Lung-Protective Ventilation for Pediatric Acute Respiratory Distress Syndrome: A Nonrandomized Controlled Trial

Wong JJM 1 , Dang H 2 , Gan CS 3 , Phan PH 4 , Kurosawa H 5 , Aoki K 5 Show all authors , Lee SW 6 , Ong JSM 7 , Fan LJ 7 , Tai CW 8 , Chuah SL 3 , Lee PC 8 , Chor YK 9 , Ngu L 9 , Anantasit N 10 , Liu C 11 , Xu W 11 , Wati DK 12 , Gede SIB 12 , Jayashree M 13 , Liauw F 14 , Pon KM 15 , Huang L 16 , Chong JY 17 , Zhu X 18 , Hon KLE 19 , Leung KKY 19 , Samransamruajkit R 20 , Cheung YB 21 , Lee JH 1 , Pediatric Acute & Critical Care Medicine Asian Network (PACCMAN)

Affiliations 

  • 1 Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
  • 2 Children's Hospital of Chongqing Medical University, Chongqing, China
  • 3 Department of Paediatrics, University Malaya Medical Centre, University Malaya, Kuala Lumpur, Malaysia
  • 4 Vietnam National Children's Hospital, Hanoi, Vietnam
  • 5 Hyogo Prefectural Kobe Children's Hospital, Hyogo, Japan
  • 6 Sultanah Aminah Hospital, Johor, Malaysia
  • 7 Division of Paediatric Critical Care, National University Hospital, Singapore
  • 8 Universiti Kebangsaan Malaysia Specialist Children's Hospital, Kuala Lumpur, Malaysia
  • 9 Sarawak General Hospital, Sarawak, Malaysia
  • 10 Ramathibodi Hospital, Bangkok, Thailand
  • 11 Shengjing Hospital of China Medical University, Liaoning, China
  • 12 Pediatric Emergency and Intensive Care Unit, Prof I.G.N.G Ngoerah Hospital, Bali, Indonesia
  • 13 Postgraduate Institute of Medical Education and Research, Chandigarh, India
  • 14 Harapan Kita National Women and Children Health Center, Jakarta, Indonesia
  • 15 Penang General Hospital, Penang, Malaysia
  • 16 Guangzhou Women and Children's Medical Center, Guangdong, China
  • 17 Hospital Tunku Azizah Kuala Lumpur, Kuala Lumpur, Malaysia
  • 18 Children's Hospital of Fudan University, Shanghai, China
  • 19 Paediatric Intensive Care Unit, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
  • 20 Division of Pediatric Critical Care, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
  • 21 Duke-NUS Medical School, Singapore
Crit Care Med, 2024 Oct 01;52(10):1602-1611.
PMID: 38920618 DOI: 10.1097/CCM.0000000000006357

Abstract

OBJECTIVES: Despite the recommendation for lung-protective mechanical ventilation (LPMV) in pediatric acute respiratory distress syndrome (PARDS), there is a lack of robust supporting data and variable adherence in clinical practice. This study evaluates the impact of an LPMV protocol vs. standard care and adherence to LPMV elements on mortality. We hypothesized that LPMV strategies deployed as a pragmatic protocol reduces mortality in PARDS.

DESIGN: Multicenter prospective before-and-after comparison design study.

SETTING: Twenty-one PICUs.

PATIENTS: Patients fulfilled the Pediatric Acute Lung Injury Consensus Conference 2015 definition of PARDS and were on invasive mechanical ventilation.

INTERVENTIONS: The LPMV protocol included a limit on peak inspiratory pressure (PIP), delta/driving pressure (DP), tidal volume, positive end-expiratory pressure (PEEP) to F io2 combinations of the low PEEP acute respiratory distress syndrome network table, permissive hypercarbia, and conservative oxygen targets.

MEASUREMENTS AND MAIN RESULTS: There were 285 of 693 (41·1%) and 408 of 693 (58·9%) patients treated with and without the LPMV protocol, respectively. Median age and oxygenation index was 1.5 years (0.4-5.3 yr) and 10.9 years (7.0-18.6 yr), respectively. There was no difference in 60-day mortality between LPMV and non-LPMV protocol groups (65/285 [22.8%] vs. 115/406 [28.3%]; p = 0.104). However, total adherence score did improve in the LPMV compared to non-LPMV group (57.1 [40.0-66.7] vs. 47.6 [31.0-58.3]; p < 0·001). After adjusting for confounders, adherence to LPMV strategies (adjusted hazard ratio, 0.98; 95% CI, 0.97-0.99; p = 0.004) but not the LPMV protocol itself was associated with a reduced risk of 60-day mortality. Adherence to PIP, DP, and PEEP/F io2 combinations were associated with reduced mortality.

CONCLUSIONS: Adherence to LPMV elements over the first week of PARDS was associated with reduced mortality. Future work is needed to improve implementation of LPMV in order to improve adherence.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

MeSH terms
Similar publications