title: Pressure characteristics of mechanical ventilation and incidence of pneumothorax before and after the implementation of protective lung strategies in the management of pediatric patients with severe ARDS.
abstract: OBJECTIVE
  To compare pressure characteristics of mechanical ventilation and their impact on pediatric patients with severe ARDS in the pre-protective lung strategy (PLS) and post-PLS eras.
  
  
  METHODS
  Medical records of 33 patients admitted to our pediatric ICU with ARDS from 1992 through 1994 (pre-PLS) and 52 patients with ARDS admitted from 2000 through 2003 (post-PLS) were retrospectively reviewed.
  
  
  RESULTS
  Patient age and gender distribution were identical in both eras. Fifty-five percent of the patients in the pre-PLS era had pneumothorax, compared to 17% in the post-PLS era (p < 0.05). Overall mortality rates for patients in the pre-PLS and post-PLS eras were 42% and 25%, respectively (p = 0.09; not significant). Mean duration of exposure to peak inspiratory pressure (PIP) values > 40 cm H2O was significantly longer in the pre-PLS era than in the post-PLS era. Pre-PLS patients with pneumothorax received mean maximum PIP of 72 +/- 17 cm H2O, mean maximum positive end-expiratory pressure (PEEP) of 20 +/- 5 cm H2O, and maximum mean airway pressure (MAP) of 46 +/- 8 cm H2O, while patients in the post-PLS era required mean maximum PIP of 42 +/- 2 cm H2O, mean maximum PEEP of 14 +/- 2 cm H2O, and maximum MAP of 30 +/- 6 cm H2O, respectively (p < 0.05 for all pressure parameters). There were no significant differences in mechanical ventilation pressure characteristics among patients who did not have pneumothorax during their course of management in both eras.
  
  
  CONCLUSIONS
  A significantly more aggressive use of ventilator pressure characteristics distinguished the pre-PLS era from the post-PLS era, and was found to be associated with a markedly higher incidence of pneumothorax. Outcome in both eras did not differ significantly, presumably due to insufficient statistical power.
authors.affiliation: Division of Pediatric Critical Care Medicine, North Shore-Long Island Jewish Health System, Schneider Children's Hospital, New Hyde Park, NY. Electronic address: mmiller@nshs.edu.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Miller
authors.affiliation: Division of Pediatric Critical Care Medicine, North Shore-Long Island Jewish Health System, Schneider Children's Hospital, New Hyde Park, NY.
authors.forename: Mayer
authors.initials: M
authors.lastname: Sagy
mesh_terms: D002648:Child; D005260:Female; D006801:Humans; D015994:Incidence; D015278:Intensive Care Units, Pediatric; D008297:Male; D011030:Pneumothorax / Q000453:epidemiology / Q000209:etiology* / Q000517:prevention & control; D011175:Positive-Pressure Respiration / Q000009:adverse effects*; D017410:Practice Guidelines as Topic; D011312:Pressure / Q000009:adverse effects; D012128:Respiratory Distress Syndrome / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate