• Craig D Smallwood, Brian K Walsh, John H Arnold, and Andrew Gouldstone.
• Division of Critical Care Medicine, Department of Anesthesia, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts and Harvard Medical School, Boston, Massachusetts. craig.smallwood@childrens.harvard.edu.
• Respir Care. 2019 Oct 1; 64 (10): 1193-1198.

BackgroundPEEP is titrated to improve oxygenation during mechanical ventilation. It is clinically desirable to identify factors that are associated with a clinical improvement or deterioration following a PEEP change. However, these factors have not been adequately described in the literature. Therefore, we aimed to quantify the empirical probability of PEEP changes having a positive effect upon oxygenation, compliance of the respiratory system (CRS), and the ratio of dead space to tidal volume (VD/VT). Further, clinical factors associated with positive response during pediatric mechanical ventilation are described.MethodsMechanically ventilated pediatric subjects in the ICU were eligible for inclusion in the study. During PEEP increases (PEEPincrease), a responder was defined as having an improved SpO2 /FIO2 ratio; non-responders demonstrated a worsening SpO2 /FIO2 ratio in the following hour. When PEEP was decreased (PEEPdecrease), a responder was anyone who maintained or increased the SpO2 /FIO2 ratio; non-responders demonstrated a worsening SpO2 /FIO2 ratio. Features from continuous mechanical ventilation variables were extracted, and differences between responders and non-responders were identified.Results286 PEEP change cases were eligible for analysis in 76 subjects. For PEEPincrease cases, the empirical probability of positive response was 56%, 67%, and 54% for oxygenation, CRS, and VD/VT, respectively. The median SpO2 /FIO2 increase was 13. For PEEPdecrease, the empirical probability of response was 46%, 53%, and 46% for oxygenation, CRS, and VD/VT, respectively. PEEPincrease responders had higher FIO2 requirements (70.8 vs 52.5%, P < .001), mean airway pressure (14.0 vs 12.9 cm H2O, P = .03), and oxygen saturation index (9.9 vs 7.5, P = .002) versus non-responders. For PEEPdecrease, VD/VT was lower in responders (0.46 vs 0.50, P = .031).ConclusionsIn children requiring mechanical ventilation, the responder rate was modest for both PEEPincrease and PEEPdecrease cases. These data suggest that PEEP titration often does not have the desired clinical effect, and predicting which patients will manifest a positive response is complex, requiring more sophisticated means of assessing individual subjects.Copyright © 2019 by Daedalus Enterprises.

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