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Flink RC, Newth CJL, Hotz JC, Kneyber MCJ, Ross PA, de Jongh FH, van Kaam AH, Khemani RG. Effort and work-of-breathing parameters strongly correlate with increased resistance in an animal model. Pediatr Res 2023; 94:944-949. [PMID: 36977768 DOI: 10.1038/s41390-023-02576-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 02/08/2023] [Accepted: 02/22/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Effort of Breathing (EOB) calculations may be a reliable alternative to Work of Breathing (WOB) calculations in which Respiratory Inductance Plethysmography (RIP) replaces spirometry. We sought to compare EOB and WOB measurements in a nonhuman primate model of increasing extrathoracic inspiratory resistance simulating upper airway obstruction (UAO). METHODS RIP, spirometry, and esophageal manometry were measured in spontaneously breathing, intubated Rhesus monkeys utilizing 11 calibrated resistors randomly applied for 2-min. EOB was calculated breath-by-breath as Pressure Rate Product (PRP) and Pressure Time Product (PTP). WOB was calculated from the Pressure-Volume curve based on spirometry (WOBSPIR) or RIP flow (WOBRIP). RESULTS WOB, PRP and PTP showed similar linear increases when exposed to higher levels of resistive loads. When comparing WOBSPIR to WOBRIP, a similar strong correlation was seen for both signals as resistance increased and there were no statistically significant differences. CONCLUSION EOB and WOB parameters utilizing esophageal manometry and RIP, independent of spirometry, showed a strong correlation as a function of increasing inspiratory resistance in nonhuman primates. This allows several potential monitoring possibilities for non-invasively ventilated patients or situations where spirometry is not available. IMPACT EOB and WOB parameters showed a strong correlation as a function of increasing inspiratory resistance in nonhuman primates. There was a strong correlation between spirometry-based WOB versus RIP-based WOB. To date, it has remained untested as to whether EOB is a reliable alternative for WOB and if RIP can replace spirometry in these measurements. Our results enable additional potential monitoring possibilities for non-invasively ventilated patients or situations where spirometry is not available. Where spirometry is not available, there is no need to apply a facemask post extubation to a spontaneously breathing, non-intubated infant to make objective EOB measurements.
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Affiliation(s)
- Rutger C Flink
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Christopher J L Newth
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Justin C Hotz
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital Groningen, University Medical Center Groningen, The University of Groningen, Groningen, The Netherlands
| | - Patrick A Ross
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Frans H de Jongh
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Robinder G Khemani
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Changes in lung volume estimated by electrical impedance tomography during apnea and high-flow nasal oxygenation: A single-center randomized controlled trial. PLoS One 2022; 17:e0273120. [PMID: 36170281 PMCID: PMC9518885 DOI: 10.1371/journal.pone.0273120] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/22/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Previous studies concerning humidified, heated high-flow nasal oxygen delivered in spontaneously breathing patients postulated an increase in functional residual capacity as one of its physiological effects. It is unclear wheter this is also true for patients under general anesthesia.
Methodology
The sincle-center noninferiority trial was registered at ClinicalTrials.gov (NCT NCT03478774). This secondary outcome analysis shows estimated differences in lung volume changes using electrical impedance tomography between different flow rates of 100% oxygen in apneic, anesthetized and paralyzed adults prior to intubation. One hundred and twenty five patients were randomized to five groups with different flow rates of 100% oxygen: i) minimal-flow: 0.25 l.min-1 via endotracheal tube; ii) low-flow: 2 l.min-1 + continuous jaw thrust; iii) medium-flow: 10 l.min-1 + continuous jaw thrust; iv) high-flow: 70l.min-1 + continuous jaw thrust; and v) control: 70 l.min-1 + continuous video-laryngoscopy. After standardized anesthesia induction with non-depolarizing neuromuscular blockade, the 15-minute apnea period and oxygen delivery was started according to the randomized flow rate. Continuous electrical impedance tomography measurements were performed during the 15-minute apnea period. Total change in lung impedance (an estimate of changes in lung volume) over the 15-minute apnea period and times to 25%, 50% and 75% of total impedance change were calculated.
Results
One hundred and twenty five patients completed the original study. Six patients did not complete the 15-minute apnea period. Due to maloperation, malfunction and artefacts additional 54 measurements had to be excluded, resulting in 65 patients included into this secondary outcome analysis. We found no differences between groups with respect to decrease in lung impedance or curve progression over the observation period.
Conclusions
Different flow rates of humidified 100% oxygen during apnea result in comparable decreases in lung volumes. The demonstrated increase in functional residual capacity during spontaneous breathing with high-flow nasal oxygenation could not be replicated during apnea under general anesthesia with neuromuscular blockade.
