Robinder G. Khemani David Conti Todd A. Alonzo Robert D. Bart III Christopher J. L. Newth Effect of tidal volume in children with acute hypoxemic respiratory failure Received: 11 September 2008 Accepted: 5 April 2009 Published online: 17 June 2009 Ó Springer-Verlag 2009 Electronic supplementary material The online version of this article (doi:10.1007/s00134-009-1527-z) contains supplementary material, which is available to authorized users. R. G. Khemani ( ) ) Á R. D. Bart III Á C. J. L. Newth Department of Anesthesia and Critical Care Medicine, Children’s Hospital Los Angeles, 4650 Sunset Blvd, Mail Stop 12, Los Angeles, CA 90027, USA e-mail: rkhemani@chla.usc.edu Tel.: ?1-323-3612557 Fax: ?1-323-3613877 R. G. Khemani Á D. Conti Á T. A. Alonzo Á R. D. Bart III Á C. J. L. Newth Keck School of Medicine, University of Southern California, Los Angeles, CA, USA Abstract Objectives: To deter- mine if tidal volume (V T ) between 6 and 10 ml/kg body weight using pressure control ventilation affects outcome for children with acute hypoxemic respiratory failure (AHRF) or acute lung injury (ALI). To validate lung injury severity markers such as oxygenation index (OI), PaO 2 /FiO 2 (PF) ratio, and lung injury score (LIS). Design: Retro- spective, January 2000–July 2007. Setting: Tertiary care, 20-bed PICU. Patients: Three hundred and ninety-eight endotracheally intubated and mechanically ventilated children with PF ratio \ 300. Outcomes were mortality and 28-day ventilator free days. Measurements and main results: Three hundred and ninety- eight children met study criteria, with 20% mortality. 192 children had ALI. Using [ 90% pressure control venti- lation, 85% of patients achieved V T less than 10 ml/kg. Median V T was not significantly different between survivors and non-survivors during the first 3 days of mechanical ventilation. After controlling for diagnostic category, age, delta P (PIP- PEEP), PEEP, and severity of lung disease, V T was not associated with mortality (P [ 0.1), but higher V T at baseline and on day 1 of mechanical ventilation was associated with more ventilator free days (P \ 0.05). This was particularly seen in patients with better respiratory system compliance [Crs [ 0.5 ml/cmH 2 0/kg, OR = 0.70 (0.52, 0.95)]. OI, PF ratio, and LIS were all associated with mortality (P \ 0.05). Conclusions: When ventilating children using lung pro- tective strategies with pressure control ventilation, observed V T is between 6 and 10 ml/kg and is not associated with increased mortality. Moreover, higher V T within this range is associated with more ventilator free days, particularly for patients with less severe disease. Keywords Pediatrics Á Positive pressure respiration Á Lung volume measurements Introduction Acute hypoxemic respiratory failure (AHRF), acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) result in morbidity and mortality for pediatric intensive care unit (PICU) patients. While contemporary ventilation strategies have improved outcome, mortality continues at 30–40% for adults [1], and 8–22% for chil- dren [2–4] with ALI or ARDS. Several adult studies demonstrate improved outcome when patients are managed in volume control mode with set tidal volumes of 6 ml/kg predicted body weight, compared to 12 ml/kg [1, 6]. However, differences between adult and pediatric practice regarding modes of Intensive Care Med (2009) 35:1428–1437 DOI 10.1007/s00134-009-1527-z PEDIATRIC ORIGINAL