Ventilation In Pediatric Respiratory Failure Research Articles

Airway pressure release ventilation in pediatric respiratory failure. Does it really work?

Airway pressure release ventilation in pediatric respiratory failure. Does it really work?

Noninvasive ventilation in pediatric respiratory failure: use at the right time

Noninvasive ventilation in pediatric respiratory failure: use at the right time

Comparison of High-Frequency Oscillatory Ventilation and Conventional Mechanical Ventilation in Pediatric Respiratory Failure

Outcomes associated with use of high-frequency oscillatory ventilation (HFOV) in children with acute respiratory failure have not been established. To compare the outcomes of HFOV with those of conventional mechanical ventilation (CMV) in children with acute respiratory failure. We performed a retrospective, observational study using deidentified data obtained from all consecutive patients receiving mechanical ventilation aged 1 month to 18 years in the Virtual PICU System database from January 1, 2009, through December 31, 2011. The study population was divided into 2 groups: HFOV and CMV. The HFOV group was further divided into early and late HFOV. Propensity score matching was performed as a 1-to-1 match of HFOV and CMV patients. A similar matching process was performed for early HFOV and CMV patients. High-frequency oscillatory ventilation. Length of mechanical ventilation, intensive care unit (ICU) length of stay, ICU mortality, and standardized mortality ratio (SMR). A total of 9177 patients from 98 hospitals qualified for inclusion. Of these, 902 (9.8%) received HFOV, whereas 8275 (90.2%) received CMV. A total of 1764 patients were matched to compare HFOV and CMV, whereas 942 patients were matched to compare early HFOV and CMV. Length of mechanical ventilation (CMV vs HFOV: 14.6 vs 20.3 days, P < .001; CMV vs early HFOV: 14.6 vs 15.9 days, P < .001), ICU length of stay (19.1 vs 24.9 days, P < .001; 19.3 vs 19.5 days, P = .03), and mortality (8.4% vs 17.3%, P < .001; 8.3% vs 18.1%, P < .001) were significantly higher in HFOV and early HFOV patients compared with CMV patients. The SMR in the HFOV group was 2.00 (95% CI, 1.71-2.35) compared with an SMR in the CMV group of 0.85 (95% CI, 0.68-1.07). The SMR in the early HFOV group was 1.62 (95% CI, 1.31-2.01) compared with an SMR in the CMV group of 0.76 (95% CI, 0.62-1.16). Application of HFOV and early HFOV compared with CMV in children with acute respiratory failure is associated with worse outcomes. The results of our study are similar to recently published studies in adults comparing these 2 modalities of ventilation for acute respiratory distress syndrome.

High frequency oscillation and airway pressure release ventilation in pediatric respiratory failure

Airway pressure release ventilation (APRV) and high frequency oscillatory ventilation (HFOV) are frequently used in acute lung injury (ALI) refractory to conventional ventilation. Our aim was to describe our experience with APRV and HFOV in refractory pediatric ALI, and to identify factors associated with survival. We analyzed 104 patients with hypoxemia refractory to conventional ventilation transitioned to either APRV or HFOV. Demographics, oxygenation index (OI), and PaO2 /FiO2 (PF ratio) were recorded before transition to either mode of nonconventional ventilation (NCV) and for every 12 hr after transition. Relative to APRV, patients on HFOV were younger and had more significant lung disease evidenced by higher OI (28.5 [18.6, 36.2] vs. 21.0 [15.5, 30.0], P = 0.008), lower PF ratios (73 [59,94] vs. 99 [76,131], P = 0.002), and more frequent use of inhaled nitric oxide. In univariate analysis, HFOV was associated with more frequent neuromuscular blockade. Forty-one of 104 patients died on NCV (39.4%). Survivors demonstrated improvement in OI 24 hr after transition to NCV, whereas non-survivors did not (12.9 [8.9, 20.9] vs. 28.1 [17.6, 37.1], P < 0.001). After controlling for immunocompromised status, number of vasopressors, and OI before transition, mode of NCV was not associated with mortality. In a heterogeneous PICU population with hypoxemia refractory to conventional ventilation transitioned to NCV, improvement in oxygenation at 24 hr was associated with survival. Immunocompromised status, number of vasopressor infusions, and the OI before transition to NCV were independently associated with survival.

High-frequency oscillatory ventilation in pediatric respiratory failure: a multicenter experience.

