1
|
Patel BM, Reilly JP, Bhalla AK, Smith LS, Khemani RG, Jones TK, Meyer NJ, Harhay MO, Yehya N. Association between Age and Mortality in Pediatric and Adult Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2024; 209:871-878. [PMID: 38306669 PMCID: PMC10995578 DOI: 10.1164/rccm.202310-1926oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/02/2024] [Indexed: 02/04/2024] Open
Abstract
Rationale: The epidemiology, management, and outcomes of acute respiratory distress syndrome (ARDS) differ between children and adults, with lower mortality rates in children despite comparable severity of hypoxemia. However, the relationship between age and mortality is unclear.Objective: We aimed to define the association between age and mortality in ARDS, hypothesizing that it would be nonlinear.Methods: We performed a retrospective cohort study using data from two pediatric ARDS observational cohorts (n = 1,236), multiple adult ARDS trials (n = 5,547), and an adult observational ARDS cohort (n = 1,079). We aligned all datasets to meet Berlin criteria. We performed unadjusted and adjusted logistic regression using fractional polynomials to assess the potentially nonlinear relationship between age and 90-day mortality, adjusting for sex, PaO2/FiO2, immunosuppressed status, year of study, and observational versus randomized controlled trial, treating each individual study as a fixed effect.Measurements and Main Results: There were 7,862 subjects with median ages of 4 years in the pediatric cohorts, 52 years in the adult trials, and 61 years in the adult observational cohort. Most subjects (43%) had moderate ARDS by Berlin criteria. Ninety-day mortality was 19% in the pediatric cohorts, 33% in the adult trials, and 67% in the adult observational cohort. We found a nonlinear relationship between age and mortality, with mortality risk increasing at an accelerating rate between 11 and 65 years of age, after which mortality risk increased more slowly.Conclusions: There was a nonlinear relationship between age and mortality in pediatric and adult ARDS.
Collapse
Affiliation(s)
- Bhavesh M Patel
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - John P Reilly
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
- Center for Translational Lung Biology, and
| | - Anoopindar K Bhalla
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California; and
| | - Lincoln S Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Robinder G Khemani
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California; and
| | - Tiffanie K Jones
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
- Center for Translational Lung Biology, and
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nuala J Meyer
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
- Center for Translational Lung Biology, and
| | - Michael O Harhay
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nadir Yehya
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| |
Collapse
|
2
|
Shaikh FAR, Ramaswamy KN, Chirla DK, Venkataraman ST, Kneyber MCJ. Mechanical power and normalized mechanical power in pediatric acute respiratory distress syndrome. Front Pediatr 2024; 12:1293639. [PMID: 38298612 PMCID: PMC10829106 DOI: 10.3389/fped.2024.1293639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/03/2024] [Indexed: 02/02/2024] Open
Abstract
Background Mechanical power (MP) refers to the energy transmitted over time to the respiratory system and serves as a unifying determinant of ventilator-induced lung injury. MP normalization is required to account for developmental changes in children. We sought to examine the relationship between mechanical energy (MEBW), MP normalized to body weight (MPBW), and MP normalized to respiratory compliance (MPCRS) concerning the severity and outcomes of pediatric acute respiratory distress syndrome (pARDS). Method In this retrospective study, children aged 1 month to 18 years diagnosed with pARDS who underwent pressure-control ventilation for at least 24 h between January 2017 and September 2020 were enrolled. We calculated MP using Becher's equation. Multivariable logistic regression analysis adjusted for age, pediatric organ dysfunction score, and oxygenation index (OI) was performed to determine the independent association of MP and its derivatives 24 h after diagnosing pARDS with 28-day mortality. The association was also studied for 28 ventilator-free days (VFD-28) and the severity of pARDS in terms of OI. Results Out of 246 admitted with pARDS, 185 were eligible, with an overall mortality of 43.7%. Non-survivors exhibited higher severity of illness, as evidenced by higher values of MP, MPBW, and MEBW. Multivariable logistic regression analysis showed that only MEBW but not MP, MPBW, or MPCRS at 24 h was independently associated with mortality [adjusted OR: 1.072 (1.002-1.147), p = 0.044]. However, after adjusting for the type of pARDS, MEBW was not independently associated with mortality [adjusted OR: 1.061 (0.992-1.136), p = 0.085]. After adjusting for malnutrition, only MP at 24 h was found to be independently associated. Only MPCRS at 1-4 and 24 h but not MP, MPBW, or MEBW at 24 h of diagnosing pARDS was significantly correlated with VFD-28. Conclusions Normalization of MP is better related to outcomes and severity of pARDS than non-normalized MP. Malnutrition can be a significant confounding factor in resource-limited settings.
