Respiratory Support In Children Research Articles

High-flow nasal oxygen in infants and children for early respiratory management of pneumonia-induced acute hypoxemic respiratory failure: the CENTURI randomized clinical trial

ObjectiveTo compare the effectiveness of early high-flow nasal cannula (HFNC) and low-flow oxygen support (LFOS) in children under 5 years with acute hypoxemic respiratory failure (AHRF) due to severe community-acquired pneumonia in low-middle-income countries.MethodsAn open-label randomized clinical trial enrolled children aged 2–59 months with AHRF due to severe community-acquired pneumonia and randomized into HFNC and LFOS. In the LFOS group, the patient received cold wall oxygen humidified by bubbling through sterile water administered through simple nasal prongs at a fixed flow rate of 2 L/min. In the HFNC group, the patient received humidified, heated (37 °C), high-flow oxygen at a flow rate assigned based on weight range, with a titratable oxygen fraction. The primary outcome was treatment failure in 72 h (escalating the respiratory support method using any modality other than primary intervention).ResultsData was analyzed intention-to-treat (HFNC = 124; LFOS = 120). Median (IQR) age was 12 (6–20) and 11 (6–27) months, respectively. Treatment failure occurred in a significantly lower proportion in the HFNC group (7.3%, n = 9/124) as compared to the LFOS group (20%, n = 24/120) (relative risk = 0.36, 95% CI 0.18 to 0.75; p = 0.004; adjusted hazard ratio 0.34, 95% CI 0.16 to 0.73; p = 0.006). The intubation rate was significantly lower in the HFNC group (7.3%, n = 9/124 vs. 16.7%, n = 20/120; relative risk = 0.44, 95% CI 0.21 to 0.92, p = 0.023). There were no significant differences noted in other secondary outcomes. No mortality occurred.ConclusionHigh-flow nasal cannula oxygen therapy used as early respiratory support in children under 5 years with acute hypoxemic respiratory failure due to severe community-acquired pneumonia was associated with significantly lower treatment failure compared with standard low-flow oxygen support.Trial registration CTRI/2016/04/006788. Registered 01 April 2016, https://ctri.nic.in/Clinicaltrials/advsearch.php.

СТРАТЕГИИ РЕСПИРАТОРНОЙ ТЕРАПИИ У ДЕТЕЙ С ТЯЖЕЛОЙ БРОНХОЛЕГОЧНОЙ ДИСПЛАЗИЕЙ

Bronchopulmonary dysplasia (BPD) is a chronic lung disease of multifactorial etiology characterized by the formation of respiratory failure and regressing as the child grows. With a severe form of BPD, adequate and safe respiratory support is required for a long time. The mechanical properties of the lungs in these patients differ significantly from those in acute respiratory pathology, which should be taken into account when setting the parameters of the ventilator. Important task is to determine the optimal moment for the transition to a strategy of respiratory support for damaged lungs, which is characterized by slow dynamics and specific parameter settings. In the absence of recommendations based on high quality evidence, most specialists choose a personalized approach that takes into account the specificity of respiratory mechanics in patients with severe BPD. An important goal is to achieve respiratory comfort, which allows achieving optimal growth and recovery of respiratory system.

Types of home respiratory support in children with bronchopulmonary dysplasia and factors determining its duration: A scoping review.

Bronchopulmonary dysplasia also known as chronic lung disease of prematurity has changed as a disease entity over the last five decades and children with "new bronchopulmonary dysplasia (BPD)" have better survival rates. This necessitates strategies to prevent severe BPD and provide organized home support. Home respiratory support in these children varies from home oxygen to noninvasive ventilation and tracheostomy ventilation. This review was conducted utilizing Joanna Briggs Institute publications on evidence synthesis and presentation of results for a scoping review. The Preferred Reporting Items for Systematic Review and Meta-Analyses were used to report the results. The risk of bias assessment was done using "The Cochrane Handbook for Systematic Reviews tool for interventional studies." After screening for the duplication of results and applying inclusion and exclusion criteria, twenty-seven studies were assessed by reading the full texts. Out of these, eleven were finally included in this systematic review. The total sample size from all studies was 4794, including 2705 males. The 4/11 studies home oxygen, one study reported continuous positive airway pressure/bilevel positive airway pressure and seven studies used tracheostomy or tracheostomy ventilation. The median duration of post-natal invasive ventilation was higher in those discharged on home oxygen compared to those who did not need oxygen at discharge. There is a significant proportion of children who are tracheostomy ventilated (8.65%) at home. In the absence of established guidelines, these children are vulnerable when it comes to care at home and the timing of decannulation. For home oxygen alone, guidelines by ERS, ATS and BTS have streamlined weaning protocols and the need for having a multi-disciplinary team to care for these children.

Pediatric long-term noninvasive respiratory support in children with central nervous system disorders.

The use of long-term noninvasive respiratory support is increasing in children along with an extension of indications, in particular in children with central nervous system (CNS) disorders. The aim of this study was to describe the characteristics of children with CNS disorders treated with long-term noninvasive respiratory support in France. Data were collected from 27 French pediatric university centers through an anonymous questionnaire filled for every child treated with noninvasive ventilatory support ≥3 months on 1st June 2019. The data of 182 patients (55% boys, median age: 10.2 [5.4;14.8] years old [range: 0.3-25]) were collected: 35 (19%) patients had nontumoral spinal cord injury, 22 (12%) CNS tumors, 63 (35%) multiple disabilities, 26 (14%) central alveolar hypoventilation and 36 (20%) other CNS disorders. Seventy five percent of the patients were treated with noninvasive ventilation (NIV) and 25% with continuous positive airway pressure (CPAP). The main investigations performed before CPAP/NIV initiation were nocturnal gas exchange recordings, alone or coupled with poly(somno)graphy (in 29% and 34% of the patients, respectively). CPAP/NIV was started in an acute setting in 10% of the patients. Median adherence was 8 [6;10] hours/night, with 12% of patients using treatment <4 h/day. Nasal mask was the most common interface (70%). Airway clearance techniques were used by 31% of patients. CPAP/NIV may be a therapeutic option in children with CNS disorders. Future studies should assess treatment efficacy and patient reported outcome measures.

Weaning from noninvasive respiratory support in children in acute settings: Expert consensus statement using modified Delphi methodology.

To reach a consensus on the definition and modalities of weaning from noninvasive ventilation in acute settings. A modified Delphi survey using closed and open-ended questions. Three rounds of consensus determination were sent via electronic mail survey to 33 experts. The survey questionnaire had four sections: definition of weaning, definition of weaning failure, criteria to initiate weaning, and modalities of weaning. Questions where agreement had been reached on round 1 were no longer part of the survey in rounds 2 and 3. Twenty-five international experts from 10 countries. Overall, this survey generated positive consensus from experts for 19/35 statements (9 with strong agreement and 10 with weak agreement) about weaning from noninvasive respiratory support. No negative consensus could be identified. The clinical practice statements issued address important aspects of definition of weaning, definition of weaning failure, criteria to initiate weaning, and modalities of weaning in acute settings.

The Weaning Protocol of High Flow Nasal Cannula Reduce Duration of Weaning in Lower-Respiratory Tract Infection in Children Who Used High Flow Nasal Cannula: Single Center Experience in Thailand