The use of high-frequency oscillatory ventilation (HFOV) has increased dramatically in the management of respiratory failure in pediatric patients. We surveyed ten pediatric centers that frequently use high-frequency oscillation to describe current clinical practice and to examine factors related to improved outcomes. Retrospective, observational questionnaire study. Ten tertiary care pediatric intensive care units. Two hundred ninety patients managed with HFOV between January 1997 and June 1998. None. Patients were classified according to presence or absence of preexisting lung disease, symptomatic respiratory syncytial virus infection, or presence of cyanotic heart disease or residual right-to-left intracardiac shunt. In addition, patients for whom HFOV acutely failed were analyzed separately. Those patients with preexisting lung disease were significantly smaller, had a significantly higher incidence of pulmonary infection as the triggering etiology, and had a significantly greater duration of conventional ventilation before institution of HFOV compared with patients without preexisting lung disease. Stepwise logistic regression was used to predict mortality and the occurrence of chronic lung disease in survivors. In patients without preexisting lung disease, the model predicted a 70% probability of death when the oxygenation index (OI) after 24 hrs was 28 in the immunocompromised patients and 64 in the patients without immunocompromise. In the immunocompromised patients, the model predicted a 90% probability of death when the OI after 24 hrs was 58. In survivors without preexisting lung disease, the model predicted a 70% probability of developing chronic lung disease when the OI at 24 hrs was 31 in the patients with sepsis syndrome and 50 in the patients without sepsis syndrome. In the patients with sepsis syndrome, the model predicted a 90% probability of developing chronic lung disease when the OI at 24 hrs was 45. Given the number of centers involved and the size of the database, we feel that our results broadly reflect current practice in the use of HFOV in pediatric patients. These results may help in deciding which patients are most likely to benefit from aggressive intervention by using extracorporeal techniques and may help identify high-risk populations appropriate for prospective study of innovative modes of supporting gas exchange (e.g., partial liquid breathing or intratracheal pulmonary ventilation).

High-frequency oscillatory ventilation in pediatric patients.

High-frequency oscillatory ventilation (HFOV) is a ventilatory mode using small tidal volumes with low phasic pressures at supraphysiological frequencies. Beyond the neonatal period there are distinct lung diseases for which HFOV is used. Data of 35 children who deteriorated on conventional ventilation were retrospectively analysed in two tertiary pediatric intensive care units. Depending on the underlying pulmonary pathophysiology, three strategies were employed. First, the 'open-lung' strategy designed to rapidly recruit and maintain optimal lung volume in DAD (n=27) and pulmonary hemorrhage (n=5). Second, the 'low-volume' strategy in persistent air leak (n=1) where, after an initial identical approach, mean airway pressure (MAP) is reduced until the air leak ceases. Third, the 'open-airway' strategy in obstructive airway disease (n=5) where MAP is used to recruit and stent the airways. Seven patients died, two due to respiratory failure. Three patients developed an air leak. Nine patients developed chronic lung disease. There was a significant decrease of the oxygenation index (OI) in the survivors. In the two patients who died of respiratory failure, the OI increased. If certain conditions are met, HFOV appears a safe and effective mode of ventilation in pediatric respiratory failure.

Prospective, randomized comparison of high-frequency oscillatory ventilation and conventional mechanical ventilation in pediatric respiratory failure

Prospective, randomized comparison of high-frequency oscillatory ventilation and conventional mechanical ventilation in pediatric respiratory failure

Prospective, randomized comparison of high-frequency oscillatory ventilation and conventional mechanical ventilation in pediatric respiratory failure

