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Mechanical Ventilation as a Therapeutic Tool to Reduce ARDS Severity in Pediatrics

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Mechanical Ventilation as a Therapeutic Tool to Reduce ARDS Severity in Pediatrics
MC Kollisch-Singule, MD1, SV Jain, MD, MBA1, B Emr, MD1, PL Andrews, RN2, SK Roy, MD1, J Satalin, BS1, S Adkisson, RN, EMT-P1, T Ahmed, MD1, LA Gatto, PhD1,3, GF Nieman, BA1 and NM Habashi, MD2, 1Department of Surgery, SUNY Upstate Medical University, Syracuse NY, 2Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore MD, 3Department of Biological Sciences, SUNY Cortland, Cortland NY

Objective: Pediatric acute respiratory distress syndrome (ARDS) carries high mortality rates (~50%). The importance of applying protective ventilation strategies early, to limit progressive lung injury, has recently been emphasized but has not been investigated in pediatric populations. In a juvenile porcine trauma model, we tested the efficacy of applying protective low tidal volume (LVt) ventilation immediately after traumatic injury to LVt applied following development of ARDS, the current standard of care. We hypothesized that preemptive application of LVt would attenuate ARDS. Methods: Female juvenile pigs (30-40kg) were anesthetized and instrumented. The superior mesenteric artery was clamped for 30min to induce an ischemia/reperfusion injury and fecal peritonitis established. Immediately following injury, pigs were placed on ventilation with PEEP 5cmH2O and FiO2 21% and randomized into Early LVt (n=4): Vt 6cc/kg applied immediately, or Late LVt (n=4): Vt 10cc/kg transitioned to Vt 6cc/kg after developing lung injury (PaO2/FiO2<300). Pigs were monitored continuously and necropsy performed at 48hrs. Results:Late LVt resulted in moderate ARDS (PaO2/FiO2=129.9±16.0mmHg) whereas Early LVt resulted in mild ARDS (PaO2/FiO2=205.2±24.2mmHg;p<0.05). Early LVt also reduced intra-abdominal pressure, levophed requirements, lactic acid levels, and positive fluid balance with improved urine output as compared with Late LVt (all p<0.05). Early LVt increased Surfactant Protein A concentrations (p<0.05) and lowered plasma IL-6 concentration (p<0.05). Conclusions:Early LVt reduced the severity of ARDS in juvenile pigs supporting recent work demonstrating the same protective effect in adults. This suggests that mechanical ventilation can be used as a therapeutic tool to reduce the severity of ARDS in the pediatric population.

Objective: Identify that early application of protective mechanical ventilation reduces the progression of acute lung injury.

Objective Content: At the end of this activity, the learner will be able to recognize that mechanical ventilation, although necessary to support the injured lung, can further exacerbate lung injury. They will understand that protective mechanical ventilation may be used to limit progressive lung injury. Furthermore, he learner will identify that not only the ventilation strategy, but the timing of application, is important to protecting the lung. Lastly, they will be able to translate this knowledge to clinical care by considering the benefits of preemptive protective mechanical ventilation in their pediatric patients.


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