Search

Ventilator associated pneumonia (VAP) is a common complication in mechanically ventilated children and adults. There remains much controversy in the literature over the definition, treatment and prevention of VAP. The incidence of VAP is variable, depending on the definition used and can effect up to 12% of ventilated children. For the prevention and reduction of the incidence of VAP, ventilation care bundles are suggested, which include vigorous hand hygiene, head elevation and use of non-invasive ventilation strategies. Diagnosis is mainly based on the clinical presentation with a lung infection occurring after 48hours of mechanical ventilation requiring a change in ventilator settings (mainly increased oxygen requirement, a positive culture of a specimen taken preferentially using a sterile sampling technique either using a bronchoscope or a blind lavage of the airways). A new infiltrate on a chest X ray supports the diagnosis of VAP. For the treatment of VAP, initial broad-spectrum antibiotics should be used followed by a specific antibiotic therapy with a narrow target once the bacterium is confirmed.

Objective: Procalcitonin has emerged as a promising infection marker, but previous reports from small-sized studies suggest nonspecific elevation of procalcitonin after pediatric heart surgery. As procalcitonin is increasingly used as a marker for infection in the PICU, the aim of this study was to identify factors associated with postoperative procalcitonin elevation and to investigate the role of procalcitonin as an early marker of outcome after cardiac surgery. Design: Prospective observational study. Setting: Single, tertiary referral PICU. Patients: Patients aged 0-16 years following cardiac surgery with or without cardiopulmonary bypass. Interventions: Procalcitonin was measured in all patients at admission to PICU, and on postoperative day 1 and 2. Outcome variables included major adverse event, length of stay in PICU, postoperative renal failure requiring temporary dialysis, duration of mechanical ventilation and duration of inotropic support. A major adverse event was defined as cardiac arrest, need for postoperative extracorporeal life support or death within 3 months of cardiac surgery. Measurements and Main Results: In 221 included patients who underwent 232 operations, procalcitonin at admission to PICU was significantly associated with mechanical ventilation prior to surgery (p = 0.001), preoperative myocardial dysfunction (p = 0.002), duration of cardiopulmonary bypass (p < 0.001), intraoperative cross-clamp time (p = 0.015), and serum lactate at admission (p < 0.001). Patients suffering a major adverse event and patients with postoperative renal failure had significantly higher procalcitonin levels at admission to PICU (p = 0.04 and 0.01, respectively). Furthermore, procalcitonin levels at admission correlated significantly with the length of stay in the PICU (p = 0.005), time on mechanical ventilation (p = 0.03), and duration of inotropic support (p = 0.02). Conclusions: Elevated levels of procalcitonin in the early phase after pediatric cardiac surgery are a marker for increased risk for major adverse events and postoperative renal failure and increased postoperative morbidity.

Respiratory support in paediatric emergency settings ranges from oxygen delivery with subnasal oxygen to invasive mechanical ventilation. Recent data suggest that oxygen can cause reperfusion injuries and should be delivered with caution within well-defined clinical target ranges. Most mild to moderate respiratory distress conditions with an oxygen requirement may benefit from early use of continuous positive airway pressure. High-flow nasal cannula therapy (HFNC) is an emerging alternative way to support the inspiratory effort combined with oxygen delivery and positive expiratory pressures without the need of complicated equipment or good compliance from the child. Besides a positive pressure support effect, HFNC therapy reduces the physiological dead space with improved CO2 clearance. A decrease in heart and respiratory rate within the first few hours after initiation of HFNC therapy is likely to identify responders of the treatment. The use of non-invasive ventilation such as continuous positive airway pressure or the use of bi-level positive airway pressure ventilation in emergency departments has increased, and it has been recognised that continuous positive airway pressure support for older children with asthma is particularly efficient.

Introduction: Studies in critically ill children within paediatric intensive care units (PICU) experience an ethical dilemma in that life-saving interventions may not allow time for prospective consent to be obtained from legal guardians. In certain circumstances there is insufficient time to consent before the intervention is performed. Objectives/Aims: This descriptive analysis aimed to identify the most common challenges to obtaining prospective consent in a randomised controlled trial (RCT) conducted within a tertiary PICU and examine how these challenges may affect recruitment of suitable study participants. Methods: Data pertaining to consent was collected at the recruitment stage of a large RCT conducted within Queensland Children’s Hospital PICU. Data included whether recruitment was via prospective or deferred consent. In the deferred consent group, researchers specified whether the parent had a prior awareness of the study and recorded reason/s why if the parent was unaware. Results: At the 2-year mark, results indicated 16% (n=49) of participants were recruited using prospective consent, with the remainder (n=252) recruited using deferred consent. Eighty-nine parents in this group had no knowledge of the study prior to the intervention occurring. Sixteen (18%) parents were too distressed to approach, 61 (69%) parents were not at the bedside, and 19 (21%) patients experienced a rapid or unexpected deterioration. Eight had “other” or “unknown” reasons recorded by research staff. Conclusion: Commonly cited challenges to prospective consent included the emergent nature of the intervention, the absence of a legal guardian, and parental distress indicating a lack of capacity to provide informed consent. This information highlights the need to consider alternate methods of consent in clinical trials within PICU. Although it should be the preferred option, prospective consent is not always possible. Deferred consent was well accepted with an absence of parental complaints regarding the consent process.

Objectives: Although the prone position is effectively used to improve oxygenation, its impact on functional residual capacity is controversial. Different techniques of body positioning might be an important confounding factor. The aim of this study was to determine the impact of two different prone positioning techniques on functional residual capacity and ventilation distribution in anesthetized, preschool-aged children. Design: Functional residual capacity and lung clearance index, ameasure of ventilation homogeneity, were calculated using asulfur-hexafluoride multibreath washout technique. After intubation, measurements were taken in the supine position and, in random order, in the flat prone position and the augmented prone position (gel pads supporting the pelvis and the upper thorax). Setting: Pediatric anesthesia unit of university hospital. Patients and participants: Thirty preschool children without cardiopulmonary disease undergoing elective surgery. Measurements and results: Mean (range) age was 48.5 (24-80) months, weight 17.2 (10.5-26.9) kg, functional residual capacity (mean ± SD) 22.9 ± 6.2 ml.kg−1 in the supine position and 23.3 ± 5.6 ml.kg−1 in the flat prone position, while lung clearance indices were 8.1 ± 2.3 vs. 7.9 ± 2.3, respectively. In contrast, functional residual capacity increased to 27.6 ± 6.5 ml.kg−1 (p

