Mechanical Ventilation, Paediatric Dysfunctional Breathing, Paediatric Intensive Care
Conditions
Keywords
Mechanical ventilation, Paediatrics, Synchronized intermittent mandatory ventilation (SIMV), Pressure control ventilation (PCV), Pressure support ventilation (PSV), Dyssynchrony
Brief summary
The goal of this trial is to learn if one mode of mechanical ventilation (i.e. machine to help with breathing) is better than another in children who need help from a machine to breathe. The main questions it aims to answer are: * How hard do children need to work to breathe when they are using different types of modes of mechanical ventilation? * Evaluate which mode of mechanical ventilation performs better when the patient is clinically awake enough to start breaths
Detailed description
Single centre, randomized crossover physiological study to assess effort of breathing and dyssynchrony burden associated with different modes of assisted ventilation in children. We hypothesize that patients on optimized pressure support ventilation (PSV) will 1) not have higher effort of breathing and 2) have a reduced rate of dyssynchronous effort compared to pressure control ventilation (PCV) or synchronized intermittent mandatory ventilation pressure control/pressure support (SIMV PC/PS) that is the current standard of care. An esophageal catheter will be inserted and calibrated for measuring esophageal pressure (Pes) swings to quantify breathing effort and diagnose dyssynchronies. During passive breathing, the chest wall compliance will be measured. When the patients are in the ventilation weaning phase and triggering consistently in SIMV mode, a 30 min recording of respiratory signals will be performed (clinical mode) followed by exposure to two modes of assisted ventilation (PCV or PSV) in a randomized crossover manner for 30 min each. Level of support (the pressure above the PEEP) and sedation will remain stable within each participant. PSV optimization: If the PS breath is too short (\< 0.2 sec), the inspiratory rise time will be increased to 0.15 sec and the cycling % reduced to 20, 15 or 10% to ensure an adequate size breath (approx 1/3 of the patient's respiratory cycle).
Interventions
DEVICEPressure Control Mode
In pressure control mode every breath is controlled by the ventilator, including when the breaths are delivered. This mode is typically used when patients are sedated and unable to breathe on their own.
DEVICEPressure Support Mode
In pressure support mode every breath is initiated and controlled by the patient. This mode is used when patients are awake enough to take all breaths on their own.
Sponsors
The Hospital for Sick Children
Study design
Allocation
RANDOMIZED
Intervention model
CROSSOVER
Primary purpose
DIAGNOSTIC
Masking
NONE
Intervention model description
An esophageal catheter will be inserted and calibrated for measuring esophageal pressure (Pes) swings. When the patients are in the ventilation weaning phase and triggering consistently in SIMV mode, a 30 min recording of respiratory signals will be performed (clinical mode, standard of care) followed by exposure to two modes of assisted ventilation: Pressure Control Ventilation (PCV) or Pressure Support Ventilation (PSV) in a randomized crossover manner for 30 min each.
Eligibility
Sex/Gender
ALL
Age
No minimum to 18 Years
Healthy volunteers
No
Inclusion criteria
1. Consent provided 2. Aged: birth to 18 years of age 3. Invasively mechanically ventilated and expected to remain intubated for ≥ 6 hours, in the ventilator weaning phase.
Exclusion criteria
1. Contraindication for esophageal catheter placement such as esophageal repair (e.g. esophageal surgery or esophageal varices) 2. On Extracorporeal Membrane Oxygenation (ECMO) 3. Undergoing assessment for brain death or brain death confirmed 4. Patients with a severe systemic disease that poses a constant threat to their life: * \<24 hrs post cardiac arrest * 2 or more inotropes increasing by \>20% within the last 24 hrs * increase in ventilation support or an FiO2 change ≥30% within the last 24 hrs * most responsible physician (MRP) determine patient is not eligible for the study intervention
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Average effort of breathing | Analyses will be performed on patient-level summaries averaged over the last 25 minutes of each ventilation mode (SIMV, PCV, PSV). | Muscular pressure or Pmus (calculated from DPes and using the chest wall compliance of the participant and measured by specific software \[FluxReview\]) during the assisted modes. For each patient, the change in Pmus from SIMV to PSV and from SIMV to PCV will be computed. The within-patient difference between these changes will be summarized in terms of median and interquartile range, and assessed using a Wilcoxon signed-rank test. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Dyssynchrony rate quantified by specific software (FluxReview) | Approximately 90 minutes (30 minutes per mode of mechanical ventilation) | Comfort quantified by RASS sedation and comfort scale. Dyssynchrony events will be summarized as the proportion of breath with any dyssynchrony per patient and period. To account for baseline variability, comparisons between PCV and PSV will be adjusted for each patient's SIMV baseline dyssynchrony. Similar to Pmus analyses, median, interquartile ranges and p-values from a Wilcoxon signed-rank test will be reported. |
Countries
Canada
Contacts
CONTACTLuciana Rodriguez Guerineau, M.D.
CONTACTCynthia de Medeiros, M.Sc.
PRINCIPAL_INVESTIGATORLuciana Rodriguez Guerineau, M.D.
The Hospital for Sick Children
Outcome results
None listed