Airway Pressure Release Ventilation as a Rescue Therapy in Pediatric Acute Respiratory Distress Syndrome (pARDS): Goodwi
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EDITORIAL COMMENTARY
Airway Pressure Release Ventilation as a Rescue Therapy in Pediatric Acute Respiratory Distress Syndrome (pARDS): Goodwill or Devil? Shyam Chandrasekhar 1 & Krishna Mohan Gulla 1 Received: 7 September 2020 / Accepted: 7 September 2020 # Dr. K C Chaudhuri Foundation 2020
Pediatric Acute Respiratory Distress Syndrome is a significant cause of morbidity and mortality among children admitted to the pediatric intensive care unit. Various ventilation strategies have been used to improve oxygenation and ventilation in pARDS with further avoidance of secondary lung injury. Lung protective strategy using low tidal volume through conventional mechanical ventilation is the standard of care in pARDS. However, evidence on non-conventional ventilation modes such as High frequency oscillatory ventilation (HFOV) and Airway pressure release ventilation (APRV) has been scarce. A recent randomised control trial comparing HFOV and APRV for refractory hypoxemia in pARDS by Lalgudi et al. showed significant increase in mortality in the APRV group which led to premature termination of the trial [1]. APRV, as the name indicates, is a continuous positive pressure with a brief intermittent release phase which allows partial release of the lung volume for carbon dioxide exhalation. The strategies in APRV include Personalized APRV (PAPRV) which uses a Tlow based on lung mechanics with a zero Plow with a THigh > 90% of the total breath time and a Fixed APRV (F-APRV) which works with a constant Tlow and a non-zero Plow with a THigh < 90% of the total cycle time [2]. The main advantage of APRV is its ability to maximize the recruitment of alveoli and hence improving oxygenation along with added benefit of spontaneous breathing minimizing the risk of barotrauma [3]. It also has added advantages such as increased comfort for the patient and decreased sedative use [1, 4]. The contraindication to its use is children who require deep sedation for the underlying disease states like
* Krishna Mohan Gulla [email protected] 1
Department of Pediatrics, AIIMS, Bhubaneswar, Odisha, India
status epilepticus, raised intracranial pressure, severe obstructive airway disease, air leak syndromes [3]. In the retrospective, observational study published in Indian Journal of Pediatrics [5], Yener et al. had used APRV as a rescue therapy in severe pARDS in 30 children with age group of 1 mo to 18 y. The study population had a mean age of 32.8 ± 22.6 mo with 83% of them were less than 5-y-old. APRV mode was used in those children who were hypoxemic despite on low tidal volume (6–8 ml/kg), PEEP > 15 cm H2O with > 60% FiO2 on SIMC-PS mode. This mode was initiated on an average 3.2 ± 2.6 d (range: 1–11 d) following intubation. At 3 h after APRV initiation, there was significant increase in the S/F ratio (165.1 ± 13.6 vs. 131.7 ± 10.2, p = 0.035), decrement in peak pressure (25.4 ± 1.26 vs. 29.8 ± 0.60, p < 0.001) and increment in mean airway pressure (19.11 ± 0.97 vs. 15.32 ± 1.3, p < 0.001). Vasopressor requirement and the pH and venous CO
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