Pediatric Respiratory Failure Research Articles

Epidemiology of Acute Respiratory Failure in US Children: Outcomes and Resource Use.

Acute respiratory failure recalcitrant to conventional management often requires specialized organ-supportive technologies to optimize outcomes. Variation in the availability of these technologies prompted testing of the hypothesis that outcomes and resource use will vary by not only patient characteristics but also hospital characteristics and receipt of organ-supportive technology. Retrospective study of children 0 to 20 years old hospitalized for acute respiratory failure using the 2019 Kids' Inpatient Database. Multivariable regression models identified factors associated with mortality, length of hospitalization, and costs. Of an estimated 75 365 hospitalizations nationally, 97% were to urban teaching hospitals, 57% were of children < 6 years, and 58% were of males. Complex chronic conditions (CCC) existed in 62%, multiorgan dysfunction in 35%, and extreme illness severity in 54%. Mortality was 7%, length of stay 15 days, and hospital costs $77 168. Elevated mortality was associated with cumulative organ dysfunction (odds ratio [OR]:2.31, 95% confidence interval [CI]: 2.22-2.42), CCC (OR: 5.49, 95% CI: 4.73-6.37), transfer, higher illness severity, and cardiopulmonary resuscitation. Lower mortality was associated with extracorporeal membrane oxygenation (OR: 0.36, 95% CI: 0.28-0.47) and new tracheostomy (OR: 0.30, 95% CI: 0.25-0.35). Longer hospitalization was associated with transfer, infancy, CCC, higher illness severity, cumulative organ dysfunction, and urban hospitals. Higher costs accrued with noninfants, cumulative organ dysfunction, private insurance, and urban teaching hospitals. Hospitalizations for pediatric acute respiratory failure incurred substantial mortality and resource consumption. Efforts to reduce mortality and resource consumption should address interhospital transfer, access to organ-supportive technology, and drivers of higher severity-adjusted resource consumption at urban hospitals.

Assessment of echocardiographic interpretation of dual-lumen cannula during venovenous extracorporeal membrane oxygenation use for pediatric respiratory failure.

Echocardiography is considered essential during cannulation placement and manipulations. Literature evaluating transthoracic echocardiography (TTE) usage during pediatric VV-ECMO is scant. The purpose of this study is to describe the use of echocardiography during VV-ECMO at a large, quaternary children's hospital. A retrospective, single-year cohort study was performed of pediatric patients on VV-ECMO via dual-lumen cannula at our institution from January 2019 through December 2019. For each echocardiogram, final cannula component (re-infusion port (ReP), distal tip, proximal port and distal port) positions were evaluated by one echocardiographer. For TTEs with ReP in the right atrium, two echocardiographers independently evaluated ReP direction using 2-point (Yes/No) and 4-point scales, which were semi-quantitative protocols using color Doppler images to estimate ReP jet direction to the tricuspid valve. Cohen's kappa or weighted kappa was used to measure interrater agreement. During study period, 11 patients (64% male) received VV-ECMO with 49 TTEs and one transesophageal echocardiogram performed. The median patient age was 4.3 years [IQR: 1.1-11.5] and median VV-ECMO run time of 192h [90-349]. The median time between TTEs on VV-ECMO was 34h [8.3-65]. Most common position for the ReP was the right atrium (n=33, 67%), and ReP location was not identified in five TTEs (10%). For ReP flow direction, echocardiographers agreed on 82% of TTEs using 2-point evaluation. There was only moderate agreement between echocardiographers on the 2-point and 4-point assessments (k=.54, kw=.46 respectively). TTE is the predominant cardiac ultrasound modality used during VV-ECMO for pediatric respiratory failure. Subjective evaluation of VV-ECMO ReP jet direction in the right atrium is challenging, regardless of assessment method.

Use of point-of-care ultrasound (POCUS) to monitor neonatal and pediatric extracorporeal life support.