Bronchiolitis is the most common lower respiratory tract disorder in infants aged less than 12 months, and research has demonstrated that there is substantial variation in practice patterns despite treatment being well defined. In order to align and improve the consistency of the management of bronchiolitis, an evidence-based guideline was developed for the Australasian population.The guideline development committee included representation from emergency and paediatric specialty medical and nursing personnel in addition to geographical representation across Australia and New Zealand - rural, remote and metropolitan. Formulation of the guideline included identification of population, intervention, comparator, outcomes and time questions and was associated with an extensive literature search from 2000 to 2015. Evidence was summarised and graded using the National Health and Medical Research Council and Grading of Recommendations Assessment, Development and Evaluation methodology, and consensus within the guideline group was sought using nominal group technique principles to formulate the clinical practice recommendations. The guideline was reviewed and endorsed by key paediatric health bodies.The guideline consists of a usable clinical interface for bedside functionality supported by evidence summary and tables. The Grading of Recommendations Assessment, Development and Evaluation and National Health and Medical Research Council processes provided a systematic and transparent process to review and assess the literature, resulting in a guideline that is relevant to the management of bronchiolitis in the Australasian setting.This is the first robust Australasian acute paediatric guideline and provides clear guidance for the management of the vast majority of patients seen in Australasian emergency departments and general paediatric wards with bronchiolitis.

BACKGROUND High-flow oxygen therapy through a nasal cannula has been increasingly used in infants with bronchiolitis, despite limited high-quality evidence of its efficacy. The efficacy of high-flow oxygen therapy through a nasal cannula in settings other than intensive care units (ICUs) is unclear. METHODS In this multicenter, randomized, controlled trial, we assigned infants younger than 12 months of age who had bronchiolitis and a need for supplemental oxygen therapy to receive either high-flow oxygen therapy (high-flow group) or standard oxygen therapy (standard-therapy group). Infants in the standard-therapy group could receive rescue high-flow oxygen therapy if their condition met criteria for treatment failure. The primary outcome was escalation of care due to treatment failure (defined as meeting ≥3 of 4 clinical criteria: persistent tachycardia, tachypnea, hypoxemia, and medical review triggered by a hospital early-warning tool). Secondary outcomes included duration of hospital stay, duration of oxygen therapy, and rates of transfer to a tertiary hospital, ICU admission, intubation, and adverse events. RESULTS The analyses included 1472 patients. The percentage of infants receiving escalation of care was 12% (87 of 739 infants) in the high-flow group, as compared with 23% (167 of 733) in the standard-therapy group (risk difference, -11 percentage points; 95% confidence interval, -15 to -7; P

IntroductionEndotracheal suction (ETS) is a frequent and necessary airway intervention for the intubated child. The aim of ETS is to clear the endotracheal tube and airways of respiratory secretions; however, the methods of performing ETS are varied. Internationally a number of ETS treatments are in use. Many have not been rigorously evaluated in a randomised controlled trial setting, and it is uncertain whether any are associated with better outcomes for the critically ill child. With approximately 50% of paediatric intensive care admissions requiring intubation, ETS interventions that maximise the efficacy and minimise the complications of ETS could translate to improved health for substantial numbers of critically ill children, and significant cost savings. The primary aim of the study is to examine two ETS interventions, normal saline instillation and lung recruitment, to determine if it is feasible to conduct a full efficacy trial.Methods and analysisNARES (Normal saline instillation versus no normal saline instillation And lung Recruitment versus no lung recruitment with paediatric Endotracheal Suction) is a single-centre, pilot, factorial randomised controlled trial conducted in a tertiary referral paediatric centre in Brisbane, Australia. Children (aged 0–16 years) are eligible if they are intubated with an endotracheal tube and mechanically ventilated. Two intervention pairs will be compared using a 2×2 factorial design: (1) normal saline instillation versus no normal saline instillation; and (2) lung recruitment versus no lung recruitment. The primary outcome is study feasibility measured by a composite analysis of eligibility, recruitment, retention, protocol adherence and missing data. Secondary outcomes are ventilator-associated pneumonia, SpO2/FiO2ratio, lung compliance, end expiratory level and regional tidal volume.Ethics and disseminationEthical approval to conduct the research has been obtained. Dissemination of the research findings will be untaken, guided by the Consolidated Standards of Reporting Trials statement recommendations. Protocol content was guided by the Standard Protocol Items: Recommendations for Interventional Trials 2013 statement.Trial registration numberACTRN12617000609358; Pre-results.

Resumen: Introducción: Los niños críticos pueden tener riesgo de trombosis venosa profunda (TVP), pero no conocemos ni su incidencia ni la eficacia de la tromboprofilaxis. Objetivo: Describir la tromboprofilaxis en niños críticos en España y Portugal, en comparación con datos internacionales. Material y métodos: Análisis secundario del estudio multinacional PROTRACT, realizado en 59 unidades de cuidados intensivos pediátricos (UCIP) de 7 países desarrollados (4 de Portugal y 10 de España). Se incluyeron los pacientes menores de 18 años que no recibieran anticoagulación terapéutica. Resultados: Se analizaron 308 pacientes, que se compararon con 2.176 de UCIP internacionales. Los factores de riesgo: catéter en vena femoral (p = 0,01), yugular (p

SummaryBackground Transnasal Humidified Rapid-Insufflation Ventilatory Exchange has been shown to safely prolong the safe apnea time in well children post induction of anesthesia and is rapidly becoming a new standard for apneic oxygenation in adults. The same oxygenation technique is described as nasal high flow and can be used in infants and children at risk of apnea during anesthesia. Aim We investigated the use of nasal high flow oxygen delivery during anesthesia in children with abnormal airways requiring tubeless airway assessment or surgery. Methods Data and outcomes of pediatric patients receiving nasal high flow for upper airway procedures were analyzed. Four categories were defined: (i) tubeless airway surgery, (ii) flexible bronchoscopy, (iii) expected difficult airway, and (iv) comorbidity related risk of apnea. Anesthesia was induced intravenously or with sevoflurane (4–8%) and then converted to total intravenous anesthesia aiming for spontaneous ventilation. Age appropriate nasal high flow cannulae were secured with 100% oxygen delivery at weight-related flow rates. Topicalization of the airway was achieved with lignocaine. Complication rates of desaturation requiring interruption of procedure for rescue oxygenation were recorded. Results Twenty children were analyzed with age range of 5 days to 11 years, ASA 1–4, and weight range 3–57 kg. Fifteen were induced with sevoflurane and 100% oxygen, five received total intravenous anesthesia only. All children received Optiflow™ nasal high flow and intravenous anesthesia during their procedure. Average SpO2 recorded was 96% with lowest SpO2 77%. One required rescue oxygenation. Median length of procedure was 32 min, (range 3–61). Most common indication was tubeless airway surgery but seven children had more than one indication. Conclusion Nasal high flow can be used in spontaneously breathing children with abnormal airways for maintenance of oxygenation during anesthesia for tubeless airway procedures.

