Positive End-Expiratory Pressure During Helmet Ventilation in Critically Ill Bronchiolitis: A Multicenter Randomized Clinical Trial

Author(s): Emanuele Rossetti MD, PhD*, Zaccaria Ricci, MD, Daniele Bonacina, MD, Cristina Giugni MD, Ezio Bonanomi MD, Marina Franci MN, Marta Ciofi degli Atti MD, Manuela L’Erario MD, Daniela Perrotta MD, Corrado Cecchetti MD, PhD, Linda Appierto MD, Luigi Dei Giudici MD, Alessandro Germani MD, Francesco Polisca MD, Francesca Tortora MD, Ivano Farinelli MD, Fabrizio Chiusolo MD, Paola Serio MD, Roberto Bianchi MD, Sergio G. Picardo MD on behalf of the SARNePI (Ital

Objectives: To evaluate the effects of two different levels of Positive End-Expiratory Pressure (PEEP) during Helmet Continuous Positive Airway Pressure (HCPAP) support on the intubation rate in infants with bronchiolitis admitted to Pediatric Intensive Care Units (PICUs).

Design: Multicentric prospective, randomized, open clinical trial.

Setting: Four tertiary PICUs in Italy.

Participants: Infants admitted to PICUs due to severe bronchiolitis and requiring respiratory support.

Interventions: The enrolled patients were randomly assigned one of two PEEP levels for HCPAP support: high (P10 group: 10 cmH2O) or low (P5 group: 5 cmH2O).

Measurements and Main Results: In total, 64 patients were randomly assigned to the P10 group, and 60 to the P5 group. The intubation rate was 9/60 (15%) and 9/64 (14%) in P5 and P10 groups (OR 0.94, 95% CI 0.36- 2.46, p=0.99). Of the patients in the P5 group, 47 (78%) were escalated to a PEEP level of 10 cmH2O. PEEP level was not associated to intubation rate (OR 0.69, 95% CI 0.19 to 2.40, p=0.57), after adjustment for age, gestational age, high flow nasal cannula application, bronchiolitis severity score and pediatric index of mortality 3. No cases of pneumothorax were observed in this study.

Conclusions: In this trial on infants with severe bronchiolitis, a PEEP level of 10 cm H2O during HCPAP in comparison to an initial level of 5 cm H2O did not show to prevent intubation. These results are not conclusive due to the premature stopping.

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