A talk by Süha Demirakca at TBS24

1. Süha Demirakca
Klinik für Neonatologie und pädiatrische Intensivmedizin
UniversitätsMedizin Mannheim,
Sueha.demirakca@umm.de
Mechanical ventilation in PARDS
Same as in adults?

2. Oxygenation
P/F Ratio vs. OI = MAP x FiO2 X 100 / PaO2
OSI = MAP x FiO2 X 100 / SpO2
Adult
- mild: PaO2 / FiO2 ≤ 300 mmHg bei PEEP ≥ 5 mbar
- moderate: PaO2 / FiO2 ≤ 200 mmHg bei PEEP ≥ 5 mbar
- severe: PaO2 / FiO2 ≤ 100 mmHg bei PEEP ≥ 5 mbar
PALICC 2 - PCCM 2023
Age, timing, origin of edema, chest imaging criteria met
Pediatric ARDS 2023
- mild / moderate 4 ≤ OI ≤ 16 - 5 ≤ OSI ≤ 12
- severe: OI ≥ 16 - OSI ≥ 12

3. PARDS reason for change in severity levels
Mortality rates from three cohorts
PARDIE 2018,
• cohort from Children’s Hospital of Philadelphia,
• cohort from Children’s Hospital of Los Angeles
• Values between 6 and 12 hr (total n = 1149)
PALICC 2 - PCCM 2023

4. PALICC 2 recommendation 2023:
Lung protective ventilation bundle (LPV)
à plateau pressure, PEEP, driving pressure, tidal volume
Recommendation
a lung protective ventilation bundle should be used as compared to no bundle
when caring for ventilated patients with PARDS.
PALICC 2 - PCCM 2023

5. Plateau Pressure (Pplat)
• Meta-analysis in adults - Petrucci 2013: Pplat ≤ 30 cm H2O
Petrucci N, De Feo C: Lung protective ventilation
strategy for the acute respiratory distress syndrome.
Cochrane Database Syst Rev 2013
PALICC 2 – Recommendation
• Pplat ≤ 28 cm H2O
• Pplat ≤ 32 cm H2O – in reduced chest wall compliance

6. Typical thorax compliance in children
Retractions

7. Thoraco-abdominal Compliance
‘Stiff’
Paw = 30 cmH2O
EL Ecw
24 6
‘Soft’
‘Soft’
EL
Ecw
Paw = 30 cmH2O
24
6
‘Stiff’
Gattinoni, et al. Crit Care 2004 Oct.
Pplat ≤ 28 cm H2O Pplat ≤ 32 cm H2O

8. Low PEEP = higher Mortality in PARDS
Khemani R et al AJRCCM 2018
N = 1134 PARDS
Multivariate analysis on mortality:
PEEP < ARDSnet vs. ARDSnet
OR (95%CI) 2.05 (1.32–3.17) p = 0.001
Recommendation
à Use low PEEP/FiO2 table

9. Driving Pressure (DP) PALICC 2
Recommendation
Limit driving pressure to 15 cm H2O (as measured under static conditions)
Rauf A et al RESPIRATORY CARE 2021 66:3
PALICC 2 - PCCM 2023
observational study in children:

10. Tidal Volume (Vt)
• Recommendation:
Tidal volumes below 6 mL/kg to stay below suggested plateau and driving
pressure limits.
• Vt related to Cdyn and PBW in children
• 6 – 8 ml/kg in mild/moderate PARDS
• 4 – 6 ml/kg in severe PARDS
PALICC 2 - PCCM 2023

11. Metaanalysis Vt and Mortality in Children
De Jager P et al. Crit Care Med 2014

12. 4 y old girl: Mycoplasma pneumoniae

13. 4.5 y old girl: Mycoplasma pneumoniae
SpO2 78%

14. 4.5 y old girl: Mycoplasma pneumoniae
SpO2 95 %

15. Causes of respiratory ECMO
Kinder Erwachsene
Diagnose Anteil Diagnose Anteil
Virale Pneumonie 21.6% Akutes Lungenversagen non-ARDS 15.4%
Akutes Lungenversagen non-ARDS 17.7% ARDS 15.2%
PARDS 11.0% Bakterielle Pneumonie 14.3%
Bakterielle Pneumonie 10.2% Virale Pneumonie 8.6%
Aspirationspneumonie 4.5% Aspirationspneumonie 2.1%
Pneumozystis-Pneumonie 0.5% Pneumozystis-Pneumonie 0.0%
Andere 34.4% Andere 44.4%
Demirakca S, Pneumologe 2016

16. PARDS: 10 mon boy (7900g) – transpulmonary pressure
16 cmH2O
10 cmH2O
∆PL = 8 cmH2O
Vt = 4.5 - 5 ml/kg
40 bpm

17. Which procedures do you use systematically in PARDS patients?
• Survey D-A-CH
• N = 44 PICUs
Oxygenierung

18. Adherence to PARDS recommendations
Pplat not measured in 97% of time
Median delta pressure ≥ 18 cmH2O in all
PARDS severities
PEEP < PEEP/FiO2 table 70% of time
Adherence to Lung-Protective Ventilation Principles in Pediatric Acute Respiratory Distress
Syndrome Bhalla et al. Crit Care Med. 2021 Oct 1;49(10):1779-1789
N = 422 PARDS, Observation in 71 PICUs (international)

19. APVcmv vs. ASV in n = 26 children – randomized crossover trial
APVcmv
ASV
Driving
pressure
Ceylan G et al, Ped Pulmonology 2021

20. Computerized decision support REDvent study

21. Ø Median ΔP was statistically significantly lower for REDvent patients vs. historical controls.
Ø 3 fewer days on mechanical ventilation among survivors (all p ≤ 0.05) – vs. historical controls.
Lung protective ventilation bundle (LPV)
à tidal volume, plateau pressure, driving pressure, PEEP
Hotz JC et al, PCCM 2020
Pilot study: computerized decision support tool
prioritized LPV management Pip, PEEP,
PEEP/FiO2, and ventilatory rate (REDvent)

22. Conclusion
Guidelines for LPV are helpful to improve outcome in PARDS
à Adherence to LPV is not fully achieved
Additional awareness is needed for individual issues of pediatric patients
• Airway mechanics
• Transpulmonary pressure
à Automatization may be a helpful solution in future

23. Thank you