Pediatric and Neonatal Intensive Care Unit, Armand-Trousseau Hospital, Sorbonne University, Paris, France.
ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden.
Eur J Pediatr. 2023 Oct;182(10):4487-4497. doi: 10.1007/s00431-023-05119-5. Epub 2023 Jul 26.
The main objective of this study was to describe the current mechanical ventilation (MV) settings during extracorporeal membrane oxygenation (ECMO) for pediatric acute respiratory distress syndrome (P-ARDS) in six European centers. This is a retrospective observational cohort study performed in six European centers from January 2009 to December 2019. Children > 1 month to 18 years supported with ECMO for refractory P-ARDS were included. Collected data were as follows: patients' pre-ECMO medical condition, pre-ECMO adjunctive therapies for P-ARDS, pre-ECMO and during ECMO MV settings on day (D) 1, D3, D7, and D14 of ECMO, use of adjunctive therapies during ECMO, duration of ECMO, pediatric intensive care unit length of stay, and survival. A total of 255 patients with P-ARDS were included. The multivariate analysis showed that PEEP on D1 (OR = 1.13, 95% CI [1.03-1.24], p = 0.01); D3 (OR = 1.17, 95% CI [1.06-1.29], p = 0.001); and D14 (OR = 1.21, 95% CI [1.05-1.43], p = 0.02) and DP on D7 were significantly associated with higher odds of mortality (OR = 0.82, 95% CI [0.71-0.92], p = 0.001). Moreover, DP on D1 above 15 cmHO (OR 2.23, 95% CI (1.09-4.71), p = 0.03) and native lung FiO above 60% on D14 (OR 10.36, 95% CI (1.51-116.15), p = 0.03) were significantly associated with higher odds of mortality. Conclusion: MV settings during ECMO for P-ARDS varied among centers; however, use of high PEEP levels during ECMO was associated with higher odds of mortality as well as a DP above 15 cmHO and a native lung FiO above 60% on D14 of ECMO. What is Known: • Invasive ventilation settings are well defined for pediatric acute respiratory distress syndrome; however, once the children required an extracorporeal respiratory support, there is no recommendation how to set the mechanical ventilator. • Impact of invasive ventilator during extracorporeal respiratory support ad only been during the first days of this support but the effects of these settings later in the assistance are not described. What is New: • It seems to be essential to early decrease FiO2 on native lung once the ECMO flow allows an efficient oxygenation. • Tight control to limit the driving pressure at 15 cmH20 during ECMO run seems to be associated with better survival rate.
本研究的主要目的是描述 6 个欧洲中心在体外膜肺氧合(ECMO)期间对儿科急性呼吸窘迫综合征(P-ARDS)进行的机械通气(MV)设置。这是一项在 2009 年 1 月至 2019 年 12 月期间在 6 个欧洲中心进行的回顾性观察队列研究。纳入接受 ECMO 治疗难治性 P-ARDS 的 > 1 个月至 18 岁的儿童。收集的数据如下:患者 ECMO 前的医疗状况、P-ARDS 的 ECMO 前辅助治疗、ECMO 第 1 天、第 3 天、第 7 天和第 14 天的 ECMO 时 MV 设置、ECMO 期间辅助治疗的使用、ECMO 持续时间、儿科重症监护病房住院时间和生存率。共纳入 255 例 P-ARDS 患者。多变量分析显示,第 1 天的 PEEP(OR=1.13,95%CI[1.03-1.24],p=0.01);第 3 天(OR=1.17,95%CI[1.06-1.29],p=0.001);第 14 天(OR=1.21,95%CI[1.05-1.43],p=0.02)和第 7 天的 DP 与更高的死亡率相关(OR=0.82,95%CI[0.71-0.92],p=0.001)。此外,第 1 天 DP 高于 15 cmHO(OR 2.23,95%CI(1.09-4.71),p=0.03)和第 14 天原生肺 FiO 高于 60%(OR 10.36,95%CI(1.51-116.15),p=0.03)与更高的死亡率显著相关。结论:ECMO 期间对 P-ARDS 的 MV 设置在各中心之间存在差异;然而,ECMO 期间使用高 PEEP 水平与更高的死亡率以及第 14 天 DP 高于 15 cmHO 和原生肺 FiO 高于 60%相关。已知:• 小儿急性呼吸窘迫综合征的有创通气设置已有明确规定;然而,一旦儿童需要体外呼吸支持,就没有如何设置机械呼吸机的建议。• 体外呼吸支持期间的有创呼吸机的影响仅在该支持的最初几天内进行,但此后这些设置的影响并未描述。新发现:• 一旦 ECMO 流量允许有效氧合,似乎必须尽早降低原生肺的 FiO2。• 在 ECMO 运行期间将驱动压限制在 15 cmH20 似乎与更高的生存率相关。