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Shkurka E, Wray J, Peters M, Shannon H. Chest Physiotherapy for Mechanically Ventilated Children: A Systematic Review. J Pediatr Intensive Care 2024; 13:109-118. [PMID: 38919696 PMCID: PMC11196142 DOI: 10.1055/s-0041-1732448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/12/2021] [Indexed: 10/20/2022] Open
Abstract
The aim of this study was to appraise and summarize the effects of chest physiotherapy in mechanically ventilated children. A systematic review was completed by searching Medline, Embase, Cinahl Plus, PEDro, and Web of Science from inception to February 9, 2021. Studies investigating chest physiotherapy for mechanically ventilated children (0-18 years), in a pediatric intensive care unit were included. Chest physiotherapy was defined as any intervention performed by a qualified physiotherapist. Measurements of effectiveness and safety were included. Exclusion criteria included preterm infants, children requiring noninvasive ventilation, and those in a nonacute setting. Thirteen studies met the inclusion criteria: two randomized controlled trials, three randomized crossover trials, and eight observational studies. The Cochrane risk of bias and the Critical Appraisal Skills Program tools were used for quality assessment. Oxygen saturations decreased after physiotherapy involving manual hyperinflations (MHI) and chest wall vibrations (CWV). Although statistically significant, these results were not of clinical importance. In contrast, oxygen saturations improved after the expiratory flow increase technique; however, this was not clinically significant. An increase in expiratory tidal volume was demonstrated 30 minutes after MHI and CWV. There was no sustained change in tidal volume following a physiotherapy-led recruitment maneuver. Respiratory compliance and dead-space increased immediately after MHI and CWV. Atelectasis scores improved following intrapulmonary percussive ventilation, and MHI and CWV. Evidence to support chest physiotherapy in ventilated children remains inconclusive. There are few high-quality studies, with heterogeneity in interventions and populations. Future studies are required to investigate multiple physiotherapy interventions and the impact on long-term outcomes.
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Affiliation(s)
- Emma Shkurka
- Physiotherapy Department, Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Jo Wray
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Mark Peters
- Infection, Immunity and Inflammation Department, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Harriet Shannon
- Infection, Immunity and Inflammation Department, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
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Reis N, Gaspar LJ, Paiva A, Pereira F, Sousa P, Machado N. Strategy nursing in children with compromised ventilation: Umbrella review. J Pediatr Nurs 2023; 73:137-156. [PMID: 37690429 DOI: 10.1016/j.pedn.2023.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 08/28/2023] [Accepted: 08/28/2023] [Indexed: 09/12/2023]
Abstract
PROBLEM Changes in the ventilation demand nursing interventions duly adapted to the management of said impairment and to the adaptability of the child/parents. This revision aimed to investigate the evidence behind the interventions performed on children with impaired ventilation.' ELIGIBILITY CRITERIA Systematic reviews of literature in English, Spanish, French, and Portuguese from studies on nursing interventions related to children with impaired ventilation in all contexts of the clinical practice. The Joanna Briggs Institute recommendations were followed. SAMPLE We conducted a comprehensive search as of January 2022 and updated as of June 2023. The following electronic databases were searched: SCOPUS, Web of Science, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, MEDLINE (via PubMed), CINAHL (via EBSCO), MedicLatina (via EBSCO), The Cochrane Database of Systematic Reviews (via EBSCO), and Database of Abstracts of Reviews of Effects (DARE). Nineteen articles published between 2012 and 2022 were included in this review. RESULTS Nineteen studies investigated the efficacy of respiratory exercises (Breathing Control - relaxed breathing, pursed lip breathing, Diaphragmatic breathing exercises, respiratory expansion exercise - deep breathing exercise, thoracic expansion exercises (with device), exercises for respiratory muscle strengthening and position to optimize ventilation. In the majority of the studies, it was not possible to evaluate the interventions separately. Thirteen studies evidenced the efficacy of respiratory exercises, BIPAP, and oxygen therapy. Seven articles demonstrated the effectiveness of respiratory muscle-strengthening exercises, and only three mentioned the efficacy of positioning regarding impaired ventilation. Interventions based on respiratory exercises and respiratory muscle training were the most common ones. CONCLUSIONS The results suggest that nursing interventions to optimize ventilation are efficient. Nevertheless, the same present a low to moderate evidence degree, justified by the population characteristics (small and heterogeneous). IMPLICATIONS There is proof of evidence for the studied interventions. However, the lack of methodological robustness points to future research to duly describe interventions, data, and comparable results, using reliable samples in which the focus of the study is clear.