Background: Use of high flow nasal cannula (HFNC) has been widely accepted as non-invasive respiratory support in children suffering from lower respiratory tract infections (LRI). Patients who use HFNC still need respiratory care from health personnel in ICU or intermediate care wards. Without the weaning protocol, the authors had noticed prolonged HFNC use, which affected the length of hospital stay (LOS). As such, a pediatric patient care team (PCT) created the weaning protocol and collected data whether the weaning protocol would shorten weaning time. Objective: To compare HFNC weaning times among children suffering from LRI, before and after using the weaning protocol. Materials and Methods: A pre- and post-intervention study of 1-month-old to 5-year-old children who received HFNC therapy for LRI at Panyananthaphikkhu Chonprathan Medical Center between August 2018 and July 2020, the one year before and after the protocol was implemented in August 2019, were carried out. Demographic data and severity of respiratory illness according to Respiratory Assessment Score (RAS) were recorded. Multivariate linear regression, adjusted for age, gender, weight, RR, HR, SpO₂, and RAS before using HFNC, was used to compare between the pre- and post-weaning protocol groups according to total HFNC time, duration of weaning time, and LOS. Results: There were 25 patients in each group. The mean age in the post-weaning protocol group was lower, but there was no difference in severity. Multivariate linear regression demonstrated that the post-weaning protocol group had a significantly shorter weaning time at 49.5±37.0 hours versus 84.2±62.8 hours (p=0.034). Moreover, total HFNC time was also significantly shorter in the post-weaning protocol group at 71.53±36.7 hours versus 119.6±78.2 hours (p=0.019). There was no difference in vital signs during weaning between the two groups. Conclusion: Implementing the weaning protocol reduce weaning time and total HFNC time, without affecting clinical outcomes. Keywords: High flow nasal cannula; Weaning protocol; Lower respiratory tract infection; Length of stay

Morphological changes in the epithelium of the auditory tube with prolonged respiratory support in children of the first year of life

To analyze the condition of the epithelium of the cartilaginous part of the auditory tube in premature and full-term infants with prolonged respiratory support using noninvasive assisted ventilation (continuous positive airway pressure - CPAP) and artificial lung ventilation (ventilator). All the obtained material is distributed relative to the gestation period into the main and control groups. The main group (25 children) is represented by premature and full-term live-born children who were on respiratory support for a period of several hours to 2 months, the average gestation period of which was 30 weeks and 40 weeks, respectively. The control group (8 children) is represented by stillborn newborns with an average gestation period of 28 weeks. The study was conducted posthumously. Prolonged use of respiratory support in premature and full-term children, regardless of the type (CPAP or ventilator), leads to a violation of the row of cilia of the ciliated epithelium, various inflammatory processes, as well as to the expansion of the ducts of the mucous glands of the epithelium of the auditory tube, which affects its drainage system. Prolonged respiratory support causes destructive changes in the epithelium of the auditory tube, which make it difficult to evacuate the mucous discharge from the tympanic cavity. This negatively affects the ventilation function of the auditory tube and in the future may lead to the development of chronic exudative otitis media.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Myeloid-Derived Suppressor Cells and Clinical Outcomes in Children With COVID-19.

BackgroundAlthough children with COVID-19 account for fewer hospitalizations than adults, many develop severe disease requiring intensive care treatment. Critical illness due to COVID-19 has been associated with lymphopenia and functional immune suppression. Myeloid-derived suppressor cells (MDSCs) potently suppress T cells and are significantly increased in adults with severe COVID-19. The role of MDSCs in the immune response of children with COVID-19 is unknown.AimsWe hypothesized that children with severe COVID-19 will have expansion of MDSC populations compared to those with milder disease, and that higher proportions of MDSCs will correlate with clinical outcomes.MethodsWe conducted a prospective, observational study on a convenience sample of children hospitalized with PCR-confirmed COVID-19 and pre-pandemic, uninfected healthy controls (HC). Blood samples were obtained within 48 h of admission and analyzed for MDSCs, T cells, and natural killer (NK) cells by flow cytometry. Demographic information and clinical outcomes were obtained from the electronic medical record and a dedicated survey built for this study.ResultsFifty children admitted to the hospital were enrolled; 28 diagnosed with symptomatic COVID-19 (10 requiring ICU admission) and 22 detected by universal screening (6 requiring ICU admission). We found that children with severe COVID-19 had a significantly higher percentage of MDSCs than those admitted to the ward and uninfected healthy controls. Increased percentages of MDSCs in peripheral blood mononuclear cells (PBMC) were associated with CD4+ T cell lymphopenia. MDSC expansion was associated with longer hospitalizations and need for respiratory support in children admitted with acute COVID-19.ConclusionThese findings suggest that MDSCs are part of the dysregulated immune responses observed in children with severe COVID-19 and may play a role in disease pathogenesis. Future mechanistic studies are required to further understand the function of MDSCs in the setting of SARS-CoV-2 infection in children.

