Variability in Usual Care Mechanical Ventilation for Pediatric Acute Respiratory Distress Syndrome: Time for a Decision Support Protocol?*
Year: 2017
Type: article
Study design: Observational Study
Abstract: OBJECTIVES: Although pediatric intensivists philosophically embrace lung protective ventilation for acute lung injury and acute respiratory distress syndrome, we hypothesized that ventilator management varies. We assessed ventilator management by evaluating changes to ventilator settings in response to blood gases, pulse oximetry, or end-tidal CO2. We also assessed the potential impact that a pediatric mechanical ventilation protocol adapted from National Heart Lung and Blood Institute acute respiratory distress syndrome network protocols could have on reducing variability by comparing actual changes in ventilator settings to those recommended by the protocol. DESIGN: Prospective observational study. SETTING: Eight tertiary care U.S. PICUs, October 2011 to April 2012. PATIENTS: One hundred twenty patients (age range 17 d to 18 yr) with acute lung injury/acute respiratory distress syndrome. MEASUREMENTS AND MAIN RESULTS: Two thousand hundred arterial and capillary blood gases, 3,964 oxygen saturation by pulse oximetry, and 2,757 end-tidal CO2 values were associated with 3,983 ventilator settings. Ventilation mode at study onset was pressure control 60%, volume control 19%, pressure-regulated volume control 18%, and high-frequency oscillatory ventilation 3%. Clinicians changed FIO2 by ±5 or ±10% increments every 8 hours. Positive end-expiratory pressure was limited at ~10 cm H2O as oxygenation worsened, lower than would have been recommended by the protocol. In the first 72 hours of mechanical ventilation, maximum tidal volume/kg using predicted versus actual body weight was 10.3 (8.5-12.9) (median [interquartile range]) versus 9.2 mL/kg (7.6-12.0) (p < 0.001). Intensivists made changes similar to protocol recommendations 29% of the time, opposite to the protocol's recommendation 12% of the time and no changes 56% of the time. CONCLUSIONS: Ventilator management varies substantially in children with acute respiratory distress syndrome. Opportunities exist to minimize variability and potentially injurious ventilator settings by using a pediatric mechanical ventilation protocol offering adequately explicit instructions for given clinical situations. An accepted protocol could also reduce confounding by mechanical ventilation management in a clinical trial.
Source: Pediatric Critical Care Medicine
Authors: Christopher J. L. Newth, Katherine A. Sward, Robinder G. Khemani, Kent Page, Kathleen L. Meert, Joseph A. Carcillo, Thomas P. Shanley, Frank W. Moler, Murray M. Pollack, Heidi J. Dalton, David L. Wessel, John T. Berger, Robert A. Berg, Rick E. Harrison, Richard Holubkov, Allan Doctor, J. Michael Dean, Tammara L. Jenkins, Carol E. Nicholson
Institutions: University of Southern California, Children's Hospital of Los Angeles, University of Utah, University of Michigan, Children's Hospital of Michigan, University of Utah Health Care, Children's Hospital of Pittsburgh, Phoenix Children's Hospital, Children's National, Children's Hospital of Philadelphia, University of California, Los Angeles, Mattel Children's Hospital, Washington University in St. Louis, Eunice Kennedy Shriver National Institute of Child Health and Human Development
Language: English
Subfield: Pulmonary and Respiratory Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: green
Awards: G1223667318, G1328420516, G2045937259, Data Coordinating Center for the Collaborative Pediatric Critical Care Research Network, G3796038147, Controlled Trial of Two Lung Protective Ventilation Modes in Acute Lung Injury, G4429562184, G4545402594, Renewal Application for the Childrens Hospital of Pittsburgh Collaborative Pediatric Critical Care Research Network Site, Collaborative Pediatric Critical Care Research Network, Collaborative Pediatric Research Critical Care Network(U10), Pediatric Critical Care Research Network at Children's Hospital of Philadelphia, G7730008487, G781365963, Collaborative Pediatric Critical Care Research Network - Clinical Site, Collaborative Pediatric Critical Care Research Network At Children's Hospital of
OpenAlex ID: W2941432770