Patient Ventilator Asynchrony in Critically Ill Children

危重儿童患者呼吸机异步

• 批准号: 10657157
• 负责人: Robinder Khemani
• 金额: $ 73.45万
• 依托单位: CHILDREN'S HOSPITAL OF LOS ANGELES
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-06-15 至 2028-04-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10657157
• 关键词: Acute Respiratory Distress Syndrome; Adult; Algorithms; Biological; Breathing; Child; Childhood; Clinical; Clinical Data; Clinical Decision Support Systems; Clinical Trials; Collection; Control Groups; Critically ill children; Data; Data Set; Delirium; Derivation procedure; Frequencies; Functional disorder; Induction of neuromuscular blockade; Intervention; Intervention Studies; Knowledge; Literature; Lung; Lung diseases; Machine Learning; Measures; Mechanical Ventilators; Mechanical ventilation; Mediating; Mediation; Methods; National Heart, Lung, and Blood Institute; Neurocognitive; Observational Study; Outcome; Pathway interactions; Patient Care; Patients; Pediatric Research; Physiological; Prevention; Randomized, Controlled Trials; Research Design; Research Personnel; Respiratory Diaphragm; Risk; Risk Factors; Sedation procedure; Strategic vision; Stress; Techniques; Testing; Therapeutic; Training; Validation; Ventilator; Ventilator-induced lung injury; cohort; high risk; improved; infection risk; innovation; lung injury; machine learning model; neural; novel; novel diagnostics; novel therapeutic intervention; patient subsets; preclinical study; premature; prevent; prospective; respiratory; secondary analysis; tool; treatment as usual; ventilation

Project Summary Mechanically ventilated children often have patient-ventilator asynchrony (PVA) although this is incompletely characterized in the literature and infrequently recognized at the bedside. When a ventilated patient has spontaneous effort, the ventilator attempts to synchronize with the patient, but PVA represents a mismatch between what the patient wants and what the ventilator delivers. PVA is common in ventilated adults and is associated with longer duration of ventilation, increased risk of infection, lung injury, diaphragm dysfunction, and adverse neurocognitive effects. While there are many types of PVA, they are not equally harmful or prevalent. Therapeutic strategies should focus on the most harmful forms of PVA. Although we still don’t know which PVA subtypes are truly most harmful, Double Cycled (DC) breaths (where a second breath is delivered before the first breath is complete) have the strongest biological plausibility for harm, because DC induces lung stress, strain, ventilator induced lung injury and eccentric contraction of the diaphragm. PVA is understudied in children, even though it may be more common and goes largely unrecognized even by highly trained clinicians. Moreover, existing pediatric studies have failed to identify a clear relationship between PVA and worse clinical outcomes, although these studies have not focused on the highest risk patients (such as those with Acute Respiratory Distress Syndrome (ARDS)), have used different definitions for PVA and its subtypes, and have been inadequately powered to evaluate the relationship between PVA subtypes and outcome. This proposal will set the stage for therapeutic strategies to manage PVA in children and will fill crucial knowledge and implementation gaps including: (1) harmonizing how PVA is measured and defined, (2) identifying the most harmful PVA subtypes and the patients at risk, and (3) using innovative and accurate bedside tools to improve the recognition of PVA. We will leverage the expertise and preliminary data from three premier pediatric research groups who have the expertise to use precise methods to capture the patient’s neural respiratory effort, which is crucial to correctly identify PVA subtypes. This proposal will include prospective, multi-center collection of ventilator waveforms from 200 ventilated children using precise techniques to capture neural respiratory effort, in addition to detailed secondary analysis of existing waveforms and clinical data from over 350 children. We will use causal inference and mediation approaches to evaluate the relationship between PVA subtypes and clinical and mechanistic outcomes by leveraging data from a randomized controlled trial (REDVent, R01HL124666) where PVA rates and subtypes likely differ between intervention and control groups. This trial is prescribing a mechanical ventilation strategy promoting more spontaneous breathing to achieve lung and diaphragm protective ventilation, compared to usual care.

项目摘要 机械通风的儿童经常患有患者 - 换剂异步（PVA），尽管这是 在文献中没有完全表征，在床边很少认可。当通风时 患者有赞助的努力，呼吸机试图与患者同步，但PVA代表 患者想要的东西与呼吸机提供的内容不匹配。 PVA在通风中很常见 成人，与通气持续时间更长，感染风险增加，肺损伤，隔膜有关 功能障碍和不良神经认知效应。虽然PVA类型多种多样，但它们并不相等 有害或普遍。治疗策略应集中在最有害的PVA上。虽然我们仍然 不知道哪种PVA亚型确实是最有害的，双循环（DC）呼吸（第二次呼吸是 在第一次呼吸完成之前交付）具有强大的生物学损害的合理性，因为DC 诱导肺应激，应变，呼吸机诱导肺损伤和隔膜的偏心收缩。 PVA在儿童中被理解，即使它可能更普遍，并且在很大程度上无法识别 即使是训练有素的临床医生。此外，现有的小儿研究未能确定明确的关系 在PVA和较差的临床结果之间，尽管这些研究并未集中在最高风险上 患者（例如患有急性呼吸窘迫综合征（ARDS）的患者）使用了不同的定义 PVA及其亚型，并且无法进行评估PVA之间关系的功能不足 亚型和结果。该提案将为管理儿童的PVA的治疗策略奠定基础 并将填补关键的知识和实施空白，包括：（1）协调如何测量PVA和 定义，（2）确定最有害的PVA亚型和有风险的患者，以及（3）使用创新和 准确的床头工具，以提高PVA的识别。我们将利用专业知识和初步数据 来自三个具有专业知识的主要儿科研究小组，可以使用精确方法来捕获 患者的神经呼吸努力，这对于正确识别PVA亚型至关重要。该建议将包括 使用精度从200个通风儿童那里收集了来自200名通风儿童的预期，多中心的呼吸机波形 除了对现有波形的详细次级分析外，还可以捕获神经呼吸努力的技术 以及来自350多名儿童的临床数据。我们将使用因果推断和调解方法来评估 PVA亚型与临床和机械结局之间的关系通过利用来自 随机对照试验（Redvent，R01HL124666），其中PVA速率和亚型可能不同 干预和对照组。该试验规定了一种机械通风策略，以促进更多 与通常的护理相比，自发呼吸以实现肺和隔膜保护通风。