Nadir Yehya1, Neal J Thomas. 1. 1Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA.2Division of Pediatric Critical Care Medicine, Department of Pediatrics and Public Health Science, Penn State Hershey Children's Hospital, Hershey, PA.
Abstract
OBJECTIVES: Both oxygenation and peak inspiratory pressure are associated with mortality in pediatric acute respiratory distress syndrome. Since oxygenation and respiratory mechanics are linked, it is difficult to identify which variables, pressure or oxygenation, are independently associated with outcome. We aimed to determine whether respiratory mechanics (peak inspiratory pressure, positive end-expiratory pressure, ΔP [PIP minus PEEP], tidal volume, dynamic compliance [Cdyn]) or oxygenation (PaO2/FIO2) was associated with mortality. DESIGN: Prospective, observational, cohort study. SETTING: University affiliated PICU. PATIENTS: Mechanically ventilated children with acute respiratory distress syndrome (Berlin). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Peak inspiratory pressure, positive end-expiratory pressure, ΔP, tidal volume, Cdyn, and PaO2/FIO2 were collected at acute respiratory distress syndrome onset and at 24 hours in 352 children between 2011 and 2016. At acute respiratory distress syndrome onset, neither mechanical variables nor PaO2/FIO2 were associated with mortality. At 24 hours, peak inspiratory pressure, positive end-expiratory pressure, ΔP were higher, and Cdyn and PaO2/FIO2 lower, in nonsurvivors. In multivariable logistic regression, PaO2/FIO2 at 24 hours and ΔPaO2/FIO2 (change in PaO2/FIO2 over the first 24 hr) were associated with mortality, whereas pressure variables were not. Both oxygenation and pressure variables were associated with duration of ventilation in multivariable competing risk regression. CONCLUSIONS: Improvements in oxygenation, but not in respiratory mechanics, were associated with lower mortality in pediatric acute respiratory distress syndrome. Future trials of mechanical ventilation in children should focus on oxygenation (higher PaO2/FIO2) rather than lower peak inspiratory pressure or ΔP, as oxygenation was more consistently associated with outcome.
OBJECTIVES: Both oxygenation and peak inspiratory pressure are associated with mortality in pediatric acute respiratory distress syndrome. Since oxygenation and respiratory mechanics are linked, it is difficult to identify which variables, pressure or oxygenation, are independently associated with outcome. We aimed to determine whether respiratory mechanics (peak inspiratory pressure, positive end-expiratory pressure, ΔP [PIP minus PEEP], tidal volume, dynamic compliance [Cdyn]) or oxygenation (PaO2/FIO2) was associated with mortality. DESIGN: Prospective, observational, cohort study. SETTING: University affiliated PICU. PATIENTS: Mechanically ventilated children with acute respiratory distress syndrome (Berlin). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Peak inspiratory pressure, positive end-expiratory pressure, ΔP, tidal volume, Cdyn, and PaO2/FIO2 were collected at acute respiratory distress syndrome onset and at 24 hours in 352 children between 2011 and 2016. At acute respiratory distress syndrome onset, neither mechanical variables nor PaO2/FIO2 were associated with mortality. At 24 hours, peak inspiratory pressure, positive end-expiratory pressure, ΔP were higher, and Cdyn and PaO2/FIO2 lower, in nonsurvivors. In multivariable logistic regression, PaO2/FIO2 at 24 hours and ΔPaO2/FIO2 (change in PaO2/FIO2 over the first 24 hr) were associated with mortality, whereas pressure variables were not. Both oxygenation and pressure variables were associated with duration of ventilation in multivariable competing risk regression. CONCLUSIONS: Improvements in oxygenation, but not in respiratory mechanics, were associated with lower mortality in pediatric acute respiratory distress syndrome. Future trials of mechanical ventilation in children should focus on oxygenation (higher PaO2/FIO2) rather than lower peak inspiratory pressure or ΔP, as oxygenation was more consistently associated with outcome.