Electrical impedance tomography (EIT) has undergone 30 years of development. Functional chest examinations with this technology are considered clinically relevant, especially for monitoring regional lung ventilation in mechanically ventilated patients and for regional pulmonary function testing in patients with chronic lung diseases. As EIT becomes an established medical technology, it requires consensus examination, nomenclature, data analysis and interpretation schemes. Such consensus is needed to compare, understand and reproduce study findings from and among different research groups, to enable large clinical trials and, ultimately, routine clinical use. Recommendations of how EIT findings can be applied to generate diagnoses and impact clinical decision-making and therapy planning are required. This consensus paper was prepared by an international working group, collaborating on the clinical promotion of EIT called TRanslational EIT developmeNt stuDy group. It addresses the stated needs by providing (1) a new classification of core processes involved in chest EIT examinations and data analysis, (2) focus on clinical applications with structured reviews and outlooks (separately for adult and neonatal/paediatric patients), (3) a structured framework to categorise and understand the relationships among analysis approaches and their clinical roles, (4) consensus, unified terminology with clinical user-friendly definitions and explanations, (5) a review of all major work in thoracic EIT and (6) recommendations for future development (193 pages of online supplements systematically linked with the chief sections of the main document). We expect this information to be useful for clinicians and researchers working with EIT, as well as for industry producers of this technology.

Viral respiratory infections are usually mild and self-limiting; still they exceptionally result in life-threatening infections in previously healthy children. To investigate a potential genetic cause, we recruited 120 previously healthy children requiring support in intensive care because of a severe illness caused by a respiratory virus. Using exome and transcriptome sequencing, we identified and characterized three rare loss-of-function variants in IFIH1, which encodes an RIG-I-like receptor involved in the sensing of viral RNA. Functional testing of the variants IFIH1 alleles demonstrated that the resulting proteins are unable to induce IFN-β, are intrinsically less stable than wild-type IFIH1, and lack ATPase activity. In vitro assays showed that IFIH1 effectively restricts replication of human respiratory syncytial virus and rhinoviruses. We conclude that IFIH1 deficiency causes a primary immunodeficiency manifested in extreme susceptibility to common respiratory RNA viruses.

Aims: Although suctioning is a standard airway maintenance procedure, there are significant associated risks, such as loss of lung volume due to high negative suction pressures. This study aims to assess the extent and duration of change in end-expiratory level (EEL) resulting from endotracheal tube (ETT) suction and to examine the relationship between EEL and regional lung ventilation in ventilated preterm infants with respiratory distress syndrome. Methods: A prospective observational clinical study of the effect of ETT suction on 20 non-muscle-relaxed preterm infants with respiratory distress syndrome (RDS) on conventional mechanical ventilation was conducted in a neonatal intensive care unit. Ventilation distribution was measured with regional impedance amplitudes and EEL using electrical impedance tomography. Results: ETT suction resulted in a significant increase in EEL post-suction (P < 0.01). Regionally, anterior EEL decreased and posterior EEL increased post-suction, suggesting heterogeneity. Tidal volume was significantly lower in volume-guarantee ventilation compared with pressure-controlled ventilation (P = 0.04). Conclusions: ETT suction in non-muscle-relaxed and ventilated preterm infants with RDS results in significant lung volume increase that is maintained for at least 90min. Regional differences in distribution of ventilation with ETT suction suggest that the behaviour of the lung is heterogeneous in nature.

Objective: To assess the effect of delivering high-flow nasal cannula flow on end-expiratory lung volume, continuous distending pressure, and regional ventilation distribution in infants less than 12 months old with bronchiolitis. Design: Prospective observational clinical study. Setting: Nineteen bed medical and surgical PICU. Patients: Thirteen infants with bronchiolitis on high-flow nasal therapy. Interventions: The study infants were measured on a flow rate applied at 2 and 8 L/min through the high-flow nasal cannula system. Measurements and Results: Ventilation distribution was measured with regional electrical impedance amplitudes and end-expiratory lung volume using electrical impedance tomography. Changes in continuous distending pressure were measured from the esophagus via the nasogastric tube. Physiological variables were also recorded. High-flow nasal cannula delivered at 8 L/min resulted in significant increases in global and anterior end-expiratory lung volume (p < 0.01) and improvements in the physiological variables of respiratory rate, SpO2, and FIO2 when compared with flows of 2 L/min. Conclusion: In infants with bronchiolitis, high-flow nasal cannula oxygen/air delivered at 8 L/min resulted in increases in end-expiratory lung volume and improved respiratory rate, FIO2, and SpO2.

The main physiological impact of high flow nasal cannula (HFNC) therapy is presumed to be a decrease in work of breathing (WOB). To assess this, diaphragmatic electrical activity and esophageal pressure changes were measured off then on HFNC delivered at 2 L/kg/min, in 14 infants with bronchiolitis and 14 cardiac infants. Electrical activity of the diaphragm (Edi) was measured using an Edi catheter with calculations of signal peak (EdiMAX ) and amplitude (EdiAMPL ). Pressure-rate and pressure-time products (PRP, PTP) were calculated from analyses of esophageal pressure. Changes in end-expiratory lung volume were measured using respiratory inductance plethysmography (RIPEEL ). The EdiMAX and EdiAMPL were significantly higher in infants with bronchiolitis than in cardiac infants (P < 0.05). Within the bronchiolitis group, both were significantly reduced between HFNC states from 27.9 µV [20.4, 35.4] to 21.0 µV [14.8, 27.2] and from 25.1 µV [18.0, 32.2] to 19.2 µV [13.3, 25.1], respectively (mean, 95% CI, P < 0.05). A less prominent offload of the diaphragm was observed in cardiac infants (P < 0.05). WOB decreased in both groups with a significant reduction of PRP and PTP (P < 0.05). RIPEEL increased significantly in bronchiolitis only (P < 0.05). HFNC offloads the diaphragm and reduces the WOB in bronchiolitis. A similar effect was demonstrated in cardiac infants, a group without signs of airway-obstruction.

