Variability in Usual Care Mechanical Ventilation for Pediatric Acute Respiratory Distress Syndrome: Time for a Decision Support Protocol?

Eunice Kennedy Shriver National Institute for Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN)

Research output: Contribution to journalArticle

11 Citations (Scopus)

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.

Fingerprint

Adult Respiratory Distress Syndrome
Mechanical Ventilators
Artificial Respiration
Pediatrics
Oximetry
Acute Lung Injury
Ventilation
Gases
High-Frequency Ventilation
National Heart, Lung, and Blood Institute (U.S.)
Pressure
Positive-Pressure Respiration
Tidal Volume
Tertiary Healthcare
Observational Studies
Body Weight
Clinical Trials
Prospective Studies
Oxygen
Lung

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Critical Care and Intensive Care Medicine

Cite this

@article{2fc3ff3bf97e4f12901f5bb4d67f8da8,
title = "Variability in Usual Care Mechanical Ventilation for Pediatric Acute Respiratory Distress Syndrome: Time for a Decision Support Protocol?",
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.",
author = "{Eunice Kennedy Shriver National Institute for Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN)} and Newth, {Christopher J.L.} and Sward, {Katherine A.} and Khemani, {Robinder G.} and Kent Page and Meert, {Kathleen L.} and Carcillo, {Joseph A.} and Shanley, {Thomas Patrick} and Moler, {Frank W.} and Pollack, {Murray M.} and Dalton, {Heidi J.} and Wessel, {David L.} and Berger, {John T.} and Berg, {Robert A.} and Harrison, {Rick E.} and Richard Holubkov and Allan Doctor and Dean, {J. Michael} and Jenkins, {Tammara L.} and Nicholson, {Carol E.}",
year = "2017",
month = "11",
day = "1",
doi = "10.1097/PCC.0000000000001319",
language = "English (US)",
volume = "18",
pages = "e521--e529",
journal = "Pediatric Critical Care Medicine",
issn = "1529-7535",
publisher = "Lippincott Williams and Wilkins",
number = "11",

}

Variability in Usual Care Mechanical Ventilation for Pediatric Acute Respiratory Distress Syndrome : Time for a Decision Support Protocol? / Eunice Kennedy Shriver National Institute for Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN).

In: Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, Vol. 18, No. 11, 01.11.2017, p. e521-e529.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Variability in Usual Care Mechanical Ventilation for Pediatric Acute Respiratory Distress Syndrome

T2 - Time for a Decision Support Protocol?

AU - Eunice Kennedy Shriver National Institute for Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN)

AU - Newth, Christopher J.L.

AU - Sward, Katherine A.

AU - Khemani, Robinder G.

AU - Page, Kent

AU - Meert, Kathleen L.

AU - Carcillo, Joseph A.

AU - Shanley, Thomas Patrick

AU - Moler, Frank W.

AU - Pollack, Murray M.

AU - Dalton, Heidi J.

AU - Wessel, David L.

AU - Berger, John T.

AU - Berg, Robert A.

AU - Harrison, Rick E.

AU - Holubkov, Richard

AU - Doctor, Allan

AU - Dean, J. Michael

AU - Jenkins, Tammara L.

AU - Nicholson, Carol E.

PY - 2017/11/1

Y1 - 2017/11/1

N2 - 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.

AB - 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.

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U2 - 10.1097/PCC.0000000000001319

DO - 10.1097/PCC.0000000000001319

M3 - Article

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VL - 18

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JO - Pediatric Critical Care Medicine

JF - Pediatric Critical Care Medicine

SN - 1529-7535

IS - 11

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