Effort of Breathing and Dyssynchrony Burden During Assisted Ventilation in Paediatric Patients

Effort of Breathing and Dyssynchrony Burden During Assisted Ventilation in Paediatric Patients

The goal of this trial is to learn if one mode of mechanical ventilation (i.e. machine to help with breathing) is better than another in children who need help from a machine to breathe. The main questions it aims to answer are:

• How hard do children need to work to breathe when they are using different types of modes of mechanical ventilation?
• Evaluate which mode of mechanical ventilation performs better when the patient is clinically awake enough to start breaths

Single centre, randomized crossover physiological study to assess effort of breathing and dyssynchrony burden associated with different modes of assisted ventilation in children. We hypothesize that patients on optimized pressure support ventilation (PSV) will 1) not have higher effort of breathing and 2) have a reduced rate of dyssynchronous effort compared to pressure control ventilation (PCV) or synchronized intermittent mandatory ventilation pressure control/pressure support (SIMV PC/PS) that is the current standard of care.

An esophageal catheter will be inserted and calibrated for measuring esophageal pressure (Pes) swings to quantify breathing effort and diagnose dyssynchronies. During passive breathing, the chest wall compliance will be measured. When the patients are in the ventilation weaning phase and triggering consistently in SIMV mode, a 30 min recording of respiratory signals will be performed (clinical mode) followed by exposure to two modes of assisted ventilation (PCV or PSV) in a randomized crossover manner for 30 min each. Level of support (the pressure above the PEEP) and sedation will remain stable within each participant. PSV optimization: If the PS breath is too short (< 0.2 sec), the inspiratory rise time will be increased to 0.15 sec and the cycling % reduced to 20, 15 or 10% to ensure an adequate size breath (approx 1/3 of the patient's respiratory cycle).

Inclusion Criteria:

1. Consent provided
2. Aged: birth to 18 years of age
3. Invasively mechanically ventilated and expected to remain intubated for ≥ 6 hours, in the ventilator weaning phase.

Exclusion Criteria:

1. Contraindication for esophageal catheter placement such as esophageal repair (e.g. esophageal surgery or esophageal varices)

2. On Extracorporeal Membrane Oxygenation (ECMO)

3. Undergoing assessment for brain death or brain death confirmed

4. Patients with a severe systemic disease that poses a constant threat to their life:

   • <24 hrs post cardiac arrest
   • 2 or more inotropes increasing by >20% within the last 24 hrs
   • increase in ventilation support or an FiO2 change ≥30% within the last 24 hrs
   • most responsible physician (MRP) determine patient is not eligible for the study intervention