To compare the effectiveness of high-frequency oscillatory ventilation with conventional mechanical ventilation in pediatric patients with respiratory failure. Five tertiary care pediatric intensive care units. A prospective, randomized, clinical study with crossover. Seventy patients with either diffuse alveolar disease and/or airleak syndrome were randomized to receive high-frequency oscillatory ventilation or conventional mechanical ventilation. Patients randomized to receive high-frequency oscillatory ventilation were managed, using a strategy that consisted of aggressive increases in mean airway pressure to attain the "ideal" lung volume and to achieve an arterial oxygen saturation of > or = 90%, with an FIO2 of < or = 0.6. Patients who were randomized to receive conventional mechanical ventilation were treated with a strategy that utilized increases in end-expiratory pressure and inspiratory time to increase mean airway pressure and to limit increases in peak inspiratory pressure. Target blood gas values were the same for both groups. Crossover to the alternate ventilator was required if the patient met defined criteria for treatment failure. Physiologic data and ventilatory parameters were collected prospectively at predetermined intervals after randomization. Airleak Scores were derived daily, based on the chest radiograph and the patient's clinical condition. In the high-frequency oscillatory ventilation group, the PaO2/PAO2 ratio increased significantly and the oxygenation index (mean airway pressure x FIO2 x 100/PaO2) decreased significantly over time. There were no differences between the groups in duration of mechanical ventilation, frequency of airleak, Airleak Scores, or 30-day survival rates. Significantly fewer patients treated with high-frequency oscillatory ventilation required supplemental oxygenation at 30 days compared with patients managed with conventional ventilation. When ventilatory subgroups were compared, the patients managed with high-frequency oscillation only had significantly better ranked outcomes than patients managed with conventional ventilation only. Our results indicate that high-frequency oscillatory ventilation, utilizing an aggressive volume recruitment strategy, results in significant improvement in oxygenation compared with a conventional ventilatory strategy designed to limit increases in peak airway pressures. Furthermore, despite the use of higher mean airway pressures, the optimal lung volume strategy used in this study was associated with a lower frequency of barotrauma, as indicated by requirement for supplemental oxygen at 30 days, and improved outcome compared with conventional mechanical ventilation.

High-frequency oscillatory ventilation in pediatric respiratory failure.

To evaluate the safety and effectiveness of high-frequency oscillatory ventilation using a protocol designed to achieve and maintain optimal lung volume in pediatric patients with respiratory failure. Tertiary care pediatric ICU in a university hospital. A prospective, clinical study. Seven patients aged 1 month to 15 yrs with diffuse alveolar disease and airleak with a variety of primary diagnoses, including pneumonia, adult respiratory distress syndrome, and pulmonary hemorrhage. After varying periods of conventional mechanical ventilation (16 to 216 hrs), patients were managed with high-frequency oscillatory ventilation using a "high-volume" strategy that consisted of incremental increases in mean airway pressure and lung volume to achieve an arterial oxygen saturation of > or = 90%, with an FIO2 of < or = 0.6. Ventilatory settings, including FIO2 and mean airway pressure, hemodynamic parameters (cardiac index, systemic and pulmonary vascular resistance indices, oxygen delivery [DO2] and oxygen extraction ratio) and the oxygenation index (oxygenation index = [FIO2 x mean airway pressure x 100]/PaO2) were monitored during the transition to high-frequency oscillation and throughout the course of the high-frequency oscillatory ventilation with rapid and sustained reductions in mean airway pressure (p = .0001, repeated-measures analysis of variance [ANOVA]) and a trend toward decreasing oxygenation index (p = .08, repeated-measures ANOVA). In the four patients from whom hemodynamic data were obtained, there were no compromises of cardiac index or DO2 despite a significant increase in mean airway pressure (26 +/- 2 to 35 +/- 2 cm H2O) during conversion from conventional ventilation to high-frequency oscillation. High-frequency oscillatory ventilation, using a high-volume strategy, may be used safely and effectively in pediatric patients with respiratory failure and with high predicted mortality rates. High mean airway pressure during oscillatory ventilation does not appear to compromise DO2. Whether this technique can alter morbidity or mortality rates in this population awaits prospective randomized study.

Long-term Mechanical Ventilation in Pediatric Respiratory Failure: Medical and Ethical Considerations

The outlook for survival of mechanically ventilated children with a variety of chronic respiratory disorders has improved to an extent that forces reexamination of traditional views of what is in these children's best interest with respect to medical care. In the ICU setting, this kind of situation represents a major dilemma in current pediatric medical practice since both alternatives (prolonged mechanical ventilation versus withholding/withdrawing) imply an unfavorable outcome. Because the survival and quality of life for children receiving long-term assisted ventilation are not highly discouraging, increasing numbers of pediatric patients are not being managed at home with life-support technology. This article reviews medical data on the survival of children managed with mechanical ventilation and discusses some of the key ethical issues pertaining to decisions about withholding/withdrawing assisted ventilation in infants and children. In addition, we suggest the following guidelines and procedures that might be useful in dealing with the prolonged mechanical ventilation dilemma in pediatric medical practice: (1) obtain the correct facts on prognosis (good ethics start with good facts); (2) avoid irreversible decisions under uncertainty; (3) remember that withdrawing treatment is ethically preferable to withholding; (4) resolve disagreements with the use of outside consultation; (5) include the entire family in the decision-making process; (6) remember that consent is a process, not an event, and requires regular discussions with the family; (7) one physician must be identified as the primary provider and communicator.