Ventilation Strategies in Children With Acute Lung Injury

Results

A total of 54 physicians answered the survey, representing 47 of 59 centers from 11 of 12 countries participating in the PALIVE study. Some sites had two physicians acting as site investigators. Centers from North America (Canada and United States) and Europe (Austria, Belgium, France, Germany, Italy, The Netherlands, Spain, Sweden, and Switzerland) were represented. Twelve centers participating in the PALIVE study from seven different countries were not represented in this survey.

The range of optimal tidal volumes chosen for the different scenarios was similar across the three scenarios (Fig. 1). The vast majority of pediatric intensivists reported using a tidal volume of 5–8 mL/kg in these patients. Only a minority of intensivists would use higher tidal volumes (9–10 mL/kg): 3.8% for scenario 1, 5.7% for scenario 2, and 11.8% for scenario 3 (p = nonsignificant [NS]). No physician chose tidal volumes higher than 10 mL/kg. There was no statistically significant difference between the three scenarios. The median (interquartile range) maximal PEEP used to obtain minimal SO₂ was 14.5 cm H₂O for scenario 1; 12 cm H₂O for scenario 2; and 14 cm H₂O for scenario 3 (p = 0.06). Finally, the median (interquartile range) maximal acceptable PIP before considering another ventilation mode was 35 cm H₂O (30–35) for all three scenarios (p = NS; Table 2).



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Figure 1.



Tidal volumes considered optimal for each case scenario.





The chosen PaCO₂ that would be tolerated in the different scenarios is presented in Figure 2. Permissive hypercapnia (PaCO₂ > 45 mm Hg) was chosen as the optimal strategy for 59% to 70% of pediatric intensivists depending on the case scenario, and most pediatric intensivists also accepted a mild acidosis (median [interquartile range] minimal acceptable pH was 7.20 (7.20–7.25) for scenarios 1 and 2, and 7.25 (7.20–7.27) for scenario 3; Table 2). In all scenarios, pediatric intensivists would accept a mild hypoxemia aiming for an SO₂ of 88% to 95% across all three scenarios (Table 2). There was no statistically significant difference between the three scenarios for PaCO₂, pH, or SO₂.



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Figure 2.



Paco₂ considered optimal for each case scenario.





Consideration of use of HFOV varied across participants, 4% of participants reported they would not use HFOV in these patients and 44% reported starting HFOV on criteria other than OI. For those that would start HFOV at a certain level of OI, 4% would start HFOV with an OI of 6–9 for all three scenarios; 41% would start HFOV with an OI of 10–19 for scenario 1, 43% for scenario 2, and 38% for scenario 3; 48% would start HFOV with an OI of 20–29 for scenario 1, 50% for scenario 2, and 54% for scenario 3; and finally 7% would start HFOV with an OI of 30–39 for scenario 1 and 4% for scenarios 2 and 3 (p = NS).

Finally, when asked if they would use adjunctive treatments in case the patient's condition worsens over the next 24 hours, a large proportion of pediatric intensivists reported they would use them (Fig. 3). Nitric oxide would be used by 85% to 87% of them; prone position by 77% to 87%; extracorporeal membrane oxygenation by 65% to 70%; surfactant by 42% to 61% of them; steroids by 30% to 35%; and [beta]-agonists by 35% to 41% of pediatric intensivists. There was no statistically significant difference between the three scenarios for any of the adjunctive treatments.



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Figure 3.



Adjunctive treatments considered if oxygenation worsens.