.883 and tenfold cross-validation. Patients aged between 1 and 6 years who were diagnosed with measles or pneumonia and had a low positive end-expiratory pressure (PEEP) or high PaO2/FiO2 ratio were associated with improved outcomes. Patients diagnosed with central respiratory failure or congenital heart diseases were associated with less desirable outcomes.
Conclusions
Patients with ARDS, a higher PCIS at admission or a higher PIP were at higher risk of air leakage.
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14
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McCrory MC, Woodruff AG, Saha AK, Evans JK, Halvorson EE, Bass AL. Nonadherence to appropriate tidal volume and PEEP in children with pARDS at a single center. Pediatr Pulmonol 2022; 57:2464-2473. [PMID: 35778788 PMCID: PMC9489656 DOI: 10.1002/ppul.26060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/22/2022] [Accepted: 06/26/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Low tidal volume and adequate positive end-expiratory pressure (PEEP) are evidence-based approaches for pediatric acute respiratory distress syndrome (pARDS), however, data are limited regarding their use since pARDS guidelines were revised in 2015. OBJECTIVE To identify prevalence of, and factors associated with, nonadherence to appropriate tidal volume and PEEP in children with pARDS. METHODS Retrospective cohort study of children 1 month to <18 years with pARDS who received invasive mechanical ventilation from 2016 to 2018 in a single pediatric intensive care unit (PICU). RESULTS At 24 h after meeting pARDS criteria, 48/86 (56%) patients received tidal volume ≤8 ml/kg of ideal body weight and 45/86 (52%) received appropriate PEEP, with 22/86 (26%) receiving both. Among patients ≥2 years of age, a lower proportion of patients with overweight/obesity (9/25, 36%) had appropriate tidal volume versus those in the normal or underweight category (16/22, 73%, p = 0.02). When FIO2 was ≥50%, PEEP was appropriate in 19/60 (32%) cases versus 26/26 (100%) with FIO2 < 50% (p < 0.0001). pARDS was documented in the progress note in 7/86 (8%) patients at 24 h. Severity of pARDS, documentation in the progress note, and other clinical factors were not significantly associated with use of appropriate tidal volume and PEEP, however pARDS was documented more commonly in patients with severe pARDS. CONCLUSIONS In a single PICU in the United States, children with pARDS did not receive appropriate tidal volume for ideal body weight nor PEEP. Targets for improving tidal volume and PEEP adherence may include overweight patients and those receiving FIO2 ≥ 50%, respectively.
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Affiliation(s)
- Michael C. McCrory
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC
| | - Alan G. Woodruff
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC
- Center for Redox in Biology and Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Amit K. Saha
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Joni K. Evans
- Department of Biostatistics; Wake Forest School of Medicine, Winston-Salem, NC
| | | | - Andora L Bass
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC
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15
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Abstract
OBJECTIVES To describe pulmonary resistance in children undergoing invasive mechanical ventilation (MV) for different causes. DESIGN A cross-sectional study. SETTING Two PICUs in the South region of Brazil. PATIENTS Children 1 month to 15 years old undergoing MV for more than 24 hours were included. We recorded ventilator variables and measured pulmonary mechanics (inspiratory and expiratory resistance, auto positive end-expiratory pressure [PEEP], and dynamic and static compliance) in the first 48 hours of MV. INTERVENTIONS Measurements of the respiratory mechanics variables during neuromuscular blockade. MEASUREMENTS AND MAIN RESULTS A total of 113 children were included, 5 months (median [interquartile range (IQR) [2.0-21.5 mo]) old, and median (IQR) weight 6.5 kg (4.5-11.0 kg), with 60% male. Median (IQR) peak inspiratory pressure (PIP) was 30 cm H 2 O (26-35 cm H 2 O), and median (IQR) PEEP was 5 cm H 2 O (5-7 cm H 2 O). The median (IQR) duration of MV was 7 days (5-9 d), and mortality was nine of 113 (8%). The median (IQR) inspiratory and expiratory resistances were 94.0 cm H 2 O/L/s (52.5-155.5 cm H 2 O/L/s) and 117 cm H 2 O/L/s (71-162 cm H 2 O/L/s), with negative association with weight and age (Spearman -0.850). When we assess weight, in smaller children (< 10 kg) had increased pulmonary resistance, with mean values over 100 mH 2 O/L/s, which were higher than larger children ( p < 0.001). CONCLUSIONS Increased pulmonary resistance is prevalent in the pediatric population undergoing invasive MV. Especially in children less than 1 year old, this variable should be considered when defining a ventilatory strategy.