Extracorporeal membrane oxygenation (ECMO) is an invasive life support technique that requires a blood pump, an artificial membrane lung, and vascular cannulae to drain de-oxygenated blood, remove carbon dioxide, oxygenate, and return it to the patient. ECMO is generally used to provide advanced and prolonged cardiopulmonary support in patients with refractory acute cardiac and/or respiratory failure. After its first use in 1975 to manage a severe form of meconium aspiration syndrome with resultant pulmonary hypertension, the following years were dominated by the use of ECMO to manage neonatal respiratory failure and limited to a few centers across the world. In the 1990s, evidence for neonatal respiratory ECMO support increased; however, the number of cases began to decline with the use of newer pharmacologic therapies (e.g., inhaled nitric oxide, exogenous surfactant, and high-frequency oscillatory ventilation). On the contrary, pediatric ECMO sustained steady growth. Combined advances in ECMO technology and bedside medical management have improved general outcomes, although ECMO-related complications remain challenging. Point-of-care ultrasound (POCUS) is an essential tool to monitor all phases of neonatal and pediatric ECMO: evaluation of ECMO candidacy, ultrasound-guided ECMO cannulation, daily evaluation of heart and lung function and brain perfusion, detection and management of major complications, and weaning from ECMO support. Conclusion: Based on these considerations and on the lack of specific guidelines for the use of POCUS in the neonatal and pediatric ECMO setting, the aim of this paper is to provide a systematic overview for the application of POCUS during ECMO support in these populations. What is Known: • Extracorporeal membrane oxygenation (ECMO) provides advanced cardiopulmonary support for patients with refractory acute cardiac and/or respiratory failure and requires appropriate monitoring. • Point-of-care ultrasound (POCUS) is an accessible and adaptable tool to assess neonatal and pediatric cardiac and/or respiratory failure at bedside. What is New: • In this review, we discussed the use of POCUS to monitor and manage at bedside neonatal and pediatric patients supported with ECMO. • We explored the potential use of POCUS during all phases of ECMO support: pre-ECMO assessment, ECMO candidacy evaluation, daily evaluation of heart, lung and brain function, detection and troubleshooting of major complications, and weaning from ECMO support.

Admission Functional Status is Associated With Intensivists Perception of Extracorporeal Membrane Oxygenation Candidacy for Pediatric Acute Respiratory Failure.

To determine the association between admission Functional Status Scale (FSS) category and perceived extracorporeal membrane oxygenation (ECMO) candidacy for pediatric acute respiratory failure. Prospective, cross-sectional study. Single-center, quaternary, and ECMO referral academic children's hospital between March 2021 and January 2022. Pediatric intensivists directly caring for patients admitted with acute respiratory failure secondary to shock or respiratory disease. None. Pediatric intensivists were surveyed about current patients within 72 hours of initiation or escalation of invasive mechanical ventilation on whether they would offer ECMO should their patient deteriorate. Baseline functional status was assessed using trichotomized admission FSS: 1) normal/mild dysfunction (6-9), 2) moderate dysfunction (10-15), and 3) severe dysfunction (> 16). Multivariable logistic regression clustered by physician was used to assess the association between admission FSS category with perceived ECMO candidacy. Thirty-seven intensivists participated with 76% (137/180) of survey responses by those with less than 10 years of experience. 81% of patients (146/180) were perceived as ECMO candidates and 19% of patients (34/180) were noncandidates. Noncandidates had worse admission FSS scores than candidates (15.5 vs. 9, p < 0.001). After adjustment for age, admission FSS category of severe dysfunction had lower odds of perceived ECMO candidacy compared with normal to mild dysfunction (odds ratio [OR] 0.18 [95% CI, 0.06-0.56], p < 0.003). Patients with an abnormal communication subscore domain had the lowest odds of being considered a candidate (unadjusted OR 0.44 [95% CI, 0.29-0.68], p < 0.0001). In this prospective, single-center, cross-sectional study, admission FSS category indicating worse baseline functional status impacted pediatric intensivists' perceptions of ECMO candidacy for patients with acute respiratory failure. Abnormal FSS subscores in the neurocognitive domains were the most important considerations. Future studies should better seek to define the decision-making priorities of both parents and medical specialists for the utilization of ECMO in children with acute respiratory failure.

Social Drivers of Health and Pediatric Extracorporeal Membrane Oxygenation Outcomes.