Collapse
Affiliation(s)
- Farhan A. R. Shaikh
- Department of Pediatric Intensive Care, Rainbow Children’s Hospital, Hyderabad, India
| | - Karthik N. Ramaswamy
- Department of Pediatric Intensive Care, Rainbow Children’s Hospital, Chennai, India
| | - Dinesh K. Chirla
- Department of Pediatric Intensive Care, Rainbow Children’s Hospital, Hyderabad, India
| | - Shekhar T. Venkataraman
- Departments of Critical Care Medicine and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Martin C. J. Kneyber
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Critical Care, Anaesthesiology, Peri-Operative & Emergency Medicine (CAPE), University of Groningen, Groningen, Netherlands
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Medeiros KJ, Morais CA, Winterton D, Rub DM, De Santis Santiago R, Shekhar N, Chipman D, Monaghan TT, Bittner EA, Carroll R, Berra L. Delivering Low Tidal Volume With Anesthesia and ICU Ventilators in a Neonatal Lung Model. Respir Care 2023; 68:384-391. [PMID: 36750259 PMCID: PMC10027158 DOI: 10.4187/respcare.10354] [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: 02/09/2023]
Abstract
BACKGROUND Mechanical ventilation of the neonate requires ventilators than can deliver precise and accurate tidal volume (VT) and PEEP to avoid lung injury. Due to small neonatal VT and the disproportionate effect of endotracheal tube leak in these patients, accomplishing precise and accurate VT delivery is difficult. Whereas neonatal ICU ventilators are validated in this population, thorough studies testing the performance of anesthesia ventilators in delivering small VT in neonates are lacking. METHODS Three anesthesia ventilators, Dräger Apollo, GE Avance, and Getinge Flow-i; and 2 ICU ventilators, Medtronic PB980 and Nihon Kohden NKV-550, were tested under volume control mode at VT of 5, 20, 40, and 60 mL. Three combinations of lung compliance and airway resistance were tested using a Servo ASL 5000 lung simulator. RESULTS In a scenario without leak, the measured VT was greater than the set VT by > 10% in the Apollo (21.0% [18.8-26.0]); measured VT was less than the set VT by > 10% in the Flow-i (-19% [-20.8 to -18.7]). The Avance, PB980, and NKV-550 presented a volume error < 10% (-9.50% [-10.8 to -4.4], -5.8% [-11.8 to -3.5], and 5.4% [-4.5 to 18.9], respectively). Considering all combinations of set VT, leaks, and respiratory mechanics, none of the anesthesia ventilators were able to deliver a median measured VT within a 10% error. The bias between measured VT and set VT varied widely among ventilators (from 4.27 mL to -10.59 mL). Additionally, in the Apollo ventilator, PEEP was underdelivered with the largest leak value. CONCLUSIONS Our results suggest that in comparison with the 2 neonatal ICU ventilators tested, the anesthesia ventilators did not greatly differ in terms of VT delivery in the presence of a gas leak.
