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Amirav I, Manucot A, Crawley J, Levi S. Work of Breathing: Physiology, Measurement, and Diagnostic Value in Childhood Pneumonia. CHILDREN (BASEL, SWITZERLAND) 2024; 11:642. [PMID: 38929222 PMCID: PMC11202000 DOI: 10.3390/children11060642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/21/2024] [Accepted: 05/23/2024] [Indexed: 06/28/2024]
Abstract
In clinical practice, increased "work of breathing" (WOB) is used to rapidly identify the acutely ill child in need of immediate clinical care, and is commonly used to support a clinical diagnosis of pneumonia. However, this key clinical sign is poorly understood and inconsistently defined. This review discusses the physiology, measurement, and clinical assessment of WOB, highlighting its utility in the recognition of pneumonia in under-resourced settings, where access to diagnostic imaging may be limited.
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Affiliation(s)
- Israel Amirav
- Pulmonary Unit, Dana-Dwek Children’s Hospital, Tel Aviv 6423906, Israel;
| | - Aleeza Manucot
- Department of Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada;
| | - Jane Crawley
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford OX3 7LG, UK;
| | - Sapir Levi
- Pulmonary Unit, Dana-Dwek Children’s Hospital, Tel Aviv 6423906, Israel;
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Li J, Deng N, He WJA, Yang C, Liu P, Albuainain FA, Ring BJ, Miller AG, Rotta AT, Guglielmo RD, Milési C. The effects of flow settings during high-flow nasal cannula oxygen therapy for neonates and young children. Eur Respir Rev 2024; 33:230223. [PMID: 38537946 PMCID: PMC10966474 DOI: 10.1183/16000617.0223-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/18/2024] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND During neonatal and paediatric high-flow nasal cannula therapy, optimising the flow setting is crucial for favourable physiological and clinical outcomes. However, considerable variability exists in clinical practice regarding initial flows and subsequent adjustments for these patients. Our review aimed to summarise the impact of various flows during high-flow nasal cannula treatment in neonates and children. METHODS Two investigators independently searched PubMed, Embase, Web of Science, Scopus and Cochrane for in vitro and in vivo studies published in English before 30 April 2023. Studies enrolling adults (≥18 years) or those using a single flow setting were excluded. Data extraction and risk of bias assessments were performed independently by two investigators. The study protocol was prospectively registered with PROSPERO (CRD42022345419). RESULTS 38 406 studies were identified, with 44 included. In vitro studies explored flow settings' effects on airway pressures, humidity and carbon dioxide clearance; all were flow-dependent. Observational clinical studies consistently reported that higher flows led to increased pharyngeal pressure and potentially increased intrathoracic airway pressure (especially among neonates), improved oxygenation, and reduced respiratory rate and work of breathing up to a certain threshold. Three randomised controlled trials found no significant differences in treatment failure among different flow settings. Flow impacts exhibited significant heterogeneity among different patients. CONCLUSION Individualising flow settings in neonates and young children requires consideration of the patient's peak inspiratory flow, respiratory rate, heart rate, tolerance, work of breathing and lung aeration for optimal care.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
- These authors contributed equally
| | - Ni Deng
- Department of Respiratory Care, West China Hospital of Sichuan University, Chengdu, China
- These authors contributed equally
| | - Wan Jia Aaron He
- School of Nursing, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- These authors contributed equally
| | - Cui Yang
- Department of Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- These authors contributed equally
| | - Pan Liu
- Department of Pediatric Intensive Care Unit, Children's Hospital of Fudan University, National Center for Children's Health, Shanghai, China
- These authors contributed equally
| | - Fai A Albuainain
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
- Department of Respiratory Care, College of Applied Medical Sciences, Imam Abdulrahman bin Faisal University, Jubail, Saudi Arabia
| | - Brian J Ring
- Department of Surgery, Division of Trauma and Critical Care, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew G Miller
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
- Respiratory Care Services, Duke University Medical Center, Durham, NC, USA
| | - Alexandre T Rotta
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Robert D Guglielmo