Aim To obtain data on the safety and clinical impact of managing infants with bronchiolitis on the ward with high-flow nasal cannula (HFNC) treatment. Methods A prospective pilot study was conducted of 61 infants aged 94%. A standard-treatment group (n = 33) managed with standard low-flow subnasal oxygen during the same time period was retrospectively identified. Results Admission demographics, heart rate (HR) and respiratory rate (RR) were similar in test and standard-treatment groups. Responders and non-responders to HFNC were identified within 60 min of treatment. Non-responders to HFNC requiring paediatric intensive care unit (PICU) admission showed no change in HR and RR, whereas responders showed decreases in HR and RR (P < 0.02). Patients receiving HFNC were four times less likely to need PICU admission than the standard treatment group (OR 4.086, 95%CI 1.0–8.2; P = 0.043). No adverse events such as pneumothorax, bradycardia, bradypnoea, emergency intubation or cardiopulmonary resuscitation were observed. No patients admitted to the PICU required intubation. Conclusions HFNC treatment in the paediatric ward is safe. Non-responders requiring PICU admission can be identified within the first hour of HFNC treatment by monitoring HR and RR. It is feasible to undertake a randomised controlled trial based on this pilot with the aim of decreasing PICU admissions.

IntroductionHypoxaemia during anaesthesia for tubeless upper airway surgery in children with abnormal airways is common due to the complexity of balancing adequate depth of anaesthesia with maintenance of spontaneous breathing and providing an uninterrupted field of view of the upper airway for the surgeon. High-flow nasal oxygenation (HIGH-FLOW) can prolong safe apnoea time and be used in children with abnormal airways but to date has not been compared with the alternative technique of low-flow nasal oxygenation (LOW-FLOW). The aim is to investigate if use of HIGH-FLOW can reduce the number of hypoxaemic events requiring rescue oxygenation compared with LOW-FLOW.Methods and analysisHigh-flow oxygen for children’sairway surgery: randomised controlledtrial (HAMSTER) is a multicentre, unmasked, randomised controlled, parallel group, superiority trial comparing two oxygenation techniques during anaesthesia. Children (n=530) aged >37 weeks to 16 years presenting for elective tubeless upper airway surgery who fulfil inclusion but not exclusion criteria will be randomised prior to surgery to HIGH-FLOW or LOW-FLOW post induction of anaesthesia. Maintenance of anaesthesia with HIGH-FLOW requires Total IntraVenous Anaesthesia (TIVA) and with LOW-FLOW, either inhalational or TIVA at discretion of anaesthetist. The primary outcome is the incidence of hypoxaemic events requiring interruption of procedure for rescue oxygenation by positive pressure ventilation and the secondary outcome includes total hypoxaemia time, adverse cardiorespiratory events and unexpected paediatric intensive care admission admission. Hypoxaemia is defined as Sp02Ethics and disseminationEthical approval has been obtained by Children’s Health Queensland Human Research Ethics Committee (HREC/18/QRCH/130). The trial commenced recruitment in 2018. The primary manuscript will be submitted for publication in a peer-reviewed journal.Trial registration numberThe HAMSTER is registered with the Australia and New Zealand Clinical TrialsRegistry: ACTRN12618000949280.

Background . Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) was introduced to adult anaesthesia to improve the safety of airway management during apnoea before intubation. The objective of our study was to determine whether THRIVE safely prolongs apnoeic oxygenation in children. Methods . This was a randomized controlled trial in 48 healthy children, with normal airways and cardiorespiratory function, in age groups 0-6 and 7-24 months, 2-5 and 6-10 yr old, presenting for elective surgery or imaging under general anaesthesia. All children were induced with sevoflurane, O2, and N2O, followed by muscle relaxation with rocuronium, and standardized preoxygenation with bag-and-mask ventilation. The control arm received jaw support during apnoea, whereas the THRIVE arm received jaw support during apnoea and age-specific flow rates. The primary outcome was to demonstrate that children allocated to THRIVE maintain transcutaneous haemoglobin saturation at least twice as long as the expected age-dependent apnoea time in the control group. Results . Both study arms (each n=24) were similar in age and weight. The apnoea time was significantly shorter in the control arm: Average 109.2 (95% CI 28.8) s in the control arm and 192 s in the THRIVE arm (0-6 months), 147.3 (95% CI 18.9) and 237 s (7-24 months), 190.5 (95% CI 15.3) and 320 s (2-5 yr), and 260.8 (95% CI 37.5) and 430 s (6-10 yr), respectively. Average transcutaneous haemoglobin saturation remained at 99.6% (95% CI 0.2) during THRIVE. Transcutaneous CO2 increased to a similar extent in both arms, with 2.4 (95% CI 0.5) mm Hg min-1 for the control arm and 2.4 (95% CI 0.4) mm Hg min-1 for the THRIVE arm. Conclusion . Transnasal humidified rapid-insufflation ventilatory exchange prolongs the safe apnoea time in healthy children but has no effect to improve CO2 clearance. Clinical trial registration. ACTRN12615001319561.

Objectives: Despite World Health Organization endorsed immunization schedules, Bordetella pertussis continues to cause severe infections, predominantly in infants. There is a lack of data on the frequency and outcome of severe pertussis infections in infants requiring ICU admission. We aimed to describe admission rates, severity, mortality, and costs of pertussis infections in critically ill infants. Design: Binational observational multicenter study. Setting: Ten PICUs and 19 general ICUs in Australia and New Zealand contributing to the Australian and New Zealand Paediatric Intensive Care Registry. Patients: Infants below 1 year of age, requiring intensive care due to pertussis infection in Australia and New Zealand between 2002 and 2014. Measurements and Main Results: During the study period, 416 of 42,958 (1.0%) infants admitted to the ICU were diagnosed with pertussis. The estimated population-based ICU admission rate due to pertussis ranged from 2.1/100,000 infants to 18.6/100,000 infants. Admission rates were the highest among infants less than 60 days old (p < 0.0001). Two hundred six infants (49.5%) required mechanical ventilation, including 20 (4.8%) treated with high-frequency oscillatory ventilation, 16 (3.8%) with inhaled nitric oxide, and 7 (1.7%) with extracorporeal membrane oxygenation. Twenty of the 416 children (4.8%) died. The need for mechanical ventilation, high-frequency oscillatory ventilation, nitric oxide, and extracorporeal membrane oxygenation were significantly associated with mortality (p < 0.01). Direct severe pertussis-related hospitalization costs were in excess of USD$1,000,000 per year. Conclusions: Pertussis continues to cause significant morbidity and mortality in infants, in particular during the first months of life. Improved strategies are required to reduce the significant healthcare costs and disease burden of this vaccine-preventable disease.

