Lung-Protective Ventilation for Pediatric Acute Respiratory Distress Syndrome: A Nonrandomized Controlled Trial∗

Judith Ju Ming Wong; Hongxing Dang; Chin Seng Gan; Phuc Huu Phan; Hiroshi Kurosawa; Kazunori Aoki; Siew Wah Lee; Jacqueline Soo May Ong; Li Jia Fan; Chian Wern Tai; Soo Lin Chuah; Pei Chuen Lee; Yek Kee Chor; Louise Ngu; Nattachai Anantasit; Chunfeng Liu; Wei Xu; Dyah Kanya Wati; Suparyatha Ida Bagus Gede; Muralidharan Jayashree; Felix Liauw; Kah Min Pon; Li Huang; Jia Yueh Chong; Xuemei Zhu; Kam Lun Ellis Hon; Karen Ka Yan Leung; Rujipat Samransamruajkit; Yin Bun Cheung; Jan Hau Lee

doi:10.1097/CCM.0000000000006357

Lung-Protective Ventilation for Pediatric Acute Respiratory Distress Syndrome: A Nonrandomized Controlled Trial∗

Judith Ju Ming Wong^*
, Hongxing Dang
, Chin Seng Gan
, Phuc Huu Phan
, Hiroshi Kurosawa
, Kazunori Aoki
, Siew Wah Lee
, Jacqueline Soo May Ong
, Li Jia Fan
, Chian Wern Tai
, Soo Lin Chuah
, Pei Chuen Lee
, Yek Kee Chor
, Louise Ngu
, Nattachai Anantasit
, Chunfeng Liu
, Wei Xu
, Dyah Kanya Wati
, Suparyatha Ida Bagus Gede
, Muralidharan Jayashree

Felix Liauw, Kah Min Pon, Li Huang, Jia Yueh Chong, Xuemei Zhu, Kam Lun Ellis Hon, Karen Ka Yan Leung, Rujipat Samransamruajkit, Yin Bun Cheung, Jan Hau Lee

^*Corresponding author for this work

Children's and Women's health, Diagnostic Medicine, Psychiatry

Research output: Contribution to journal › Article › Scientific › peer-review

19 Citations (Scopus)

Abstract

OBJECTIVES: Despite the recommendation for lung-protective mechanical ventilation (LPMV) in pediatric acute respiratory distress syndrome (PARDS), there is a lack of robust supporting data and variable adherence in clinical practice. This study evaluates the impact of an LPMV protocol vs. standard care and adherence to LPMV elements on mortality. We hypothesized that LPMV strategies deployed as a pragmatic protocol reduces mortality in PARDS. DESIGN: Multicenter prospective before-and-after comparison design study. SETTING: Twenty-one PICUs. PATIENTS: Patients fulfilled the Pediatric Acute Lung Injury Consensus Conference 2015 definition of PARDS and were on invasive mechanical ventilation. INTERVENTIONS: The LPMV protocol included a limit on peak inspiratory pressure (PIP), delta/driving pressure (DP), tidal volume, positive end-expiratory pressure (PEEP) to Fio2 combinations of the low PEEP acute respiratory distress syndrome network table, permissive hypercarbia, and conservative oxygen targets. MEASUREMENTS AND MAIN RESULTS: There were 285 of 693 (41·1%) and 408 of 693 (58·9%) patients treated with and without the LPMV protocol, respectively. Median age and oxygenation index was 1.5 years (0.4-5.3 yr) and 10.9 years (7.0-18.6 yr), respectively. There was no difference in 60-day mortality between LPMV and non-LPMV protocol groups (65/285 [22.8%] vs. 115/406 [28.3%]; p = 0.104). However, total adherence score did improve in the LPMV compared to non-LPMV group (57.1 [40.0-66.7] vs. 47.6 [31.0-58.3]; p < 0·001). After adjusting for confounders, adherence to LPMV strategies (adjusted hazard ratio, 0.98; 95% CI, 0.97-0.99; p = 0.004) but not the LPMV protocol itself was associated with a reduced risk of 60-day mortality. Adherence to PIP, DP, and PEEP/Fio2 combinations were associated with reduced mortality. CONCLUSIONS: Adherence to LPMV elements over the first week of PARDS was associated with reduced mortality. Future work is needed to improve implementation of LPMV in order to improve adherence.

