Airway Pressure Release Ventilation as a Recruitment Maneuver in Mechanically Ventilated Children with Restrictive Lung Disease

Mashael F Alqahtani^1*Jessica E Allen²Craig M Johnson²Timothy M. Maul²Christine K Koshel²

• ¹University of Kentucky, Lexington, United States
• ²Nemours Children's Hospital, Orlando, United States

Rationale: Restrictive lung disease is common in pediatric patients, leading to acute-on-chronic respiratory failure and the need for invasive mechanical ventilation. There is no consensus on lung recruitment maneuvers. Objectives: To examine the use of airway pressure release ventilation (APRV) in patients with restrictive lung disease as an effective open-lung tool maneuver. Methods: This single-center retrospective case series included patients with restrictive lung disease in a 28-bed pediatric intensive care unit from 2013 to 2024, who developed acute-on-chronic respiratory failure requiring invasive mechanical ventilation. Inclusion criteria were ventilation for at least 48 hours, with at least 24 hours in APRV. Descriptive statistics were performed. Measurements and Main Results: 18 patient encounters met inclusion criteria. Subjects were divided into two groups: neuromuscular disease (14 encounters) and truncal obesity (4 encounters). Lung surface area improved significantly in the first 12-24 hours of APRV use: neuromuscular group by 7600 mm² [95% CI, 4000-11000 mm²]; p <0.001, and obesity group by 15000 mm² [95% CI, 3000-27000]; p = 0.018. Atelectasis improved at 12-24 hours and 48 hours from starting APRV, with mean differences of 14% [95% CI, 4-24%]; p = 0.005 and 14% [95% CI, 3-25%]; p = 0.009, respectively. As expected, oxygenation improved substantially in both groups. Conclusion: APRV is a safe and effective method for improving atelectasis and oxygenation in children with RLD related to neuromuscular conditions and obesity. Further high-quality prospective studies are needed to establish clear guidelines for its use.