Relationships between social drivers of health (SDoH) and pediatric health outcomes are highly complex with substantial inconsistencies in studies examining SDoH and extracorporeal membrane oxygenation (ECMO) outcomes. To add to this literature with emerging novel SDoH measures, and to address calls for institutional accountability, we examined associations between SDoH and pediatric ECMO outcomes. This single-center retrospective cohort study included children (<18 years) supported on ECMO (2012-2021). SDoH included Child Opportunity Index (COI), race, ethnicity, payer, interpreter requirement, urbanicity, and travel-time to hospital. COI is a multidimensional estimation of SDoH incorporating traditional (eg, income) and novel (eg, healthy food access) neighborhood attributes ([range 0-100] higher indicates healthier child development). Outcomes included in-hospital mortality, ECMO run duration, and length of stay (LOS). 540 children on ECMO (96%) had a calculable COI. In-hospital mortality was 44% with median run duration of 125 hours and ICU LOS 29 days. Overall, 334 (62%) had cardiac disease, 92 (17%) neonatal respiratory failure, 93 (17%) pediatric respiratory failure, and 21 (4%) sepsis. Median COI was 64 (interquartile range 32-81), 323 (60%) had public insurance, 174 (34%) were from underrepresented racial groups, 57 (11%) required interpreters, 270 (54%) had urban residence, and median travel-time was 89 minutes. SDoH including COI were not statistically associated with outcomes in univariate or multivariate analysis. We observed no significant difference in pediatric ECMO outcomes according to SDoH. Further research is warranted to better understand drivers of inequitable health outcomes in children, and potential protective mechanisms.

New Nurse Self-assessed Clinical Competence, Immersion, and Attitudes Following Virtual Reality Training on the Assessment of Pediatric Respiratory Distress

BackgroundNurse residency programs continually identify needs to enhance educational experiences for new nurses to build clinical competence when transitioning to practice. Virtual reality (VR) based education may play an important role in this experience. MethodsIn this prospective cohort educational study nurses (n = 83) participated in a VR experience on the assessment of pediatric respiratory distress and failure, followed by a survey assessing demographics, retrospective pre/post self-assessment of competence, immersion, and attitudes toward VR. ResultsThe VR curriculum significantly improved nurses’ self-assessed competence in the recognition and management of respiratory distress and failure. Participants endorsed that the VR experience mimicked real-life patient experiences, was more effective than traditional education modalities, accurately depicted, reinforced, and would influence future care of patients with respiratory distress and failure. ConclusionsFindings suggest the VR curriculum improved nurse perception of their ability to care for patients with respiratory distress and failure. VR may represent a new modality for training new nurses on the clinical assessment of respiratory distress and failure.

Advances in pulmonary management and weaning from ECLS

ECMO for neonatal and pediatric respiratory failure provides gas exchange to allow lung recovery from reversible pulmonary ailments. This is a comprehensive discussion on the various strategies and advances utilized by pediatric ECLS specialists today. ECMO patients require continual monitoring, serial gasses and radiographs, near-infrared spectroscopy (NIRS - to monitor oxygen delivery to regional tissue beds), and more quality ECLS directed care. As the foundation to lung recovery, good EMCO closely monitors ECLS flow rates, sweep gasses, and membrane lung function. Mixed venous oxygen saturation (Sv02) greater than 65% indicates good oxygen delivery and sweep gas adjustments maintain PaCO2 of 40–45 mm Hg. Lung recovery ventilatory settings do not fully rest the lungs but maintain normal or nontoxic pressure and oxygen levels. Neonatal recovery settings are PIP (cm H20) of 15–20, PEEP of 5–10, ventilator rate of 12–20 and an inspiratory time of 0.5–1 s, and FiO2 of 0.3–0.5. Pediatric recovery settings are PIP (cm H20) < 25, PEEP of 5–15, ventilator rate of 10–20 and an inspiratory time of 0.8–1 s, and FiO2 of <0.5. Some studies demonstrate a higher recovery PEEP level decreases duration of ECMO, but do not demonstrate a mortality difference. Multiple adjunctive therapies such as surfactant, routine pulmonary clearance and respiratory physiotherapy, iNO, prone positioning, bronchoscopy, POCUS, CT imaging, and extubation or “awake ECLS” can significantly affect pulmonary recovery. Patience is necessary as lung recovery may take weeks or even months on the nontoxic settings. On these settings, dynamic recovery will be revealed by improvement in tidal volume, minute ventilation and radiographic pulmonary aeration, prompting discussion about weaning. When this pulmonary compliance recovery becomes evident, decreasing ECLS flow while also decreasing circuit FiO2 and/or sweep gas are common components to ECMO weaning strategies.

