IJCCM October-December 2003 Vol 7 Issue 4 Indian J Crit Care Med October-December 2005 Vol 9 Issue 4

Original Article
Comparisionoftwoventilationmodesandtheir
clinicalimplicationsinsickchildren
AnilSachdev,KrishanChugh,DhirenGupta,ShrutiAgarwal
A
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Objective:Tocomparetheventilationparametersofconventional,volume-controlled(VC),andpressure-
regulatedvolume-controlledmodesinsickchildrenwithvaryinglungdisease,theeffectsofspecificmode
on ventilation-related complications and patient outcome, and improvement in oxygenation with any spe-
cific mode. Design: Retrospective case record analysis. Setting: Seven-bedded tertiary-care pediatric
intensivecareunitinNorthIndia.Patients:Twenty-eightventilatedchildrenadmittedfromJulytoDecem-
ber 2000. Intervention: None. Measurements and Main Results: Twenty-eight patients were studied
with equal number in VC and pressure-regulated (PR) VC groups. The demographic profile, as well as
preventilationandonventilatorblood-gasanalysiswerecomparableinthetwogroups.Meanairwaypres-
sureinPRVCgroupwas17.5%lowerascomparedwiththatinVCgroup(P=0.03).Similarly,preventilation
PaO (65 17 mmHg), PaO /FiO (121 41 mmHg), and respiratory index (RI) (4.91 2.7) improved
2 2 2
significantly (P<0.05) with PRVC ventilation (PaO = 99 25 mmHg, PaO /FiO = 183 8 mmHg, RI =
2 2 2
3.362.95) and not in VC ventilation group. There was no difference in duration of ventilation, ventilator-
relatedcomplications,andpatientoutcomeinthetwogroups.Conclusion:PRVCventilationisbeneficial
andimprovesoxygenationininitialstagesofventilation.
Key Words: Mean airway pressure, Mechanical ventilation, Oxygenation, Pediatric, Pressure-regulated
volume-controlled ventilation
Introduction isrequiredtodeliverit,whereasinpressure-controlled
Mechanicalventilationisamajorpartofpediatriccriti- ventilationdeliveredtidalvolumevarieswiththecompli-
cal care and is associated with significant morbidity, anceandresistanceofthoraxandlungsbutthesetpeak
especiallyventilator-inducedlunginjury.
[1]
Tocircumvent pressureisnotexceeded.Inanattempttomakeventi-
these deleterious effects of mechanical ventilation, a lationmorepatientfriendlyandgentlerthePRVCventi-
variety of sophisticated and expensive methods have lationwasdevelopedwhichhasthedistincttheoretical
beendeveloped.Conventionalmechanicalventilations, advantagesofbothVCandpressure-controlledventila-
volume-controlled (VC) or pressure controlled, are still tion.
[3]
But very few studies are available in children to
theprincipalmodesofventilationusedinallagegroups.
[2]
showadiscernableclinicaladvantageofPRVC.Study
VCventilationhastheadvantageofdeliveringasettidal byKocisetal.,
[4]
comparingPRVCandVC,includedonly
volume (Vt), whatever peak inspiratory pressure (PIP) postoperativecongenitalheartdiseaseandchildrenwith
minimallungdisease,whereasPiotrowskietal.
[5]
stud-
From: ied the use of PRVC in neonates only. This limits our
SirGangaRamHospital,RajinderNagar,NewDelhi110060,India
understandingofuseofPRVCinmajorityofchildrenin
Correspondence:
pediatricintensivecareunit(PICU)whohavevarietyof
AnilSachdev,63/12,OldRajinderNagar,NewDelhi110060,India.
E-mail: anilcriticare@hotmail.com lungpathologiesofvaryingseverity.
Freefulltextavailablefromwww.ijccm.org
205
IJCCM October-December 2003 Vol 7 Issue 4 Indian J Crit Care Med October-December 2005 Vol 9 Issue 4
Thisstudywascarriedoutinthesickchildrenhaving
varyingdegreeoflungdiseasetocompare(a)theven-
tilationparametersofconventionalVCandPRVCventi-
lationintheinitialventilatorysettingand(b)theeffects
of a specific mode on ventilation-related complications
and patient outcome. In view of the distinct theoretical
advantages of PRVC mode, it was hypothesized that
PRVC would result in lower peak pressure and mean
airwaypressurewithimprovementinoxygenation.
