Search

BACKGROUND: Pediatric patients with ARDS will on occasion need venovenous extracorporeal membrane oxygenation (VV-ECMO) for organ support. As these patients recover, they may benefit from lung recruitment maneuvers including flexible bronchoscopy (FB). The objective of this study was to assess the clinical course of patients who underwent FB while on VV-ECMO for ARDS. METHODS: This was a secondary analysis of a retrospective multi-center cohort at 10 United States pediatric academic quaternary care centers. Data were collected on 204 subjects age 14 d-18 y on VV-ECMO. RESULTS: 271 FBs were performed on 129 (63%) subjects. Pre-FB tidal volume was 1.8 mL/kg compared to 2.22 mL/kg following FB (P = .007). Dynamic compliance also improved from pre-FB to post-FB (2.23 vs 3.04 mL/cm H2O, P = .005). There was a low incidence of complications following FB (3.1%). Subjects in the FB group had fewer ECMO-free days (EFDs) (17.9 vs 22.1 d, P < .001), fewer ventilator-free days (VFDs) (40.0 vs 46.5 d, P = .001), and longer ICU length of stay (LOS) (18 vs 32 d, P < .001). Subjects in the early versus late FB group had more EFDs (19.4 vs 15.2 d, P = .003), more VFDs (43.0 vs 34.0 d, P = .004), and shorter ICU LOS (27.5 vs 35.5 d, P = .045). Mortality in the subjects who had at least one FB was 27.1% compared to 40% in the subjects who did not have a FB while on VV-ECMO (P = .057). CONCLUSIONS: FB can be performed on patients while anticoagulated on VV-ECMO with a low incidence of complications. FB may be beneficial especially when performed early in the course of VV-ECMO. [ABSTRACT FROM AUTHOR]

Acute respiratory failure with inadequate oxygenation and/or ventilation is a common reason for ICU admission in children and adults. Despite the morbidity and mortality associated with acute respiratory failure, few proven treatment options exist beyond invasive ventilation. Attempts to develop intravascular respiratory assist catheters capable of providing clinically important gas exchange have had limited success. Only one device, the IVOX catheter, was tested in human clinical trials before development was halted without FDA approval. Overcoming the technical challenges associated with providing safe and effective gas exchange within the confines of the intravascular space remains a daunting task for physicians and engineers. It requires a detailed understanding of the fundamentals of gas transport and respiratory physiology to optimize the design for a successful device. This article reviews the potential benefits of such respiratory assist catheters, considerations for device design, previous attempts at intravascular gas exchange, and the motivation for continued development efforts. [ABSTRACT FROM AUTHOR]

BACKGROUND: Extubation failure is associated with increased duration of mechanical ventilation, length of hospital stay, and mortality. An elevated dead-space-to-tidal-volume ratio (VD/VT) has been proposed as a predictor of successful extubation in children. We hypothesized that a higher VD/VT value would be associated with extubation failure and higher postextubation respiratory support. METHODS: This was a prospective, observational, cohort study. All subjects were < 18 y old and were extubated in the pediatric multidisciplinary ICU or the cardiac ICU at an academic medical center from June 2016 through March 2017. Using arterial blood gas analysis and mainstream volumetric capnography, daily VD/VT measurements were obtained on intubated subjects using an automated algorithm. Respiratory support upon extubation was based on the clinical team's judgment and defined as low (ie, room air or nasal cannula) or high (ie, high-flow nasal cannula, CPAP, or bi-level positive airway pressure). Subjects were monitored for 48 h after extubation for escalation in respiratory support and need for re-intubation. RESULTS: Of 189 subjects included in the analysis, 166 were successfully extubated and 23 (12%) required re-intubation. There was no significant difference in final VD/VT between those who extubated successfully and those who failed extubation, with a median VD/VT of 0.28 (interquartile range [IQR] 0.20-0.37) vs 0.29 (IQR 0.21-0.33), respectively (P = .87). Those who received a high level of support upon extubation had a higher VD/VT than those who received a low level of support, with a median of 0.32 (IQR 0.23-0.39) vs 0.25 (IQR 0.16-0.30), respectively (P < .001). This association remained significant when controlling for age, duration of intubation, and cyanotic congenital heart disease (odds ratio 1.63, 95% CI 1.18-2.24). CONCLUSIONS: There was no significant relationship between VD/VT and extubation success, although VD/VT was associated with the level of respiratory support provided following extubation. Further studies should investigate whether the use of VD/VT can help reduce extubation failure rates with varying levels of postextubation respiratory support. [ABSTRACT FROM AUTHOR]

