Objectives: 

Reduced morbidity and mortality associated with lung-protective mechanical ventilation is not proven in pediatric acute respiratory distress syndrome. This study aims to determine if a lung-protective mechanical ventilation protocol in pediatric acute respiratory distress syndrome is associated with improved clinical outcomes.

Design: 

This pilot study over April 2016 to September 2019 adopts a before-and-after comparison design of a lung-protective mechanical ventilation protocol. All admissions to the PICU were screened daily for fulfillment of the Pediatric Acute Lung Injury Consensus Conference criteria and included.

Setting: 

Multidisciplinary PICU.

Patients: 

Patients with pediatric acute respiratory distress syndrome.

Interventions: 

Lung-protective mechanical ventilation protocol with elements on peak pressures, tidal volumes, end-expiratory pressure to Fio₂ combinations, permissive hypercapnia, and permissive hypoxemia.

Measurements and Main Results: 

Ventilator and blood gas data were collected for the first 7 days of pediatric acute respiratory distress syndrome and compared between the protocol (n = 63) and nonprotocol groups (n = 69). After implementation of the protocol, median tidal volume (6.4 mL/kg [5.4–7.8 mL/kg] vs 6.0 mL/kg [4.8–7.3 mL/kg]; p = 0.005), Pao₂ (78.1 mm Hg [67.0–94.6 mm Hg] vs 74.5 mm Hg [59.2–91.1 mm Hg]; p = 0.001), and oxygen saturation (97% [95–99%] vs 96% [94–98%]; p = 0.007) were lower, and end-expiratory pressure (8 cm H₂O [7–9 cm H₂O] vs 8 cm H₂O [8–10 cm H₂O]; p = 0.002] and Paco₂ (44.9 mm Hg [38.8–53.1 mm Hg] vs 46.4 mm Hg [39.4–56.7 mm Hg]; p = 0.033) were higher, in keeping with lung protective measures. There was no difference in mortality (10/63 [15.9%] vs 18/69 [26.1%]; p = 0.152), ventilator-free days (16.0 [2.0–23.0] vs 19.0 [0.0–23.0]; p = 0.697), and PICU-free days (13.0 [0.0–21.0] vs 16.0 [0.0–22.0]; p = 0.233) between the protocol and nonprotocol groups. After adjusting for severity of illness, organ dysfunction and oxygenation index, the lung-protective mechanical ventilation protocol was associated with decreased mortality (adjusted hazard ratio, 0.37; 95% CI, 0.16–0.88).

Conclusions: 

In pediatric acute respiratory distress syndrome, a lung-protective mechanical ventilation protocol improved adherence to lung-protective mechanical ventilation strategies and potentially mortality.

中文翻译：

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小儿急性呼吸窘迫综合征的肺保护机械通气策略。

目标： 

在小儿急性呼吸窘迫综合征中，尚未证明与肺保护性机械通气相关的发病率和死亡率降低。本研究旨在确定小儿急性呼吸窘迫综合征的肺保护性机械通气方案是否与改善的临床结局相关。

设计： 

该研究于2016年4月至2019年9月进行，采用了肺保护性机械通气方案的前后对比设计。每天对PICU的所有入院患者进行筛查，以符合《小儿急性肺损伤共识会议》的标准并包括在内。

设置： 

多学科PICU。

耐心： 

小儿急性呼吸窘迫综合征患者。

干预措施： 

肺保护性机械通气方案，包括峰值压力，潮气量，呼气末至F io ₂组合的要素，允许的高碳酸血症和允许的低氧血症。

测量和主要结果： 

收集了小儿急性呼吸窘迫综合征前7天的呼吸机和血气数据，并比较了方案（n = 63）和非协议组（n = 69）。实施方案后，潮气中位数（6.4 mL / kg [5.4–7.8 mL / kg] vs 6.0 mL / kg [4.8–7.3 mL / kg]；p = 0.005），Pa o ₂（78.1 mm Hg [67.0] –94.6 mm Hg]和74.5 mm Hg [59.2–91.1 mm Hg]；p = 0.001）和氧饱和度（97％[95–99％] vs 96％[94–98％]；p = 0.007）更低和呼气末压（8 cm H ₂ O [7–9 cm H ₂ O]与8 cm H ₂ O [8–10 cm H ₂O]; p = 0.002]和Pa co ₂（44.9 mm Hg [38.8-53.1 mm Hg]对46.4 mm Hg [39.4-56.7 mm Hg]；p = 0.033）较高，符合肺保护措施。无呼吸机天数（10/63 [15.9％] vs 18/69 [26.1％]；p = 0.152），无呼吸机天数（16.0 [2.0–23.0] vs 19.0 [0.0–23.0]；p = 0.697）无差异）以及协议和非协议组之间的无PICU的天数（分别为13.0 [0.0-21.0]和16.0 [0.0-22.0]；p = 0.233）。在根据疾病的严重程度，器官功能障碍和氧合指数进行调整后，进行肺保护性机械通气的方案可降低死亡率（调整后的危险比为0.37； 95％CI为0.16-0.88）。

结论： 

在小儿急性呼吸窘迫综合征中，肺保护性机械通气方案改善了对肺保护性机械通气策略的依从性，并提高了死亡率。