Identification of a pediatric acute hypoxemic respiratory failure signature in peripheral blood leukocytes at 24 hours post-ICU admission with machine learning.

There is no generalizable transcriptomics signature of pediatric acute respiratory distress syndrome. Our goal was to identify a whole blood differential gene expression signature for pediatric acute hypoxemic respiratory failure (AHRF) using transcriptomic microarrays within twenty-four hours of diagnosis. We used publicly available human whole-blood gene expression arrays of a Berlin-defined pediatric acute respiratory distress syndrome (GSE147902) cohort and a sepsis-triggered AHRF (GSE66099) cohort within twenty-four hours of diagnosis and compared those children with a PaO2/FiO2 < 200 to those with a PaO2/FiO2 ≥ 200. We used stability selection, a bootstrapping method of 100 simulations using logistic regression as a classifier, to select differentially expressed genes associated with a PaO2/FiO2 < 200 vs. PaO2/FiO2 ≥ 200. The top-ranked genes that contributed to the AHRF signature were selected in each dataset. Genes common to both of the top 1,500 ranked gene lists were selected for pathway analysis. Pathway and network analysis was performed using the Pathway Network Analysis Visualizer (PANEV) and Reactome was used to perform an over-representation gene network analysis of the top-ranked genes common to both cohorts. Changes in metabolic pathways involved in energy balance, fundamental cellular processes such as protein translation, mitochondrial function, oxidative stress, immune signaling, and inflammation are differentially regulated early in pediatric ARDS and sepsis-induced AHRF compared to both healthy controls and to milder acute hypoxemia. Specifically, fundamental pathways related to the severity of hypoxemia emerged and included (1) ribosomal and eukaryotic initiation of factor 2 (eIF2) regulation of protein translation and (2) the nutrient, oxygen, and energy sensing pathway, mTOR, activated via PI3K/AKT signaling. Cellular energetics and metabolic pathways are important mechanisms to consider to further our understanding of the heterogeneity and underlying pathobiology of moderate and severe pediatric acute respiratory distress syndrome. Our findings are hypothesis generating and support the study of metabolic pathways and cellular energetics to understand heterogeneity and underlying pathobiology of moderate and severe acute hypoxemic respiratory failure in children.

Discontinuation of the OriGen® Dual-Lumen Right Atrial Cannula Decreased Venovenous ECMO Usage in Neonates and Older Children: A Survey of the American Pediatric Surgical Association

IntroductionDual-lumen cannulas for venovenous (VV)-ECMO are widely used in pediatric patients. The popular OriGen® dual-lumen right atrial cannula was discontinued in 2019 without a comparable replacement. MethodsA survey covering VV-ECMO practice and opinions was distributed to attending members of the American Pediatric Surgical Association. Results137 pediatric surgeons responded (14%). Prior to discontinuation of the OriGen®, 82.5% offered VV-ECMO to neonates, and 79.6% cannulated with the OriGen®. Following its discontinuation, those that offered only venoarterial (VA)-ECMO to neonates increased to 37.6% from 17.5% (p = 0.0002). An additional 33.8% changed their practice to sometimes use VA-ECMO when VV-ECMO was indicated. Reasons for not incorporating dual-lumen bi-caval cannulation into practice included risk of cardiac injury (51.7%), inexperience with bi-caval cannulation in neonates (36.8%), difficulty with placement (31.0%), and recirculation and/or positioning problems (27.6%). For the pediatric/adolescent population, 95.5% of surgeons offered VV-ECMO prior to OriGen® discontinuation. Few switched to exclusive VA-ECMO (1.9%) when the OriGen® was discontinued, but 17.8% of surgeons began to incorporate selective use of VA-ECMO. ConclusionDiscontinuation of the OriGen® cannula drove pediatric surgeons to alter their cannulation practices, dramatically increasing VA-ECMO use for neonatal and pediatric respiratory failure. These data may suggest a need for targeted education accompanying major technological shifts. Level of evidenceLevel IV.

Association Between Mortality and Ventilator Parameters in Children With Respiratory Failure on ECMO.

