Use Of Positive Pressure Ventilation Research Articles

Sequential development of diffuse panbronchiolitis and myasthenia gravis after thymectomy for thymic neoplasm: a case report

BackgroundMyasthenia gravis (MG) is the most common paraneoplastic disorder associated with thymic neoplasms. MG can develop after thymectomy, and this condition is referred to post-thymectomy myasthenia gravis (PTMG). Diffuse panbronchiolitis (DPB), is a rare form of bronchiolitis and is largely restricted to East Asia, has been reported in association with thymic neoplasms. Only three cases of combined MG and DPB have been reported in the literature.Case presentationA 45-year-old Taiwanese woman presented to our hospital with productive cough, rhinorrhea, anosmia, ear fullness, shortness of breath, and weight loss. She had a history of thymoma, and she underwent thymectomy with adjuvant radiotherapy 7 years ago. Chest computed tomography scan revealed diffuse bronchitis and bronchiolitis. DPB was confirmed after video-assisted thoracoscopic surgery lung biopsy, and repeated sputum cultures grew Pseudomonas aeruginosa. She has been on long-term oral azithromycin therapy thereafter. Intravenous antipseudomonal antibiotics, inhaled amikacin, as well as oral levofloxacin were administered. Three months after DPB diagnosis, she developed ptosis, muscle weakness, and hypercapnia requiring the use of noninvasive positive pressure ventilation. MG was diagnosed based on the acetylcholine receptor antibody and repetitive stimulation test results. Her muscle weakness gradually improved after pyridostigmine and corticosteroid therapies. Oral corticosteroids could be tapered off ten months after the diagnosis of MG. She is currently maintained on azithromycin, pyridostigmine, and inhaled amikacin therapies, with intravenous antibiotics administered occasionally during hospitalizations for respiratory infections.ConclusionsTo our knowledge, this might be the first case report of sequential development of DPB followed by PTMG. The coexistence of these two disorders poses a therapeutic challenge for balancing infection control for DPB and immunosuppressant therapies for MG.

Factors associated with adherence to noninvasive positive pressure ventilation in amyotrophic lateral sclerosis.

This cohort study aimed to investigate the factors associated with noninvasive positive pressure ventilation adherence and assess the long-term effects of noninvasive positive pressure ventilation adherence in patients with amyotrophic lateral sclerosis (ALS). The medical records of patients with ALS admitted to a tertiary hospital for noninvasive positive pressure ventilation initiation were retrospectively reviewed. Pulmonary function parameters, variables of blood gas analysis, the site of symptom onset, the time from onset and diagnosis to noninvasive positive pressure ventilation application, ALS Functional Rating Scale-Revised, neurophysiological index, and the length of hospital stay were evaluated. The adherence to noninvasive positive pressure ventilation was defined as the use of noninvasive positive pressure ventilation for ≥ 2 h/day or ≥ 4 h/day. The correlations between noninvasive positive pressure ventilation adherence or length of hospital stay and other clinical parameters were analyzed. Fifty-one patients with ALS were included in the study. The time from onset and diagnosis to NIPPV application was reduced by 16 months in the adherent group than that in the non-adherent group; however, the parameters of blood gas analysis and pulmonary function tests did not differ significantly between the groups. Furthermore, the neurophysiological index of the abductor digiti minimi muscle was higher by 4.05 in the adherent group than that in the non-adherent group. The adherence to noninvasive positive pressure ventilation prolonged tracheostomy-free survival compared to that of non-adherence. Desaturation events, lower forced vital capacity, last pCO2, bicarbonate, and base excess, and higher differences in pCO2, were associated with an increase in the length of hospital stay. Noninvasive positive pressure ventilation application shortly after symptom onset and ALS diagnosis in patients with CO2 retention and reduced forced vital capacity can be considered for successful adherence. Adherence to noninvasive positive pressure ventilation may result in reduced tracheostomy conversion rates and prolonged tracheostomy-free survival.

Noninvasive Positive Pressure Ventilation Use and In-Hospital Cardiac Arrest in Bronchiolitis.

