Hypoxemia In Children Research Articles

Reduced antiviral gene expression and elevated CXCL8 expression in peripheral blood are associated with severe hypoxemia in RSV-infected children.

The pathology of respiratory syncytial virus (RSV) infection remains unclear. An unbalanced immune response to RSV infection can lead to immunopathology, causing airway damage and impaired exchange of oxygen and carbon dioxide between the air and the bloodstream. We aimed to evaluate the association of the expression of inflammatory and antiviral genes in peripheral blood with severe hypoxemia in children with RSV infection seen in the hospital emergency room. We conducted a cross-sectional study on 121 RSV-infected children seen in hospital emergency rooms between 2015 and 2023. Total RNA was extracted from whole blood samples, and gene expression (IL-6, TNFα, CXCL8, ISG15, IFIT1, RIGI, IFNβ, CCL5, and CXCL10) was quantified using quantitative RT-PCR. The outcome variable was having severe hypoxemia (SpO2 ≤ 90%). The association analysis was performed using a volcano plot, adjusted logistic regression, and orthogonal partial least squares discriminant analysis (OPLS-DA). We found that 26 of 121 children had severe hypoxemia (SpO2 ≤ 90%). CXCL8 was overexpressed [fold changes (FC) > 2; q-value < 0.05], and ISG15, IFIT1, RIGI, IFNβ, CCL5, and CXCL10 were underexpressed (FC <0.5; q-value <0.05) in children with severe hypoxemia. These associations were ratified using adjusted logistic regression. The OPLS-DA showed that the gene expressions of CXCL8, ISG15, IFIT1, RIGI, and CXCL10 had values of variable importance in projection (VIP) ≥1, being the most relevant features. In conclusion, an imbalance favoring inflammation over antiviral defense may contribute to the pathogenesis of severe hypoxemia in RSV-infected children. These findings provide valuable insights into the pathology of RSV infection.

Atmospheric particulate matter and hypoxaemia in Korean children receiving general anaesthesia: A retrospective analysis.

The association between the concentration of atmospheric particulate matter on the day of surgery and the occurrence of intra-operative hypoxaemia in children receiving general anaesthesia is unclear. To investigate the association between the exposure to particulate matter on the day of surgery and the occurrence of intra-operative hypoxaemia, defined as a pulse oximetry oxygen saturation of less than 90% for more than 1 min, in children. Retrospective study. Single-centre. Children aged 18 years or younger who received general anaesthesia between January 2019 and October 2020. Information on daily levels of particulate matter with a diameter 10 μm or less and 2.5 μm or less measured within a neighbourhood corresponding to the area defined by the hospital's zip code was obtained from publicly available air-quality data. The primary outcome was intra-operative hypoxaemia, defined as a pulse oximetry oxygen saturation of less than 90% lasting for more than 1 min, manually verified by anaesthesiologists using vital sign registry data extracted at 2 s intervals. Of the patients finally analysed, 3.85% (489/13 175) experienced intra-operative hypoxaemia. Higher levels of particulate matter 10 μm or less in diameter (≥81 μg m -3 , 17/275, 6.2%) were associated with an increased occurrence of intra-operative hypoxaemia compared with lower particulate matter concentrations [<81 μg m -3 , 472/12 900, 3.7%; adjusted odds ratio, 1.71; 95% confidence interval (CI), 1.04 to 2.83; P = 0.035]. The level of particulate matter on the day of surgery pose a risk of intra-operative hypoxaemia in children receiving general anaesthesia. If the concentrations of particulate matter 10 μm or less in diameter on the day of surgery are high, children receiving general anaesthesia should be managed with increased caution.

How to ventilate critically ill children with cancer?: a narrative review

Abstract The management of respiratory failure and hypoxemia in children with cancer presents a critical challenge. Choosing between invasive and noninvasive mechanical ventilation can profoundly impact mortality rates, especially in resource-limited settings. Choosing between invasive and noninvasive mechanical ventilation can impact mortality rates, particularly in resource-limited settings. Extensive clinical studies are imperative to thoroughly evaluate the efficacy of invasive mechanical ventilation (IMV) and noninvasive ventilation (NIV) during the early stages of treatment. Further research is crucial to determine the most optimal therapeutic approach. Early implementation of IMV or NIV could significantly reduce mortality rates in these patients.[ 1 ] Additionally, this article examines the admission of children with terminal cancer, evaluating their use of invasive and noninvasive ventilatory support versus palliative care. The interdisciplinary medical team, in collaboration with the family, must carefully consider the benefits and risks of these interventions, whether in the early or terminal stages of the disease. Furthermore, the article delves into the controversies surrounding the utilization of ventilation in critically ill children with cancer.

