Have changes in ventilation practice improved outcome in children with acute lung injury?

Objectives: To describe the changes that have occurred in mechanical ventilation in children with acute lung injury in our institution over the last 10-15 yrs and to examine the impact of these changes, in particular of the delivered tidal volume on mortality. Design: Retrospective study. Setting. University-affiliated children's hospital. Patients: The management of mechanical ventilation between 1988 and 1992 (past group, n = 79) was compared with the management between 2000 and 2004 (recent group, n = 85). Interventions: None. Measurements and Main Results: The past group patients were ventilated with a significantly higher mean tidal volume (10.2 +/- 1.7 vs. 8.1 +/- 1.4 mL.kg(-1) actual body weight, p < .001), lower levels of positive end-expiratory pressure (6.1 +/- 2.7 vs. 7.1 +/- 2.4 cm H2O, P = .007), and higher mean peak inspiratory pressure (31.5 +/- 7.3 vs. 27.8 +/- 4.2 cm H2O, P < .001) than the recent group patients. The recent group had a lower mortality (21% vs. 35%, p =.04) and a greater number of ventilator-free days (16.0 +/- 9.0 vs. 12.6 +/- 9.9 days, p =.03) than the past group. A higher tidal volume was independently associated with increased mortality (odds ratio 1.59; 95% confidence interval 1.20, 2.10, p < .001) and reduction in ventilation-free days (95% confidence interval -1.24, -0.77, p < .001). Conclusions: The changes in the clinical practice of mechanical ventilation in children in our institution reflect those reported for adults. In our experience, mortality among children with acute lung injury was reduced by 40%, and tidal volume was independently associated with reduced mortality and an increase in ventilation-free days.