Collapse
Affiliation(s)
- Kyle J Medeiros
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Caio A Morais
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; and Departamento de Fisioterapia, Universidade Federal de Pernambuco, Recife, Brazil
| | - Dario Winterton
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - David M Rub
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Roberta De Santis Santiago
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Nitika Shekhar
- Respiratory Care Department, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Daniel Chipman
- Respiratory Care Department, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Thomas T Monaghan
- Department of Biomedical Engineering, Massachusetts General Hospital, Boston, Massachusetts
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ryan Carroll
- Division of Pediatric Critical Care, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, Massachusetts
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; and Respiratory Care Department, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
5
|
Pathobiology, Severity, and Risk Stratification of Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2023; 24:S12-S27. [PMID: 36661433 DOI: 10.1097/pcc.0000000000003156] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To review the literature for studies published in children on the pathobiology, severity, and risk stratification of pediatric acute respiratory distress syndrome (PARDS) with the intent of guiding current medical practice and identifying important areas for future research related to severity and risk stratification. DATA SOURCES Electronic searches of PubMed and Embase were conducted from 2013 to March 2022 by using a combination of medical subject heading terms and text words to capture the pathobiology, severity, and comorbidities of PARDS. STUDY SELECTION We included studies of critically ill patients with PARDS that related to the severity and risk stratification of PARDS using characteristics other than the oxygenation defect. Studies using animal models, adult only, and studies with 10 or fewer children were excluded from our review. 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 for clinical practice. There were 192 studies identified for full-text extraction to address the relevant Patient/Intervention/Comparator/Outcome questions. One clinical recommendation was generated related to the use of dead space fraction for risk stratification. In addition, six research statements were generated about the impact of age on acute respiratory distress syndrome pathobiology and outcomes, addressing PARDS heterogeneity using biomarkers to identify subphenotypes and endotypes, and use of standardized ventilator, physiologic, and nonpulmonary organ failure measurements for future research. CONCLUSIONS Based on an extensive literature review, we propose clinical management and research recommendations related to characterization and risk stratification of PARDS severity.
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
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.
Collapse
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.
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
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.
Collapse
|
11
|
van Schelven P, Koopman AA, Burgerhof JG, Markhorst DG, Blokpoel RG, Kneyber MC. Driving Pressure Is Associated With Outcome in Pediatric Acute Respiratory Failure. Pediatr Crit Care Med 2022; 23:e136-e144. [PMID: 34669679 PMCID: PMC8897270 DOI: 10.1097/pcc.0000000000002848] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [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 Driving pressure (ratio of tidal volume over respiratory system compliance) is associated with mortality in acute respiratory distress syndrome. We sought to evaluate if such association could be identified in critically ill children. DESIGN We studied the association between driving pressure on day 1 of mechanical ventilation and ventilator-free days at day 28 through secondary analyses of prospectively collected physiology data. SETTING Medical-surgical university hospital PICU. PATIENTS Children younger than 18 years (stratified by Pediatric Mechanical Ventilation Consensus Conference clinical phenotype definitions) without evidence of spontaneous respiration. INTERVENTIONS Inspiratory hold maneuvers. MEASUREMENTS AND MAIN RESULTS Data of 222 patients with median age 11 months (2-51 mo) were analyzed. Sixty-five patients (29.3%) met Pediatric Mechanical Ventilation Consensus Conference criteria for restrictive and 78 patients (35.1%) for mixed lung disease, and 10.4% of all patients had acute respiratory distress syndrome. Driving pressure calculated by the ratio of tidal volume over respiratory system compliance for the whole cohort was 16 cm H2O (12-21 cm H2O) and correlated with the static airway pressure gradient (plateau pressure minus positive end-expiratory pressure) (Spearman correlation coefficient = 0.797; p < 0.001). Bland-Altman analysis showed that the dynamic pressure gradient (peak inspiratory pressure minus positive end-expiratory pressure) overestimated driving pressure (levels of agreement -2.295 to 7.268). Rematching the cohort through a double stratification procedure (obtaining subgroups of patients with matched mean levels for one variable but different mean levels for another ranking variable) showed a reduction in ventilator-free days at day 28 with increasing driving pressure in patients ventilated for a direct pulmonary indication. Competing risk regression analysis showed that increasing driving pressure remained independently associated with increased time to extubation (p < 0.001) after adjusting for Pediatric Risk of Mortality III 24-hour score, presence of direct pulmonary indication jury, and oxygenation index. CONCLUSIONS Higher driving pressure was independently associated with increased time to extubation in mechanically ventilated children. Dynamic assessments of driving pressure should be cautiously interpreted.