Objective To synthesise research findings regarding the efficacy and safety of normal saline instillation (NSI) during endotracheal suction in the paediatric intensive care unit. Data sources The Cochrane Library, PROSPERO, the National Health Service Centre for Reviews and Dissemination, PubMed and Cumulative Index to Nursing and Allied Health (CINAHL) databases were systematically searched. Subject headings included “suctioning, endotracheal”, “suction”, “sodium chloride”, “normal saline” and “paediatrics”. Additional references were sourced from hand searches of journal article reference lists and Google Scholar. Method An integrative, systematic approach was used to qualitatively synthesise study results in the context of paediatric intensive care nursing practice. Data were extracted using a standardised data extraction form. Quality assessment was performed independently by two reviewers. Results Three studies met pre-defined inclusion criteria. Quality of all study methods was 75% on the Mixed Method Appraisal Tool, although reporting quality varied. Overall, there was a scarcity of high quality evidence examining NSI and paediatric endotracheal suction. Outcome measures included oxygen saturation (SpO 2 ), serious adverse events (author/s defined) and ventilation parameters (author/s defined). Endotracheal suction with NSI was associated with a transient decrease in blood oxygen saturation; research protocols did not include interventions to mitigate alveolar derecruitment. Studies were not powered to detect differences in endotracheal tube (ETT) occlusion or ventilator associated pneumonia (VAP). Conclusion NSI was associated with a transient decrease in oxygen saturation. In children with obstructive mucous, NSI may have a positive effect. Practices which maximise secretion removal and mitigate the negative physiological interactions of ETS have been poorly evaluated in the paediatric population. High quality, powered, clinical trials are needed to determine the safety and efficacy of normal saline instillation and to inform clinical practice.

Infants with respiratory dysfunction undergo regular position changes to improve lung function however it is not known how often a position change should occur. This study measured changes in lung function occurring over time after repositioning in preterm infants.Changes in end-expiratory level (EEL) and ventilation distribution were measured 30 mins, 2 h, and 4 h after repositioning into either prone, quarter turn from prone, or supine using Electrical Impedance Tomography (EIT). Physiological measurements were also taken.Sixty preterm infants were included in the study. Infants receiving respiratory support (mechanical ventilation or continuous positive airway pressure (CPAP)) had improved ventilation homogeneity after 2 h (P0.01), maintained at 4 h. Spontaneously breathing infants had improved homogeneity at 2 h (P0.01) and improved global EEL after 4 h (P0.01) whereas infants receiving CPAP demonstrated an improved global EEL at 2 h (P0.01).Regional ventilation distribution is influenced by time independent of changes due to body position. Differences exist between infants on ventilatory support compared with those who are spontaneously breathing. Infants receiving ventilatory support have a physiological peak in lung function after 2 h which remains above baseline at 4 h. A change in body position facilitates an improvement in lung function in infants on ventilatory support.

Although continuous positive airway pressure is used extensively in neonatal intensive care units, and despite the belief that positioning is considered vital to the maintenance of good lung ventilation, no data exist on regional ventilation distribution in infants on continuous positive airway pressure ventilatory support.To investigate the effect of body position on regional ventilation in preterm infants on continuous positive airway pressure ventilatory support using electrical impedance tomography.Randomized crossover study design.Neonatal intensive care unit.Twenty-four preterm infants on continuous positive airway pressure were compared to six spontaneously breathing preterm infants.Random assignment of the order of the positions supine, prone, and quarter prone.Changes in global and regional lung volume were measured with electrical impedance tomography. Although there were no differences between positions, regional tidal volume was increased in the posterior compared with the anterior lung (p.01) and in the right compared with the left lung (p.03) in both the spontaneously breathing infants and in the infants on continuous positive airway pressure. The posterior lung filled earlier than the anterior lung in the spontaneously breathing infants (p.02), whereas in the infants on continuous positive airway pressure the right lung filled before the left lung (p.01). There was more ventilation inhomogeneity in the infants on continuous positive airway pressure than in the healthy infants (p.01).This study presents the first results on regional ventilation distribution in preterm infants on continuous positive airway pressure using electrical impedance tomography. Gravity had little impact on regional ventilation distribution in preterm infants on continuous positive airway pressure or in spontaneously breathing infants in the supine or prone position, indicating that ventilation distribution in preterm infants is not gravity-dependent but follows an anatomical pattern. AUSTRALIA NEW ZEALAND CLINICAL TRIALS REGISTRY:: ACTRN12606000210572.

Background: During the induction of anesthesia, changes in functional residual capacity and ventilation distribution (VD) occur. Although these physiological changes are well investigated in adults, little data are available in infants and children.

Synchronised volume-targeted ventilation (SIPPV + VTV) attempts to reduce lung injury by standardising volume delivery to the preterm lung. The aim of this study is to describe the regional distribution and variability of ventilation within the preterm lung during SIPPV + VTV. Twenty-seven stable, supine, preterm infants with 7 days), supplemental oxygen requirement and set tidal volume. In all sub-groups, the middle third of the chest accounted for the greatest ∆Z VT [p 7 days compared with ≤7 days (p

Electrical impedance tomography (EIT) has been used to study regional ventilation distribution in neonatal and paediatric lung disease; however, little information has been obtained in healthy newborns and infants. Data on regional ventilation distribution and regional filling characteristics were obtained using EIT in the neonatal period, at 3 and 6 months of age, in spontaneously breathing infants during non-rapid eye movement sleep. Regional ventilation distribution was described using regional end-expiratory and end-inspiratory impedance amplitudes, and geometric centre of ventilation. Regional filling characteristics were described with the phase lag or lead of the regional impedance change in comparison to global impedance change. 32 infants were measured in the supine position. Regional impedance amplitudes increased with age but regional ventilation distribution remained unchanged in all infants at any age, with the dependent (posterior) lung always better ventilated. Regional filling characteristics showed that the dependent lung filled during inspiration before the nondependent lung during all follow-up measurements. Regional ventilation distribution and regional filling characteristics remained unchanged over the first 6 months of life, and the results obtained on regional ventilation distribution are very similar to those in adult subjects.

Introduction: Normal saline instillation (NSI) with endotracheal suction (ETS) is a controversial practice. While there is growing evidence for the abandonment of this practice in mechanically ventilated adults, there is a dearth of quality evidence to support or refute NSI use in intubated children. This lack of guidance has resulted in variable NSI practices in the paediatric intensive care unit (PICU). It is not understood what factors influence a nurse to apply NSI with ETS, or what perceived effect NSI treatment has on patient outcomes.