A recent study showed an association between high hospital-level noninvasive positive pressure ventilation (NIPPV) use and in-hospital cardiac arrest (IHCA) in children with bronchiolitis. We aimed to determine if patient-level exposure to NIPPV in children with bronchiolitis was associated with IHCA. Retrospective cohort study at a single-center quaternary PICU in North America including children with International Classification of Diseases primary or secondary diagnoses of bronchiolitis in the Virtual Pediatric Systems database. The primary exposure was NIPPV and the primary outcome was IHCA. Of 4698 eligible ICU admissions with bronchiolitis diagnoses, IHCA occurred in 1.2% (57/4698). At IHCA onset, invasive mechanical ventilation (IMV) was the most frequent level of respiratory support (65%, 37/57), with 12% (7/57) receiving NIPPV. Patients with IHCA had higher Pediatric Risk of Mortality-III scores (3 [0-8] vs. 0 [0-2]; p < 0.001), more frequently had a complex chronic condition (94.7% vs. 46.2%; p < 0.001), and had higher mortality (21.1% vs. 1.0%; p < 0.001) compared with patients without IHCA. Return of spontaneous circulation (ROSC) was achieved in 93% (53/57) of IHCAs; 79% (45/57) survived to hospital discharge. All seven children without chronic medical conditions and with active bronchiolitis symptoms at the time of IHCA achieved ROSC, and 86% (6/7) survived to discharge. In multivariable analysis restricted to patients receiving NIPPV or IMV, NIPPV exposure was associated with lower odds of IHCA (adjusted odds ratio [aOR], 0.07; 95% CI, 0.03-0.18) compared with IMV. In secondary analysis evaluating categorical respiratory support in all patients, compared with IMV, NIPPV was associated with lower odds of IHCA (aOR, 0.35; 95% CI, 0.14-0.87), whereas no difference was found for minimal respiratory support (none/nasal cannula/humidified high-flow nasal cannula [aOR, 0.56; 95% CI, 0.23-1.36]). Cardiac arrest in children with bronchiolitis is uncommon, occurring in 1.2% of bronchiolitis ICU admissions. NIPPV use in children with bronchiolitis was associated with lower odds of IHCA.

Measuring practice preference variation for quality improvement in neonatal respiratory care.

The authors sought to measure and compare practice preference variation in neonatal respiratory care within and between neonatal intensive care units (NICUs) using the Neonatology Survey of Interdisciplinary Groups in Healthcare Tool (NSIGHT). Eleven NICUs completed the NSIGHT between 2019 and 2021. Net preference was measured by mean response; agreement was ranked by standard distribution of response values. Heat maps showed comparisons between NICUs and disciplines. NICUs and individuals agreed most often on use of pressure support with mandatory ventilation and on use of non-invasive positive pressure ventilation for apnea. High preference variation surrounded decisions for invasive ventilation versus continuous positive airway pressure for extremely low birth weight infants. Preference difference was most frequent between neonatologists and nurses. Patterns of practice preference variation in neonatal respiratory care are specific to clinical scenario. Measuring preference variation may inform psychology of change and strengthen quality improvement efforts.

Transition to Weight-Based High-Flow Nasal Cannula Use Outside of the ICU for Bronchiolitis

Most children's hospitals have adopted weight-based high-flow nasal cannula (HFNC) bronchiolitis protocols for use outside of the intensive care unit (ICU) setting. Whether these protocols are achieving their goal of reducing bronchiolitis-related ICU admissions remains unknown. To measure the association between hospital transition to weight-based non-ICU HFNC use and subsequent ICU admission. This multicenter retrospective cohort study was conducted with a controlled interrupted time series approach and involved 18 children's hospitals that contribute data to the Pediatric Health Information Systems database. The cohort included patients aged 0 to 24 months who were hospitalized with a diagnosis of bronchiolitis between January 1, 2010, and December 31, 2021. Data were analyzed from July 2023 to January 2024. Hospital-level transition from ICU-only to weight-based non-ICU protocol for HFNC use. Data for the ICU-only group were obtained from a previously published survey. Proportion of patients with bronchiolitis admitted to the ICU. A total of 86 046 patients with bronchiolitis received care from 10 hospitals in the ICU-only group (n = 47 336; 27 850 males [58.8%]; mean [SD] age, 7.6 [6.2] years) and 8 hospitals in the weight-based protocol group (n = 38 710; 22 845 males [59.0%]; mean [SD] age, 7.7 [6.3] years). Mean age and sex were similar for patients between the 2 groups. Hospitals in the ICU-only group vs the weight-based protocol group had higher proportions of Black (26.2% vs 19.8%) and non-Hispanic (81.6% vs 63.8%) patients and patients with governmental insurance (68.1% vs 65.9%). Hospital transition to a weight-based HFNC protocol was associated with a 6.1% (95% CI, 8.7%-3.4%) decrease per year in ICU admission and a 1.5% (95% CI, 2.8%-0.1%) reduction per year in noninvasive positive pressure ventilation use compared with the ICU-only group. No differences in mean length of stay or the proportion of patients who received invasive mechanical ventilation were found between groups. Results of this cohort study of hospitalized patients with bronchiolitis suggest that transition from ICU-only to weight-based non-ICU HFNC protocols is associated with reduced ICU admission rates.

