Adherence to Lung-Protective Ventilation Principles in Pediatric Acute Respiratory Distress Syndrome: A Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Study.
Adherence to Lung-Protective Ventilation Principles in Pediatric Acute Respiratory Distress Syndrome: A Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Study.
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DOI：
10.1097/ccm.0000000000005060
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发表时间：
2021-10-01
影响因子：
8.8
通讯作者：
Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology (PARDIE) V.2. Investigators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network
中科院分区：
文献类型：
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作者：
Bhalla AK;Klein MJ;Emeriaud G;Lopez-Fernandez YM;Napolitano N;Fernandez A;Al-Subu AM;Gedeit R;Shein SL;Nofziger R;Hsing DD;Briassoulis G;Ilia S;Baudin F;Piñeres-Olave BE;Maria Izquierdo L;Lin JC;Cheifetz IM;Kneyber MCJ;Smith L;Khemani RG;Newth CJL;Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology (PARDIE) V.2. Investigators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network
描述小儿急性呼吸窘迫综合征（PARDS）的机械通气管理和与不遵守肺保护性通气原则相关的因素。一项前瞻性国际观察性研究的计划辅助研究。描述了PARDS第0-3天期间的机械通气管理（每6小时测量一次），并与儿科急性肺损伤共识会议潮气量（VT）建议（呼吸系统顺应性受损儿童<7 ml/kg，所有其他儿童<9 ml/kg）和ARDSNet较低呼气末正压（PEEP）/较高FiO 2网格建议进行了比较。71个国际儿科重症监护病房。有PARDS的孩子没有。研究对象包括422名儿童。在PARDS第0天，中位VT为7.6 ml/kg（IQR 6.3，8.9），并且在PARDS严重程度方面没有差异。在97%的测量中未记录平台压力。使用Δ压（吸气峰压- PEEP），中位VT增加超过中位Δ压的四分位数（p=0.007）。所有PARDS严重度水平的中位δ压≥18 cm H2O。在重度PARDS中，62%的时间VT ≥7 ml/kg，70%的时间PEEP低于PEEP/FiO 2网格推荐值。在多变量分析中，室性心动过速非依从性在重度PARDS、较少PICU入院/年、非欧洲PICU、较高Δ压、皮质类固醇使用和压力控制模式中更常见。依从性与体重过轻的身材和带套囊的气管插管有关。在多变量分析中，PEEP/FiO 2网格不依从性在PARDS严重程度较高、主要由主治医生决定呼吸机、ICU前心肺复苏、体重过轻和年龄<2岁的患者中更常见。依从性与呼吸治疗师参与呼吸机管理和PARDS诊断时间较长相关。调整混杂变量后，较高的不依从VT和PEEP建议与较高的死亡率和较长的通气持续时间独立相关。在分层分析中，这些相关性主要受重度PARDS儿童的影响。不遵守肺保护性通气原则在PARDS中很常见，并可能影响结局。存在可能改善依从性的可修改因素。
To describe mechanical ventilation management and factors associated with non-adherence to lung protective ventilation principles in pediatric acute respiratory distress syndrome (PARDS). A planned ancillary study to a prospective international observational study. Mechanical ventilation management (every 6-hour measurements) during PARDS days 0-3 was described and compared with Pediatric Acute Lung Injury Consensus Conference tidal volume (VT) recommendations (<7 ml/kg in children with impaired respiratory system compliance, <9 ml/kg in all other children) and the ARDSNet lower positive end-expiratory pressure (PEEP)/higher FiO2 grid recommendations. 71 international pediatric intensive care units. Children with PARDS. None. Analyses included 422 children. On PARDS day 0, median VT was 7.6 ml/kg (IQR 6.3, 8.9) and did not differ by PARDS severity. Plateau pressure was not recorded in 97% of measurements. Using delta pressure (peak inspiratory pressure - PEEP), median VT increased over quartiles of median delta pressure (p=0.007). Median delta pressure was ≥18 cm H2O for all PARDS severity levels. In severe PARDS, VT was ≥7 ml/kg 62% of the time and PEEP was lower than recommended by the PEEP/FiO2 grid 70% of the time. In multivariable analysis, VT non-adherence was more common with severe PARDS, fewer PICU admissions/year, non-European PICUs, higher delta pressure, corticosteroid use, and pressure control mode. Adherence was associated with underweight stature and cuffed endotracheal tubes. In multivariable analysis, PEEP/FiO2 grid non-adherence was more common with higher PARDS severity, ventilator decisions made primarily by the attending physician, pre-ICU cardiopulmonary resuscitation, underweight stature, and age <2 years. Adherence was associated with respiratory therapist involvement in ventilator management and longer time from PARDS diagnosis. Higher non-adherence to VT and PEEP recommendations were independently associated with higher mortality and longer duration of ventilation after adjustment for confounding variables. In stratified analyses, these associations were primarily influenced by children with severe PARDS. Non-adherence to lung protective ventilation principles is common in PARDS and may impact outcome. Modifiable factors exist that may improve adherence.