Computerized Decision Support Systems for Mechanical Ventilation in Children

Abstract

Mechanical ventilation is an effective treatment in the ICU but can have significant adverse effects. Approaches from adult research have been adopted in pediatric critical care despite known differences in respiratory physiology and ICU processes. There continues to be considerable variation in how ventilators are managed. Computerized decision support systems implement explicit protocols, and are designed to make mechanical ventilation management safer, more consistent, and more lung protective. Variable results and low or unknown compliance with protocols and CDSS tools have been reported. To date, there has been limited research regarding CDSS for mechanical ventilation in children.

Keywords

mechanical ventilation - computerized decision support

• References

• 1 Khemani RG, Markovitz BP, Curley MA. Characteristics of children intubated and mechanically ventilated in 16 PICUs. Chest 2009; 136 (3) 765-771
• 2 Randolph AG. A practical approach to evidence-based medicine: lessons learned from developing ventilator management protocols. Crit Care Clin 2003; 19 (3) 515-527
• 3 Randolph AG. How are children mechanically ventilated in pediatric intensive care units?. Intensive Care Med 2004; 30 (5) 746-747
• 4 Slutsky AS. History of mechanical ventilation. From Vesalius to ventilator-induced lung injury. Am J Respir Crit Care Med 2015; 191 (10) 1106-1115
• 5 Hickling KG, Henderson SJ, Jackson R. Low mortality associated with low volume pressure limited ventilation with permissive hypercapnia in severe adult respiratory distress syndrome. Intensive Care Med 1990; 16 (6) 372-377
• 6 The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000; 342 (18) 1301-1308
• 7 Papazian L, Forel JM, Gacouin A , et al; ACURASYS Study Investigators. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 2010; 363 (12) 1107-1116
• 8 Briel M, Meade M, Mercat A , et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA 2010; 303 (9) 865-873
• 9 Cortes GA, Marini JJ. Update: adjuncts to mechanical ventilation. Curr Opin Anaesthesiol 2012; 25 (2) 156-163
• 10 Lyerla F, LeRouge C, Cooke DA, Turpin D, Wilson L. A nursing clinical decision support system and potential predictors of head-of-bed position for patients receiving mechanical ventilation. American journal of critical care: an official publication. American Association of Critical-Care Nurses 2010; 19 (1) 39-47
• 11 Santschi M, Jouvet P, Leclerc F , et al; PALIVE Investigators; Pediatric Acute Lung Injury and Sepsis Investigators Network (PALISI); European Society of Pediatric and Neonatal Intensive Care (ESPNIC). Acute lung injury in children: therapeutic practice and feasibility of international clinical trials. Pediatr Crit Care Med 2010; 11 (6) 681-689
• 12 de Jager P, Burgerhof JG, van Heerde M, Albers MJ, Markhorst DG, Kneyber MC. Tidal volume and mortality in mechanically ventilated children: a systematic review and meta-analysis of observational studies*. Crit Care Med 2014; 42 (12) 2461-2472
• 13 Khemani RG, Newth CJ. The design of future pediatric mechanical ventilation trials for acute lung injury. Am J Respir Crit Care Med 2010; 182 (12) 1465-1474
• 14 Sucher JF, Moore FA, Todd SR, Sailors RM, McKinley BA. Computerized clinical decision support: a technology to implement and validate evidence based guidelines. J Trauma 2008; 64 (2) 520-537
• 15 Newth CJ. Respiratory disease and respiratory failure: implications for the young and the old. Br J Dis Chest 1986; 80 (3) 209-217
• 16 Restrepo RD, Fortenberry JD, Spainhour C, Stockwell J, Goodfellow LT. Protocol-driven ventilator management in children: comparison to nonprotocol care. J Intensive Care Med 2004; 19 (5) 274-284
• 17 Bernstein DB, Nguyen B, Allen GB, Bates JH. Elucidating the fuzziness in physician decision making in ARDS. J Clin Monit Comput 2013; 27 (3) 357-363
• 18 Newth CJ, Venkataraman S, Willson DF , et al; Eunice Shriver Kennedy National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. Weaning and extubation readiness in pediatric patients. Pediatr Crit Care Med 2009; 10 (1) 1-11
• 19 The Pediatric Acute Lung Injury Consensus Conference Group. Pediatric acute respiratory distress syndrome: consensus recommendations from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2015; 16 (5) 428-439
• 20 Jouvet P, Hernert P, Wysocki M. Development and implementation of explicit computerized protocols for mechanical ventilation in children. Ann Intensive Care 2011; 1 (1) 51
• 21 Morris AH. Treatment algorithms and protocolized care. Curr Opin Crit Care 2003; 9 (3) 236-240