Collapse
Affiliation(s)
- Patrick van Schelven
- Department of Pediatrics, division of Pediatric Critical Care Medicine, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Alette A. Koopman
- Department of Pediatrics, division of Pediatric Critical Care Medicine, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Johannes G.M. Burgerhof
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Dick G. Markhorst
- Department of Pediatrics, division of Paediatric Critical Care Medicine, Amsterdam UMC, Amsterdam, the Netherlands
| | - Robert G.T. Blokpoel
- Department of Pediatrics, division of Pediatric Critical Care Medicine, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Martin C.J. Kneyber
- Department of Pediatrics, division of Pediatric Critical Care Medicine, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Critical care, Anaesthesiology, Peri-operative & Emergency medicine (CAPE), University of Groningen, Groningen, the Netherlands
| |
Collapse
|
12
|
Ceylan G, Topal S, Atakul G, Colak M, Soydan E, Sandal O, Sari F, Ağın H. Randomized crossover trial to compare driving pressures in a closed-loop and a conventional mechanical ventilation mode in pediatric patients. Pediatr Pulmonol 2021; 56:3035-3043. [PMID: 34293255 DOI: 10.1002/ppul.25561] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 06/17/2021] [Accepted: 06/22/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION In mechanically ventilated patients, driving pressure (ΔP) represents the dynamic stress applied to the respiratory system and is related to ICU mortality. An evolution of the Adaptive Support Ventilation algorithm (ASV® 1.1) minimizes inspiratory pressure in addition to minimizing the work of breathing. We hypothesized that ASV 1.1 would result in lower ΔP than the ΔP measured in APV-CMV (controlled mandatory ventilation with adaptive pressure ventilation) mode with physician-tailored settings. The aim of this randomized crossover trial was therefore to compare ΔP in ASV 1.1 with ΔP in physician-tailored APV-CMV mode. METHODS Pediatric patients admitted to the PICU with heterogeneous-lung disease were enrolled if they were ventilated invasively with no detectable respiratory effort, hemodynamic instability, or significant airway leak around the endotracheal tube. We compared two 60-min periods of ventilation in APV-CMV and ASV 1.1, which were determined by randomization and separated by 30-min washout periods. Settings were adjusted to reach the same minute ventilation in both modes. ΔP was calculated as the difference between plateau pressure and total PEEP measured using end-inspiratory and end-expiratory occlusions, respectively. RESULTS There were 26 patients enrolled with a median age of 16 (9-25 [IQR]) months. The median ΔP for these patients was 10.4 (8.5-12.1 [IQR]) and 12.4 (10.5-15.3 [IQR]) cmH2O in the ASV 1.1 and APV-CMV periods, respectively (p < .001). The median tidal volume (VT) selected by the ASV 1.1 algorithm was 6.4 (5.1-7.3 [IQR]) ml/kg and RR was 41 (33 50 [IQR]) b/min, whereas the median of the same values for the APV-CMV period was 7.9 (6.8-8.3 [IQR]) ml/kg and 31 (26-41[IQR]) b/min, respectively. In both ASV 1.1 and APV-CMV modes, the highest ΔP was used to ventilate those patients with restrictive lung conditions at baseline. CONCLUSION In this randomized crossover trial, ΔP in ASV 1.1 was lower compared to ΔP in physician-tailored APV-CMV mode in pediatric patients with different lung conditions. The use of ASV 1.1 may therefore result in continued, safe ventilation in a heterogeneous pediatric patient group.