Pulse Oximetry Accuracy in Children with Dark Skin Tones: Relevance to Acute Lower Respiratory Infection Care in Low- and Middle-Income Countries.

Acute lower respiratory infections (ALRI) are the leading post-neonatal cause of death in children under 5 years old. There is a high prevalence of pediatric ALRI-related hypoxemia in low- and middle-income countries. The WHO defines clinically meaningful hypoxemia in children as a SpO2 (peripheral oxygen saturation) <90%. Multiple studies put this convention into question and found SpO2 of 90% to 92% to be associated with child ALRI mortality. An evolving body of evidence suggests that pulse oximeters systematically overestimate oxygen saturation in individuals with dark skin tones. We conducted a narrative review of pediatric studies evaluating pulse oximeter accuracy in children without COVID-19. Four studies, one prospective, examined pulse oximeter accuracy in children of varying ages with dark skin tones. All studies had limitations that affect their generalizability. There is evidence that certain pulse oximeters may overestimate oxygen saturation in children with dark skin tones. Further prospective research is urgently needed to identify affected populations and clinical implications. Despite recognized challenges, we strongly urge continued and expanded use of pulse oximetry as its use will save lives.

Elevated periodic limb movement index is associated with hypoxemia in children with early onset scoliosis.

Patients with early onset scoliosis are at high risk of sleep disordered breathing, sleep disruption, and adverse consequences of poor sleep. In this study, we aim to assess the prevalence of periodic limb movements of sleep in a cohort of children with early onset scoliosis and identify factors that correlate with the presence of periodic limb movements. This is a retrospective chart review of 40 patients with EOS (ages 1-17years) who underwent a PSG from 2003 through 2019. Data collected included age, sex, and polysomnography parameters. Descriptive statistics were used: independent T test and Pearson correlation. The average age was 9.6years (SD 5.2); 22 were female. Eleven patients (27.5%) had elevated periodic limb movement index (PLMI) (≥ 5). Those with PLMI ≥ 5 had arousal index of 15.4 (SD 7.2) and those with normal PLMI having an arousal index of 9.4 (SD 4.9); this reached statistical significance (p < 0.05). Those with elevated PLMI spent 4.9 (SD 8.3) minutes with saturations below 88%, while those with normal PLMI spent 1.0 (SD 1.8); this was statistically significant. There was a moderate positive correlation between arousal index, hypoxemia, and PLMI. The study suggests that children with early onset scoliosis have higher frequency of periodic limb movements during sleep, and these may be correlated with increased arousal and with hypoxemia.

Hypoxemia in School Age Children Undergoing One-Lung Ventilation: A Retrospective Cohort Study from the Multicenter Perioperative Outcomes Group (MPOG).

Risk factors for hypoxemia in school age children undergoing one-lung ventilation remain poorly understood. We hypothesize that certain modifiable and non-modifiable factors may be associated with increased risk of hypoxemia in school age children undergoing one-lung ventilation and thoracic surgery. The Multicenter Perioperative Outcomes Group database was queried for children 4 to 17 years of age undergoing one-lung ventilation. Patients undergoing vascular or cardiac procedures were excluded. The original cohort was divided into two cohorts: 4-9 and 10-17 years of age inclusive. All records were reviewed electronically for the primary outcome of hypoxemia during one-lung ventilation defined as an oxygen saturation (SpO2)<90% for≥3 minutes continuously and severe hypoxemia, SpO2<90% for ≥5 minutes. Potential modifiable and non-modifiable risk factors associated with these outcomes were evaluated using separate multivariable least absolute shrinkage and selection operator regression analyses for each cohort. Covariates evaluated included: age, extremes of weight, American Society of Anesthesiologists Physical Status≥3, duration of one-lung ventilation, preoperative SpO2<98%, approach to one lung ventilation, right operative side, video assisted thoracoscopic surgery, lower tidal volume ventilation defined as tidal volume≤6ml/kg + positive end expiratory pressure ≥ 4cmH2O >80% of the duration of one-lung ventilation, and procedure type. The prevalence of hypoxemia in the 4-9 and 10-17 year old cohorts was 24/228 (10.5%, 95%CI[6.5%-14.5%]) and 76/1012 (7.5%, 95%CI[5.9%-9.1%]) respectively. The prevalence of severe hypoxemia in both cohorts was 14/228 (6.1%, 95%CI[3.0%-9.3%]) and 47/1012 (4.6%, 95%CI[3.3%-5.8%]). Initial SpO2<98% was associated with hypoxemia in the 4-9 year old cohort, OR 4.20 [95%CI(1.61 - 6.29)]. Initial SpO2<98%, OR 2.76[95%CI(1.69-4.48)], extremes of weight, OR 2.18[95%CI(1.29-3.61)], right sided cases, OR 2.33[95%CI(1.41-3.92)], were associated with an increased risk of hypoxemia in the older cohort. Increasing age (1 year increment), OR 0.88[95%CI(0.80-0.97)] was associated with a decreased risk of hypoxemia. An initial room air oxygen saturation <98% was associated with an increased risk of hypoxemia in all children 4-17 years of age. Extremes of weight, right sided cases, and decreasing age were associated with an increased risk of hypoxemia in children 10-17 years of age.