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Affiliation(s)
- Neuza Reis
- Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), 1900-160 Lisbon, Portugal; Rehabilitation Nurse, CHULC, Portugal.
| | - Luís Jorge Gaspar
- RN Centro Hospitalar Universitário S. Joao, 4200-319 Porto, Portugal
| | - Abel Paiva
- NursingOntos, Escola Superior de Enfermagem do Porto, 4200-072, Portugal.
| | - Filipe Pereira
- NursingOntos, Escola Superior de Enfermagem do Porto, 4200-072, Portugal.
| | - Paula Sousa
- NursingOntos, Escola Superior de Enfermagem do Porto, 4200-072, Portugal.
| | - Natália Machado
- NursingOntos, Escola Superior de Enfermagem do Porto, 4200-072, Portugal.
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Shkurka E, Wray J, Peters MJ, Shannon H. Chest physiotherapy for mechanically ventilated children: a survey of current UK practice. Physiotherapy 2022; 119:17-25. [PMID: 36706622 DOI: 10.1016/j.physio.2022.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 11/02/2022] [Accepted: 11/12/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Chest physiotherapy is a treatment option for mechanically ventilated children. However, there is a lack of consensus regarding its value and informal discussions suggest variation in practice. This study describes chest physiotherapy practices for mechanically ventilated children in the UK and explores clinical decision making related to its delivery. DESIGN Cross-sectional study, using an anonymous, electronic survey. PARTICIPANTS Qualified physiotherapists working in UK NHS paediatric intensive care units (PICUs). RESULTS The response rate was 61% (72/118), this included physiotherapists from 26/27 (96%) PICUs. All participants reported using manual hyperinflations and position changes 'always' or 'often'. Variation in practice was evident for some techniques, including Metaneb® and percussion. DNase (99%, 71/72) and hypertonic saline (90%, 65/72) were the most frequently used mucoactives: 91% (59/65) of physiotherapists reported only nebulising hypertonic saline and 69% (49/71) use both nebulised and instilled DNase. Use and delivery of N-acetylcysteine was inconsistent (nebulised only 55%, 26/47; instilled only 15%, 7/47; both 30%, 14/47). Chest physiotherapy was most commonly delivered with a nurse (67%, 48/72). Clinical decision making processes were comparable between physiotherapists and encompassed three main elements: individual patient assessment, involvement of the multidisciplinary team, and risk versus benefit analysis. CONCLUSIONS A range of chest physiotherapy treatments and adjuncts were used with ventilated children. Variation was apparent and may be due to individual preferences of those training staff or local policies. Pragmatic, interventional studies are required to determine best practice. Further exploration is necessary to understand the variation in practice and intricacies of decision making.
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Affiliation(s)
- Emma Shkurka
- Physiotherapy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; Infection, Immunity & Inflammation Department, UCL Great Ormond Street Institute of Child Health, London, UK.
| | - Jo Wray
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Mark J Peters
- Infection, Immunity & Inflammation Department, UCL Great Ormond Street Institute of Child Health, London, UK; Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Harriet Shannon
- Infection, Immunity & Inflammation Department, UCL Great Ormond Street Institute of Child Health, London, UK
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Rodrigues-Gomes RM, Martí JD, Rolán RM, Gelabert-González M. Rapid chest compression effects on intracranial pressure in patients with acute cerebral injury. Trials 2022; 23:312. [PMID: 35428364 PMCID: PMC9012060 DOI: 10.1186/s13063-022-06189-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 03/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with acute brain injury often require invasive mechanical ventilation, increasing the risk of developing complications such as respiratory secretions retention. Rapid chest compression is a manual chest physiotherapy technique that aims to improve clearance of secretions in these patients. However, the rapid chest compression technique has been suggested to be associated with increased intracranial pressure in patients with acute brain injury. The aim of this work is to elucidate the effects of the technique on intracranial pressure in mechanically ventilated patients with acute brain injury. Furthermore, the effects of the technique in different volumes and flows recorded by the ventilator and the relationship between the pressure applied in the intervention group and the different variables will also be studied. METHODS Randomized clinical trial, double-blinded. Patients with acute brain injury on invasive mechanical ventilation > 48 h will be included and randomized in two groups. In the control group, a technique of passive hallux mobilization will be applied, and in the intervention group, it will be performed using the rapid chest compression technique. Intracranial pressure (main variable) will be collected with an intracranial pressure monitoring system placed at the lateral ventricles (Integra Camino). DISCUSSION The safety of chest physiotherapy techniques in patients at risk of intracranial hyperpressure is still uncertain. The aim of this study is to identify if the rapid manual chest compression technique is safe in ventilated patients with acute brain injury. TRIAL REGISTRATION NCT03609866 . Registered on 08/01/2018.