BACKGROUND: Venovenous extracorporeal membrane oxygenation (VV-ECMO) is used when mechanical ventilation can no longer support oxygenation or ventilation, or if the risk of ventilator- induced lung injury is considered excessive. The optimum mechanical ventilation strategy once on ECMO is unknown. We sought to describe the practice of mechanical ventilation in children on VV-ECMO and to determine whether mechanical ventilation practices are associated with clinical outcomes. METHODS: We conducted a multicenter retrospective cohort study in 10 pediatric academic centers in the United States. Children age 14 d through 18 y on VV-ECMO from 2011 to 2016 were included. Exclusion criteria were preexisting chronic respiratory failure, primary diagnosis of asthma, cyanotic heart disease, or ECMO as a bridge to lung transplant. RESULTS: Conventional mechanical ventilation was used in about 75% of children on VV-ECMO; the remaining subjects were managed with a variety of approaches. With the exception of PEEP, there was large variation in ventilator settings. Ventilator mode and pressure settings were not associated with survival. Mean ventilator FIO2 on days 1–3 was higher in nonsurvivors than in survivors (0.5 vs 0.4, P = .009). In univariate analysis, other risk factors for mortality were female gender, higher Pediatric Risk Estimate Score for Children Using Extracorporeal Respiratory Support (Ped-RESCUERS), diagnosis of cancer or stem cell transplant, and number of days intubated prior to initiation of ECMO (all P < .05). In multivariate analysis, ventilator FIO2 was significantly associated with mortality (odds ratio 1.38 for each 0.1 increase in FIO2 , 95% CI 1.09-1.75). Mortality was higher in subjects on high ventilator FIO2 (≥ 0.5) compared to low ventilator FIO2 (> 0.5) (46% vs 22%, P = .001). CONCLUSIONS: Ventilator mode and some settings vary in practice. The only ventilator setting associated with mortality was FIO2 , even after adjustment for disease severity. Ventilator FIO2 is a modifiable setting that may contribute to mortality in children on VV-ECMO. [ABSTRACT FROM AUTHOR]

INTRODUCTION: The effectiveness of high-frequency oscillatory ventilation (HFOV) in the pediatric hematopoietic cell transplant patient has not been established. We sought to identify current practice patterns of HFOV, investigate parameters during HFOV and their association with mortality, and compare the use of HFOV to conventional mechanical ventilation in severe pediatric ARDS. METHODS: This is a retrospective analysis of a multi-center database of pediatric and young adult allogeneic hematopoietic cell transplant subjects requiring invasive mechanical ventilation for critical illness from 2009 through 2014. Twelve United States pediatric centers contributed data. Continuous variables were compared using a Wilcoxon rank-sum test or a Kruskal-Wallis analysis. For categorical variables, univariate analysis with logistic regression was performed. RESULTS: The database contains 222 patients, of which 85 subjects were managed with HFOV. Of this HFOV cohort, the overall pediatric ICU survival was 23.5% (n = 20). HFOV survivors were transitioned to HFOV at a lower oxygenation index than nonsurvivors (25.6, interquartile range 21.1-36.8, vs 37.2, interquartile range 26.5-52.2, P = .046). Survivors were transitioned to HFOV earlier in the course of mechanical ventilation, (day 0 vs day 2, P = .002). No subject survived who was transitioned to HFOV after 1 week of invasive mechanical ventilation. We compared subjects with severe pediatric ARDS treated only with conventional mechanical ventilation versus early HFOV (within 2 d of invasive mechanical ventilation) versus late HFOV. There was a trend toward difference in survival (conventional mechanical ventilation 24%, early HFOV 30%, and late HFOV 9%, P = .08). CONCLUSIONS: In this large database of pediatric allogeneic hematopoietic cell transplant subjects who had acute respiratory failure requiring invasive mechanical ventilation for critical illness with severe pediatric ARDS, early use of HFOV was associated with improved survival compared to late implementation of HFOV, and the subjects had outcomes similar to those treated only with conventional mechanical ventilation. [ABSTRACT FROM AUTHOR]