Background: Delirium is a common and serious neuropsychiatric complication in all critically ill patients. Previous studies have examined treatment-related factors which may contribute to the development of delirium, however understanding of the factors which increase a paediatric patient's risk of delirium is still in its infancy.

This review highlights and summarizes the current evidence and knowledge of nasal high flow therapy management in infants and children. This review outlines the distinct differences in the use of NHF therapy between children and adults. A comprehensive literature review has been performed reviewing the relevant physiological studies and current evidence of support measures in these children. Despite the quick uptake of nasal high flow therapy in the clinical area there has been limited high-grade evidence, with new studies showing beneficial results with the use of nasal high flow therapy in acute respiratory disease and children.

Ventilation in larger animals and humans is gravity dependent and mainly distributed to the dependent lung. Little is known of the effect of gravity on ventilation distribution in small animals such as rodents. The aim of this study was to investigate gravity-dependent ventilation distribution and regional filling characteristics in rats. Ventilation distribution and regional lung filling were measured in six rats using electrical impedance tomography (EIT). Measurements were performed in four body positions (supine, prone, left and right lateral), and all animals were ventilated with increasing tidal volumes from 3 to 8 mL kg(-1). The effect of gravity on regional ventilation distribution was assessed with profiles of relative impedance change and calculation of the geometric centre. Regional filling was measured by calculating the slope of the plot of regional versus global relative impedance change on a breath-by-breath basis. Ventilation was significantly distributed to the non-dependent lung regardless of body position and tidal volume used. The geometric centre was located in the dependent lung in all but prone position. The regional filling characteristics followed an anatomical pattern with the posterior and the right lung generally filling faster. Gravity had little impact on regional filling. Ventilation distribution in rats is gravity dependent, whereas regional filling characteristics are dependent on anatomy.

Background: In adults, ventilation is preferentially distributed towards the dependent lung. A reversal of the adult pattern has been observed in infants using radionuclide ventilation scanning. But these results have been obtained in infants and children with lung disease. In this study we investigate whether healthy infants have a similar reverse pattern of ventilation distribution. Study Design: Measurement of regional ventilation distribution in healthy newborn infants during non-REM sleep in comparison to adults. Methods: Twenty-four healthy newborns and 13 adults were investigated with electrical impedance tomography (EIT) in supine and prone position. Regional ventilation distribution was assessed with profiles of relative impedance change. The phase lag between dependent and non-dependent ventilation was calculated as a measure of asynchronous ventilation. Results: In newborns and adults the geometric center of ventilation was centrally located in the lung at 52.2 +/- 6.2% from anterior to posterior and at 50.5 +/- 14.7%, respectively Using impedance profiles, ventilation was equally distributed to the dependent and non-dependent lung regions in newborns. Ventilation distribution in adults was similar Phase lag characteristics of the impedance signal showed that infants had slower emptying of the dependent lung than adults. Conclusion: The speculated reverse pattern of regional ventilation distribution in healthy infants compared to adults could not be demonstrated. Gravity had little effect on ventilation distribution in both infants and adults measured in supine and prone position. Pediatr Pulmonol. 2009;44:851-858. (C) 2009 Wiley-Liss, Inc.

BACKGROUND: Ketamine is commonly used in children in the emergency setting and while undergoing diagnostic and therapeutic interventions because of its combination of hypnotic and analgesic properties. Although studies comparing various levels of ketamine anesthesia are lacking, previous work suggests that lung mechanics might only be minimally affected by ketamine. METHODS: After approval from the Ethics Committee, anesthesia was induced with 2 mg.kg(-1) racemic ketamine followed by a continuous infusion of ketamine 2 mg.kg(-1) h(-1) (level I) in 26 children (2-6 years of age), and after 5 min, the first set of measurements was performed. Then, a second bolus of ketamine 2 mg.kg(-1) followed by ketamine 4 mg.kg(-1) h(-1) was administered (level II) and after 5 min, the second set of measurements was performed. Functional residual capacity (FRC) and lung clearance index (LCI) were calculated using a multibreath analysis by a blinded observer. RESULTS: Functional residual capacity and LCI did not change between the two levels (FRC 25.6 [4.3] ml.kg(-1) vs 25.5 [4.2] ml.kg(-1), P=0.769, LCI 10.5 [1.2] vs 10.3 [1.1], P=0.403). The minute ventilation was similar between the two levels of anesthesia. The University of Michigan Sedation Scale increased from 3 (3) to 4 (3-4) at the second level of ketamine anesthesia. CONCLUSIONS: A deeper level of anesthesia induced by ketamine does not affect FRC, ventilation distribution or minute ventilation suggesting that the depth of ketamine anesthesia has a minimal effect on pulmonary function.

BACKGROUND: Assessment of lung volume (FRC) and ventilation inhomogeneities with ultrasonic flowmeter and multiple breath washout (MBW) has been used to provide important information about lung disease in infants. Sub-optimal adjustment of the mainstream molar mass (MM) signal for temperature and external deadspace may lead to analysis errors in infants with critically small tidal volume changes during breathing. METHODS: We measured expiratory temperature in human infants at 5 weeks of age and examined the influence of temperature and deadspace changes on FRC results with computer simulation modeling. A new analysis method with optimized temperature and deadspace settings was then derived, tested for robustness to analysis errors and compared with the previously used analysis methods. RESULTS: Temperature in the facemask was higher and variations of deadspace volumes larger than previously assumed. Both showed considerable impact upon FRC and LCI results with high variability when obtained with the previously used analysis model. Using the measured temperature we optimized model parameters and tested a newly derived analysis method, which was found to be more robust to variations in deadspace. Comparison between both analysis methods showed systematic differences and a wide scatter. CONCLUSION: Corrected deadspace and more realistic temperature assumptions improved the stability of the analysis of MM measurements obtained by ultrasonic flowmeter in infants. This new analysis method using the only currently available commercial ultrasonic flowmeter in infants may help to improve stability of the analysis and further facilitate assessment of lung volume and ventilation inhomogeneities in infants.