Original language	English
Pages (from-to)	1602-1611
Number of pages	10
Journal	Critical Care Medicine
Volume	52
Issue number	10
DOIs	https://doi.org/10.1097/CCM.0000000000006357
Publication status	Published - Oct 2024
Publication type	A1 Journal article-refereed

Funding

This study was funded by the Pediatric Academic Clinical Program/Tan Cheng Lim (grant number: PAEDSACP-TCL/2020/RES/001, principal investigator to Dr. Wong). Dr. Wong\u2019s institution received funding from the Pediatric Academic Clinical Program/Nurturing Clinician Scientist Scheme (2020), the National Medical Research Council (NMRC) Research Training Fellowship (FLWP20nov_0002), and the Academy of Medicine Malaysia. Drs. Wong\u2019s and Lee\u2019s institutions received funding from the NMRC Singapore. Dr. Pon disclosed government work. Dr. Hon\u2019s institution received funding from the Health and Medical Research Fund. Dr. Jan Hau Lee\u2019s institution received funding from the Thrasher foundation. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Funders	Funder number
Pediatric Academic Clinical Program
Health and Medical Research Fund
Academy of Medicine Malaysia
Thrasher Research Fund
Tan Cheng Lim	PAEDSACP-TCL/2020/RES/001
National Medical Research Council	FLWP20nov_0002

Keywords

acute lung injury
artificial ventilation
children
mortality
pediatric intensive care units

Publication forum classification

Publication forum level 2

ASJC Scopus subject areas

Critical Care and Intensive Care Medicine

Access to Document

10.1097/CCM.0000000000006357

Cite this

Wong, J. J. M., Dang, H., Gan, C. S., Phan, P. H., Kurosawa, H., Aoki, K., Lee, S. W., Ong, J. S. M., Fan, L. J., Tai, C. W., Chuah, S. L., Lee, P. C., Chor, Y. K., Ngu, L., Anantasit, N., Liu, C., Xu, W., Wati, D. K., Gede, S. I. B., ... Lee, J. H. (2024). Lung-Protective Ventilation for Pediatric Acute Respiratory Distress Syndrome: A Nonrandomized Controlled Trial∗. Critical Care Medicine, 52(10), 1602-1611. https://doi.org/10.1097/CCM.0000000000006357

@article{5aae3016d5fb43ec8a1dd7073342de8b,

title = "Lung-Protective Ventilation for Pediatric Acute Respiratory Distress Syndrome: A Nonrandomized Controlled Trial∗",

abstract = "OBJECTIVES: Despite the recommendation for lung-protective mechanical ventilation (LPMV) in pediatric acute respiratory distress syndrome (PARDS), there is a lack of robust supporting data and variable adherence in clinical practice. This study evaluates the impact of an LPMV protocol vs. standard care and adherence to LPMV elements on mortality. We hypothesized that LPMV strategies deployed as a pragmatic protocol reduces mortality in PARDS. DESIGN: Multicenter prospective before-and-after comparison design study. SETTING: Twenty-one PICUs. PATIENTS: Patients fulfilled the Pediatric Acute Lung Injury Consensus Conference 2015 definition of PARDS and were on invasive mechanical ventilation. INTERVENTIONS: The LPMV protocol included a limit on peak inspiratory pressure (PIP), delta/driving pressure (DP), tidal volume, positive end-expiratory pressure (PEEP) to Fio2 combinations of the low PEEP acute respiratory distress syndrome network table, permissive hypercarbia, and conservative oxygen targets. MEASUREMENTS AND MAIN RESULTS: There were 285 of 693 (41·1\%) and 408 of 693 (58·9\%) patients treated with and without the LPMV protocol, respectively. Median age and oxygenation index was 1.5 years (0.4-5.3 yr) and 10.9 years (7.0-18.6 yr), respectively. There was no difference in 60-day mortality between LPMV and non-LPMV protocol groups (65/285 [22.8\%] vs. 115/406 [28.3\%]; p = 0.104). However, total adherence score did improve in the LPMV compared to non-LPMV group (57.1 [40.0-66.7] vs. 47.6 [31.0-58.3]; p < 0·001). After adjusting for confounders, adherence to LPMV strategies (adjusted hazard ratio, 0.98; 95\% CI, 0.97-0.99; p = 0.004) but not the LPMV protocol itself was associated with a reduced risk of 60-day mortality. Adherence to PIP, DP, and PEEP/Fio2 combinations were associated with reduced mortality. CONCLUSIONS: Adherence to LPMV elements over the first week of PARDS was associated with reduced mortality. Future work is needed to improve implementation of LPMV in order to improve adherence.",