- Division of Pediatric Critical Care, Department of Pediatrics, Loma Linda University Children's Hospital, Loma Linda, CA, USA
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Christophe Milési
- Pediatric Intensive Care Unit, University of Montpellier I, Montpellier, France
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Kovatis K, Mackley A, Traczykiewicz S, Subedi K, Rahman T, Shaffer TH. Oxygen saturation and work of breathing indices in preterm infants with bronchopulmonary dysplasia compared to healthy preterm infants at discharge. J Neonatal Perinatal Med 2024; 17:589-595. [PMID: 38968059 DOI: 10.3233/npm-230222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2024]
Abstract
BACKGROUND Thoracoabdominal asynchrony (TAA) is commonly seen in preterm infants. Respiratory inductive plethysmography (RIP) is a noninvasive way to objectively assess work of breathing (WOB) indices. The impact of bronchopulmonary dysplasia (BPD) on TAA at discharge has not been established. The aim of this study is to compare WOB indices in premature infants with a diagnosis of BPD to premature infants without a diagnosis of BPD at discharge. METHODS A prospective, observational study of premature infants (<32 weeks gestation) at discharge during quiet breathing in the supine position. RIP noninvasively measured WOB indices. A high-resolution pulse oximeter collected oxygen saturation and heart rate data. RESULTS This study included thirty-one infants with BPD and thirty-four infants without BPD. Infants diagnosed with BPD had increased phase angle [BPD Φ = 73 . 90 (8.2) vs NoBPD Φ = 52.6 (8.2), p = 0.039]. Infants diagnosed with BPD had decreased saturations [BPD SpO2 = 96% (0.4) vs NoBPD Sp02 98% (0.3), p=<0.001], increased time with saturations less than 85% [BPD % =2.74 (0.7) vs NoBPD % =0.91 (0.4), p = .018], and increased time with saturations less than 80% [BPD % =1.57 (0.5) vs NoBPD % =0.52 (0.3), p = 0.045]. There was no difference in heart rate or breaths per minute for infants with BPD versus controls. CONCLUSION Premature infants with BPD demonstrated increased TAA and had lower saturations compared to infants without BPD at discharge despite being chronologically older and being discharged at an older corrected gestational age. The impact of BPD on breathing patterns persists at discharge and suggests these patients may have residual lung and/or respiratory muscle dysfunction.
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Affiliation(s)
- K Kovatis
- Department of Neonatology, ChristianaCare. Newark DE, USA
| | - A Mackley
- Department of Neonatology, ChristianaCare. Newark DE, USA
| | | | - K Subedi
- Institute for Research on Equity and Community Health (iREACH), ChristianaCare, Newark, DE, USA
| | - T Rahman
- Nemours Biomedical Research, Nemours Children's Health, Wilmington, DE, USA
| | - T H Shaffer
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Physiology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
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Gable M, Shaffer TH, Locke R, Mackley A, Kovatis K. The impact of kangaroo mother care on work of breathing and oxygen saturation in very low birth weight infants with respiratory insufficiency. J Neonatal Perinatal Med 2022; 16:141-150. [PMID: 36314219 DOI: 10.3233/npm-221068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Kangaroo mother care (KMC) is defined as prolonged skin to skin care between a mother and infant with the infant lying in prone position on mom’s chest. KMC decreases morbidity and mortality and promotes physiologic stability. The aim of this study is to measure work of breathing (WOB) during KMC in very low birth weight (VLBW) infants on non-invasive respiratory support. METHODS: A prospective observational pilot study was conducted comparing WOB indices during standard care (SC) and KMC. Respiratory inductive plethysmography (RIP) measured WOB indices non-invasively: phase angle and labored breathing index. VLBW infants who were stable on non-invasive respiratory support were randomized to receive RIP measurements during KMC or during SC first. Summary statistics and mixed linear models were used to compare WOB and vital signs. RESULTS: A total of 32 infants were consented for the study, data collection and analysis was completed on 28 infants. There were no significant differences in mean phase angle during KMC or SC (73.5±4.6 SE deg vs 66.8±3.9 SE deg, p = 0.25). No differences in WOB and vital signs were detected. Controlling for respiratory support or randomization/first location did not change the results. CONCLUSION: In this pilot cohort, infants demonstrated no differences in work of breathing indices or oxygen saturation during KMC or SC while receiving non-invasive respiratory support. KMC appears to be safe and well tolerated with no worsened WOB. Larger studies should be performed to confirm our findings.