Feasibility and acceptability of bubble continuous positive airway pressure oxygen therapy for the treatment of childhood severe pneumonia and hypoxaemia in Bangladeshi children

Effective management of hypoxaemia is key to reducing pneumonia deaths in children. In an intensive care setting within a tertiary hospital in Bangladesh, bubble continuous positive airway pressure (bCPAP) oxygen therapy was beneficial in reducing deaths in this population. To inform a future trial, we investigated the feasibility of introducing bCPAP in this population in non-tertiary/district hospitals in Bangladesh. We conducted a qualitative assessment using a descriptive phenomenological approach to understand the structural and functional capacity of the non-tertiary hospitals (Institute of Child and Mother Health and Kushtia General Hospital) for the clinical use of bCPAP. We conducted interviews and focus group discussions (23 nurses, seven physicians, 14 parents). We retrospectively (12 months) and prospectively (three months) measured the prevalence of severe pneumonia and hypoxaemia in children attending the two study sites. For the feasibility phase, we enrolled 20 patients with severe pneumonia (age two to 24 months) to receive bCPAP, putting in place safeguards to identify risk. Retrospectively, while 747 of 3012 (24.8%) children had a diagnosis of severe pneumonia, no pulse oxygen saturation information was available. Of 3008 children prospectively assessed with pulse oximetry when attending the two sites, 81 (3.7%) had severe pneumonia and hypoxaemia. The main structural challenges to implementation were the inadequate number of pulse oximeters, lack of power generator backup, high patient load with an inadequate number of hospital staff, and inadequate and non-functioning oxygen flow meters. Functional challenges were the rapid turnover of trained clinicians in the hospitals, limited post-admission routine care for in-patients by hospital clinicians due to their extreme workload (particularly after official hours). The study implemented a minimum of four hourly clinical reviews and provided oxygen concentrators (with backup oxygen cylinders), and automatic power generator backup. Twenty children with a mean age of 6.7 (standard deviation (SD) = 5.0)) months with severe pneumonia and hypoxaemia (median (md) SpO2 = 87% in room air, interquartile range (IQR) = 85-88)) with cough (100%) and severe respiratory difficulties (100%) received bCPAP oxygen therapy for a median of 16 hours (IQR = 6-16). There were no treatment failures or deaths. Implementation of low-cost bCPAP oxygen therapy is feasible in non-tertiary/district hospitals when additional training and resources are allocated.

Risk and accuracy of outpatient-identified hypoxaemia for death among suspected child pneumonia cases in rural Bangladesh: a multifacility prospective cohort study

