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BACKGROUND: As allergic disorders are increasing across all age groups, we aim to detect the common offending allergens in various allergic disorders with respiratory, gastrointestinal, or skin manifestations in children between the age group of 2 months and 18 years from the northern part of India. MATERIALS AND METHODS: The study was conducted in patients aged between 2 months and 18 years residing in North India having allergic symptoms such as asthma, allergic rhinitis, the combination of allergic rhinitis and asthma, eczema, urticaria, or gastrointestinal symptoms. All the patients underwent skin prick tests (SPTs) for different allergens, which were selected on the basis of history. RESULTS: A total of 458 patients were enrolled in the study with male: female ratio of 1.7:1. Based on the results of SPT, the most common offending allergens in different allergic manifestations were shortlisted. Patients with respiratory system involvement, the common allergens were house dust mites (HDM) and cockroaches, followed by mosquitoes. Most of the patients with gastrointestinal symptoms have sensitization due to egg white, followed by soybean flour. In children having skin manifestations, sensitization to HDM was most commonly seen. HDM is also responsible in patients having two system involvement such as respiratory with skin and respiratory with gastrointestinal whereas the groundnut was responsible in patients having gastrointestinal along with skin manifestations. CONCLUSION: This study contributed in delineating the most prevalent offending allergens in children of North India with various allergic disorders.

Background: Lung function testing is recommended for the management of asthma. Due to certain limitations of conventional spirometry in vulnerable patients, forced oscillation technique (FOT) has been studied with promising results. As there is a paucity of data from developing world, we planned to conduct this study in children using FOT. To assess airway reversibility after inhaled salbutamol in asymptomatic children with suspected asthma. Settings: This study was conducted at pediatric asthma clinic of a tertiary care referral hospital in North India. Design: This was a prospective interventional study over 1-year period. Subjects and Methods: Asymptomatic children between 2 and 18 years of age, with history suggestive of asthma, were eligible for participation. Baseline and postbronchodilator pulmonary functions were assessed using FOT. Airway resistance and reactance were monitored at various frequencies. SPSS version 17 was used for statistical analysis. Results: Among the 345 enrolled children, baseline mean ± standard deviation total airway resistance (R5), central airway resistance (R19), peripheral airway resistance (R5–R19), reactance (X5), and resonant frequency (Fres) were 6.85 ± 2.60, 5.23 ± 1.93, 1.6 ± 1.16, and − 2.54 ± 1.36 cmH2O/L/s and 17.28 ± 3.06 Hz. The median (interquartile range) percentage change after inhaled salbutamol was 19.9 (11.40, 29.12), 22.86 (6.88, 38.76), 14.08 (3.40, 22.62), 39.20 (8.20, 62.39), and 15.79 (8.33, 27.27) in respective parameters. All changes were statistically significant. The studied respiratory variables were in maximum negative correlation with height, followed by body mass index. Conclusions: FOT is a simple technique for monitoring lung functions in children during asthma management.

CONTEXT: Various types of allergic disorders are increasing worldwide. The diagnostic and treatment facilities are limited compared to their vast magnitude. Lack of awareness among caregivers and beneficiaries could be one of the critical factors for inadequate management especially in developing countries. AIM: This study aims to evaluate the knowledge among caregivers about various allergic disorders in a pediatric setup. SUBJECTS AND METHODS: Caregivers of children, presenting for their illness at pediatric outpatient department of a tertiary care hospital of North India, were recruited over 6 months' period using a 22-item prevalidated questionnaire. STATISTICAL ANALYSIS USED: Sigma Plot Software version 12. RESULTS: Among the 1000 participants, majority (94%) had some knowledge about allergy. Doctors were major source (55%) of information. More than half (53%) believed it to be contagious. House dust (70%) and food additives (24%) were considered major allergens. Seasonal variations (54%) and environmental pollution (48%) were considered the most common aggravating factors while steam inhalation (14%), yoga (11%), and air purifiers (10%) helped in symptom reduction. Skin and respiratory symptoms were a common knowledge amongst many study participants. Only 8% were aware about skin tests for allergy diagnosis. Alternative medicine was the treatment of choice among two-third of people. Oral route was preferred over inhaled medicines. CONCLUSION: The current study highlights limited knowledge and existence of misconceptions regarding allergic disorders in general population necessitating the need to improvise awareness campaigns.

