Phenotypes based on respiratory drive and effort to identify the risk factors when P0.1 fails to estimate ?PES in ventilated children
Javier Amador-Casta?eda, BHS, RRT, FCCM
| Respiratory Care Practitioner | Author | Speaker | Veteran | ESICM Representative, North America
Vedrenne-Cloquet, M., Ito, Y., Hotz, J. et al. Phenotypes based on respiratory drive and effort to identify the risk factors when P0.1 fails to estimate ?PES in ventilated children. Crit Care 28, 325 (2024). https://doi.org/10.1186/s13054-024-05103-x
Summary of "Phenotypes based on respiratory drive and effort to identify the risk factors when P0.1 fails to estimate ?PES in ventilated children"
Summary:
This study explores the discrepancies between airway occlusion pressure (P0.1) and esophageal pressure swings (?PES) in estimating respiratory drive and effort in mechanically ventilated children with pediatric acute respiratory distress syndrome (PARDS). The goal was to identify phenotypes based on respiratory effort and drive, focusing on cases where P0.1 underestimated or overestimated respiratory effort. The research found that P0.1 often underestimates high respiratory effort, especially in cases with high airway resistance, high tidal volume, and opioid use, while overestimations were rare. This study underscores the importance of personalized ventilation management in pediatric patients.
Key Points:
1. P0.1 and ?PES Discrepancies: P0.1 frequently underestimates high respiratory effort (?PES), particularly in children with PARDS, while overestimation is rare.
2. Respiratory Phenotypes: Six distinct phenotypes were identified, ranging from passive breathing to normal or high effort, with or without alignment between P0.1 and ?PES.
3. Risk Factors for Underestimation: High airway resistance, high tidal volume, and opioid use were associated with P0.1 underestimating high effort.
4. Overestimation Phenotype: Overestimated effort was uncommon and associated with higher alveolar dead space and lower airway resistance.
5. Evolution Over Time: The proportion of patients with high respiratory effort increased during the course of mechanical ventilation, while low effort was more common in the early stages.
6. Clinical Implications: The study advises caution when using P0.1 as a surrogate for respiratory effort in cases with high airway resistance, intrinsic PEEP, or significant opioid use.
7. Mismatch Phenotypes: The mismatch between P0.1 and ?PES could result in suboptimal ventilation management, leading to potential lung or diaphragm injury.
8. Multivariate Analysis: Higher opioid doses, higher tidal volume, and increased airway resistance were the most significant predictors of high underestimated effort.
9. Need for Better Monitoring: The findings suggest that more accurate methods or a combination of P0.1 and ?PES should be used to guide ventilation management in pediatric patients.
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10. Future Research: Further studies are needed to assess how mismatch phenotypes influence clinical outcomes and to refine strategies for ventilatory support in children with high respiratory effort.
Conclusion:
The study highlights the frequent underestimation of high respiratory effort using P0.1 in children with PARDS, especially in patients with high airway resistance or those receiving opioids. Clinicians should be cautious when interpreting low P0.1 values, as they may not accurately reflect the patient’s true respiratory effort, potentially leading to suboptimal ventilation strategies. The findings emphasize the need for personalized ventilation management and further research on how to best monitor respiratory drive and effort in mechanically ventilated children.
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Discussion Questions:
1. How can clinicians improve the accuracy of respiratory effort estimation in pediatric patients using both P0.1 and ?PES?
2. What are the potential risks of relying solely on P0.1 to guide ventilation management in children with high airway resistance or opioid use?
3. How can future studies further investigate the impact of mismatch phenotypes on clinical outcomes in pediatric patients with PARDS?
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