High-flow nasal cannula may prolong the length of hospital stay in patients with hypercapnic acute COPD exacerbation

BackgroundHigh-flow nasal cannula (HFNC) is increasingly used in patients with acute exacerbation of COPD (AECOPD). We aimed to confirm whether the baseline bicarbonate is an independent predictor of outcomes in patients with hypercapnic AECOPD receiving HFNC. MethodsThis was a secondary analysis of a multicentre randomised trial that enrolled 330 patients with non-acidotic hypercapnic AECOPD supported by HFNC or conventional oxygen treatment (COT). We compared the length of stay (LOS) in hospital and the rate of non-invasive positive pressure ventilation (NPPV) use according to baseline bicarbonate levels using the log-rank test or Cox proportional hazard model. ResultsIn the high bicarbonate subgroup (n = 165, bicarbonate 35.0[33.3–37.9] mmol/L, partial pressure of arterial carbon dioxide [PaCO2] 56.8[52.0–62.8] mmHg), patients supported by HFNC had a remarkably prolonged LOS in hospital when compared to COT (HR 1.59[1.16–2.17], p = 0.004), whereas patients in the low bicarbonate subgroup (n = 165, bicarbonate 28.8[27.0–30.4] mmol/L, PaCO2 48.0[46.0–50.0] mmHg) had a comparable LOS in hospital regardless of respiratory support modalities. The rate of NPPV use in patients with high baseline bicarbonate level was significantly higher than that in patients with low baseline bicarbonate level (19.4 % vs. 3.0 %, p < 0.0001). Patients with high bicarbonate level in HFNC group had a lower rate of NPPV use compared to COT group (15.4 % vs. 23.0 %, p = 0.217). ConclusionsAmong patients with non-acidotic hypercapnic AECOPD with high baseline bicarbonate level, HFNC is significantly associated with a prolonged LOS in hospital, which may be due to the reduced escalation of NPPV treatment. Trial registrationclinicaltrials.gov (NCT 03003559)

Interfacility Transport of Children with Traumatic Pneumothorax: Does Elevation Make a Difference?

IntroductionTraumatic pneumothorax (PTX) remains a source of significant morbidity and mortality in pediatric trauma patients. Management with tube thoracostomy is routinely dictated by symptoms, use of positive pressure ventilation, or plan for air transport. Many patients transferred to our pediatric trauma center (PTC) require transport at considerable elevation. We sought to characterize the effect of transport at elevation in this population to inform management recommendations. MethodsThe trauma registry was queried for pediatric patients transferred to our tertiary referral center with traumatic PTX from 2010 to 2022, yielding 412 charts for analysis. Data abstracted included mechanism of injury, mode of transport, size of pneumothorax, chest tube placement, endotracheal intubation, and estimated elevation change during transport. ResultsThere were 412 patients included for analysis. Most patients had small pneumothoraces that resolved without chest tube placement (388 patients, 94.1%). No patients experienced acute respiratory decompensation in transport. There were four (0.9%) patients with increased PTX on arrival, however, none experienced acute decompensation as a result. Average elevation gain was 2337 feet. There was no association between elevation change and requirement of post-transport chest tube placement. No patients experienced PTX-related complications after discharge. ConclusionsIn this large patient series, no patient experienced a meaningful increase in the size of their traumatic PTX during or immediately following transport at elevation to our institution. These findings suggest it is safe to transfer a pediatric trauma patient with a small, hemodynamically insignificant PTX without tube thoracostomy despite considerable changes in elevation during transport. Levels of evidenceII-III, Retrospective Study.

