Department of Pediatrics, Division of Pediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
Pediatr Crit Care Med. 2022 Mar 1;23(3):e136-e144. doi: 10.1097/PCC.0000000000002848.
Driving pressure (ratio of tidal volume over respiratory system compliance) is associated with mortality in acute respiratory distress syndrome. We sought to evaluate if such association could be identified in critically ill children.
We studied the association between driving pressure on day 1 of mechanical ventilation and ventilator-free days at day 28 through secondary analyses of prospectively collected physiology data.
Medical-surgical university hospital PICU.
Children younger than 18 years (stratified by Pediatric Mechanical Ventilation Consensus Conference clinical phenotype definitions) without evidence of spontaneous respiration.
Inspiratory hold maneuvers.
Data of 222 patients with median age 11 months (2-51 mo) were analyzed. Sixty-five patients (29.3%) met Pediatric Mechanical Ventilation Consensus Conference criteria for restrictive and 78 patients (35.1%) for mixed lung disease, and 10.4% of all patients had acute respiratory distress syndrome. Driving pressure calculated by the ratio of tidal volume over respiratory system compliance for the whole cohort was 16 cm H2O (12-21 cm H2O) and correlated with the static airway pressure gradient (plateau pressure minus positive end-expiratory pressure) (Spearman correlation coefficient = 0.797; p < 0.001). Bland-Altman analysis showed that the dynamic pressure gradient (peak inspiratory pressure minus positive end-expiratory pressure) overestimated driving pressure (levels of agreement -2.295 to 7.268). Rematching the cohort through a double stratification procedure (obtaining subgroups of patients with matched mean levels for one variable but different mean levels for another ranking variable) showed a reduction in ventilator-free days at day 28 with increasing driving pressure in patients ventilated for a direct pulmonary indication. Competing risk regression analysis showed that increasing driving pressure remained independently associated with increased time to extubation (p < 0.001) after adjusting for Pediatric Risk of Mortality III 24-hour score, presence of direct pulmonary indication jury, and oxygenation index.
Higher driving pressure was independently associated with increased time to extubation in mechanically ventilated children. Dynamic assessments of driving pressure should be cautiously interpreted.
在急性呼吸窘迫综合征患者中，驱动压（潮气量与呼吸系统顺应性的比值）与死亡率相关。我们试图评估该关联是否可在危重症患儿中得到识别。
我们通过对前瞻性收集的生理学数据进行二次分析，研究了机械通气第 1 天的驱动压与第 28 天无呼吸机天数之间的关系。
医科大学附属综合医院 PICU。
年龄小于 18 岁（根据小儿机械通气共识会议临床表型定义分层）且无自主呼吸证据的患儿。
吸气保持操作。
共分析了 222 例患儿的数据，中位年龄为 11 个月（2-51 个月）。65 例（29.3%）患儿符合小儿机械通气共识会议标准的限制型肺疾病，78 例（35.1%）为混合性肺部疾病，10.4%的患儿为急性呼吸窘迫综合征。整个队列的呼吸系统顺应性潮气量比计算出的驱动压为 16cmH2O（12-21cmH2O），与静态气道压力梯度（平台压减去呼气末正压）相关（Spearman 相关系数=0.797；p<0.001）。Bland-Altman 分析显示，动态压力梯度（峰压减去呼气末正压）高估了驱动压（一致性水平为-2.295 至 7.268）。通过双分层程序（获得一个变量的平均水平匹配但另一个排序变量的平均水平不同的亚组）重匹配队列，结果显示在因直接肺部原因而接受机械通气的患者中，随着驱动压的增加，第 28 天无呼吸机天数减少。竞争风险回归分析显示，在调整小儿死亡率风险 III 24 小时评分、直接肺部指征、氧合指数后，驱动压增加与拔管时间延长独立相关（p<0.001）。
较高的驱动压与机械通气患儿拔管时间延长独立相关。应谨慎解读驱动压的动态评估。
