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Permissive Hypercapnia as a Ventilatory Strategy in Burned Children: Effect on Barotrauma, Pneumonia, and Mortality

Sheridan, Robert L. MD; Kacmarek, Robert M. PhD, RPT; McEttrick, Marjorie M. BSN, MPA/H; Weber, Joan M. BSN, CIC; Ryan, Colleen M. MD; Doody, Daniel P. MD; Ryan, Daniel P. MD; Schnitzer, Jay J. MD, PhD; Tompkins, Ronald G. MD, ScD

The Journal of Trauma: Injury, Infection, and Critical Care: November 1995 - Volume 39 - Issue 5 - p 854-859

Objective  To document the incidence of barotrauma, pneumonia, and respiratory death associated with a mechanical ventilation protocol based on permissive hypercapnia in pediatric burn patients.

Design  Retrospective review.

Materials and Methods  Patients were managed using a mechanical ventilation protocol based on permissive hypercapnia, tolerating moderate (pH>7.20) respiratory acidosis to keep inflating pressures below 40 cm H sub 2 O.

Main Results  Over a 2.5-year interval, 54 burned children (11% of 495 acute admissions) with an average age of 6.5 years (range 5 weeks to 17 years), average burn size of 44% (range 0 to 98%), and median burn size of 46% required mechanical ventilatory support for an average of 12.5 days (range 1 to 56 days). Inhalation injury was diagnosed in 34 (63%) of the children and 72% percent were admitted within 24 hours of injury. Overt barotrauma occurred in 5.6% of the patients, pneumonia in 32%, and respiratory death in 0%.

Conclusions  A conventional ventilation protocol based on permissive hypercapnia is associated with acceptable rates of barotrauma and pneumonia. The low incidence of respiratory death associated with this strategy suggests that it also minimizes ventilator-induced lung injury.

From the Shriners Burns Institute-Boston Unit (R.L.S, M.M.M., J.M.W., C.M.R., D.P.D., D.P.R., J.J.S., R.G.T.), Department of Surgery, Massachusetts General Hospital (R.L.S., C.M.R., D.P.D., D.P.R., J.J.S., R.G.T.), Department of Anesthesia, Massachusetts General Hospital (R.M.K.), Department of Anesthesia, Harvard Medical School (R.M.K.), and Department of Surgery, Harvard Medical School (R.L.S., C.M.R., D.P.D., D.P.R., J.J.S., R.G.T.).

Supported by the Shriners Hospitals for Crippled Children and the National Institutes of General Medical Sciences (P50 GM21700 and T32 GM07035).

Presented to the annual meeting of the American Burn Association in Orlando, Florida, April, 1994.

Address for reprints: Robert Sheridan, MD, Assistant Chief of Staff, Shriners Burns Institute, 51 Blossom Street, Boston, MA 02114.

The reader is referred to the Clinical Management Update, a new section beginning this issue on page 000.

© Williams & Wilkins 1995. All Rights Reserved.