S/F and ROX indices in predicting failure of high-flow nasal cannula in children.

A high-flow nasal cannula (HFNC) is a useful respiratory support for children with respiratory distress; however, it elevates the risk of belated intubation. Recently, indices based on percutaneous oxygen saturation, a fraction of inspired oxygen, and respiratory rate (RR) have been suggested for the prediction of HFNC failure. We aimed to evaluate various indices predicting HFNC failure in children who started receiving HFNC at a tertiary center for 27 months. Cases of HFNC failure were classified as hypoxic respiratory failure (HRF) or non-HRF (NHRF) depending on the cause of intubation. The ratio of percutaneous oxygen saturation to the fraction of inspired oxygen (S/F), the ratio of S/F to RR (ROX), the ratio of S/F to RR/median RR (ROX-M), and the ratio of S/F to z-score of RR (ROX-Z) were calculated and compared between groups. Of the 152 cases, 45 (29.6%) failed to wean from the HFNC support, of which 21 (46.7%) were HRFs and 24 (53.3%) were NHRFs. The S/F and ROX-M at 6 h and 3 h, respectively, predicted HRF well with a high area under the curve. Initial hypercapnia and low weight were good predictors for NHRF. For the management of children with HFNC, these risk factors and indicators should be monitored to make an early decision regarding intubation.

Oxygen therapy and respiratory support in SARS COVID 19 infection in children

Covid 19 pandemic has been a very dreadful experience and affected all of us badly. Although children are asymptomatic and less severely affected by covid illness as compared to adult population, however the patients presenting with severe symptoms require hospitalisation and need oxygen and respiratory support. Inappropriate, prolonged use and failure to monitor oxygen therapy can have serious consequences. Oxygen therapy in children requires the selection of proper oxygen delivery system that suits the patient's size, needs, and the therapeutic goals. Low flow and high flow oxygen devices are being used to deliver oxygen in children. High flow nasal cannula has been used proved to be wonderful modality for respiratory support in children. We need to follow all guidelines laid down by various agencies while delivering oxygen and respiratory support to sick children suffering from covid infection. All precautions should be taken to avoid aerosol generation. Close monitoring of oxygen therapy is a must. In this article we have tried to cover the indication and modes, it’s relation with mucormycosis, monitoring and the precautions which we should take while giving oxygen therapy in covid era. Update of knowledge of indication of use and other modalities of treatment by treating doctors and patients are equally important so that we can fight a battle of third wave if it arrives.

Clinical Profile and Outcome of Children Requiring Noninvasive Ventilation (NIV).

To determine the clinical profile and outcome of children requiring noninvasive ventilation (NIV) in a PICU. This prospective observational study was conducted in the PICU at Dayanand Medical College and Hospital, Punjab. Children (1 mo-18 y) with moderate-to-severe respiratory distress who received NIV during one-year period were included. Failure was defined as the need for endotracheal intubation. The patients received bilevel positive airway pressure (BiPAP) with inspiratory and expiratory positive airway pressure (8-18cm H2O and 4-8cm), respectively and indigenous continuous positive airway pressure (CPAP) were included. Vital signs (heart rate, respiratory rate) and gasometric parameters (pH, HCO3, pCO2, pO2) were recorded. Out of total 115 patients, 81.7% were successfully treated by NIV whereas 18.3% constituted NIV failure group. Two types of NIV were used, 65.2% were started on BiPAP and 34.8% on indigenous bubble CPAP. Most common diagnosis was tropical fever (24.3%), bronchopneumonia (20%), and sepsis with multiple organ dysfunction syndrome (MODS) (7.8%). Commonest indication of NIV was respiratory distress (70.4%) and prevention of postextubation respiratory failure (20.8%). Seven patients (6.9%) died during the study. NIV failure is higher in children with sepsis with MODS, abnormal blood gas (acidosis), and moderate-to-severe acute respiratory distress syndrome (ARDS). This study demonstrates that NIV is an effective form of respiratory support for children with acute respiratory distress/failure. Sepsis with MODS, acidosis and ARDS (moderate to severe) were predictors of NIV failure. Careful patient selection may help in judicious use of NIV in PICU.