In refractory respiratory failure, extracorporeal membrane oxygenation (ECMO) is a rescue therapy to prevent ventilator-induced lung injury. Optimal ventilator parameters during ECMO remain unknown. Our objective was to describe the association between mortality and ventilator parameters during ECMO for neonatal and pediatric respiratory failure. We performed a secondary analysis of the Bleeding and Thrombosis on ECMO dataset. Ventilator parameters included breathing frequency, tidal volume, peak inspiratory pressure, PEEP, dynamic driving pressure, pressure support, mean airway pressure, and FIO2 . Parameters were evaluated before cannulation, on the calendar day of ECMO initiation (ECMO day 1), and the day before ECMO separation. Of 237 included subjects analyzed, 64% were neonates, of whom 36% had a congenital diaphragmatic hernia. Of all the subjects, 67% were supported on venoarterial ECMO. Overall in-hospital mortality was 35% (n = 83). The median (interquartile range) PEEP on ECMO day 1 was 8 (5.0-10.0) cm H2O for neonates and 10 (8.0-10.0) cm H2O for pediatric subjects. By multivariable analysis, higher PEEP on ECMO day 1 in neonates was associated with lower odds of in-hospital mortality (odds ratio 0.77, 95% CI 0.62-0.92; P = .01), with a further amplified effect in neonates with congenital diaphragmatic hernia (odds ratio 0.59, 95% CI 0.41-0.86; P = .005). No ventilator type or parameter was associated with mortality in pediatric subjects. Avoiding low PEEP on ECMO day 1 for neonates on ECMO may be beneficial, particularly those with a congenital diaphragmatic hernia. No additional ventilator parameters were associated with mortality in either neonatal or pediatric subjects. PEEP is a modifiable parameter that may improve neonatal survival during ECMO and requires further investigation.

Comparing outcomes of venovenous versus venoarterial extracorporeal membrane oxygenation in neonatal and pediatric respiratory failure: A retrospective review of Extracorporeal Life Support Organization registry

Comparing outcomes of venovenous versus venoarterial extracorporeal membrane oxygenation in neonatal and pediatric respiratory failure: A retrospective review of Extracorporeal Life Support Organization registry

629: VARIATION OF PEDIATRIC EXTRACORPOREAL MEMBRANE OXYGENATION UTILIZATION BY SOCIOECONOMIC STATUS

Introduction: Previous studies demonstrate variation in extracorporeal membrane oxygenation (ECMO) utilization by race and payer. However, limited data examine relationships with socioeconomic status (SES) and no analyses employ multidimensional neighborhood-level tools. Methods: This is a retrospective cohort analysis of admissions to 49 pediatric hospitals in the Pediatric Health Information Systems database. We identified children (< 18 years) born at term (>35 weeks) requiring intensive care with “high” or “very high” illness severity (10/1/2015 to 3/1/2021). Primary SES predictor was the Childhood Opportunity Index (COI), a multidimensional SES tool comprising 29 neighborhood-level indicators. COI was measured from 0 to 100 with lower COI indicating lower SES. We compared patient variables across 3 outcomes: supported on ECMO, survival without ECMO and those who died without ECMO (DWE). Multivariable analysis compared patients supported on ECMO and the DWE cohort adjusting for clinical covariates. Results: Of 331194 children included, 9071 (2.7%) were supported on ECMO, 308490 (93.1%) survived without ECMO and 13633 (4.1%) DWE. The ECMO cohort had a higher proportion of cardiac patients (65% vs 39% in both survived and DWE; p< 0.001). Patients who DWE had lower SES (median COI[IQR] 41 [19,66]) compared with patients who survived without ECMO (44 [20,70]) or supported on ECMO (47 [22,72]; p< 0.001). There was a higher proportion of patients with diverse racial backgrounds (versus white) in the DWE population (45%) than those that survived (42%) or received ECMO (39%; p< 0.001). Outcomes differed by payer with proportions of patients who were supported on ECMO, survived or DWE who were publicly insured (57% vs 62% vs 63%) vs privately insured (41% vs 35% vs 32%; p< 0.001). In the multivariable analysis for every 5 points lower COI, the odds of DWE increased by 2%. Independent predictors of DWE included lower COI, pediatric respiratory failure, younger age, comorbidities, Asian or other race, residence closer to hospital, and non-midwest centers. Conclusions: Social determinants of health influence ECMO utilization. Lower SES is independently associated with greater odds of DWE. Further research is needed to understand the systemic, hospital-level and individual factors contributing to health disparities.