Sonographic assessment of mean pulmonary artery pressure and diaphragmatic excursion in chronic respiratory failure patient after using home non-invasive positive pressure ventilation

BackgroundNon-invasive positive pressure ventilation (NIPPV) has emerged as a recognized and effective long-term therapeutic approach for individuals suffering from chronic respiratory insufficiency resulting from various diverse disorders. Nevertheless, providing home non-invasive positive pressure ventilation encounters several challenges, including compliance, training inadequacies, and limited resources. Therefore, the objective of this study was to observe the impact of home non-invasive positive pressure ventilation on patients with chronic respiratory failure, specifically focusing on its effects on the mean pulmonary artery pressure, diaphragmatic excursion, and associated complications.ResultsThe study included a total of 48 patients, consisting of 26 males (54.1%) and 22 females (45.9%). The baseline mean pulmonary artery pressure (PAP) was found to be 39.79 ± 7.51. Additionally, the baseline diaphragmatic excursion in quiet breathing was measured to be 1.80 ± 0.38 cm, while the baseline diaphragmatic excursion in deep breathing was recorded as 4.35 ± 0.99 cm. Following the implementation of home non-invasive ventilation, specifically bilevel-positive airway pressure or continuous positive airway pressure, significant improvements were observed in the aforementioned parameters. The most commonly reported complications among the patients included skin ulcers and aerophagia. Furthermore, mortality rate of 6.3% was observed.ConclusionsThe use of home non-invasive positive pressure ventilation has been shown to be a successful and sustainable therapeutic approach for persons suffering from chronic respiratory failure. This therapy method has significantly improved PAP, diaphragm force, and overall mortality rates. The use of ultrasonography to evaluate pulmonary pressure or diaphragmatic excursion is considered a beneficial and straightforward approach for the follow-up of subjects with chronic respiratory failure.

Surfactant delivery strategies to prevent bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) is one of the most devastating morbidities of preterm infants. Antenatal factors like growth restriction and inflammation are risk factors for its development. Use of oxygen and positive pressure ventilation, which are often necessary to treat respiratory distress syndrome (RDS), increase the risk for development of BPD. Continuous positive airway pressure (CPAP) as primary respiratory support allows for avoidance of positive pressure ventilation in many cases but may lead to a delay of surfactant administration which is a proven therapy for RDS. Several alternative surfactant delivery strategies, including nebulization of surfactant, pharyngeal instillation of surfactant, delivery of surfactant via supraglottic airway device or surfactant delivery via a thin endotracheal catheter have been described which allow for the benefit of surfactant therapy while on CPAP. This review reports available data and discusses the existing evidence of their value in preventing BPD as well as further research directions.

Nasopharyngeal fungal subtypes of infant bronchiolitis and disease severity risk

Bronchiolitis is a leading cause of infant hospitalization. Recent research suggests the heterogeneity within bronchiolitis and the relationship of airway viruses and bacteria with bronchiolitis severity. However, little is known about the pathobiological role of fungi. We aimed to identify bronchiolitis mycotypes by integrating fungus and virus data, and determine their association with bronchiolitis severity and biological characteristics. In a multicentre prospective cohort study of 398 infants (age <1 year, male 59%) hospitalized for bronchiolitis, we applied clustering approaches to identify mycotypes by integrating nasopharyngeal fungus (detected in RNA-sequencing data) and virus data (respiratory syncytial virus [RSV], rhinovirus [RV]) at hospitalization. We examined their association with bronchiolitis severity-defined by positive pressure ventilation (PPV) use and biological characteristics by nasopharyngeal metatranscriptome and transcriptome data. In infants hospitalized for bronchiolitis, we identified four mycotypes: A) fungiM.restrictavirusRSV/RV, B) fungiM.restrictavirusRSV, C) fungiM.globosavirusRSV/RV, D) funginot-detectedvirusRSV/RV mycotypes. Compared to mycotype A infants (the largest subtype, n=211), mycotype C infants (n=85) had a significantly lower risk of PPV use (7% vs. 1%, adjOR, 0.21; 95% CI, 0.02-0.90; p=0.033), while the risk of PPV use was not significantly different in mycotype B or D. In the metatranscriptome and transcriptome data, mycotype C had similar bacterial composition and microbial functions yet dysregulated pathways (e.g., Fc γ receptor-mediated phagocytosis pathway and chemokine signaling pathway; FDR <0.05). In this multicentre cohort, fungus-virus clustering identified distinct mycotypes of infant bronchiolitis with differential severity risks and unique biological characteristics. This study was supported by the National Institutes of Health.

