Rowan Courtney M, Gertz Shira J, McArthur Jennifer, Fitzgerald Julie C, Nitu Mara E, Loomis Ashley, Hsing Deyin D, Duncan Christine N, Mahadeo Kris M, Smith Lincoln S, Moffet Jerelyn, Hall Mark W, Pinos Emily L, Cheifetz Ira M, Tamburro Robert F
1Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN. 2Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack, NJ. 3Department of Pediatrics, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI. 4Department of Anesthesia, Children's Hospital of Philadelphia University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. 5Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN. 6Department of Pediatrics, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY. 7Department of Pediatrics, Dana-Farber Cancer Institute, Boston, MA. 8Department of Pediatrics, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY. 9Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, WA. 10Department of Pediatrics, Duke Children's Hospital, Durham, NC. 11Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH. 12Department of Pediatrics, Pennsylvania State University College of Medicine, Penn State Hershey Children's Hospital, Hershey, PA. 13Department of Public Health, Pennsylvania State University College of Medicine, Penn State Hershey Children's Hospital, Hershey, PA.
Pediatr Crit Care Med. 2016 Apr;17(4):294-302. doi: 10.1097/PCC.0000000000000673.
To establish the current respiratory practice patterns in pediatric hematopoietic stem cell transplant patients and investigate their associations with mortality across multiple centers.
Retrospective cohort between 2009 and 2014.
Twelve children's hospitals in the United States.
Two hundred twenty-two pediatric allogeneic hematopoietic stem cell transplant recipients with acute respiratory failure using invasive mechanical ventilation.
None.
PICU mortality of our cohort was 60.4%. Mortality at 180 days post PICU discharge was 74%. Length of PICU stay prior to initiation of invasive mechanical ventilation was significantly lower in survivors, and the odds of mortality increased for longer length of PICU stay prior to intubation. A total of 91 patients (41%) received noninvasive ventilation at some point during their PICU stay prior to intubation. Noninvasive ventilation use preintubation was associated with increased mortality (odds ratio, 2.1; 95% CI, 1.2-3.6; p = 0.010). Patients ventilated longer than 15 days had higher odds of death (odds ratio, 2.4; 95% CI, 1.3-4.2; p = 0.004). Almost 40% of patients (n = 85) were placed on high-frequency oscillatory ventilation with a mortality of 76.5% (odds ratio, 3.3; 95% CI, 1.7-6.5; p = 0.0004). Of the 20 patients who survived high-frequency oscillatory ventilation, 18 were placed on high-frequency oscillatory ventilation no later than the third day of invasive mechanical ventilation. In this subset of 85 patients, transition to high-frequency oscillatory ventilation within 2 days of the start of invasive mechanical ventilation resulted in a 76% decrease in the odds of death compared with those who transitioned to high-frequency oscillatory ventilation later in the invasive mechanical ventilation course.
This study suggests that perhaps earlier more aggressive critical care interventions in the pediatric hematopoietic stem cell transplant patient with respiratory failure requiring invasive mechanical ventilation may offer an opportunity to improve outcomes.
确立儿科造血干细胞移植患者当前的呼吸治疗模式，并调查多中心中这些模式与死亡率的关联。
2009年至2014年的回顾性队列研究。
美国的12家儿童医院。
222例接受有创机械通气的急性呼吸衰竭儿科异基因造血干细胞移植受者。
无。
我们队列的儿科重症监护病房（PICU）死亡率为60.4%。PICU出院后180天的死亡率为74%。在开始有创机械通气之前，幸存者的PICU住院时间显著更短，插管前PICU住院时间越长，死亡几率越高。共有91例患者（41%）在插管前的PICU住院期间的某个时间接受了无创通气。插管前使用无创通气与死亡率增加相关（比值比，2.1；95%置信区间，1.2 - 3.6；p = 0.010）。通气时间超过15天的患者死亡几率更高（比值比，2.4；95%置信区间，1.3 - 4.2；p = 0.004）。近40%的患者（n = 85）接受了高频振荡通气，死亡率为76.5%（比值比，3.3；95%置信区间，1.7 - 6.5；p = 0.0004）。在20例高频振荡通气存活的患者中，18例在不晚于有创机械通气第三天时接受了高频振荡通气。在这85例患者的亚组中，与在有创机械通气过程后期转为高频振荡通气的患者相比，在开始有创机械通气后2天内转为高频振荡通气的患者死亡几率降低了76%。
本研究表明，对于需要有创机械通气的呼吸衰竭儿科造血干细胞移植患者，或许更早、更积极的重症监护干预可能提供改善预后的机会。