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Sequera-Ramos L, Garcia-Marcinkiewicz A, Riva T, Fuchs A. Noninvasive ventilation in children: A review for the pediatric anesthesiologist. Paediatr Anaesth 2022; 32:262-272. [PMID: 34877751 DOI: 10.1111/pan.14364] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 01/19/2023]
Abstract
Preserving adequate respiratory function is essential in the perioperative period. Mechanical ventilation with endotracheal intubation is widely used for this purpose. In select patients, noninvasive ventilation (NIV) may be an alternative to invasive ventilation or may complement respiratory management. NIV is used to provide ventilatory support and increase gas exchange at the alveolar level without the use of an invasive artificial airway such as an endotracheal tube or tracheostomy. NIV includes both continuous positive airway pressure (CPAP) and noninvasive positive pressure ventilation. Indications for NIV range from acute hypoxic respiratory failure in the intensive care unit or the emergency department, to chronic respiratory failure in patients with neuromuscular disease with nocturnal hypoventilation. In the perioperative setting, NIV is commonly applied as CPAP, and bilevel positive airway pressure (BPAP). There are limited data on the role of NIV in children in the perioperative setting, and there are no clear guidelines regarding optimal timing of use and pressure settings of perioperative NIV. Contraindications to the use of NIV include reduced level of consciousness, apnea, severe respiratory distress, and inability to maintain upper airway patency or airway protective reflexes. Common problems encountered during NIV involve airway leaks and asynchrony with auto-triggering. High-flow nasal oxygen (HFNO) has emerged as an alternative to NIV when trying to decrease the work of breathing and improve oxygenation in children. HFNO delivers humidified and heated oxygen at rates between 2 and 70 L/min using specific nasal cannulas, and flows are determined by the patient's weight and clinical needs. HFNO can be useful as a method for preoxygenation in infants and children by prolonging apnea time before desaturation, yet in children with decreased minute ventilation or apnea HFNO does not improve alveolar gas exchange. Clinicians experienced with these devices, such as pediatric intensivists and pulmonary medicine specialists, can be useful resources for the pediatric anesthesiologist caring for complex patients on NIV.
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Affiliation(s)
- Luis Sequera-Ramos
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Annery Garcia-Marcinkiewicz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Unit for Research & Innovation in Anaesthesia, Department of Paediatric Anaesthesia, Istituto Giannina Gaslini, Genoa, Italy
| | - Alexander Fuchs
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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A New Trick for an Old Dog: L-Epinephrine Delivered Continuously in the Vapor Phase. Crit Care Explor 2021; 3:e0541. [PMID: 34604784 PMCID: PMC8480938 DOI: 10.1097/cce.0000000000000541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Inhaled L-epinephrine is a known treatment of severe croup and postextubation upper airway obstruction. L-epinephrine can be delivered continuously in the vapor phase, but the indications, safety, and efficacy of this novel practice have yet to be evaluated. Theoretical risks are tachycardia, hypertension, and dysrhythmias. The study objective was to describe patient characteristics and vital sign changes related to continuous vaporized L-epinephrine use in critically ill children with the hypothesis that it can be practically and safely administered to children with subglottic edema and lower airway obstruction.
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Riva T, Meyer J, Theiler L, Obrist D, Bütikofer L, Greif R, Nabecker S. Measurement of airway pressure during high-flow nasal therapy in apnoeic oxygenation: a randomised controlled crossover trial . Anaesthesia 2020; 76:27-35. [PMID: 32776518 DOI: 10.1111/anae.15224] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2020] [Indexed: 12/19/2022]
Abstract
It is recognised that high-flow nasal therapy can prevent desaturation during airway management. Studies in spontaneously breathing patients show an almost linear relationship between flow rate and positive airway pressure in the nasopharynx. Positive airway pressure has been suggested as one of the possible mechanisms explaining how high-flow nasal therapy works. However, data on pressures generated by high-flow nasal therapy in apnoeic adults under general anaesthesia are absent. This randomised controlled crossover trial investigated airway pressures generated by different flow rates during high-flow nasal therapy in anaesthetised and paralysed apnoeic patients, comparing pressures with closed and open mouths. Following induction of anaesthesia and neuromuscular blockade, a continuous jaw thrust was used to enable airway patency. Airway pressure was measured in the right main bronchus, the middle of the trachea and the pharynx, using a fibreoptically-placed catheter connected to a pressure transducer. Each measurement was randomised with respect to closed or open mouth and different flow rates. Twenty patients undergoing elective surgery were included (mean (SD) age 38 (18) years, BMI 25.0 (3.3) kg.m-2 , nine women, ASA physical status 1 (35%), 2 (55%), 3 (10%). While closed mouths and increasing flow rates demonstrated non-linear increases in pressure, the pressure increase was negligible with an open mouth. Airway pressures remained below 10 cmH2 O even with closed mouths and flow rates up to 80 l.min-1 ; they were not influenced by catheter position. This study shows an increase in airway pressures with closed mouths that depends on flow rate. The generated pressure is negligible with an open mouth. These data question positive airway pressure as an important mechanism for maintenance of oxygenation during apnoea.