Hypoxaemic pneumonia mortality risk in low-income and middle-income countries is high in children who have been hospitalised, but unknown among outpatient children. We sought to establish the outpatient burden, mortality risk, and prognostic accuracy of death from hypoxaemia in children with suspected pneumonia in Bangladesh. We conducted a prospective community-based cohort study encompassing three upazila (subdistrict) health complex catchment areas in Sylhet, Bangladesh. Children aged 3-35 months participating in a community surveillance programme and presenting to one of three upazila health complex Integrated Management of Childhood Illness (IMCI) outpatient clinics with an acute illness and signs of difficult breathing (defined as suspected pneumonia) were enrolled in the study; because lower respiratory tract infection mortality mainly occurs in children younger than 1 year, the primary study population comprised children aged 3-11 months. Study physicians recorded WHO IMCI pneumonia guideline clinical signs and peripheral arterial oxyhaemoglobin saturations (SpO2) in room air. They treated children with pneumonia with antibiotics (oral amoxicillin [40 mg/kg per dose twice per day for 5-7 days, as per local practice]), and recommended oxygen, parenteral antibiotics, and hospitalisation for those with an SpO2 of less than 90%, WHO IMCI danger signs, or severe malnutrition. Community health workers documented the children's vital status and the date of any vital status changes during routine household surveillance (one visit to each household every 2 months). The primary outcome was death at 2 weeks after enrolment in children aged 3-11 months (primary study population) and 12-35 months (secondary study population). Primary analyses included estimating the outpatient prevalence, mortality risk, and prognostic accuracy of hypoxaemia for death in children aged 3-11 months with suspected pneumonia. Risk ratios were produced by fitting a multivariable model that regressed predefined SpO2 ranges (<90%, 90-93%, and 94-100%) on the primary 2-week mortality outcome (binary outcome) using Poisson models with robust variance estimation. We established the prognostic accuracy of WHO IMCI guidelines for death with and without varying SpO2 thresholds. Participants were recruited between Sept 1, 2015, to Aug 31, 2017. During the study period, a total of 7440 children aged 3-35 months with the first suspected pneumonia episode were enrolled, of whom 3848 (54·3%) with an attempted pulse oximeter measurement and 2-week outcome were included in our primary study population of children aged 3-11-months. Among children aged 3-11 months, an SpO2 of less than 90% occurred in 102 (2·7%) of 3848 children, an SpO2 of 90-93% occurred in 306 (8·0%) children, a failed SpO2 measurement occurred in 67 (1·7%) children, and 24 (0·6%) children with suspected pneumonia died. Compared with an SpO2 of 94-100% (3373 [87·7%] of 3848), the adjusted risk ratio for death was 10·3 (95% CI 3·2-32·3; p<0·001) for an SpO2 of less than 90%, 4·3 (1·5-11·8; p=0·005) for an SpO2 of 90-93%, and 11·4 (3·1-41·4; p<0·001) for a failed measurement. When not considering pulse oximetry, of the children who died, WHO IMCI guidelines identified only 25·0% (95% CI 9·7-46·7; six of 24 children) as eligible for referral to hospital. For identifying deaths, in children with an SpO2 of less than 90% WHO IMCI guidelines had a 41·7% sensitivity (95% CI 22·1-63·4) and 89·7% specificity (88·7-90·7); for children with an SpO2 of less than 90% or measurement failure the guidelines had a 54·2% sensitivity (32·8-74·4) and 88·3% specificity (87·2-89·3); and for children with an SpO2 of less than 94% or measurement failure the guidelines had a 62·5% sensitivity (40·6-81·2) and 81·3% specificity (80·0-82·5). These findings support pulse oximeter use during the outpatient care of young children with suspected pneumonia in Bangladesh as well as the re-evaluation of the WHO IMCI currently recommended threshold of an SpO2 less than 90% for hospital referral. Fogarty International Center of the National Institutes of Health (K01TW009988), The Bill & Melinda Gates Foundation (OPP1084286 and OPP1117483), and GlaxoSmithKline (90063241).

Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease exception policy and outcomes in pediatric patients with hepatopulmonary syndrome requiring liver transplantation.

Hepatopulmonary syndrome (HPS) is associated with increased waitlist mortality in liver transplantation (LT) candidates. Children with HPS are granted Model for End-Stage Liver Disease (MELD)/Pediatric End-Stage Liver Disease (PELD) exception points for waitlist prioritization in the United States based on criterion developed for adults. In this study, the impact of this MELD/PELD exception policy on post-LT survival in children was examined. A retrospective cohort of patients aged younger than 18 years with a MELD/PELD exception request who underwent LT between 2007 and 2018 were identified in the Scientific Registry of Transplant Recipients. Patients were stratified by waitlist partial pressure of arterial oxygen (PaO 2 ) to assess risk factors for waitlist mortality and post-LT survival. Among 3082 pediatric LT recipients included in the study, 124 patients (4%) received MELD/PELD exception points for HPS. Patients with HPS were a median age of 9 years (interquartile range: 6, 12 years), 54.8% were girls, and 54% were White. Most patients (87.9%) were listed with laboratory MELD/PELD scores <15. Waitlist mortality for patients with HPS exception points was rare and not different from patients without HPS. When stratified by pre-LT PaO 2 , hypoxemia severity was not associated with differences in 1-, 3-, or 5-year survival rates after LT ( p = 0.13). However, patients with HPS showed a slightly lower survival rate at 5 years compared with patients without HPS (88.7% vs. 93.4%; p = 0.04). MELD/PELD exceptions for children with HPS mitigated waitlist mortality, and recipients with HPS experienced excellent 5-year survival after LT, although slightly lower than in patients without HPS. Unlike adults with HPS, the severity of pre-LT hypoxemia in children does not impact post-LT survival. These data suggest that adult criteria for granting MELD/PELD exception points may not appropriately capture HPS severity in pediatric patients. Further prospective multicenter studies to examine the risk factors predicting negative survival outcomes in children with HPS are warranted.

