Critical care medicine · 2025
Differentiating Lung From Chest Wall Mechanics Is Difficult Without Esophageal Manometry in Children With Acute Respiratory Distress Syndrome.
СтатьяРандомизированное исследованиеНазвание и аннотация: Перевод пока не подготовлен
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Ito Yukie, Vedrenne-Cloquet Meryl, Chang Daniel, Hotz Justin C, Kyogoku Miyako, Takeuchi Muneyuki, Flink Rutger C, Bhalla Anoopindar K, Newth Christopher J L, Khemani Robinder G
Аннотация
OBJECTIVES: Pediatric acute respiratory distress syndrome (PARDS) guidelines recommend limiting airway plateau pressure (Pplat) to 28 cm H 2 O, allowing for higher limits when chest wall compliance (C CW ) is poor since less of the pressure is transmitted to lung (transpulmonary pressure). Transpulmonary pressure depends on Pplat and the ratio of lung elastance to respiratory system elastance (E L /E RS ). E L /E RS measurement requires esophageal manometry, although it is not routinely available. We sought to determine if routinely available clinical data could reliably predict E L /E RS or changes in E L /E RS , to understand when Pplat greater than 28 cm H 2 O could be acceptable.
DESIGN: Secondary analysis of randomized controlled trial with esophageal manometry monitoring.
SETTING: Quaternary PICU.
PATIENTS: Mechanically ventilated children with PARDS.
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: Two hundred seven patients and 750 patient days were included. Using the first day per patient, median E L /E RS was 0.83 (interquartile range, 0.72-0.87), with a weak negative correlation with respiratory system compliance (C RS ) ( r = -0.26; p < 0.001). C RS was strongly correlated with lung compliance (C l ) ( r = 0.94; p < 0.001) and moderately correlated with C CW ( r = 0.53; p < 0.001). Multivariable analysis identified that higher C RS , younger age and peripheral neuromuscular disease were associated with higher C CW , while higher C RS was the only variable independently associated with higher C l (all p < 0.01). When trying to predict high (> 0.9) or low (< 0.7) E L /E RS , C RS was the only variable retaining an independent association: lower C RS (C RS × 10 [mL/cm H 2 O/kg × 1/10]) with high E L /E RS (odds ratio [OR], 0.70; 95% CI, 0.54-0.86; p = 0.002; area under the receiver operating characteristic curve [AUC], 0.73) and higher C RS (C RS × 10 [mL/cm H 2 O/kg × 1/10]) with low E L /E RS (OR, 1.14; 95% CI, 1.02-1.28; p = 0.017; AUC, 0.60). Change in E L /E RS from day to day was not predictable.
CONCLUSIONS: In PARDS, C RS is more strongly tied to C l than C CW . While E L /E RS is not easily predictable from clinical variables, when C RS is low, E L /E RS is generally high. Therefore, increasing Pplat above the suggested thresholds when C RS is impaired may be inappropriate without measuring esophageal pressure.
DESIGN: Secondary analysis of randomized controlled trial with esophageal manometry monitoring.
SETTING: Quaternary PICU.
PATIENTS: Mechanically ventilated children with PARDS.
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: Two hundred seven patients and 750 patient days were included. Using the first day per patient, median E L /E RS was 0.83 (interquartile range, 0.72-0.87), with a weak negative correlation with respiratory system compliance (C RS ) ( r = -0.26; p < 0.001). C RS was strongly correlated with lung compliance (C l ) ( r = 0.94; p < 0.001) and moderately correlated with C CW ( r = 0.53; p < 0.001). Multivariable analysis identified that higher C RS , younger age and peripheral neuromuscular disease were associated with higher C CW , while higher C RS was the only variable independently associated with higher C l (all p < 0.01). When trying to predict high (> 0.9) or low (< 0.7) E L /E RS , C RS was the only variable retaining an independent association: lower C RS (C RS × 10 [mL/cm H 2 O/kg × 1/10]) with high E L /E RS (odds ratio [OR], 0.70; 95% CI, 0.54-0.86; p = 0.002; area under the receiver operating characteristic curve [AUC], 0.73) and higher C RS (C RS × 10 [mL/cm H 2 O/kg × 1/10]) with low E L /E RS (OR, 1.14; 95% CI, 1.02-1.28; p = 0.017; AUC, 0.60). Change in E L /E RS from day to day was not predictable.
CONCLUSIONS: In PARDS, C RS is more strongly tied to C l than C CW . While E L /E RS is not easily predictable from clinical variables, when C RS is low, E L /E RS is generally high. Therefore, increasing Pplat above the suggested thresholds when C RS is impaired may be inappropriate without measuring esophageal pressure.