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Affiliation(s)
- T Riva
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Switzerland
| | - J Meyer
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Switzerland
| | - L Theiler
- Department of Anaesthesia, Kantonsspital Aarau, Switzerland
| | - D Obrist
- ARTORG Center for Biomedical Engineering Research, University of Bern, Switzerland
| | | | - R Greif
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Switzerland.,School of Medicine, Sigmund Freud University Vienna, Austria
| | - S Nabecker
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Switzerland.,Department of Anaesthesia and Pain Management, Sinai Health System, University of Toronto, Canada
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DiBlasi RM, Crotwell DN, Poli J, Hotz J, Cogen JD, Carter E. A pilot study to assess short-term physiologic outcomes of transitioning infants with severe bronchopulmonary dysplasia from ICU to two subacute ventilators. CANADIAN JOURNAL OF RESPIRATORY THERAPY : CJRT = REVUE CANADIENNE DE LA THERAPIE RESPIRATOIRE : RCTR 2018; 54:01. [PMID: 29636639 PMCID: PMC5875982 DOI: 10.29390/cjrt-2018-001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Introduction This study was designed to evaluate short-term physiologic outcomes of transitioning neonates with bronchopulmonary dysplasia (BPD) from intensive care unit (ICU) ventilators to both the Trilogy 202 (Philips Healthcare, Andover, MA) and LTV 1200 (CareFusion, Yorba Linda, CA) subacute ventilators. Methods Six infants with BPD requiring tracheostomies for support with a neonatal-specific ICU ventilator underwent placement of esophageal balloon catheters, airway pressure transducers, flow sensors, oxygen saturation (SpO2), and end tidal carbon dioxide (PETCO2) monitors. Noninvasive gas exchange, airflow, and airway and esophageal pressures (PES) were recorded following 20 min on the ICU ventilator. The infants were placed on the Trilogy 202 and LTV 1200 ventilators in random order at identical settings as the ICU ventilator. We measured noninvasive gas exchange, pressure-rate product (respiratory rate × ΔPES), ventilator response times, and the percentage of spontaneous breaths that triggered the ventilator at 20 min in each subject while being supported with each of the different subacute ventilators. Results The mean (SD) weight of the six infants was 4.983 (0.56) kg. There were no differences in heart rate (p = 0.51) or SpO2 (p = 0.97) but lower PETCO2, ΔPES, respiratory rate, pressure rate-product, response times, and greater percentage of subject initiated breaths that triggered the ventilator (p < 0.05) was observed with the Trilogy 202 than the LTV 1200. All six infants transitioned successfully from the ICU ventilator to the Trilogy 202 ventilator. Conclusion In this small group of infants with BPD, the Trilogy 202 ventilator performed better than the LTV 1200. The improved subject efforts, per cent subject triggering, and response times observed with the Trilogy are likely related to differences in triggering algorithms, location of triggering mechanisms, and gas delivery system performance within the ventilators. These pilot data may be useful for informing future clinical study design and understanding differences in the level of support provided by different subacute ventilators in infants with BPD.
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Affiliation(s)
- Robert M DiBlasi
- Center for Developmental Therapeutics, Seattle Children's Research Institute, Seattle, WA, USA.,Respiratory Care Department, Seattle Children's Hospital, Seattle, WA, USA
| | - Dave N Crotwell
- Respiratory Care Department, Seattle Children's Hospital, Seattle, WA, USA
| | - Jonathan Poli
- Center for Developmental Therapeutics, Seattle Children's Research Institute, Seattle, WA, USA
| | - Justin Hotz
- Respiratory Care Department, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Jonathan D Cogen
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, WA, USA
| | - Edward Carter
- Division of Pulmonary and Sleep Medicine, Banner Health, Phoenix, AZ, USA
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8
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Weiler T, Kamerkar A, Hotz J, Ross PA, Newth CJL, Khemani RG. The Relationship between High Flow Nasal Cannula Flow Rate and Effort of Breathing in Children. J Pediatr 2017; 189:66-71.e3. [PMID: 28669609 DOI: 10.1016/j.jpeds.2017.06.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 04/17/2017] [Accepted: 06/02/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To use an objective metric of effort of breathing to determine optimal high flow nasal cannula (HFNC) flow rates in children <3 years of age. STUDY DESIGN Single-center prospective trial in a 24-bed pediatric intensive care unit of children <3 years of age on HFNC. We measured the percent change in pressure∙rate product (PRP) (an objective measure of effort of breathing) as a function of weight-indexed flow rates of 0.5, 1.0, 1.5, and 2.0 L/kg/minute. For a subgroup of patients, 2 different HFNC delivery systems (Fisher & Paykel [Auckland, New Zealand] and Vapotherm [Exeter, New Hampshire]) were compared. RESULTS Twenty-one patients (49 titration episodes) were studied. The most common diagnoses were bronchiolitis and pneumonia. Overall, there was a significant difference in the percent change in PRP from baseline (of 0.5 L/kg/minute) with increasing flow rates for the entire cohort (P < .001) with largest change at 2.0 L/kg/min (-21%). Subgroup analyses showed no significant difference in percent change in PRP from baseline when comparing the 2 different HFNC delivery systems (P = .12). Patients ≤8 kg experienced a larger percent change in PRP as HFNC flow rates were increased (P = .001) than patients >8 kg. CONCLUSIONS The optimal HFNC flow rate to reduce effort of breathing in infants and young children is approximately 1.5-2.0 L/kg/minute with more benefit seen in children ≤8 kg.
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Affiliation(s)
- Thomas Weiler
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA.
| | - Asavari Kamerkar
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - Justin Hotz
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Patrick A Ross
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - Christopher J L Newth
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - Robinder G Khemani
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, University of Southern California, Keck School of Medicine, Los Angeles, CA
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Abstract
OBJECTIVES The Vapotherm system delivers high humidity to the airway of patients by using semipermeable tubules where heated liquid water is in contact with air. The humidified air is conducted to the patient via a heated tube. Preliminary clinical observations in infants with croup suggested that epinephrine added to the water supplying the humidity was delivered successfully in the vapor phase. The purpose of this study was to evaluate the efficiency of the delivery of epinephrine in the vapor phase and to develop the feasibility criteria for a clinical pilot study. DESIGN Thirty milligrams of epinephrine in a 1-L bag of sterile water was used as the humidification source for a Vapotherm 2000i. The output of the heated circuit was condensed and collected into a small Erlenmeyer flask via a metal coil while the whole collection system was submerged in an ice slurry to maintain the outflow temperature from the flask between 0°C and 2°C. The in vitro system was tested at 40°C with flows of 5, 10, and 15 L/min and L-epinephrine concentrations of 15, 30, and 60 mg/L. Each test was duplicated at each of the six conditions. SETTING Academic children's hospital research laboratory. PATIENTS None. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The system recovered more than 90% of the water vapor from the fully saturated air at 40°C. The epinephrine concentration recovery quantified by ultraviolet-visible spectrophotometry was 23.9% (27.5-20.4%) (mean and range) of the initial concentration. At flows of 5, 10, and 15 L/min, the delivery of epinephrine would be 1.8, 3.6, and 4.2 μg/min, respectively, which is in the therapeutic range used for parenteral infusion in young children. CONCLUSIONS The Vapotherm system can be used to deliver epinephrine in pharmacological doses to the respiratory system as a vapor and thus as an alternative to droplets by conventional nebulization.
