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Association of Ventilator Settings With Mortality in Pediatric Patients Treated With Extracorporeal Life Support for
David G Blauvelt1, Hussam S Inany1,2, Jamie M Furlong-Dillard3
1From the Department of Pediatrics, University of California, San Francisco, California.
Insights
Higher positive end-expiratory pressure (PEEP) and fraction of inspired oxygen (FiO2) during extracorporeal life support (ECLS) in pediatric patients were linked to increased mortality. Optimal PEEP and delta pressure may shorten ECLS duration.
Area of Science:
- Pediatric critical care medicine
- Respiratory physiology
- Extracorporeal membrane oxygenation (ECMO) research
Background:
- Extracorporeal life support (ECLS) provides gas exchange for acute respiratory failure, allowing lung rest.
- Mechanical ventilation is common during ECLS, but evidence guiding ventilator settings is limited.
- Understanding ventilator settings' impact on outcomes is crucial for optimizing ECLS therapy.
Purpose of the Study:
- To investigate the association between mechanical ventilator settings 24 hours after ECLS initiation and mortality in pediatric patients.
- To explore the relationship between ventilator settings and ECLS run-time in pediatric survivors.
- To identify specific ventilator parameters that may influence outcomes in critically ill children on ECLS.
Main Methods:
- Retrospective analysis of the Extracorporeal Life Support Organization (ELSO) Registry data.
- Inclusion of 3497 pediatric patients (29 days to 18 years) treated with ECLS for respiratory failure (2015-2021).
- Multivariate analysis to assess associations between ventilator settings (PEEP, delta pressure, rate, FiO2) and mortality, and secondary analysis for ECLS run-time in survivors.
Main Results:
- Elevated positive end-expiratory pressure (PEEP) >10 cm H2O (OR: 1.53) and fraction of inspired oxygen (FiO2) ≥0.45 (ORs: 1.31-2.30) were associated with increased mortality.
- In survivors, PEEP of 8-10 cm H2O (coefficient: -1.64) and delta pressure (ΔP) >16 cm H2O (coefficient: -2.72) were linked to shorter ECLS run times.
- Commonly used settings included PEEP of 10 cm H2O, ΔP of 10 cm H2O, rate of 10-14 breaths/min, and FiO2 of 0.31-0.4.
Conclusions:
- Specific mechanical ventilation settings, including higher PEEP and FiO2, are associated with increased mortality in pediatric ECLS patients.
- Certain PEEP and delta pressure ranges may be associated with reduced ECLS duration in survivors.
- Further research is needed to establish causality and refine ventilator strategies during pediatric ECLS.
Abstract:
Extracorporeal life support (ECLS) is a treatment for acute respiratory failure that can provide extracorporeal gas exchange, allowing lung rest. However, while most patients remain mechanically ventilated during ECLS, there is a paucity of evidence to guide the choice of ventilator settings. We studied the associations between ventilator settings 24 hours after ECLS initiation and mortality in pediatric patients using a retrospective analysis of data from the Extracorporeal Life Support Organization Registry. 3497 patients, 29 days to 18 years of age, treated with ECLS for respiratory failure between 2015 and 2021, were included for analysis. 93.3% of patients on ECLS were ventilated with conventional mechanical ventilation. Common settings included positive end-expiratory pressure (PEEP) of 10 cm H 2 O (45.7%), delta pressure (ΔP) of 10 cm H 2 O (28.3%), rate of 10-14 breaths per minute (55.9%), and fraction of inspired oxygen (FiO 2 ) of 0.31-0.4 (30.3%). In a multivariate model, PEEP >10 cm H 2 O ( versus PEEP < 8 cm H 2 O, odds ratio [OR]: 1.53, 95% CI: 1.20-1.96) and FiO 2 ≥0.45 ( versus FiO 2 < 0.4; 0.45 ≤ FiO 2 < 0.6, OR: 1.31, 95% CI: 1.03-1.67 and FiO 2 ≥ 0.6, OR: 2.30; 95% CI: 1.81-2.93) were associated with higher odds of mortality. In a secondary analysis of survivors, PEEP 8-10 cm H 2 O was associated with shorter ECLS run times ( versus PEEP < 8 cm H 2 O, coefficient: -1.64, 95% CI: -3.17 to -0.11), as was ΔP >16 cm H 2 O ( versus ΔP < 10 cm H 2 O, coefficient: -2.72, 95% CI: -4.30 to -1.15). Our results identified several categories of ventilator settings as associated with mortality or ECLS run-time. Further studies are necessary to understand whether these results represent a causal relationship.
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