Department of Pediatric Intensive Care Unit, Dr Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey.
Department of Medical Research, HamiltonMedical AG, Bonaduz, Switzerland.
Pediatr Pulmonol. 2021 Sep;56(9):3035-3043. doi: 10.1002/ppul.25561. Epub 2021 Jul 22.
In mechanically ventilated patients, driving pressure (ΔP) represents the dynamic stress applied to the respiratory system and is related to ICU mortality. An evolution of the Adaptive Support Ventilation algorithm (ASV® 1.1) minimizes inspiratory pressure in addition to minimizing the work of breathing. We hypothesized that ASV 1.1 would result in lower ΔP than the ΔP measured in APV-CMV (controlled mandatory ventilation with adaptive pressure ventilation) mode with physician-tailored settings. The aim of this randomized crossover trial was therefore to compare ΔP in ASV 1.1 with ΔP in physician-tailored APV-CMV mode.
Pediatric patients admitted to the PICU with heterogeneous-lung disease were enrolled if they were ventilated invasively with no detectable respiratory effort, hemodynamic instability, or significant airway leak around the endotracheal tube. We compared two 60-min periods of ventilation in APV-CMV and ASV 1.1, which were determined by randomization and separated by 30-min washout periods. Settings were adjusted to reach the same minute ventilation in both modes. ΔP was calculated as the difference between plateau pressure and total PEEP measured using end-inspiratory and end-expiratory occlusions, respectively.
There were 26 patients enrolled with a median age of 16 (9-25 [IQR]) months. The median ΔP for these patients was 10.4 (8.5-12.1 [IQR]) and 12.4 (10.5-15.3 [IQR]) cmH2O in the ASV 1.1 and APV-CMV periods, respectively (p < .001). The median tidal volume (VT) selected by the ASV 1.1 algorithm was 6.4 (5.1-7.3 [IQR]) ml/kg and RR was 41 (33 50 [IQR]) b/min, whereas the median of the same values for the APV-CMV period was 7.9 (6.8-8.3 [IQR]) ml/kg and 31 (26-41[IQR]) b/min, respectively. In both ASV 1.1 and APV-CMV modes, the highest ΔP was used to ventilate those patients with restrictive lung conditions at baseline.
In this randomized crossover trial, ΔP in ASV 1.1 was lower compared to ΔP in physician-tailored APV-CMV mode in pediatric patients with different lung conditions. The use of ASV 1.1 may therefore result in continued, safe ventilation in a heterogeneous pediatric patient group.
在机械通气患者中，驱动压（ΔP）代表作用于呼吸系统的动态压力，与 ICU 死亡率相关。自适应支持通气算法（ASV® 1.1）的演进除了最小化呼吸功外，还最小化吸气压力。我们假设 ASV 1.1 会导致比 APV-CMV（适应性压力通气下的控制强制通气）模式下测量的 ΔP 更低，APV-CMV 模式下的 ΔP 是由医生定制设置的。因此，本随机交叉试验的目的是比较 ASV 1.1 中的 ΔP 与医生定制的 APV-CMV 模式中的 ΔP。
患有异质性肺部疾病并接受有创机械通气且无可检测呼吸努力、血流动力学不稳定或气管内导管周围有明显气道泄漏的儿科患者被纳入研究。我们比较了 APV-CMV 和 ASV 1.1 两种通气方式下的 60 分钟通气期，这两种通气方式是通过随机化确定的，并通过 30 分钟的洗脱期分开。调整设置以在两种模式下达到相同的分钟通气量。ΔP 是通过分别使用吸气末和呼气末闭塞测量的平台压和总 PEEP 之间的差值计算得出的。
共有 26 名患者入选，中位年龄为 16（9-25 [IQR]）个月。这些患者的中位 ΔP 分别为 ASV 1.1 期的 10.4（8.5-12.1 [IQR]）和 APV-CMV 期的 12.4（10.5-15.3 [IQR]）cmH2O（p<0.001）。ASV 1.1 算法选择的中位潮气量（VT）为 6.4（5.1-7.3 [IQR]）ml/kg，RR 为 41（33-50 [IQR]）次/分，而 APV-CMV 期的相应值的中位数为 7.9（6.8-8.3 [IQR]）ml/kg和 31（26-41[IQR]）次/分。在 ASV 1.1 和 APV-CMV 两种模式下，在基线时，限制性肺部疾病患者使用的最高 ΔP 来进行通气。
在这项随机交叉试验中，在患有不同肺部疾病的儿科患者中，ASV 1.1 中的 ΔP 低于医生定制的 APV-CMV 模式中的 ΔP。因此，ASV 1.1 的使用可能会导致在异质儿科患者群体中持续、安全的通气。