Paediatric dengue shock syndrome and acute respiratory failure: a single-centre retrospective study

ObjectiveDengue shock syndrome (DSS) is a serious health condition leading to paediatric intensive care unit (PICU) admissions and deaths in tropical countries. Acute respiratory failure (ARF) is associated with DSS...

COVID-19 in Immunocompromised Children and Adolescents.

COVID-19 in Immunocompromised Children and Adolescents.

Utilising pneuRIP device in determining the adequacy of respiratory support when weaning high-flow nasal cannula in paediatric patients with acute respiratory distress: A pilot study.

Recognition of paediatric respiratory distress and timely intervention is critical, especially during the weaning phase of support in paediatric acute respiratory failure, as weaning too aggressively can lead to further setbacks in a patient's recovery. We aimed to determine if pulmonary function measurements obtained with the pneuRIP device, a noninvasive pulmonary function testing device that provides measurements of labored breathing index (LBI), phase angle and %rib cage (%RC) contribution to breathing, will provide predictive values to assess the adequacy of respiratory support while weaning from HFNC. We reviewed patients ages 0-18 years admitted to the PICU for respiratory distress due to respiratory infections receiving HFNC. Patients with history of chronic lung disease and chronic neuromuscular disease with baseline habnormal breathing patterns were excluded. Phase angle, LBI and %RC were obtained every hour and with every wean of HFNC. Nine patients were enroled. Mean LBI range remained 1.27-1.68 when LBI was plotted as a function of the HFNC flow rate. Mean values of %RC contribution to breathing ranged 43.65-57.12 as a function of the HFNC flow rate. No significant deviations existed in either %RC (P=0.16) or LBI (P=0.16) during the weaning of HFNC. Mean phase angle for all subjects was 41.48°-74.12° for the duration of wean and showed significant deviation from baseline during the weaning process (p=0.001). Measurements of LBI and %RC on the pneuRIP device effectively demonstrated tolerance of weaning HFNC during the recovery phase of acute respiratory failure from a respiratory infection.

Extracorporeal membrane oxygenation for paediatric refractory hypoxic respiratory failure caused by adenovirus in Shanghai: a case series

BackgroundTo assess the outcome of extracorporeal membrane oxygenation (ECMO) for severe adenovirus (Adv) pneumonia with refractory hypoxic respiratory failure (RHRF) in paediatric patients.MethodsA retrospective observational study was performed in a tertiary paediatric intensive care unit (PICU) in China. Patients with RHRF caused by Adv pneumonia who received ECMO support after mechanical ventilation failed to achieve adequate oxygenation between 2017 and 2020 were included. The outcome variables were the in-hospital survival rate and the effects of ECMO on the survival rate.ResultsIn total, 18 children with RHRF received ECMO. The median age was 19 (9.5, 39.8) months, and the median ECMO duration was 196 (152, 309) h. The in-hospital survival rate was 72.2% (13/18). Thirteen patients (72.2%) required continuous renal replacement therapy (CRRT) due to fluid imbalance or acute kidney injury (AKI). At ECMO initiation, compared with survivors, nonsurvivors had a lower PaO2/FiO2 ratio [49 (34.5, 62) vs. 63 (56, 71); p = 0.04], higher oxygen index (OI) [41 (34.5, 62) vs. 30 (26.5, 35); p = 0.03], higher vasoactive inotropic score (VIS) [30 (16.3, 80) vs. 100 (60, 142.5); p = 0.04], longer duration from mechanical ventilation to ECMO support [8 (4, 14) vs. 4 (3, 5.5) h, p=0.02], and longer time from confirmed RHRF to ECMO initiation [9 (4.8, 13) vs. 5 (1.3, 5.5) h; p = 0.004]. Patients with PaO2/FiO2 <61 mmHg or an OI >43 and hypoxic respiratory failure for more than 9 days before the initiation of ECMO had worse outcomes.ConclusionsECMO seemed to be effective, as severe paediatric Adv pneumonia patients with RHRF had a cumulative survival rate of 72.2% in our study. Our study provides insight into ECMO rescue in children with severe Adv pneumonia.