Collapse
Affiliation(s)
- Gokhan Ceylan
- Department of Pediatric Intensive Care Unit, Dr Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey.,Department of Medical Research, HamiltonMedical AG, Bonaduz, Switzerland
| | - Sevgi Topal
- Department of Pediatric Intensive Care Unit, Dr Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Gulhan Atakul
- Department of Pediatric Intensive Care Unit, Dr Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Mustafa Colak
- Department of Pediatric Intensive Care Unit, Dr Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Ekin Soydan
- Department of Pediatric Intensive Care Unit, Dr Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Ozlem Sandal
- Department of Pediatric Intensive Care Unit, Dr Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Ferhat Sari
- Department of Pediatric Intensive Care Unit, Dr Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Hasan Ağın
- Department of Pediatric Intensive Care Unit, Dr Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
| |
Collapse
|
13
|
Hon KL, Leung KKY, Oberender F, Leung AK. Paediatrics: how to manage acute respiratory distress syndrome. Drugs Context 2021; 10:dic-2021-1-9. [PMID: 34122589 PMCID: PMC8177958 DOI: 10.7573/dic.2021-1-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/17/2021] [Indexed: 12/13/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) is a significant cause of mortality and morbidity amongst critically ill children. The purpose of this narrative review is to provide an up-to-date review on the evaluation and management of paediatric ARDS (PARDS). Methods A PubMed search was performed with Clinical Queries using the key term "acute respiratory distress syndrome". The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies and reviews. Google, Wikipedia and UpToDate were also searched to enrich the review. The search was restricted to the English literature and children. Discussion Non-invasive positive pressure ventilation, lung-protective ventilation strategies, conservative fluid management and adequate nutritional support all have proven efficacy in the management of PARDS. The Pediatric Acute Lung Injury Consensus Conference recommends the use of corticosteroids, high-frequency oscillation ventilation and inhaled nitric oxide in selected scenarios. Partial liquid ventilation and surfactant are not considered efficacious based on evidence from clinical trials. Conclusion PARDS is a serious but relatively rare cause of admission into the paediatric intensive care unit and is associated with high mortality. Non-invasive positive pressure ventilation, lung-protective ventilation strategies, conservative fluid management and adequate nutrition are advocated. As there has been a lack of progress in the management of PARDS in recent years, further well-designed, large-scale, randomized controlled trials in this field are urgently needed.
Collapse
Affiliation(s)
- Kam Lun Hon
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Karen Ka Yan Leung
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Felix Oberender
- Paediatric Intensive Care Unit, Monash Children's Hospital, Melbourne, Australia.,Monash University, School of Clinical Sciences, Department of Paediatrics, Melbourne, Australia
| | - Alexander Kc Leung
- Department of Pediatrics, The University of Calgary and The Alberta Children's Hospital, Calgary, Alberta, Canada
| |
Collapse
|
14
|
Abstract
Purpose of Review Knowledge of ventilator waveforms is important for clinicians working with children requiring mechanical ventilation. This review covers the basics of how to interpret and use data from ventilator waveforms in the pediatric intensive care unit. Recent Findings Patient-ventilator asynchrony (PVA) is a common finding in pediatric patients and observed in approximately one-third of ventilator breaths. PVA is associated with worse outcomes including increased length of mechanical ventilation, increased length of stay, and increased mortality. Identification of PVA is possible with a thorough knowledge of ventilator waveforms. Summary Ventilator waveforms are graphical descriptions of how a breath is delivered to a patient. These include three scalars (flow versus time, volume versus time, and pressure versus time) and two loops (pressure-volume and flow-volume). Thorough understanding of both scalars and loops, and their characteristic appearances, is essential to being able to evaluate a patient’s respiratory mechanics and interaction with the ventilator.
Collapse
Affiliation(s)
- Elizabeth Emrath
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Medical University of South Carolina, 125 Doughty Street, MSC 917, Charleston, SC 29425 USA
| |
Collapse
|
15
|
Carlotti APDCP, de Carvalho WB, Johnston C, Gilio AE, de Sousa Marques HH, Ferranti JF, Rodriguez IS, Delgado AF. Update on the diagnosis and management of COVID-19 in pediatric patients. Clinics (Sao Paulo) 2020; 75:e2353. [PMID: 33263635 PMCID: PMC7688073 DOI: 10.6061/clinics/2020/e2353] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/15/2020] [Indexed: 12/15/2022] Open
Abstract
Coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), became a pandemic in March 2020, affecting millions of people worldwide. However, COVID-19 in pediatric patients represents 1-5% of all cases, and the risk for developing severe disease and critical illness is much lower in children with COVID-19 than in adults. Multisystem inflammatory syndrome in children (MIS-C), a possible complication of COVID-19, has been described as a hyperinflammatory condition with multiorgan involvement similar to that in Kawasaki disease or toxic shock syndrome in children with evidence of SARS-CoV-2 infection. This review presents an update on the diagnostic methods for COVID-19, including reverse-transcriptase polymerase chain reaction (RT-PCR) tests, serology tests, and imaging, and summarizes the current recommendations for the management of the disease. Particular emphasis is placed on respiratory support, which includes noninvasive ventilation and invasive mechanical ventilation strategies according to lung compliance and pattern of lung injury. Pharmacological treatment, including pathogen-targeted drugs and host-directed therapies, has been addressed. The diagnostic criteria and management of MIS-C are also summarized.
