Can Computer Decision Support Help Us Follow Our Own Rules in Pediatric Acute Respiratory Distress Syndrome?*

OBJECTIVE: Mechanical ventilation of patients with ARDS should balance lung and diaphragm protective principles, which may be difficult to achieve in routine clinical practice. Through a Phase I clinical trial, we sought to determine whether a computerized decision support (CDS) based protocol (Real-time Effort Driven ventilator management (REDvent)) is feasible to implement, results in improved acceptance for lung and diaphragm protective ventilation and improves clinical outcomes over historical controls. DESIGN: Interventional non-blinded pilot study SETTING: Pediatric Intensive Care Unit PATIENTS: Mechanically ventilated children with ARDS INTERVENTIONS: A CDS tool was tested which prioritized lung protective management of ΔP (PIP-PEEP), PEEP/FiO(2), and ventilator rate. Esophageal manometry was used to maintain patient effort in a physiologic range. Protocol acceptance was reported, and enrolled patients were matched 4:1 with respect to age, initial OI, and percentage of immune compromise to historical control patients for outcome analysis. MEASUREMENTS AND MAIN RESULTS: Thirty-two patients were included. Acceptance of protocol recommendations was over 75%. 128 matched historical controls were used for analysis. Compared to historical controls, patients treated with REDvent received lower ΔP and V(T), and higher PEEP when FiO(2) was > 0.60. REDvent was associated with 6 more ventilator free days, shorter duration until the first spontaneous breathing trial and 3 fewer days on MV amongst survivors (all p = < 0.05) in comparison to historical controls, while maintaining no difference in the rate of reintubation. CONCLUSIONS: A CDS based protocol prioritizing lung protective ventilation balanced with reduction of controlled ventilation to maintain physiologic levels of patient effort can be implemented and may be associated with shorter duration of ventilation.