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

IF 7.7 1区医学 Q1 CRITICAL CARE MEDICINE Critical Care Medicine Pub Date : 2024-10-01 Epub Date: 2024-06-26 DOI:10.1097/CCM.0000000000006357

Judith Ju Ming Wong, Hongxing Dang, Chin Seng Gan, Phuc Huu Phan, Hiroshi Kurosawa, Kazunori Aoki, Siew Wah Lee, Jacqueline Soo May Ong, Li Jia Fan, Chian Wern Tai, Soo Lin Chuah, Pei Chuen Lee, Yek Kee Chor, Louise Ngu, Nattachai Anantasit, Chunfeng Liu, Wei Xu, Dyah Kanya Wati, Suparyatha Ida Bagus Gede, Muralidharan Jayashree, Felix Liauw, Kah Min Pon, Li Huang, Jia Yueh Chong, Xuemei Zhu, Kam Lun Ellis Hon, Karen Ka Yan Leung, Rujipat Samransamruajkit, Yin Bun Cheung, Jan Hau Lee

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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.

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小儿急性呼吸窘迫综合征的肺保护性通气：非随机对照试验。

目的：尽管在儿科急性呼吸窘迫综合征（PARDS）中推荐使用肺保护性机械通气（LPMV），但目前缺乏有力的支持数据，临床实践中的坚持情况也不尽相同。本研究评估了肺保护性机械通气方案与标准护理以及坚持肺保护性机械通气对死亡率的影响。我们假设，作为实用方案部署的 LPMV 策略可降低 PARDS 的死亡率：多中心前瞻性前后对比设计研究：21所儿童重症监护病房：患者：符合 2015 年儿科急性肺损伤共识会议对 PARDS 的定义，并接受有创机械通气：LPMV方案包括限制吸气峰压（PIP）、δ/驱动压（DP）、潮气量、呼气末正压（PEEP）与低PEEP急性呼吸窘迫综合征网络表中的Fio2组合、允许性高碳酸血症和保守氧目标：693 名患者中分别有 285 人（41-1%）和 408 人（58-9%）接受和未接受 LPMV 方案治疗。中位年龄和氧合指数分别为 1.5 岁（0.4-5.3 岁）和 10.9 岁（7.0-18.6 岁）。LPMV 方案组和非 LPMV 方案组的 60 天死亡率没有差异（65/285 [22.8%] vs. 115/406 [28.3%]；P = 0.104）。不过，与非 LPMV 组相比，LPMV 组的依从性总分确实有所提高（57.1 [40.0-66.7] vs. 47.6 [31.0-58.3]; p < 0-001）。调整混杂因素后，坚持 LPMV 策略（调整后危险比为 0.98；95% CI 为 0.97-0.99；p = 0.004）而非 LPMV 方案本身与 60 天死亡风险降低有关。坚持PIP、DP和PEEP/Fio2组合与死亡率降低有关：结论：在 PARDS 第一周坚持 LPMV 要素与死亡率降低有关。未来需要改进 LPMV 的实施，以提高坚持率。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Critical Care Medicine 医学-危重病医学

CiteScore

16.30

自引率

5.70%

发文量

728

审稿时长

2 months

期刊介绍： Critical Care Medicine is the premier peer-reviewed, scientific publication in critical care medicine. Directed to those specialists who treat patients in the ICU and CCU, including chest physicians, surgeons, pediatricians, pharmacists/pharmacologists, anesthesiologists, critical care nurses, and other healthcare professionals, Critical Care Medicine covers all aspects of acute and emergency care for the critically ill or injured patient. Each issue presents critical care practitioners with clinical breakthroughs that lead to better patient care, the latest news on promising research, and advances in equipment and techniques.