Pressure-Regulated Volume Control and Pressure-Control Ventilation Modes in Pediatric Acute Respiratory Failure

ObjectiveThe objective of this study is to present our experience using the pressure-regulated volume control and the pressure-control ventilation modes in children.MethodsPatients with acute respiratory failure ventilated with pressure-regulated volume control or pressure-control modes were retrospectively evaluated. The patient’s ventilation parameters (of the first 7 days of ventilation or of the whole ventilation period, if the patient had been ventilated less than 7 days), SpO2, blood gases, and demographic data were collected from the pediatric intensive care unit database. ResultsSixty-one patients (median age 12 [4.8-36.4] months) were enrolled in the study. The pressure-control ventilation mode was used on 40 patients (65.6%) and the pressure-regulated volume-control mode was used on 21 (34.4%) patients. Twenty-eight patients (45.9%) had hypoxemic respiratory failure and 44 (72.1%) had hypercapnic respiratory failure. The median positive end-expiratory pressure was higher in pressure-control ventilation mode (5.4 [4.2-6.3] cmH2O) than the pressure-regulated volume-control mode (4.05 [3.68-4.41] H2O, P < .001). Pressure-control mode was used more frequently in hypoxemic cases but both modes were used equally in hypercapnic cases. Hypoxic respiratory failure (yes/no), odds ratio: 3.9 (95% CI 1.2-12.3, P = .02), Ph (nadir), odds ratio: 0.004 (95% CI 0.000-0.275, P = .01), and base excess, odds ratio: 0.88 (95% CI 0.79-0.98, P = .02) were associated with intensive care mortality.ConclusionsAlthough the pressure-control ventilation mode was preferred more frequently in hypoxemic respiratory failure, there was no significant difference between the 2 respiratory modes in terms of length of pediatric intensive care unit stay, MV duration, and mortality. The pressure-regulated volume-control mode seems to be a safer option for physicians who do not have enough experience in using pressure-control ventilation mode.

Prehospital Pediatric Respiratory Distress and Airway Management Interventions: An NAEMSP Position Statement and Resource Document

Devices and techniques such as bag-valve-mask ventilation, endotracheal intubation, supraglottic airway devices, and noninvasive ventilation offer important tools for airway management in critically ill EMS patients. Over the past decade the tools, technology, and strategies used to assess and manage pediatric respiratory and airway emergencies have evolved, and evidence regarding their use continues to grow. NAEMSP recommends: Methods and tools used to properly size pediatric equipment for ages ranging from newborns to adolescents should be available to all EMS clinicians. All pediatric equipment should be routinely checked and clearly identifiable in EMS equipment supply bags and vehicles. EMS agencies should train and equip their clinicians with age-appropriate pulse oximetry and capnography equipment to aid in the assessment and management of pediatric respiratory distress and airway emergencies. EMS agencies should emphasize noninvasive positive pressure ventilation and effective bag-valve-mask ventilation strategies in children. Supraglottic airways can be used as primary or secondary airway management interventions for pediatric respiratory failure and cardiac arrest in the EMS setting. Pediatric endotracheal intubation has unclear benefit in the EMS setting. Advanced approaches to pediatric ETI including drug-assisted airway management, apneic oxygenation, and use of direct and video laryngoscopy require further research to more clearly define their risks and benefits prior to widespread implementation. If considering the use of pediatric endotracheal intubation, the EMS medical director must ensure the program provides pediatric-specific initial training and ongoing competency and quality management activities to ensure that EMS clinicians attain and maintain mastery of the intervention. Paramedic use of direct laryngoscopy paired with Magill forceps to facilitate foreign body removal in the pediatric patient should be maintained even when pediatric endotracheal intubation is not approved as a local clinical intervention.

