儿科急性呼吸窘迫综合征常规机械通气的变异性：是否需要决策支持方案？
Variability in Usual Care Mechanical Ventilation for Pediatric Acute Respiratory Distress Syndrome: Time for a Decision Support Protocol?
机构信息
1Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA. 2Department of Pediatrics, University of Southern California, Keck School of Medicine, Los Angeles, CA. 3University of Utah College of Nursing, Salt Lake City, UT. 4Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, UT. 5Department of Pediatrics, Division of Pediatric Critical Care, University of Utah School of Medicine, Salt Lake City, UT. 6Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI. 7Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA. 8Department of Pediatrics, University of Michigan, Ann Arbor, MI. 9Department of Child Health, Phoenix Children's Hospital, Phoenix, AZ. 10Department of Pediatrics, Children's National Medical Center, Washington, DC. 11Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA. 12Department of Pediatrics, Mattel Children's Hospital, UCLA, Los Angeles, CA. 13Departments of Pediatrics and Biochemistry, Washington University School of Medicine, St. Louis, MO. 14Pediatric Trauma and Critical Illness Branch, National Institutes of Child Health and Human Development (NICHD), Bethesda, MD. 15Formerly Pediatric Trauma and Critical Illness Branch, National Institutes of Child Health and Human Development (NICHD), Bethesda, MD.
出版信息
Pediatr Crit Care Med. 2017 Nov;18(11):e521-e529. doi: 10.1097/PCC.0000000000001319.
OBJECTIVES
Although pediatric intensivists philosophically embrace lung protective ventilation for acute lung injury and acute respiratory distress syndrome, we hypothesized that ventilator management varies. We assessed ventilator management by evaluating changes to ventilator settings in response to blood gases, pulse oximetry, or end-tidal CO2. We also assessed the potential impact that a pediatric mechanical ventilation protocol adapted from National Heart Lung and Blood Institute acute respiratory distress syndrome network protocols could have on reducing variability by comparing actual changes in ventilator settings to those recommended by the protocol.
DESIGN
Prospective observational study.
SETTING
Eight tertiary care U.S. PICUs, October 2011 to April 2012.
PATIENTS
One hundred twenty patients (age range 17 d to 18 yr) with acute lung injury/acute respiratory distress syndrome.
MEASUREMENTS AND MAIN RESULTS
Two thousand hundred arterial and capillary blood gases, 3,964 oxygen saturation by pulse oximetry, and 2,757 end-tidal CO2 values were associated with 3,983 ventilator settings. Ventilation mode at study onset was pressure control 60%, volume control 19%, pressure-regulated volume control 18%, and high-frequency oscillatory ventilation 3%. Clinicians changed FIO2 by ±5 or ±10% increments every 8 hours. Positive end-expiratory pressure was limited at ~10 cm H2O as oxygenation worsened, lower than would have been recommended by the protocol. In the first 72 hours of mechanical ventilation, maximum tidal volume/kg using predicted versus actual body weight was 10.3 (8.5-12.9) (median [interquartile range]) versus 9.2 mL/kg (7.6-12.0) (p < 0.001). Intensivists made changes similar to protocol recommendations 29% of the time, opposite to the protocol's recommendation 12% of the time and no changes 56% of the time.
CONCLUSIONS
Ventilator management varies substantially in children with acute respiratory distress syndrome. Opportunities exist to minimize variability and potentially injurious ventilator settings by using a pediatric mechanical ventilation protocol offering adequately explicit instructions for given clinical situations. An accepted protocol could also reduce confounding by mechanical ventilation management in a clinical trial.
目的
尽管儿科重症监护医生从哲学上接受肺保护性通气治疗急性肺损伤和急性呼吸窘迫综合征，但我们假设通气管理会有所不同。我们通过评估血气、脉搏血氧饱和度或呼气末二氧化碳变化时对呼吸机设置的调整来评估通气管理。我们还评估了从美国国立心肺血液研究所急性呼吸窘迫综合征网络协议改编的小儿机械通气协议对减少变异性的潜在影响，即将实际呼吸机设置的变化与协议推荐的变化进行比较。
设计
前瞻性观察性研究。
地点
美国 8 个三级护理儿科重症监护病房，2011 年 10 月至 2012 年 4 月。
患者
120 名患有急性肺损伤/急性呼吸窘迫综合征的患儿（年龄 17 天至 18 岁）。
测量和主要结果
与 3983 个呼吸机设置相关的有 2000 次动脉和毛细血管血气、3964 次脉搏血氧饱和度和 2757 次呼气末二氧化碳值。研究开始时的通气模式为压力控制 60%、容量控制 19%、压力调节容量控制 18%和高频振荡通气 3%。临床医生每 8 小时将 FIO2 改变±5 或±10%。随着氧合恶化，呼气末正压被限制在~10 cm H2O，低于协议推荐的值。在机械通气的头 72 小时内，使用预测体重和实际体重的最大潮气量/kg 分别为 10.3（8.5-12.9）（中位数[四分位间距]）和 9.2 mL/kg（7.6-12.0）（p < 0.001）。重症监护医生的调整与协议建议相似的时间为 29%，与协议建议相反的时间为 12%，没有调整的时间为 56%。
结论
患有急性呼吸窘迫综合征的儿童的通气管理差异很大。通过使用提供特定临床情况的明确说明的小儿机械通气协议，可以有机会减少变异性和潜在的呼吸机设置损伤。一个被接受的协议也可以在临床试验中减少机械通气管理的混杂因素。
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