Suspicion of a teenager with Duchenne disease in the pediatrics department of Sainte Thérèse De Hinche Hospital

Duchenne disease is caused by a deletion of the gene coding for dystrophin. The absence of this protein is responsible for the myonecrosis observed during the evolution of the pathology. It is X-linked recessive which explains its occurrence, especially in boys. The manifestation of the disease begins in 3 years - 5 years, and the life expectancy is 20 years - 30 years. In the classic clinic, we have gait disorders, kyphoscoliosis, pseudo hypertrophy of the calves, and a positive Gower’s sign. Cardiorespiratory impairment is often incriminated as the cause of death in these patients. Management is based on physiotherapy and corticosteroid therapy. In the event of a cardio-respiratory manifestation, the use of positive pressure ventilation, and anti-hypertensives such as ACE inhibitors and beta-blockers may be necessary. We will discuss the 10 years old patients who present with the classic symptoms of Duchenne disease and how we managed it in a low-income country.

Factors associated with non-invasive positive pressure ventilation failure in a COVID-19 intermediate care unit

BackgroundThe use of non-invasive positive pressure ventilation (NIPPV) in COVID-19 patients with hypoxaemia is still under debate. The aim was to evaluate the efficacy of NIPPV (CPAP, HELMET-CPAP or NIV) in COVID-19 patients treated in the dedicated COVID-19 Intermediate Care Unit of Coimbra Hospital and University Centre, Portugal, and to assess factors associated with NIPPV failure.MethodsPatients admitted from December 1st 2020 to February 28th 2021, treated with NIPPV due to COVID-19 were included. Failure was defined as orotracheal intubation (OTI) or death during hospital stay. Factors associated with NIPPV failure were included in a univariate binary logistic regression analysis; those with a significance level of p < 0.001 entered a multivariate logistic regression model.ResultsA total of 163 patients were included, 64.4% were males (n = 105). The median age was 66 years (IQR 56–75). NIPPV failure was observed in 66 (40.5%) patients, 26 (39.4%) were intubated and 40 (60.6%) died during their hospital stay. The highest CRP (OR 1.164; 95%CI 1.036–1.308) and morphine use (OR 24.771; 95%CI 1.809–339.241) were identified as predictors of failure after applying multivariate logistic regression. Adherence to prone positioning (OR 0.109; 95%CI 0.017–0.700) and a higher value of the lowest platelet count during hospital stay (OR 0.977; 95%CI 0.960–0.994) were associated with a favorable outcome.ConclusionsNIPPV was successful in over half of patients. Highest CRP during hospital stay and morphine use were predictors of failure. Adherence to prone positioning and a higher value of the lowest platelet count during hospital stay were associated with a favourable outcome.

COVID-19 severity appears to be reduced in spring/summer.

