Improved oxygenation 24 hours after transition to airway pressure release ventilation or high-frequency oscillatory ventilation accurately discriminates survival in immunocompromised pediatric patients with acute respiratory distress syndrome

Nadir Yehya, Alexis A. Topjian, Neal J. Thomas, Stuart H. Friess

Research output: Contribution to journalArticlepeer-review

30 Scopus citations

Abstract

Objectives: Children with an immunocompromised condition and requiring invasive mechanical ventilation have high risk of death. Such patients are commonly transitioned to rescue modes of nonconventional ventilation, including airway pressure release ventilation and high-frequency oscillatory ventilation, for acute respiratory distress syndrome refractory to conventional ventilation. Our aim was to describe our experience with airway pressure release ventilation and high-frequency oscillatory ventilation in children with an immunocompromised condition and acute respiratory distress syndrome refractory to conventional ventilation and to identify factors associated with survival. Design: Retrospective cohort study. Setting: Tertiary care, university-affiliated PICU. Patients: Sixty pediatric patients with an immunocompromised condition and acute respiratory distress syndrome refractory to conventional ventilation transitioned to either airway pressure release ventilation or high-frequency oscillatory ventilation. Interventions: None. Measurements and Main Results: Demographic data, ventilator settings, arterial blood gases, oxygenation index, and PaO2/FIO2 were recorded before transition to either mode of nonconventional ventilation and at predetermined intervals after transition for up to 5 days. Mortality in the entire cohort was 63% and did not differ between patients transitioned to airway pressure release ventilation and high-frequency oscillatory ventilation. For both airway pressure release ventilation and high-frequency oscillatory ventilation, improvements in oxygenation index and PaO2/FIO2 at 24 hours expressed as a fraction of pretransition values (oxygenation index24/oxygenation indexpre and PaO2/FIO224/PaO2/FIO2pre) reliably discriminated nonsurvivors from survivors, with receiver operating characteristic areas under the curves between 0.89 and 0.95 (p for all curves < 0.001). Sensitivity-specificity analysis suggested that less than 15% reduction in oxygenation index (90% sensitive, 75% specific) or less than 90% increase in PaO2/FIO2 (80% sensitive, 94% specific) 24 hours after transition to airway pressure release ventilation were the optimal cutoffs to identify nonsurvivors. The comparable values 24 hours after transition to high-frequency oscillatory ventilation were less than 5% reduction in oxygenation index (100% sensitive, 83% specific) or less than 80% increase in PaO2/FIO2 (91% sensitive, 89% specific) to identify nonsurvivors. Conclusions: In this single-center retrospective study of pediatric patients with an immunocompromised condition and acute respiratory distress syndrome failing conventional ventilation transitioned to either airway pressure release ventilation or high-frequency oscillatory ventilation, improved oxygenation at 24 hours expressed as PaO2/FIO 224/PaO2/FIO2pre or oxygenation index24/oxygenation indexpre reliably discriminates nonsurvivors from survivors. These findings should be prospectively verified.

Original languageEnglish
Pages (from-to)e147-e156
JournalPediatric Critical Care Medicine
Volume15
Issue number4
DOIs
StatePublished - May 2014

Keywords

  • Acute lung injury
  • Acute respiratory distress syndrome
  • Airway pressure release ventilation
  • High-frequency oscillatory ventilation
  • Mechanical ventilation
  • Pediatric

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