Mucus in paediatric mechanical ventilation.

Rationale:
Ipratropiumbromide (Atrovent®) is an ammonium-containing muscarinic antagonist (i.e. an anticholinergic agent) that conceptually may decrease sputum production with resulting increase in lung volume defined by end-expiratory lung volume (EELV) and improved oxygenation. However, its efficacy on these outcomes is unclear that warrants further study to rationalise this supportive treatment.

Objective:

1. To study the differences in changes in EELV between mechanically ventilated children after endotracheal suctioning with prior nebulisation of ipratropriumbromide, prior instillation of NaCl 0.9% or nothing;

2. To study the differences in PaO2/FiO2 and oxygenation index between mechanically ventilated children after endotracheal suctioning with prior nebulisation of ipratropriumbromide, prior instillation of NaCl 0.9% or nothing.

Study design:
The study is designed as a prospective, randomized interventional pilot study in the period September – December 2009.

Study population:
All mechanically ventilated children aged 0 – 18 years old.

Intervention (if applicable):
Patients will be randomized to either nebulisation of ipratropiumbromide (if age less than 4 years 125 micrograms, if age > 4 years then 250 micrograms) four times a day, endotracheal installation of sodium chloride (NaCl 0.9%) 2 – 4 ml or to control group (no intervention at all).

Main study parameters/endpoints:
Primary endpoint includes the difference in changes in EELV measured with EIT. Secondary endpoints include the difference in oxygenation defined by PaO2 ratio and the oxygenation index (OI).

We hypothesize that nebulisation of ipratropiumbromide results in decreased production of sputum resulting in a better lung aeration (defined by an increase in EELV) and improved oxygenation (as defined by the PaO2/FiO2 ratio and the oxygenation index) in a heterogeneous group of mechanically ventilated critically ill children.

The study periods lasts 24 hours after inclusion, incorporating 4 time points at which measurements are made.

Patients will be randomized to either nebulisation of ipratropiumbromide (if age less than 4 years 125 micrograms, if age > 4 years then 250 micrograms) four times a day, endotracheal installation of sodium chloride (NaCl 0.9%) 2 – 4 ml or to control group (no intervention at all).