Respiratory and hemodynamic effects of a stepwise lung recruitment maneuver in pediatric ARDS: A feasibility study

Background Little is known about the efficacy and safety of recruitment maneuvers (RMs) in pediatric patients with acute respiratory distress syndrome (ARDS). We therefore assessed the effects on gas exchange and lung mechanics and the possible detrimental effects of a sequential lung RMs and decremental positive end-expiratory pressure (PEEP) titration in pediatric ARDS patients. Methods We enrolled patients <15 years of age with ARDS, progressive hypoxemia, <72 hr of mechanical ventilation, and hemodynamic stability. A step-wise RM and decremental PEEP trial were performed. Safety was evaluated as the occurrence of hypotension and low pulse oxymeter oxygen saturation during the maneuver and development of airleaks after. Efficacy was evaluated as changes in lung compliance (C_dyn) and gas exchange 1, 12, and 24 hr after the RM. Results We included 25 patients, of median age 5 (1-16) months, median weight 7.0 (4.1-9.2) kg, median PaO₂/FIO₂ 117 (96-139), and median C_dyn 0.48 (0.41-0.68) ml/cmH₂O/kg at baseline. Thirty RM were performed, with all completed successfully. No airleaks developed. Mild hypotension was detected during four procedures. Following RM, C_dyn, and PaO₂/FIO₂ increased significantly (P < 0.01 each), without changes in PaCO₂ (P = 0.4). A >25% improvement in lung function (C_dyn or PaO₂/FIO ₂) was observed after 90% of the RM procedures. Gas exchange worsening over the next 24 hr resulted in HFOV use in 36% of patients, while the remaining subjects sustained improvements in oxygenation at 12 and 24 hr. The 28-day mortality rate was 16%. Conclusions Sequential RMs were safe and well tolerated in hemodynamically stable children with ARDS. RMs and a decremental PEEP trial may improve lung function in pediatric patients with ARDS and severe hypoxemia. Pediatr Pulmonol. 2013; 48:1135-1143.