Reply to Tremlett and Kanthimathinathan and to Koopman and Kneyber
Year: 2018
Type: letter
Abstract: We appreciate the interest in our recent article, which found that children with pediatric acute respiratory distress syndrome (PARDS) managed with higher FI O 2 relative to the positive endexpiratory pressure (PEEP) levels recommended by the ARDS Network PEEP/FI O 2 protocol had higher mortality (1).This higher mortality held after extensive multivariable and propensity adjustment.However, given the observational, retrospective nature of our study, causality should not be implied.Although our study has limitations, we believe we have demonstrated the need to look more closely at PEEP management in PARDS.There have been no clinical trials surrounding PEEP management in PARDS.Furthermore, PEEP is generally underused as part of the lung recruitment strategy in many pediatric intensive care units, as observational data have consistently demonstrated that PEEP levels are rarely escalated above 10 cm H 2 O, even in circumstances of severe hypoxemia (2-4).With that in mind, we believe the letters provided by Drs.Koopman and Kneyber and Drs.Tremlett and Kanthimathinathan highlight some important pragmatic points to consider as we move forward with further investigations into PEEP management in PARDS.The first point relates to the potential attributable mortality fraction from ARDS.Indeed, it is likely that many children are dying with PARDS and not necessarily from PARDS.Mortality in ARDS (both adult and pediatric) is multifactorial, and both these letters to the editor, as well as texts by many other authors, have argued that mortality may not be the best outcome for ARDS studies (5).In this manuscript, we did not explore specific cause of death, and although that may provide some insight, the somewhat subjective nature of assessments of cause of death limit conclusions.Drs.Koopman and Kneyber argue that children who have withdrawal of support or withholding of life-sustaining therapies are not dying from PARDS.Withdrawal of support is the most common mode of death (not cause) in most intensive care units (6).The factors that contribute to the decision to withdraw support in these patients may relate to underlying comorbidities, but these decisions are invariably tied to the effects of the acute disease (i.e., ARDS) and how it informs the clinician's proposed prognosis.Decoupling this complexity to limit analysis to certain types of patients who have a prespecified cause of death
Language: English
Subfield: Pulmonary and Respiratory Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W2811157167