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Published on: April 7, 2021
Mechanical power in pediatric acute respiratory distress syndrome: a PARDIE study
Anoopindar K Bhalla1,2, Margaret J Klein3, Vicent Modesto I Alapont4
1Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA. abhalla@chla.usc.edu.
Insights
High mechanical power in mechanical ventilation is linked to fewer ventilator-free days in children with pediatric acute respiratory distress syndrome (PARDS). This effect is more pronounced in younger children under two years old.
Area of Science:
- Pediatric Critical Care Medicine
- Respiratory Physiology
- Mechanical Ventilation
Background:
- Mechanical power, a measure of energy transfer to the respiratory system, may better predict ventilator-induced lung injury than individual settings.
- Pediatric acute respiratory distress syndrome (PARDS) is a critical condition requiring mechanical ventilation.
Purpose of the Study:
- To investigate the association between high mechanical power during ventilation and ventilator-free days (VFD) in children with PARDS.
- To identify potential differences in mechanical ventilation management and outcomes based on age.
Main Methods:
- Retrospective analysis of a prospective observational international cohort study involving 306 children across 55 pediatric intensive care units.
- Statistical analysis controlled for confounding variables to assess the relationship between mechanical power and 28-day VFD and mortality.
Main Results:
- Higher mechanical power was associated with fewer 28-day VFD (SHR 0.93; p=0.013) and higher mortality in a subgroup excluding neurologic deaths (OR 1.22; p=0.036).
- The association between higher mechanical power and fewer VFD was significant in children younger than 2 years (SHR 0.89; p=0.005).
- Younger children (<2 years) received lower tidal volumes but higher delta pressure and respiratory rates compared to older children.
Conclusions:
- Higher mechanical power is associated with fewer ventilator-free days in children with PARDS, particularly in those under two years old.
- Ventilator management strategies, especially in younger children, may influence outcomes and warrant further investigation for lung-protective ventilation.
- While not directly linked to overall ICU mortality in the entire cohort, mechanical power's impact on VFD highlights its clinical relevance in PARDS management.
Background:
Mechanical power is a composite variable for energy transmitted to the respiratory system over time that may better capture risk for ventilator-induced lung injury than individual ventilator management components. We sought to evaluate if mechanical ventilation management with a high mechanical power is associated with fewer ventilator-free days (VFD) in children with pediatric acute respiratory distress syndrome (PARDS).
Methods:
Retrospective analysis of a prospective observational international cohort study.
Results:
There were 306 children from 55 pediatric intensive care units included. High mechanical power was associated with younger age, higher oxygenation index, a comorbid condition of bronchopulmonary dysplasia, higher tidal volume, higher delta pressure (peak inspiratory pressure-positive end-expiratory pressure), and higher respiratory rate. Higher mechanical power was associated with fewer 28-day VFD after controlling for confounding variables (per 0.1 J·min-1·Kg-1 Subdistribution Hazard Ratio (SHR) 0.93 (0.87, 0.98), p = 0.013). Higher mechanical power was not associated with higher intensive care unit mortality in multivariable analysis in the entire cohort (per 0.1 J·min-1·Kg-1 OR 1.12 [0.94, 1.32], p = 0.20). But was associated with higher mortality when excluding children who died due to neurologic reasons (per 0.1 J·min-1·Kg-1 OR 1.22 [1.01, 1.46], p = 0.036). In subgroup analyses by age, the association between higher mechanical power and fewer 28-day VFD remained only in children < 2-years-old (per 0.1 J·min-1·Kg-1 SHR 0.89 (0.82, 0.96), p = 0.005). Younger children were managed with lower tidal volume, higher delta pressure, higher respiratory rate, lower positive end-expiratory pressure, and higher PCO2 than older children. No individual ventilator management component mediated the effect of mechanical power on 28-day VFD.
Conclusions:
Higher mechanical power is associated with fewer 28-day VFDs in children with PARDS. This association is strongest in children < 2-years-old in whom there are notable differences in mechanical ventilation management. While further validation is needed, these data highlight that ventilator management is associated with outcome in children with PARDS, and there may be subgroups of children with higher potential benefit from strategies to improve lung-protective ventilation.
Take Home Message:
Higher mechanical power is associated with fewer 28-day ventilator-free days in children with pediatric acute respiratory distress syndrome. This association is strongest in children <2-years-old in whom there are notable differences in mechanical ventilation management.
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