Collapse
Affiliation(s)
- Ana Paula de Carvalho Panzeri Carlotti
- Departamento de Puericultura e Pediatria, Hospital das Clinicas (HCFMUSP), Faculdade de Medicina de Ribeirao Preto, Universidade de Sao Paulo, Ribeirao Preto, SP, BR
| | - Werther Brunow de Carvalho
- Departamento de Pediatria, Instituto da Crianca e do Adolescente (ICR), Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Cíntia Johnston
- Departamento de Pediatria, Instituto da Crianca e do Adolescente (ICR), Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Alfredo Elias Gilio
- Departamento de Pediatria, Hospital Universitario, Faculdade de Medicina (FMUSP), Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Heloisa Helena de Sousa Marques
- Departamento de Pediatria, Instituto da Crianca e do Adolescente (ICR), Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Juliana Ferreira Ferranti
- Departamento de Pediatria, Instituto da Crianca e do Adolescente (ICR), Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Isadora Souza Rodriguez
- Departamento de Pediatria, Instituto da Crianca e do Adolescente (ICR), Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Artur Figueiredo Delgado
- Departamento de Pediatria, Instituto da Crianca e do Adolescente (ICR), Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| |
Collapse
|
16
|
Kache S, Chisti MJ, Gumbo F, Mupere E, Zhi X, Nallasamy K, Nakagawa S, Lee JH, Di Nardo M, de la Oliva P, Katyal C, Anand KJS, de Souza DC, Lanziotti VS, Carcillo J. COVID-19 PICU guidelines: for high- and limited-resource settings. Pediatr Res 2020; 88:705-716. [PMID: 32634818 PMCID: PMC7577838 DOI: 10.1038/s41390-020-1053-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/19/2020] [Accepted: 06/22/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Fewer children than adults have been affected by the COVID-19 pandemic, and the clinical manifestations are distinct from those of adults. Some children particularly those with acute or chronic co-morbidities are likely to develop critical illness. Recently, a multisystem inflammatory syndrome (MIS-C) has been described in children with some of these patients requiring care in the pediatric ICU. METHODS An international collaboration was formed to review the available evidence and develop evidence-based guidelines for the care of critically ill children with SARS-CoV-2 infection. Where the evidence was lacking, those gaps were replaced with consensus-based guidelines. RESULTS This process has generated 44 recommendations related to pediatric COVID-19 patients presenting with respiratory distress or failure, sepsis or septic shock, cardiopulmonary arrest, MIS-C, those requiring adjuvant therapies, or ECMO. Evidence to explain the milder disease patterns in children and the potential to use repurposed anti-viral drugs, anti-inflammatory or anti-thrombotic therapies are also described. CONCLUSION Brief summaries of pediatric SARS-CoV-2 infection in different regions of the world are included since few registries are capturing this data globally. These guidelines seek to harmonize the standards and strategies for intensive care that critically ill children with COVID-19 receive across the world. IMPACT At the time of publication, this is the latest evidence for managing critically ill children infected with SARS-CoV-2. Referring to these guidelines can decrease the morbidity and potentially the mortality of children effected by COVID-19 and its sequalae. These guidelines can be adapted to both high- and limited-resource settings.