Bronchiolitis imposes the largest health care burden on non-elective paediatric hospital admissions worldwide, with up to 15 % of cases requiring admission to intensive care. A number of previous studies have failed to show benefit of pharmaceutical treatment in respect to length of stay, reduction in PICU admission rates or intubation frequency. The early use of non-invasive respiratory support devices in less intensive scenarios to facilitate earlier respiratory support may have an impact on outcome by avoiding progression of the disease process. High Flow Nasal Cannula (HFNC) therapy has emerged as a new method to provide humidified air flow to deliver a non-invasive form of positive pressure support with titratable oxygen fraction. There is a lack of high-grade evidence on use of HFNC therapy in bronchiolitis. Prospective multi-centre randomised trial comparing standard treatment (standard subnasal oxygen) and High Flow Nasal Cannula therapy in infants with bronchiolitis admitted to 17 hospitals emergency departments and wards in Australia and New Zealand, including 12 non-tertiary regional/metropolitan and 5 tertiary centres. The primary outcome is treatment failure; defined as meeting three out of four pre-specified failure criteria requiring escalation of treatment or higher level of care; i) heart rate remains unchanged or increased compared to admission/enrolment observations, ii) respiratory rate remains unchanged or increased compared to admission/enrolment observations, iii) oxygen requirement in HFNC therapy arm exceeds FiO2 ≥ 40 % to maintain SpO2 ≥ 92 % (or ≥94 %) or oxygen requirement in standard subnasal oxygen therapy arm exceeds >2L/min to maintain SpO2 ≥ 92 % (or ≥94 %), and iv) hospital internal Early Warning Tool calls for medical review and escalation of care. Secondary outcomes include transfer to tertiary institution, admission to intensive care, length of stay, length of oxygen treatment, need for non-invasive/invasive ventilation, intubation, adverse events, and cost. This large multicenter randomised trial will allow the definitive assessment of the efficacy of HFNC therapy as compared to standard subnasal oxygen in the treatment of bronchiolitis. The trial is registered with the Australian and New Zealand Clinical Trials Registry ACTRN12613000388718 (registered on 10 April 2013).

Respiratory support in paediatric emergency settings ranges from oxygen delivery with subnasal oxygen to invasive mechanical ventilation. Recent data suggest that oxygen can cause reperfusion injuries and should be delivered with caution within well-defined clinical target ranges. Most mild to moderate respiratory distress conditions with an oxygen requirement may benefit from early use of continuous positive airway pressure. High-flow nasal cannula therapy (HFNC) is an emerging alternative way to support the inspiratory effort combined with oxygen delivery and positive expiratory pressures without the need of complicated equipment or good compliance from the child. Besides a positive pressure support effect, HFNC therapy reduces the physiological dead space with improved CO2 clearance. A decrease in heart and respiratory rate within the first few hours after initiation of HFNC therapy is likely to identify responders of the treatment. The use of non-invasive ventilation such as continuous positive airway pressure or the use of bi-level positive airway pressure ventilation in emergency departments has increased, and it has been recognised that continuous positive airway pressure support for older children with asthma is particularly efficient.

Contains fulltext : 155373.pdf (Publisher’s version ) (Closed access) RATIONALE: Limited data exist about the international burden of severe sepsis in critically ill children. OBJECTIVES: To characterize the global prevalence, therapies, and outcomes of severe sepsis in pediatric intensive care units to better inform interventional trials. METHODS: A point prevalence study was conducted on 5 days throughout 2013-2014 at 128 sites in 26 countries. Patients younger than 18 years of age with severe sepsis as defined by consensus criteria were included. Outcomes were severe sepsis point prevalence, therapies used, new or progressive multiorgan dysfunction, ventilator- and vasoactive-free days at Day 28, functional status, and mortality. MEASUREMENTS AND MAIN RESULTS: Of 6,925 patients screened, 569 had severe sepsis (prevalence, 8.2%; 95% confidence interval, 7.6-8.9%). The patients' median age was 3.0 (interquartile range [IQR], 0.7-11.0) years. The most frequent sites of infection were respiratory (40%) and bloodstream (19%). Common therapies included mechanical ventilation (74% of patients), vasoactive infusions (55%), and corticosteroids (45%). Hospital mortality was 25% and did not differ by age or between developed and resource-limited countries. Median ventilator-free days were 16 (IQR, 0-25), and vasoactive-free days were 23 (IQR, 12-28). Sixty-seven percent of patients had multiorgan dysfunction at sepsis recognition, with 30% subsequently developing new or progressive multiorgan dysfunction. Among survivors, 17% developed at least moderate disability. Sample sizes needed to detect a 5-10% absolute risk reduction in outcomes within interventional trials are estimated between 165 and 1,437 patients per group. CONCLUSIONS: Pediatric severe sepsis remains a burdensome public health problem, with prevalence, morbidity, and mortality rates similar to those reported in critically ill adult populations. International clinical trials targeting children with severe sepsis are warranted.

Background Based on age-dependent differences in pulmonary mechanics, the effect of neuromuscular blockade may differ in infants compared with older children. The aim of this study was to determine the impact of neuromuscular blockade and its reversal by positive end-expiratory pressure (PEEP) on functional residual capacity (FRC) and ventilation distribution in young infants and preschool children. Methods The authors studied 14 infants (aged 0-6 months) and 25 preschool children (aged 2-6 yr). FRC and lung clearance index were calculated. Measurements were taken (1) after intubation, (2) during neuromuscular blockade, and (3) during neuromuscular blockade plus application of PEEP (3 cm H2O). Results Functional residual capacity (mean +/- SD) decreased from 21.3 +/- 4.7 ml/kg to 12.2 +/- 4.8 ml/kg (P < 0.001) during neuromuscular blockade in infants and from 25.6 +/- 5.9 ml/kg to 23.0 +/- 5.3 ml/kg (P < 0.001) in preschool children. With the application of PEEP, FRC increased to 22.3 +/- 5.9 ml/kg (P = 0.4829, compared with baseline) in infants and 28.2 +/- 5.8 ml/kg (P < 0.001) in children. The lung clearance index increased after neuromuscular blockade, whereas baseline values were regained after the application of PEEP. The changes induced by neuromuscular blockade were significantly greater in infants compared with preschool children (P < 0.001). Conclusions Although the use of neuromuscular blockade decreased FRC and ventilation distribution substantially in both groups, the changes were more pronounced in young infants. With PEEP, FRC increased and ventilation homogeneity was restored. These results provide a rationale to use PEEP in anesthetized, paralyzed infants and children.

