Agreement Between Peak Inspiratory Pressure in Decelerating-Flow Ventilation and Plateau Pressure in Square-Flow Ventilation in Pediatric ARDS
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Pulmonary, Procedures, Pediatrics, 2022
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INTRODUCTION: Lung-protective ventilation guidelines for acute respiratory distress syndrome (ARDS) suggest limiting plateau pressure to 30 cmH2O. Plateau pressure is most accurately measured in square-flow modes of ventilation, such as volume control. In children, decelerating-flow modes of ventilation (pressure-regulated volume control and pressure control) are more common, and plateau pressures are rarely obtained. Pressure limits are instead provided for peak inspiratory pressure (PIP). The degree to which PIP in decelerating-flow overestimates plateau pressure is unknown. Therefore, we aimed to assess the correlation and accuracy of PIP in decelerating-flow for approximating plateau pressure in square-flow ventilation. We hypothesized that PIP in decelerating-flow would approximate plateau pressure in square-flow within 0.5 cmH2O. METHODS: We carried out a prospective, observational study in a tertiary, academic pediatric intensive care unit. Fifty-two intubated children with pediatric ARDS (PARDS) were enrolled between January 2020 and May 2021. PIP in decelerating-flow ventilation and plateau pressure after transition to square-flow ventilation were measured within 24 hours of onset of PARDS. After the first 10 subjects, we calculated the standard deviation of the difference between PIP in decelerating-flow and plateau pressures in square-flow to calculate a sample size. In an equivalence test of paired means, a sample size of 45 was required for 90% power at an α of 0.05 to demonstrate a true difference (± SD) of 0 ± 1, with equivalence limits of -0.5 and 0.5. RESULTS: Of the 52 patients with PARDS, there were 8 non-survivors (17%) at day 28. Hypoxemia was consistent with moderate PARDS, with a median oxygenation index of 10.5 and PaO2/FIO2 of 177. PIP in decelerating-flow was highly correlated (r2 = 0.99, p < 0.001) with plateau pressure in square-flow. PIP was 0.98 ± 0.63 cmH2O higher than plateau pressure, with 96% of values within 2 cmH2O. Inspiratory flows approached zero in decelerating-flow in all subjects except one outlier with concurrent obstructive lung disease. CONCLUSIONS: PIP measured during decelerating-flow ventilation is an adequate surrogate of plateau pressure in PARDS. Practitioners should not be reassured that PIPs in decelerating-flow are substantially higher than plateau pressures.
Meta Tag
Content Type Presentation
Knowledge Area Pulmonary
Knowledge Area Procedures
Knowledge Area Pediatrics
Knowledge Level Intermediate
Knowledge Level Advanced
Membership Level Select
Tag Acute Respiratory Distress Syndrome ARDS
Tag Mechanical Ventilation
Tag Pediatrics
Tag Respiratory Failure
Year 2022
Dr. Bhavesh Patel
pediatric ARDS
peak inspiratory pressure
plateau pressure
driving pressure


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