Introduction: Serum lactate is an important parameter to assess adequacy of microcirculation in septic shock. However, prediction of outcome in pediatric septic shock with mutli organ dysfunction (MODS) based on serial lactate levels and it's clearance is not well studied. Materials and Methods: In this prospective study from a tertiary PICU in India, 43 children with septic shock and MODS aged 1month to 16 years were enrolled over one year. Our objective was to predict early ICU mortality (within 72 hours) as well as in-hospital mortality using serial serum lactate levels and it's rate of clearance. Serial serum lactate levels were measured at admission to PICU (0 hours) and 6 hourly for initial 24 hours and 12 hourly till 120 hours. Results: The median (IQR) age of enrolled children was 32 (4.5,96) months. Median (IQR) PRISM-12 score was 16.5 (12,22). Seventeen children died. Serum lactate ≥2.6 mmol/L at 24 hours predicted early ICU mortality with sensitivity and specificity of 83.3% and 85.7% (AUC: 0.873, 95% CI 0.727, 1.000). In hospital mortality could be predicted with sensitivity and specificity of 60% and 73% (AUC: 0.734, 95% CI 0.571, 0.897) when serum lactate ≥1.8 mmol/L at 24 hours. Percentage of lactate clearance (median, IQR) at 24 hours of ICU stay were 15.1 (-21.4, 24.6) and -33.2 ( -262, 0.4) (p=0.04) between survivors and non-survivors at 72 hours of ICU stay. Conclusion: Pediatric septic shock and MODS carries high mortality and serum lactate of ≥2.6 mmol/L predicted early ICU mortality with good precision.

Objective: The objective is to study the intra- and postoperative cardiopulmonary complications, metabolic derangements, and mortality in the recipients of orthotopic liver transplantation (OLT). Materials and Methods: Medical records of all children who underwent OLT at our institution from January 2003 to December 2019 were reviewed, and the clinical and laboratory data were collected. Results: Eighty-two patients (48 males) underwent living-related OLT and one received cadaveric liver. The median age of recipients was 6 years (range: 4 months–16 years). The two common indications for OLT were biliary atresia (n = 27, 32.9%) and Wilson's disease (n = 20, 24.3%). Common metabolic problems during intraoperative phase included hypokalemia (43.9%) and hyperglycemia (57.3%). The mean duration of postoperative ventilation was 35.8 ± 51.4 h. Fifty-two patients were extubated within 24 h of surgery. Pleural effusion was most common present in 52 patients postoperatively. It did not interfere with mechanical ventilation. Hypertension, hypotension, and oliguria were recorded in 28, 31, and 22 patients, respectively. There were 11 graft rejection episodes. Ten children required re-operations. There were 4 (4.8%) early deaths, aged ≤1 year, in the first 2 weeks of transplantation. Conclusion: Medical and surgical complications are common in patients after liver transplantation. Intensive monitoring and laboratory workup help in detection of these complications. Early and 1-year survival rates are comparable to that in the developed world.

Personal Protective Equipments (PPEs) are used to safeguard the health of workers. Airborne aerosol with size below 5 micron can enter lower respiratory system directly whereas bigger size particles either settles on surrounding equipment and become fomites. COVID 19 can stay in air after 3 hours with airborne spread in health care with fomites especially plastic showing infection up to 72 hours. Examples of PPE include items as mask, gloves, shield, goggles, gowns and full body suits. All health care workers need to be taught the correct sequence of wearing and taking off the PPE in order to avoid contamination.

Coronovirus-19 disease (CVOID-19) caused by severe acute respiratory syndrome-CoV2 has more than affected 3 million people worldwide, accounting for one of the largest pandemics known to humankind. Originating in China and traveling all across the globe, it spreads by droplets and fomites. Cohort intensive care units have been set up to manage critically ill CVOID-19 patients requiring organ support. Respiratory support, including low and high-flow oxygen devices, noninvasive and invasive ventilatory support have been used in the management of patients with severe acute respiratory illness. Aerosol generating procedures pose a high risk of transmission to health-care workers and need strict infection control practices and the use of personal protective equipment. Various anti-viral drugs have been tried, but there is inadequate evidence to recommend their routine use.

Objective: In recent years, there has been an increase in the use of noninvasive positive pressure ventilation (NIPPV) and high-flow nasal cannula (HFNC) in children with increased work of breathing due to acute bronchiolitis. However, there are only limited studies comparing the efficacy of these two interventions. This study was done to compare efficacy and patients' comfort while receiving HFNC and NIPPV for acute bronchiolitis. Materials and Methods: Children admitted with the first episode of acute bronchiolitis with respiratory distress (modified Wood's Clinical Asthma Score >3) were randomized to receive NIPPV and HFNC. FiO2was titrated to achieve a SpO2of ≥94%. If the child was agitated and had a COMFORT B score of ≥17, dexmedetomidine infusion was started. The protocol lasted for at least 24 h or till the respiratory support was required as decided by the treating physician. Outcome parameters measured were failure of intervention and patient comfort (using COMFORT B scores). Social science system version SPSS 17.0 was used for statistical testing.P < 0.05 was taken to indicate a significant difference for all statistical tests. Results: Twenty-five cases were enrolled in each study group. Failure of therapy was noted in 11 (44%) patients in the HFNC group and 6 (24%) in the NIPPV group (P = 0.18). COMFORT B score was significantly better in the HFNC group as compared to the NIPPV group (NIPPV12 vs. HFNC 8;P < 0.001). A number of cases requiring sedation and duration of sedation (dexmedetomidine) were more in the NIPPV group as compared to the HFNC group (22 vs. 10, P = 0.02, and 31.2 vs. 20.6 h, P = 0.04). Conclusion: This study suggests that possibly HFNC and NIPPV are equally efficient in the treatment of moderate-to-severe bronchiolitis. HFNC is more comfortable for bronchiolitis patients in comparison to NIPPV.