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Pham TMT, O'Malley L, Mayfield S, Martin S, Schibler A. The effect of high flow nasal cannula therapy on the work of breathing in infants with bronchiolitis. Pediatr Pulmonol 2015; 50:713-20. [PMID: 24846750 DOI: 10.1002/ppul.23060] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 04/18/2014] [Indexed: 11/10/2022]
Abstract
The main physiological impact of high flow nasal cannula (HFNC) therapy is presumed to be a decrease in work of breathing (WOB). To assess this, diaphragmatic electrical activity and esophageal pressure changes were measured off then on HFNC delivered at 2 L/kg/min, in 14 infants with bronchiolitis and 14 cardiac infants. Electrical activity of the diaphragm (Edi) was measured using an Edi catheter with calculations of signal peak (EdiMAX ) and amplitude (EdiAMPL ). Pressure-rate and pressure-time products (PRP, PTP) were calculated from analyses of esophageal pressure. Changes in end-expiratory lung volume were measured using respiratory inductance plethysmography (RIPEEL ). The EdiMAX and EdiAMPL were significantly higher in infants with bronchiolitis than in cardiac infants (P < 0.05). Within the bronchiolitis group, both were significantly reduced between HFNC states from 27.9 µV [20.4, 35.4] to 21.0 µV [14.8, 27.2] and from 25.1 µV [18.0, 32.2] to 19.2 µV [13.3, 25.1], respectively (mean, 95% CI, P < 0.05). A less prominent offload of the diaphragm was observed in cardiac infants (P < 0.05). WOB decreased in both groups with a significant reduction of PRP and PTP (P < 0.05). RIPEEL increased significantly in bronchiolitis only (P < 0.05). HFNC offloads the diaphragm and reduces the WOB in bronchiolitis. A similar effect was demonstrated in cardiac infants, a group without signs of airway-obstruction.
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Affiliation(s)
- Trang M T Pham
- Paediatric Critical Care Research Group, Mater Research Institute, The University of Queensland, South Brisbane, QLD, 4101, Australia.,School of Electrical Engineering and Computer Science, Queensland University of Technology, Brisbane, QLD, 4000, Australia
| | - Lee O'Malley
- Paediatric Critical Care Research Group, Mater Research Institute, The University of Queensland, South Brisbane, QLD, 4101, Australia
| | - Sara Mayfield
- Paediatric Critical Care Research Group, Mater Research Institute, The University of Queensland, South Brisbane, QLD, 4101, Australia.,The School of Nursing and Midwifery, The University of Queensland, Brisbane, QLD, 4006, Australia
| | - Simon Martin
- Paediatric Critical Care Research Group, Mater Research Institute, The University of Queensland, South Brisbane, QLD, 4101, Australia
| | - Andreas Schibler
- Paediatric Critical Care Research Group, Mater Research Institute, The University of Queensland, South Brisbane, QLD, 4101, Australia
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Mayfield S, Jauncey‐Cooke J, Hough JL, Schibler A, Gibbons K, Bogossian F. High-flow nasal cannula therapy for respiratory support in children. Cochrane Database Syst Rev 2014; 2014:CD009850. [PMID: 24604698 PMCID: PMC6516984 DOI: 10.1002/14651858.cd009850.pub2] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Respiratory support is a central component of the management of critically ill children. It can be delivered invasively via an endotracheal tube or non-invasively via face mask, nasal mask, nasal cannula or oxygen hood/tent. Invasive ventilation can be damaging to the lungs, and the tendency to use non-invasive forms is growing. However, non-invasive delivery is often poorly tolerated by children. High-flow nasal cannula (HFNC) oxygen delivery is a relatively new therapy that shows the potential to reduce the need for intubation and be better tolerated by children than other non-invasive forms of support. HFNC therapy differs from other non-invasive forms of treatment in that it delivers heated, humidified and blended air/oxygen via nasal cannula at rates > 2 L/kg/min. This allows the user to deliver high concentrations of oxygen and to potentially deliver continuous distending pressure; this treatment often is better tolerated by the child. OBJECTIVES To determine whether HFNC therapy is more effective than other forms of non-invasive therapy in paediatric patients who require respiratory support. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 4); MEDLINE via PubMed (January 1966 to April 2013); EMBASE (January 1980 to April 2013); CINAHL (1982 to April 2013); and LILACS (1982 to April 2013). Abstracts from conference proceedings, theses and dissertations and bibliographical references to relevant studies were also searched. We applied no restriction on language. SELECTION CRITERIA We planned to included randomized controlled trials (RCTs) and quas-randomized trials comparing HFNC therapy with other forms of non-invasive respiratory support for children. Non-invasive support encompassed cot, hood or tent oxygen; low-flow nasal cannulae (flow rates ≤ 2 L/min); and continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) delivered via facial or nasal mask/cannula. Treatment failure was defined by the need for additional respiratory support. We excluded children with a diagnosis of bronchiolitis. DATA COLLECTION AND ANALYSIS Two review authors independently assessed all studies for selection and data extraction. We used standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS Our search yielded 922 records. A total of 109 relevant records were retrieved with reference to our search criteria. After duplicates and irrelevant studies were removed, 69 studies were further scrutinized. Of these, 11 studies involved children. No study matched our inclusion criteria. AUTHORS' CONCLUSIONS Based on the results of this review, no evidence is available to allow determination of the safety or effectiveness of HFNC as a form of respiratory support in children.