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16
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Kopstick AJ, Rufener CR, Banerji AO, Hudkins MR, Kirby AL, Markwardt S, Orwoll BE. Recognizing Pediatric ARDS: Provider Use of the PALICC Recommendations in a Tertiary Pediatric ICU. Respir Care 2022; 67:985-994. [PMID: 35728822 PMCID: PMC9994144 DOI: 10.4187/respcare.09806] [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 For almost 50 years, pediatricians used adult guidelines to diagnose ARDS. In 2015, specific criteria for pediatric ARDS were defined. However, it remains unclear how frequently providers recognize pediatric ARDS and whether recognition affects adherence to consensus recommendations. METHODS This was a mixed-method, retrospective study of mechanically ventilated pediatric subjects after the release of the pediatric ARDS recommendation statement. Pediatric ARDS cases were identified according to the new criteria. Provider recognition was defined by documentation in the medical record. Pediatric ARDS subjects with and without provider recognition were compared quantitatively according to clinical characteristics, adherence to lung-protective ventilation (LPV), adjunctive therapies, and outcomes. A qualitative document analysis (QDA) was performed to evaluate knowledge and beliefs surrounding the Pediatric Acute Lung Injury Consensus Conference recommendations. RESULTS Of 1,983 subject encounters, pediatric ARDS was identified in 321 (16%). Provider recognition was present in 97 (30%) cases and occurred more often in subjects who were older, had worse oxygenation deficits, or were bone marrow transplant recipients. Recognition rates increased each studied year. LPV practices did not differ based on provider recognition; however, subjects who received it were more likely to experience permissive hypoxemia and adherence to extrapulmonary recommendations. Ultimately, there was no differences in outcomes between the provider recognition and non-provider recognition groups. Three themes emerged from the QDA: (1) pediatric ARDS presents within a complex, multidimensional context, with potentially competing organ system failures; (2) similar to historical conceptualizations, pediatric ARDS was often considered a visual diagnosis, with measures of oxygenation unreferenced; and (3) emphasis was placed on non-evidence-based interventions, such as pulmonary clearance techniques, rather than on consensus recommendations. CONCLUSIONS Among mechanically ventilated children, pediatric ARDS was common but recognized in a minority of cases. Potential opportunities, such as an opt-out approach to LPV, may exist for improved dissemination and implementation of recommended best practices.
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Affiliation(s)
- Avi J Kopstick
- Division of Pediatric Critical Care Medicine, Texas Tech University Health Science Center, El Paso, Texas.
| | - Christina R Rufener
- Division of Pediatric Critical Care Medicine, University of California, San Diego, California
| | - Adrian O Banerji
- Division of General Pediatrics, Oregon Health & Science University, Portland, Oregon
| | - Matthew R Hudkins
- Division of Pediatric Critical Care Medicine, Oregon Health & Science University, Portland, Oregon
| | - Aileen L Kirby
- Division of Pediatric Critical Care Medicine, Oregon Health & Science University, Portland, Oregon
| | - Sheila Markwardt
- Biostatistics and Design Program, Oregon Health & Science University, Portland, Oregon
| | - Benjamin E Orwoll
- Division of Pediatric Critical Care Medicine, and Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
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17
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Ito Y, Takeuchi M, Inata Y, Kyogoku M, Hotz JC, Bhalla AK, Newth CJL, Khemani RG. Normalization to Predicted Body Weight May Underestimate Mechanical Energy in Pediatric Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2022; 205:1360-1363. [PMID: 35315733 PMCID: PMC9873119 DOI: 10.1164/rccm.202111-2641le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
- Yukie Ito
- Osaka Women’s and Children’s HospitalOsaka, Japan
| | - Muneyuki Takeuchi
- Osaka Women’s and Children’s HospitalOsaka, Japan,Corresponding author (e-mail: )
| | - Yu Inata
- Osaka Women’s and Children’s HospitalOsaka, Japan
| | | | | | - Anoopindar K. Bhalla
- Children’s Hospital Los AngelesLos Angeles, California,University of Southern CaliforniaLos Angeles, California
| | - Christopher J. L. Newth
- Children’s Hospital Los AngelesLos Angeles, California,University of Southern CaliforniaLos Angeles, California
| | - Robinder G. Khemani
- Children’s Hospital Los AngelesLos Angeles, California,University of Southern CaliforniaLos Angeles, California
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18