Authors: Cristina M Alvira; Aida Abate; Guang Yang; Phyllis A Dennery; Marlene Rabinovitch Journal: Am J Respir Crit Care Med Date: 2007-01-25 Impact factor: 21.405
Authors: G R Bernard; A Artigas; K L Brigham; J Carlet; K Falke; L Hudson; M Lamy; J R Legall; A Morris; R Spragg Journal: Am J Respir Crit Care Med Date: 1994-03 Impact factor: 21.405
Authors: John G Laffey; Giacomo Bellani; Tài Pham; Eddy Fan; Fabiana Madotto; Ednan K Bajwa; Laurent Brochard; Kevin Clarkson; Andres Esteban; Luciano Gattinoni; Frank van Haren; Leo M Heunks; Kiyoyasu Kurahashi; Jon Henrik Laake; Anders Larsson; Daniel F McAuley; Lia McNamee; Nicolas Nin; Haibo Qiu; Marco Ranieri; Gordon D Rubenfeld; B Taylor Thompson; Hermann Wrigge; Arthur S Slutsky; Antonio Pesenti Journal: Intensive Care Med Date: 2016-10-18 Impact factor: 17.440
Authors: Michael G Gaies; James G Gurney; Alberta H Yen; Michelle L Napoli; Robert J Gajarski; Richard G Ohye; John R Charpie; Jennifer C Hirsch Journal: Pediatr Crit Care Med Date: 2010-03 Impact factor: 3.624
Authors: Tobias R Kollmann; Juliet Crabtree; Annie Rein-Weston; Darren Blimkie; Francis Thommai; Xiu Yu Wang; Pascal M Lavoie; Jeff Furlong; Edgardo S Fortuno; Adeline M Hajjar; Natalie R Hawkins; Steven G Self; Christopher B Wilson Journal: J Immunol Date: 2009-11-16 Impact factor: 5.422
Authors: Simon Erickson; Andreas Schibler; Andrew Numa; Gabrielle Nuthall; Michael Yung; Elaine Pascoe; Barry Wilkins Journal: Pediatr Crit Care Med Date: 2007-07 Impact factor: 3.624
Authors: Jasmine C Dowell; Kaushik Parvathaneni; Neal J Thomas; Robinder G Khemani; Nadir Yehya Journal: Crit Care Med Date: 2018-11 Impact factor: 7.598
Authors: Adam S Himebauch; Nadir Yehya; Yan Wang; Thomas Conlon; Todd J Kilbaugh; Francis X McGowan; Laura Mercer-Rosa Journal: Crit Care Med Date: 2018-11 Impact factor: 7.598
Authors: Scott L Weiss; Mark J Peters; Waleed Alhazzani; Michael S D Agus; Heidi R Flori; David P Inwald; Simon Nadel; Luregn J Schlapbach; Robert C Tasker; Andrew C Argent; Joe Brierley; Joseph Carcillo; Enitan D Carrol; Christopher L Carroll; Ira M Cheifetz; Karen Choong; Jeffry J Cies; Andrea T Cruz; Daniele De Luca; Akash Deep; Saul N Faust; Claudio Flauzino De Oliveira; Mark W Hall; Paul Ishimine; Etienne Javouhey; Koen F M Joosten; Poonam Joshi; Oliver Karam; Martin C J Kneyber; Joris Lemson; Graeme MacLaren; Nilesh M Mehta; Morten Hylander Møller; Christopher J L Newth; Trung C Nguyen; Akira Nishisaki; Mark E Nunnally; Margaret M Parker; Raina M Paul; Adrienne G Randolph; Suchitra Ranjit; Lewis H Romer; Halden F Scott; Lyvonne N Tume; Judy T Verger; Eric A Williams; Joshua Wolf; Hector R Wong; Jerry J Zimmerman; Niranjan Kissoon; Pierre Tissieres Journal: Intensive Care Med Date: 2020-02 Impact factor: 17.440
Authors: Anna L Roberts; Julia S Sammons; Peter M Mourani; Neal J Thomas; Nadir Yehya Journal: Pediatr Crit Care Med Date: 2019-09 Impact factor: 3.624
Authors: David Castiñeira; Katherine R Schlosser; Alon Geva; Amir R Rahmani; Gaston Fiore; Brian K Walsh; Craig D Smallwood; John H Arnold; Mauricio Santillana Journal: Respir Care Date: 2020-09 Impact factor: 2.258