MaterialsandMethods
Thisretrospectivecaserecordanalysiswasconducted
inamultidisciplinaryPICUofatertiary-carehospitalof
adevelopingcountry.Caserecordsofchildrenwithvar-
ied medical or surgical problems who were ventilated
duringa6monthsperiodbeginningfromJuly2000were
analysed.Duringthisperiodatotalof189patientswere
admitted to the PICU and 44 children were ventilated.
Sixteenpatientswereexcludedfromstudy.Elevenchil-
dren received pressure-controlled ventilation and two
wereneonateswhereasthreepatientsreceivedventila-
tionforlessthan24h.Theseincludedonechildofse-
vereheadinjurywithglassgowcomascale(GCS)of3
and had cardiac arrest and was revived in emergency
anddiedwithin2hofPICUadmission.Theotherwas
aninfantwhohadprolongeddrowningathomeandwas
receivedinPICUinpostarreststateanddiedwithina
few hours. The third patient had laparotomy and had
failedextubationandwastransferredtoPICUforpost-
operative care. She was successfully extubated within
1hofarrivaltoPICUTwenty-eightpatientswereincluded
inthestudy,withequalnumberinPRVCandVCgroups.
Patient characteristics including age, gender, clinical
features,laboratoryparameters,andPrismIIIscore
[6]
at
the time of admission and primary medical diagnosis
were recorded (Table 1). The nonpulmonary cases in
VCgrouphadclinical,radiological,andblood-gasanaly-
sis evidence of pulmonary involvement. One case of
meningoencephalitishadradiologicalevidenceofaspi-
rationpneumoniawhilepatientofacuterenalfailurehad
pulmonaryedema,hypoxemia,andrightupperlobeat-
electasiswasseeninthechildwithinfectivepolyneuri-
tis.Plateletcountslessthan2lac/mm
3
wererecordedin
10patientsinVCgroupandin8casesinPRVCgroup.
Seven children in VC group and six patients in PRVC
group had prolonged prothrombin time and activated
partialthromboplastintime.
Table 1: Patient characteristic
VC PRVC P
(n=14) (n=14)
Age(median;years) 2 1.5
M:F 10:4 12:2
Shock 6 5
Altered sensorium 9 9
Seizures 7 6
Hemoglobin(g/dl) 8.82.0
a
9.51.4 0.3
BUN(mg/dl) 2522.0 168.0 0.16
Creatinine(mg/dl) 1.21.6 0.70.3 0.27
Calcium(mg/dl) 8.31.0 8.51.0 0.53
Sodium(meq/l) 137.55.5 135.15.5 0.09
Potassium(meq/l) 4.40.0.87 4.00.58 0.17
Bloodglucose 146.363.5 137.259.1 0.7
PRISMIIIscore
b
10(0-22)
c
11(1-21)
d
Primarymedicaldiagnosis
Pneumonia 5 3
Meningoencephalitis 2 3
Septicemia 2
Acuterenalfailure 2
Degenerativebraindisease 2
Infective Polyneuritis 1
Cysticfibrosis - 2
Bronchialasthma - 1
Burns - 1
Lungcyst - 1
ARDS - 1
Subdural hematoma - 2
ARDS,acuterespiratorydistresssyndrome.
a
MeanSD.
b
Medianandrange.
c
n=11.
d
Bloodureanitrogen(BUN)=12.