Clinical Analysis of 86 Cases of Children with Plastic Bronchitis

To investigate the clinical features of pediatric patients who had plastic bronchitis (PB) and to explore the risk factors for respiratory support in the pediatric patients with PB in order to improve the ability to identify PB in children. The basic information and clinical manifestations of 86 children diagnosed with PB at West China Second University Hospital of Sichuan University from March 2014 to December 2019 were collected and analyzed retrospectively. The patients were divided into the respiratory support (RS) group and non-respiratory support (NRS) group as per their need for respiratory support. Logistic regression was conducted to analyze the risk factors for respiratory support in PB patients. A total of 86 children with PB were included in the study, including 62 (72.1%) who were over 3 years old. 57 patients (66.3%) had complications. 56 patients were given respiratory support after admission. All the 86 children had a history of fever and cough, and 76 (88.4%) experienced fever peaks≥39.5°C. Chest imaging showed large lung consolidation or atelectasis in 82 cases (95.3%) and pleural effusion in 63 cases (73.3%). 70 cases (81.4%) were tested positive for pathogens, with the highest infection rate of 68.6% for mycoplasma pneumoniae. There were 30 patients (34.9%) in the NRS group and 56 patients (65.1%) in the RS group. Logistic regression analysis showed that patient being younger than 3 years old ( OR=4.99) and having complications ( OR=7.22) were independent risk factors for respiratory support in children with PB (all P<0.05). Clinically, severe clinical symptoms combined with other systemic complications, large lung consolidation or atelectasis, pleural effusion, and positive lab results for mycoplasma pneumoniae should be an alert indicating the possibility of having PB. Young age and complications were independent risk factors for respiratory support in PB patients.

Efficacy and safety of high flow nasal oxygen for children with bronchiolitis: systematic review and meta-analysis

BackgroundTo assess the published evidence to establish the efficacy and safety of high flow oxygen cannula (HFNC) as respiratory support for children up to 24 months of age with bronchiolitis...

The Use of High-Flow Nasal Cannula and the Timing of Safe Feeding in Children with Bronchiolitis.

ObjectiveThe use of high-flow nasal cannula (HFNC) as non-invasive respiratory support in children with bronchiolitis has increased over the last several years. Several studies have investigated enteral feeding safety while on HFNC. This study compares the safety of oral feeding prior to and following implementation of an HFNC feeding guideline.Patients and methodsA retrospective study was designed, in children ≤2 years of age with bronchiolitis, requiring HFNC, from 2017 to 2019. We defined feeding complications on HFNC and defined safety as the absence of such complications. We gathered the following data: oral feeding timing from the HFNC initiation, duration of enteral feeding on HFNC, and HFNC flow rate at which the feeding was initiated. We compare the data prior to and post-implementation of an HFNC feeding guideline.ResultsDescriptive statistics were calculated separately by pre and post guideline implementation. Patients in both pre and post guideline implementation groups had no feeding complications on HFNC. Subjects in the post (n=50) vs. pre-guideline implementation (n=36) had a higher median amount of liters flow when initiating enteral feeding (8.0 vs. 6.0 respectively, p<0.024), spent fewer days in the pediatric intensive care unit (PICU) (two days vs. 0 days). Post guideline implementation, enteral feeding was initiated sooner (days nil per os [NPO] 1.0 vs 2.0). No other significant differences between the two cohorts with respect to other variables were observed. ConclusionsOur data supports that oral feeding in patients with bronchiolitis on HFNC is safe. Utilization of current guidelines allowed safe earlier feeding of children on HFNC, reducing the time spent NPO.

