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Nonadherence to appropriate tidal volume and PEEP in children with pARDS at a single center
Michael C McCrory1,2, Alan G Woodruff1,2, Amit K Saha1
1Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.
Insights
Many children with pediatric acute respiratory distress syndrome (pARDS) did not receive evidence-based mechanical ventilation settings. Adherence to low tidal volume and appropriate positive end-expiratory pressure (PEEP) was suboptimal, especially in overweight children and those requiring high oxygen levels.
Area of Science:
- Pediatric Critical Care Medicine
- Respiratory Physiology
- Mechanical Ventilation
Background:
- Low tidal volume and adequate positive end-expiratory pressure (PEEP) are recommended for pediatric acute respiratory distress syndrome (pARDS).
- Limited data exist on the adherence to these evidence-based strategies since the 2015 pARDS guideline revisions.
Purpose of the Study:
- To determine the prevalence of adherence to appropriate tidal volume and PEEP in children with pARDS.
- To identify factors associated with nonadherence to these ventilation strategies.
Main Methods:
- Retrospective cohort study of pediatric patients (1 month to <18 years) with pARDS receiving invasive mechanical ventilation.
- Data collected from a single pediatric intensive care unit (PICU) between 2016 and 2018.
- Analysis focused on adherence to tidal volume (≤8 mL/kg ideal body weight) and PEEP at 24 hours post-pARDS criteria.
Main Results:
- Only 56% of patients received appropriate tidal volume and 52% received appropriate PEEP at 24 hours; 26% received both.
- Overweight/obese children (≥2 years) had lower adherence to appropriate tidal volume (36%) compared to normal/underweight children (73%).
- Patients requiring high fraction of inspired oxygen (FiO2 ≥50%) had significantly lower adherence to appropriate PEEP (32%) versus those with FiO2 <50% (100%).
Conclusions:
- Children with pARDS in this PICU frequently did not receive recommended tidal volume or PEEP.
- Improving adherence may involve targeted strategies for overweight pediatric patients regarding tidal volume.
- Patients requiring high FiO2 necessitate closer attention to PEEP adherence.
Background:
Low tidal volume and adequate positive end-expiratory pressure (PEEP) are evidence-based approaches for pediatric acute respiratory distress syndrome (pARDS), however, data are limited regarding their use since pARDS guidelines were revised in 2015.
Objective:
To identify prevalence of, and factors associated with, nonadherence to appropriate tidal volume and PEEP in children with pARDS.
Methods:
Retrospective cohort study of children 1 month to <18 years with pARDS who received invasive mechanical ventilation from 2016 to 2018 in a single pediatric intensive care unit (PICU).
Results:
At 24 h after meeting pARDS criteria, 48/86 (56%) patients received tidal volume ≤8 ml/kg of ideal body weight and 45/86 (52%) received appropriate PEEP, with 22/86 (26%) receiving both. Among patients ≥2 years of age, a lower proportion of patients with overweight/obesity (9/25, 36%) had appropriate tidal volume versus those in the normal or underweight category (16/22, 73%, p = 0.02). When FIO2 was ≥50%, PEEP was appropriate in 19/60 (32%) cases versus 26/26 (100%) with FIO2 < 50% (p < 0.0001). pARDS was documented in the progress note in 7/86 (8%) patients at 24 h. Severity of pARDS, documentation in the progress note, and other clinical factors were not significantly associated with use of appropriate tidal volume and PEEP, however pARDS was documented more commonly in patients with severe pARDS.
Conclusions:
In a single PICU in the United States, children with pARDS did not receive appropriate tidal volume for ideal body weight nor PEEP. Targets for improving tidal volume and PEEP adherence may include overweight patients and those receiving FIO2 ≥ 50%, respectively.
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