Pressure characteristics of mechanical ventilation and incidence of pneumothorax before and after the implementation of protective lung strategies in the management of pediatric patients with severe ARDS

Chest. 2008 Nov;134(5):969-973. doi: 10.1378/chest.08-0743. Epub 2008 Aug 8.

Abstract

Objective: To compare pressure characteristics of mechanical ventilation and their impact on pediatric patients with severe ARDS in the pre-protective lung strategy (PLS) and post-PLS eras.

Methods: Medical records of 33 patients admitted to our pediatric ICU with ARDS from 1992 through 1994 (pre-PLS) and 52 patients with ARDS admitted from 2000 through 2003 (post-PLS) were retrospectively reviewed.

Results: Patient age and gender distribution were identical in both eras. Fifty-five percent of the patients in the pre-PLS era had pneumothorax, compared to 17% in the post-PLS era (p < 0.05). Overall mortality rates for patients in the pre-PLS and post-PLS eras were 42% and 25%, respectively (p = 0.09; not significant). Mean duration of exposure to peak inspiratory pressure (PIP) values > 40 cm H2O was significantly longer in the pre-PLS era than in the post-PLS era. Pre-PLS patients with pneumothorax received mean maximum PIP of 72 +/- 17 cm H2O, mean maximum positive end-expiratory pressure (PEEP) of 20 +/- 5 cm H2O, and maximum mean airway pressure (MAP) of 46 +/- 8 cm H2O, while patients in the post-PLS era required mean maximum PIP of 42 +/- 2 cm H2O, mean maximum PEEP of 14 +/- 2 cm H2O, and maximum MAP of 30 +/- 6 cm H2O, respectively (p < 0.05 for all pressure parameters). There were no significant differences in mechanical ventilation pressure characteristics among patients who did not have pneumothorax during their course of management in both eras.

Conclusions: A significantly more aggressive use of ventilator pressure characteristics distinguished the pre-PLS era from the post-PLS era, and was found to be associated with a markedly higher incidence of pneumothorax. Outcome in both eras did not differ significantly, presumably due to insufficient statistical power.

Publication types

  • Comparative Study

MeSH terms

  • Child
  • Female
  • Humans
  • Incidence
  • Intensive Care Units, Pediatric
  • Male
  • Pneumothorax / epidemiology
  • Pneumothorax / etiology*
  • Pneumothorax / prevention & control
  • Positive-Pressure Respiration / adverse effects*
  • Practice Guidelines as Topic*
  • Pressure / adverse effects
  • Respiratory Distress Syndrome, Adult / diagnosis
  • Respiratory Distress Syndrome, Adult / physiopathology
  • Respiratory Distress Syndrome, Adult / therapy*
  • Retrospective Studies
  • Risk Factors
  • Survival Rate