Abstract
ABSTRACTObjective: Acute respiratory distress syndrome (ARDS) can be a devastating condition in children with cancer and alveolar recruitment maneuvers (ARMs) can theoretically improve oxygenation and survival. The study aimed to assess the feasibility of ARMs in critically ill children with cancer and ARDS.Methods: We retrospectively analyzed 31 maneuvers in a series of 12 patients (median age of 8.9 years) with solid tumors (n=4), lymphomas (n=2), acute lymphoblastic leukemia (n=2), and acute myeloid leukemia (n=4). Patients received positive end-expiratory pressure from 25 up to 40 cmH20, with a delta pressure of 15 cmH2O for 60 seconds. We assessed blood gases pre- and post-maneuvers, as well as ventilation parameters, vital signs, hemoglobin, clinical signs of pulmonary bleeding, and radiological signs of barotrauma. Pre- and post-values were compared by the Wilcoxon test.Results: Median platelet count was 53,200/mm3. Post-maneuvers, mean arterial pressure decreased more than 20% in two patients, and four needed an increase in vasoactive drugs. Hemoglobin levels remained stable 24 hours after ARMs, and signs of pneumothorax, pneumomediastinum, or subcutaneous emphysema were absent. Fraction of inspired oxygen decreased significantly after ARMs (FiO2; p=0.003). Oxygen partial pressure (PaO2)/FiO2 ratio increased significantly (p=0.0002), and the oxygenation index was reduced (p=0.01), but all these improvements were transient. Recruited patients’ 28-day mortality was 58%.Conclusions: ARMs, although feasible in the context of thrombocytopenia, lead only to transient improvements, and can cause significant hemodynamic instability.
Highlights
Acute respiratory failure is a frequent condition in children with cancer admitted to the Intensive Care Unit (ICU)
Post-maneuvers, mean arterial pressure decreased more than 20% in two patients, and four needed an increase in vasoactive drugs
In lungs progressing with increased resistance, high positive end-expiratory pressure (PEEP) settings during alveolar recruitment maneuvers (ARMs) can lead to complications, hemodynamic impairment.[4]
Summary
Acute respiratory failure is a frequent condition in children with cancer admitted to the Intensive Care Unit (ICU) Those who develop acute respiratory distress syndrome (ARDS) and need mechanical ventilation (MV) have a poor prognosis.[1] Twenty-eight-day mortality can be as high as 58% in patients with neoplasms, septic shock, and ARDS.[2] Studies performing lung computed tomography (CT) have shown that ARDS presents multiple gravity-dependent atelectasis areas, which are prone to opening with alveolar recruitment maneuvers (ARMs).[3] Extension of the recruitment area is influenced by the time elapsed since ARDS onset, and ARMs have their best efficacy the earlier they are initiated due to the development of fibrosis in the affected lung in later stages of the disease. In lungs progressing with increased resistance, high positive end-expiratory pressure (PEEP) settings during ARMs can lead to complications, hemodynamic impairment.[4]
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