because of different human behaviours, SARS-CoV-2 spread may be lower in spring/summer. On the contrary, it is not clearly known whether the clinical course/severity of hospitalized patients infected by SARS-CoV-2 can be different in the various seasons.. to understand whether there were differences in severity of COVID-19 in patients who had contracted the infection in winter versus those infected in spring/summer. observational retrospective cohort study. from the administrative database of the SARS-CoV-2 surveillance system and that of hospital discharge, a cohort of patients (8,221, 653 of which were hospitalized) who tested positive to the RT-PCR test for SARS-CoV-2 between 01.12.2020 and 31.07.2021 in the Grosseto province (Tuscany Region, Central Italy) was selected and analysed. hospitalization rate and length, continuous positive airway pressure (CPAP) or non-invasive ventilation (NIV) use, Intensive Care Unite (ICU) admissions, intra-hospital mortality and PaO2/FiO2 values were measured and compared between subjects infected in winter and those who developed COVID-19 in spring/summer. Viral load (cycle threshold, Ct), vitamin D, serum ferritin, IL-6, procalcitonin, D-dimer, and C-reactive protein measured in the two periods were also compared. in the considered months, the hospitalization rate among 8,221 patients with COVID-19 was 8%: 370 (8.5%) individuals were hospitalized in winter and 283 (7,3%; p=0.31) in spring/summer; 62 (16.8%), 88 (23.8%), and 63 (17%) in winter and 28 (9.9%), 40 (14.1%), and 36 (12.7%) in spring/summer were admitted in ICU (p=0.01), used CPAP/NIV (p=0.002) and died (p=0.13), respectively. Hospitalization days were 14.5±11.6 in winter and 10.3±8.84 in spring/summer (p=0.001), while minimum PaO2/FiO2, measured during hospital stays was 123.2±38.6 in spring/summer and 112.6±40.8 in winter (p=0.054). Multivariate analysis (adjusted for all confounding factors) also confirmed reduced risks of having ICU admissions (0.53; 95%CI 0.32;0.88; p=0.01) and of using CPAP/NIV (0.48; 95%CI 0.32;0.75; p=0.001) in spring/summer when compared to winter. Hospitalization days and minimum PaO2/FiO2 were also lower in spring/summer (β= -3.9; 95%CI -5.5;-2.2; p=0.001) and winter (β= -17; 95%CI -0.93;35; p=0.06), respectively. The adjusted hazard ratio of mortality in winter, obtained with a Cox model, was higher of about 38% compared to spring/summer. No Ct values (viral load) differences were found either in winter (19.45±6.18) or spring/summer (20.3±6.7; p=0.343). IL-6, ferritin, procalcitonin, D-dimer were similar. Conversely, CRP was lower whereas vitamin D was higher in the warmer seasons. COVID-19 may be less severe during spring/summer in hospitalized patients. This does not seem to be influenced by different SARS-CoV-2 viral load in the different periods considered. C-reactive protein was found to be lower whereas vitamin D higher in the warmer months. It can be hypothesized that higher levels of vitamin D in spring/summer, compared to winter, may be associated to a positive modulation of COVID-19 induced inflammation with a possible disease severity reduction during spring/summer.

Transition of Extremely Preterm Infants from Birth to Stable Breathing: A Secondary Analysis of the CORSAD Trial

Objective: Exploratory secondary analysis of the CORSAD trial compared a new resuscitation system (rPAP) to the standard T-piece system. This analysis focused on the subgroup of infants who were not intubated in the delivery room. The aim was to compare the use of noninvasive positive pressure ventilation (PPV), oxygen saturation, and Apgar scores for the two resuscitation systems during the 30-min intervention period. Methods: This is secondary analysis of CORSAD trial using data from the intervention period in the delivery room. Infants in the original randomized system groups were divided into intubated and nonintubated groups. For nonintubated breathing infants, we compared demographics, the use of PPV, Apgar scores, and oxygen saturation at 5 and 10 min after birth. Generalized linear models were applied to calculate the risk difference and odds ratio with 95% CI between the two groups. Results: Among nonintubated infants, the use of PPV repeatedly (defined as PPV with at least 1 min of spontaneous breathing between PPV cycles) was less frequent in the rPAP group (26.8% vs. 43.3%, %RD −16.5, 95% CI [−31.7 to −1.1], p 0.04). The use of PPV after 5 min of age was also less common in the rPAP group (23.2% vs. 38.8%, %RD −15.6, 95% CI [−30.7 to −0.8], p 0.04). There were no statistically significant differences in Apgar scores or oxygen saturation levels between the groups. Conclusion: In the CORSAD trial, less PPV was needed to establish stable breathing in extremely preterm infants using the rPAP compared to using the standard T-piece without significant difference in Apgar scores or oxygenation.

