Improved oxygenation 24 hours after transition to airway pressure release ventilation or high-frequency oscillatory ventilation accurately discriminates survival in immunocompromised pediatric patients with acute respiratory distress syndrome

Nadir Yehya, Alexis A. Topjian, Neal J. Thomas, Stuart H. Friess

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Abstract

Objectives: Children with an immunocompromised condition and requiring invasive mechanical ventilation have high risk of death. Such patients are commonly transitioned to rescue modes of nonconventional ventilation, including airway pressure release ventilation and high-frequency oscillatory ventilation, for acute respiratory distress syndrome refractory to conventional ventilation. Our aim was to describe our experience with airway pressure release ventilation and high-frequency oscillatory ventilation in children with an immunocompromised condition and acute respiratory distress syndrome refractory to conventional ventilation and to identify factors associated with survival. Design: Retrospective cohort study. Setting: Tertiary care, university-affiliated PICU. Patients: Sixty pediatric patients with an immunocompromised condition and acute respiratory distress syndrome refractory to conventional ventilation transitioned to either airway pressure release ventilation or high-frequency oscillatory ventilation. Interventions: None. Measurements and Main Results: Demographic data, ventilator settings, arterial blood gases, oxygenation index, and PaO2/FIO2 were recorded before transition to either mode of nonconventional ventilation and at predetermined intervals after transition for up to 5 days. Mortality in the entire cohort was 63% and did not differ between patients transitioned to airway pressure release ventilation and high-frequency oscillatory ventilation. For both airway pressure release ventilation and high-frequency oscillatory ventilation, improvements in oxygenation index and PaO2/FIO2 at 24 hours expressed as a fraction of pretransition values (oxygenation index24/oxygenation indexpre and PaO2/FIO224/PaO2/FIO2pre) reliably discriminated nonsurvivors from survivors, with receiver operating characteristic areas under the curves between 0.89 and 0.95 (p for all curves < 0.001). Sensitivity-specificity analysis suggested that less than 15% reduction in oxygenation index (90% sensitive, 75% specific) or less than 90% increase in PaO2/FIO2 (80% sensitive, 94% specific) 24 hours after transition to airway pressure release ventilation were the optimal cutoffs to identify nonsurvivors. The comparable values 24 hours after transition to high-frequency oscillatory ventilation were less than 5% reduction in oxygenation index (100% sensitive, 83% specific) or less than 80% increase in PaO2/FIO2 (91% sensitive, 89% specific) to identify nonsurvivors. Conclusions: In this single-center retrospective study of pediatric patients with an immunocompromised condition and acute respiratory distress syndrome failing conventional ventilation transitioned to either airway pressure release ventilation or high-frequency oscillatory ventilation, improved oxygenation at 24 hours expressed as PaO2/FIO 224/PaO2/FIO2pre or oxygenation index24/oxygenation indexpre reliably discriminates nonsurvivors from survivors. These findings should be prospectively verified.

Original languageEnglish (US)
JournalPediatric Critical Care Medicine
Volume15
Issue number4
DOIs
StatePublished - Jan 1 2014

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High-Frequency Ventilation
Continuous Positive Airway Pressure
Adult Respiratory Distress Syndrome
Immunocompromised Host
Ventilation
Pediatrics
Survival
Survivors
Retrospective Studies
Tertiary Healthcare
Mechanical Ventilators
Artificial Respiration
ROC Curve
Area Under Curve
Cohort Studies
Gases
Demography
Sensitivity and Specificity
Mortality

All Science Journal Classification (ASJC) codes

  • Pediatrics, Perinatology, and Child Health
  • Critical Care and Intensive Care Medicine