Ventilation dataThe criteria of placing a child with
normal or abnormal lungs on mechanical ventilation in
ourunitincludeunprotectedairway,increasedworkof
breathing,highoxygenrequirement(FiO
2
>0.6),PaO
2
<60mmHg,PaCO
2
>50mmHg,andhemodynamicin-
stabilityorresistantshock.AsaprotocolinPICU,deci-
sionstostartmechanicalventilationchangeinventila-
torsettingsandtimingandmodeofweaningaretaken
byattendingconsultants(KC,AS)basedonclinicalfea-
tures,bedsidemonitoringandarterialbloodgasanaly-
sis(ABG)reports.Inthepresentstudyequalnumberof
patientsreceivedPRVCandVCventilationbutthechoice
ofparticularmodewasdeterminedbytheavailabilityof
a particular machine (Siemens servo 900 for VC and
Siemens300forPRVC).Atthetimeofstudy,onlyfour
ventilatorswereavailableinthisbusyunit.Ononlytwo
occasions both ventilators were available. So, on the
discretion of consultant-in-charge, the mode was se-
lected.Allpatientsweresedatedandparalyzedwitha
continuousinfusionofmidazolamandvecuronium.Prior
tomechanicalventilationallpatientswereprovidedoxy-
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IJCCM October-December 2003 Vol 7 Issue 4 Indian J Crit Care Med October-December 2005 Vol 9 Issue 4
genwithanoverheadboxorwithaventurimask.Oxy-
genanalyzer(MinionIMSAMedicalproducts,Pittsburgh,
USA) was used to measure FiO
2
in overhead oxygen
hood.Radialarterycatheterwasinplaceforsampling
in all patients. Preventilation ABG reports were avail-
ablein11and12childreninVCandPRVCgroups,re-
spectively. Rest of the patients (i.e., five) were put on
ventilator on the basis of clinical assessment. For this
reason,PrismIIIscoreandrespiratoryindex{RI=p
alveolar
O
- p
arterial
O
2
/p
arterial
O
2
}
[7]
couldnotbecalculatedinthesefive
patients.IfmorethanonepreventilationABGreportwas
available, the one done immediately prior to starting
ventilationwasrecorded.Ventilationdataavailablefrom
nursingchartswererecorded.ABGreportandventila-
tion setting recorded after initial stabilization (approxi-
mately34h)wasusedforanalysis.Initialstabilization
included fluid therapy, blood glucose check, and oxy-
gentherapy,andcheckstheresponsetointerventions.
Ifthepatientsclinicalconditionwasnotmoribund,ABG
reportwascheckedbeforeinitiationofventilation.Asa
policyinourunit,theventilationsettingsaresetatmini-
mumtoachievepO
2
between60and90mmHgandpCO
between 40 and 50 mmHg, whenever possible. Eight
childreninVCandninecasesinPRVCgroupwereven-
tilated within 6 h of admission. Three patients in each
group were ventilated within 12 h and rest of patients
wasinitiatedonventilatorafter24hofadmission.Medi-
calrecordswerealsosearchedformechanicalventila-
tion related complications including air leaks, atelecta-
sis, hyperinflation, and ventilation-associated pneumo-
nia.
Statisticalanalysismeanandstandarddeviation(SD)
werecalculatedforeachvariableinbothVCandPRVC
group. Nonparametric tests and Mann-Whitney and
Wilcoxon signed rank tests were used wherever appli-
cable.P<0.05wasconsideredsignificant.
Results
Of the 28 patients studied, median age in VC group
was2years(range7monthsto7years)andinPRVC
group it was 1.5 years (range 2 months to 6 years).
PreventilationandonventilatorABGreportsandventi-
latorsettingsinVCandPRVCgroupsareshowninTa-
bles2and3,respectively.Therewassignificantimprove-
ment in preventilation blood pH in both VC and PRVC
groupswithmechanicalventilation(P<0.001).Improve-
2
ment in the oxygenation status as revealed by PaO
2,
PaO
2
/FiO
2
ratioandrespiratoryindexwassignificantin
patients who were ventilated with PRVC mode (Table
4).Therewasnosignificantdifferenceinvariablessuch
asFiO
2
and pCO
2
in before- and after-ventilation ABG
reports in both groups. In PRVC group, mean airway
pressure(Paw)was17.5%lowerascomparedwithVC
group(P=0.03).Althoughnosignificantdifferenceswere
found in PIP, Ti, and positive end-expiratory pressure
(PEEP) values in two study groups. Kaplan-Meier sur-
vivaltestrevealedthatmediandurationofventilationin
PRVC group was 570 h and in VC group was 588 h
(log-rank P=0.83).
2
Chestradiographfindingsatadmissionandwhilepa-
tientswereonventilatorsdidnotshowsignificantdiffer-
enceintwostudygroups(Table5).
Table3:ComparisonofventilationparametersinVC
and pressure-regulated VC ventilations
Parameter VC PRVC P
b
(n=14) (n=14)
FiO
2
0.60.2
a
0.560.19 1.0
Vt(ml) 11772 9447 0.2
RR(/min) 26.56.7 26.54.5 0.8
PEEP(cmH
2
O) 5.01.3 4.21.2 0.07
PIP(cmH
2
O) 233.5 204.1 0.09
Ti(s) 0.630.1 0.520.06 0.1
Paw(cmH
2
O) 112.2 9.071.5 0.03
FiO, Inspired oxygen concentration.