Objective: To compare the effects of noninvasive positive pressure ventilation(NIPPV) and oxygen (OX) therapy in post-extubated patients on re-intubation rate, length of PICU and hospital stay and mortality. Methods: It was randomized interventional study.All patients on mechanical ventilation (MV) for more than 48 hours were assessed and were enrolled only after fulfilling inclusion criteria. Patients were randomized prior to extubation to receive NIPPV or OX therapy with mask after planned weaning and extubation following institutional protocols. Reintubation required within 48 hours of extubation was considered extubation failure. Results: 97 out of 137 patients were randomized and analyzed. There was no significant difference between two groups in the distribution of underlying disease, PRISM score 12 and 24, arterial blood gases, hemodynamic parameters and duration of invasive MV prior to extubation.The PaO2 at 2 and 6 hours after extubation were significantly higher in patients receiving NIPPV (P value 0.04, 0.01 respectively). Nineteen (19.5%) patients were reintubated within 48 hours of extubation. Thirteen (25%) patients belonged to OX group and 6 (13%) were in NIPPV group (P value 0.12, odds ratio 2.28, 95% CI 0.78-6.61). Commonest reason for reintubation was increased work of breathing. Four patients with failed extubation from OX group were provided rescue NIPPV with success. The total duration of stay in the PICU and hospital were not significantly different in study groups (P value 0.4, 0.4 respectively). Conclusion: Although reintubation were less, our study did not support early elective use of NIPPV immediately after extubation in children.

Background and Objective: The treatment of ventilator-associated pneumonia (VAP) caused by multidrug resistant organisms is challenging even with appropriate intravenous antibiotics. The study was conducted to evaluate the efficacy and safety of nebulised Colistimethate sodium (CS) in the treatment of Gram negative VAP. Methods: For this prospective, interventional, open label, intention-to-treat, randomized trial, 40 consecutive patients were enrolled on the suspicion of VAP. After exclusion, 13 patients in CS nebulisation group and 15 patients in normal saline (NS) nebulisation group were randomized and completed the study. All patients were on systemic antibiotics. The clinical cure was the primary outcome and secondary outcomes included were microbiological cure, durations of mechanical ventilation and stay in PICU and adverse events related with nebulization therapy. Results: Two study groups had comparable clinical characteristics. Clinical and microbiological cures occurred in all patients of CS nebulisation group (100%) but in 11 out of 15 (73.3%) patients in NS nebulisation group (p-0.06). The total duration of mechanical ventilation and PICU stay were not significantly different in two groups. No statistically significant differences were observed with regard to adverse events. Conclusion: Aerosolized CS seems to be safe with no major adverse effects and with no clinical and microbiological benefits. There is need for adequately powered, multicentre study.

Hyperleukocytosis in pertussis has a correlation with disease severity. We describe a 5-week-old infant with severe pertussis and hyperleukocytosis requiring mechanical ventilation. Baby developed refractory hypoxemia. Two cycles of exchange transfusion were done on different occasions. Exchange transfusion resulted in significant improvement in oxygenation and hemodynamic parameters. Exchange transfusion is a viable treatment option in pertussis hyperleukocytosis complicated by refractory hypoxemia or persistent features of Systemic Inflammatory Response Syndrome.

Manipulation of positive end-expiratory pressure (PEEP) has been shown to improve the outcome in pediatric acute respiratory distress syndrome (PARDS), but the “ideal” PEEP, in which the compliance and oxygenation are maximized, while overdistension and undesirable hemodynamic effects are minimized, is yet to be determined. Also, for a given level of PEEP, transpulmonary pressure (TPP) may vary unpredictably from patient to patient. Patients with high pleural pressure who are on conventional ventilator settings under inflation may cause hypoxemia. In such patients, raising PEEP to maintain a positive TPP might improve aeration and oxygenation without causing overdistension. We report a case of PARDS, who was managed using real-time esophageal pressure monitoring using the AVEA ventilator and thereby adjusting PEEP to maintain the positive TPP.