Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil.
Department of Pediatrics, Botucatu Medical School, São Paulo State University Júlio de Mesquita Filho, Botucatu, São Paulo, Brazil.
Respir Care. 2024 Oct 25;69(11):1409-1416. doi: 10.4187/respcare.12005.
PEEP is a cornerstone treatment for children with pediatric ARDS. Unfortunately, its titration is often performed solely by evaluating oxygen saturation, which can lead to inadequate PEEP level settings and consequent adverse effects. This study aimed to assess the impact of increasing PEEP on hemodynamics, respiratory system mechanics, and oxygenation in children with ARDS.
Children receiving mechanical ventilation and on pressure-controlled volume-guaranteed mode were prospectively assessed for inclusion. PEEP was sequentially changed to 5, 12, 10, 8 cm HO, and again to 5 cm HO. After 10 min at each PEEP level, hemodynamic, ventilatory, and oxygenation variables were collected.
A total of 31 subjects were included, with median age and weight of 6 months and 6.3 kg, respectively. The main reasons for pediatric ICU admission were respiratory failure caused by acute viral bronchiolitis (45%) and community-acquired pneumonia (32%). Most subjects had mild or moderate ARDS (45% and 42%, respectively), with a median (interquartile range) oxygenation index of 8.4 (5.8-12.7). Oxygen saturation improved significantly when PEEP was increased. However, although no significant changes in blood pressure were observed, the median cardiac index at PEEP of 12 cm HO was significantly lower than that observed at any other PEEP level ( = .001). Fourteen participants (45%) experienced a reduction in cardiac index of > 10% when PEEP was increased to 12 cm HO. Also, the estimated oxygen delivery was significantly lower, at 12 cm HO PEEP. Finally, respiratory system compliance significantly reduced when PEEP was increased. At a PEEP of 12 cm HO, static compliance had a median reduction of 25% in relation to the initial assessment (PEEP of 5 cm HO).
Although it may improve arterial oxygen saturation, inappropriately high PEEP levels may reduce cardiac output, oxygen delivery, and respiratory system compliance in pediatric subjects with ARDS with low potential for lung recruitability.
PEEP 是儿科 ARDS 患儿的基石治疗方法。遗憾的是，其滴定通常仅通过评估氧饱和度来完成，这可能导致 PEEP 水平设置不足，并产生相应的不良后果。本研究旨在评估增加 PEEP 对 ARDS 患儿血流动力学、呼吸系统力学和氧合的影响。
前瞻性评估接受机械通气和压力控制容量保证模式的患儿是否符合纳入标准。PEEP 依次改为 5、12、10、8 cmH2O，然后再次改为 5 cmH2O。在每个 PEEP 水平下 10 分钟后，收集血流动力学、通气和氧合变量。
共纳入 31 例患儿，中位年龄和体重分别为 6 个月和 6.3 kg。儿科 ICU 入院的主要原因是急性病毒性细支气管炎（45%）和社区获得性肺炎（32%）导致的呼吸衰竭。大多数患儿为轻度或中度 ARDS（分别为 45%和 42%），氧合指数中位数（四分位间距）为 8.4（5.8-12.7）。增加 PEEP 时，氧饱和度显著改善。然而，尽管血压无显著变化，但 PEEP 为 12 cmH2O 时的中位心指数显著低于其他任何 PEEP 水平（=.001）。14 名患儿（45%）在 PEEP 增加至 12 cmH2O 时心指数下降超过 10%。同样，在 PEEP 为 12 cmH2O 时，估计的氧输送量也显著降低。最后，当 PEEP 增加时，呼吸系统顺应性显著降低。在 PEEP 为 12 cmH2O 时，与初始评估（PEEP 为 5 cmH2O）相比，静态顺应性中位数降低了 25%。
尽管可能提高动脉氧饱和度，但在潜在肺可复张性低的 ARDS 患儿中，不适当的高 PEEP 水平可能会降低心输出量、氧输送和呼吸系统顺应性。
