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Published on: April 7, 2021
Poor Adherence to Lung-Protective Mechanical Ventilation in Pediatric Acute Respiratory Distress Syndrome
Shan L Ward1, Carson M Quinn, Stacey L Valentine
11Division of Critical Care, Department of Pediatrics, UCSF Benioff Children's Hospital San Francisco, San Francisco, CA.2Department Volunteer Services, UCSF Benioff Children's Hospital Oakland, Oakland, CA.3Department of Pediatric Critical Care, UMass Memorial Medical Center, Worcester, MA.4Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at UCLA Medical Center, Los Angeles, CA.5Department of Family and Community Health, University of Pennsylvania, School of Nursing, Philadelphia, PA.6Division of Pediatric Critical Care, Children's Hospital of Richmond at VCU, Richmond, VA.7Department of Medicine, UCSF Medical Center, San Francisco, CA.8Department of Anesthesia, UCSF Medical Center, San Francisco, CA.9Cardiovascular Research Institute, UCSF Medical Center, San Francisco, CA.10Division of Pediatric Critical Care Medicine, C.S. Mott Children's Hospital, Ann Arbor, MI.
Insights
Low-tidal volume ventilation is underused in pediatric acute respiratory distress syndrome (ARDS). Overweight children were less likely to receive this lung-protective strategy, with no improvement in adherence over time.
Area of Science:
- Pediatric Critical Care Medicine
- Respiratory Medicine
- Mechanical Ventilation
Background:
- Pediatric acute respiratory distress syndrome (ARDS) management guidelines recommend lung-protective ventilation strategies.
- Low-tidal volume ventilation (LTVV) is a key component of lung protection in ARDS.
- Adherence to LTVV in pediatric populations requires further investigation.
Purpose of the Study:
- To determine the frequency of LTVV use in pediatric ARDS.
- To assess demographic and clinical factors associated with LTVV adherence.
- To evaluate changes in LTVV adherence over the initial 24 hours of pediatric ARDS.
Main Methods:
- Post hoc analysis of four multicenter pediatric ARDS studies.
- Included 315 pediatric ARDS patients receiving conventional mechanical ventilation.
- Assessed LTVV adherence using two tidal volume cutoffs (≤6.5 mL/kg and ≤8 mL/kg ideal body weight) at 0 and 24 hours.
Main Results:
- LTVV adherence was low, ranging from 32% to 60% at 0 and 24 hours, depending on the tidal volume cutoff used.
- No significant differences in adherence were observed based on ARDS severity or patient age.
- Overweight children were less likely to receive LTVV (≤6.5 mL/kg IBW) at hour 0, and using admission weight led to misclassification.
- LTVV adherence did not improve over the first 24 hours of pediatric ARDS.
Conclusions:
- LTVV is underutilized in the early management of pediatric ARDS.
- Factors such as age, disease severity, and mortality risk scores did not predict adherence.
- Overweight status was associated with lower LTVV use, highlighting potential challenges in applying lung-protective strategies in specific pediatric populations.
Objectives:
To determine the frequency of low-tidal volume ventilation in pediatric acute respiratory distress syndrome and assess if any demographic or clinical factors improve low-tidal volume ventilation adherence.
Design:
Descriptive post hoc analysis of four multicenter pediatric acute respiratory distress syndrome studies.
Setting:
Twenty-six academic PICU.
Patients:
Three hundred fifteen pediatric acute respiratory distress syndrome patients.
Measurements And Main Results:
All patients who received conventional mechanical ventilation at hours 0 and 24 of pediatric acute respiratory distress syndrome who had data to calculate ideal body weight were included. Two cutoff points for low-tidal volume ventilation were assessed: less than or equal to 6.5 mL/kg of ideal body weight and less than or equal to 8 mL/kg of ideal body weight. Of 555 patients, we excluded 240 for other respiratory support modes or missing data. The remaining 315 patients had a median PaO2-to-FIO2 ratio of 140 (interquartile range, 90-201), and there were no differences in demographics between those who did and did not receive low-tidal volume ventilation. With tidal volume cutoff of less than or equal to 6.5 mL/kg of ideal body weight, the adherence rate was 32% at hour 0 and 33% at hour 24. A low-tidal volume ventilation cutoff of tidal volume less than or equal to 8 mL/kg of ideal body weight resulted in an adherence rate of 58% at hour 0 and 60% at hour 24. Low-tidal volume ventilation use was no different by severity of pediatric acute respiratory distress syndrome nor did adherence improve over time. At hour 0, overweight children were less likely to receive low-tidal volume ventilation less than or equal to 6.5 mL/kg ideal body weight (11% overweight vs 38% nonoverweight; p = 0.02); no difference was noted by hour 24. Furthermore, in the overweight group, using admission weight instead of ideal body weight resulted in misclassification of up to 14% of patients as receiving low-tidal volume ventilation when they actually were not.
Conclusions:
Low-tidal volume ventilation is underused in the first 24 hours of pediatric acute respiratory distress syndrome. Age, Pediatric Risk of Mortality-III, and pediatric acute respiratory distress syndrome severity were not associated with improved low-tidal volume ventilation adherence nor did adherence improve over time. Overweight children were less likely to receive low-tidal volume ventilation strategies in the first day of illness.
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