2
a
MeanSD.
b
Mann-Whitney test.
Table2:ComparisonofABGanalysisinVCandPRVCventilation
Preventilation Onventilator
VC(n=11) PRVC(n=12) P
b
VC(n=14) PRVC(n=14) P
b
FiO
2
0.560.1 0.560.08
a
0.6 0.600.2 0.560.1 1.0
pH 7.20.08 7.270.08 0.8 7.390.06 7.370.07 0.8
PaO
2
(mmHg) 8348 6517 0.7 10032 9823 0.6
PaCO
2
(mmHg) 5729 4916 0.6 414 4312 0.7
PaO
2
/FiO
2
15386 12141 0.7 18479 19481 0.4
RI 4.132.4 4.912.7 0.6 3.272.8 3.062.8 0.7
a
MeanSD.
b
Mann-Whitney test.
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IJCCM October-December 2003 Vol 7 Issue 4 Indian J Crit Care Med October-December 2005 Vol 9 Issue 4
Table4:AnalysisofoxygenationindicesinVCventilationandpressure-regulatedVCventilationusingpaired
samples
VC(n=11) P
b
PRVC(n=12) P
b
Preventilation Onventilator Preventilation Onventilator
PaO
2
(mmHg) 8348
a
9633 0.3 6517 9925 0.03
PaO
2
/FiO
2
15386 18086 0.2 12141 18380 0.01
RI 4.132.4 3.543.2 0.4 4.912.7 3.362.95 0.01
a
MeanSD.
b
Wilcoxansignedrankstest.
Table5:Chestradiographfindingsonadmissionandon
ventilator
VC PRVC
(n=14) (n=14)
Normal 5 4
Aspiration pneumonia 1 0
Collapse consolidation 2 3
Bronchopneumonia 4 2
Pulmonary edema 2 2
Atelectesis -
[3]
-
[5]
Diffuseinfiltration - 1
Bilateral hyperinflation - 1
Lungcyst - 1
Pneumothorax -
[1]
-
VAP -
[1]
-
[2]
Figuresaregiveninparentheses.
Eight patients in VC group and eleven from PRVC
groupweredischarged.Therewerethreedeathsinthe
VC group (one each of septicemia, encephalitis, and
acuterenalfailure)andtwodeathsinPRVCgroup(sub-
dural hematoma and cystic fibrosis). Four patients out
of28(threefromVCgroupandonefromPRVCgroup)
leftagainstmedicaladvice(twocasesofbronchopneu-
moniaandoneeachofLeighdiseaseandacuterenal
failure).
Discussion
We found in our study that PRVC mode is advanta-
geousininitialstagesofventilationinsickchildrenand
itresultsinlowermeanairwaypressureandimproves
PaO
2
,PaO
2
/FiO
2
,andrespiratoryindexascomparedwith
VCventilation.VCventilationavailableonSiemensservo
900machinehasaconstantflowpattern,whereasPRVC
hastheadvantagesofdeceleratingflow.
[8]
PRVCventi-
lationisamarriageofvolumeandpressureventilation
controlledbythephysiologicparametersofcompliance.
Inspiratorypressureisregulatedbyfeedbacklooptoa
valuebasedonvolume/pressurecalculationofthepre-
viousbreathcomparedwithapresettargettidalvolume.
[3]
Thismodetheoreticallycombinesthebenefitsofdecel-
erating flow of pressure-controlled ventilation with a
safety of a volume guarantee.
[1]
This decelerating flow
has been shown to improve oxygenation by better re-
cruitmentofalveoli,evendistributionofventilation,fill-
ingofalveoliwithslowtimeconstantswhilepreventing
overdistensionofnormalalveoli,andaugmentingcol-
lateral ventilation.
[9,10]
Thereareveryfewreportsonpediatricventilationcom-
paringPRVCandconventionalVCventilation.Kociset
al.
[4]
comparedtheeffectsofPRVCandVConcardiac
output,airwaypressure,andbloodgasesintheimme-
diate postoperative period in children with congenital
heart disease with minimal lung disease. This study
showed significant reduction in PIP of 19% with no
changeinPawwhentheventilationmodewaschanged
from VC to PRVC while Ti, respiratory rate, and FiO
2
werekeptconstant.Therewasnosignificantchangein
oxygenationstatus.Piotrowskietal.