“New Trach Mom Here…”: A qualitative study of internet‐based resources by caregivers of children with tracheostomy

Decision-making around tracheostomy placement and chronic respiratory support in children is complicated. Families often seek support and advice from outside the medical care team, including from social media. We undertook this study to characterize the content and nature of online resources created and managed primarily by caregivers of children living with tracheostomy and chronic mechanical ventilation. We used a "grey literature" search methodology to identify internet resources created by caregivers of children with tracheostomy. We included only publicly available, nonindustry associated, English language, North American websites updated at least once in 2019. We then applied inductive content analysis to establish central themes, patterns and associations. We identified six blogs/forums that met our search criteria. We identified four main themes: (1) Uncertainty, (2) Lived experience-wants, needs, and emotions, (3) Seeking context and meaning, and (4) Advice/information sharing/support. Two patterns of coping were identified on the basis of the relationships between codes. The "Acceptance pathway" is associated with a sense of self-actualization, mastery, satisfaction, return to normalcy, and ultimately acceptance. The "Resignation pathway" is associated with a sense of lack of control, frustration, burnout and stress, persistent lack of normalcy, and resignation to the tracheostomy as a negative but necessary outcome. Caregivers often come to see themselves as experts in the care of children with tracheostomy, though many still express ambivalence about their knowledge and skills. Those early in the experience express a desire for community and can potentially benefit from online resources.

Point-of-care lung ultrasound in children with bronchiolitis in a pediatric emergency department

ObjectivesThis study assessed the association between findings of lung ultrasound (LUS) performed in the pediatric emergency department (PED) on infants with bronchiolitis and need for respiratory support. MethodsAn observational study was carried out in the PED during the epidemic seasons in two consecutive years. Infants diagnosed with bronchiolitis who fulfilled the inclusion criteria were evaluated. A group of six pediatricians performed LUS and classified lung findings into four groups: normal pattern (A), moderate interstitial pattern (B1), severe interstitial pattern (B2), and isolated consolidation (C). The relationship between LUS findings and need for respiratory support was explored. An expert sonographer, blinded to the results, reviewed the ultrasound studies to determine the interobserver reliability. ResultsA total of 200 infants were included (mean age 5.7 months±4.4 SD); 65 (32.5%) obtained moderate clinical scores, while 23 (11.5%) needed respiratory support at admission and 34 (17.0%) at 48h. The ultrasound findings in the PED were the following: A=89 (44.5%), B1=55 (27.5%), B2=34 (17%), and C=22 (11%). Age less than 6 weeks and moderate bronchiolitis were correlated with abnormal LUS (P<0.005). The severity of interstitial ultrasound pattern has some correlation with an increased need for respiratory support. The interobserver concordance was high (0.95, confidence interval: 0.92–0.98). ConclusionLUS is a feasible tool that may help to confirm the clinical impression and assess the need for respiratory support in children with bronchiolitis, but further multicenter studies are needed.

High Flow Nasal Cannula Therapy as a Primary Mode of Respiratory Support in a Pediatric Intensive Care Unit

To assess efficacy and safety of High flow nasal cannula therapy (HFNC) as primary mode of treatment for children with respiratory distress. Consecutive patients (1 mo-16 years) with respiratory distress were assessed for respiratory clinical score, COMFORT score and saturation to FiO2 (SF) ratio. A total of 188 (91.7%) patients out of 205 responded to HFNC alone. The respiratory clinical score and COMFORT score were lower with higher SF ratio in these than 17 patients who required ventilation (P<0.001). Median (IQR) time to failure was 2 (1.75-24) hours. Air leak was seen in 2 (1%) patients. HFNC is an effective and safe primary mode of respiratory support in children with respiratory distress. Children who succeed on HFNC show a favorable clinical response within first few hours.

The Use of High Flow Nasal Cannula (HFNC) in Children with Bronchiolitis and Timing of Safe Enteral Feeding in a Pediatric In Patient Unit: A Retrospective Review

Title: The Use of High Flow Nasal Cannula (HFNC) in Children with Bronchiolitis and Timing of Safe Enteral Feeding in a Pediatric In Patient Unit: A Retrospective Review Background: The use of HFNC as non- invasive respiratory support in children with bronchiolitis has increased over the last several years. HFNC offers alternative as non- invasive respiratory support and allows delivery of blended, warmed oxygen. Several studies have investigated enteral feeding safety while on HFNC. This study investigates the safety of oral feeding prior …

Ethical issues regarding respiratory support for children with severe neurological conditions

Ethical issues regarding respiratory support for children with severe neurological conditions