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Invasive Mechanical Ventilation and Mortality in Pediatric Hematopoietic Stem Cell Transplantation: A Multicenter
Courtney M Rowan1, Shira J Gertz, Jennifer McArthur
11Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN. 2Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack, NJ. 3Department of Pediatrics, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI. 4Department of Anesthesia, Children's Hospital of Philadelphia University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. 5Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN. 6Department of Pediatrics, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY. 7Department of Pediatrics, Dana-Farber Cancer Institute, Boston, MA. 8Department of Pediatrics, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY. 9Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, WA. 10Department of Pediatrics, Duke Children's Hospital, Durham, NC. 11Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH. 12Department of Pediatrics, Pennsylvania State University College of Medicine, Penn State Hershey Children's Hospital, Hershey, PA. 13Department of Public Health, Pennsylvania State University College of Medicine, Penn State Hershey Children's Hospital, Hershey, PA.
Insights
Pediatric hematopoietic stem cell transplant patients with respiratory failure have high mortality. Earlier, aggressive critical care interventions, including timely mechanical ventilation, may improve survival rates in these critically ill children.
Area of Science:
- Pediatric critical care medicine
- Hematopoietic stem cell transplantation
- Respiratory failure management
Background:
- Pediatric hematopoietic stem cell transplant (HSCT) recipients are at high risk for acute respiratory failure.
- Current respiratory support strategies and their impact on outcomes in this population are not well-defined.
Purpose of the Study:
- To examine respiratory practice patterns in pediatric HSCT patients with acute respiratory failure.
- To investigate the association between these practices and mortality.
Main Methods:
- Retrospective cohort study of 222 pediatric HSCT recipients with acute respiratory failure requiring invasive mechanical ventilation.
- Data collected from 12 US children's hospitals between 2009 and 2014.
- Analysis of noninvasive ventilation use, timing of mechanical ventilation, and high-frequency oscillatory ventilation (HFOV).
Main Results:
- Overall pediatric intensive care unit (PICU) mortality was 60.4%, with 74% mortality at 180 days post-discharge.
- Delayed initiation of invasive mechanical ventilation was associated with increased mortality.
- Noninvasive ventilation use prior to intubation and prolonged mechanical ventilation (>15 days) were linked to higher mortality.
- Early initiation of HFOV (within 2 days of invasive ventilation) significantly reduced mortality odds.
Conclusions:
- Respiratory failure in pediatric HSCT patients carries a high mortality risk.
- Earlier and more aggressive critical care interventions, particularly timely initiation of mechanical ventilation and HFOV, may improve outcomes.
- Further research into optimized respiratory support strategies is warranted.
Objective:
To establish the current respiratory practice patterns in pediatric hematopoietic stem cell transplant patients and investigate their associations with mortality across multiple centers.
Design:
Retrospective cohort between 2009 and 2014.
Setting:
Twelve children's hospitals in the United States.
Patients:
Two hundred twenty-two pediatric allogeneic hematopoietic stem cell transplant recipients with acute respiratory failure using invasive mechanical ventilation.
Interventions:
None.
Measurements And Main Results:
PICU mortality of our cohort was 60.4%. Mortality at 180 days post PICU discharge was 74%. Length of PICU stay prior to initiation of invasive mechanical ventilation was significantly lower in survivors, and the odds of mortality increased for longer length of PICU stay prior to intubation. A total of 91 patients (41%) received noninvasive ventilation at some point during their PICU stay prior to intubation. Noninvasive ventilation use preintubation was associated with increased mortality (odds ratio, 2.1; 95% CI, 1.2-3.6; p = 0.010). Patients ventilated longer than 15 days had higher odds of death (odds ratio, 2.4; 95% CI, 1.3-4.2; p = 0.004). Almost 40% of patients (n = 85) were placed on high-frequency oscillatory ventilation with a mortality of 76.5% (odds ratio, 3.3; 95% CI, 1.7-6.5; p = 0.0004). Of the 20 patients who survived high-frequency oscillatory ventilation, 18 were placed on high-frequency oscillatory ventilation no later than the third day of invasive mechanical ventilation. In this subset of 85 patients, transition to high-frequency oscillatory ventilation within 2 days of the start of invasive mechanical ventilation resulted in a 76% decrease in the odds of death compared with those who transitioned to high-frequency oscillatory ventilation later in the invasive mechanical ventilation course.
Conclusions:
This study suggests that perhaps earlier more aggressive critical care interventions in the pediatric hematopoietic stem cell transplant patient with respiratory failure requiring invasive mechanical ventilation may offer an opportunity to improve outcomes.
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