keywords = "acute lung injury, artificial ventilation, children, mortality, pediatric intensive care units",

author = "Wong, \{Judith Ju Ming\} and Hongxing Dang and Gan, \{Chin Seng\} and Phan, \{Phuc Huu\} and Hiroshi Kurosawa and Kazunori Aoki and Lee, \{Siew Wah\} and Ong, \{Jacqueline Soo May\} and Fan, \{Li Jia\} and Tai, \{Chian Wern\} and Chuah, \{Soo Lin\} and Lee, \{Pei Chuen\} and Chor, \{Yek Kee\} and Louise Ngu and Nattachai Anantasit and Chunfeng Liu and Wei Xu and Wati, \{Dyah Kanya\} and Gede, \{Suparyatha Ida Bagus\} and Muralidharan Jayashree and Felix Liauw and Pon, \{Kah Min\} and Li Huang and Chong, \{Jia Yueh\} and Xuemei Zhu and Hon, \{Kam Lun Ellis\} and Leung, \{Karen Ka Yan\} and Rujipat Samransamruajkit and Cheung, \{Yin Bun\} and Lee, \{Jan Hau\}",

year = "2024",

month = oct,

doi = "10.1097/CCM.0000000000006357",

language = "English",

volume = "52",

pages = "1602--1611",

journal = "Critical Care Medicine",

issn = "0090-3493",

publisher = "Lippincott Williams and Wilkins",

number = "10",

}

Wong, JJM, Dang, H, Gan, CS, Phan, PH, Kurosawa, H, Aoki, K, Lee, SW, Ong, JSM, Fan, LJ, Tai, CW, Chuah, SL, Lee, PC, Chor, YK, Ngu, L, Anantasit, N, Liu, C, Xu, W, Wati, DK, Gede, SIB, Jayashree, M, Liauw, F, Pon, KM, Huang, L, Chong, JY, Zhu, X, Hon, KLE, Leung, KKY, Samransamruajkit, R, Cheung, YB & Lee, JH 2024, 'Lung-Protective Ventilation for Pediatric Acute Respiratory Distress Syndrome: A Nonrandomized Controlled Trial∗', Critical Care Medicine, vol. 52, no. 10, pp. 1602-1611. https://doi.org/10.1097/CCM.0000000000006357

TY - JOUR

T1 - Lung-Protective Ventilation for Pediatric Acute Respiratory Distress Syndrome

