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Association between pediatric intensive care mortality and mechanical ventilation settings during extracorporeal membrane oxygenation for pediatric acute respiratory distress syndrome

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Abstract

The main objective of this study was to describe the current mechanical ventilation (MV) settings during extracorporeal membrane oxygenation (ECMO) for pediatric acute respiratory distress syndrome (P-ARDS) in six European centers. This is a retrospective observational cohort study performed in six European centers from January 2009 to December 2019. Children > 1 month to 18 years supported with ECMO for refractory P-ARDS were included. Collected data were as follows: patients’ pre-ECMO medical condition, pre-ECMO adjunctive therapies for P-ARDS, pre-ECMO and during ECMO MV settings on day (D) 1, D3, D7, and D14 of ECMO, use of adjunctive therapies during ECMO, duration of ECMO, pediatric intensive care unit length of stay, and survival. A total of 255 patients with P-ARDS were included. The multivariate analysis showed that PEEP on D1 (OR = 1.13, 95% CI [1.03–1.24], p = 0.01); D3 (OR = 1.17, 95% CI [1.06–1.29], p = 0.001); and D14 (OR = 1.21, 95% CI [1.05–1.43], p = 0.02) and DP on D7 were significantly associated with higher odds of mortality (OR = 0.82, 95% CI [0.71–0.92], p = 0.001). Moreover, DP on D1 above 15 cmH2O (OR 2.23, 95% CI (1.09–4.71), p = 0.03) and native lung FiO2 above 60% on D14 (OR 10.36, 95% CI (1.51–116.15), p = 0.03) were significantly associated with higher odds of mortality.

   Conclusion: MV settings during ECMO for P-ARDS varied among centers; however, use of high PEEP levels during ECMO was associated with higher odds of mortality as well as a DP above 15 cmH2O and a native lung FiO2 above 60% on D14 of ECMO.

What is Known:

• Invasive ventilation settings are well defined for pediatric acute respiratory distress syndrome; however, once the children required an extracorporeal respiratory support, there is no recommendation how to set the mechanical ventilator.

• Impact of invasive ventilator during extracorporeal respiratory support ad only been during the first days of this support but the effects of these settings later in the assistance are not described.

What is New:

• It seems to be essential to early decrease FiO2 on native lung once the ECMO flow allows an efficient oxygenation.

• Tight control to limit the driving pressure at 15 cmH20 during ECMO run seems to be associated with better survival rate.

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Abbreviations

CI:

Confidence intervals

DP:

Driving pressure

ECMO:

Extracorporeal membrane oxygenation

ELSO:

Extracorporeal Life Support Organization

MAP:

Mean airways pressure

MV:

Mechanical ventilation

NMB:

Neuromuscular blockers

OR:

Odds ratio

PALICC:

Pediatric Acute Lung Injury Consensus Conference

P-ARDS:

Pediatric acute respiratory distress syndrome

PEEP:

Positive end expiratory pressure

PELOD:

Pediatric Logistic Organ Dysfunction score

PICU:

Pediatric intensive care unit

PIM II:

Pediatric Index of Mortality 2 score

Ppeak:

Peak airway pressure

VFD-28:

Ventilator-free days at 28 days

Vt:

Tidal volume

VV:

Veno-venous

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Author information

Authors and Affiliations

  1. Pediatric and Neonatal Intensive Care Unit, Armand-Trousseau Hospital, Sorbonne University, Paris, France

    Jerome Rambaud & Pierre-Louis Leger

  2. ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden

    Lars M. Broman

  3. Saint Louis Hospital, Paris, France

    Sylvie Chevret

  4. Anaesthesia and Intensive Care, Padova University Hospital, Padua, Italy

    Federico Visconti

  5. Division of Pediatric Surgery, Children’s Hospital of Orange County, Orange, CA, USA

    Yigit Guner

  6. Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain

    Laura Butragueño-Laiseca

  7. Pediatric and Neonatal Intensive Care Unit, Nantes Universitary Hospital, Nantes, France

    Jean-eudes Piloquet

  8. Pediatric Intensive Care Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy

    Matteo Di Nardo

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Contributions

JR and MD defined the project and write the main manuscript FV, PLL, LB, JEP collected data and help preparing all the table SC et YG performed the statistics All authors review the manuscript.

Corresponding author

Correspondence to Jerome Rambaud.

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Ethical approval

All procedures were followed in accordance with the ethical standards of the responsible committee on human experimentation (institutional or regional) and with the Helsinki Declaration of 1975.

Conflict of interest

Dr. Matteo Di Nardo is an Advisory Board Member of Eurosets (Eurosets srl: Medolla, Modena, Italy). Dr. Broman is an Advisory Board Member of Eurosets (Eurosets srl: Medolla, Modena, Italy) and Xenios AG, Heilbronn, Germany. All other authors have no conflict of interest to declare.

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Rambaud, J., Broman, L.M., Chevret, S. et al. Association between pediatric intensive care mortality and mechanical ventilation settings during extracorporeal membrane oxygenation for pediatric acute respiratory distress syndrome. Eur J Pediatr 182, 4487–4497 (2023). https://doi.org/10.1007/s00431-023-05119-5

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