Evaluation of Clinical Predictors of Hypoxemia in Children With Bronchiolitis: A Bidirectional Cohort Study

Background: Bronchiolitis is common in children under 2 years of age and is a leading cause of hospitalization in infants and children. Children with bronchiolitis are generally well-appearing and active despite being tachypneic or hypoxic. Objectives: This study aims to identify the predictors of hypoxia in children with bronchiolitis, as well as to find the average duration of oxygen requirement and hospitalization in children with hypoxia. Methods: A total of 65 children between the age group of 1 month to 2 years with bronchiolitis were included in the study. Data were collected retrospectively from case records and prospective cases were consecutively enrolled. Oxygen saturation was monitored in all hospitalized children. An oxygen saturation (SpO2)&lt;92% was considered hypoxia. The relationship between presenting clinical features and subsequent development of hypoxia was assessed using the Pearson chi-square test. Results: The presenting features of bronchiolitis in our study were cough, fever, tachypnea, increased work of breathing, and wheezing. Cough was the most common symptom and fever was the least common symptom. A total of 59.3% of children with a cough had hypoxia. Of the 23 children who had a fever, 52.1% of them had hypoxia. Among 51 children with tachypnea, 68.6% had hypoxia (P=0.001). Among 57 children whose respiratory work was increased, 68% of children had hypoxia (P=0.000); 71.8% of children with wheezing had hypoxia (P=0.05). Conclusions: Our study shows that in children with bronchiolitis, the presence of tachypnea, increased work of breathing and wheezing increases the risk of developing hypoxia. Identifying these predictors of hypoxia can help as a guide for deciding on the need for hospitalization in children with bronchiolitis.

The Clinical Predictors of Hypoxaemia in Children with WHO Defined Pneumonia Aged 2 Months to 59 Months

Introduction: Hypoxaemia is common in radiographically confirmed pneumonia. Children are mostly affected by this. Identification of the clinical signs in early stage can reduce the severity and death rate. Aim of the study: The aim of this study was to determine the clinical predictors of hypoxaemia in children with WHO defined pneumonia aged 2 months to 59 months. Methods: This cross-sectional type of descriptive study was conducted in Department of Pediatric, Rangpur Medical Collage and Hospital, Rangpur from July 2014 to June 2016. This study was carried out on 205 Children aged 2-59 months suffering from pneumonia. Result: Among 205 cases of pneumonia, hypoxeamia were 51(24.9%) &amp; non hypoxeamia were 154(75.1%). It was observed that almost three fourth (72.2%) patients belonged to age 2-11 months. The mean age was found 9.2±10.0 months with range from 2 to 59 months. Almost two third (64.9%) patients were male. Majority (91.7%) patients had cough, 184(89.8%). Most of the patients (90.7%) had crepitations. Three (1.5%) patients were found pallor of palms, 178 (86.8%) patients were heart rate ≥100 beats per minute, 196(95.6%) were capillary refill time &lt;3 second, 4(2.0%) hepatomegaly &gt;2 cm and 131(63.9%) had temperature ≥ 38 °C. Mean age was found 8.5±8.0 months in hypoxemia group and 9.9±11.8 months in non hypoxemia group. More than half (52.9%) patients were male in hypoxemia group and 106(68.8%) in non hypoxemia group. Majority (84.3%) patients had severe pneumonia in hypoxemia group and 97(63.0%) in non hypoxemia group. Nearly two third (60.8%) patients had irritability in hypoxemia group and 58(37.7%) in non hypoxemia group. More than three fourth (76.5%) patients had severely reduced feeding in hypoxemia group and 65(42.2%) in non hypoxemia group. Forty five (88.2%) patients had inability to drink or feed in hypoxemia group and 51(33.1%) in non hypoxemia group. Four (7.8%) patients had unusually sleepy in hypoxemia group but not in non hypoxemia group. ......

Need for routine pulse oximetry and oxygen delivery systems in low-income and middle-income countries

The systematic review and meta-analysis of the prevalence of hypoxaemia among children with pneumonia in low-income and middle-income (LMIC) countries by Ahmed Ehsanur Rahman and colleagues is timely and emphasises some important current trends related to pulse oximetry and the identification of hypoxaemia in children with pneumonia.1 Firstly, Rahman and colleagues report a high prevalence of hypoxaemia at 31% (95% CI 26–36; 101 775 children) among all children under 5 years with WHO-classified pneumonia.