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Affiliation(s)
- Sara Mayfield
- Children’s Health Queensland Hospital and Health ServicePatient Safety and Quality ServiceRaymond TerraceSouth BrisbaneQueenslandAustralia4010
- The University of QueenslandSchool of Nursing, Midwifery and Social WorkSt LuciaAustralia
| | - Jacqueline Jauncey‐Cooke
- The University of QueenslandSchool of Nursing, Midwifery and Social WorkSt LuciaAustralia
- Mater Research Institute ‐ The University of QueenslandPaediatric Critical Care Research GroupSouth BrisbaneAustralia
- Children’s Health Queensland Hospital and Health ServiceLearning and Workforce DevelopmentSouth BrisbaneAustralia
| | - Judith L Hough
- Mater Research Institute, The University of Queensland, and The Physiotherapy Department, Mater Health ServicesProgram for Optimising Outcomes for Mothers and Babies at RiskSouth BrisbaneAustralia
- Australian Catholic UniversitySchool of PhysiotherapyBanyoQueenslandAustralia
| | - Andreas Schibler
- Mater Research Institute ‐ The University of QueenslandPaediatric Critical Care Research GroupSouth BrisbaneAustralia
| | - Kristen Gibbons
- Mater Research Institute ‐ The University of Queensland (MRI‐UQ)South BrisbaneQueenslandAustralia4101
| | - Fiona Bogossian
- The University of QueenslandSchool of Nursing, Midwifery and Social WorkSt LuciaAustralia
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Abstract
OBJECTIVE High-flow humidified nasal cannula is often used to provide noninvasive respiratory support in children. The effect of high-flow humidified nasal cannula on effort of breathing in children has not been objectively studied, and the mechanism by which respiratory support is provided remains unclear. This study uses an objective measure of effort of breathing (Pressure. Rate Product) to evaluate high-flow humidified nasal cannula in critically ill children. DESIGN Prospective cohort study. SETTING Quaternary care free-standing academic children's hospital. PATIENTS ICU patients younger than 18 years receiving high-flow humidified nasal cannula or whom the medical team planned to extubate to high-flow humidified nasal cannula within 72 hours of enrollment. INTERVENTIONS An esophageal pressure monitoring catheter was placed to measure pleural pressures via a Bicore CP-100 pulmonary mechanics monitor. Change in pleural pressure (ΔPes) and respiratory rate were measured on high-flow humidified nasal cannula at 2, 5, and 8 L/min. ΔPes and respiratory rate were multiplied to generate the Pressure.Rate Product, a well-established objective measure of effort of breathing. Baseline Pes, defined as pleural pressure at end exhalation during tidal breathing, reflected the positive pressure generated on each level of respiratory support. MEASUREMENTS AND MAIN RESULTS Twenty-five patients had measurements on high-flow humidified nasal cannula. Median age was 6.5 months (interquartile range, 1.3-15.5 mo). Median Pressure,Rate Product was lower on high-flow humidified nasal cannula 8 L/min (median, 329 cm H2O·min; interquartile range, 195-402) compared with high-flow humidified nasal cannula 5 L/min (median, 341; interquartile range, 232-475; p = 0.007) or high-flow humidified nasal cannula 2 L/min (median, 421; interquartile range, 233-621; p < 0.0001) and was lower on high-flow humidified nasal cannula 5 L/min compared with high-flow humidified nasal cannula 2 L/min (p = 0.01). Baseline Pes was higher on high-flow humidified nasal cannula 8 L/min than on high-flow humidified nasal cannula 2 L/min (p = 0.03). CONCLUSIONS Increasing flow rates of high-flow humidified nasal cannula decreased effort of breathing in children, with the most significant impact seen from high-flow humidified nasal cannula 2 to 8 L/min. There are likely multiple mechanisms for this clinical effect, including generation of positive pressure and washout of airway dead space.