34: COMPARISON OF STRAIN AND CONVENTIONAL ECHOCARDIOGRAPHY IN PREDICTING ICU NEEDS IN MIS-C

Introduction: Multisystem Inflammatory Syndrome in Children (MIS-C) after SARS-CoV-2 infection is often complicated by ventricular dysfunction. Our prior work suggests that strain echocardiography (SE) detects abnormalities in cardiac function in ICU patients unrecognized by conventional echocardiography (CE). This study compares the relative strengths of CE and SE in predicting needs for ICU level therapies in MIS-C patients. Methods: A retrospective, single center analysis was performed on patients admitted to a quaternary-care children’s hospital with the diagnosis of MIS-C from March 2020 to January 2022. Only patients with CE and SE measured prior to initiation of vasoactives were included. Abnormal LVEF was defined as < 55% and abnormal strain as <= -17.2%. Clinical metrics included use of positive pressure ventilation (PPV), vasoactives, or any ICU level care. Results: Of 90 patients diagnosed with MIS-C, median LVEF was normal in both normal (64.0%) and abnormal strain (57.2%) groups. We found 97.6% of patients with normal strain had normal LVEF but only 57.1% of those with normal LVEF had normal strain. Median LVEF was normal in both those who did and did not require ICU level care (63% vs 57.1%), and those who did and did not require vasoactives (62.4% vs 56.5%). Strain was abnormal in patients who required ICU level care, PPV, and vasoactives (-13.8%, -12.9%, -13.8% respectively), compared to those who did not (all -19.3%, p all < 0.001). Sensitivity analysis showed strain was superior to LVEF in identifying need for ICU level care (75.8% vs 39%), PPV (88% vs 48%), and vasoactives (90% vs 55%). Negative predictive value of strain was superior to LVEF for similar outcomes (ICU level care (80.9% vs 72%), PPV (92.7% vs 81.9%) and vasoactives (95.1% vs 87.2%)). Conclusions: We demonstrate that SE detects abnormalities in cardiac function in MIS-C patients unrecognized by CE. In both ICU and non-ICU patients, we found compared to LVEF, detection of abnormal strain better identifies patients who will need ICU level therapies. Similarly, a measurement of normal strain is superior to a normal LVEF in predicting those who will not need these interventions.

1238: ASSOCIATION OF LEFT VENTRICULAR DIASTOLIC DYSFUNCTION WITH RESPIRATORY FAILURE IN PEDIATRIC SEPSIS

Introduction: Left ventricular diastolic dysfunction (LVDD) is associated with longer mechanical ventilation and increased mortality in adults with sepsis. The significance of LVDD in pediatric sepsis is not well characterized. We prospectively evaluated the prevalence of LVDD in pediatric sepsis patients and hypothesized that LVDD is associated with development of respiratory failure (primary outcome), use of non-invasive positive pressure ventilation (NIPPV), vasopressor/inotrope requirement, PICU length of stay (LOS), and mortality (secondary outcomes). Methods: This is an interim analysis of a prospective study of pediatric patients with severe sepsis or septic shock in a quaternary non-cardiac PICU. Goal enrollment is 120 patients. Point-of-care cardiac ultrasound (POCUS) images were obtained for mitral inflow (E), atrial (A), early mitral annular motion septal and lateral (e’) velocities within 48 hours of sepsis onset by PICU providers. LVDD was defined as E/e’ >10 or E/A < 0.8 or >1.5. Respiratory failure was defined as PaO2:FiO2 ratio < 300 or SpO2:FiO2 ratio < 264 at 48-96 hours after sepsis onset. Fisher’s exact and Wilcoxon rank-sum tests were utilized to compare patients with and without LVDD. Results: 42 patients have been enrolled. Secondary cardiologist review of POCUS images deemed that 70% were of acceptable quality for inclusion, yielding 37 evaluable patients. 19 (51%) patients met LVDD criteria. Among patients with LVDD vs without LVDD, there was no difference in age (8.2 vs 6.5 years; p=0.58), admission risk of mortality (PIM2 %ROM median 4.1, IQR [3.1,5.6] vs 4.7 [1.3,5.4]; p=0.82), or vasopressor support at the time of study (84% vs 83%; p=1). LVDD was associated with subsequent respiratory failure (47% with LVDD vs 11% without LVDD; p=0.03), however not with NIPPV use (53% vs 33%; p=0.33), vasopressor/inotrope requirement (84% vs 94%; p=0.34), PICU LOS (5 [3,9.5] vs 4.5 [3,8.3] days; p=0.52) or mortality (5% vs 0%; p=1). Conclusions: Half of children with sepsis exhibited LVDD on POCUS evaluation. This interim analysis suggests that LVDD may be associated with the development of hypoxemic respiratory failure but not NIPPV use, vasopressor/inotrope requirement, PICU LOS, or mortality.