School and Work Absences After Critical Care Hospitalization for Pediatric Acute Respiratory Failure

Patients who survive pediatric critical illness and their caregivers commonly experience physical, emotional, and cognitive sequelae. However, the rate and duration of school absence among patients and work absence among their caregivers are unknown. To determine the rates and duration of school absence among children who survived hospitalization with acute respiratory failure and work absence among their caregivers. The Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) cluster randomized trial included 2449 children from 31 sites to protocolized sedation (intervention) vs usual care (control) from June 6, 2009, to December 2, 2013. In total, 1360 children survived hospitalization and were selected for follow-up at 6 months after pediatric intensive care unit (PICU) discharge, which was completed from January 12, 2010, to April 13, 2015. This secondary analysis was conducted from July 1, 2020, to September 30, 2021. PICU hospitalization for acute respiratory failure, including invasive mechanical ventilation. Postdischarge assessments with caregivers of eligible participants at 6 months after PICU discharge, including questions about school and work absence. Risk factors associated with longer absence from school and work were identified. Postdischarge assessments were completed for 960 children who survived treatment for acute respiratory failure, of whom 443 (46.1%) were girls and 517 (53.9%) were boys; 509 of 957 (53.2%) were non-Hispanic White. Median age was 1.8 years (IQR, 0.4-7.9 years). In total, 399 children (41.6%) were enrolled in school, of whom 279 (69.9%) missed school after discharge. Median duration of postdischarge absence was 9.1 days (IQR, 0-27.9 days) among all children enrolled in school and 16.9 days (IQR, 7.9-43.9 days) among the 279 children with postdischarge absence. Among 960 primary caregivers, 506 (52.7%) were employed outside the home, of whom 277 (54.7%) missed work. Median duration of postdischarge work absence was 2 days (IQR, 0-10 days) among all employed primary caregivers, and 8 days (IQR, 4-20 days) among the 277 caregivers who missed work after discharge. The odds of postdischarge school absence and greater duration of absence increased for children 5 years or older (compared with 0-4 years, odds ratios [ORs] for 5-8 years, 3.20 [95% CI, 1.69-6.05] and 2.09 [95% CI, 1.30-3.37], respectively; ORs for 9-12 years, 2.49 [95% CI, 1.17-5.27] and 2.32 [95% CI, 1.30-4.14], respectively; and ORs for 13-18 years, 2.37 [95% CI, 1.20-4.66] and 1.89 [95% CI, 1.11-3.24], respectively) and those with a preexisting comorbidity (ORs, 1.90 [95% CI, 1.10-3.29] and 1.76 [95% CI, 1.14-2.69], respectively). In this secondary analysis of a cluster randomized trial, 2 in 3 children hospitalized for acute respiratory failure missed school after discharge, for a median duration of nearly 2 weeks. In addition, more than half of primary caregivers missed work after discharge. The magnitude of school absenteeism suggests that children may be at increased risk for lower educational achievement, economic hardship, and poor health outcomes in adulthood.

Update on ventilation management in the Pediatric Intensive Care Unit.

Studies have shown that up to 63% of pediatric intensive care unit patients admitted with acute respiratory or cardiorespiratory illness require mechanical ventilation. Mechanical ventilator support can be divided into three phases: initiation, escalation, and resolution. Noninvasive ventilation is typical during the initiation phase in the management of acute pediatric respiratory failure. The major advancements in the use of noninvasive ventilation involve the emergence of high-flow nasal cannula and how widespread the use of high-flow nasal cannula has become in pediatric critical care practice. When high-flow nasal cannula fails, escalation to continuous positive airway pressure or bi-level positive airway pressure is the next step in respiratory care progression. Careful clinical assessment is necessary to avoid delayed escalation between forms of noninvasive support or escalation to intubation and invasive mechanical ventilation. Advancements in conventional mechanical ventilation are centered on optimizing ventilator settings and customizing monitoring with the overarching goal to reduce complications of mechanical ventilation, such as ventilator-induced lung injury. New mechanical ventilator strategies integrating esophageal pressure monitoring, volumetric capnography, and neurally adjusted ventilator assist help to optimize conventional ventilator support. Nonconventional modes of ventilation in the intensive care unit are high-frequency modes and airway pressure release ventilation. Extracorporeal pulmonary support via extracorporeal membrane oxygenation or paracorporeal lung assist devices provides rescue options when conventional and nonconventional methods fail. During resolution of a course of mechanical ventilator support, reliable weaning strategies and extubation readiness testing are lacking in pediatric critical care. Further, timing of tracheostomy, risk reduction in ventilator-induced lung injury, and decreased sedation requirements in pediatric patients requiring mechanical ventilation in the pediatric intensive care unit are areas of ongoing research.