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Schibler A, Pham TMT, Dunster KR, Foster K, Barlow A, Gibbons K, Hough JL. Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen delivery. Intensive Care Med 2011; 37:847-52. [DOI: 10.1007/s00134-011-2177-5] [Citation(s) in RCA: 210] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Accepted: 01/17/2011] [Indexed: 11/24/2022]
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The mechanics of breathing in children with acute severe croup. Intensive Care Med 2007; 34:324-32. [PMID: 18008061 DOI: 10.1007/s00134-007-0910-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2006] [Accepted: 09/26/2007] [Indexed: 10/22/2022]
Abstract
RATIONALE The assessment of the severity of croup and response to therapy has remained a clinical one. Despite recognition of the importance of a reproducible and easily applicable method for objectively measuring severity, currently, no such technique exists. OBJECTIVES We postulated that measurements of air flow and intrathoracic pressure changes in patients with severe croup would provide detailed information about the mechanics of breathing and the potential for the development of continuous bedside methods for objective monitoring of upper airway obstruction. METHODS Twenty out of 21 eligible infants and children with severe upper airway obstruction from croup, and 5 control participants, were studied under light sedation utilizing face masks and nasogastric feeding tubes for flow and esophageal pressure measurements. MEASUREMENTS AND MAIN RESULTS Children with croup had lower tidal volumes, but breathed faster, thus maintaining similar minute volumes to the controls. During inspiration, all but 2 croup patients (but no controls) displayed flow limitation. Area within the flow-volume curve was significantly decreased and minute ventilation for effort expended was nearly 4.5 times higher in croup patients than in controls. Peak-to-trough pleural pressure swings, pressure-rate product and pressure-time integral were also significantly higher than in controls (p<0.001) and returned to the normal range in the 9 patients who were subsequently intubated (p<0.001). CONCLUSIONS Patients with severe croup maintain minute ventilation by means of huge increases in intrathoracic pressure changes. Inspiratory flow limitation is present. In future outcome studies, measurements of respiratory function that do not include intrathoracic pressure changes are unlikely to be effective measures of the severity of croup.
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Graham AS, Chandrashekharaiah G, Citak A, Wetzel RC, Newth CJL. Positive end-expiratory pressure and pressure support in peripheral airways obstruction. Intensive Care Med 2006; 33:120-7. [PMID: 17111110 DOI: 10.1007/s00134-006-0445-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2005] [Accepted: 10/09/2006] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Children with peripheral airways obstruction suffer the negative effects of intrinsic positive end-expiratory pressure: increased work of breathing and difficulty triggering assisted ventilatory support. We examined whether external positive end-expiratory pressure to offset intrinsic positive end-expiratory pressure decreases work of breathing in children with peripheral airways obstruction. The change in work of breathing with incremental pressure support was also tested. DESIGN AND SETTING Prospective clinical trial in a pediatric intensive care unit. PATIENTS Eleven mechanically ventilated, spontaneously breathing children with peripheral airways obstruction. INTERVENTIONS Work of breathing (using pressure-rate product as a surrogate) was measured in three tiers: (a) Increasing pressure support over zero end-expiratory pressure. (b) Increasing applied positive end-expiratory pressure and fixed pressure support. The level of applied positive end-expiratory pressure at which pressure-rate product was least determined the compensatory positive end-expiratory pressure. (c) Increasing pressure support over compensatory (fixed) positive end-expiratory pressure. MEASUREMENTS AND RESULTS Increases in pressure support alone decreased pressure-rate product from mean 724+/-311 to 403+/-192 cmH2O/min. Applied positive end-expiratory pressure alone decreased pressure-rate product from mean 608+/-301 to 250+/-169 cmH2O/min. The lowest pressure-rate product (136+/-128 cmH2O/min) was achieved using compensatory positive end-expiratory pressure (12+/-4 cmH2O) with pressure support 16 cmH2O. CONCLUSIONS For children with peripheral airways obstruction who require assisted ventilation, work of breathing during spontaneous breaths is decreased by the application of either compensatory positive end-expiratory pressure or pressure support.
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Affiliation(s)
- Alan S Graham
- Department of Pediatrics, Division of Pediatric Critical Care, Oregon Health and Science University, 707 S.W. Gaines Street, Portland, OR 97239-2901, USA.
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16
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Willis BC, Graham AS, Yoon E, Wetzel RC, Newth CJL. Pressure-rate products and phase angles in children on minimal support ventilation and after extubation. Intensive Care Med 2005; 31:1700-5. [PMID: 16228176 DOI: 10.1007/s00134-005-2821-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2005] [Accepted: 09/08/2005] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To compare the pressure-rate products and phase angles of children during minimal support ventilation and after extubation. DESIGN AND SETTING Prospective, randomized single-center trial in a pediatric intensive care unit in a tertiary children's hospital. METHODS Seventeen endotracheally intubated, mechanically ventilated children were placed on T-piece, T-piece with heliox, continuous positive airway pressure, and pressure support in random order. Esophageal pressure swings, phase angles, respiratory mechanics, and physiological parameters were measured on these modes and after extubation. MEASUREMENTS AND RESULTS Pressure-rate product postextubation was significantly higher than on support modes. For each mode and after extubation they were: pressure support 198+/-31, continuous positive airway pressure 237+/-30, T-piece 323+/-47, T-piece/heliox 308+/-61, and extubation 378+/-43 cmH2O/min. Phase angles were significantly higher during T-piece ventilation than pressure support but not did not differ significantly from postextubation. CONCLUSIONS Assessment of effort of breathing during even minimal mechanical ventilation may underestimate postextubation effort in children. Postextubation pressure-rate product and hence "effort of breathing" in children is best approximated by T-piece ventilation.
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Affiliation(s)
- Brigham C Willis
- Division of Pediatric Critical Care, Department of Pediatrics, University of Texas Southwestern Medical School, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9063, USA.