The Pediatric Acute Lung Injury Consensus Conference (PALICC) has provided the critical care community with the first pediatric-focused definition for ARDS. The PALICC recommendations provide guidance on conventional ventilator management, gas exchange goals, use of high-frequency ventilation, adjunct management approaches, and the application of extracorporeal membrane oxygenation for pediatric ARDS (PARDS). Although outcomes for PARDS have improved over the past decade, mortality and morbidity remain significant. Pediatric-specific criteria may provide the ability to more promptly recognize and diagnose PARDS in clinical practice. Improvements in prognostication and stratification of disease severity may help to guide therapeutic interventions. Improved comparisons between patients and studies may help to promote future clinical investigations. Hopefully, the recommendations provided by PALICC, in terms of defining and managing ARDS, will stimulate additional research to better guide therapy and further improve outcomes for critically ill infants and children with ARDS. [ABSTRACT FROM AUTHOR]

The article discusses the effectiveness of integrating electrical impedance tomography (EIT) in the assessment and clinical care of children managed with mechanical ventilation. Topics include a study on the use of EIT to determine the distribution of tidal volume/gas delivery during the recovery of children with acute respiratory failure and the issue of ventilator liberation in pediatrics.

Led by the work of the Pediatric Acute Lung Injury Consensus Conference, much was published on the topic of pediatric ARDS in 2015. Although the availability of definitive data to the pediatric practitioner for the management of infants and children with pediatric ARDS continues to lag behind that for the adult clinician, 2015 augmented the available medical literature with more information than had been seen for years. This article will review key pediatric ARDS publications with a focus on the Pediatric Acute Lung Injury Consensus Conference consensus definition, sedation management, use of high-frequency oscillatory ventilation, diagnosis of delirium, noninvasive respiratory support, lung-protective ventilation, and adjunct management therapies. Despite the recent progress, additional investigation in each of these areas is essential to the continued advancement of our knowledge and, more importantly, improvements in the outcome for pediatric patients with ARDS. [ABSTRACT FROM AUTHOR]

The overall goal of the cardiorespiratory system is to provide the organs and tissues of the body with an adequate supply of oxygen in relation to oxygen consumption. An understanding of the complex physiologic interactions between the respiratory and cardiac systems is essential to optimal patient management. Alterations in intrathoracic pressure are transmitted to the heart and lungs and can dramatically alter cardiovascular performance, with significant differences existing between the physiologic response of the right and left ventricles to changes in intrathoracic pressure. In terms of cardiorespiratory interactions, the clinician should titrate the mean airway pressure to optimize the balance between mean lung volume (ie, arterial oxygenation) and ventricular function (ie, global cardiac output), minimize pulmonary vascular resistance, and routinely monitor cardiorespiratory parameters closely. Oxygen delivery to all organs and tissues of the body should be optimized, but not necessarily maximized. The heart and lungs are, obviously, connected anatomically but also physiologically in a complex relationship. [ABSTRACT FROM AUTHOR]

Whether defined as chronically critically ill, long-term mechanical ventilator dependent (or otherwise chronically medically supported), or medically fragile, a population of infants and children with chronic illness clearly exists. Infants and children with chronic healthcare needs are at an increased risk for physical, developmental, behavioral, and/or emotional conditions and generally require healthcare services of a type or amount beyond that of a general pediatric or adult population. This review will focus on the specific management and psychosocial needs associated with the healthcare of this subgroup of infants and children with chronic illness. Attention will be paid to defining the population, describing trends over time, reviewing their special needs, and discussing outcomes. Increased focus and an increasing quantity of resources for this subgroup of infants and children are needed, as the number of such pediatric patients continues to grow. [ABSTRACT FROM AUTHOR]

The data available to guide clinical management of acute lung injury and acute respiratory distress syndrome are much more limited for infants and children than for adult patients. This paper reviews the available medical data and the pertinent physiology on the management of pediatric patients with acute lung injury. With the collaboration of multicenter investigation networks, definitive pediatric data may be on the horizon to better guide our clinical practice. [ABSTRACT FROM AUTHOR]

As the basis for this paper, it must be acknowledged that children are not simply small adults. But this acknowledgment must go further: infants are not simply small adolescents. As data for pediatric mechanical ventilation, in general, and the management for pediatric acute lung injury, more specifically, are very limited, the pediatric critical care clinician must closely assess the available adult data and evaluate its application for infants and children. Given the hurdles in studying pediatric acute lung injury and acute respiratory distress syndrome, clinicians involved with the care of critically ill infants and children are left with extrapolation of data from the neonatal and adult populations, reliance on the limited available pediatric data, careful assessment of the applicable physiologic and pathophysiologic principles, and/or reliance on their own experience and their colleagues' experience. Hopefully, with the collaboration of multicenter investigator networks, additional and definitive pediatric data may be on the horizon. In the meantime, sharing data between adult and pediatric populations seems to be an essential approach to the management of critically ill patients. [ABSTRACT FROM AUTHOR]

