Lung ultrasound morphology and PEEP alignment linked to extubation in children

A secondary analysis of a prospective cohort across 25 PICUs in Spain and Portugal included 160 children with acute hypoxemic respiratory failure. PEEP categorized as aligned with lung ultrasound morphology was associated with more ventilator-free days and a higher probability of extubation by day 28, but the analysis was exploratory and observational.

Analysis included 160 children across 25 PICUs.
PEEP alignment was associated with more ventilator-free days.
Adjusted extubation association: SHR 1.87 (95% CI, 1.30–2.69).
Retrospective, exploratory findings do not establish causality.

Researchers conducted a non-prespecified secondary analysis of a prospective multicenter cohort assembled in 2020–2021. The analysis included 160 mechanically ventilated children aged 1 month to 18 years with acute hypoxemic respiratory failure from 25 PICUs in Spain and Portugal. Lung ultrasound examinations performed 12 or 48–72 hours after admission were used to classify morphology as focal or nonfocal. PEEP was considered aligned when it was at least 10 cm H₂O for nonfocal morphology or below 10 cm H₂O for focal morphology. The primary outcome was ventilator-free days at 28 days.

PEEP was classified as aligned in 84 children (52.5%); 101 (63.1%) had nonfocal morphology. Compared with nonaligned PEEP, aligned PEEP was associated with lower median driving pressure (13 vs. 16 cm H₂O) and more ventilator-free days (22 vs. 17). Adjusted competing-risk analysis found a higher cumulative probability of extubation by day 28 with alignment (subdistribution hazard ratio, 1.87; 95% CI, 1.30–2.69). Associations were also reported in focal and nonfocal subgroups.

The findings suggest a possible role for morphology-informed ventilation, but do not establish that changing PEEP accordingly improves outcomes. Morphology and PEEP alignment were assessed retrospectively, and LUS did not guide ventilator management during the cohort study. The results require prospective evaluation before they can support a change in practice.

In practice

For children with acute hypoxemic respiratory failure receiving invasive ventilation, this exploratory analysis suggests that PEEP categorized according to focal versus nonfocal lung ultrasound morphology may be associated with more ventilator-free days and earlier extubation. It does not show that ultrasound-guided PEEP adjustment causes better outcomes: the analysis was retrospective and non-prespecified, and clinicians did not use the study morphology classifications to guide ventilation. The findings are not sufficient to support changing ventilator practice without prospective validation.

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Source

Pediatric Critical Care Medicine: Lung Morphology Assessed by Ultrasound and Positive End-Expiratory Pressure During Mechanical Ventilation for Acute Hypoxemic Respiratory Failure: Secondary Analysis of a Multicenter PICU Cohort From Spain and Portugal, 2020–2021 ↗

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