Mechanical Ventilation in Pediatric Intensive Care Unit at Minia University Hospital

Background: Mechanical Ventilation is essential intervention, Every year, MV is administered to thousands of pediatric patients. The study aimed to assess the indications and outcomes of Mechanical Ventilation in all ventilated patients aged from 1 Month to 18 years in Minia University PICU. Methods: This is a Hospital based cross sectional study at Minia University Hospital PICU during the period Octobor 2019 to May 2022 in Minia governorate, Egypt. Results: About 54% were males 46% were females, the mean of age of all mechanically ventilated children was 25.6 ± 33.9 months. Non-Respiratory causes represents the majority of causes that leads to mechanical Ventilation in (54%) and the commonest non-respiratory causes was apnea after status epilepticus (11.6%) and central apnea (7.6%) causing respiratory failure in 48 (19.1%) infants. Pneumonia was the commonest respiratory indication for mechanical ventilation in (33.5%). The mode that was used mostly was PCV in (86.1%) and the mean duration of mechanical ventilation was 4 ± 2.6 days. there is Significant correlation between mortality rate and indication for MV, duration of ventilation, relapse rate and complication rate (Spearman test, P < .05) and according to Binary logistic regression model, indication, duration, and complications of mechanical ventilation are the major determinants of the mortality outcome. Conclusions: VAP is more likely to be the most common complication of the Mechanical Ventilation. The outcome of mechanically ventilated patients depended on characteristics at the start of MV, as well as on the development of complications and management protocols in the PICU.


Introduction
Mechanical ventilation is mostly a lifesaving procedure in pediatric critical care, but many complications in conditions that require intensive care are related to ventilatory support, particularly if it was prolonged.When other simple respiratory support treatments fail to improve oxygenation and/or ventilation, mechanical ventilatory assistance is recommended. Indications of Mechanical Ventilation are divided into three categories: (Respiratory, Non-Respiratory, both Respiratory and Non-Respiratory). Although Mechanical Ventilation is a widely used in Pediatric intensive care units, usage and particularly Prolonged usage of MV causes many complications such as: Pulmonary Barotrauma related to Mechanical Ventilation, Atelectasis related to Mechanical Ventilation, Ventilator Associated Pneumonia (VAP), Tracheal Edema and Tracheal Stenosis after the extubation Period, Mechanical Ventilator dependence and Broncho-Pulmonary dysplasia.

Ethical consideration:
Following the ethical guidelines of epidemiological research, a written informed consent form from pediatric patients' mothers was developed and attached to all questionnaires. Each patients' mothers was explained the objectives of the study and details of the data collected. Subjects were also assured confidentiality which was maintained by removing names of subjects from data collection forms. Only numbers were kept for identification. The researcher was the only person having access to link numbers to persons' names.

Statistical analysis:
Data entry and analysis were all done with I.B.M. compatible computer using software called SPSS for windows version 19. Graphics were done by Excel Microsoft office 2010. Quantitative data were presented by mean and standard deviation, while qualitative data were presented by frequency distribution. Chi square test, Fisher's exact and Z (test of proportions) test was used to compare between proportions. Student t-test was used to compare two means.

Results
In our study, males were the most predominant than females by a percentage of 54% of all mechanically ventilated children, the mean of age of all mechanically ventilated children was 25.6 ± 33.9 months, when we come to the indications of mechanical Ventilation, we will find that Non-Respiratory causes represents the majority of causes that leads to mechanical Ventilation in children by a percentage of 54%, the most common non-respiratory causes was apnea after status epilepticus (11.6%) and central apnea (7.6%) causing respiratory failure in 48 (19.1%) infants in our cohort. Pneumonia was the most common respiratory indication for mechanical ventilation causing respiratory failure in 84 (33.5%) infants. The mode that was used mostly was PCV by percentage of 86.1% and the mean duration of mechanical ventilation was 4 ± 2.6 days. We found that there is Significant relation was found between indications of Mechanical Ventilation and age groups (Spearman test, P < .05).

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Mechanical Ventilation in Pediatric Intensive Care Unit at Minia University Hospital    (4) showed that the indications for mechanical ventilation in PICU were divided into four major categories including acute neurological illness (35.8%), respiratory illness (20.8%), cardiac failure (13%) and miscellaneous group (30.3%) mostly involve safety of airway like postoperative patients and septic shock, etc. But they are in agreement with (5) study, in which the indications for MV in all the studied patients were acute on top of chronic respiratory failure (77.7%) followed by acute hypoxemic respiratory failure (11.54%), post arrest (10%) and coma (0.77%).
The mean duration for mechanical ventilation was 4.1 ± 2.6 days, ranging from 1 to 17 days. This in agreement with (4) showed that the duration of mechanical ventilation was 4-6 days in few published reports. dual modes (5%). But, this against the study done by (6) and (7) , that showed different modes of mechanical ventilation. In NIMV, the modes were BiPAP (84.9%) followed by CPAP (15.2%).
The overall mortality rate was 46.2%. On the other hand, 126 (50.1%) infants demonstrated clinical improvement and were discharged to the inpatient ward. Nine (3.5%) infants were discharged with residual morbidities. This is against (9) study, in which the survival rate of mechanical ventilated cases was (23%) while the mortality rate was (77%). But, in contrary with this study and in agreement with our study (10), (11), (12), (13) who reported that the mortality rate was less than that reported in this study and reported to be between (43-67 %).
Significant relation was found between the indication for Mechanical Ventilation and age group with (P value < .05). this in agreement with (4) The age was further divided in to three subcategories: <12 month (n=99), 1-5 yr (n=98) and >5 yr (n=110). The indications for mechanical ventilation in PICU were divided into four major categories including acute neurological illness (35.8%), respiratory illness (20.8%), cardiac failure (13%) and miscellaneous group (30.3%) mostly involve safety of airway like postoperative patients and septic shock, etc.

Conclusion
In a large cohort of mechanically ventilated patients, VAP is more likely to be the most common complication of the Mechanical Ventilation. Demographic data of the patients and associated co-morbidities did not affect the choice of type of MV. So the outcome of mechanically ventilated patients depended mainlyon characteristics at the start of MV, as well as on the development of complications and management protocols in the PICU.