Collapse
Affiliation(s)
- Saraswati Kache
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Mohammod Jobayer Chisti
- Intensive Care Unit and Clinical Research, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Felicity Gumbo
- Department of Pediatrics and Child Health, College of Health Sciences University of Zimbabwe, Harare, Zimbabwe
| | - Ezekiel Mupere
- Department of Pediatrics and Child Health, School of Medicine College of Health Sciences, Makerere University, Kampala, Uganda
| | - Xia Zhi
- Department of Pediatric Intensive Care Unit, Maternal and Child Health Hospital of Hubei Province, Wuhan City, Hubei Province, China
| | - Karthi Nallasamy
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab, India
| | - Satoshi Nakagawa
- Critical Care Medicine, National Center for Child Health & Development, Tokyo, Japan
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore, Singapore
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, Rome, Italy
| | - Pedro de la Oliva
- Pediatric Intensive Care Department, Hospital Universitario La Paz, Department of Pediatrics Medical School, Universidad Autónoma de Madrid, Madrid, Spain
| | - Chhavi Katyal
- Pediatric Critical Care Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Kanwaljeet J S Anand
- Department of Pediatrics, Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Daniela Carla de Souza
- Pediatric Intensive Care Unit, University of São Paulo & Hospital Sírio Libanês-, São Paulo, Brazil
| | - Vanessa Soares Lanziotti
- Pediatric Intensive Care Unit & Research and Education Division/Maternal and Child Health Postgraduate Program, Federal University of Rio De Janeiro, Rio De Janeiro, Brazil
| | - Joseph Carcillo
- Departments of Critical Care Medicine and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
17
|
Lee JH, Ji SH, Lee HC, Jang YE, Kim EH, Kim HS, Kim JT. Evaluation of the intratidal compliance profile at different PEEP levels in children with healthy lungs: a prospective, crossover study. Br J Anaesth 2020; 125:818-825. [DOI: 10.1016/j.bja.2020.06.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/24/2020] [Accepted: 06/23/2020] [Indexed: 12/21/2022] Open
|
18
|
Lung-Protective Mechanical Ventilation Strategies in Pediatric Acute Respiratory Distress Syndrome. Pediatr Crit Care Med 2020; 21:720-728. [PMID: 32205663 DOI: 10.1097/pcc.0000000000002324] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Reduced morbidity and mortality associated with lung-protective mechanical ventilation is not proven in pediatric acute respiratory distress syndrome. This study aims to determine if a lung-protective mechanical ventilation protocol in pediatric acute respiratory distress syndrome is associated with improved clinical outcomes. DESIGN This pilot study over April 2016 to September 2019 adopts a before-and-after comparison design of a lung-protective mechanical ventilation protocol. All admissions to the PICU were screened daily for fulfillment of the Pediatric Acute Lung Injury Consensus Conference criteria and included. SETTING Multidisciplinary PICU. PATIENTS Patients with pediatric acute respiratory distress syndrome. INTERVENTIONS Lung-protective mechanical ventilation protocol with elements on peak pressures, tidal volumes, end-expiratory pressure to FIO2 combinations, permissive hypercapnia, and permissive hypoxemia. MEASUREMENTS AND MAIN RESULTS Ventilator and blood gas data were collected for the first 7 days of pediatric acute respiratory distress syndrome and compared between the protocol (n = 63) and nonprotocol groups (n = 69). After implementation of the protocol, median tidal volume (6.4 mL/kg [5.4-7.8 mL/kg] vs 6.0 mL/kg [4.8-7.3 mL/kg]; p = 0.005), PaO2 (78.1 mm Hg [67.0-94.6 mm Hg] vs 74.5 mm Hg [59.2-91.1 mm Hg]; p = 0.001), and oxygen saturation (97% [95-99%] vs 96% [94-98%]; p = 0.007) were lower, and end-expiratory pressure (8 cm H2O [7-9 cm H2O] vs 8 cm H2O [8-10 cm H2O]; p = 0.002] and PaCO2 (44.9 mm Hg [38.8-53.1 mm Hg] vs 46.4 mm Hg [39.4-56.7 mm Hg]; p = 0.033) were higher, in keeping with lung protective measures. There was no difference in mortality (10/63 [15.9%] vs 18/69 [26.1%]; p = 0.152), ventilator-free days (16.0 [2.0-23.0] vs 19.0 [0.0-23.0]; p = 0.697), and PICU-free days (13.0 [0.0-21.0] vs 16.0 [0.0-22.0]; p = 0.233) between the protocol and nonprotocol groups. After adjusting for severity of illness, organ dysfunction and oxygenation index, the lung-protective mechanical ventilation protocol was associated with decreased mortality (adjusted hazard ratio, 0.37; 95% CI, 0.16-0.88). CONCLUSIONS In pediatric acute respiratory distress syndrome, a lung-protective mechanical ventilation protocol improved adherence to lung-protective mechanical ventilation strategies and potentially mortality.
