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Published on: April 7, 2021
Permissive hypercapnia for severe acute respiratory distress syndrome in immunocompromised children: A single center
Hans Fuchs1, Nicola Rossmann2, Manuel B Schmid3
1Center for Pediatrics, Department of Neonatology and Pediatric Intensive Care, Medical Center - Albert Ludwig University of Freiburg, Faculty of Medicine, Freiburg, Germany.
Insights
Controlled hypoventilation with high carbon dioxide levels (hypercapnia) can improve survival in immunocompromised children with acute respiratory distress syndrome (ARDS). This strategy, allowing lower lung pressures, was well-tolerated and showed promising results in a pediatric intensive care unit (PICU) cohort.
Area of Science:
- Pediatric Critical Care Medicine
- Respiratory Physiology
- Mechanical Ventilation
Background:
- Controlled hypoventilation accepting hypercapnia is proposed to mitigate ventilator-induced lung injury.
- Immunocompromised children with acute respiratory distress syndrome (ARDS) face significant mortality.
- The study investigated a strategy of progressively increasing carbon dioxide (PCO2) targets in these high-risk children.
Purpose of the Study:
- To evaluate the outcomes of immunocompromised children with ARDS managed with a ventilation strategy allowing severe hypercapnia.
- To assess the feasibility and safety of stepwise increasing PCO2 targets up to 140 mm Hg in this vulnerable population.
Main Methods:
- Retrospective analysis of a cohort of children with oncologic disease or post-stem cell transplantation experiencing severe respiratory failure.
- Comparison with a historical control group.
- In a subgroup, PCO2 targets were stepwise increased, with outcomes meticulously recorded.
Main Results:
- Overall survival in the PICU was 75% for children requiring invasive mechanical ventilation >24h.
- In a subgroup (n=38) with high ventilator needs, a stepwise increase in PCO2 targets was implemented.
- Survival in immunocompromised children on mechanical ventilation >24h increased from 32% (historical) to 48% with the new strategy.
- Severe pulmonary hypertension occurred in 2 patients; no cerebral edema was observed.
- Long-term follow-up in 15 patients showed 10 survived without neurological sequelae.
Conclusions:
- A ventilation strategy accepting very high PCO2 levels is feasible and potentially beneficial in children.
- Severe hypercapnia was well-tolerated, with no observed severe side effects.
- This approach may improve survival rates for immunocompromised children with severe ARDS.
Background:
Controlled hypoventilation while accepting hypercapnia has been advocated to reduce ventilator-induced lung injury. The aim of the study was to analyze outcomes of a cohort of immunocompromised children with acute respiratory distress syndrome (ARDS) ventilated with a strategy of stepwise increasing PCO2 targets up to 140 mm Hg.
Methods:
Retrospective analysis of outcomes of a cohort of children with oncologic disease or after stem cell transplantation and severe respiratory failure in comparison with a historical control cohort.
Results:
Out of 150 episodes of admission to the PICU 88 children underwent invasive mechanical ventilation for >24h (overall survival 75%). In a subgroup of 38 children with high ventilator requirements the PCO2 target ranges were increased stepwise. Fifteen children survived and were discharged from the PICU. Severe pulmonary hypertension was seen in two patients and no case of cerebral edema was observed. Long term outcome was available in 15 patients and 10 of these patients survived without adverse neurological sequelae. With introduction of this strategy survival of immunocompromised children undergoing mechanical ventilation for >24h increased to 48% compared to 32% prior to introduction (historical cohort).
Conclusions:
A ventilation strategy incorporating very high carbon dioxide levels to allow for low tidal volumes and limited inspiratory pressures is feasible in children. Even severe hypercapnia may be well tolerated. No severe side effects associated with hypercapnia were observed. This strategy could potentially increase survival in immunocompromised children with severe ARDS.
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