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Published on: April 19, 2024
Driving Pressure Is Associated With Outcome in Pediatric Acute Respiratory Failure
Patrick van Schelven1, Alette A Koopman1, Johannes G M Burgerhof2
1Department of Pediatrics, Division of Pediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
Insights
In critically ill children, higher driving pressure during mechanical ventilation is linked to longer time to extubation. This highlights the importance of careful monitoring of driving pressure in pediatric intensive care units.
Area of Science:
- Pediatric critical care medicine
- Respiratory physiology
- Mechanical ventilation
Background:
- Driving pressure, a measure of respiratory system compliance, is a known predictor of mortality in adult acute respiratory distress syndrome.
- Its association with outcomes in critically ill children remains less understood.
Purpose of the Study:
- To investigate the association between driving pressure on day 1 of mechanical ventilation and clinical outcomes in critically ill children.
- To evaluate if driving pressure predicts time to extubation in this population.
Main Methods:
- Secondary analysis of prospectively collected physiology data from 222 mechanically ventilated children (median age 11 months).
- Driving pressure calculated as tidal volume/respiratory system compliance.
- Association with ventilator-free days and time to extubation analyzed using competing risk regression, adjusting for relevant covariates.
Main Results:
- Higher driving pressure was independently associated with increased time to extubation (p < 0.001) in mechanically ventilated children.
- Dynamic pressure gradients (PIP-PEEP) were found to overestimate driving pressure.
- A reduction in ventilator-free days was observed with increasing driving pressure in patients with direct pulmonary indications.
Conclusions:
- Elevated driving pressure is an independent predictor of prolonged mechanical ventilation duration in critically ill children.
- Clinicians should interpret dynamic assessments of driving pressure cautiously.
- Further research into optimal driving pressure targets in pediatric mechanical ventilation is warranted.
Objectives:
Driving pressure (ratio of tidal volume over respiratory system compliance) is associated with mortality in acute respiratory distress syndrome. We sought to evaluate if such association could be identified in critically ill children.
Design:
We studied the association between driving pressure on day 1 of mechanical ventilation and ventilator-free days at day 28 through secondary analyses of prospectively collected physiology data.
Setting:
Medical-surgical university hospital PICU.
Patients:
Children younger than 18 years (stratified by Pediatric Mechanical Ventilation Consensus Conference clinical phenotype definitions) without evidence of spontaneous respiration.
Interventions:
Inspiratory hold maneuvers.
Measurements And Main Results:
Data of 222 patients with median age 11 months (2-51 mo) were analyzed. Sixty-five patients (29.3%) met Pediatric Mechanical Ventilation Consensus Conference criteria for restrictive and 78 patients (35.1%) for mixed lung disease, and 10.4% of all patients had acute respiratory distress syndrome. Driving pressure calculated by the ratio of tidal volume over respiratory system compliance for the whole cohort was 16 cm H2O (12-21 cm H2O) and correlated with the static airway pressure gradient (plateau pressure minus positive end-expiratory pressure) (Spearman correlation coefficient = 0.797; p < 0.001). Bland-Altman analysis showed that the dynamic pressure gradient (peak inspiratory pressure minus positive end-expiratory pressure) overestimated driving pressure (levels of agreement -2.295 to 7.268). Rematching the cohort through a double stratification procedure (obtaining subgroups of patients with matched mean levels for one variable but different mean levels for another ranking variable) showed a reduction in ventilator-free days at day 28 with increasing driving pressure in patients ventilated for a direct pulmonary indication. Competing risk regression analysis showed that increasing driving pressure remained independently associated with increased time to extubation (p < 0.001) after adjusting for Pediatric Risk of Mortality III 24-hour score, presence of direct pulmonary indication jury, and oxygenation index.
Conclusions:
Higher driving pressure was independently associated with increased time to extubation in mechanically ventilated children. Dynamic assessments of driving pressure should be cautiously interpreted.
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