Prevalence of hypoxaemia in children with pneumonia in low-income and middle-income countries: a systematic review and meta-analysis

SummaryBackgroundPneumonia accounts for around 15% of all deaths of children younger than 5 years globally. Most happen in resource-constrained settings and are potentially preventable. Hypoxaemia is one of the strongest predictors of these deaths. We present an updated estimate of hypoxaemia prevalence among children with pneumonia in low-income and middle-income countries.MethodsWe conducted a systematic review using the following key concepts “children under five years of age” AND “pneumonia” AND “hypoxaemia” AND “low- and middle-income countries” by searching in 11 bibliographic databases and citation indices. We included all articles published between Nov 1, 2008, and Oct 8, 2021, based on observational studies and control arms of randomised and non-randomised controlled trials. We excluded protocol papers, articles reporting hypoxaemia prevalence based on less than 100 pneumonia cases, and articles published before 2008 from the review. Quality appraisal was done with the Joanna Briggs Institute tools. We reported pooled prevalence of hypoxaemia (SpO2 <90%) by classification of clinical severity and by clinical settings by use of the random-effects meta-analysis models. We combined our estimate of the pooled prevalence of pneumonia with a previously published estimate of the number of children admitted to hospital due to pneumonia annually to calculate the total annual number of children admitted to hospital with hypoxaemic pneumonia.FindingsWe identified 2825 unique records from the databases, of which 57 studies met the eligibility criteria: 26 from Africa, 23 from Asia, five from South America, and four from multiple continents. The prevalence of hypoxaemia was 31% (95% CI 26–36; 101 775 children) among all children with WHO-classified pneumonia, 41% (33–49; 30 483 children) among those with very severe or severe pneumonia, and 8% (3–16; 2395 children) among those with non-severe pneumonia. The prevalence was much higher in studies conducted in emergency and inpatient settings than in studies conducted in outpatient settings. In 2019, we estimated that over 7 million children (95% CI 5–8 million) were admitted to hospital with hypoxaemic pneumonia. The studies included in this systematic review had high τ2 (ie, 0·17), indicating a high level of heterogeneity between studies, and a high I2 value (ie, 99·6%), indicating that the heterogeneity was not due to chance. This study is registered with PROSPERO, CRD42019126207.InterpretationThe high prevalence of hypoxaemia among children with severe pneumonia, particularly among children who have been admitted to hospital, emphasises the importance of overall oxygen security within the health systems of low-income and middle-income countries, particularly in the context of the COVID-19 pandemic. Even among children with non-severe pneumonia that is managed in outpatient and community settings, the high prevalence emphasises the importance of rapid identification of hypoxaemia at the first point of contact and referral for appropriate oxygen therapy.FundingUK National Institute for Health Research (Global Health Research Unit on Respiratory Health [RESPIRE]; 16/136/109).

Opioids and obstructive sleep apnea.

Freire C, Sennes LU, Polotsky VY. Opioids and obstructive sleep apnea. J Clin Sleep Med. 2022;18(2):647-652.

This Month in Anesthesiology

This Month in Anesthesiology

Original Research Article on Study of Correlation between Various Clinical Parameters and Hypoxemia in Children with Lower Respiratory Tract Infection of Age 2 Months to 5 Years

A case control study was conducted from October 2018 to September 2020 by taking children between the age group 2 months to 5 years, admitted to Sishu Bhawan and SCB Medical College Hospital, Cuttack with an acute history of cough and rapid respiration or difficulty in breathing, to know the correlation between various clinical parameters and hypoxemia along with ability of each parameter to predict the presence of hypoxemia in children. Among 109 children, 50 children were hypoxemic and 59 children were non hypoxemic with the prevalence of hypoxemia about 45.8%. Among symptoms in children with Acute Lower Respiratory Tract Infection (ALRI), inability to feed, cough and difficulty in breathing had a sensitivity of 100%, 98% and 92% respectively and specificity was maximum for difficulty in breathing (62.7%) to predict hypoxemia. On comparison between hypoxemic and non-hypoxemic children difficulty in breathing and inability to feed had a p value &lt;0.001 and was statistically significant. Among signs in children with ALRI, appearance of the child, lower chest retraction, respiratory rate had a sensitivity of 100%, 100% and 98% respectively to predict hypoxemia. Central cyanosis was the most specific sign with the specificity of 100% to predict hypoxemia followed by grunting with a specificity of 96.6%. When compared between hypoxemic and non-hypoxemic children the p-value was very highly significant for appearance of nasal flaring, grunting, suprasternal indrawing parameters whereas upon combination of variables, a combination of cough, inability to feed, tachypnoea and the combination of cough, subcostal retractions, tachypnoea had high sensitivity of 96% and 95% respectively to predict hypoxemia in children with ALRI. Combination of difficulty in breathing, cyanosis and grunting had high specificity of 98%. Keeping in view of less feasibility of detection of hypoxemia in lower respiratory tract infection by pulse oximeter and ABG in developing countries and no available study in the state of Odisha, this study is conducted in an attempt to find out the alternative methods by various clinical parameters to detect hypoxemia which are easily recognized by the health personnel in developing countries for the further management of Lower Respiratory Tract Infection (LRTI). Keywords: Hypoxemia, Acute Lower Respiratory Tract Infection, Lower Respiratory Tract Infection, Management.