Neonatal and pediatric respiratory care continues to move forward at a truly impressive pace. Recent technologic advances and an increasing number of randomized clinical trials are leading to improved outcomes for neonates, infants, children, and adolescents with respiratory illness. The goals of this 47th RESPIRATORY CARE Journal Conference were to review pertinent recent advances in neonatal and pediatric respiratory care and, more importantly, to offer thoughts and perspectives for the future of our field. It is important to note that of the prior 46 Journal Conferences, only 2 have been dedicated to neonatal and/or pediatric respiratory care topics. It is our hope that the publication of these proceedings will provide respiratory therapists, physicians, and other members of the clinical care team a foundation on which to ponder the future of neonatal and pediatric respiratory care. [ABSTRACT FROM AUTHOR]

Permissive hypoxemia is a lung-protective strategy that aims to provide a patient with severe acute respiratory distress syndrome (ARDS) a level of oxygen delivery that is adequate to avoid tissue hypoxia while minimizing the detrimental effects of the often toxic ventilatory support required to maintain normal arterial oxygenation. However, in many patients with severe ARDS it can be difficult to achieve a balance between maintaining adequate tissue oxygenation and avoiding ventilator- induced lung injury (VILI). A potential strategy for the management of such patients involves goal-oriented manipulation of cardiac output and, if necessary, hemoglobin concentration, to compensate for hypoxemia and maintain a normal (but not supranormal) value of oxygen delivery. Although it has not yet been studied, this approach is theorized to improve clinical outcomes of critically ill patients with severe ARDS. We stress that the goal of this article is not to convince the reader that this approach is necessarily correct, as data are clearly lacking, but rather to provide a basis for continued thought, discussion, and potential research. [ABSTRACT FROM AUTHOR]

BACKGROUND: End-tidal carbon dioxide (PETCO2) is a surrogate, noninvasive measurement of arterial carbon dioxide (PaCO2), but the clinical applicability of PETCO2 in the intensive care unit remains unclear. Available research on the relationship between PETCO2 and PaCO2 has not taken a detailed assessment of physiologic dead space into consideration. We hypothesized that PETCO2 would reliably predict PaCO2 across all levels of physiologic dead space, provided that the expected PETCO2-PaCO2 difference is considered. METHODS: Fifty-six mechanically ventilated pediatric patients (0-17 y old, mean weight 19.5 ± 24.5 kg) were monitored with volumetric capnography. For every arterial blood gas measurement during routine care, we measured PETCO2 and calculated the ratio of dead space to tidal volume (VD/VT). We assessed the PETCO2-PaCO2 relationship with Pearson's correlation coefficient, in 4 VD/VT ranges. RESULTS: VD/VT was < 0.40 for 125 measurements (25%), 0.41-0.55 for 160 measurements (32%), 0.56-0.70 for 154 measurements (31%), and > 0.7 for 54 measurements (11%). The correlation coefficients between PETCO2 and PaCO2 were 0.95 (mean difference 0.3 ± 2.1 mm Hg) for VD/VT < 0.40, 0.88 (mean difference 5.9 ± 4.3 mm Hg) for VD/VT 0.41-0.55, 0.86 (mean difference 13.6 ± 5.2 mm Hg) for VD/VT 0.56-0.70, and 0.78 (mean difference 17.8 ± 6.7 mm Hg) for VD/VT > 0.7. CONCLUSIONS: There were strong correlations between PETCO2 and PaCO2 in all the VD/VT ranges. The PETCO2-PaCO2 difference increased predictably with increasing VD/VT. [ABSTRACT FROM AUTHOR]

Summary: Helium-oxygen (heliox) gas mixtures have been studied for over 70 years as an adjunctive therapy for airway obstruction in a variety of respiratory diseases. The medical use of heliox is based on the physical properties of helium as its low density makes it advantageous in promoting more efficient flow through narrowed passages. Clinical evidence of the efficacy of heliox in treating paediatric respiratory diseases is increasing in the medical literature. This article consists of a comprehensive review of the literature investigating the utility of heliox in the treatment of paediatric respiratory disorders, including upper and lower airway obstruction, mechanical ventilation, and aerosol delivery. [Copyright &y& Elsevier]

The article reports on a retrospective chart review of children requiring positive-pressure ventilation via tracheostomy while hospitalized in a non-intensive care unit (ICU) respiratory care unit. Highlights include the rates of rapid response and code events, comparison population of all other hospitalized children, and extension of the medical home to the in-patient and ICU wards for fully integrative and comprehensive continuity of care.