Mechanical Ventilation Strategies in Children With Acute Lung Injury: A Survey on Stated Practice Pattern

Objectives: The aim of this survey was to determine North American and European pediatric intensivists' knowledge and stated practice in the management of children with acute respiratory distress syndrome with regard to mechanical ventilation settings; blood gas and So(2) targets; and use of adjunctive treatments at sites where actual practice had just been assessed. Design and Setting: A survey using three case scenarios to assess mechanical ventilation strategies used in children with acute respiratory distress syndrome was sent out toward the end of data collection to all centers participating in the Pediatric Acute Lung Injury Mechanical Ventilation study (59 PICUs in 12 countries). For each case scenario, intensivists were asked to report the optimal mechanical ventilation parameters; blood gas and So(2) acceptable targets; and threshold for considering high-frequency oscillatory ventilation, and other adjunctive treatments. Participants: Fifty-four pediatric intensivists, representing 47 centers from 11 countries. Interventions: None. Measurements and Main Results: Many pediatric intensivists reported using a tidal volume of 5-8 mL/kg (88-96%) and none reported using a tidal volume above 10 mL/kg. On average, the upper threshold of positive inspiratory pressure at which intensivists would consider another ventilation mode was 35 cm H2O. Permissive hypercapnia and mild hypoxemia (So(2) as low as 88%) was considered tolerable by many pediatric intensivists. Finally, a large proportion of pediatric intensivists reported they would use adjunctive treatments (nitric oxide, prone position, extracorporeal membrane oxygenation, surfactant, steroids, -agonists) if the patient's condition worsened. Conclusions: Although in theory, many pediatric intensivists agreed with adult recommendations to ventilate with lower tidal volumes and pressure limits, the Pediatric Acute Lung Injury Mechanical Ventilation data revealed that over 25% of pediatric patients with acute lung injury/acute respiratory distress syndrome at many of these practice sites were ventilated with tidal volumes above 10 mL/kg and that high positive inspiratory pressure levels (> 35 mm Hg) were often tolerated.