Caudal block results in a motor blockade that can reduce abdominal wall tension. This could interact with the balance between chest wall and lung recoil pressure and tension of the diaphragm, which determines the static resting volume of the lung. On this rationale, we hypothesised that caudal block causes an increase in functional residual capacity and ventilation distribution in anaesthetised children. Fifty-two healthy children (15-30 kg, 3-8 years of age) undergoing elective surgery with general anaesthesia and caudal block were studied and randomly allocated to two groups: caudal block or control. Following induction of anaesthesia, the first measurement was obtained in the supine position (baseline). All children were then turned to the left lateral position and patients in the caudal block group received a caudal block with bupivacaine. No intervention took place in the control group. After 15 min in the supine position, the second assessment was performed. Functional residual capacity and parameters of ventilation distribution were calculated by a blinded reviewer. Functional residual capacity was similar at baseline in both groups. In the caudal block group, the capacity increased significantly (p < 0.0001) following caudal block, while in the control group, it remained unchanged. In both groups, parameters of ventilation distribution were consistent with the changes in functional residual capacity. Caudal block resulted in a significant increase in functional residual capacity and improvement in ventilation homogeneity in comparison with the control group. This indicates that caudal block might have a beneficial effect on gas exchange in anaesthetised, spontaneously breathing preschool-aged children with healthy lungs.

Functional electrical impedance tomography (EIT) measures relative impedance changes in lung tissue during tidal breathing and creates images of local ventilation distribution. A novel approach to analyse the effect of body position and positive pressure ventilation on intrapulmonary tidal volume distribution was evaluated in healthy adult subjects.Prospective experimental study in healthy adult subjects in the intensive care unit at university hospital.Ten healthy male adults.Change in body position from supine to prone, left and right lateral during spontaneous breathing and positive pressure support ventilation.EIT measurements and multiple-breath sulphur hexafluoride (SF6) washout were performed. Profiles of average relative impedance change in regional lung areas were calculated. Relative impedance time course analysis and Lissajous figure loop analysis were used to calculate phase angles between dependent or independent lung and total lung (phi). EIT data were compared to SF6 data washout measuring the lung clearance index (LCI). Proposed EIT profiles allowed inter-individual comparison of EIT data and identified areas with reduced regional tidal volume using pressure support ventilation. Phase angle phi of dependent lung in supine position was 11.7+/-1.4 degrees, in prone 5.3+/-0.5 degrees, in right lateral 11.0+/-1.3 degrees and in left lateral position 10.8+/-1.0 degree. LCI increased in supine position from 5.63+/-0.43 to 7.13+/-0.64 in prone position. Measured phi showed inverse relationship to LCI in the four different body positions.EIT profiles and phi of functional EIT are new methods to describe regional ventilation distribution with EIT allowing inter-individual comparison.

Measurement of functional residual capacity (FRC) during mechanical ventilation is important to standardise respiratory system compliance and adjust the ventilator settings to optimise lung recruitment. In the present study we compared three methods to measure FRC.The bias flow nitrogen washout technique (FRC(N2MC)), the multiple breath nitrogen washout (FRC(MBNW)) and the multiple breath sulphur-hexafluoride washout using the molar mass signal of an ultrasonic flow meter (FRC(MBSF6)) were compared in six adult monkeys after endotracheal intubation and during spontaneous breathing and mechanical ventilation at three different positive end-expiratory pressure (PEEP) levels of 0, 5 and 10 cmH2O.Animal research laboratory.We found good agreement between all three methods and they all accurately measured changes in FRC when PEEP was increased. The coefficients of variance of the three measurement techniques were in the same range (1.3-9.2%).The measurement of the tracer gas concentration with the molar mass signal of the ultrasonic flow meter provides a good and simple alternative to respiratory mass spectrometer for FRC measurements in ventilated subjects.

Aim: To evaluate the efficacy and safety of treatment with recombinant growth hormone (rGH) in patients with cystic fibrosis (CF). Methods: Twenty patients with CF (aged 10–23 years) were randomised to age and sex matched treatment and control groups. The treatment group received daily subcutaneous injections of 1 IU/kg/wk rGH for 12 months. Pulmonary function (forced expiratory volume in one second (FEV 1 ) and airway resistance), exercise capacity measured with a bicycle ergometer, body composition (dual energy x ray absorptiometry), and weight were assessed at the beginning of the study and after 6 and 12 months. Results: rGH treatment did not improve weight and pulmonary function, but lean body mass increased significantly in the treatment group. Exercise capacity increased in the treatment group from 143 (16) W (mean (SD)) to 164 (19) W after 12 months of rGH treatment. Conclusion: Treatment of CF patients with rGH for one year improved the exercise capacity significantly but not pulmonary function. The improved exercise capacity needs confirmation in a larger population before such an expensive treatment is justified.

Small airway disease in infants is characterised by abnormal lung volume and uneven ventilation distribution. An inert tracer gas washin/washout technique using a pulsed ultrasonic flow meter is presented to measure functional residual capacity (FRC) and ventilation distribution in spontaneously breathing and unsedated infants. With a pulsed ultrasound sent through the main stream of the flow meter, flow, volume and MM of the breathing gas can be calculated. Sulphur hexafluoride was used as a tracer gas. In a mechanical lung model (volume range 53-188 mL) and in 12 healthy infants (aged 38.3+/-9.2 days; mean+/-SD) accuracy and reproducibility of the technique was assessed. Indices of ventilation distribution such as alveolar-based mean dilution number (AMDN) and pulmonary clearance delay (PCD) were calculated. Mean error of volume measurement in the lung model was 0.58% (coefficient of variance (CV) 1.3%). FRC was in the low predicted range for normal infants (18.0+/-2.0 mL x kg(-1)) and highly reproducible (5.5+/-1.7% intra-subject CV). AMDN was 1.63+/-0.15 and PCD was 52.9+/-11.1%. Measurement of functional residual capacity and ventilation distribution using a sulphur hexafluoride washin/washout and an ultrasonic flow meter proved to be highly accurate and reproducible in a lung model and in healthy, spontaneously breathing and unsedated infants.

Bronchiolitis represents the most common cause of non-elective admission to paediatric intensive care units (ICUs).We assessed changes in admission rate, respiratory support, and outcomes of infants During the study period, bronchiolitis was responsible for 9628 (27.6%) of 34 829 non-elective ICU admissions. The estimated population-based ICU admission rate due to bronchiolitis increased by 11.76 per 100 000 each year (95% CI 8.11–15.41). The proportion of bronchiolitis patients requiring intubation decreased from 36.8% in 2002, to 10.8% in 2014 (adjusted OR 0.35, 95% CI 0.27–0.46), whilst a dramatic increase in high-flow nasal cannula therapy use to 72.6% was observed (pWe observed an increasing healthcare burden due to severe bronchiolitis, with a major change in practice in the management from invasive to non-invasive support that suggests thresholds to admittance of bronchiolitis patients to ICU have changed. Future studies should assess strategies for management of bronchiolitis outside ICUs.