T2 - A Nonrandomized Controlled Trial∗

AU - Wong, Judith Ju Ming

AU - Dang, Hongxing

AU - Gan, Chin Seng

AU - Phan, Phuc Huu

AU - Kurosawa, Hiroshi

AU - Aoki, Kazunori

AU - Lee, Siew Wah

AU - Ong, Jacqueline Soo May

AU - Fan, Li Jia

AU - Tai, Chian Wern

AU - Chuah, Soo Lin

AU - Lee, Pei Chuen

AU - Chor, Yek Kee

AU - Ngu, Louise

AU - Anantasit, Nattachai

AU - Liu, Chunfeng

AU - Xu, Wei

AU - Wati, Dyah Kanya

AU - Gede, Suparyatha Ida Bagus

AU - Jayashree, Muralidharan

AU - Liauw, Felix

AU - Pon, Kah Min

AU - Huang, Li

AU - Chong, Jia Yueh

AU - Zhu, Xuemei

AU - Hon, Kam Lun Ellis

AU - Leung, Karen Ka Yan

AU - Samransamruajkit, Rujipat

AU - Cheung, Yin Bun

AU - Lee, Jan Hau

PY - 2024/10

Y1 - 2024/10

N2 - OBJECTIVES: Despite the recommendation for lung-protective mechanical ventilation (LPMV) in pediatric acute respiratory distress syndrome (PARDS), there is a lack of robust supporting data and variable adherence in clinical practice. This study evaluates the impact of an LPMV protocol vs. standard care and adherence to LPMV elements on mortality. We hypothesized that LPMV strategies deployed as a pragmatic protocol reduces mortality in PARDS. DESIGN: Multicenter prospective before-and-after comparison design study. SETTING: Twenty-one PICUs. PATIENTS: Patients fulfilled the Pediatric Acute Lung Injury Consensus Conference 2015 definition of PARDS and were on invasive mechanical ventilation. INTERVENTIONS: The LPMV protocol included a limit on peak inspiratory pressure (PIP), delta/driving pressure (DP), tidal volume, positive end-expiratory pressure (PEEP) to Fio2 combinations of the low PEEP acute respiratory distress syndrome network table, permissive hypercarbia, and conservative oxygen targets. MEASUREMENTS AND MAIN RESULTS: There were 285 of 693 (41·1%) and 408 of 693 (58·9%) patients treated with and without the LPMV protocol, respectively. Median age and oxygenation index was 1.5 years (0.4-5.3 yr) and 10.9 years (7.0-18.6 yr), respectively. There was no difference in 60-day mortality between LPMV and non-LPMV protocol groups (65/285 [22.8%] vs. 115/406 [28.3%]; p = 0.104). However, total adherence score did improve in the LPMV compared to non-LPMV group (57.1 [40.0-66.7] vs. 47.6 [31.0-58.3]; p < 0·001). After adjusting for confounders, adherence to LPMV strategies (adjusted hazard ratio, 0.98; 95% CI, 0.97-0.99; p = 0.004) but not the LPMV protocol itself was associated with a reduced risk of 60-day mortality. Adherence to PIP, DP, and PEEP/Fio2 combinations were associated with reduced mortality. CONCLUSIONS: Adherence to LPMV elements over the first week of PARDS was associated with reduced mortality. Future work is needed to improve implementation of LPMV in order to improve adherence.

AB - OBJECTIVES: Despite the recommendation for lung-protective mechanical ventilation (LPMV) in pediatric acute respiratory distress syndrome (PARDS), there is a lack of robust supporting data and variable adherence in clinical practice. This study evaluates the impact of an LPMV protocol vs. standard care and adherence to LPMV elements on mortality. We hypothesized that LPMV strategies deployed as a pragmatic protocol reduces mortality in PARDS. DESIGN: Multicenter prospective before-and-after comparison design study. SETTING: Twenty-one PICUs. PATIENTS: Patients fulfilled the Pediatric Acute Lung Injury Consensus Conference 2015 definition of PARDS and were on invasive mechanical ventilation. INTERVENTIONS: The LPMV protocol included a limit on peak inspiratory pressure (PIP), delta/driving pressure (DP), tidal volume, positive end-expiratory pressure (PEEP) to Fio2 combinations of the low PEEP acute respiratory distress syndrome network table, permissive hypercarbia, and conservative oxygen targets. MEASUREMENTS AND MAIN RESULTS: There were 285 of 693 (41·1%) and 408 of 693 (58·9%) patients treated with and without the LPMV protocol, respectively. Median age and oxygenation index was 1.5 years (0.4-5.3 yr) and 10.9 years (7.0-18.6 yr), respectively. There was no difference in 60-day mortality between LPMV and non-LPMV protocol groups (65/285 [22.8%] vs. 115/406 [28.3%]; p = 0.104). However, total adherence score did improve in the LPMV compared to non-LPMV group (57.1 [40.0-66.7] vs. 47.6 [31.0-58.3]; p < 0·001). After adjusting for confounders, adherence to LPMV strategies (adjusted hazard ratio, 0.98; 95% CI, 0.97-0.99; p = 0.004) but not the LPMV protocol itself was associated with a reduced risk of 60-day mortality. Adherence to PIP, DP, and PEEP/Fio2 combinations were associated with reduced mortality. CONCLUSIONS: Adherence to LPMV elements over the first week of PARDS was associated with reduced mortality. Future work is needed to improve implementation of LPMV in order to improve adherence.

KW - acute lung injury

KW - artificial ventilation

KW - children

KW - mortality

KW - pediatric intensive care units

U2 - 10.1097/CCM.0000000000006357

DO - 10.1097/CCM.0000000000006357

M3 - Article

C2 - 38920618

AN - SCOPUS:85204167638

SN - 0090-3493

VL - 52

SP - 1602

EP - 1611

JO - Critical Care Medicine

JF - Critical Care Medicine

IS - 10

ER -

Lung-Protective Ventilation for Pediatric Acute Respiratory Distress Syndrome: A Nonrandomized Controlled Trial∗

Abstract

Funding

Keywords

Publication forum classification

ASJC Scopus subject areas

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