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Patel B, Thomas NJ, Yehya N. Agreement Between Peak Inspiratory Pressure in Decelerating-Flow Ventilation and Plateau Pressure in Square-Flow Ventilation in Pediatric Acute Respiratory Distress Syndrome. Pediatr Crit Care Med 2022; 23:201-204. [PMID: 34991137 PMCID: PMC8897219 DOI: 10.1097/pcc.0000000000002884] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Acute respiratory distress syndrome guidelines suggest limiting plateau pressures to 28-30 cm H2O. Plateau pressure is most accurately measured in square-flow modes, such as volume control. In children, decelerating-flow modes, such as pressure-regulated volume control and pressure control, are more common. Consequently, plateau pressures are rarely obtained, and pressure limits are instead provided for peak inspiratory pressure. The degree to which peak inspiratory pressure in decelerating-flow overestimates plateau pressure is unknown. Therefore, we assessed the correlation and accuracy of peak inspiratory pressure in decelerating-flow ventilation for approximating plateau pressure during square-flow ventilation. DESIGN Prospective, observational study. SETTING Tertiary, academic PICU. PATIENTS Fifty-two intubated children with acute respiratory distress syndrome enrolled between January 2020 and May 2021. INTERVENTIONS Measurement of peak inspiratory pressure in decelerating-flow ventilation and plateau pressure after transition to square-flow ventilation. MEASUREMENTS AND MAIN RESULTS Peak inspiratory pressure in decelerating-flow was highly correlated (r2 = 0.99; p < 0.001) with plateau pressure in square-flow. Peak inspiratory pressure was 1.0 ± 0.6 cm H2O higher than plateau pressure, with 96% of values within 2 cm H2O. The single outlier had coexistent asthma and inspiratory flows that did not reach zero. CONCLUSIONS Peak inspiratory pressure measured during decelerating-flow ventilation may be an adequate surrogate of plateau pressure in pediatric acute respiratory distress syndrome when inspiratory flow approaches zero. Practitioners should be aware that peak inspiratory pressures in decelerating-flow may not be substantially higher than plateau pressures.
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Affiliation(s)
- Bhavesh Patel
- Department of Medicine, Hospital of the University of Pennsylvania and University of Pennsylvania, Philadelphia, PA
- Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
| | - Neal J. Thomas
- Department of Pediatrics and Public Health Science, Division of Pediatric Critical Care Medicine, Penn State Hershey Children’s Hospital, Hershey, PA
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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19
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Bhalla AK, Klein MJ, Modesto I Alapont V, Emeriaud G, Kneyber MCJ, Medina A, Cruces P, Diaz F, Takeuchi M, Maddux AB, Mourani PM, Camilo C, White BR, Yehya N, Pappachan J, Di Nardo M, Shein S, Newth C, Khemani R. Mechanical power in pediatric acute respiratory distress syndrome: a PARDIE study. Crit Care 2022; 26:2. [PMID: 34980228 PMCID: PMC8722295 DOI: 10.1186/s13054-021-03853-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/01/2021] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Mechanical power is a composite variable for energy transmitted to the respiratory system over time that may better capture risk for ventilator-induced lung injury than individual ventilator management components. We sought to evaluate if mechanical ventilation management with a high mechanical power is associated with fewer ventilator-free days (VFD) in children with pediatric acute respiratory distress syndrome (PARDS). METHODS Retrospective analysis of a prospective observational international cohort study. RESULTS There were 306 children from 55 pediatric intensive care units included. High mechanical power was associated with younger age, higher oxygenation index, a comorbid condition of bronchopulmonary dysplasia, higher tidal volume, higher delta pressure (peak inspiratory pressure-positive end-expiratory pressure), and higher respiratory rate. Higher mechanical power was associated with fewer 28-day VFD after controlling for confounding variables (per 0.1 J·min-1·Kg-1 Subdistribution Hazard Ratio (SHR) 0.93 (0.87, 0.98), p = 0.013). Higher mechanical power was not associated with higher intensive care unit mortality in multivariable analysis in the entire cohort (per 0.1 J·min-1·Kg-1 OR 1.12 [0.94, 1.32], p = 0.20). But was associated with higher mortality when excluding children who died due to neurologic reasons (per 0.1 J·min-1·Kg-1 OR 1.22 [1.01, 1.46], p = 0.036). In subgroup analyses by age, the association between higher mechanical power and fewer 28-day VFD remained only in children < 2-years-old (per 0.1 J·min-1·Kg-1 SHR 0.89 (0.82, 0.96), p = 0.005). Younger children were managed with lower tidal volume, higher delta pressure, higher respiratory rate, lower positive end-expiratory pressure, and higher PCO2 than older children. No individual ventilator management component mediated the effect of mechanical power on 28-day VFD. CONCLUSIONS Higher mechanical power is associated with fewer 28-day VFDs in children with PARDS. This association is strongest in children < 2-years-old in whom there are notable differences in mechanical ventilation management. While further validation is needed, these data highlight that ventilator management is associated with outcome in children with PARDS, and there may be subgroups of children with higher potential benefit from strategies to improve lung-protective ventilation. TAKE HOME MESSAGE Higher mechanical power is associated with fewer 28-day ventilator-free days in children with pediatric acute respiratory distress syndrome. This association is strongest in children <2-years-old in whom there are notable differences in mechanical ventilation management.
