Mechanical power in pediatric acute respiratory distress syndrome: a PARDIE study

Critical Care

Peter M. Mourani¹  Pablo Cruces²  Margaret J. Klein³  Robinder Khemani⁴  Christopher Newth⁴  Anoopindar K. Bhalla⁴  Nadir Yehya⁵  Muneyuki Takeuchi⁶  Martin C. J. Kneyber⁷  Steven Shein⁸  Alberto Medina⁹  Franco Diaz^1,10  Cristina Camilo^1,11  John Pappachan^1,12  Aline B. Maddux^1,13  Guillaume Emeriaud^1,14  Matteo Di Nardo^1,15  Benjamin R. White^1,16  Vicent Modesto I Alapont^1,17 

[1] Arkansas Children’s Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA;Centro 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;Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA;Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA;Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA;Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA;Department of Intensive Care Medicine, Osaka Women’s and Children’s Hospital, Osaka, Japan;Division of Paediatric Critical Care Medicine, Department of Paediatrics, University Medical Center Groningen, Beatrix Children’s Hospital, University of Groningen, Groningen, The Netherlands;Critical Care, Anaesthesiology, Peri-Operative & Emergency Medicine (CAPE), University of Groningen, Groningen, The Netherlands;Division of Pediatric Critical Care Medicine, Rainbow Babies and Children’s Hospital, Cleveland, OH, USA;Hospital Universitario Central de Asturias, Oviedo, Spain;Instituto de Ciencias e Innovación ed Medicina (ICIM), Universidad del Desarrollo, Santiago, Chile;Hospital Clínico La Florida, Santiago, Chile;PICU, Hospital de Santa Maria – CHULN, Lisbon, Portugal;Paediatric Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK;Faculty of Medicine, University of Southampton, Southampton, UK;Pediatric Critical Care, University of Colorado School of Medicine, Aurora, CO, USA;Children’s Hospital Colorado, Aurora, CO, USA;Pediatric Intensive Care Unit, CHU Sainte-Justine, Department of Pediatrics, Université de Montréal, Montreal, Canada;Pediatric Intensive Care Unit, Children’s Hospital Bambino Gesù, IRCCS, Rome, Italy;Penn State Health Children’s Hospital, Hershey, PA, USA;University and Polytechnic Hospital La Fe Valencia, Valencia, Spain;

关键词: Ventilators;    Mechanical;    Ventilator-induced lung injury;    Critical care;    Pediatrics;   

DOI  :  10.1186/s13054-021-03853-6

来源: Springer

【 摘 要 】

BackgroundMechanical 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).MethodsRetrospective analysis of a prospective observational international cohort study.ResultsThere 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.ConclusionsHigher 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.

【 授权许可】

CC BY