Cite this

@article{9ea4c29878f94299be5b338a72592be5,
title = "Improved oxygenation 24 hours after transition to airway pressure release ventilation or high-frequency oscillatory ventilation accurately discriminates survival in immunocompromised pediatric patients with acute respiratory distress syndrome",
abstract = "Objectives: Children with an immunocompromised condition and requiring invasive mechanical ventilation have high risk of death. Such patients are commonly transitioned to rescue modes of nonconventional ventilation, including airway pressure release ventilation and high-frequency oscillatory ventilation, for acute respiratory distress syndrome refractory to conventional ventilation. Our aim was to describe our experience with airway pressure release ventilation and high-frequency oscillatory ventilation in children with an immunocompromised condition and acute respiratory distress syndrome refractory to conventional ventilation and to identify factors associated with survival. Design: Retrospective cohort study. Setting: Tertiary care, university-affiliated PICU. Patients: Sixty pediatric patients with an immunocompromised condition and acute respiratory distress syndrome refractory to conventional ventilation transitioned to either airway pressure release ventilation or high-frequency oscillatory ventilation. Interventions: None. Measurements and Main Results: Demographic data, ventilator settings, arterial blood gases, oxygenation index, and PaO2/FIO2 were recorded before transition to either mode of nonconventional ventilation and at predetermined intervals after transition for up to 5 days. Mortality in the entire cohort was 63{\%} and did not differ between patients transitioned to airway pressure release ventilation and high-frequency oscillatory ventilation. For both airway pressure release ventilation and high-frequency oscillatory ventilation, improvements in oxygenation index and PaO2/FIO2 at 24 hours expressed as a fraction of pretransition values (oxygenation index24/oxygenation indexpre and PaO2/FIO224/PaO2/FIO2pre) reliably discriminated nonsurvivors from survivors, with receiver operating characteristic areas under the curves between 0.89 and 0.95 (p for all curves < 0.001). Sensitivity-specificity analysis suggested that less than 15{\%} reduction in oxygenation index (90{\%} sensitive, 75{\%} specific) or less than 90{\%} increase in PaO2/FIO2 (80{\%} sensitive, 94{\%} specific) 24 hours after transition to airway pressure release ventilation were the optimal cutoffs to identify nonsurvivors. The comparable values 24 hours after transition to high-frequency oscillatory ventilation were less than 5{\%} reduction in oxygenation index (100{\%} sensitive, 83{\%} specific) or less than 80{\%} increase in PaO2/FIO2 (91{\%} sensitive, 89{\%} specific) to identify nonsurvivors. Conclusions: In this single-center retrospective study of pediatric patients with an immunocompromised condition and acute respiratory distress syndrome failing conventional ventilation transitioned to either airway pressure release ventilation or high-frequency oscillatory ventilation, improved oxygenation at 24 hours expressed as PaO2/FIO 224/PaO2/FIO2pre or oxygenation index24/oxygenation indexpre reliably discriminates nonsurvivors from survivors. These findings should be prospectively verified.",
author = "Nadir Yehya and Topjian, {Alexis A.} and Thomas, {Neal J.} and Friess, {Stuart H.}",
year = "2014",
month = "1",
day = "1",
doi = "10.1097/PCC.0000000000000069",
language = "English (US)",
volume = "15",
journal = "Pediatric Critical Care Medicine",
issn = "1529-7535",
publisher = "Lippincott Williams and Wilkins",
number = "4",

}

TY - JOUR

T1 - Improved oxygenation 24 hours after transition to airway pressure release ventilation or high-frequency oscillatory ventilation accurately discriminates survival in immunocompromised pediatric patients with acute respiratory distress syndrome

AU - Yehya, Nadir

AU - Topjian, Alexis A.

AU - Thomas, Neal J.

AU - Friess, Stuart H.

