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Published on: April 7, 2021
Dynamic Airway Driving Pressure and Outcomes in Children With Acute Hypoxemic Respiratory Failure
Abdul Rauf1, Anil Sachdev2, Shekhar T Venkataraman3
1Pediatric Emergency, Critical Care and Pulmonology, Department of Pediatrics, Sir Ganga Ram Hospital, New Delhi, India.
Insights
Lowering airway driving pressure (ΔP) in pediatric acute hypoxemic respiratory failure significantly reduces morbidity. A driving pressure below 15 cm H2O is associated with shorter ventilation duration and ICU stays in children.
Area of Science:
- Pediatric Critical Care Medicine
- Respiratory Physiology
- Mechanical Ventilation
Background:
- Adult studies suggest airway driving pressure (ΔP) better predicts lung injury risk and correlates with mortality in ARDS than tidal volume.
- Data on the effect of driving pressure on pediatric acute respiratory distress syndrome (ARDS) mortality are lacking.
Purpose of the Study:
- To evaluate the effect of driving pressure on morbidity and mortality in children with acute hypoxemic respiratory failure.
- To determine if a driving pressure threshold of 15 cm H2O impacts clinical outcomes in pediatric patients.
Main Methods:
- Retrospective cohort study in a tertiary pediatric ICU.
- Included children receiving invasive mechanical ventilation for acute hypoxemic respiratory failure within a 2-year period.
- Divided patients into low (<15 cm H2O) and high (≥15 cm H2O) ΔP groups based on the highest value in the first 24 hours.
Main Results:
- Children with low ΔP (<15 cm H2O) had significantly shorter ventilation duration (5 vs 8 days), ICU length of stay (6 vs 12 days), and more ventilator-free days at day 28.
- Driving pressure was an independent predictor of morbidity after adjusting for confounders.
- No significant difference in mortality was observed between the low and high ΔP groups (17% vs 24%).
Conclusions:
- A driving pressure threshold below 15 cm H2O is associated with significantly decreased morbidity in pediatric patients with acute hypoxemic respiratory failure.
- While driving pressure impacts morbidity, its effect on mortality in this pediatric cohort requires further investigation.
Background:
Limited adult data suggest that airway driving pressure might better reflect the potential risk for lung injury than tidal volume based on ideal body weight, and the parameter correlates with mortality in ARDS. There is a lack of data about the effect of driving pressure on mortality in pediatric ARDS. This study aimed to evaluate the effect of driving pressure on morbidity and mortality of children with acute hypoxemic respiratory failure.
Methods:
This retrospective cohort study was performed in a tertiary level pediatric ICU. Children who received invasive mechanical ventilation for acute hypoxemic respiratory failure (defined as [Formula: see text] < 300 within 24 h after intubation), in a 2-y period were included. The cohort was divided into 2 groups based on the highest dynamic driving pressure (ΔP, calculated as the difference between peak inspiratory pressure and PEEP) in the first 24 h, with a cutoff value of 15 cm H2O.
Results:
Of the 380 children who were mechanically ventilated during the study period, 101 children who met eligibility criteria were enrolled. Common diagnoses were pneumonia (n = 51), severe sepsis (n = 24), severe dengue (n = 10), and aspiration pneumonia (n = 7). In comparison to the group with high ΔP (ie, ≥ 15 cm H2O), children in the group with low ΔP (ie, < 15 cm H2O) had significantly lower median (interquartile range) duration of ventilation (5 [4-6] d vs 8 [6-11] d, P < .001], ICU length of stay (6 [5-8] d vs 12 [8-15] d, P < .001], and more ventilator-free days at day 28 (23 [20-24] vs 17 [0-22] d, P < .001). Logistic regression analysis also suggested driving pressure as an independent predictor of morbidity after adjusting for confounding variables. However, there was no statistically significant difference in mortality between the 2 groups (17% in low ΔP vs 24% in high ΔP, P = .38). Subgroup analysis of 65 subjects who fulfilled ARDS criteria yielded similar results with respect to mortality and morbidity.
Conclusions:
Below a threshold of 15 cm H2O, ΔP was associated with significantly decreased morbidity in children with acute hypoxemic respiratory failure.
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