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Affiliation(s)
- M. Gable
- Department of Neonatology, Janet Weis Children’s Hospital at Geisinger Medical Center, Danville, 7 PA, USA
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - T. H. Shaffer
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Biomedical Research, Nemours/Alfred I Du Pont Hospital for Children, Wilmington, DE, USA
- Department of Pediatrics, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - R. Locke
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Neonatology, Christiana Care, Newark, (DE,) USA
| | - A. Mackley
- Department of Neonatology, Christiana Care, Newark, (DE,) USA
| | - K.Z. Kovatis
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Neonatology, Christiana Care, Newark, (DE,) USA
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Murala DK, Levenbrown Y, Xiao W, Hossain J, Shaffer TH. Utilising pneuRIP device in determining the adequacy of respiratory support when weaning high-flow nasal cannula in paediatric patients with acute respiratory distress: A pilot study. J Paediatr Child Health 2022; 58:1548-1553. [PMID: 35652438 DOI: 10.1111/jpc.16031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 04/18/2022] [Accepted: 05/02/2022] [Indexed: 11/28/2022]
Abstract
AIM Recognition of paediatric respiratory distress and timely intervention is critical, especially during the weaning phase of support in paediatric acute respiratory failure, as weaning too aggressively can lead to further setbacks in a patient's recovery. We aimed to determine if pulmonary function measurements obtained with the pneuRIP device, a noninvasive pulmonary function testing device that provides measurements of labored breathing index (LBI), phase angle and %rib cage (%RC) contribution to breathing, will provide predictive values to assess the adequacy of respiratory support while weaning from HFNC. METHODS We reviewed patients ages 0-18 years admitted to the PICU for respiratory distress due to respiratory infections receiving HFNC. Patients with history of chronic lung disease and chronic neuromuscular disease with baseline habnormal breathing patterns were excluded. Phase angle, LBI and %RC were obtained every hour and with every wean of HFNC. Nine patients were enroled. RESULTS Mean LBI range remained 1.27-1.68 when LBI was plotted as a function of the HFNC flow rate. Mean values of %RC contribution to breathing ranged 43.65-57.12 as a function of the HFNC flow rate. No significant deviations existed in either %RC (P = 0.16) or LBI (P = 0.16) during the weaning of HFNC. Mean phase angle for all subjects was 41.48°-74.12° for the duration of wean and showed significant deviation from baseline during the weaning process (p = 0.001). CONCLUSIONS Measurements of LBI and %RC on the pneuRIP device effectively demonstrated tolerance of weaning HFNC during the recovery phase of acute respiratory failure from a respiratory infection.
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Affiliation(s)
- Deepika K Murala
- Department of Pediatrics, Nemours Children's Hospital, Delaware, Wilmington, Delaware, United States
| | - Yosef Levenbrown
- Division of Pediatric Critical Care, Nemours Children's Hospital, Delaware, Wilmington, Delaware, United States.,Department of Pediatrics, Sidney Kimmel Medical School of Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Wendi Xiao
- Nemours Biomedical Research, Nemours Children's Health, Wilmington, Delaware, United States.,Department of Applied Economics and Statistics, University of Delaware, Newark, Delaware, United States
| | - Jobayer Hossain
- Nemours Biomedical Research, Nemours Children's Health, Wilmington, Delaware, United States.,Department of Applied Economics and Statistics, University of Delaware, Newark, Delaware, United States
| | - Thomas H Shaffer
- Nemours Biomedical Research/Research Lung Center, Nemours Children's Health, Wilmington, Delaware, United States.,Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, United States.,Department of Pediatrics, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, United States
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