• 22 Khemani RG, Sward K, Morris A, Dean JM, Newth CJ ; NICHD Collaborative Pediatric Critical Care Research Network (CPCCRN). Variability in usual care mechanical ventilation for pediatric acute lung injury: the potential benefit of a lung protective computer protocol. Intensive Care Med 2011; 37 (11) 1840-1848
• 23 East TD, Heermann LK, Bradshaw RL , et al. Efficacy of computerized decision support for mechanical ventilation: results of a prospective multi-center randomized trial. Proc AMIA Symp 1999; 251-255
• 24 Willson DF, Thomas NJ, Markovitz BP , et al; Pediatric Acute Lung Injury and Sepsis Investigators. Effect of exogenous surfactant (calfactant) in pediatric acute lung injury: a randomized controlled trial. JAMA 2005; 293 (4) 470-476
• 25 Curley MA, Arnold JH, Thompson JE , et al; Pediatric Prone Positioning Study Group. Clinical trial design—effect of prone positioning on clinical outcomes in infants and children with acute respiratory distress syndrome. J Crit Care 2006; 21 (1) 23-32 , discussion 32–37
• 26 Jouvet P, Farges C, Hatzakis G , et al. Weaning children from mechanical ventilation with a computer-driven system (closed-loop protocol): a pilot study. Pediatr Crit Care Med 2007; 8 (5) 425-432
• 27 Randolph AG, Wypij D, Venkataraman ST , et al; Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network. Effect of mechanical ventilator weaning protocols on respiratory outcomes in infants and children: a randomized controlled trial. JAMA 2002; 288 (20) 2561-2568
• 28 Randolph AG, Clemmer TP, East TD , et al. Evaluation of compliance with a computerized protocol: weaning from mechanical ventilator support using pressure support. Comput Methods Programs Biomed 1998; 57 (3) 201-215
• 29 Sward K, Newth CJ, Page K, Dean JM. Pediatric intensivist attitudes about a ventilator management computer protocol. Am J Respir Crit Care Med 2015; 191: A4772
• 30 Morris AH. Developing and implementing computerized protocols for standardization of clinical decisions. Ann Intern Med 2000; 132 (5) 373-383
• 31 Petty J. Understanding neonatal ventilation: strategies for decision making in the NICU. Neonatal Netw 2013; 32 (4) 246-261
• 32 Eslami S, Abu-Hanna A, Schultz MJ, de Jonge E, de Keizer NF. Evaluation of consulting and critiquing decision support systems: effect on adherence to a lower tidal volume mechanical ventilation strategy. J Crit Care 2012; 27 (4) 425.e1-425.e8
• 33 Eslami S, de Keizer NF, Abu-Hanna A, de Jonge E, Schultz MJ. Effect of a clinical decision support system on adherence to a lower tidal volume mechanical ventilation strategy. J Crit Care 2009; 24 (4) 523-529
• 34 Blagev DP, Hirshberg EL, Sward K , et al. The evolution of eProtocols that enable reproducible clinical research and care methods. J Clin Monit Comput 2012; 26 (4) 305-317
• 35 Morris AH, Orme Jr J, Truwit JD , et al. A replicable method for blood glucose control in critically Ill patients. Crit Care Med 2008; 36 (6) 1787-1795
• 36 Morris AH, Hirshberg E, Sward KA. Computer protocols: how to implement. Best Pract Res Clin Anaesthesiol 2009; 23 (1) 51-67
• 37 Sward K, Orme Jr J, Sorenson D, Baumann L, Morris AH ; Reengineering Critical Care Clinical Research Investigators. Reasons for declining computerized insulin protocol recommendations: application of a framework. J Biomed Inform 2008; 41 (3) 488-497
• 38 Bhutani VK. Clinical applications of pulmonary function and graphics. Semin Neonatol 2002; 7 (5) 391-399
• 39 Gholami B, Bailey JM, Haddad WM, Tannenbaum AR. Clinical decision support and closed-loop control for cardiopulmonary management and intensive care unit sedation using expert systems. IEEE Trans Contr Syst Technol 2012; 20 (5) 1343-1350
• 40 Sorenson D, Grissom CK, Carpenter L , et al; Reengineering Clinical Research in Critical Care Investigators. A frame-based representation for a bedside ventilator weaning protocol. J Biomed Inform 2008; 41 (3) 461-468
• 41 Nguyen B, Bernstein DB, Bates JH. Controlling mechanical ventilation in acute respiratory distress syndrome with fuzzy logic. J Crit Care 2014; 29 (4) 551-556
• 42 Karbing DS, Allerød C, Thomsen LP , et al. Retrospective evaluation of a decision support system for controlled mechanical ventilation. Med Biol Eng Comput 2012; 50 (1) 43-51
• 43 Tehrani FT, Abbasi S. A model-based decision support system for critiquing mechanical ventilation treatments. J Clin Monit Comput 2012; 26 (3) 207-215
• 44 Tzavaras A, Weller PR, Prinianakis G, Lahana A, Afentoulidis P, Spyropoulos B. Locating of the required key-variables to be employed in a ventilation management decision support system. Conf Proc IEEE Eng Med Biol Soc 2011; 2011: 112-115