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17
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Willis BC, Graham AS, Wetzel R, L Newth CJ. Respiratory inductance plethysmography used to diagnose bilateral diaphragmatic paralysis: a case report. Pediatr Crit Care Med 2004; 5:399-402. [PMID: 15215015 DOI: 10.1097/01.pcc.0000124019.99266.b6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To report the use of respiratory inductance plethysmography in the diagnosis and management for a case of bilateral diaphragmatic paralysis after repeated sternotomies in a 23-month-old child. DESIGN Case report. SETTING A 15-bed pediatric cardiothoracic intensive care unit in an academic children's hospital. INTERVENTIONS The patient could not be weaned from the ventilator after a repeat sternotomy for pulmonary artery reconstruction. Pulmonary function test results were within normal limits, and plain film radiography, ultrasonography, and fluoroscopy were unable to establish a definitive diagnosis. Evaluation of thoracoabdominal synchrony was undertaken using respiratory inductance plethysmography (RespiTrace). The work of breathing was assessed using esophageal manometry to obtain the pressure-rate product. RESULTS During spontaneous breathing, complete thoracoabdominal asynchrony was noted, with clockwise Konno-Mead loops and associated phase angles of nearly 180 degrees. The pressure-rate product was 120 cm H(2)O/min, indicating elevated work of breathing. The pressure-rate product decreased dramatically, as indicated by measurement and observation, in response to increased levels of continuous positive airway pressure. CONCLUSIONS The diagnosis of bilateral diaphragmatic paralysis can be confirmed by measurement of thoracoabdominal synchrony. Therapeutic and diagnostic application of continuous positive airway pressure may predict response to diaphragmatic plication. Controlled trials comparing measurement of thoracoabdominal synchrony with standard methods for the early diagnosis of diaphragmatic paralysis are needed.
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Affiliation(s)
- Brigham C Willis
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA.
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18
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Abstract
Acquired upper airway obstruction is a common cause of respiratory emergencies in children. Most pathologic processes that result in upper airway compromise are a consequence of infection, trauma or aspiration. Today, many of the infectious causes of upper airway obstruction have lost their threat as a result of the progress made in preventing and treating these infections. Prompt recognition and appropriate management of the child presenting with upper airway obstruction remains critical, because certain causes can progress rapidly from a mild to a potentially life-threatening disease state. A correct diagnosis can often be made by history and physical examination, but additional studies may be useful in selected cases. The child's clinical appearance is the most reliable indicator of severity, and measurable signs are of less value. If respiratory failure is imminent, airway protection and endoscopy for definitive diagnosis may have priority over any other therapeutic or diagnostic procedure.
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Affiliation(s)
- Jürg Hammer
- Division of Paediatric Intensive Care and Pulmonology, University Children's Hospital Basel, Römergasse 8, 4005 Basel, Switzerland.
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19
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Cozzi DA, Bonanni M, Cozzi F, Villa MP, Polidori G. Recurrent apparent life-threatening event relieved by glossopexy. J Pediatr Surg 1996; 31:1715-8. [PMID: 8986999 DOI: 10.1016/s0022-3468(96)90060-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
An infant with repaired esophageal atresia presented with several apparent life-threatening events (ALTEs). He had upper airway instability, gastroesophageal reflux (GER), and tracheomalacia. Oxygen breathing test results showed a modest increase in arterial Po2 consistent with the development of an intrapulmonary shunt from absorption collapse of some hypoventilated areas of the lung. Glossopexy was followed by improvement in upper airway stability, normal oxygen test, and disappearance of ALTE. These findings support the concept that upper airway instability, obstructive apnea, lower airway instability, absorption collapse, massive intrapulmonary shunt, and ALTE are the result of a cascade reaction. The authors conclude that infants with ALTE associated with obstructive apnea and O2 shunting require glossopexy to reduce the risk of sudden death.
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Affiliation(s)
- D A Cozzi
- Pediatric Surgical Unit, Policlinico Umberto I, University of Rome, La Sapienza, Italy
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20
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Abstract
Sleep problems in children may differ in various ways from analogous problems in the adult. This is less because of neurophysiologic differences between the two groups than it is because of the child's greater level of dependency. Young children make few decisions on their own and, as a result, parent-child interactions become connected intimately to the child's sleep process at bedtime and throughout the night. Parental desires and expectations are at least as important as those of the child in determining the pattern of sleep that follows. Such interactions are most important when it comes to understanding causes of sleeplessness in the young child, and only by appreciating these interactions can the clinician serve a useful role in helping the family to understand and improve a young child's problematic sleep patterns.
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Affiliation(s)
- R Ferber
- Center for Pediatric Sleep Disorders, Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Hammer J, Newth CJ. Infant lung function testing in the intensive care unit. Intensive Care Med 1995; 21:744-52. [PMID: 8847430 PMCID: PMC7095417 DOI: 10.1007/bf01704742] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/1993] [Accepted: 08/30/1994] [Indexed: 02/02/2023]
Abstract
As a result of the previous shortage of tools to assess objectively the overall physiological status of the respiratory system in infants and young children, it has been difficult to measure the degree of physiological disorder or the response to therapy in respiratory diseases such as BPD, the pediatric version of ARDS, bronchiolitis, pneumonia, asthma and croup in this patient population. The newborn- four-year old child is particularly difficult to study because of their lack of cooperation and size. The recent progress in computer technology made pulmonary function testing available for this age range and opened up new possibilities for monitoring changes in disease processes affecting the respiratory system. This may improve medical management of infants and children with lung and heart diseases in particular. In 1989, Shannon [49] proposed in this Journal that the minimum physiological information needed for the intelligent use of mechanical ventilation (particularly if lower airway and/or pulmonary parenchymal disease was apparent) required the measurement of at least 4 variables: i) arterial partial pressure of carbon dioxide; ii) arterial oxygen saturation; iii) the mechanical time constant of the lung and iv) FRC. In many circumstances, arterial CO2 is approximated by alveolar (end-tidal) CO2 and the arterial oxygen saturation is obtained from pulse oximetry accurately if perfusion is adequate. The mechanical time constant and FRC are easily measured by the techniques described above and together provide important information concerning appropriate ventilator settings for a given disease. The described techniques bring new insights and awareness, but also new responsibilities in the management of infants and children with respiratory compromise. Not all of these techniques need to be applied to all infants in the ICU. Not all the assumptions upon which some of the techniques we have described are based will prove true. Any such methods which do not withstand solid scientific testing must be quickly discarded and replaced with better and (hopefully) easier methods.