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Luadsri T, Boonpitak J, Pongdech-Udom K, Sukpom P, Chidnok W. Immediate effects of manual hyperinflation on cardiorespiratory function and sputum clearance in mechanically ventilated pediatric patients: A randomized crossover trial. Hong Kong Physiother J 2021; 42:15-22. [PMID: 35782699 PMCID: PMC9244603 DOI: 10.1142/s1013702522500020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 08/24/2021] [Indexed: 11/18/2022] Open
Abstract
Background: In developing countries, lower respiratory tract infection is a major cause of death in children, with severely ill patients being admitted to the critical-care unit. While physical therapists commonly use the manual hyperinflation (MHI) technique for secretion mass clearance in critical-care patients, its efficacy has not been determined in pediatric patients. Objective: This study investigated the effects of MHI on secretion mass clearance and cardiorespiratory responses in pediatric patients undergoing mechanical ventilation. Methods: A total of 12 intubated and mechanically ventilated pediatric patients were included in this study. At the same time of the day, the patients received two randomly ordered physical therapy treatments (MHI with suction and suction alone) from a trained physical therapist, with a washout period of 4 h provided between interventions. Results: The MHI treatment increased the tidal volume [Vt; 1.2 mL/kg (95% CI, 0.8–1.5)] and static lung compliance [Cstat; 3.7 mL/cmH2O (95% CI, 2.6–4.8)] immediately post-intervention compared with the baseline (p<0.05). Moreover, the MHI with suction induced higher Vt [1.4 mL/kg (95% CI, 0.8–2.1)] and Cstat [3.4 mL/cmH2O (95% CI, 2.1–4.7)] compared with the suction-alone intervention. In addition, the secretion mass [0.7 g (95% CI, 0.6–0.8)] was greater in MHI with suction compared with suction alone (p<0.05). However, there was no difference in peak inspiratory pressure, mean airway pressure, respiratory rate, heart rate, blood pressure, mean arterial blood pressure or oxygen saturation (p>0.05) between interventions. Conclusions: MHI can improve Vt, Cstat and secretion mass without inducing adverse hemodynamic effects upon the pediatric patients requiring mechanical ventilation.
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Affiliation(s)
- Tawatchai Luadsri
- Exercise and Rehabilitation Sciences Research Unit, Department of Physical Therapy, Faculty of Allied Health Sciences, Naresuan University, Pitsanulok, Thailand
| | - Jaturon Boonpitak
- Department of Physical Medicine and Rehabilitation, Lampang Hospital, Lampang, Thailand
| | | | - Patnuch Sukpom
- Pediatrics Intensive Care Unit, Lampang Hospital, Lampang, Thailand
| | - Weerapong Chidnok
- Exercise and Rehabilitation Sciences Research Unit, Department of Physical Therapy, Faculty of Allied Health Sciences, Naresuan University, Pitsanulok, Thailand
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Kawaguchi A, Bernier G, Adler A, Emeriaud G, Jouvet PA. Incremental effect of non-invasive oscillating device on chest physiotherapy in critically ill children: a cross-over randomised trial. BMJ Open 2020; 10:e038648. [PMID: 33020101 PMCID: PMC7537431 DOI: 10.1136/bmjopen-2020-038648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Chest physiotherapy (CPT) and intrathoracic percussion ventilation have been recognised as to encourage dislodging the secretions; nonetheless, the tolerance to the procedure and its efficiency have not been proven to be sufficient. METHOD AND ANALYSES This study aims to examine the tolerance, feasibility and physiological effects in airway clearance by using a novel extrathoracic non-invasive oscillating transducer device (NIOD) in critically ill children. A two-stage cross-over randomised controlled study in a paediatric intensive care unit in a Canadian Academic Children's Hospital will be applied. Children under 24 months old, for whom CPT is prescribed for airway clearance, will be included. The study consists of two stages; (1) Stage 1 'Frequency Level': we will apply two different frequencies of the NIOD (40 Hz vs 60 Hz) for 12 min each, on each patient 3 hours apart, and (2) Stage 2 'NIOD versus CPT': we will implement NIOD and CPT alternatingly for 3 hours apart. The order of the procedures will be randomly allocated for each case. We will compare the average Δchanges of tidal lung volume measured by a 3D imaging system and regional lung functions using electrical impedance tomography, between the two different frequencies and between the NIOD periods and the CPT periods. We will also examine tolerance by seeing COMFORT Scales and related complications during the procedures. We estimate necessary sample size as 6 for each arm (Total 12 cases) for stage 1 and 48 cases for Stage 2, with power of 0.8 and alpha of 0.05. ETHICS AND DISSEMINATION This study has been approved by the Health Research Ethics Board of University of Montreal, Canada (REB number: 2020-2471). We will disseminate our findings through peer-reviewed publications and conference presentations in paediatric or/and critical care fields. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT03821389).
