Article of the month

Khemani RG, Bhalla A, Hotz JC, Klein MJ, Kwok J, Kohler K, Bornstein D, Chang D, Armenta-Quiroz A, Vu K, Smith E, Suresh A, Baron D, Bonilla-Cartagena J, Ross PA, Deakers T, Beltramo F, Nelson L, Shah S, Elkunovich M, Curley MAQ, Mack W, Newth CJL. 

Randomized Trial of Lung and Diaphragm Protective Ventilation in Children 

NEJM Evid. 2025 Jun;4(6):EVIDoa2400360. doi: 10.1056/EVIDoa2400360. Epub 2025 May 27. PMID: 40423397.

Abstract

Background: Mechanical ventilation strategies that balance lung and diaphragm protection have not been extensively tested in clinical trials.

Methods: We conducted a single-center, phase II randomized controlled trial in children with acute respiratory distress syndrome with two time points of random assignment: the acute and weaning phases of ventilation. Patients in the intervention group were managed with a computerized decision support (CDS) tool, named REDvent, and esophageal manometry to deliver lung and diaphragm protective ventilation. The control group received usual care. A daily standardized spontaneous breathing trial (SBT) was performed in both groups. The primary outcome was the length of weaning.

Results: From October 2017 through March 2024, 248 children were randomly assigned to the acute phase. When participants were triggering the ventilator, the adjusted mean difference (REDvent-acute - usual care-acute) for peak inspiratory pressure was -3 cmH2O (95% CI, -5 to -2), positive end-expiratory pressure was -2 cmH2O (95% CI, -2 to -1), and the esophageal pressure swing was -1.8 cmH2O (95% CI, -3.2 to -0.3). For the primary outcome, 55% of REDvent-acute patients passed their SBT or were extubated on the day of the first SBT, compared with 39% in the usual care-acute group. After adjusting for age, immunosuppression, and oxygenation index value, the REDvent-acute intervention resulted in a 1.67 (95% CI, 1.01 to 2.77; P=0.045) odds of a shorter length of weaning than usual care. The median time from intubation to SBT passage was 3.83 days in the intervention group versus 4.75 days in the usual care group. The length of ventilation among survivors was 5.0 days in the intervention group versus 5.6 days in the usual care group. When comparing weaning phase random assignment, clinical outcomes were similar between groups. There were no differences in adverse events between the groups.

Conclusions: A lung and diaphragm protective ventilation strategy using a CDS tool during the acute phase of ventilation resulted in a shorter length of weaning than usual care. Phase III trials in mechanically ventilated patients are warranted. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT03266016.).