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Published on: November 4, 2010
Efficacy, results, and complications of mechanical ventilation in children with status asthmaticus
R G Cox1, G A Barker, D J Bohn
1Pediatric Intensive Care Unit, Hospital for Sick Children, Toronto, Canada.
Insights
Controlled hypoventilation during mechanical ventilation safely manages severe pediatric asthma. This approach, using low airway pressure, reduces complications in status asthmaticus patients, allowing for faster recovery and extubation.
Area of Science:
- Pediatric Critical Care Medicine
- Respiratory Medicine
- Emergency Medicine
Background:
- Severe status asthmaticus in children presents significant management challenges.
- Mechanical ventilation is often required for pediatric patients with severe respiratory distress and CO2 retention.
- Traditional ventilation strategies may carry risks of pressure-related complications.
Purpose of the Study:
- To evaluate the safety and efficacy of controlled hypoventilation in pediatric patients with severe status asthmaticus requiring mechanical ventilation.
- To assess the incidence of pressure-related complications, such as pneumothorax, using a specific ventilation strategy.
- To determine the impact of this strategy on ventilation duration and patient outcomes.
Main Methods:
- Retrospective survey of 79 pediatric patients admitted to the ICU for severe status asthmaticus over 32 months.
- Mechanical ventilation was initiated in 19 patients with severe respiratory distress and CO2 retention unresponsive to bronchodilators.
- Ventilation employed slow rates (<12/min) and controlled airway pressure (Paw) below 45 cmH2O, accepting compensated hypercapnia (PaCO2 45-60 mmHg).
Main Results:
- Two patients developed pneumothoraces, which resolved without incident; five with pre-existing air leaks did not develop pneumothoraces.
- The mean duration of intubation was 42 hours, with 14 of 19 patients extubated within 48 hours.
- All patients survived without sequelae, indicating a favorable safety profile.
Conclusions:
- Controlled hypoventilation, defined by Paw < 45 cmH2O, is a successful strategy for ventilating children with severe status asthmaticus.
- This approach can reduce the rate of pressure-related complications.
- The strategy facilitates timely extubation and positive patient outcomes in pediatric severe asthma exacerbations.
Abstract:
We have conducted a retrospective survey of 79 children out of a total hospital asthmatic patient population of 2,412, admitted over a 32 month period to the ICU for the management of severe status asthmaticus. All patients were in severe respiratory distress with CO2 retention; 19 required mechanical ventilation due to increasing fatigue and worsening bronchospasm, having failed to respond to either inhaled or IV bronchodilator therapy. All patients were ventilated at slow rates (less than 12 min) and their airway pressure (Paw) was deliberately kept below 45 cmH2O, while accepting a PaCO2 in the 45-60 mmHg range, as long as the pH was compensated. Although two patients developed pneumothoraces while on positive pressure ventilation, these were resolved without incidents. Five patients who had mediastinal or subcutaneous air leaks prior to intubation did not develop pneumothoraces. Following the initiation of mechanical ventilation, IV beta-agonist therapy was increased in order to reverse the bronchospasm and reduce the duration of mechanical ventilation. Mean duration of intubation was 42 hours. Fourteen of the 19 patients were weaned and extubated within 48 hours. All patients survived without sequelae. We conclude that a degree of controlled "hypoventilation" by deliberately choosing Paw less than 45 cmH2O can be successfully used to ventilate children with severe status asthmaticus with a reduced rate of pressure-related complications.
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