Collapse
|
19
|
Carvalho WBD, Rodriguez IS, Motta EHGD, Delgado AF. Ventilatory support recommendations in children with Sars-CoV-2. ACTA ACUST UNITED AC 2020; 66:528-533. [PMID: 32578791 DOI: 10.1590/1806-9282.66.4.528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 04/11/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Werther Brunow de Carvalho
- . Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo Brasil
| | - Isadora Souza Rodriguez
- . Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo Brasil
| | | | - Artur Figueiredo Delgado
- . Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo Brasil
| |
Collapse
|
20
|
Koopman AA, de Jager P, Blokpoel RGT, Kneyber MCJ. Ventilator-induced lung injury in children: a reality? ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:506. [PMID: 31728359 DOI: 10.21037/atm.2019.09.13] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Mechanical ventilation (MV) is inextricably linked to the care of critically ill patients admitted to the paediatric intensive care unit (PICU). Even today, little evidence supports best MV practices for life-threatening acute respiratory failure in children. However, careful attention must be paid because this life-saving technique induces pulmonary inflammation that aggravates pre-existing lung injury, a concept that is known as ventilator-induced lung injury (VILI). The delivery of too large tidal volumes (Vt) (i.e., volutrauma) and repetitive opening and closure of alveoli (i.e., atelectrauma) are two key mechanisms underlying VILI. Despite the knowledge of these mechanisms, the clinical relevance of VILI in critically ill children is poorly understood as almost all of our knowledge has been obtained from studies in adults or experimental studies mimicking the adult critical care situation. This leaves the question if VILI is relevant in the paediatric context. In fact, limited paediatric experimental data showed that the use of large, supraphysiologic Vt resulted in less inflammation and injury in paediatric animal models compared to adult models. Furthermore, the association between large Vt and adverse outcome has not been confirmed and the issue of setting positive end-expiratory pressure (PEEP) to prevent atelectrauma has hardly been studied in paediatric clinical studies. Hence, even today, the question whether or not there VILI is relevant in pediatric critical remains to be answered. Consequently, how MV is used remains thus based on institutional preferences, personal beliefs and clinical data extrapolated from adults. This signifies the need for clinical and experimental studies in order to better understand the use and effects of MV in paediatric patients with or without lung injury.
Collapse
Affiliation(s)
- Alette A Koopman
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Pauline de Jager
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert G T Blokpoel
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Martin C J Kneyber
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Critical Care, Anaesthesiology, Peri-Operative & Emergency Medicine (CAPE), University of Groningen, Groningen, The Netherlands
| |
Collapse
|
21
|
Affiliation(s)
- Matteo Di Nardo
- Department of Pediatric Anesthesia and Critical Care, Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, Rome, Italy Department of Emergency and Organ Transplantation, Section of Anesthesia and Intensive Care, "Aldo Moro" University of Bari, Bari, Italy
| | | |
Collapse
|
22
|
The authors reply. Pediatr Crit Care Med 2019; 20:905-906. [PMID: 31483390 DOI: 10.1097/pcc.0000000000002064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
23
|
de Souza LCVF, Delgado AF, Brunow de Carvalho W. What Is the Best Weight to Obtain Protective Mechanical Ventilation? Pediatr Crit Care Med 2019; 20:693. [PMID: 31274804 DOI: 10.1097/pcc.0000000000001970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Leonardo C V F de Souza
- Pediatric Intensive Care Unit of Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | | |
Collapse
|
24
|
The authors reply. Pediatr Crit Care Med 2019; 20:693-694. [PMID: 31274805 PMCID: PMC6613807 DOI: 10.1097/pcc.0000000000001976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
25
|
What Is Weighing Us Down From Elucidating Ideal Ventilation Strategies in Pediatric Acute Respiratory Distress Syndrome? Pediatr Crit Care Med 2019; 20:303-305. [PMID: 30830026 DOI: 10.1097/pcc.0000000000001857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|