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Affiliation(s)
- Atsushi Kawaguchi
- Pediatrics, University of Montreal, Montreal, Quebec, Canada
- Pediatrics, University of Ottawa, Children's Hospital Eastern Ontario, Ottawa, Ontario, Canada
| | - Gabrielle Bernier
- Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Andy Adler
- Systems and Computer Engineering, Carleton University, Ottawa, Ontario, Canada
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Pouzot-Nevoret C, Goy-Thollot I, Billet D, Barthélemy A, Blesch M, Pin A, Hopper K. Evaluation of a new chest physiotherapy technique in dogs with airway fluid accumulation hospitalized in an intensive care unit. J Vet Emerg Crit Care (San Antonio) 2018; 28:213-220. [PMID: 29645400 DOI: 10.1111/vec.12713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 08/26/2016] [Accepted: 11/02/2016] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To evaluate the feasibility, benefits, and adverse effects of prolonged slow expiration (PSE) and assisted cough (AC) as chest physiotherapy (CP) techniques in dogs with airway fluid accumulation. DESIGN Prospective interventional study. SETTINGS University teaching hospital. ANIMALS Intervention group of 30 client-owned dogs and retrospective control group of 71 client-owned dogs. INTERVENTIONS PSE was performed on dogs with evidence of airway fluid accumulation, identified based on physical examination and thoracic radiographs. AC was performed if spontaneous cough or swallowing were not evident. The PSE treatment was performed every 6 hours until normalization of respiratory status or hospital discharge. Animals were monitored for respiratory distress, discomfort, and SpO2 during the procedure. A retrospective control group was identified by computer search. MEASUREMENTS AND MAIN RESULTS One hundred thirty-three sessions of CP were performed on 30 dogs. Discomfort frequency during physiotherapy was low (9%). The most commonly used position for CP was in lateral recumbency (95%) and this was well tolerated in most cases. There was no significant difference in the median SpO2 before and after CP sessions (P = 0.24). Sixty percent of sessions had a spontaneous cough or swallowing evident, 21% had successful AC performed, and no cough or swallowing occurred in the remaining (19%) sessions despite attempts of AC being made. The length of hospitalization was significantly longer in the intervention group (6 days vs 4) (P = 0.02). There was no difference in survival between the intervention (76.7%) and the control (57.7%) group (P = 0.055). CONCLUSIONS PSE associated with AC are easily adaptable, well-tolerated techniques in dogs. The benefit of CP in dogs with airway fluid accumulation remains to be determined and it is hoped that future randomized controlled prospective studies may help answer this line of inquiry.
