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Predictors of mortality in children with respiratory failure: possible indications for ECMO
1Intensive Care Unit, Royal Children's Hospital, Parkville, Victoria.
Insights
Objective predictors for mortality in pediatric acute respiratory failure are lacking. This study identified ventilation and oxygenation criteria that reliably predict death in children over one month old.
Area of Science:
- Pediatric Critical Care Medicine
- Respiratory Physiology
- Medical Informatics
Background:
- Acute respiratory failure is a leading cause of mortality in children.
- Unproven ventilation and oxygenation methods are used, but objective predictors for initiating them are absent.
- Deciding when to use advanced therapies like extracorporeal devices or high-frequency ventilation is challenging.
Purpose of the Study:
- To identify objective predictors of death in children aged one month to eighteen years with acute respiratory failure.
- To establish criteria for initiating advanced ventilation and oxygenation therapies.
Main Methods:
- Retrospective chart review of 42 pediatric patients (1 month - 18 years) with acute respiratory failure.
- Inclusion criteria: mechanical ventilation >12 hours, >90% oxygen, peak inspiratory pressure >25 cmH2O, no pre-existing neurodevelopmental handicap.
- Analysis of ventilation and oxygenation variables to predict mortality.
Main Results:
- A combination of ventilation index (>40) and oxygenation index (>0.4) predicted death with 77% mortality chance (Sensitivity 65%, Specificity 74%).
- Peak inspiratory pressure (>40 cmH2O) and A-aDO2 (>580) predicted death with 81% mortality chance (Sensitivity 74%, Specificity 79%).
Conclusions:
- Specific ventilation and oxygenation criteria can reliably predict mortality in pediatric acute respiratory failure.
- These criteria may aid clinicians in deciding on the use of advanced respiratory support therapies.
- Further validation of these predictors is warranted.
Abstract:
There are many unproven methods of ventilation and oxygenation that have been used in children dying from respiratory failure, including extracorporeal devices and high frequency ventilation. However, no objective predictors of death have been developed that enable clinicians to decide when it is reasonable to use these therapies in children over one month of age with acute respiratory failure. To determine predictors of death, we evaluated the charts of all 42 children aged one month to eighteen years admitted to the intensive care unit who were ventilated for more than twelve hours, received greater than 90% oxygen, received a peak inspiratory pressure greater than 25 cmH2O and had no pre-existing neurodevelopmental handicap. A combination of a variable reflecting ventilation and a variable reflecting oxygenation reliably predicted death: a combination of ventilation index greater than 40 and oxygenation index greater than 0.4 was associated with a 77% chance of mortality (sensitivity 65% and specificity 74%); a combination of peak inspiratory pressure greater than 40 cmH2O and A-aDO2 greater than 580 was associated with an 81% chance of mortality (sensitivity 74% and specificity 79%). These criteria may be useful in predicting death from respiratory failure in children.