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Epidemiology, risk factors and outcomes of prolonged mechanical ventilation with different cut-points in a PICU

Tatchanapong Chongcharoenyanon¹, Rujipat Samransamruajkit², Jiratchaya Sophonphan³

¹Division of Pulmonology, Department of Pediatrics, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

Frontiers in Pediatrics

|May 1, 2023

Insights

Defining prolonged mechanical ventilation (PMV) in children is crucial. This study found that PMV exceeding 30 days in pediatric intensive care units (PICUs) is associated with significantly worse outcomes, suggesting a 30-day threshold may be more appropriate.

Area of Science:

Pediatric Critical Care Medicine
Respiratory Therapy
Clinical Epidemiology

Background:

Lack of a standardized definition for prolonged mechanical ventilation (PMV) in pediatric patients.
Limited data on the epidemiology, risk factors, and outcomes associated with PMV at various time points.
Importance of defining PMV for treatment planning and prognosis counseling for families.

Purpose of the Study:

To determine the incidence, baseline characteristics, risk factors, and outcomes of PMV in pediatric patients.
To analyze PMV outcomes at different duration cut-points: >14 days, >21 days, and >30 days.

Main Methods:

Retrospective cohort study of pediatric patients (<18 years) requiring mechanical ventilation >14 days in a PICU.
Patients stratified into three groups based on ventilation duration: >14-21 days, >21-30 days, and >30 days.
Analysis of baseline characteristics, risk factors, and outcomes (extubation success, tracheostomy, death) using logistic regression.

Main Results:

Incidence of PMV was 10.9% (>14 days), 7.3% (>21 days), and 5.0% (>30 days).
Patients with PMV >30 days showed significantly lower extubation success (15.4%) and higher rates of tracheostomy (63.5%), VAP (98.1%), and mortality (34.6%).
Ventilator-associated pneumonia (VAP) was a significant factor for PMV >30 days; factors associated with non-survival included severe malnutrition, high PIM3 score, and muscle relaxant use.

Conclusions:

Prolonged mechanical ventilation exceeding 30 days in pediatric intensive care units is associated with substantially worse outcomes, including higher rates of extubation failure, tracheostomy, VAP, and mortality.
A 30-day duration may serve as a more appropriate definition for prolonged mechanical ventilation in pediatric intensive care settings.
Further research is warranted to refine definitions and identify targeted interventions for pediatric patients requiring extended mechanical ventilation.

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Abstract

Background:

A consensus on the definition of prolonged mechanical ventilation (PMV) for children does not exist. There is still lack of published work presenting the epidemiology, risk factors and outcomes at different cut-points for PMV patients. These are important for planning the goals of treatment and counseling of the prognosis for patient families. We aimed to determine the incidence, baseline characteristics, risk factors and outcomes of PMV in pediatric patients at various cut-points (>14, >21 or >30days).

Methods:

A retrospective cohort study among children <18-years-old who were PMV > 14 days in the PICU of King Chulalongkorn Memorial Hospital was conducted. The primary outcomes were incidence of PMV with various cut-points. We stratified patients into three groups (Group 1; PMV > 14-21, Group 2; >21-30, Group 3; >30 days) for evaluating the baseline characteristics, risk factors, and outcomes of PMV (extubation success, tracheostomy status and death). Factors associated with PMV and deaths were analyzed using univariate and multivariate logistic regression.

Results:

From January 2018 to August 2022, 1,050 patients were screened. Of these, 114 patients were enrolled. The incidence of PMV > 14, >21 and >30 days were 10.9%, 7.3% and 5.0% respectively. Extubation success was significantly lower in Group 3 than in Groups 1 & 2 (15.4% vs. 62.2% & 56.0%, P < 0.001). Consequently, the tracheostomy rate (63.5% vs. 16.2% & 12.0%, P < 0.001), VAP rate (98.1% vs. 59.5% & 80.0%, P < 0.001), mortality rate by disease (34.6% vs. 5.4% & 20.0%, P = 0.003), median PICU LOS (50.5 vs. 22.0 & 28.0 days, P < 0.001) and median hospital LOS (124.5 vs. 55.0 & 62.0 days, P < 0.001) were also significantly higher for Group 3 compared with Groups 1 & 2. The factor associated with PMV > 30 days was VAP (aOR: 19.53, 95% CI: 2.38-160.34, P = 0.01). Factors associated with non-surviving patients were 3rd degree PEM (aOR: 5.14, 95% CI: 1.57-16.88, P = 0.01), PIM3 score ≥14 (aOR: 6.75, 95% CI: 2.26-20.15, P < 0.001) and muscle relaxant usage (aOR: 5.58, 95% CI: 1.65-18.86, P = 0.01).

Conclusion:

Extubation failure, tracheostomy rate, VAP rate, mortality rate by disease, PICU LOS and hospital LOS were significantly higher for PMV >30 days. Consequently, we suggest that a 30-day duration as a cut-point for PMV in PICUs might be more appropriate.

Keywords:

children cut-point definition incidence long-term ventilation pediatrics prolong mechanical ventilation tracheostomy

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