Mechanical power in pediatric acute respiratory distress syndrome: a PARDIE study
Authors: Bhalla Anoopindar K. , Klein Margaret J. , Modesto I Alapont Vicent , Emeriaud Guillaume , Kneyber Martin C. J. , Medina Alberto , Cruces Pablo , Diaz Franco , Takeuchi Muneyuki , Maddux Aline B. , Mourani Peter M. , Camilo Cristina , White Benjamin R. , Yehya Nadir , Pappachan John , Di Nardo Matteo , Shein Steven , Newth Christopher , Khemani Robinder ,   Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network, Poterala Rossana , Fernandez Analia , Vera Antonio Avila , Vidal Nilda Agueda , Rosemary Deheza , Turon Gonzalo , Monjes Cecilia , Serrate Alejandro Siaba , Iolster Thomas , Torres Silvio , Castellani Pablo , Giampieri Martin , Pedraza Claudia , Landry Luis Martin , Althabe Maria , Fortini Yanina Vanesa , Erickson Simon , Barr Samantha , Shea Sara , Butt Warwick , Delzoppo Carmel , Pintimalla Alyssa , Leon Alejandro Fabio Martinez , Rivera Gustavo Alfredo Guzman , Jouvet Philippe , Emeriaud Guillaume , Dumitrascu Mariana , French Mary Ellen , Caro I Daniel , Acuna Carlos , Diaz Franco , Nunez Maria Jose , Chen Yang , Alarcon Yurika Paola Lopez , Izquierdo Ledys Maria , Piñeres Olave Byron Enrique , Hoyos Pablo Vasquez , Bourgoin Pierre , Baudin Florent , Briassoulis George , Ilia Stavroula , Di Nardo Matteo , Chiusolo Fabrizio , Shime Nobuaki , Ohshimo Shinichiro , Kida Yoshiko , Kyo Michihito , Tang Swee Fong , Tai Chian Wern , Lum Lucy Chai See , Elghuwael Ismail , Escobar Carlos Gil , Moniz Marta Sousa , Camilo Cristina , Hazwani Tarek , Aldairi Nedaa , Al Amoudi Ahmed , Alahmadti Ahmad , Fernandez Yolanda Lopez , Valle Juan Ramon , Martinez Lidia , Orive Javier Pilar , Modesto I Alapont Vicent , Odena Marti Pons , Medina Alberto , Dominguez Susana Reyes , Dursun Oguz , Ongun Ebru Atike , Can Fulya Kamit , Anil Ayse Berna , Lillie Jon , Tibby Shane , Wellman Paul , Belfield Holly , Brierley Joe , Dominguez Troy E. , Abaleke Eugenia , Feinstein Yael , Weitz James , Fortune Peter-Marc , Subramanian Gayathri , Jennings Claire , Inwald David , Feather Calandra , Agbeko Rachel , Lawton-Woodhall Angela , McIntyre Karen , Nofziger Ryan , Latifi Samir , Anthony Heather , Sanders Ron , Hefley Glenda , Virk Manpreet , Jaimon Nancy , Khemani Robinder , Newth Christopher , Bhalla Anoopindar , Kwok Jeni , Morzov Rica , Mahapatra Sidharth , Truemper Edward , Kustka Lucinda , Nett Sholeen T. , Singleton Marcy , Jarvis J. Dean , Yehya Nadir , Napolitano Natalie , Murphy Marie , Ronan Laurie , Morgan Ryan , Kubis Sherri , Broden Elizabeth , Gedeit Rainer , Murkowski Kathy , Woods Katherine , Kasch Mary , Han Yong Y. , Affolter Jeremy T. , Tieves Kelly S. , Hughes-Schalk Amber , Chima Ranjit S. , Krallman Kelli , Stoneman Erin , Benken Laura , Yunger Toni , Schneider James , Sweberg Todd , Kessel Aaron , Carroll Christopher L. , Santanelli James , Ackerman Kate G. , Cullimore Melissa , Rowan Courtney , Bales Melissa , Dockery W. Keith , Jafari-Namin Shirin , Barry Dana , Jane’t Keary , Gertz Shira , Coates Bria , Wellisch Lawren , Allen Kiona , Shukla Avani , Thomas Neal J. , Spear Debbie , Shein Steven L. , Parker Margaret M. , Sloniewsky Daniel , Allen Christine , Harrell Amy , Cvijanovich Natalie , Typpo Katri , Kelley Connor , King Caroline , Sapru Anil , Ratiu Anna , Ashtari Neda , Jeyapalan Asumthia S. , Coronado-Munoz Alvaro , Hume Janet , Nerheim Dan , Smith Lincoln , Hartmann Silvia , Sullivan Erin , Merritt Courtney , Al-Subu Awni , Blom Andrea , Hsing Deyin D. , Pon Steve , Estil Jim Brian , Gautam Richa , Giuliano John S. , Tala Joana 
Published: January 2022

Abstract
Background
Mechanical power is a composite variable for energy transmitted to the respiratory system over time that may better capture risk for ventilator-induced lung injury than individual ventilator management components. We sought to evaluate if mechanical ventilation management with a high mechanical power is associated with fewer ventilator-free days (VFD) in children with pediatric acute respiratory distress syndrome (PARDS).

Methods
Retrospective analysis of a prospective observational international cohort study.

Results
There were 306 children from 55 pediatric intensive care units included. High mechanical power was associated with younger age, higher oxygenation index, a comorbid condition of bronchopulmonary dysplasia, higher tidal volume, higher delta pressure (peak inspiratory pressure—positive end-expiratory pressure), and higher respiratory rate. Higher mechanical power was associated with fewer 28-day VFD after controlling for confounding variables (per 0.1 J·min−1·Kg−1 Subdistribution Hazard Ratio (SHR) 0.93 (0.87, 0.98), p = 0.013). Higher mechanical power was not associated with higher intensive care unit mortality in multivariable analysis in the entire cohort (per 0.1 J·min−1·Kg−1 OR 1.12 [0.94, 1.32], p = 0.20). But was associated with higher mortality when excluding children who died due to neurologic reasons (per 0.1 J·min−1·Kg−1 OR 1.22 [1.01, 1.46], p = 0.036). In subgroup analyses by age, the association between higher mechanical power and fewer 28-day VFD remained only in children < 2-years-old (per 0.1 J·min−1·Kg−1 SHR 0.89 (0.82, 0.96), p = 0.005). Younger children were managed with lower tidal volume, higher delta pressure, higher respiratory rate, lower positive end-expiratory pressure, and higher PCO2 than older children. No individual ventilator management component mediated the effect of mechanical power on 28-day VFD.

Conclusions
Higher mechanical power is associated with fewer 28-day VFDs in children with PARDS. This association is strongest in children < 2-years-old in whom there are notable differences in mechanical ventilation management. While further validation is needed, these data highlight that ventilator management is associated with outcome in children with PARDS, and there may be subgroups of children with higher potential benefit from strategies to improve lung-protective ventilation.
Take Home Message: Higher mechanical power is associated with fewer 28-day ventilator-free days in children with pediatric acute respiratory distress syndrome. This association is strongest in children <2-years-old in whom there are notable differences in mechanical ventilation management.