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Affiliation(s)
- Céline Pouzot-Nevoret
- Intensive Care Unit (SIAMU).,APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis
| | - Isabelle Goy-Thollot
- Intensive Care Unit (SIAMU).,APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis
| | | | - Anthony Barthélemy
- Intensive Care Unit (SIAMU).,APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis.,VetAgro-Sup campus vétérinaire de Lyon, Université de Lyon, Marcy l'Etoile, France; IKARE, 18 rue du Prof. Joseph Nicolas, Lyon, France
| | | | | | - Kate Hopper
- Department of Veterinary Surgical and Radiological Sciences, University of California Davis, CA
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Beningfield A, Jones A. Peri-operative chest physiotherapy for paediatric cardiac patients: a systematic review and meta-analysis. Physiotherapy 2017; 104:251-263. [PMID: 29361296 DOI: 10.1016/j.physio.2017.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 08/19/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Chest physiotherapy (CPT) is implemented before and after congenital heart disease (CHD) surgery in paediatrics to prevent and treat postoperative pulmonary complications (PPC). Currently, there are no systematic reviews or meta-analyses on the efficacy of CPT in this population. OBJECTIVE To conduct a systematic review and meta-analysis to determine whether peri-operative CPT is safe and effective for paediatric patients with CHD. DATA SOURCES A literature search was conducted on PEDro, MEDLINE, CINAHL, Informit, The Cochrane Library and Scopus in March and April 2016. ELIGIBILITY CRITERIA English peer-reviewed articles that utilised CPT before or after cardiac surgery for paediatric CHD. Systematic reviews were excluded. DATA EXTRACTION AND SYNTHESIS Completed by two independent researchers using the Crowe Critical Appraisal Tool. Data were collated using a piloted data extraction tool. Mix Version 2.0.1.4 was used for meta-analysis, and data were extracted using an odds ratio (with a random effects model). RESULTS Eleven studies met the inclusion criteria for the systematic review. Variable results were found regarding the effect of CPT on peripheral oxygen saturation and pain. Meta-analysis showed that CPT did not prevent pneumonia (odds ratio (OR) 2.01; 95% confidence interval (CI) 0.80 to 5.05; P=0.13), and did not prevent or treat atelectasis (OR 1.27; 95% CI 0.18 to 8.87; P=0.81). LIMITATIONS There was a lack of high-quality studies. The included studies were comprised of heterogeneous treatment, limiting external validity. CONCLUSION Active therapies such as mobilisation, deep breathing and incentive spirometry were more effective than passive treatment. Percussion led to oxygen desaturation, and percussion, vibration and suctioning increased the risk of developing atelectasis. Systematic review registration number CRD42015024768.
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Affiliation(s)
- A Beningfield
- Discipline of Physiotherapy, College of Healthcare Sciences, James Cook University, Townsville, Australia.
| | - A Jones
- Discipline of Physiotherapy, College of Healthcare Sciences, James Cook University, Townsville, Australia
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Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC). Intensive Care Med 2017; 43:1764-1780. [PMID: 28936698 PMCID: PMC5717127 DOI: 10.1007/s00134-017-4920-z] [Citation(s) in RCA: 185] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/22/2017] [Indexed: 12/15/2022]
Abstract
Purpose Much of the common practice in paediatric mechanical ventilation is based on personal experiences and what paediatric critical care practitioners have adopted from adult and neonatal experience. This presents a barrier to planning and interpretation of clinical trials on the use of specific and targeted interventions. We aim to establish a European consensus guideline on mechanical ventilation of critically children. Methods The European Society for Paediatric and Neonatal Intensive Care initiated a consensus conference of international European experts in paediatric mechanical ventilation to provide recommendations using the Research and Development/University of California, Los Angeles, appropriateness method. An electronic literature search in PubMed and EMBASE was performed using a combination of medical subject heading terms and text words related to mechanical ventilation and disease-specific terms. Results The Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) consisted of a panel of 15 experts who developed and voted on 152 recommendations related to the following topics: (1) general recommendations, (2) monitoring, (3) targets of oxygenation and ventilation, (4) supportive measures, (5) weaning and extubation readiness, (6) normal lungs, (7) obstructive diseases, (8) restrictive diseases, (9) mixed diseases, (10) chronically ventilated patients, (11) cardiac patients and (12) lung hypoplasia syndromes. There were 142 (93.4%) recommendations with “strong agreement”. The final iteration of the recommendations had none with equipoise or disagreement. Conclusions These recommendations should help to harmonise the approach to paediatric mechanical ventilation and can be proposed as a standard-of-care applicable in daily clinical practice and clinical research. Electronic supplementary material The online version of this article (doi:10.1007/s00134-017-4920-z) contains supplementary material, which is available to authorized users.
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