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Affiliation(s)
- Anoopindar K. Bhalla
- grid.239546.f0000 0001 2153 6013Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, CA USA ,grid.42505.360000 0001 2156 6853Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA USA
| | - Margaret J. Klein
- grid.239546.f0000 0001 2153 6013Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, CA USA
| | - Vicent Modesto I Alapont
- grid.84393.350000 0001 0360 9602University and Polytechnic Hospital La Fe Valencia, Valencia, Spain
| | - Guillaume Emeriaud
- grid.14848.310000 0001 2292 3357Pediatric Intensive Care Unit, CHU Sainte-Justine, Department of Pediatrics, Université de Montréal, Montreal, Canada
| | - Martin C. J. Kneyber
- grid.4830.f0000 0004 0407 1981Division of Paediatric Critical Care Medicine, Department of Paediatrics, University Medical Center Groningen, Beatrix Children’s Hospital, University of Groningen, Groningen, The Netherlands ,grid.4830.f0000 0004 0407 1981Critical Care, Anaesthesiology, Peri-Operative & Emergency Medicine (CAPE), University of Groningen, Groningen, The Netherlands
| | - Alberto Medina
- grid.411052.30000 0001 2176 9028Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Pablo Cruces
- grid.412848.30000 0001 2156 804XCentro de Investigación de Medicina Veterinaria, Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile ,Departamento de Pediatría, Unidad de Paciente Crítico Pediátrico, Hospital El Carmen de Maipú, Santiago, Chile
| | - Franco Diaz
- grid.412187.90000 0000 9631 4901Instituto de Ciencias e Innovación ed Medicina (ICIM), Universidad del Desarrollo, Santiago, Chile ,Hospital Clínico La Florida, Santiago, Chile
| | - Muneyuki Takeuchi
- grid.416629.e0000 0004 0377 2137Department of Intensive Care Medicine, Osaka Women’s and Children’s Hospital, Osaka, Japan
| | - Aline B. Maddux
- grid.430503.10000 0001 0703 675XPediatric Critical Care, University of Colorado School of Medicine, Aurora, CO USA ,grid.413957.d0000 0001 0690 7621Children’s Hospital Colorado, Aurora, CO USA
| | - Peter M. Mourani
- grid.241054.60000 0004 4687 1637Arkansas Children’s Hospital, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Cristina Camilo
- grid.411265.50000 0001 2295 9747PICU, Hospital de Santa Maria – CHULN, Lisbon, Portugal
| | - Benjamin R. White
- grid.29857.310000 0001 2097 4281Penn State Health Children’s Hospital, Hershey, PA USA
| | - Nadir Yehya
- grid.239552.a0000 0001 0680 8770Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - John Pappachan
- grid.430506.4Paediatric Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK ,grid.5491.90000 0004 1936 9297Faculty of Medicine, University of Southampton, Southampton, UK
| | - Matteo Di Nardo
- grid.414125.70000 0001 0727 6809Pediatric Intensive Care Unit, Children’s Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Steven Shein
- grid.415629.d0000 0004 0418 9947Division of Pediatric Critical Care Medicine, Rainbow Babies and Children’s Hospital, Cleveland, OH USA
| | - Christopher Newth
- grid.239546.f0000 0001 2153 6013Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, CA USA ,grid.42505.360000 0001 2156 6853Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA USA
| | - Robinder Khemani
- grid.239546.f0000 0001 2153 6013Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, CA USA ,grid.42505.360000 0001 2156 6853Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA USA
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20
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Khemani RG. Should We Embrace Mechanical Power to Understand the Risk of Ventilator-Induced Lung Injury in Children? Pediatr Crit Care Med 2022; 23:71-74. [PMID: 34989714 PMCID: PMC8851678 DOI: 10.1097/pcc.0000000000002844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Robinder G Khemani
- Department of Pediatrics, University of Southern California, Keck School of Medicine, Los Angeles, CA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
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21
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DeSanti RL, Al-Subu AM. Adaptive support ventilation in pediatric respiratory failure: Should intensivists be reliant on assistive technology? Pediatr Pulmonol 2021; 56:3087-3088. [PMID: 34314571 DOI: 10.1002/ppul.25568] [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: 06/22/2021] [Accepted: 07/07/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Ryan L DeSanti
- Department of Pediatrics, Drexel University College of Medicine, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania, USA
| | - Awni M Al-Subu
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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22
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Adherence to Lung-Protective Ventilation in Pediatric Acute Respiratory Distress Syndrome: Principles Versus Explicit Targets. Crit Care Med 2021; 49:1836-1839. [PMID: 34529616 DOI: 10.1097/ccm.0000000000005108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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