Peak & Driving Pressures Stratify Respiratory Failure Severity in Cyanotic Congenital Heart Disease
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Pulmonary, Cardiovascular, Pediatrics, 2022
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INTRODUCTION: Intensive care unit (ICU) clinicians rely on hypoxemia to stratify the severity of acute respiratory failure (ARF), including in pediatric acute respiratory distress syndrome (PARDS). PARDS is stratified based on hypoxemia as mild, moderate, and severe, with better oxygenation associated with lower mortality. However, hypoxemia caused by intracardiac mixing or right-to-left shunting in patients with cyanotic congenital heart disease (CCHD) decreases oxygenation in the absence of lung disease. We aimed to determine whether variables related to respiratory mechanics were associated with mortality and ventilator-free days (VFDs) to assist with stratifying ARF severity in pediatric CCHD. METHODS: We performed a retrospective cohort study of children with CCHD admitted to the cardiac ICU at the Children’s Hospital of Philadelphia with ARF (intubated with FIO2 ≥ 0.3 and new infiltrates) ventilated for ≥ 72 hours. Demographics and cardiac history were recorded, and respiratory metrics and oxygenation data were averaged at ARF onset, 12 hours, and 24 hours. We tested for association between markers of ventilator mechanics and both 28-day mortality and VFDs at 28 days using logistic and competing risk regression, respectively. RESULTS: Between 2011 and 2019, 344 patients were eligible, of whom 226 (66%) had ARF due to cardiopulmonary bypass. Respiratory metrics and oxygenation data were screened for univariate association with mortality. Average peak inspiratory pressure (PIP) and driving pressure (ΔP = PIP minus PEEP) were both associated with higher mortality and lower probability of extubation. PIP and ΔP remained associated with mortality (PIP: odds ratio [OR] 1.10, 95%CI 1.02-1.19, p=0.020; ΔP: OR 1.11, 95%CI 1.01-1.21, p=0.017) and VFDs (PIP: subdistribution hazard ratio [SHR] 0.95, 95%CI 0.93-0.98, p < 0.001; ΔP: SHR 0.96, 95%CI 0.93-0.99, p=0.006) after adjusting for age, severity of cardiac lesion and FIO2. PIP and ΔP showed increasing mortality and decreasing VFDs across a three-level (mild, moderate, severe) severity stratification scheme (PIP: mild ≤20, moderate 21-29, severe ≥29; ΔP: mild ≤16, moderate 17-24, severe ≥24). CONCLUSIONS: PIP and ΔP were associated with mortality and VFDs in pediatric CCHD and may be useful to stratify ARF severity in a population whose deoxygenation is multifactorial.
Meta Tag
Content Type Presentation
Knowledge Area Pulmonary
Knowledge Area Cardiovascular
Knowledge Area Pediatrics
Knowledge Level Advanced
Membership Level Select
Tag Acute Respiratory Distress Syndrome ARDS
Tag Pediatrics
Tag Congenital Heart Disease
Tag Cardiothoracic Critical Care
Year 2022
respiratory failure
cyanotic congenital heart disease
Pediatric Acute Lung Injury Consensus Conference
pediatric acute respiratory distress syndrome
severity stratification


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