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Affiliation(s)
- J Hammer
- Division of Pediatric Critical Care, Children's Hospital of Los Angeles, University of Southern California School of Medicine 90027, USA
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22
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Abstract
When the airway obstruction related to laryngomalacia becomes significant, surgical correction of the underlying laryngeal deformity is indicated. The three elements of the supraglottic soft tissue that prolapses, namely, the corniculate mounds on the arytenoid cartilages, the shortened ary-epiglottic folds, and the omega shaped epiglottis, can all be appropriately "trimmed" using either conventional instruments or the surgical laser. Relief of symptoms is dramatic and, provided surgery is performed precisely and not during episodes of infection, complications should not occur. The aid of specialized, skillful anesthesia is required for this type of surgery. We present a series of 40 children with significant obstruction: 30% had neuromuscular disorders, 68% had an infantile epiglottis, seven required airway support prior to surgery, all had laser "supraglottic trimming," and 13 required airway support after surgery. Relief of stridor and airway obstruction was generally rapid. There was only one complication: croup developing 4 days after surgery.
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Affiliation(s)
- C A Prescott
- Department of Otolaryngology, University of Cape Town Medical School, South Africa
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24
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25
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Abstract
Eight studies that examined the relation between snoring and vascular disease were identified. The prevalence of habitual snoring, measured by questionnaire or interview, varied from 3% to 29% of adults and was dependent on age, sex, obesity, and smoking habit. In men, habitual snoring was associated with hypertension and ischaemic heart disease, with adjusted relative risks in the range 1.3-2.0. For women, only one study provided adjusted estimates of relative risk, which were 2.8 for hypertension and 1.2 for angina. Adequately adjusted relative risks for cerebrovascular disease have not been reported, but unadjusted estimates varied from 1.6 to 10.3. These studies had several limitations, including the lack of a standard definition of snoring, the use of unvalidated questionnaires, and failure to account for confounding variables and the possibility of reporting bias. Only one study was prospective. Epidemiological criteria for a causal association between snoring and vascular disease have not been satisfied. The apparent excess risk is probably due to the consequences of sleep apnoea rather than snoring itself.
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Affiliation(s)
- P C Waller
- Glasgow Blood Pressure Clinic, Western Infirmary
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26
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Klein M, Reynolds LG. Treatment of obstructive sleep apnea (OSA). Pediatr Pulmonol 1989; 6:208-9. [PMID: 2717246 DOI: 10.1002/ppul.1950060317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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27
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Berkhout AM, Cools HJ. Dangerous oronasal obstruction in weak senile patients. BMJ (CLINICAL RESEARCH ED.) 1988; 297:723. [PMID: 3147744 PMCID: PMC1834081 DOI: 10.1136/bmj.297.6650.723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- A M Berkhout
- de Bieslandhof Nursing and Rehabilitation Centre, VC Delft, The Netherlands
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28
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Capellà D, Laporte JR, Castel JM, Tristán C, Cos A, Morales-Olivas FJ. Parkinsonism, tremor, and depression induced by cinnarizine and flunarizine. BMJ (CLINICAL RESEARCH ED.) 1988; 297:722-3. [PMID: 3147743 PMCID: PMC1834078 DOI: 10.1136/bmj.297.6650.722] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- D Capellà
- Department of Pharmacology, Universitat Autònoma de Barcelona, Spain
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29
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Millar AJ, Prescott C. Vocal-cord paresis in infants: another use for continuous insufflation of the pharynx. Lancet 1988; 2:100. [PMID: 2898667 DOI: 10.1016/s0140-6736(88)90027-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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30
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Tal A, Leiberman A, Margulis G, Sofer S. Ventricular dysfunction in children with obstructive sleep apnea: radionuclide assessment. Pediatr Pulmonol 1988; 4:139-43. [PMID: 2836784 DOI: 10.1002/ppul.1950040304] [Citation(s) in RCA: 191] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Ventricular function was evaluated using radionuclide ventriculography in 27 children with oropharyngeal obstruction and clinical features of obstructive sleep apnea. Their mean age was 3.5 years (9 months to 7.5 years). Conventional clinical assessment did not detect cardiac involvement in 25 of 27 children; however, reduced right ventricular ejection fraction (less than 35%) was found in 10 (37%) patients (mean: 19.5 +/- 2.3% SE, range: 8-28%). In 18 patients wall motion abnormality was detected. In 11 children in whom radionuclide ventriculography was performed before and after adenotonsillectomy, right ventricular ejection fraction rose from 24.4 +/- 3.6% to 46.7 +/- 3.4% (P less than 0.005), and in all cases wall motion showed a definite improvement. In five children, left ventricular ejection fraction rose greater than 10% after removal of oropharyngeal obstruction. It is concluded that right ventricular function may be compromised in children with obstructive sleep apnea secondary to adenotonsillar hypertrophy, even before clinical signs of cardiac involvement are present.
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Affiliation(s)
- A Tal
- Pediatric Division, Soroka University Hospital, Beer-Sheva, Israel
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