[5]
comparedtheuse
ofpatienttriggeredPRVCandintermittentventilationin
neonatesinaprospectiverandomizedstudyanddidnot
findanydifferenceinPIPoroxygenationstatus.Inthe
presentstudyPawwassignificantlylowerincriticallyill
patients receiving PRVC ventilation as compared with
thoseonVCmodewithnosignificantdifferenceinPaO
2
(on ventilator) in two groups during initial few hours of
ventilation.Inotherwords,adequateoxygenationcould
beachievedwithPRVCventilationatlowerPaw.
Davisetal.,
[10]
inaprospectivecrossoverstudyin25
adults with acute lung injury comparing constant flow
anddeceleratingflow,showedincreaseinPawandPaO
2
anddecreaseinPIPwithlatter.Al-saddyandBennett
[11]
reported decrease in PIP, total respiratory resistance,
workofinspiration,ratioofdeadspacetotidalvolume,
and alveolar-arterial gradient for oxygen and improve-
mentincomplianceandPaO
2
whilecomparingvolume-
targetedventilationusingdeceleratingandconstant-flow
patternsinadultpatients.Thepresentstudyshowssig-
nificant improvement in oxygenation indices including
PaO
2
,PaO
2
/FiO
2
,andRIwithPRVCventilationandnot
with VC ventilation. This may indicate advantages of
decelerating flow.
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IJCCM October-December 2003 Vol 7 Issue 4 Indian J Crit Care Med October-December 2005 Vol 9 Issue 4
Thereareveryfewreportsontheinfluenceofspecific
modeofventilationonthedurationofventilation,related
morbidity, and outcome. Significantly shorter duration
ofPRVCventilationwasreportedinneonateslessthan
1000gonlybyPiotrowskietal.
[5]
Similarfindingwasnot
observedbytheauthorinneonatesmorethan1000g.
Rappaportetal.
[12]
reportedshorterdurationofventila-
tionwhenpressurelimitedmode(deceleratingflow)was
comparedwithVCventilationinadultsbutGuldagaret
al.
[13]
did not obtain similar results in their study. The
presentstudydidnotfindsignificantdifferenceindura-
tionofventilationintwogroupsprobablyowingtosmall
samplesize.
Occurrence of ventilation-related complications such
asair-leaksyndromes,atelectasis,orpneumoniawere
notfoundtobedifferentinPRVCorVCgroups,though
Paw were lower in former. Experimental study on iso-
latedrabbitlungmodel
[14]
showedthatPawcontributes
morethantidalexcursiontolunghemorrhageandlung
permeabilityalterationsinducedbymechanicalventila-
tion.Parkeretal.
[15]
studysuggestedthatincreaseddu-
rationofthehighPIPandresultantalveolaroverdisten-
sion is probably the injurious aspect of high Paw. De-
creasedincidenceofintraventricularhemorrhagewas
reportedinneonatesreceivingPRVC,
[5]
thoughnosimi-
larobservationwasreportedforpneumothorax.
Webelievethatthepresentstudyisthefirsttocom-
paretheuseofPRVCandVCventilationmodesinsick
childrenwithlungdiseaseowingtovariedclinicaldiag-
nosisadmittedinthePICUofadevelopingcountry.This
study is different from previous studies that no experi-
mentalmanipulationofventilatorparameterswasdone,
as would be the characteristic of a prospective study.
Butthesamplesizeinthisstudyissmall,owingtowhich
comparisonindifferentagegroupsorspecificdisease
or influence of ventilation mode on duration or related
complicationscouldnotbedone.Thisstudyisfocused
onthebenefitsofPRVCmodeintheinitialventilation.
ThepreventilationPaO
2
andPaO
2
/FiO
2
ratioinVCgroup
ofpatientsappearsbetterthanthatofPRVCgroup.This
difference was not found to statistically significant (P=
0.7). PIP rather than plateau pressure was recorded
whichhasitsownlimitation.
[4]
Becauseallourpatients
weresedatedandparalyzed,theseresultsmaynotbe
extrapolatedtopatient-triggeredmodes.
WeconcludethatalthoughPRVCmodesupportsben-
efitsininitialventilation,aprospectivecrossoverstudy
withalargenumberofpatientswithaspecificlungdis-
easeisneededtoassesstheadvantagesofPRVCven-
tilation,itseffectonoxygenation,relatedcomplications,
andoutcome.
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