Hypoxemia in Young Children Undergoing One-lung Ventilation: A Retrospective Cohort Study.

One-lung ventilation in children remains a specialized practice with low case numbers even at tertiary centers, preventing an assessment of best practices. The authors hypothesized that certain case factors may be associated with a higher risk of intraprocedural hypoxemia in children undergoing thoracic surgery and one-lung ventilation. The Multicenter Perioperative Outcomes database and a local quality improvement database were queried for documentation of one-lung ventilation in children 2 months to 3 yr of age inclusive between 2010 and 2020. Patients undergoing vascular or other cardiac procedures were excluded. All records were reviewed electronically for the presence of hypoxemia, oxygen saturation measured by pulse oximetry (Spo2) less than 90% for 3 min or more continuously, and severe hypoxemia, Spo2 less than 90% for 5 min or more continuously during one-lung ventilation. Records were also assessed for hypercarbia, end-tidal CO2 greater than 60 mmHg for 5 min or more or a Paco2 greater than 60 on arterial blood gas. Covariates assessed for association with these outcomes included age, weight, American Society of Anesthesiologists (Schaumburg, Illinois) Physical Status 3 or greater, duration of one-lung ventilation, preoperative Spo2 less than 98%, bronchial blocker versus endobronchial intubation, left operative side, video-assisted thoracoscopic surgery, lower tidal volume ventilation (tidal volume less than or equal to 6 ml/kg plus positive end expiratory pressure greater than or equal to 4 cm H2O for more than 80% of the duration of one-lung ventilation), and type of procedure. Three hundred six cases from 15 institutions were included for analysis. Hypoxemia and severe hypoxemia occurred in 81 of 306 (26%) patients and 56 of 306 (18%), respectively. Hypercarbia occurred in 153 of 306 (50%). Factors associated with lower risk of hypoxemia in multivariable analysis included left operative side (odds ratio, 0.45 [95% CI, 0.251 to 0.78]) and bronchial blocker use (odds ratio, 0.351 [95% CI, 0.177 to 0.67]). Additionally, use of a bronchial blocker was associated with a reduced risk of severe hypoxemia (odds ratio, 0.290 [95% CI, 0.125 to 0.62]). Use of a bronchial blocker was associated with a lower risk of hypoxemia in young children undergoing one-lung ventilation.

Global burden of acute lower respiratory infection associated with human parainfluenza virus in children younger than 5 years for 2018: a systematic review and meta-analysis