Comparison Between Continuous Positive Airway Pressure and High-Flow Nasal Cannula as Postextubation Respiratory Support in Neonates: A Systematic Review and Meta-Analysis.

The interest in noninvasive respiratory support has been increasing, including continuous positive airway pressure and recent respiratory methods, namely high-flow nasal cannula. It is discussed if high-flow nasal cannula can reduce continuous positive airway pressure or invasive ventilation use. This systematic review and meta-analysis aimed to compare continuous positive airway pressure and high-flow nasal cannula as postextubation respiratory support in neonates. A literature search, based on Preferred Reporting of Items of Systematic Reviews and Meta-Analyses guidelines, was conducted across MEDLINE (through PubMed), Scopus, and Web of Science in 15 years (2006-2021) assessing randomized controlled trials that compared continuous positive airway pressure with high-flow nasal cannula as postextubation interventions in neonates. The primary outcome was extubation failure at 72 hours and/or at 7 days and the secondary outcomes included air leak syndrome, pneumothorax, bronchopulmonary dysplasia, nasal trauma, abdominal distension, and mortality. Seven studies were included, comprising 1044 neonates. No statistically significant differences were found between high-flow nasal cannula and continuous positive airway pressure in extubation failure (at 72 hours and 7 days), air leak syndrome, pneumothorax, bronchopulmonary dysplasia, abdominal distension, and mortality. High-flow nasal cannula was associated with a lower incidence of nasal trauma (odds ratio = 0.21; 95% CI 0.08-0.52; P = .0008). Studies assessing extreme premature infants (<28 weeks) raised some efficacy and safety concerns. High-flow nasal cannula may be as effective and safe as continuous positive airway pressure, with similar extubation failure and risk of air leak syndrome, pneumothorax, bronchopulmonary dysplasia, abdominal distension, and mortality with the advantage of less nasal trauma. High-flow nasal cannula should be considered as an alternative to continuous positive airway pressure in postextubation settings in neonates. Further studies are needed to establish efficacy and safety in lower gestational ages.

Comprehensive Imaging Review of Pleural Fistulas from Diagnosis to Management.

Pleural fistula is an abnormal communication between the pleural cavity and an adjacent structure. The interplay of anatomic and physiologic factors including proximity to various intrathoracic structures, deep pleural recesses, and negative pleural pressures makes the pleura an easy victim of fistulization. Iatrogenic creation followed by necrotizing infections and malignancies are the most common causes. While the overall incidence and size of postsurgical pleural fistulas are decreasing with increased adoption of vascularized flaps for high-risk resections, the smaller fistulas that develop in the setting of post-radiation therapy changes, with necrotizing infections in immunosuppressed patients, and with use of newer antiangiogenic chemotherapies can be challenging to visualize directly. Imaging signs in clinical practice are often subtle and indirect. Multimodality imaging and biochemical pleural fluid analysis can offer important adjunctive information when a diagnosis is only suggested with the first imaging study. Certain pleural fistulas are inconsequential, some spontaneously close with or without diversion of flow or use of positive-pressure ventilation, while others carry a higher risk of complications or recurrence. Estimated fistula size, factors that impair healing, and the possibility of diversion are important considerations when deciding between endoscopic or surgical closure. The authors have tailored this article for a general imager or clinical practitioner and review 10 types of pleural fistulas, ranging from routine to rare, with regard to their etiology, pathophysiology, clinical cues, imaging features, nuances of pleural fluid analysis, and management options available today. ©RSNA, 2022.

A POTENTIALLY UNDER-RECOGNIZED COMPLICATION OF POSITIVE PRESSURE VENTILATION: ACUTE HYPOCALCEMIA

A POTENTIALLY UNDER-RECOGNIZED COMPLICATION OF POSITIVE PRESSURE VENTILATION: ACUTE HYPOCALCEMIA

CPAP USE IN PATIENTS WITH OSA AND HEART FAILURE WITH REDUCED EJECTION FRACTION: INSIGHT FROM NATIONAL INPATIENT SAMPLE DATABASE (2011-2018)

CPAP USE IN PATIENTS WITH OSA AND HEART FAILURE WITH REDUCED EJECTION FRACTION: INSIGHT FROM NATIONAL INPATIENT SAMPLE DATABASE (2011-2018)