PY - 2014/1/1

Y1 - 2014/1/1

N2 - Objectives: Children with an immunocompromised condition and requiring invasive mechanical ventilation have high risk of death. Such patients are commonly transitioned to rescue modes of nonconventional ventilation, including airway pressure release ventilation and high-frequency oscillatory ventilation, for acute respiratory distress syndrome refractory to conventional ventilation. Our aim was to describe our experience with airway pressure release ventilation and high-frequency oscillatory ventilation in children with an immunocompromised condition and acute respiratory distress syndrome refractory to conventional ventilation and to identify factors associated with survival. Design: Retrospective cohort study. Setting: Tertiary care, university-affiliated PICU. Patients: Sixty pediatric patients with an immunocompromised condition and acute respiratory distress syndrome refractory to conventional ventilation transitioned to either airway pressure release ventilation or high-frequency oscillatory ventilation. Interventions: None. Measurements and Main Results: Demographic data, ventilator settings, arterial blood gases, oxygenation index, and PaO2/FIO2 were recorded before transition to either mode of nonconventional ventilation and at predetermined intervals after transition for up to 5 days. Mortality in the entire cohort was 63% and did not differ between patients transitioned to airway pressure release ventilation and high-frequency oscillatory ventilation. For both airway pressure release ventilation and high-frequency oscillatory ventilation, improvements in oxygenation index and PaO2/FIO2 at 24 hours expressed as a fraction of pretransition values (oxygenation index24/oxygenation indexpre and PaO2/FIO224/PaO2/FIO2pre) reliably discriminated nonsurvivors from survivors, with receiver operating characteristic areas under the curves between 0.89 and 0.95 (p for all curves < 0.001). Sensitivity-specificity analysis suggested that less than 15% reduction in oxygenation index (90% sensitive, 75% specific) or less than 90% increase in PaO2/FIO2 (80% sensitive, 94% specific) 24 hours after transition to airway pressure release ventilation were the optimal cutoffs to identify nonsurvivors. The comparable values 24 hours after transition to high-frequency oscillatory ventilation were less than 5% reduction in oxygenation index (100% sensitive, 83% specific) or less than 80% increase in PaO2/FIO2 (91% sensitive, 89% specific) to identify nonsurvivors. Conclusions: In this single-center retrospective study of pediatric patients with an immunocompromised condition and acute respiratory distress syndrome failing conventional ventilation transitioned to either airway pressure release ventilation or high-frequency oscillatory ventilation, improved oxygenation at 24 hours expressed as PaO2/FIO 224/PaO2/FIO2pre or oxygenation index24/oxygenation indexpre reliably discriminates nonsurvivors from survivors. These findings should be prospectively verified.

AB - Objectives: Children with an immunocompromised condition and requiring invasive mechanical ventilation have high risk of death. Such patients are commonly transitioned to rescue modes of nonconventional ventilation, including airway pressure release ventilation and high-frequency oscillatory ventilation, for acute respiratory distress syndrome refractory to conventional ventilation. Our aim was to describe our experience with airway pressure release ventilation and high-frequency oscillatory ventilation in children with an immunocompromised condition and acute respiratory distress syndrome refractory to conventional ventilation and to identify factors associated with survival. Design: Retrospective cohort study. Setting: Tertiary care, university-affiliated PICU. Patients: Sixty pediatric patients with an immunocompromised condition and acute respiratory distress syndrome refractory to conventional ventilation transitioned to either airway pressure release ventilation or high-frequency oscillatory ventilation. Interventions: None. Measurements and Main Results: Demographic data, ventilator settings, arterial blood gases, oxygenation index, and PaO2/FIO2 were recorded before transition to either mode of nonconventional ventilation and at predetermined intervals after transition for up to 5 days. Mortality in the entire cohort was 63% and did not differ between patients transitioned to airway pressure release ventilation and high-frequency oscillatory ventilation. For both airway pressure release ventilation and high-frequency oscillatory ventilation, improvements in oxygenation index and PaO2/FIO2 at 24 hours expressed as a fraction of pretransition values (oxygenation index24/oxygenation indexpre and PaO2/FIO224/PaO2/FIO2pre) reliably discriminated nonsurvivors from survivors, with receiver operating characteristic areas under the curves between 0.89 and 0.95 (p for all curves < 0.001). Sensitivity-specificity analysis suggested that less than 15% reduction in oxygenation index (90% sensitive, 75% specific) or less than 90% increase in PaO2/FIO2 (80% sensitive, 94% specific) 24 hours after transition to airway pressure release ventilation were the optimal cutoffs to identify nonsurvivors. The comparable values 24 hours after transition to high-frequency oscillatory ventilation were less than 5% reduction in oxygenation index (100% sensitive, 83% specific) or less than 80% increase in PaO2/FIO2 (91% sensitive, 89% specific) to identify nonsurvivors. Conclusions: In this single-center retrospective study of pediatric patients with an immunocompromised condition and acute respiratory distress syndrome failing conventional ventilation transitioned to either airway pressure release ventilation or high-frequency oscillatory ventilation, improved oxygenation at 24 hours expressed as PaO2/FIO 224/PaO2/FIO2pre or oxygenation index24/oxygenation indexpre reliably discriminates nonsurvivors from survivors. These findings should be prospectively verified.

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U2 - 10.1097/PCC.0000000000000069

DO - 10.1097/PCC.0000000000000069

M3 - Article

VL - 15

JO - Pediatric Critical Care Medicine

JF - Pediatric Critical Care Medicine

SN - 1529-7535

IS - 4

ER -