Data Without Borders: Exposing Practice Gaps Through Collaborative Research
Ethan Sanford MD, Justin L. Lockman MD MSEd, Proshad Efune MD, Shawn Jackson MD PhD
Mechanical ventilation is a fundamental therapy in the OR and in pediatric critical care units, but it carries a risk of ventilator-induced lung injury. Although lung-protective ventilation strategies are well established in adults,1,2 evidence guiding pediatric ventilation practices remains limited and largely extrapolated from adult data. The Paediatric Patients (PRoVENT-PED) study was designed to characterize global ventilation practices in critically ill children and to identify potentially modifiable ventilatory factors associated with clinical outcomes. Many of these findings may also have implications for how you ventilate patients in the OR as well. In today’s PAAD, our PICU team reviews the article and offers their insights into the power of the study’s design. Myron Yaster MD
Original article
van Vliet R, Melger JWJ, Bem RA, Blokpoel RGT, Schultz MJ, Paulus F, Kneyber MCJ, van Meenen DMP; PRoVENT-PED steering committee and investigators. Epidemiology, ventilation management, and clinical outcomes in children (PRoVENT-PED): first results from the 10-year, investigator-initiated, international, multicentre, prospective cohort study. Lancet Respir Med. 2026 May 1:S2213-2600(26)00044-5. doi: 10.1016/S2213-2600(26)00044-5. Epub ahead of print. PMID: 42081907.
Breathing is the first life-sustaining miracle our bodies perform after birth. During anesthesia and critical illness, mechanical ventilators are both lifelines and liabilities, blunt instruments that require fine-tuning to avoid exacerbating or causing pulmonary injury. Invasive mechanical ventilation is usually a temporizing measure, supporting gas exchange while we treat the underlying pathology. The art and science of optimizing gas exchange is like home ownership… it requires maintenance of baseline function for safety, intermittent minor upgrades to improve function, and occasional major remodeling. Today’s PAAD offers insights into real-life ventilator management in critically ill children and the importance of collaborative data to maintain and drive clinical practice.3
The PROVENT-PED study is an investigator-initiated, international, prospective observational study spanning 83 ICUs across 34 countries intended to provide insights into actual global ventilator practices. The study included 1,427 invasively ventilated children, in which respiratory failure was the leading indication for ventilation (37%), followed by postoperative support (31%) and neurologic impairment (18%). For the 11% of patients diagnosed with pediatric acute respiratory distress syndrome (PARDS), ventilation strategies often strayed from lung-protective ideals. While children with PARDS were managed with slightly lower median tidal volumes than those without PARDS (7 mL/kg versus 8 mL/kg), nearly one-third of patients still received a Vt greater than 8 mL/kg. The median driving pressure (ΔP) for PARDS patients was 17 cm H2O, and over one-third of these patients were exposed to a ΔP exceeding 15 cm H2O (the threshold above which outcomes are worse in adult studies). Ultimately, the study found that elevated PEEP, high ΔP, and excessive FiO2 were potential modifiable factors independently associated with 28-day ICU mortality. That elevated FiO₂ exposure was associated with worse outcomes shouldn’t be a surprise to PAAD readers.4 We’ve discussed the value of conservative oxygen strategies in several recent PAADs here and here.
But none of that is why our team wanted to highlight this study. We believe that prospective, large-scale, cross-sectional collaborations that include diverse geographic and economic populations – like the PROVENT-PED study – are vital! They serve as an unforgiving and beneficial mirror. We assume that we generally practice medicine according to evidence-based guidelines. Of course, we may stray from guidelines on a case-by-case basis. However, registries and multi-center observational cohort studies strip away personal and institutional bias to reveal the gaps between what we believe is best and how we actually manage patients – keys to implementation science. Further, if we are often deviating from guidelines, it’s likely they need to be modified or updated.
These massive datasets can also drive new research hypotheses. For instance, PROVENT-PED found that ΔP is independently linked to mortality, while Vt adjusted to actual body weight is not; this suggests we may need to abandon rigid mL/kg targets and instead titrate volumes utilizing lung compliance and driving pressure. This is an area for further study in pediatrics.
We have already seen the transformative power of this collaborative model in other corners of pediatric anesthesia. Consider the phenomenal success of the Pediatric Difficult Intubation (PeDI) Registry, which has reshaped how we approach airway management5 by identifying factors associated with airway complications and serving as the scaffold to organize prospective, interventional studies that inform our current practice. Similarly, the Pediatric Craniofacial Collaborative Group (PCCG) and its perioperative registry standardized and drastically improved blood product management during complex cranial vault procedures. The adoption of shared, electronic medical record-based, real-time research databases (such as Epic Cosmos, Cerner Real-World Data, and others) are likely to ease this work in the future.
The lesson is clear: we must expand multi-institutional research collaboratives across core topics of pediatric anesthesia and critical care. These collaboratives serve several functions: 1) to break down institutional silos and personal biases, 2) maintain and disseminate best practice, and 3) expose crucial opportunities for targeted quality improvement and novel research. When we collaborate, we democratize knowledge—and our patients breathe a little easier for it!
What do you think? Email Myron at myasterster@gmail.com and he’ll include in a Friday Reader Response.
References
1. Amato MB, Barbas CS, Medeiros DM, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. The New England journal of medicine 1998;338(6):347–54. (In eng). DOI: 10.1056/nejm199802053380602.
2. Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, Wheeler A. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The New England journal of medicine 2000;342(18):1301–8. (In eng). DOI: 10.1056/nejm200005043421801.
3. van Vliet R, Melger JWJ, Bem RA, et al. Epidemiology, ventilation management, and clinical outcomes in children (PRoVENT-PED): first results from the 10-year, investigator-initiated, international, multicentre, prospective cohort study. Lancet Respir Med 2026 (In eng). DOI: 10.1016/s2213-2600(26)00044-5.
4. Lilien TA, Groeneveld NS, van Etten-Jamaludin F, et al. Association of Arterial Hyperoxia With Outcomes in Critically Ill Children: A Systematic Review and Meta-analysis. JAMA network open 2022;5(1):e2142105. (In eng). DOI: 10.1001/jamanetworkopen.2021.42105.
5. Stein ML, Sarmiento Argüello LA, Staffa SJ, et al. Airway management in the paediatric difficult intubation registry: a propensity score matched analysis of outcomes over time. EClinicalMedicine 2024;69:102461. (In eng). DOI: 10.1016/j.eclinm.2024.102461.