SummaryBackgroundHuman parainfluenza virus (hPIV) is a common virus in childhood acute lower respiratory infections (ALRI). However, no estimates have been made to quantify the global burden of hPIV in childhood ALRI. We aimed to estimate the global and regional hPIV-associated and hPIV-attributable ALRI incidence, hospital admissions, and mortality for children younger than 5 years and stratified by 0–5 months, 6–11 months, and 12–59 months of age.MethodsWe did a systematic review of hPIV-associated ALRI burden studies published between Jan 1, 1995, and Dec 31, 2020, found in MEDLINE, Embase, Global Health, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Global Health Library, three Chinese databases, and Google search, and also identified a further 41 high-quality unpublished studies through an international research network. We included studies reporting community incidence of ALRI with laboratory-confirmed hPIV; hospital admission rates of ALRI or ALRI with hypoxaemia in children with laboratory-confirmed hPIV; proportions of patients with ALRI admitted to hospital with laboratory-confirmed hPIV; or in-hospital case–fatality ratios (hCFRs) of ALRI with laboratory-confirmed hPIV. We used a modified Newcastle-Ottawa Scale to assess risk of bias. We analysed incidence, hospital admission rates, and hCFRs of hPIV-associated ALRI using a generalised linear mixed model. Adjustment was made to account for the non-detection of hPIV-4. We estimated hPIV-associated ALRI cases, hospital admissions, and in-hospital deaths using adjusted incidence, hospital admission rates, and hCFRs. We estimated the overall hPIV-associated ALRI mortality (both in-hospital and out-hospital mortality) on the basis of the number of in-hospital deaths and care-seeking for child pneumonia. We estimated hPIV-attributable ALRI burden by accounting for attributable fractions for hPIV in laboratory-confirmed hPIV cases and deaths. Sensitivity analyses were done to validate the estimates of overall hPIV-associated ALRI mortality and hPIV-attributable ALRI mortality. The systematic review protocol was registered on PROSPERO (CRD42019148570).Findings203 studies were identified, including 162 hPIV-associated ALRI burden studies and a further 41 high-quality unpublished studies. Globally in 2018, an estimated 18·8 million (uncertainty range 12·8–28·9) ALRI cases, 725 000 (433 000–1 260 000) ALRI hospital admissions, and 34 400 (16 400–73 800) ALRI deaths were attributable to hPIVs among children younger than 5 years. The age-stratified and region-stratified analyses suggested that about 61% (35% for infants aged 0–5 months and 26% for 6–11 months) of the hospital admissions and 66% (42% for infants aged 0–5 months and 24% for 6–11 months) of the in-hospital deaths were in infants, and 70% of the in-hospital deaths were in low-income and lower-middle-income countries. Between 73% and 100% (varying by outcome) of the data had a low risk in study design; the proportion was 46–65% for the adjustment for health-care use, 59–77% for patient groups excluded, 54–93% for case definition, 42–93% for sampling strategy, and 67–77% for test methods. Heterogeneity in estimates was found between studies for each outcome.InterpretationWe report the first global burden estimates of hPIV-associated and hPIV-attributable ALRI in young children. Globally, approximately 13% of ALRI cases, 4–14% of ALRI hospital admissions, and 4% of childhood ALRI mortality were attributable to hPIV. These numbers indicate a potentially notable burden of hPIV in ALRI morbidity and mortality in young children. These estimates should encourage and inform investment to accelerate the development of targeted interventions.FundingBill & Melinda Gates Foundation.

Incidence of post-induction hypoxemia in children and the effect of induction gas composition.

Pediatric preoxygenation and inhalation induction of anesthesia can include a mixture of gases. In children, the clinical impact on oxygenation while using other gases with oxygen during an inhalation induction is unknown. We aimed to determine the impact of oxygen, nitrous oxide, and air concentrations added to the volatile agent by recording the incidence of hypoxemia following an inhalation gaseous induction in children. Records from an Automated Information Management System were used to find the incidence of hypoxemia following an inhalation induction of anesthesia. Episodes of hypoxemia (SaO2 <90% sustained for at least 120s) were recorded in the 10min after the 3-min induction period. Nitrous oxide and oxygen concentrations were recorded and nitrogen concentration was deduced. We also considered patient sex, age, and ASA status as covariates. A total of 27258 cases were included in the analysis. The overall incidence of hypoxemia following an inhalation induction of anesthesia was 5.08% (95% CI 4.83 5.35). Hypoxemia was more common in younger patients and those with higher ASA scores. Controlling for those factors and sex, the incidence of hypoxemia increased 1.2-fold when inspired oxygen concentration was less than 60% and hypoxemia was 2.37 times greater than the overall incidence when the inspired oxygen concentration was less than 40%. There was no clear effect of different concentrations of nitrous oxide or nitrogen when those were factored into the model. The risk of hypoxemia following an inhalation induction of anesthesia in children is minimized when the inspired concentration of oxygen is greater than 60%.

Central breathing abnormalities in children with trisomy 21: Effect of age, sex, and concomitant OSA.

Trisomy 21 (TS21) is a condition with a high risk for sleep apnea. In the pediatric population, the risk also includes central breathing disorders. The aim of this study was to define the clinical and polysomnographic characteristics of central apnea in infants, children, and adolescents with TS21. Retrospective review of baseline polysomnograms (PSGs) in children with TS21 in the sleep center at Children's National Medical Center in Washington DC. We included a total of 158 infants, children, and adolescents (0-18 years) with TS21 in this study. The median age was 4.82 years and 62% were male. The primary findings of the study are that (1) 12% of all pediatric subjects with TS21 included had a central apnea index (CAI) > 2/h; (2) the proportion of TS21 individuals with central breathing abnormalities progressively decreased with age being common in young individuals (≤2 years of age) but rare after 10 years of age; (3) additional sleep breathing disturbances (e.g., OSA and/or hypoxemia) are often present in children with TS21 and central apnea; and (4) the prevalence of central breathing abnormalities in TS21 is influenced by sex, being more likely to persist beyond early childhood (>2 years of age) in females than in males. Central breathing abnormalities are common in TS21 among young children (≤2 years of age) and in females older than 2 years of age. Central apnea is often associated with concomitant obstructive sleep apnea and/or hypoxemia in children with TS21.