• 45 Lee A, Mouhieddine M, Zekert M, Popow C. Computer determined compliance of the respiratory system (Crs) in ventilated newborn infants. Wien Klin Wochenschr 1994; 106 (7) 193-196
• 46 Flechelles O, Ho A, Hernert P , et al. Simulations for mechanical ventilation in children: review and future prospects. Crit Care Res Pract 2013; 2013: 943281
• 47 Kretschmer J, Wahl A, Möller K. Dynamically generated models for medical decision support systems. Comput Biol Med 2011; 41 (10) 899-907
• 48 Khemani RG, Celikkaya EB, Shelton CR , et al. Algorithms to estimate PaCO2 and pH using noninvasive parameters for children with hypoxemic respiratory failure. Respir Care 2014; 59 (8) 1248-1257
• 49 Kelly AM, Klim S, Rees SE. Agreement between mathematically arterialised venous versus arterial blood gas values in patients undergoing non-invasive ventilation: a cohort study. Emerg Med J 2014; 31 (e1): e46-e49
• 50 Newth CJ, Sward K, Khemani RG, Page K, Dean JM. Variability in usual care oxygenation and ventilation decisions during mechanical ventilation for pediatric acute lung injury. Am J Respir Crit Care Med 2015; 190: 314
• 51 Newth CJ, Sward K, Khemani RG, Page K, Dean JM ; Eunice Kennedy Shriver NICHD Collaborative Pediatric Critical Care Network Investigators. Variability in usual care mechanical ventilation for pediatric acute lung injury. Am J Respir Crit Care Med 2014; 189: A2613
• 52 Laubscher TP, Frutiger A, Fanconi S, Jutzi H, Brunner JX. Automatic selection of tidal volume, respiratory frequency and minute ventilation in intubated ICU patients as start up procedure for closed-loop controlled ventilation. Int J Clin Monit Comput 1994; 11 (1) 19-30
• 53 Claure N, Gerhardt T, Hummler H, Everett R, Bancalari E. Computer-controlled minute ventilation in preterm infants undergoing mechanical ventilation. J Pediatr 1997; 131 (6) 910-913
• 54 Jouvet P, Eddington A, Payen V , et al. A pilot prospective study on closed loop controlled ventilation and oxygenation in ventilated children during the weaning phase. Crit Care 2012; 16 (3) R85
• 55 Blackwood B, Junk C, Lyons JD, McAuley DF, Rose L. Role responsibilities in mechanical ventilation and weaning in pediatric intensive care units: a national survey. American journal of critical care: an official publication. American Association of Critical-Care Nurses 2013; 22 (3) 189-197
• 56 Rose L, Schultz MJ, Cardwell CR, Jouvet P, McAuley DF, Blackwood B. Automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill adults and children. Cochrane Database Syst Rev 2013; 6: CD009235
• 57 Carlo WA, Pacifico L, Chatburn RL, Fanaroff AA. Efficacy of computer-assisted management of respiratory failure in neonates. Pediatrics 1986; 78 (1) 139-143
• 58 Despotova-Toleva L, Petrov A. Feasibility for evaluation of the efficacy of conventional ventilatory support in very low birth weight infants. Folia Med (Plovdiv) 1997; 39 (4) 55-64
• 59 van Kaam AH, Hummler HD, Wilinska M , et al. Automated versus manual oxygen control with different saturation targets and modes of respiratory support in preterm infants. J Pediatr 2015; 167 (3) 545-550.e2
• 60 Akbulut FP, Akkur E, Akan A, Yarman BS. A decision support system to determine optimal ventilator settings. BMC Med Inform Decis Mak 2014; 14: 3
• 61 Allerød C, Rees SE, Rasmussen BS , et al. A decision support system for suggesting ventilator settings: retrospective evaluation in cardiac surgery patients ventilated in the ICU. Comput Methods Programs Biomed 2008; 92 (2) 205-212
• 62 Blackwood B, Murray M, Chisakuta A, Cardwell CR, O'Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of invasive mechanical ventilation in critically ill paediatric patients. Cochrane Database Syst Rev 2013; 7: CD009082
• 63 Kurachek SC, Newth CJ, Quasney MW , et al. Extubation failure in pediatric intensive care: a multiple-center study of risk factors and outcomes. Crit Care Med 2003; 31 (11) 2657-2664
• 64 Bouadma L, Lellouche F, Cabello B , et al. Computer-driven management of prolonged mechanical ventilation and weaning: a pilot study. Intensive Care Med 2005; 31 (10) 1446-1450
• 65 Leclerc F, Noizet O, Botte A , et al. [Weaning from invasive mechanical ventilation in pediatric patients (excluding premature neonates)]. Arch Pediatr 2010; 17 (4) 399-406
• 66 Schultz TR, Lin RJ, Watzman HM , et al. Weaning children from mechanical ventilation: a prospective randomized trial of protocol-directed versus physician-directed weaning. Respir Care 2001; 46 (8) 772-782
• 67 Hsu JC, Chen YF, Chung WS, Tan TH, Chen T, Chiang JY. Clinical verification of a clinical decision support system for ventilator weaning. Biomed Eng Online 2013; 12 (Suppl. 01) S4
• 68 Kacmarek RM. The mechanical ventilator: past, present, and future. Respir Care 2011; 56 (8) 1170-1180